Every finding on record at South Mountain Post Acute

Based on resident and staff interviews, facility documentation, staffing records, and policy review, the facility failed to provide sufficient nursing staff to provide nursing and related services to meet residents' needs based on the number and acuity of the resident population. This deficient practice resulted in delayed staff response to a resident who required assistance and had the potential to result in delayed or unmet care needs for residents requiring staff assistance.Findings include:Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility triggered for excessively low weekend staffing during three reporting quarters in 2025, which affected the facility's staffing rating.Review of the facility assessment, revised February 11, 2026, revealed that the facility was licensed to provide care for 124 residents and had an average daily census during the previous six months ranging from 103 to 116 residents. The resident population included 23 residents receiving enteral feedings and 26 residents receiving tracheostomy care.Review of the facility assessment staffing plan identified the following nursing staffing structure:Full-time Director of Nursing (DON);Full-time wound care Licensed Practical Nurse (LPN);Full-time direct-care Certified Nursing Assistants (CNAs);Two full-time Assistant Directors of Nursing (ADONs), including Saturday and Sunday with flexible hours;Full-time Infection Preventionist (IP), including Saturday and Sunday from 8:00 a.m. to 5:00 p.m. with flexible hours;Two full-time Minimum Data Set (MDS) LPNs Monday through Friday, with one flexing weekends;Two Registered Nurses (RNs) for the 6:00 a.m. to 6:00 p.m. shift, including Saturday and Sunday;Two RNs for the 6:00 p.m. to 6:00 a.m. shift, including Saturday and Sunday;Five LPNs for the 6:00 a.m. to 6:00 p.m. shift, including Saturday and Sunday;Five LPNs for the 6:00 p.m. to 6:00 a.m. shift, including Saturday and Sunday;Twelve CNAs for the 7:00 a.m. to 7:00 p.m. shift, including Saturday and Sunday;Eight CNAs for the 7:00 p.m. to 7:00 a.m. shift, including Saturday and Sunday; andA full-time Restorative Nursing Assistant (RNA) from 8:00 a.m. to 5:00 p.m., Monday through Friday.The facility consisted of four halls/units: 100, 200, 300, and 400. Review of the daily staffing postings revealed shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m., and 10:00 p.m. to 6:00 a.m.Review of assignment sheets, daily staffing postings, punch-detail records, facility census information, and PBJ staffing data identified variations in the number of nursing staff and hours actually worked. The assignment sheets and daily staffing postings generally reflected scheduled nursing staffing levels; however, comparison with corresponding punch-detail records revealed that nursing staff did not consistently complete their scheduled shifts.Staffing records reviewed included the following:On January 4, 2025, the facility census was 102. Four RNs worked a total of 26.38 hours, 13 LPNs worked 93.08 hours, and 30 CNAs worked 177.48 hours.On January 5, 2025, the facility census was 101. Four RNs worked a total of 25.57 hours, 16 LPNs worked 101.08 hours, and 29 CNAs worked 200.82 hours.On January 26, 2025, the facility census was 98. Four RNs worked a total of 34.30 hours, 15 LPNs worked 99.30 hours, and 30 CNAs worked 193.03 hours.On February 15, 2025, the facility census was 106. Four RNs worked a total of 34.05 hours, 15 LPNs worked 115.85 hours, and 28 CNAs worked 178.95 hours.On February 16, 2025, the facility census was 106. Three RNs worked a total of 26.90 hours, 18 LPNs worked 119.48 hours, and 31 CNAs worked 178.18 hours.On March 8, 2025, the facility census was 100. Four RNs worked a total of 23.88 hours, 16 LPNs worked 115.37 hours, and 37 CNAs worked 193.68 hours.On March 9, 2025, the facility census was 99. Four RNs worked a total of 33.60 hours, 16 LPNs worked 103.36 hours, and 37 CNAs worked 173.43 hours.On April 6, 2025, the facility census was 106. Two RNs worked a total of 22.73 hours, 17 LPNs worked 117.40 hours, and 28 CNAs worked 169.80 hours.On May 4, 2025, the facility census was 100. Four RNs worked a total of 41.87 hours, 16 LPNs worked 104.68 hours, and 30 CNAs worked 169.52 hours.On May 24, 2025, the facility census was 97. Four RNs worked a total of 54.03 hours, 16 LPNs worked 78.62 hours, and 30 CNAs worked 172.50 hours.On August 3, 2025, the facility census was 106. Four RNs worked a total of 48.45 hours, 16 LPNs worked 100.52 hours, and 30 CNAs worked 205.05 hours.On September 20, 2025, the facility census was 116. Eight RNs worked a total of 62.23 hours, 15 LPNs worked 105.63 hours, and 35 CNAs worked 222.97 hours.An interview was conducted with resident #94 on August 16, 2026 at 9:16 a.m. Resident #94 stated that the facility was always short-staffed. Resident #94 stated that she had Urinary Catheter draining bag that needed to be emptied, particularly in the morning. The resident stated that when she observed that her catheter drainage bag was full, she activated her call light for staff assistance; however, it could take a nursing aide one to two hours to respond to her call light.An interview was conducted with resident #149 on August 16, 2026 at 11:07 a.m. Resident #149 stated that Unit 100 consisted of 17 rooms with two residents in each room. Resident #149 stated that two nursing aides were not enough to assist all the residents, particularly during the morning when the unit was busiest. The resident stated that she had expressed her concern to nursing aides and was told that the facility's census and resident acuity determined staffing.An interview was conducted with a Certified Nursing Assistant Supervisor (CNA/staff #27) on August 17, 2026 at 1:40 p.m. Staff #27 stated that staffing call-offs varied daily and that weekends could be difficult because that was when most nursing aides called off, particularly when a holiday occurred on a Friday. Staff #27 stated that Units 100, 200, and 400 were assigned two CNAs and a float CNA to assist with showers, while Unit 300 was assigned three CNAs and a float CNA.Staff #27 further stated that Unit 300 required more assistance because the unit housed residents with ventilators and tracheostomies, as well as residents who required Hoyer lifts for transfers.An interview was conducted with a Certified Nursing Assistant (CNA/staff #70) on August 18, 2026 at 2:29 p.m. Staff #70 stated that she had injured herself while working in Unit 300 in May 2026. Staff #70 further stated that Unit 300 housed residents who required total assistance, including residents with tracheostomies, ventilators, and residents requiring Hoyer lifts for transfers. Staff #70 stated that she notified CNA Supervisor Staff #27 that only two CNAs were working on Unit 300 that morning and requested another CNA because of the workload on the unit. According to Staff #70, Staff #27 responded, The census is low so it will only be two on the hall.Review of the staffing schedule for May 9, 2026, revealed that the facility census was 94 residents. The staffing schedule showed that three CNAs were scheduled to work from 7:00 a.m. to 7:00 p.m.; however, the third CNA called off, leaving two CNAs scheduled for the unit.An interview was conducted with the Director of Nursing (DON/staff #302) on August 18, 2026 at 2:40 p.m. Staff #302, stated that staffing was based on facility census and resident acuity. The DON further stated that she reviewed the staffing schedule daily and weekly with the staffing coordinator.Review of the facility policy titled Sufficient Staff, revised June 2023, revealed that it was the facility's policy to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to promote resident safety and attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The policy further required staffing to be determined by resident assessments and individual plans of care and to consider the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment.

Based on clinical record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to implement and follow contact precautions and ensure contact precautions were discontinued in accordance with facility policy for three residents (#131, #157, and #158). The universe was 24. The deficient practice could lead to the spread of infectious organisms to other residents. Findings include:Regarding Resident #157-Resident #157 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, enterocolitis due to clostridium difficile, and infection of amputation stump right lower extremity.Review of the Minimum Data Set (MDS) assessment list revealed the admission MDS was not yet complete at the time of the survey. However, review of the Brief Interview for Mental Status (BIMS) evaluation, dated August 11, 2026 revealed a BIMS score of 14 which indicated Resident #157 was cognitively intact.A physician's order, dated August 5, 2026, revealed Resident #157 was to take Vancomycin (antibiotic) HCI Oral Capsule 125 milligrams (MG) every 6 hours for clostridium difficile for two weeks. The end date for the order was August 19, 2026.A Clinical admission note, dated August 5, 2026 at 9:00 P.M. noted that Resident #157's last bowel movement was on August 5, 2026 and was loose. It further noted Resident #157 was on isolation precautions due to an active infectious disease.A second physician's order, dated August 13, 2026, revealed Resident #157 was on contact isolation.A Care Plan, initiated on August 7, 2026, noted that Resident #157 was on Enhanced Barrier Precautions (EBP) due to his indwelling device.Review of the Bowel movement/Bowel continence task sheet revealed the following stool consistencies: August 6, 2026 at 12:18 A.M. loose/diarrhea August 7, 2026 at 1:00 A.M. loose/diarrhea August 8, 2026 at 3:22 A.M. putty-like August 9, 2026 at 10:49 A.M. formed/soft/normal August 9, 2026 at 10:13 P.M. formed/soft/normal August 10, 2026 at 6:42 P.M. formed/soft/normal August 11, 2026 at 1:46 A.M. loose/diarrhea August 12, 2026 at 5:17 P.M. loose/diarrhea August 12, 2026 at 9:39 P.M. loose/diarrhea August 12, 2026 at 11:40 P.M. loose/diarrhea August 13, 2026 at 1:36 A.M. loose/diarrhea August 13, 2026 at 6:59 P.M. loose/diarrhea August 14, 2026 at 3:32 A.M. loose/diarrhea August 14, 2026 at 5:00 P.M. formed/soft/normal August 15, 2026 noted Not applicable August 16, 2026 at 2:40 A.M. loose/diarrheaRegarding Resident #131-Resident #131 was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile, hypoosmolality and hyponatremia, and type 2 diabetes mellitus.Review of the MDS list revealed the admission MDS was not yet complete at the time of the survey. However, a review of the BIMS evaluation, dated August 12, 2026, revealed a BIMS score of 15 which indicated Resident #131 was cognitively intact.A Physician's Order, dated August 6, 2026 revealed Resident #131 was to take Vancomycin HCI Oral Capsule 125 mg every 6 hours for 10 days. The order further revealed that the resident was to receive the medication for clostridium difficile. The end date for the order was August 16, 2026.A second physician's order, dated August 6, 2026, revealed Resident #131 was to take Vancomycin HCI Oral Capsule 125 mg every 6 hours for five days starting on August 17, 2026. The end date for the order was August 22, 2026. An additional Physician's Order, dated August 6, 2026, revealed Resident #131 was to be on contact isolation due to a diagnosis of clostridium difficile. However, the order revealed that it was discontinued on August 17, 2026 due to Resident #131 having formed stool and not needing to be on iso.A Care Plan, initiated on August 6, 2026, revealed Resident #131 was on antibiotic therapy related to clostridium difficile. Interventions included contact isolation per Medical Doctor (MD) orders. Review of Resident #131's Bowel Movement (BM) task chart revealed the following stool consistencies: August 12, 2026 at 5:17 P.M. as loose/diarrhea August 13, 2026 at 1:35 A.M. as loose/diarrhea August 13, 2026 at 4:59 P.M. as not applicable August 14, 2026 at 3:28 A.M. as not applicable August 14, 2026 at 4:29 P.M. as formed/soft/normal August 15, 2026 at 2:52 A.M. as not applicable August 15, 2026 at 5:20 P.M. as not applicable August 16, 2026 at 2:46 A.M. as putty-like.An observation was conducted on August 16, 2026 at 8:08 A.M. of a room that was shared by Resident #131 and #157. Outside of the room was a sign saying Contact Precautions and a staff member carrying a breakfast tray stopped outside of the Resident's room and donned personal protective equipment (PPE) and then entered the room with the breakfast tray.During that same observation period, at 8:15 A.M. , Certified Nursing Assistant (CNA/Staff #103) was observed entering the contact-precaution room shared by Resident #131 and #157 without donning PPE. Staff #103 walked to the area directly in front of resident #157's bed, retrieved clothing from the top of the closet, and exited the room approximately 15 seconds later.An interview was conducted with Staff #103 on August 16, 2026 at 8:16 A.M. Staff #103 shared that he went into the residents' room to retrieve his jacket and acknowledged that he was required to wear PPE before entering the room. Staff #103 was unable to explain why he entered the room without first donning the required PPE.An interview was conducted on August 17, 2026 at 7:28 A.M. with CNA/Staff #5. Staff #5 shared that if a resident is on contact precautions then there would be signage on the door and the nurse or the Infection Preventionist (IP) nurse will notify staff before the resident is put on isolation. Staff #5 further shared that when a room is a contact precaution room, staff need to gown up before entering the room to protect the staff member and the resident. She further shared that staff cannot enter the room to retrieve something without donning and doffing.An interview was conducted on August 17, 2026 at 7:32 A.M. with Licensed Practical Nurse (LPN/Staff #155). Staff #155 shared that if a resident was on contact precautions, there would be an order in place and signage outside of the door. Staff #155 further shared that clostridium difficile would be a reason to be on contact isolation. Staff #155 explained that if a room has been identified as a contact precautions room, then staff need to gown up before entering the room. She further explained that if a staff person forgot something in the room, they cannot go back inside without gowning up. Staff #155 shared that Resident #131 was on contact precautions yesterday (August 16, 2026) and that the signage had come down around noon. Staff #155 explained that the risk of going into a room, that is on contact precautions, without gowning up is that the spores can get on you. She added that the staff can also transfer it to another resident if you are going to be providing resident care.An interview was conducted on August 17, 2026 at 7:40 A.M. with the Infection Preventionist (IP)/LPN (Staff #13). Staff #13 shared that when a resident is admitted to the facility, the orders are double checked upon admission and once they are verified, they are entered into the electronic health record (EHR). Once that is done, the staff are told that they need to have PPE on when entering the room and there is PPE available for staff. Staff #13 further shared that if a resident room has a contact precautions signage outside of their door staff are to don PPE when entering the room and then doff inside the room and put their PPE in a trashcan located inside the room. Staff #13 explained that there were residents inside a room yesterday (August 16, 2026) that were on contact precautions. Staff #13 further explained that the contact precautions ended the day before because the stools were formed and the lab results were within normal limits. Staff #13 shared that she had taken down the contact precaution signage between 10:30 A.M. and 11:00 A.M. Staff #13 explained that staff cannot go into a room without donning and doffing to get something because whatever is in the room is contaminated. She further explained that there would be a risk of spreading whatever the resident has.An interview was conducted with the Director of Nursing (DON/Staff #143) on August 17, 2026 at 7:48 A.M. Staff #143 explained that when a resident is admitted , the IP nurse will review the order and then determines if the resident needs to be on contact precautions. If they do, then orders are put in, the contact precautions signage is put up, and the care plan is communicated to staff. She further explained that infectious disease consultants will also review the resident's chart and provide a consultation. Staff #143 shared that when there is a contact precautions sign up, it is to alert staff what precautions are in place for the residents and themselves. If a resident is on contact precautions then they have to gown up, perform hand hygiene, and put on gloves. She further shared that donning is done outside of the resident's room and doffing is done inside the room. Staff #143 explained that if staff will be contacting the resident or touching anything in the room that came into contact with the resident, staff want to be sure they are gowning up before they enter the room. Staff #143 further explained that she was fine with a staff member going into a resident's room without donning if, after they retrieved the item they needed, they did not go into any other patient's room. Staff #143 shared that if staff entered a room without donning PPE and retrieved an item and went into another patient's room, there would be a risk of spreading the infection to another resident.A follow-up interview was conducted on August 17, 2026 at 10:30 A.M. with Staff #13. Staff #13 explained that she reviewed the issue with the contact precautions signage outside of Resident #131's room and spoke with the provider. Staff #13 further explained that the provider had seen Resident #131 the previous day and removed the resident from contact precautions. Staff #13 shared that the order for the removal of the contact precautions was communicated with the Nurses and CNAs but she was not informed until later in the day and that is when she removed the contact precautions sign. Staff #13 stated that when the CNA entered the room without PPE, Resident #131 was no longer on contact precautions.Regarding Resident #158-Resident #158 was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile, not specified as recurrent, acute and chronic respiratory failure with hypoxia, and type 2 diabetes mellitus with diabetic chronic kidney disease.Review of the MDS list revealed the admission MDS was not yet complete at the time of the survey. However, review of the BIMS evaluation, dated August 13, 2026 revealed a BIMS score of 12 which indicated Resident #158 had moderate cognitive impairment.The Physician's Order Summary revealed the following orders for Resident #158: Enhanced barrier precautions: PPE required for high resident contact care activities with a start date of August 13, 2026 and end date of August 17, 2026. Vancomycin HCI Oral Suspension 2.5 ml enterally every 48 hours for clostridium difficile infection for 3 administrations. The order had a start date of August 13, 2026 and an end date of August 19, 2026.A Required Notification of Interfacility Transfers Infection Control Transfer Form dated August 12, 2026 indicated the resident was on Transmission-Based Precautions (TBP) on the date of transfer from the hospital to the facility. The form further noted that the resident was on contact precautions due to an active infection of clostridium difficile.Review of the Infectious Disease (ID) Progress Notes from the hospital revealed an entry signed by a hospital provider on August 12, 2026 at 9:45 A.M. The ID Progress Note noted that Resident #158 had clostridium difficile which was initially diagnosed on [DATE]. It further noted that Resident #158 was on oral antibiotics of Vancomycin which was being tapered off. The ID Progress Note explained that the plan was for Resident #158 to continue on the Vancomycin tapering course, monitoring of the diarrhea, as well as her labs. It further explained that Resident #158 was to be on contact precautions per infection control policies.A Clinical admission Note, dated August 12, 2026 at 9:00 P.M. described Resident #158's bowel movement as fatty. The note also indicated Resident #158 was on Vancomycin due to clostridium difficile.A Nursing note, dated August 13, 2026 at 12:58 A.M. noted that Resident #158's admitting diagnosis was clostridium difficile and she was on contact isolation.A late entry admission Health and Physical Note (H&P) completed by Nurse Practitioner (NP/Staff #226), dated August 13, 2026 at 12:09 P.M. noted that Resident #158 was being treated for clostridium difficile and was on an oral vancomycin taper. It further noted that the most recent infectious disease evaluation recommended continuing the vancomycin taper and monitoring the diarrhea labs and continuing contact precautions. The H&P note indicated the plan was to continue to oral vancomycin taper per infectious disease recommendations, to monitor the stool frequency and consistency, and to continue contact precautions per facility protocol.A Care Plan, initiated on August 13, 2026, revealed Resident #158 was at risk of an infection related to an indwelling device. Interventions included EBP during the provision of close contact care. Review of the clinical record for Resident #158, revealed no documentation regarding the removal of contact precautions. Furthermore, there were no progress notes, treatment evaluations, or physician reassessments to indicate whether the clostridium difficile had improved or resolved.An observation was made on August 16, 2026 at 10:11 A.M. of Resident #158's room revealed no contact precautions or enhanced barrier precaution signage posted on or near the door.A second observation of Resident #158's room was made on August 17, 2026 at 3:53 P.M. During this observation a sign indicating Resident #158 was on EBP was posted outside of the room. There was no other signage indicating Resident #158 was on contact precautions.An interview was conducted on August 17, 2026 at 3:55 P.M. with LPN/Staff #150. Staff #150 shared that Resident #158 was receiving vancomycin due to clostridium difficile every 48 hours for three administrations. Staff #150 further shared that Resident #158 used to have clostridium difficile but her stool had been formed and there were no reports of loose stool. Review of the Bowel movement/Bowel Continence Task sheet for Resident #158 revealed the bowel movement consistencies for the following dates: August 13, 2026 at 4:09 A.M. Putty like August 14, 2026 there was no record of bowel movement August 15, 2026 at 11:19 P.M. formed/soft/normal August 16, 2026 at 5:55 P.M. resident refused August 17, 2026 at 9:03 A.M. loose diarrhea August 18, 2026 at 9:34 A.M. putty likeThe bowel movement record documented loose/diarrheal stool on August 17, 2026, after Contact Precautions had been discontinued.An interview was conducted on August 17, 2026 at 4:06 P.M. with Staff #13. Staff #13 shared that Resident #158 had clostridium difficile at the hospital and was on a tapered dose of Vancomycin. Staff #13 further shared that when Resident #158 arrived at the facility she was taken off of contact precautions. Staff #13 explained that the facility had requested lab work from the hospital but the hospital did not send the results because they had lost it and because there was no lab work, the facility had put Resident #158 on a low dose of vancomycin and tapered it off. When asked to review the Bowel Movement task sheet for Resident #158, Staff #13 shared that there should have been more documentation regarding the formed stools for the resident.A follow-up interview was conducted with Staff #13 on August 17, 2026 at 4:19 P.M. Staff #13 shared that the primary provider had made the decision to remove Resident #158's contact precautions based on her vancomycin being tapered off and the resident only having one episode of loose stool/diarrhea (since admission). Staff #13 further shared that there is more of a concern of clostridium difficile when there are three episodes of loose and runny stools. Staff #13 added that the low dose of vancomycin is for clostridium difficile colitis which was different from clostridium difficile and that a person could be on a taper dose of vancomycin for months. Staff #13 further added that Resident #158 did not have active clostridium difficile and continues to be monitored by ID. Staff #13 also added that Resident #158's stool did not have the smell that is associated with clostridium difficile.An interview was conducted with Staff #143 on August 18, 2026 at 2:30 P.M. Staff #143 shared that Resident #158 was admitted to the facility with a diagnosis of clostridium difficile colitis. Staff #143 further shared that Resident #158 was on vancomycin 2.5 ml every 48 hours for 3 administrations. Staff #143 shared that Resident #158 was taken off of contact precautions on August 14th because she had formed stools. Staff #143 further shared that on August 13th, Resident #158 had putty like stool, on August 15th the stool was formed, and on August 17th, the stool was loose, and on August 18th the stool was putty like. Staff #143 explained that based on the formation of the resident's stools that told Staff #143 that the resident no longer needed to be on isolation due to her stools starting to form. Staff #143 further explained that putty is not diarrhea so putty stool is the same as formed stool and residents who had putty like stool did not have to be on contact precautions. Staff #143 explained that it was the provider's discretion to determine that the clostridium difficile had resolved and that the IP nurse (Staff #13) would have a conversation with the provider regarding the resident's status. Staff #143 further explained that she agreed with the provider's decision to remove Resident #158 from contact precautions because the resident was on vancomycin for 6 weeks.On August 19, 2026 at 9:25 A.M. Staff #143 shared that all infectious disease notes are in the clinical chart with the progress notes with a title of Infectious Disease Notes. An additional review of the clinical charts revealed no documentation from the facility's Infectious Disease provider.Review of the facility's policies and procedures titled Transmission Based Precaution & Isolation indicated it was last revised in January 2026. The policy explains that the facility will implement infection control measures to prevent the spread of communicable diseases and conditions. The policy further categorizes clostridium difficile as one of the Multi-drug Resistant Organisms (MDRO). A subcategory titled Termination of Contact Precautions explains that contact precautions can be discontinued with a MDRO resident becomes asymptomatic. It further explains that it is not necessary to wait until a resident completes the antibiotic to remove them from contact precautions. However, it was noted that good assessments and documentation of each resident's clinical condition is necessary before discontinuing the isolation precautions. It also noted that the final decision to remove a resident from contact precautions lies with the facility's IP. The policy further noted that if symptoms recur, the resident may be placed on Empiric Isolation until the infection is cultured and the results are available.

Based on observation, record review, staff interviews, and facility policy, the facility failed to ensure one resident (#33) received care and services necessary to attain or maintain their highest practicable physical well-being, as evidenced by failure to notify the provider when blood pressure medication was held and failure to obtain and document vital signs before hospitalization. The deficient practice could potentially limit the provider's ability to assess the resident's condition and potentially delay appropriate medical intervention. The sample size was 3. Findings include:Resident (#33) was admitted to the facility on [DATE], and discharged to the hospital on November 12, 2025, with a diagnosis including acute pyelonephritis, acute respiratory failure, unspecified whether with hypoxia or hypercapnia, dysphagia, oral phase, cognitive communication deficit, essential (primary) hypertension. Review of the care plan, date-initiated October 29, 2025, revealed a focus on hypertension related to congestive heart failure. Interventions include Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia), and effectiveness. Monitor/record medication side effects, report to the medical doctor as necessary. Review of the Medicare 5-day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 15, indicating cognition was intact. No identified indicators for mood or behaviors. The assessment revealed the resident required substantial maximum assistance with activities of daily living. Review of the assessment revealed the resident had medically complex conditions, including heart failure, hypertension, diabetes mellitus (DM), respiratory failure, and acute pyelonephritis. Further review of the assessment revealed the resident received insulin injections, antidepressants, opioids and continuous oxygen.Review of the order summary revealed a current order for Amlodipine Besylate Tablet 5 mg, give 1 tablet by mouth one time a day for hypertension (HTN). Start date October 30, 2025. Vital signs every shift, start date October 29, 2025.Review of the eMAR Medication Administration Note, effective date November 1, 202,5 at 9:20 am revealed hypertension medication 5mg Amlodipine Besylate Tablet was held due to resident #33's blood pressure 108/63. Further review revealed no documentation that the provider was notified of the held medication. Review of the eMAR Medication Administration Note, effective date November 6, 2025, at 8:22 am revealed hypertension medication 5mg Amlodipine Besylate Tablet was held due to resident #33 blood pressure 117/73. Further review revealed no documentation that the provider was notified of the held medication. Review of the medication administration record for November 2025 revealed the resident's vital signs were documented on November 12, 2025, in the am shift. There were no additional vital signs documented for November 12, 2025. Review of the weights and vitals summary for November 12, 2025 revealed vital signs were obtained at 8:45 am with the following readings: blood pressure-158/76, pulse-80, 20 breaths per minute, temperature-98.6.Record review revealed that on November 1, 2025, and November 6, 2025, Resident # 33's blood pressure medication was held due to low blood pressure parameters. However, there was no documentation that the provider was notified of the held medication. Additionally, prior to the resident being transferred to the hospital on November 12, 2025, vital signs were not obtained and documented, limiting the provider's ability to assess the resident's condition and potentially delaying appropriate medical intervention.Review of the progress nursing notes, effective date November 12, 202,5 4:34 PM revealed a nursing note documenting Confirmed with AMR that transport nonemergent will arrive by 1610.Review of the progress nursing notes, effective date November 12, 202,5 6:20 PM, revealed a nursing note documenting x3 attempts to speak with charge at BUMC ED with no success to provide report. Was picked by AMR and family following in a private vehicle. The report was given at the bedside to paramedics. All pertinent documentation was given to the driver.An interview was conducted on December 30, 2025, at 12:41 PM with Registered Nurse (RN/Staff #9). RN/Staff#9 stated that most of the facility's blood pressure medications do not have parameters and that nurses have to rely on their nursing judgement. Staff #9 stated it is the nurse's responsibility to obtain the vital signs due to the nurses not receiving the vital signs until 10 am from the certified nursing assistants, and that blood pressure medications are due at 8 am. Staff #9 stated if medications are held,d the provider should be notified and obtain an order for parameters and a care plan for the new parameters. Staff #9 stated that the risk of not informing the provider of held medications is that staff will continue to administer medications as ordered by the MAR, not realizing the medication had been held. Staff #9 stated the facility process for residents sent to the hospital is to obtain a new set of vital signs, and the risks in not obtaining a new set prior to discharge to the hospital is the hospital will not know what the resident's baseline is; if it is higher or lower when they left the facility. An interview was conducted on December 30, 2025, at 1:22 PM with Certified Nursing Assistant (CNA/Staff #4). Staff #4 stated vital signs are obtained before a resident is sent to the hospital, and when they return from the hospital, vital signs are obtained and are reported directly to the nurse.An interview was conducted on December 30, 2025, at 1:47 PM with the Director of Nursing (DON/Staff#12). The DON states the facility's process for blood pressure medications is to obtain vital signs before administering the medication. The DON stated if the blood pressure medication is held the provider should be notified. The DON reviewed the November 2025 MAR and confirmed that resident #33 order for Amlodipine 5mg was held on November 1, 2025, and November 6, 2025. During the interview on the DON confirmed she was unable to locate documentation of provider notification related to the held blood pressure medication and acknowledged that vital signs were not obtained before hospital transfer. The DON did not provide any risks in not notifying the provider for held medications when questioned. This failure placed the resident at risk for delayed diagnosis, treatment, and potential harm. The DON stated the risks in not obtaining vital signs before hospitalization is there are no baseline vital signs for the resident at the receiving facility. Review of the facility policy titled Medication Administration, last revised June 2024, states that it is the policy of this facility that medications shall be administered as prescribed by the attending physician.1. Only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications.Review of the facility policy titled Admission, Transfer, and Discharge last revision December 2024, states that It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on clinical record review, interviews, and review of the facility's policy and procedures, the facility failed to ensure pain medications were administered in accordance with physician's orders for two out of twenty-three residents (#13 and #131). The deficient practice could result in the resident receiving unnecessary medications and being overmedicated.Findings include:Related to resident #13-Resident #13 was admitted to the facility on [DATE] with diagnoses that include Bipolar Disorder, type 2 diabetes, schizophrenia, and prior history of a stroke which has affected her right dominant side. Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) assessment and scored a 15 which indicated the resident was cognitively intact.Review of Resident #13's care plan indicated she was prescribed an opioid for pain and interventions included administering opioid medications as prescribed.A physician's order, dated March 12, 2025, indicated Oxycodone HCI Oral Tablet 5 mg (milligrams) was to be given by mouth every 6 hours as needed for pain level 1-10. Review of the following medication administration record (MAR) revealed that oxycodone was administered within the pain parameters established by the physician's orders for the following months:- March 2025 had 4 instances where oxycodone was administered and the pain rating, documented on the MAR, was a 0.- April 2025 had 6 instances where oxycodone was administered and the pain rating, documented on the MAR, was a 0.- May 2025 had 2 instances where oxycodone was administered and the pain rating, documented on the MAR, was a 0.- June 2025 had 1 instance where oxycodone was administered and the pain rating, documented on the MAR, was a 0.- July 2025 had 2 instances where oxycodone was administered and the pain rating, documented on the MAR, was a 0.- August 2025 had 2 instances where oxycodone was administered and the pain rating, documented on the MAR, was a 0.The clinical record revealed no documentation of the reason why oxycodone was administered outside of the parameters established by the physician's orders and that the physician was notified. Related to resident #131-Resident #131 was admitted to the facility on [DATE] with diagnoses that included spinal infusion in the lumbar region, acute kidney failure and Anxiety disorder. Review of the admission MDS (Minimum Data Set), dated August 18, 2023, indicated Resident #131 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. A care plan, initiated on August 15, 2023, indicated that Resident #131 was prescribed an opioid for pain. Interventions included administering the opioid as prescribed and to educate the resident on the risks and benefits of the medication. Review of the physician's orders, dated August 14, 2023, for Acetaminophen Tablet 325 mg indicated that 2 tabs was to be given by mouth every 6 hours as needed for mild pain. The order also noted that the pain scale was to be 1-3 for this medication. Review of the physician's orders, dated August 14, 2023, for Oxycodone-Acetaminophen Oral tablet 5-325 mg indicated that 1 tablet was to be given by mouth every 4 hours as needed for pain 4-6. Review of the physician's orders, dated August 14, 2023, for Oxycodone-Acetaminophen Oral tablet 5-325 mg indicated that 2 tablets was to be given by mouth every 4 hours as needed for pain 7-10. On September 12, 2023 this order was changed to administer 2 tablets by mouth every 4 hours as needed for pain 6-10. Review of the August 2023 MAR revealed that Acetaminophen 325 mg was administered two times outside of the established pain parameters. - The documented pain rating for August 26 was a 7.- The documented pain rating for August 27 was a 8. The same August 2023 MAR revealed that Oxycodone-acetaminophen 5-325mg one tablet was administered three times outside of the established pain parameters which was 4-6. - The documented pain rating for August 21 was a 8.- The documented pain rating for August 24 was a 8. - The documented pain rating for August 26 was a 7. The same August 2023 MAR revealed that Oxycodone-acetaminophen 5-325mg two tablets was administered five times outside of the established pain parameters which was 7-10.- The documented pain rating for August 15 was a 4.- The documented pain rating for August 21 was a 4.- The documented pain rating for August 22 at 3:02 PM was a 4.- The documented pain rating for August 22 10:56 PM was a 4.- The documented pain rating for August 23 was a 4. Review of the September 2023 MAR revealed that Oxycodone-acetaminophen 5-325mg one tablet was administered once outside of the established pain parameters which was 4-6. On September 3, the documented pain rating was a 9. The same September 2023 MAR revealed that Oxycodone-acetaminophen 5-325mg two tablets was administered four times outside of the established pain parameters which was identified as 7-10.- The documented pain rating for August 2 was a 6.- The documented pain rating for August 3 was a 6.- The documented pain rating for August 7 was a 6.- The documented pain rating for August 8 was a 6. The same September 2023 MAR revealed that Oxycodone-acetaminophen 5-325mg two tablets was administered outside of the established pain parameters which was 6-10. On September 13, the documented pain rating was a 0. An interview was conducted with Licensed Practical Nurse (LPN/Staff # 31) on August 19, 2025 at 9:22 AM. Staff #31 shared that if a resident has a prescription for Oxycodone for pain management, she would look at the MAR to make sure they have an order, when the last time the resident took the medication, and look when the medication was last signed out. She would then administer the resident the medication. She also added that the resident would also tell her where they rate their pain. Staff #31 acknowledged that it was not okay to administer pain medications to residents outside of the pain parameters. She also shared that the risks to the residents, for administering medications outside of the ordered pain parameters, would be increased pain, sedation, constipation, or nausea. When asked about resident #131's August 21, 2023 MAR at 4:37 PM, she confirmed that the MAR reflected her signature for the Oxycodone-Acetaminophen 3-525 mg 1 tablet with a pain parameter of 4-6. Staff #31 explained that she must have given the resident the correct dosage for the correct parameters but sometimes the MAR will record it for both medications which would not be right. Further review of the August 2023 MAR for August 21, 2023 revealed an entry for Oxycodone-Acetaminophen 5-325 mg two tablets for pain rated 7-10. The entry was recorded by Staff #31 at 4:36 PM and reflected a pain rating of 8. An interview conducted with Registered Nurse (RN/Staff #231) on August 19, 2025 at 9:44 AM. Staff #231 explained that if a resident is in pain, she would then assess the resident and if they were conscious, ask them where their pain level was. She explained that pain rated 4 or below was considered mild pain, pain 4-6 was considered moderate pain, and 6 and up was extreme pain. Staff #231 shared that it was not appropriate to administer pain medications outside of parameters and that she would consult the provider first and if they said no, then it should not be administered. Staff #231 explained that the residents would be at risk for respiratory issues if they were administered pain medications outside of ordered parameters. An interview was conducted with LPN/Staff #247 on August 19, 2025 at 3:58 PM. Staff #247 explained that if a resident is alert and oriented he would ask them to rate their pain using the pain scale and then ask the resident for permission to medicate them. If they indicate their pain is 0-4 then typically the resident will be given Tylenol but if it is more than that, they will get oxycodone or something similar. Staff #247 continued explaining that it was not okay to give pain medications outside of parameters because that is not following what the order says. The risks to the residents include respiratory hypoxia or overdose. Staff #247 indicated he was vaguely familiar with Resident #131 and was shown the August 2023 MAR for Resident #131. He stated that it looked like the Tylenol (Acetaminophen) 325mg was given to the resident outside of parameters on August 26 and August 27. He also reviewed the Oxycodone-Acetaminophen 5-325 mg 1 tablet by mouth every 4 hours as needed for pain 4-6. He noted that there were three instances of the medication being given outside of parameters. When it was revealed that he was the staff member that signed off on the four instances where pain medications were administered outside of parameters, he was not able to explain why orders were not followed. An interview was conducted with Director of Nursing (DON/Staff #25) on August 19, 2025 at 4:12 PM. Staff #25 shared that when patients ask for pain medications, the nurse will do a pain assessment and ask them the pain level and medicate the resident accordingly. She shared that all pain medications have pain parameters except for Tylenol as that is for general discomfort while everything else has a pain scale. Staff #25 indicated it was not okay to administer medications outside of parameters and the risk to the residents when doing so includes increased sedation, makes the resident difficult to arouse, and there could be a change in vital signs. She added that it would also mean that nurses are not following pain parameters as ordered by a physician. When reviewing the MAR for Resident #13 for March 2025 through the current date, Staff #25 was asked if pain parameters for Oxycodone-Acetaminophen 5-325 mg medications were administered according to the established parameters. She reviewed the MARs and shared that there were several instances where it was not administered appropriately. She then attempted to explain that it could have been one staff who was not doing the charting correctly. It was then pointed out that the errors were done by multiple staff members. Staff #25 shared that it did not meet her expectations. The August and September 2023 MARs for Resident #131 was shared with Staff #25 and she acknowledged the same errors were made, according to the MAR and that it did not meet her expectations. She shared that she would do some re-education with staff. Review of the facility's policy titled Physician's Orders, which was last revised in July 2024, revealed that the policy was to accurately implement orders in addition to medication orders.

The facility failed to ensure proper monitoring for 1 out of 3 dialysis residents (#1).Based on clinical record review, interviews, and facility policy, the facility failed to ensure proper monitoring for 1 out of 3 dialysis residents (#1). The deficient practice could result in the inability to detect changes of condition. Findings include: Resident # 1 was admitted on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, hemiplegia following cerebral infarct, and need for assistance of personal care. Review of the Resident's care plan dated May 7, 2025 revealed that Resident #1 was on hemodialysis due to end stage renal disease. Resident #1 was to receive dialysis on Tuesdays, Thursdays, and Fridays, with facility intervention of obtaining vital signs and weight, reporting significant changes in pulse, respirations and blood pressure immediately Review of Resident # 1's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated resident had moderate cognitive impairment. The MDS also revealed that resident does receive dialysis. Review of the Resident's orders revealed an order dated May 7, 2025, for dialysis on Tuesdays, Thursdays, and Saturdays. The order did not have an end date. Further review of Resident's # 1 orders revealed an order dated June 17, 2025 for vital signs before and after hemodialysis every day shift and every night shift to start on June 19, 2025 with no end date. Review of Dialysis reports revealed that Resident # 1 received dialysis on July 1, 3, 5, 8, 12, 16, and 17, 2025. Review of Resident # 1 Medical Administration Record (MAR) for the month of July 2025, revealed that pre and post vitals were not documented on July 16, 2025 and post vitals were not documented on July 17, 2025. Furthermore, pre and post vitals were taken on July 15, 2025 and July 19, 2025 when dialysis was not performed. An interview conducted on July 21, 2025 at 2:10 p.m., with Licensed Practical Nurse (LPN/ Staff # 10) revealed that before residents go out for dialysis vitals are done, the residents are clean, and they have arrangements with food. When the residents return from dialysis we always do vitals and go over any new orders they may have. It is important we get vitals because if medications were held, especially if they have heart medications we want to make sure heart rate does not drop after dialysis.An Interview with Social Services Director (Staff # 36) on July 21, 2025 at 2:35 p.m., revealed that there had been problems with Resident # 1's transportation company arriving late or not at all. When that happens they have to either reschedule or the facility pays for transportation. Staff # 36 revealed that formal complaints have been sent into Resident #1's insurance company. Staff # 36 stated that his current transport is the only transport company that would accept Resident # 1's insurance.An interview conducted with Director of Nursing (DON/ Staff # 21) on July 21, 2025, at 2:57 p.m. revealed that they have had some transportation issues regarding Resident # 1. There were days the transport company did not show up and the facility had to cover the cost of transportation to return him back to the facility. The DON revealed that on July 16, 2025, they changed dialysis days from Tuesday, Thursday, Saturday to Monday, Wednesday, Friday. In reviewing the MAR, DON # 21 said that the correct pre and post dialysis orders were not in the system so staff were still performing them and documenting them on Thursday, and Saturday. DON # 21 stated that her expectation would bet that vitals are preformed prior to transporting to dialysis and upon return from dialysis. A policy and procedure titled, Nursing Services, Physician Orders dated July 2024, revealed that it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance wit the resident's plan of care.

Based on clinical record review, staff interviews and policy reviews, the facility failed to ensure that 1 of 3 sampled residents (#2) received long-acting insulin per hospital discharge orders upon admission. The deficient practice could result in uncontrolled blood sugar levels. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, Parkinson's disease, and dementia. Review of final orders/discharge instructions from the referring hospital, dated February 13, 2024 (prior to admission), included that the patient was to continue insulin Glargine (insulin glargine/Lantus) 15 units twice daily without any changes. Review of physician's orders dated February 13th- 19th,2024 revealed no evidence of physician orders regarding Insulin Glargine despite being listed on the hospital final orders/discharge instructions. An order summery dated February 13, 2024 revealed all medication orders were reviewed by the attending physician and he concurred with the present plan of care and discharge plan. Further review of physician orders dated February 14, 2024 included Glucose monitoring with instructions to notify the provider if glucose is less than 70 or more than 400 mg/dL. A Care Plan dated February 14, 2024, revealed a focus of Diabetes Mellitus with interventions that included diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness, monitor/document/report to MD PRN (as needed) signs and symptoms of hyperglycemia. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated severe cognitive impairment. The assessment indicated the resident had clear speech, was not oriented to time or place and at times appeared anxious, fearful and wandered. On February 18, 2024 the resident's blood glucose test results were 572.0 mg/dL. A progress note dated February 18, 2024 revealed that the resident's blood sugar was 572.0 mg/dL at 1:06pm and the provider was notified. However, there was no evidence regarding the provider's response including any medication changes, related to the increase in blood glucose levels. On February 18, 2024 at 4:41pm, the resident's blood glucose level was 219.0 mg/dL. A nursing progress note dated February 18, 2024 revealed blood glucose level at baseline and well controlled, despite evidence of blood glucose fluctuations during the day. A review of the resident's blood glucose results on February 19 through February 20, 2024 revealed: February 19, 2024 - 8:32 am- 229.0 mg/dL - 11:37 am- 271.0 mg/dL - 5:01 pm- 333.0 mg/dL - 10:03 pm- 321.0 mg/dL February 20, 2024 - 8:03 am- 337.0 mg/dL - 8:33 am- 337.0 mg/dL - 12:03 pm-337.0 mg/dL - 4:45 pm -357.0 mg/dL - 7:08 pm- 335.0 mg/dL A FNP (Family Nurse Practitioner) progress note dated February 20, 2024 indicated that, the resident's blood glucose remains elevated and to start a low dose of Glargine/Lantus 5 units at bed time. A Physician Order dated, February 20, 2024 was written for Insulin Glargine 5 units at bed time, despite the hospital's final order/discharge instructions for Glargine 15 units twice a day on February 13, 2024. A review of resident's blood glucose results dated February 21, 2024 revealed the following: - 8:80 am- 350.0 mg/dL - 8:31 am- 350.0 mg/dL - 12:28 pm- 397.0 mg/dL - 2:00 pm- 314.0 mg/dL - 8:55 pm- 301.0 mg/dL A Physician's Order dated February 21, 2024 revealed an increase in Glargine/Lantus to 15 units at bed time. Review of resident's blood sugar results dated February 22, 2024 revealed: - 7:46 am- 328.0 mg/dL - 12:08 pm- 505.0 mg/dL - 3:30 pm-180.0 mg/dL A nursing progress note dated February 22, 2024, revealed that the provider was notified at 12:08 pm and received verbal orders to administer 22 units of Lispro. Despite the blood glucose reading of 505.0 mg/dL at 12:08 pm, on February 22, 2024 a daily skilled note, dated February 22, 2024 at 1:51 pm , revealed the resident's blood glucose is being monitored, blood glucose level at baseline, well controlled. Review of resident's blood sugar results dated February 26, 2024 revealed the following: - 7:35 am- 219.0 mg/dL - 7:37 am- 219.0 mg/dL - 12:18 pm- 319.0 mg/dL - 4:43 pm- 398.0 mg/dL - 8:21 pm- 266.0 mg/dL Per a physician order, dated February 26, 2024 at 6:05 pm, Glargine order was changed to 20 units at bedtime. A daily skilled note dated February 26, 2024 revealed the resident's blood glucose is being monitored, blood glucose level is not baseline or well controlled, and that Teachings/Education were not provided regarding Blood Glucose levels. Review of resident's blood sugar results dated February 27, 2024 revealed the following: - 7:05 am- 337.0 mg/dL - 8:29 am- 337.0 mg/dL - 11:06 am- 144.0 mg/dL - 5:07 pm- 326.0 mg/dL - 7:47 pm- 444.0 mg/dL - 7:49 pm- 444.0 mg/dL - 10:52 pm- 342.0 mg/dL A Nursing Progress note dated February 27, 2024 relayed that the FNP was notified at 7:49 pm regarding increase in blood sugar to 444.0 mg/dL, and received an order to administer Lispro 15 units and to recheck blood sugars in 2 hours. On February 28, 2024 Resident #2 was placed on hospice and all orders for blood sugar monitoring and insulin treatment were discontinued at 1:50 pm. An interview was conducted on December 17, 2024 at 2:45 pm with a Licensed Practical Nurse (LPN, staff #10) who stated when admitting a new resident, she would review discharge paperwork and compare discharge orders with what is in EMDR (Electronic Medical Record). If an order is missing, she would notify the provider and determine if orders need to be entered or changed, and ask for clarification. She, also stated that she would be concerned if a Glargine order was not in the EMDR, but was included in the final hospital orders. Furthermore, she stated that the provider would catch this discrepancy. An interview conducted on December 18, 2024 at 10:10 am with FNP (staff #13), stated that during a resident admission, providers review final orders from the hospital, and they continue the same orders until they become familiar with the resident and determine if a medication needs to be changed. The FNP reviewed the clinical record and stated that he did not know why Glargine had not been ordered on admission, but blood sugars were monitored four times a day, and would be adjusted as indicated. An interview was conducted with the Director of Nursing (DON, staff #33) on December 18, 2024 at 11:46 am, she stated that the primary provider will review the orders for any changes when a resident is admitted , orders are placed in the EMDR, and assessments are completed. She further stated that the primary provider reviews the final orders/discharge instructions and there is a standing order in place that the provider has verified the orders, and if they want to make changes, they can write it on a paper for admissions to change. She reviewed the records for Resident #2 and stated that the attending provider reviewed the resident's medication on February 14, 2024 at 12:00 AM. She also stated that once everything is final the nurse would put in the medication orders. She stated that she does not know what happens to the form that has the changes, but she will check with Medical Records. Now those changes are documented in EMDR. During interview conducted on December 18, 2024 at 12:59 pm with Medical Records Director (staff #21), who stated that when a resident is admitted the hospital's final orders/discharge instructions are reviewed by the provider, and after the nurse adds the orders to the EMDR, the paperwork goes into a box and is uploaded by medical records into EMDR. She reviewed the clinical record and stated there is nothing as far as changes to final orders for Resident #2. A policy and procedure titled, Nursing Services, Physician Orders, include admission orders are reviewed with physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly. The policy further indicated that the facility accurately implements orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on clinical record review, staff and resident interview, and policy review, the facility failed to ensure diet orders were followed for one resident (#70). The deficient practice could result in residents not receiving physician ordered diets. Findings include: Resident #70 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, end stage renal disease, and dysphagia, oropharyngeal phase. Review of the order summary revealed a physician order for a regular diet mechanical soft texture, nectar thick consistency, Renal Preferences with a start date of October 2, 2024. Review of the resident's Minimum Data Set Section K - Swallowing/Nutritional Status dated October5, 2024 revealed a mechanically altered diet which required change in the texture of food or liquids (pureed food, thickened liquids) used as a nutritional approach. During a dining observation conducted in the resident's room on November 7, 2024 at 12:12 p.m., a small container of strawberry ice cream was observed on the lunch tray along with the meal. A meal ticket on the resident's tray stated, regular diet, mechanical soft texture, nectar thick liquids. Present during the meal observation was the resident's spouse, DON (Staff #31) and Certified Nursing Assistant (CNA/Staff #69) assisting the resident with his meal. The resident refused his meal and the CNA offered the resident the ice cream. The CNA placed ice cream on a spoon and attempted to feed the resident the ice cream. CNA #69 was asked by this surveyor if the resident could have ice cream for his meal. CNA/Staff #69 stated yes and proceeded to serve the resident. The resident began to cough. This surveyor informed ice cream should not be served and was not considered a thickened liquid. Spouse stated, add thickener to the ice cream, that's what I do to all his meals. This surveyor informed thickener should not be added to ice cream. The DON asked that the ice cream no longer be served. An interview was conducted on November 8, 2022 at 9:11 a.m. with (LPN/Staff #58) Staff #58 stated resident # 70 had orders for a mechanically altered diet with nectar thickened liquids. She stated the resident required assistance with all his meals; and that, the wife will come in and help the resident eat during some meals. Staff #58 stated the resident's meal orders are on their meal tickets and should refer back to the kitchen if there's something incorrect. Staff #58 stated the resident is a risk for aspirations and his bed should be at 90 degrees when eating, but has had no aspirations. Staff #58 stated she was unsure if ice cream was a nectar thick liquid and would refer to dietary if unsure. An interview was conducted on November 8, 2022 at 9:23 a.m. with dietary manager (Staff #27). According to Staff #27, if a resident is on a mechanical soft diet the resident dietary staff are made aware from the resident's meal tickets that are generated by the speech therapist, doctors' orders and the dietician. Staff #27 stated resident #70 s on a mechanical soft, nectar thick diet and the dietary aides oversee the trays to ensure the trays are correct and match the diet. Staff#27 stated ice cream is not considered nectar thick and should not be served to residents with nectar thick diets because once placed in the mouth it is no longer thick. Staff #27 stated the risks serving a resident ice cream who is on a nectar thick diet is possible chocking. A phone interview was conducted on November 8, 2024 at 9:32 a.m. with Registered Dietician Consultant (RDA/Staff #74). Staff #74 stated the dietician and diet tech are involved in evaluating and addressing any underlying causes for nutritional risks and/or impairments for the facilities residents. Staff # 74 stated resident #70 has a mechanical soft, nectar thickened liquid diet, is an assist of one with eating and should have his head elevated while eating. Stated she had been contacted by the DON/Staff #31 who had questioned if the resident could be served ice cream. Staff # 74 stated she had informed the DON that the resident should not be served ice cream because it becomes warm in the mouth and more liquid and that thickener should never be added to ice cream. Staff #74 stated staff will be educated. Staff #74 stated the risks associated with serving a resident ice cream who had orders for mechanical soft, nectar thickened liquids places the resident at risk for aspiration and difficulty in swallowing. An interview was conducted on November 8, 2024 at 12:46 p.m. with Director of Nursing (DON/Staff #31). Staff #31 stated that resident #70 is prescribed a diet for mechanical soft, nectar thick liquids; and that, the speech therapist has been working with the resident to progress his diet. The DON stated that staff should look at the meal ticket before serving the resident and any changes are communicated from dietary to the nursing staff. The DON stated the risks with not adhering to the diets as ordered places the resident at risk for potential aspiration. Review of the facility's policy titled, Physician Orders states It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Review of the facility's policy titled, Nutrition revealed Diets will be provided according to physician orders, including regular and therapeutic diets. Dietician technicians and registered dieticians will make recommendations for therapeutic diets.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that dignity was maintained for one sampled resident (#23). The deficient practice could result in residents not being treated in a dignified manner. Findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, hepatic encephalopathy, postprocedural hypertension, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease. Review of the MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) was not conducted, but the assessment revealed there is evidence of an acute change in the residents mental status from the resident's baseline. The assessment also revealed the resident needed supervision or touching assistance with upper body dressing, partial/moderate assistance with lower body dressing. Review of the care plan dated July 7, 2024 revealed the resident had an ADL (activity of daily living) self-performance deficit related to impaired mobility and muscle weakness. The care plan interventions included patient often removes gown, prefers to wear off shoulders, encourage to discuss feelings about self-care deficit. An initial observation of the resident was conducted on August 5, 2024 at 9:56 a.m. Resident #23 was observed in the resident's room lying in bed that is closest to the door to the hallway. The door was completely open. Resident #23 was lying in bed at an angle with both breasts exposed and in an incontinence brief. Multiple residents and staff in the hallway. (Staff/CNA#7) then entered the resident's room and placed clothing on the resident. A second observation of the resident was conducted on August 6, 2024 at 12:42 p.m. The resident was observed sleeping in bed and fully dressed. A third observation was conducted August 9, 2024 at 8:30 a.m. The resident was observed in bed dressed in a hospital gown. Nasal cannula was not properly placed and was observed hanging off her face and not in her nostrils. A fourth Observation was conducted on August 9, 2024 at 11:25 a.m. resident observed in bed, upper body exposed with door open, curtain partially drawn but resident could be observed from the hallway- housekeeping in hallway, two CNA's (Certified Nursing Assistant)-observed seated at the end of the hallway, with other resident in room no privacy curtain closed between the two residents. Additionally, following observations were conducted: 08/09/24 11:28 AM CNA/staff #64 walked by resident's room twice 08/09/24 11:29 AM LPN/Staff #141walked by resident's room 08/09/24 11:30 AM ADON/Staff #167 walked by resident's room 08/09/24 11:30 AM Shower Aide/Staff #96- observed the resident's condition from the hallway and entered the resident's room. An interview was conducted on August 9, 2024 at 11:37 a.m. with (Shower Aide/Staff #96). Staff #96 stated he observed the resident had her gown off from the hallway. He stated she may have got confused with the sheet and gown. He stated anyone could have observed the resident from the hallway. He further stated it's a dignity thing for the resident. An interview was conducted on August 9, 2024 at 12:30 p.m. with the Director of Nursing (DON/ Staff #145) who stated the resident likes to have her clothing pulled down and that this is care planned. Review of the care plan clearly states prefers to wear off shoulders. The DON stated the risks associated with this, is that it could affect dignity issues for the other resident's. The DON however stated they haven't had anyone complain. She further stated it is the responsibility of the facility to educate the resident, as it is their right and to make sure that it is noted in their chart. Review of the facility policy titled Dignity and Respect states it is the policy of this facility that all residents be treated with kindness, dignity and respect.

Based on observation, resident and staff interviews, clinical record review and facility policy and procedures, the facility failed to ensure care and services related to an indwelling urinary catheter was provided to two residents (#164 and #300) out of 20 sampled residents. The deficient practice could result in residents being at risk for urinary catheter complications and urinary tract infections. Findings include: Resident #164 was admitted on [DATE] with diagnosis (dx) that includes encephalopathy, unspecified, unspecified hydronephrosis, malignant neoplasm of endometrium, obstructive and reflux uropathy, unspecified. The care plan revealed the resident had an indwelling catheter related to obstructive uropathy. The goals were that the resident will remain free from catheter related trauma through review and will show no signs or symptoms of a urinary infection through the review date. The interventions for the catheter were to position the catheter bag and tubing below the level of the bladder and away from entrance room door, secure catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal, and resident requires moderate to maximum assist with bed mobility, transfers, locomotion, dressing, toileting, hygiene, and bathing. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS assessment also revealed the resident had an indwelling urinary catheter, required substantial to maximum assistance with toileting hygiene and required substantial to maximum assistance for transfers. The physician order dated July 15, 2024 included for indwelling Catheter Care Q (every) shift and prn (as needed). In an observation conducted on August 5, 2024 at 9:58 a.m., resident #164 was observed being wheeled by a staff through the facility hallway with her catheter bag hanging filled with urine and uncovered attached to the bottom cross bars of the resident's wheelchair. The uncovered catheter bag was dragging on the floor as the resident was being pushed in her wheelchair. An interview was conducted on August 5, 2024 at approximately 10:05 a.m. with CNA (Certified Nursing Assistant/ Staff#7) who had stated the resident should have had a cover on her catheter and placed one on the catheter bag and repositioned the bag so that it did not drag on the floor. She stated the risks associated with the catheter can cause an infection from dragging on the floor. An interview was conducted on August 9, 2024 at approximately 11:32 a.m. with a CNA (Staff# 134) who stated there are signs or orange dots on the resident's door to indicate PPE is required with care. She stated when providing catheter care it is important to make sure the tubing is not kinked and to empty as needed or every shift, clean the catheter tubing to prevent infections and to place the catheter bag with a cover on the wheelchair. An interview was conducted on August 9, 2024 at approximately 11:05 a.m. with a Licensed Practical Nurse (LPN/Staff #141) who stated all catheters should have a cover and be hung below the resident's waist. She further stated the resident should not attend activities or go to therapy without a catheter cover. She stated the CNA's are responsible for making sure the resident's catheters have a cover and are placed correctly. Staff # 141 stated resident #164 recently had a urinary infection and could be at risk again with her catheter dragging on the floor. An interview was conducted with Director of Nursing (DON/staff #145) on August 9, 2024 at 12:32 p.m., the DON stated her current expectation is that there is an order and a care plan for the catheter and that placement of the catheter should be below the bladder, make sure that it is not dragging on the floor and should have privacy bag. 50553 Regarding Resident #300: Resident #300 was admitted to the facility on [DATE] with diagnoses including fluid overload, muscle weakness, and neuromuscular dysfunction of the bladder. Review of a nursing progress note dated April 8, 2022 at 7:25PM revealed that the resident was identified to have been incontinent of bowel and bladder on the date of admission. Review of physician orders for April 2022 revealed no evidence of physician orders for having or changing an indwelling Foley catheter or catheter care. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated April 2022 revealed no evidence of catheter care being provided, including no evidence of the catheter being cleaned or changed, in the month of April 2022. Review of the resident's care plan initiated on April 9, 2022 revealed no focus area regarding the resident having an indwelling catheter or interventions for providing catheter care. Review of the Toilet Use task dated April 2022 revealed that all entries for this task on April 11, 2022 were charted as NA (Not Applicable). Additionally, this task area did not address emptying of the catheter or specifically cleaning of the catheter. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had an indwelling catheter in place for a diagnosis of a neurogenic bladder. An interview was conducted on August 9, 2024 at 8:38AM with a Licensed Practical Nurse (LPN/ Staff #160) who stated that there should be physician orders for catheter care. She also stated that if there are no orders for catheter care for a resident with a catheter, she would let the physician know. She also elaborated that there may be batch orders that can be initiated for catheters, and the size of the catheter and balloon should be noted. An interview was conducted on August 9, 2024 at 9:12AM with a Certified Nursing Assistant (CNA / Staff #95) who stated that catheter care should be provided by CNAs every time the resident is changed. She reports that it should be charted in the Electronic Health Record (EHR), Point Click Care (PCC). She was unable to identify specifically which area or task to record catheter care in. An interview was conducted on August 9,2024 at 10:10AM with the Director of Nursing (DON/ Staff #145) who stated she expected her nursing staff to follow provider's orders for catheter care and to document the care in the TAR. She also stated that there are batch orders for catheters, so there should be an order in the medical record, and catheters should be reflected in the care plan. When asked if Resident #300's medical record should have reflected an order for an indwelling catheter and care, she stated that she was not in the DON position at that time and therefore did not know what the expectation and policy was at that time. Review of the facility policy titled, Catheter Care, Indwelling, revealed that each resident with an indwelling catheter should receive catheter care daily and as needed for soiling. The policy included to cover drainage bag with privacy bag. This policy also revealed that documentation of catheter care is done under the toileting task. This policy was revised May 2007, July 2012, and July 2013 and was reviewed July 2023 and July 2024, indicating this policy applied for Resident #300 during her stay at the facility. Review of the facility policy titled, ADL's - hygiene, grooming, toileting, bathing, oral care, dressing, grooming, mobility, transfers, ambulation, etc., revealed that residents should be given the appropriate treatment and services to attain or maintain the highest practicable well-being of each resident in accordance with a written plan of care. This policy also revealed that ADL care, including personal hygiene, will be provided according to the resident's needs, and it will be documented in the medical record. This policy was revised on November 2007 and July 2015, and was reviewed multiple occasions since these dates, indicating this policy applied for Resident #300 during her stay at the facility.

Based on review of clinical records, policy, and staff interviews the facility failed to ensure an order for pain medication was followed as prescribed for one of six sampled residents (Resident #88) by failing to administer pain medication within the physician ordered parameters. The deficient practice of administering unnecessary medication may result in undesirable medication-induced harm. Findings Include: Resident #88 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included cutaneous abscess of left lower limb, pedestrian on foot injured in collision with car, sequela weakness and muscle weakness. Review of care plan, initiated on June 30, 2024 revealed that the resident was prescribed an opioid for pain, and interventions included to administer opioid as prescribed. Review of the physician orders revealed the following order dated July 1, 2024: Oxycodone-Acetaminophen tablet (an Opioid) 5-325 milligram to give 2 tablets by mouth every 4 hours, as needed for pain 6-10. Review of an admission minimum data set (MDS) asessment from July 3, 2024, the Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition. Review of the July 2024 Medication Administration Records (MAR) revealed that Oxycodone-Acetaminophen medication was administered outside of physician ordered parameters (pain 6-10) on: Saturday July 13, 2024 for pain level of 4. Sunday July 14, 2024 for pain level of 3. Monday July 22, 2024 for pain level of 3. Sunday July 28, 2024 for pain level of 3. An interview was conducted with Licensed Practical Nurse (LPN, staff # 155) on August 08, 2024 at 12:24 p.m., who stated that according to the pain scale: 10 means most pain and 0 means no pain. She further stated when assessing for pain, nurse should observe residents for facial expression, anxiety and breathing. She also stated that the risk for medication administer outside of order parameters could result in an over dose or interaction with other medications. An interview was conducted with Director of Nursing (DON, staff # 145) on August 08, 2024 at 12:47 p.m., who stated when administering medication to resident staff follow the 7 rights (right medication, right patient, right dose, right time, right route, right reason and right documentation). She also stated that the pain scale corelates the level of pain with the medication administered per physician orders. The DON stated the risk of not following physician order parameters would depend on the patient and the medication. A review of the policy titled, Documentation of Medication Administration-Oral, revealed to verify resident medication cards with medication orders. It also revealed that no medication is to be administered without a physician's written order and if there is any question in regard to dosage, the person in doubt should not give the drug until dosage has been clarified. A review of the policy titled, Pain Management, revealed to document on the Care Plan any preventive or care interventions (pharmacological and non-pharmacological) for any resident admitted with pain. It also revealed that medication(s) received, refused, and response to medication will be documented on the Medication Administration Record (MAR).

Based on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure clinical record documentation was accurate for one resident (#2) regarding catheter care. The sample size was five (5) residents. The deficient practice has the potential for clinical records to inaccurately and incompletely reflect the status of residents. Findings include: Resident #2 was admitted to the facility on [DATE], with diagnoses that included obstructive reflux uropathy, type 2 diabetes mellitus and history of UTI's. Review of the physician's orders revealed an order dated June 1, 2024 to complete indwelling catheter care every shift. Review of a Care Plan initiated on June 1, 2024, revealed that Resident #2 had indwelling catheter related to obstructive uropathy, provide catheter care every shift and as needed. Review of Resident #2's Minimum Data Set (MDS) June 4, 2024 assessment, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition, and included an IV and catheter present. A review of the Plan of Care (POC) Response History for catheter care for the past 30 days, revealed that Resident #2's catheter care was documented by Certified Nursing Assistant (CNA/staff # 31), as having been provided at 09:41 AM, on June 27, 2024. Further review of Resident #2's POC revealed catheter care had not been conducted every shift on 8 out of 27 days. An interview conducted with Resident #2 on June 27, 2024 at 11:00 a.m., who stated that he had not received catheter care today, and have not cleansed around the insertion site. An interview was conducted at 11:11 a.m. on June 27, 2024, with CNA (staff #31), who stated that she had not yet completed Resident #2's catheter care, but had documented it as completed in POC. Staff #31 further stated that catheter care was expected to be performed every shift, and to be documented after the care had been provided. Staff #31admitted that she made a mistake, and accidently documented completion of catheter care after rounds. An interview was conducted on June 27, 2024, at approximately 1:00 p.m, with a Licensed Practical Nurse (LPN/staff #1), who stated that CNA's perform catheter care every shift, and as required. Staff #1 also stated that the facility documentation policy requires documentation to be completed once the task is completed. Staff #1 further stated that the risk could included staff may forget to complete the task, and other staff would have inaccurate information. An interview was conducted with the Director of Nursing (DON/staff #41), and [NAME] (staff #111), Clinical Resource on June 27, 2024, at 03.26 p.m. Staff #41, DON, stated that her expectation is that catheter care be documented within that shift. Staff #111, stated that the standard of care is to document every shift. A facility policy titled, Indwelling Catheter Care, included that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling. To promote hygiene, comfort and decrease risk of infection for catheterized residents. Documentation of catheter care is done in POC. A facility policy titled, Documentation and Charting, included that a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored in accordance with professional standards. Findings include: During a walk through in the kitchen conducted on [DATE] at 8:24 a.m. with the Dietary Supervisor (staff #11), multiple observations were made in the large refrigerator, freezer, and dry storage: -a one-gallon container of sweet relish was observed with approximately a fifth of the relish remaining and there was no open date or use by date on the container. -,d+[DATE] size containers with diced onions, diced carrots, and diced tomatoes were observed with no preparation dates. -2 small plastic containers of ketchup dated [DATE] to [DATE]. -a 400 size pan of chopped cauliflower was observed with no preparation date. -one full pan sheet of uncovered mashed potatoes with a preparation date of [DATE] and a use-by date of [DATE]. -9 pieces of BBQ chicken on a full tray uncovered with a preparation date of [DATE] and use-by date of [DATE]. -2 large cooked pork loins, approximately 10 lbs. a piece, uncovered with a preparation date of [DATE] and a use-by date of [DATE]. -one bag of opened frozen sausage that was not secured with a tie, so it was open to the air and didn't have an open date. -one open bag of Vanilla wafers was observed in a large cardboard box and 4.5 wafers were out of the bag lying in the box. During a walk through in the kitchen conducted on [DATE] at 8:24 a.m. with the Dietary Supervisor (staff #11), he stated that there should be an open date and use by date when a product is opened. He stated that relish is typically good for three months. He stated that all staff are responsible for checking the dates on food products and he checks all the dates on the food products once a week. He stated that the purpose of using preparation dates and use-by dates is so expired foods are not being used. He stated that the small containers of ketchup were expired. He stated that the pan sheet of uncovered mashed potatoes and the pork loins were left to cool the night before and all leftovers are supposed to be covered. He stated that he had not had a chance to cover the BBQ chicken and when food is not stored properly, there is a potential for residents to get sick, a loss of nutritive value, and can become dried out. He stated that frozen food left open to the air is at risk of freezer burn. He stated that the bag of vanilla wafers should have been closed to keep fresh and so as not to attract buds, and should have had an open date. An interview was conducted on [DATE] at 8:40 a.m. with the Administrator (staff #25), who stated that he supervises the Dietary Supervisor (staff #37), who is responsible for the entire kitchen. He stated that dry goods should be closed and secured after opened to prevent contamination, and freezer items, once opened, should be secured and would agree that food could lose nutritive value and/or freezer burn could occur. The facility policy, Food Storage and Date Marking, dated 2018 states that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. (Follow regulatory authority procedure for date marking). -Left-overs TCS food is stored carefully and securely. Each item is clearly labeled (if not easily identifiable) and dated if stored for over 24 hours. Leftover food is used within seven (7) days or discarded. NOTE: Preparation date is day one. (Also see policy on Use of Leftovers in this section.) Follow state regulations for more detail. -Refrigerated TCS foods should be stored, labeled and dated if stored and not for immediate use, all foods will be checked to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable}, or discarded, at the end of the day, use by dates for TCS foods are 7 days or less of prep date. -Frozen foods should be properly stored to ensure wholesomeness and stored to allow adequate air circulation. All foods will be checked to assure that foods will be consumed by their use by dates or discarded.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#46) had an order for the use and care of a urostomy. The deficient practice could result in resident's not receiving appropriate care and services for a urostomy. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included atherosclerotic heart disease without angina pectoris, acute kidney failure and malignant neoplasm of the prostate. Review of the initial admission record dated December 7, 2022 revealed that the resident had a urinary ostomy present. Review of the 5-dayminimum data set (MDS) dated [DATE] revealed that the resident scored 13 on the brief interview for mental status (BIMS) which indicated that the resident was cognitively intact. The MDS further revealed that the resident had a urinary ostomy. Review of the progress notes dated December 11, 2022 revealed that the resident had a urostomy in the right lower quadrant. Review of the resident's care plan revealed no focus area for a urinary ostomy. Review of the resident's orders revealed that there was no order for care of the urostomy or to monitor the urostomy site for signs and symptoms of infection. Review of the December 2022 treatment administration record (TAR) revealed no documented care for the urostomy. An interview was conducted with a licensed practical nurse (staff/LPN# 130) on January 5,2023 at 1:31 PM. The LPN stated that most resident care should have an order in the clinical record. He stated that the resident had an order entered on January 4, 2023 for his urostomy care and monitoring. Staff # 130 stated that he found no other order than the order dated January 4, 2023. However, the resident had the urostomy prior to the order. He further stated that the urostomy care should be completed and charted in the TAR every shift. Staff#130 stated that it was a concern that there was no order for the urostomy because the proper care might not be provided in a timely manner for the resident's urostomy. An interview was conducted on January 6, 2023 at 10:05 AM with the director of nursing (DON/staff #129). The DON stated that a new resident should have orders in place for all treatments including the care and monitoring of a urostomy. A note should be placed at the top of the EHR (electronic health record) in special instructions if there is a urostomy in place because it should be monitored every shift. There should be an order to monitor the site and care for and empty the urostomy bag. The urostomy should also be on the care plan for this resident however, it is not on the care planning the case of this resident. Review of the facility policy Physician Orders (reviewed 8/22) revealed that admission orders are reviewed with the physician upon admission based on instructions from the discharging facility and are transcribed accordingly. The policy further stated that the treatment order was to be transcribed in the eTAR accordingly.

Based on clinical record review, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure there was a physician's order to administer oxygen to one resident (#46). The deficient practice could result in adverse clinical outcomes. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included; unspecified atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina pectoris, adult failure to thrive, history of covid-19, pleurodynia and anemia. Review of the Minimum Data Set (MDS), quarterly assessment dated [DATE] revealed that resident #46 had a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS assessment included that the resident required extensive 1-2-person assistance with Activities of Daily Living (ADL's.) The MDS assessment included that in the past seven days resident #46 did not have oxygen while being a resident and that the resident did not have oxygen while not being at the facility. During an observation conducted on January 5, 2022 from approximately 8:20 a.m. to 8:30 a.m. of resident #46, resident was observed wearing a nasal cannula oxygen delivery system. During continued observation it was revealed that the resident was receiving 2 LPM (liters per minute) from an oxygen concentrator on the floor located on the left side of the bed. An interview was conducted on January 5, 2023 at 1:10 p.m. with resident #46, who stated that he has been on oxygen for about two weeks. Resident #46 reported he was not admitted to the facility with oxygen and it was recommended by the therapy department, due to his oxygen levels being too low. Resident #46 oxygen were observed being administered using an oxygen concentrator at his bedside via nasal cannula at 2 LPM. Review of the Medication Administration Record (MAR) dated December 2022 and January 2023 revealed no physician order for oxygen therapy. Review of the Treatment Administration Record (TAR) for December 2022 and January 2023 revealed no treatment order for oxygen therapy. Occupational Therapy notes dated December 8, 2022 revealed patient's oxygen needs to be monitored as patient desaturates on room air. Review of the Nursing Progress Notes dated December 2022 and January 2023 for Nursing revealed no documentation for resident oxygen use. Review of the Order Summary Report dated January 5, 2023 revealed no provider order for oxygen via nasal cannula. The Order Summary Report also revealed no documentation of a provider order for an oxygen concentrator delivery system. An interview was conducted on January 5, 2023 at 01:18 p.m. with a Certified Nursing Assistant (CNA/staff # 19). Staff #19 reported the resident has been on oxygen for approximately one week. Staff #19 stated she was off for three days and when she returned the resident was on oxygen. Staff #19 stated she is not responsible for the resident's oxygen care and it is the responsibility of the nurse or respiratory therapist. An interview was conducted on January 5, 2023 01:29 p.m. with a Licensed Practical Nurse (LPN/staff #130). Staff #130 reported an oxygen order had been revised on January 5, 2023 and the revision was to provide resident #46 with oxygen via nasal cannula at one liter per minute (LPM). During the interview the LPN (staff #130) went into resident #46's room. Staff #130 was observed checking the oxygen concentrator delivery system. Staff #130 stated resident #46 current oxygen was being administered at 2 LPM. Staff #130 stated he would change the oxygen rate to reflect the current physician order for the resident's oxygen use. Staff #130 was observed turning down the oxygen level from 2 LPM to one LPM. During the interview with staff #130, he stated that while documentation had not been completed on the care or maintenance of nasal cannula for resident #46, it was being changed and reported each shift. An interview was conducted on January 6, 2023 at 10:04 a.m. with the Director of Nursing (DON/RN/Staff #129). She stated she has been the DON for five years at the facility. Staff #129 stated she entered the physician orders for oxygen therapy through a concentrator delivery system via nasal cannula for resident #46 on January 5, 2023 following a conversation with the therapy department. Staff #129 stated the Physical Therapist informed her resident #46 did not profuse accurately and had a need for oxygen therapy. Staff #129 stated there were no prior orders for oxygen use prior to January 5, 2023 when she had entered them. Staff #129 also acknowledged oxygen therapy was not in the care plan or nursing documentation. Staff #129 stated the new oxygen order was for one LPM for resident #46. Staff #129 was informed resident #46 was observed receiving two LPM of oxygen the prior day, and not as prescribed in recent order for one LPM of oxygen. Staff #129 stated it is a concern for residents to be on oxygen without a doctor's order or administered as prescribed and could result in adverse clinical outcomes. Review of the Policy for Oxygen Administration, revised on December 2022, revealed that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained.

Based on observations, staff interviews, and policy, the facility failed to ensure garbage was disposed of correctly. Findings include: -During a walkthrough of the kitchen conducted on January 3, 2023, two large dumpster areas (#1 and #2), outside the building was observed at 9:54 a.m. with the Dietary Supervisor (staff #11). There were multiple items observed lying on the ground by the dumpsters: -Dumpster 1: one clear plastic bad lying on the ground to the left of the dumpster and appeared to have a dirty blue chuck, soiled adult brief along with other trash. -Dumpster 1: three used lancets on the ground in front of the dumpster. -Dumpster 1: used gauze with clear tape wrapped around it on the ground in front of the dumpster. -Dumpster 2: three used plastic pill cups with the room numbers written on them were lying on the ground in front of the dumpster. -Dumpster 2: a Tony's pizza carton on the ground to the left of the dumpster. -Dumpster 2: a Three Musketeer's Bar wrapper on the ground to the right of the dumpster. -12 used gloves lying on the ground around the dumpster area. An interview was conducted on January 3, 2023 at 9:45 a.m. with the Dietary Supervisor (staff #11), while observing the dumpster areas outside of the building. He observed the clear plastic bag lying to the left, next to dumpster (#1) and identified the items in the bag as items a certified nursing assistant would use. He stated that it is the responsibility of maintenance to ensure the area is clean. A licensed practical nurse (LPN/staff #133) joined the interview and confirmed that the three items in front of dumpster (#1) were lancets used to check blood sugar levels and stated that there is a risk of contamination if the lancets are used. She also, identified the three plastic cups in front of dumpster (#2) as used pill cups. An interview was conducted on January 6, 2023 at 8:40 a.m. with the Administrator (staff #25), who stated that the Maintenance Director is off this week, but usually does a walk around the facility each morning to ensure the dumpster area is clean. He agrees that the gloves and lancets have the potential for contamination. The facility's policy, Garbage and Rubbish Disposal, dated December 2022 states outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area.

Based on clinical record review, resident and staff interviews, and review of facility documentation, policies, and procedures, the facility failed to ensure one resident (#18) was provided a means to communicate with the staff by a method to call for assistance accessible to him. The deficient practice could result in residents not having the means to communicate with staff. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, acquired absence of right leg above the knee, epilepsy, and unspecified intellectual disabilities. The quarterly Minimum Data Set (MDS) dated [DATE] did not include a brief interview for mental status score. It did include that the resident needs a one-person extensive assist with activities of daily living: bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Review of the care plan revealed the resident has self-care deficits as evidenced by impaired cognition and mobility and muscle weakness, anoxic brain injury, left above knee amputation, major depressive disorder, epilepsy, anxiety/agitation, and increased serum ammonia. Interventions included to encourage use of bell to call for assistance. During an interview conducted on January 3, 2023 at 10:48 a.m. with resident #18, he stated in a very low voice that he wanted to turn the TV channel on. He was observed sitting in his wheelchair facing the TV, but there was no call-light present to call for assistance. The resident's roommate stated that the resident doesn't have a call-light and he didn't know why. It was observed that there was only one call-light plugged into the wall and that was for the roommate. On January 6, 2023 at 1:10 p.m. resident #18 was observed sitting in his wheelchair, while a certified nursing assistant (CNA/staff #49) was assisting him with drinking his milk. When asked how the resident called for assistance, she observed that the call-light was not present, and stated that she would have to go ask her supervisor how the resident calls for assistance and left the room. When she came back, she stated the call-light was removed for safety reasons and is care planned. She stated that the resident is supposed to have a bell to call for assistance. She searched for the bell in the resident's drawers, under his bed, the resident's closet, and on the dresser table located between two closets. The bell was on the dresser table under the roommate's blanket, robe, radio, 2 pairs of sweatpants, a fan, jacket, a bag of cereal, and a Christmas bag, so the bell was not within sight and the resident did not have access to the bell. An interview was conducted on January 6, 2023 at 1:22 p.m. with a licensed practical nurse (LPN/staff #130), who stated that he was assigned to the resident's hall, he knew the resident, and he had worked with the resident before. He stated that the resident can call for assistance with the call-light. Then, staff #130 went to the resident's room and observed that the call-light was not present in the room. He stated that the last time he worked with the resident, there was a call-light in the room. An interview was conducted on January 6, 2023 at 1:28 p.m. with the Director of Nursing (DON/staff #129), who stated that the resident is supposed to have a bell to call for assistance and it should be in reach when the resident is in bed and when he is in his wheelchair and there are no staff present. She stated that the bell was put in place, so the resident is able to call for help. The facility policy, Care and Treatment, Subject Rounds, Licensed Staff, dated November 2016 states that It is the policy of this facility to ensure the safety and comfort of the resident and to assist in continuity of care and to identify potential change in condition. Note positioning, incontinence, proper placement of Pole, IV's, feeding tube, safety and special devices in place & call lights are within resident's reach.

Based on clinical record review, facility documents, staff interviews, and policy review, the facility failed to ensure services met professional standards, by failing to schedule appointments as ordered for one resident (#336). The sample size was 22. The deficient practice could result in residents not having appointments scheduled. Findings include: Resident #336 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An Initial Care Plan initiated on February 26, 2021 revealed the resident had acute/chronic pain. Interventions included to administer [MEDICATION(S)] medication as per orders and to identify, record, and treat the resident's existing conditions which may increase pain or discomfort. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely impaired of cognitive skills for daily decision making. The assessment included the resident had surgical wounds. A review of a Telephone Call Log dated March 3, 2021 revealed the resident's family member had called and stated they could not attend the neurosurgery and neurology appointment. However, a review of the Appointment Logs from February 26, 2021 through March 16, 2021 revealed appointments had not been scheduled with neurology/neurosurgery or the surgical/traumatic clinic, or that a primary care had been found regarding hospital care and injury. The resident was discharged [DATE]. An interview was conducted with the Scheduler/Transportation Coordinator (staff #156) on December 14, 2021 at 10:27 AM. Staff #156 stated that usually she receives the orders and discharge documents from the hospital and will review them to see if the resident has appointments that need to be scheduled. She stated that she will schedule the appointment, arrange transportation, and notify the resident's family. Staff #156 stated that she did not see an appointment for this resident. She further stated that the appointment may be documented in the notes. Staff #156 stated the appointment with orthopedics on March 15, 2021 was cancelled. She stated that she did not know if the other appointments were made because the resident went to the hospital. Staff #156 stated that she cannot always schedule the appointments within the time frame. She stated that she when she attempts to schedule appointments, she will document the attempts. Staff #156 further stated that she did not think she had any record of attempting to schedule appointments for this resident. She stated that she would check and follow up. A follow up interview was conducted with staff #156 on December 14, 2021 at 11:16, who stated the other appointments were not scheduled. During an interview conducted with the Director of Nursing (DON/staff #91) on December 16, 2021 at 11:49 AM, the DON stated staff #156 schedules the appointments. The DON stated that she was only able to find documentation for the neurology and neurosurgery appointment, that the resident's family needed to accompany the resident and was unable to go. A facility policy titled Appointments revealed it is the policy of this facility to coordinate and arrange for appointments as ordered by the physician. This policy also revealed the facility will maintain a system to monitor for ordered appointments. The appointments will be scheduled as ordered unless medically contraindicated. If unable to arrange for the ordered appointment, the Nurse Manager or designee will be notified for further directions/interventions.

Based on clinical record reviews, observation, resident and staff interviews, and policy reviews, the facility failed to ensure necessary treatments and services were provided by failing to ensure surgical wounds with staples were consistently monitored and staples were removed for one resident (#336), and a dressing was changed as ordered for one resident (#52). The sample size was 22. The deficient practice increases the risk of infection. Findings include: Resident #336 was admitted to this facility on February 26, 2021 for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Initial Admission Record dated February 26, 2021 included the resident had 26 staples to the lower left extremity. An admission Minimum Data Set (MDS) assessment dated [DATE] included this resident had surgical wounds. A Non-Pressure Weekly assessment dated [DATE] included the scalp surgical wound had 2 staples and the left lateral lower leg surgical staples were intact. However, continued review of the weekly assessments revealed no other assessments of the scalp staples or of the leg staples. An Initial Care Plan initiated March 3, 2021 revealed the resident had actual impairment to skin integrity. The goals included the resident would not have complications related to the surgical site to the left lower leg and to the surgical site to the scalp. Interventions included treatments as per orders. A Wound Physician Note dated March 9, 2021 included to discontinue the staples to the left lower leg. However, a Daily Skilled Note dated March 14, 2021 included the resident had sutured lacerations/incisions to the scalp, and the lateral lower left extremity wound staples were intact. An interview was conducted on December 14, 2021 at 11:41 AM with a Licensed Practical Nurse (LPN/staff #20), who stated that when a resident has staples, the staff initially will assess the area, count the number of staples, note if there is drainage, how well approximated the wound is, if the wound needs to be covered, and then notify the wound team. An interview was conducted on December 15, 2021 at 2:41 with a Wound Care Nurse (LPN/staff #161). She stated the floor nurses will do the initial evaluation and the wound nurses will do a second head to toe assessment of the resident's skin within 24 hours. The LPN stated the wound team would track some non-pressure wounds such as surgical wounds. She stated wounds are reviewed weekly in an Interdisciplinary Team Meeting and are tracked with weekly assessments. Staff #20 stated the weekly assessments turn red every seven days to prompt the nurse to do it. She stated staples should be monitored daily. This nurse reviewed the clinical record and stated that she did not see the initial assessment by the wound nurse, or monitoring for the staples in the scalp. The LPN stated interventions ordered by the wound physician are entered and performed by the nurse that rounds with that physician and if they are not able to do it, they pass it on to the Assistant Director of Nursing (ADON) or sometimes the DON (Director of Nursing). She reviewed the clinical record and stated that the person rounding should have put the orders in and discontinued the staples the next day. She stated now they just do it right then and there. The LPN stated someone should have caught it. The wound nurse also stated someone should have been monitoring the scalp staples. In an interview conducted with the DON (staff #91) on December 16, 2021 at 11:49 AM, the DON stated her expectation is for the nurse to complete and document an assessment upon admission and that the wound nurse would conduct and document another skin assessment. The DON stated the expectation is for wounds to be assessed weekly. After reviewing the clinical record, the DON stated the wound physician usually removes staples and that the staples should have removed by March 16 or 17, 2021. A facility policy titled Wound Management revealed the nurse is responsible for assessing and evaluating the resident's condition on admission and readmission and is expected to identify any alterations in skin integrity noted at time. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 1 which indicated the resident had severe impaired cognition. The assessment also included the resident received antibiotic medications. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) for November 2021 and December 2021 revealed that midline placement was checked off on November 29 at 1:02 a.m. Continued review of the TARs for November 2021 and December 2021 revealed the midline dressing change was checked off on November 30 and December 7, 2021; and that the dressing was due to be changed on December 14, 2021. On December 13, 2021 at 9:32 a.m., resident #52 was observed with a hospital gown on sitting in a power wheelchair between the two beds in the resident's room. The resident was observed to have an IV (intravenous) line to left upper arm. A small portion of the IV-line dressing was visible and the clear transparent part of the IV dressing was observed to be crumbled. The full vision IV-line dressing observation was conducted after obtaining the resident's permission. The IV-line dressing was observed to have a white dressing tape at the edge of the dressing dated November 28, 2021. The dressing was observed to be crumbled with slightly peeling on the edges. No drainage was observed. At 10:59 a.m. on December 14, 2021, a second observation of the midline dressing was conducted. The midline dressing was observed to be dated December 13, 2021. When asked, resident #52 stated that the dressing was changed the day before. An interview was conducted with a Licensed Practical Nurse (LPN/staff #68) on December 14, 2021 at 12:57 p.m. She stated a dressing to an IV PICC or midline is changed every 7 days or as needed if the dressing is coming off or dirty. She stated resident #52 has an IV line to the left upper arm and was receiving antibiotics through it. She stated the nurses assess the IV dressing and site every shift and flush the line every shift with normal saline (NS) to make sure the line is patent. The LPN stated that she does not remember when the resident's dressing was changed. She stated the staff try not to change the PICC line or midline dressing too often as it is a process to change the dressing. Staff #68 stated the staff will not change the dressing unless the dressing is peeling off or dirty. The LPN stated it is important to change the dressing to prevent infection. After reviewing the TAR, the LPN stated the dressing was due to be changed on her shift. The LPN then went to the resident's room, observed the dressing and stated the dressing was changed the day before. She stated she thought the dressing might have been changed by the evening shift nurse and that she did not know whose initial was on the dressing. An interview was conducted with a Registered Nurse (RN/staff #79) on December 14, 2021 at 1:19 p.m., who stated that she knew someone changed all the IV line dressing the day before. She stated if the dressing was changed then it should be documented in the progress note. The RN stated when a dressing is changed, it should be documented in the progress note and in the TAR. An interview was conducted with the Medical Record supervisor (staff #54) on December 14, 2021 at 1:35 p.m. She stated that the case manager (staff #46) who is a nurse changed the resident's IV line dressing the day before. An interview was conducted with staff #46 on December 15, 2021 at 10:00 a.m. She stated that she checked on all residents with IV dressing on Monday and that she was the one that changed resident #52's dressing on Monday December 13, 2021. She stated the IV dressing was peeling off from all the sides so she changed the dressing and applied a fresh one. When asked if she knew when the dressing was last changed, she looked at the TAR and stated December 7, 2021 and a dressing changed is documented on December 14, 2021. The LPN stated that after she changed the dressing on December 13, 2021, she clicked off the PRN order but did not know why it was checked off on December 14, 2021. She stated that she will fix the date as the dressing was changed on December 13, 2021. She stated she might have made a mistake and clicked the scheduled order instead of the PRN order. The LPN stated that when she changed resident's #52 midline dressing, she observed how the dressing looked and did not look at the date on the dressing. Therefore, she stated she was not able to recall the date written on the dressing. An interview was conducted with the DON (staff #91) on December 15, 2021 at 2:25 p.m., who stated her expectation is for the nurses to monitoring the IV site for any signs and symptoms of infection, change the dressing as ordered, and document it in the TAR or progress notes. She stated the check mark on the TAR meant the task was completed or done. She stated if the IV dressing was changed as needed then there should be a progress note or a daily skilled note, and it should be captured on the TAR prn. The DON stated IV dressing change every 7 days is important for infection control reasons, to prevent infection and infiltration. The DON stated the nurse manager makes rounds every Monday and assess residents' IV sites and dressings. She stated for 2 weeks, the case manager was assigned to make the IV rounds. The facility's policy titled PICC line dressing change reviewed May 2021 stated the transparent dressings are changed every 7 days or sooner when it becomes loosened to the point of compromising sterility or presents a risk of accidental dislodgement of the catheter.

Based on clinical record review, staff interviews, the DSM-5 (Diagnostic and Statistical Manual of Mental Disorder), the National Institute of Mental Health, and facility policies, the facility failed to ensure that one resident (#37) had adequate indications for the use of an antipsychotic medication. The sample size was 5. The deficient practice could result in the resident receiving an unnecessary [CONDITION(S)] medication. Findings include: Resident #37 was admitted on [DATE] with diagnoses that included metabolic [CONDITION(S)], cognitive social or emotional deficit following cerebral infarction, and unspecified [CONDITION(S)] not due to a substance or known physiological condition. A physician order dated 10/19/21 included for [MEDICATION(S)], also known as [MEDICATION(S)], (an antipsychotic) 25 milligrams (mg) every 8 hours for [CONDITION(S)] as evidenced by pulling at life sustaining devices. A modified admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had short and long-term memory problems. The assessment also revealed that the resident had no evidence of acute change in mental status, but the resident did have continuous inattention and a fluctuating level of altered consciousness. The assessment included the resident had no potential indicators of [CONDITION(S)] such as hallucinations or delusions. The assessment included the resident had a diagnosis of [CONDITION(S)] disorder other than [CONDITION(S)]. Review of the care plan dated 10/19/21, revealed the resident was receiving [CONDITION(S)] medications related to [CONDITION(S)] as evidenced by yelling out and crying out. A physician's order dated 10/20/21 included for monitoring antipsychotic medication side effects every shift and to notify the provider if side effects were present (drowsiness, dry mouth, blurred vision, constipation, temporary impotence, nasal stuffiness, weight gain, loss of appetite, and sweating). Review of the medication administration record (MAR) for October 2021 revealed the resident was administered [MEDICATION(S)] as ordered. Review of the treatment administration record (TAR) for October 2021 revealed the resident was being monitored for antipsychotic medication side effects and for the number of behavioral instances. A physician's order dated 11/01/21 included to monitor for psychotic behavior every shift as evidenced by hallucinations. A psychiatric progress note dated 11/02/21 revealed the resident had been attempting to crawl out of bed, was being extremely restless, and having episodes of yelling and crying out at all times. The resident was also noted to have successfully self-decannulated several days prior and removed the nasogastric (NG) tube the previous day. The note included that during the interview the resident did not answer questions and only cried out loud. The note also included [MEDICATION(S)] would be increased to 100 mg every 8 hours. A physician order dated 11/02/21 included for [MEDICATION(S)] 100 mg every 8 hours for [CONDITION(S)] as evidenced by pulling at life sustaining devices. A physician's order dated 11/03/21 included to monitor for psychotic behavior every shift as evidenced by pulling at life sustaining devices. An interdisciplinary team note dated 11/04/21 revealed the resident was continuing to pull out their life sustaining devices including successfully pulling out the NG tube. The note indicated that the psychiatric provider had been notified of this behavior and the resident's continued yelling out. The resident's current treatment was to be continued as is. Review of a pharmacist medication regimen review dated 11/04/2021 revealed Diagnoses for the following orders could not be supported by chart documentation: [MEDICATION(S)] for [CONDITION(S)] as evidenced by pulling at life sustaining tubes. The pharmacist recommended the use of [CONDITION(S)] related to [CONDITION(S)] as evidenced by pulling at life sustaining tubes. A provider progress note dated 11/06/21 revealed that the resident had been moaning and crying, but denied pain and was redirectable. A physician order dated 11/08/21 included for [MEDICATION(S)] 100 mg every 8 hours for [CONDITION(S)] as evidenced by pulling at life sustaining devices. A psychiatric note dated 11/09/21 revealed the resident was tolerating the increased dose of [MEDICATION(S)]. The resident continued to still have some intermittent pulling of devices, but was doing better than the previous week. The resident did, however, continue to have daily episodes of crying out and yelling out. The resident's treatments were to continue as is. A daily skilled nursing note dated 11/09/21 indicated that the resident was oriented to self and would continually cry to self in between naps. Review of the provider progress note dated 11/12/21 revealed the resident appeared to have persistent symptoms of depression but decreased episodes of agitation and [CONDITION(S)]. A physician progress note dated 11/14/21 indicated the resident was still having depressive symptoms but decreased episodes of agitation and [CONDITION(S)]. The resident's treatment was the to be continued as is. A psychiatric note dated 11/16/21 revealed that that resident was alert during the interview and answered some questions, reporting mood is fine and reported no feelings of anxiety or depression. Resident denied any recent auditory or visual hallucinations. Resident denied any [CONDITION(S)], thoughts of self-harm, or death wishes. Staff reported resident has not had any worsening episodes of restlessness or agitation. Staff reported resident continued to pull at life-sustaining devices at times, but reportedly improving. The note included the resident visually appeared tearful, anxiety symptoms were restlessness, psychotic symptoms were pulling at life-sustaining devices, indicated by successfully self-decannulating the week of 10/28/2021 and removing the NG tube on 11/01/2021. The note included the resident agitation was evidenced by severe restlessness, and cognition was impaired. A provider progress note dated 11/17/21 indicated the resident was still having episodes of crying out and facial grimacing and continued to pull at life sustaining devices, requiring the continuation of current therapy. A provider progress note dated 11/20/21 indicated the resident was still having depressive symptoms but decreased episodes of agitation and [CONDITION(S)]. The resident's treatment was the to be continued as is. Review of a physician progress note dated 11/22/21 revealed the resident was still having episodes of crying out and facial grimacing in addition to pulling at life sustaining equipment which required bilateral mittens. The resident's current treatments were to be continued. An interdisciplinary team note dated 11/25/21 indicated the resident attempted to pull out the NG tube multiple times and was also yelling out. The resident was to be referred for a percutaneous endoscopic gastrostomy (PEG) tube. A provider progress note dated 11/28/21 revealed the resident was not following commands well, was pulling at the [CONDITION(S)] and was oriented only to self. A general nursing note dated 11/29/21 at 07:10 AM included the resident had pulled out the NG tube. A daily skilled nursing note dated 11/29/21 included the resident was alert and oriented only to self and was continuing to have episodes of crying. Review of a psychiatric progress note dated 11/30/21 revealed the resident was expressing some worsening episodes of agitation and was pulling at life sustaining devices, including removing the NG tube the day before. The psychiatric interventions included continuing bilateral hand mitts and [MEDICATION(S)] 100 mg every 8 hours. Review of the MAR for November 2021 revealed the resident was administered [MEDICATION(S)] as ordered. Review of the TAR for November 2021 revealed the resident was being monitored for antipsychotic side effects and for the number of behavioral instances. A pharmacist medication regimen review dated 12/1/21 included Diagnoses for the following orders could not be supported by chart documentation: [MEDICATION(S)] for [CONDITION(S)] as evidenced by pulling at life sustaining tubes. The pharmacist recommended the use of [CONDITION(S)] related to [CONDITION(S)] as evidenced by pulling at life sustaining tubes. A physician order dated 12/04/21 included for [MEDICATION(S)] 150 mg every 8 hours for [CONDITION(S)] related to [CONDITION(S)] as evidenced by pulling at life sustaining devices. A physician order dated 12/04/21 included for psychotic behavior monitoring every shift as evidenced by [CONDITION(S)] related to [CONDITION(S)] as evidence by pulling at life sustaining devices. An interdisciplinary team note dated 12/06/21 revealed the resident had continued to make multiple attempts at pulling out life sustaining devices. The family was informed about the resident health status. A psychiatric note dated 12/07/21 revealed the resident continued to tolerate the increased dose of [MEDICATION(S)]. The resident continued to have intermittent episodes of pulling at life sustaining devices, yelling out and crying out, but the resident condition had not worsened. During the interview the resident was sleepy and made eye contact, but did not answer most questions. The resident was oriented to self and had no evidence of hallucinations or delusions. However, in the recommendations it stated that the resident was continuing to have intermittent episodes of anxiety, agitation, and [CONDITION(S)]. The resident's current treatment was to be continued as is. Review of a provider note dated 12/08/21 revealed the resident's spouse stated the resident behavior was due to being upset about the current situation. This was in regard to discussion about the resident being provided with a PEG tube, which the family declined. A physician's order dated 12/08/21 was for [MEDICATION(S)] 150 mg every 8 hours for [CONDITION(S)] as evidenced by continuous yelling out and crying out. A physician's order dated 12/08/21 was for behavior monitoring every shift for psychotic episodes as evidenced by yelling out and crying out. An interdisciplinary team note dated 12/09/21 revealed the resident was again attempting to pull out life sustaining devices, and was crying and yelling out. The family was provided with an update, and an update on the process for a PEG placement. A psychiatric note dated 12/14/21 revealed psychiatry was consulted due to the resident's history of depression, recent episodes of agitation and for management of [CONDITION(S)] medications. The resident was continuing to have intermittent episodes of restlessness, pulling out of life-sustaining devices, and crying out. The resident had continued to attempt to self-decannulate and has dislodge the NG tube. The resident was a poor historian during the interview and was unable to answer the interview questions. The [MEDICATION(S)] was going to be continued as is. The resident displayed the mood symptoms of agitation, anxiety, and tearfulness. The resident appeared severely restless. The resident was oriented to self only, and the resident had no evidence of hallucinations or delusions. A nursing note dated 12/15/21 revealed the resident had again pulled out the NG tube and was awaiting replacement of a new one. Review of the MAR for December 2021 revealed the resident was administered [MEDICATION(S)] as ordered. Review of the TAR for December 2021 revealed the resident was being monitored for antipsychotic side effects and for the number of behavioral instances. An interview was conducted on 12/16/21 at 9:53 AM with a Certified Nursing Assistant (CNA/staff #131), who stated the resident's behavior of pulling at the [CONDITION(S)] tube and yelling appeared to be due to confusion and discomfort. Staff #131 remarked that having a [CONDITION(S)] and nasogastric tube is uncomfortable and painful, and those sensations were most likely why the resident was removing life sustaining devices. An interview was conducted with a Registered Nurse (RN/staff #32) on 12/16/21 at 10:07 AM. She stated the resident was receiving [MEDICATION(S)] for a diagnosis of [CONDITION(S)] as indicated by yelling out and crying out. She stated resident #37 yells out multiple times a day and cannot communicate words, but seems to be able to answer yes/no type questions. The RN stated the resident is not yelling for anything in specific; sometimes the resident will yell out no, or just keep yelling. The RN stated that she defines [CONDITION(S)] as suffering from an altered sense of reality. Staff #32 stated it appears as if resident #37 was in a state of mass confusion. Staff #32 also stated resident #37 would wake up and pull out the NG tube due to confusion and lack of understanding of the consequences of the actions. An interview was conducted on 12/16/21 at 12:35 PM with the Director of Nursing (DON/staff #91). The DON stated that she defines [CONDITION(S)] as the symptoms of auditory and visual hallucinations, yelling, and pulling at life sustaining devices. When the DON was presented with the DSM-5 hallmark characteristic symptoms of psychoses being, defined by abnormalities in one or more of the following five domains: delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal motor behavior (including catatonia), and negative symptoms, the DON stated the resident exhibited these behaviors. The DON stated the resident is not alert and oriented x 4 (person, place, time and event) and that yelling out and crying out throughout the day is an indication of disorganized thinking or speech and that pulling out life saving devices such as a [CONDITION(S)] tube or nasogastric tube is abnormal motor behavior. The DON stated resident #37's behavior indicates the resident has symptoms of [CONDITION(S)]. The DSM-5 defines the diagnosis of, Other Specified [CONDITION(S)] Spectrum and Other Psychotic Disorder as applying to presentations in which symptoms characteristic of a [CONDITION(S)] spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the [CONDITION(S)] spectrum and other psychotic disorders class. The other specified [CONDITION(S)] spectrum and other psychotic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific [CONDITION(S)] spectrum and other psychotic disorder. This is done by recording other specified [CONDITION(S)] spectrum and other psychotic disorder followed by the specific reason (e.g., persistent auditory hallucinations). A facility policy titled, Psychoactive Medications, revealed no psychoactive medications will be utilized without a specific physician's order, or without a diagnosed specific condition, and will include the target behavior. A facility policy titled, Medication Administration, revealed medications are to be administered according to appropriate indication/diagnosis. The National Institute of Mental Health defines [CONDITION(S)] as a condition that affects the mind, where there has been some loss of contact with reality. During a period of [CONDITION(S)], a person's thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not. Symptoms of [CONDITION(S)] include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech, and behavior that is inappropriate for the situation.

Based on facility documentation, staff interviews, and policy review, the facility failed to ensure dish machine temperatures and quaternary sanitizing PPM (parts per million) levels were consistently monitored. The deficient practice could result in dishes not being sanitized properly. Findings include: Review of the facility's dish machine temperature log dated July 2020 revealed spaces to document the wash and rinse temperature, and the chemical sanitizing PPM level for the morning, afternoon, and evening each day. However, review of the log for the evening of July 10, 2020 and the morning, afternoon, and evening for July 11-21, 2020 revealed no documentation for the wash and rinse temperature, and the chemical sanitizing PPM level. Review of the facility's third sink sanitizer test strip log for monitoring the quaternary PPM level dated July 2020 revealed spaces to daily document the quaternary PPM level for the morning, afternoon, and evening. However, review of the log for the evening reading on July 10, 2020 and the morning, afternoon, and evening reading for July 11-21, 2020 revealed no documentation for the quaternary PPM level. Review of the facility's sanitizer bucket log for monitoring the quaternary PPM level revealed spaces to daily document the quaternary PPM level for the AM and PM. However, review of the log revealed no documentation for the quaternary PPM level on June 26-30 and July 7-21, 2020 for the AM and the PM. An interview was conducted with the Dietary Supervisor (staff #27) on July 22, 2020 at 10:15 a.m. Staff #27 stated the logs are to be completed three times per day. He stated the dishwasher temperature logs and the sanitizer logs were to be completed by the cook but that the cook was not doing it. Staff #27 stated that the last time he reviewed the logs for completeness was July 11, 2020. Staff #27 stated he was having to cover a lot of shifts and it just slipped his mind. He also stated that there was enough chemical in the lines because he checks that daily. An interview was conducted with the Cook (staff #32) on July 22, 2020 at 11:25 a.m. Staff #32 stated that for the past 2 weeks, she was the one responsible for checking the dishwasher temperatures and sanitizer levels. She said that because of added responsibilities since COVID-19, she tried to keep up with everything but that she was too busy to check the temperatures and the sanitizer levels. Review of the facility's policy regarding the Dish Machine Temperature Log dated 2018 revealed the dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. The director of food and nutritional services will post a log near the dish machine for staff to document temperatures. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The policy also included the director of food and nutritional services will spot check this log to assure temperatures are appropriate and staff are correctly monitoring dish machine temperatures. The facility's policy titled Cleaning Dishes - Manual Dishwashing dated 2018 revealed dishes and cookware will be cleaned and sanitized after each meal. Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate. Follow chemical manufacturer's guidelines to prepare sanitizing solution.

Based on observations, clinical record review, staff interviews, and review of policies and procedures, the facility failed to provide the necessary care and treatment to prevent the development and worsening of a pressure ulcer for one resident (#121). Findings include: Resident #121 was admitted to the facility on [DATE] at 7:13 p.m., with [DIAGNOSES REDACTED]. Review of the admission nursing assessment dated [DATE] at 7:13 p.m., revealed the resident had multiple scabs to the shins and the right heel was discolored. There was no documentation of any skin breakdown to the coccyx or buttocks area. An admission Braden scale for predicting pressure ulcer sore risk dated January 8, 2016 revealed a score of 9, which indicated that the resident was at high risk. A late entry nursing progress note which was created on January 11, 2016 at 10:02 p.m. with an effective date of January 8, 2016 at 10:13 p.m., included the following: Addendum: Skin assessment - Coccyx open area. Cleaned with soap and water, patted dry and applied skin barrier. A weekly nursing skin assessment dated [DATE] did not mention a pressure ulcer on the coccyx or buttocks. Physician orders [REDACTED]. The January 2016 TAR (treatment administration record) included the above order for wound care to the coccyx and was initiated on January 11. However, there was no documentation that treatments were performed on January 12 and 13, on the day shift. A weekly nursing skin assessment dated [DATE] did not include a pressure ulcer on the coccyx or buttocks. However, a nursing progress note completed by a nursing supervisor dated January 12, 2016, documented that the resident had pressure ulcers to bilateral buttocks. Review of a care plan initiated on January 12, 2016 revealed the resident was at risk for pressure ulcer development and skin integrity, due to a history of pneumonia, poor oral intake, diabetes mellitus and incontinence of bowel. It was also noted that the resident had an open area to the sacrum. A goal included that the open area to the sacrum would decrease in size by the next review. Interventions included the following: administer treatments as ordered and monitor for effectiveness; keep body parts from excessive moisture; monitor and document location, size and treatment of [REDACTED]. A nursing daily skilled note dated January 15, 2016 included the resident was receiving daily pressure ulcer care and had moisture associated skin damage to his coccyx. physician's orders [REDACTED]. The orders also included for a wound consultation for the buttocks. Further review of the clinical record revealed that there was no documentation that the coccyx/buttocks wound had been thoroughly assessed (i.e. measurements, description of the wound bed and surrounding skin and if any drainage was present). A physician's orders [REDACTED]. A weekly skin assessment completed by a nursing supervisor dated January 19, 2016 documented the resident had a pressure ulcer on the buttocks, which was open. The documentation included that this was an initial evaluation and that the pressure ulcer was not present on admission and that the onset date was January 12, 2016. The assessment further included that the pressure ulcer was a stage 3, and measured 6.5 cm (centimeters). The assessment included a space to document the length and width of the wound, however, only one measurement was included (6.5 cm). The documentation also noted that the depth of the wound was 0.1 cm. The wound bed was described as beefy red, with moderate serosanguinous drainage. Interventions included cleanse with soap and water, pat dry, apply [MEDICATION NAME] gauze, [MEDICATION NAME], gauze, and tape and change dressing daily and as needed for soilage. Review of the clinical record revealed no documentation that the wound care consultation ordered on January 15, had been obtained. A second physician's orders [REDACTED]. A wound physician's skin assessment was completed on January 20, 2016. The documentation revealed that the resident had a stage 3 ulcer to the sacrum, which measured 6.5 cm x 5.0 cm x 0.1 cm., and had slough on the surface. Treatments included for a low airloss mattress, turn every 2 hours, and apply [MEDICATION NAME], Alginate, and gauze daily. A physician's orders [REDACTED]. Review of the January TAR revealed the above order, however, the treatment was not done on January 21. (This order was discontinued on January 22). According to the MDS (Minimum Data Set) significant change assessment dated [DATE], the resident was assessed to be cognitively intact and required extensive assistance with two persons for bed mobility and transfers. The assessment also identified that the resident was at risk for pressure ulcer development and had one stage 3 pressure ulcer, which measured 6.5 cm x 6.5 cm. In the section to document the number of pressure ulcers that were present upon admission, the information was not completed. Per the MAR, a physician's orders [REDACTED]. However, there was no documentation that the treatment had been provided from January 22 through 26. The order was discontinued January 26. The physician's treatment order initiated on January 26, 2016 was included on both the January and February TARs. The order included to cleanse buttocks wound with wound cleanser, pat dry, apply zinc cream to periwound and [MEDICATION NAME] to wound, cover with foam dressing, secure with tape, and change as needed for soilage. However, the treatment was not documented as being done from January 26 through February 3. Review of a weekly skin assessment performed by an LPN (Licensed Practical Nurse) dated February 3, 2016, revealed the coccyx pressure ulcer measured 6.5 cm x 6.5 cm, and was unstageable, as the depth was unable to be determined. The assessment did not described the wound bed or surrounding tissue, or if any drainage was present. A wound physician's skin assessment dated [DATE] documented that the resident had an unstageable sacrococcygeal ulcer measuring 9.5 cm x 6 cm, with an unknown depth. The assessment also included that the wound bed had slough with minimal drainage, but no undermining, tunneling, odor or exposed tissue. Despite the wound increasing in size from the previous assessment, the documentation included that the wound was improving. Further review of the February 2016 TAR revealed the wound treatment was not provided from February 4 through 9. The wound treatment was changed on February 9, 2016. A physician's orders [REDACTED]. Despite documentation from the physician that the sacrococcygeal pressure ulcer was unstageable on February 8, the weekly skin assessment dated [DATE], which was two days later, included the wound on the sacrum and buttocks area was a stage 2. A wound physician's skin assessment dated [DATE] documented the unstageable sacrococcygeal buttocks ulcer measured 6 cm x 3 cm with unknown depth and that it continues to show improvement. A wound physician's skin assessment dated [DATE], included documentation that the unstageable buttocks, sacral, coccygeal wound was improving. Review of the Interdisciplinary Team Skin Review weekly update dated February 23, 2016 revealed the wound to the coccyx showed visible improvement, wound bed had less slough and will continue with treatment. The wound physician's skin assessment of the sacrococcygeal ulcer dated February 26, 2016, revealed the wound continues to get smaller, with no more slough and mild bleeding on the surface. The treatment plan included to continue current treatment and turning schedule. No wound measurements were documented for this exam. A weekly nursing skin assessment dated [DATE] documented the following: the coccyx pressure ulcer was unstageable as the depth was unable to be determined, wound measured 5.5 cm x 2 cm, wound bed had slough with a scant amount of serous exudate, no tunneling or undermining and wound edges were defined. A physician's orders [REDACTED]. A wound care observation was conducted on March 2, 2016 at 2 p.m., with the wound nurse. The treatment was performed as ordered. An interview was conducted with the resident's physician on March 2, 2016 at 1:35 p.m. He stated that he does not have standing orders for pressure ulcer treatment, but the facility can contact him to obtain treatment orders if necessary. An interview was conducted with the wound nurse on March 2, 2016 at 2:30 p.m. He said that the resident is seen every Monday by a wound specialist physician and that wound assessments are completed every week. An interview was conducted with a CNA on March 3, 2016 at 1:31 p.m. The CNA stated residents are on a standard turning schedule of every two hours, which is documented in the computer. She stated that if she were to notice an area of redness or suspected pressure, she would first notify the nurse and then it is standard procedure to apply barrier cream to the area. Another interview was conducted with the wound nurse LPN on March 4, 2016 at 12:16 p.m. He stated residents who are admitted over the weekends and require wound assessments by the wound nurse, are evaluated on the following Monday, so as to provide consistency in wound assessments and staging. He stated the nurses can apply several types of barrier creams until Monday, and that after physician or wound nurse staging, the nurses can provide additional treatments as ordered. Review of the facility's policy and procedures regarding wound care revealed that stage 2 and stage 3 pressure ulcers are to be measured weekly and evaluated for the effectiveness of treatment. The policy further stated to document with each dressing change and measure weekly, and as needed. Review of a facility's policy regarding wound management revealed that a resident who enters the facility without pressure ulcers does not develop a pressure ulcer unless the individuals clinical condition or other factors demonstrate that a developed pressure was unavoidable; and a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable sores from developing. The policy also included that the nurse responsible for assessing and evaluating the resident's condition on admission/readmission is expected to complete a comprehensive admission assessment/evaluation to identify risk and to identify any alterations of skin integrity at the time. Once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area, per the physician's orders [REDACTED]. Review of the skin breakdown policy revealed to complete an initial assessment upon admission and that skin integrity will be monitored on an ongoing basis and any reddened area noted will be reported to the licensed nurse.