Every finding on record at Stonebridge Marble Hill

Based on interview and record review, the facility failed to ensure informed consent was obtained and documented for the use of psychotropic (a medication that affects brain activities associated with mental processes and behavior) medications for three residents (Residents #8, #10, and #61) out of six sampled residents. This failure prevented the resident and/or their representative from knowing the risks and the benefits of using psychotropic medications. The facility census was 71. Review of the facility's policy titled, Psychotropic Medication Use, revised October 2017, showed: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others; - The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of psychotropic medications. 1. Review of Resident #8's medical record showed: - admitted on [DATE]; - Diagnoses of spinal cord injury, quadriplegia (paralysis caused by illness or injury that results in the loss of use of all limbs and torso), post-traumatic stress disorder (PTSD - psychological distress following a traumatic event), and major depressive disorder (long-term loss of pleasure or interest in life); - An order for Seroquel (an antipsychotic (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking) medication) 50 milligrams (mg) by mouth one time a day related to PTSD, dated 04/23/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. During an interview on 01/08/26 at 1:30 P.M., Resident #8 said he/she did not remember if the risks and benefits were reviewed with him/her before starting the medication. 2. Review of Resident #10's medical record showed: - admitted on [DATE]; - Diagnosis of schizophrenia (a long-term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations); - An order for Risperdal (an antipsychotic medication) 1 mg by mouth one time a day related to schizophrenia, dated 05/16/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. During an interview on 01/08/26 at 3:15 P.M., Resident #10 said that he/she did not remember receiving any medication consent forms or going over medication risks and benefits prior to today. 3. Review of Resident #61's medical record showed: - admitted on [DATE]; - An order for Seroquel 25 mg by mouth in the morning and 50 mg by mouth at bedtime, dated 06/28/25; - No documentation of consents or education of risks and benefits for the psychotropic medication use were provided to the resident and/or their representative. During an interview on 01/08/26 at 1:20 P.M., Resident #61 and the resident's spouse said they did not recall signing any consent form for the resident's medications. They did not recall staff discussing the medication, the potential side effects, or other possible treatment options with them. During an interview on 01/08/26 at 4:00 P.M., the Administrator and the Director of Nursing (DON) said they would expect signed psychotropic consent forms to be completed by the residents or their representatives when starting psychotropic medications or medication adjustments were completed for psychotropic medications.

Based on interview and record review, the facility failed to attempt a gradual dose reduction (GDR) for psychotropic (medications that affect how the brain works and causes changes in mood, awareness, thoughts, feelings, or behaviors) medications for two residents (Residents #7 and #10) out of five sampled residents. The facility census was 71. Review of the facility policy titled, Psychotropic Medication Use, dated October 2017, showed: - Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review; - The physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 1. Review of Resident #7's medical record showed: - admission date of 03/16/22; - Diagnoses of Parkinson's disease (a movement disorder of the nervous system that worsens over time), polyneuropathy (damage to multiple peripheral nerves, causing symptoms like numbness, tingling, weakness, and burning pain, often starting in the feet and hands), dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels), post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event), and anxiety disorder (mental health conditions causing intense, excessive, and persistent fear or worry that disrupts daily life); - An order for Abilify (an antipsychotic (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking) medication) 15 milligrams (mg) one time a day for bipolar disorder, dated 07/15/23, and with an end date of 09/11/25; - An order for Abilify 15 mg one time a day for bipolar disorder, dated 09/12/25; - A GDR request from the pharmacist for the resident's Abilify be reduced from 15 mg to 10 mg one time a day on 02/24/25 and 11/21/25 without the physician's response or documentation the request was sent to the physician. 2. Review of Resident #10's medical record showed: - admission date of 05/16/25; - Diagnoses of cerebral infarction (stroke), major depressive disorder (MDD - long-term loss of pleasure or interest in life), PTSD, restless leg syndrome, schizophrenia (a long-term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), and Parkinson's disease; - An order for Risperdal (an antipsychotic medication) 1 mg by mouth one time a day related to schizophrenia, dated 05/16/25; - No documentation of a pharmacist GDR request, a GDR attempt, or a GDR was considered clinically contraindicated for the Risperdal. During an interview on 01/08/26 at 4:15 P.M. the Administrator and the Director of Nursing (DON) said GDRs should be completed when they were due. GDRs were done the month they received them with most being for psychotropics and as needed medications. The GDR process went by receiving the pharmacy recommendations each month, the facility sending those recommendations to the physicians and providers, and then the physicians and providers acted on the recommendations. One provider did not address the recommendations the facility sent until the provider rounded each month. During an interview on 01/20/26 at 9:46 A.M., the Pharmacist said he/she sent recommendations to the facility digitally and by paper. The reports were sent the same day they were completed. He/She expected pharmacy recommendations and GDRs to be addressed by the next monthly review. He/She would not do a GDR recommendation for a resident diagnosed with schizophrenia.

Based on interview and record review, the facility failed to provide required written notice and documentation related to discharge and bed hold policy requirements, including the required daily bed hold rate for four residents (Residents #1, #3, #13, and #70) out of four sampled residents. The facility also failed to complete a recapitulation of stay upon discharge to home for one resident (Resident #72) out of two closed records reviewed. The facility census was 71.Review of facility policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, the facility will provide information regarding the bed hold policy to the resident or representative in a written format that is understood by the resident or the representative; - The covered service for therapeutic and hospital leaves for the Medicaid state plan will be defined in the bed hold notice and will be provided to the resident at the time of transfer or in an emergency, within 24 hours; - Bed hold days in excess of the State Medicaid Plan are considered non-covered services. A resident may elect to pay for additional days that he/she wishes the facility to hold the bed. Review of the facility policy titled, Transfer or Discharge Notice, dated December 2016, showed: - If an immediate transfer or discharge is required by the resident's urgent medical needs, the transfer/discharge notice will be given as soon as it is practicable but before the transfer or discharge; - The resident and/or representative will be notified in writing of the reason for the transfer or discharge, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged . 1. Review of Resident #1's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the written notification of the transfer and the bed hold policy, including the bed hold rate, were provided to the resident and/or the resident representative for this transfer. 2. Review of Resident #3's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the written notification of the transfer and the bed hold policy, including the bed hold rate, were provided to the resident and/or the resident representative for these transfers. 3. Review of Resident #13's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the written notification of the transfer and the bed hold policy, including the bed hold rate, were provided to the resident and/or the resident representative for this transfer. 4. Review of Resident #70's medical record showed: - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and returned to the facility on [DATE]; - No documentation the written notification of the transfer and the bed hold policy, including the bed hold rate, were provided to the resident and/or the resident representative for these transfers. During an interview on 01/08/26 at 2:28 P.M., Registered Nurse (RN) E said the nurses were responsible for completing the transfer and bed hold documentation and notifying the appropriate people involved. The nurse filled out the transfer bed hold documentation in the electronic medical record for the resident and printed the completed documentation to send with the resident to the hospital. Sometimes the nurse had to fax the documentation to the hospital if it was not able to be sent with the resident. The resident representative would be notified, but no paperwork would be provided to them. He/She did not know where the bed hold rate information was located and didn't know how to find that information. During an interview on 01/08/26 at 4:20 P.M., the Administrator said she would expect the residents or their representatives to be informed in writing of transfers and the bed hold policy along with the daily bed hold rate. 5. Review of Resident #72's medical record showed: - admitted on [DATE]; - discharged on 11/10/25 to the community; - No documentation of a recapitulation of the resident's stay at the facility was completed and provided to the resident and/or the resident representative. During an interview on 01/08/26 at 2:10 P.M., the Administrator said the facility did not have a recapitulation of stay completed for Resident #72. Each department was responsible for completing their portion of the summary of a resident's stay. During an interview on 01/08/26 4:15 P.M., the Administrator and the Director of Nursing (DON) said they would expect a recapitulation of a resident's stay to be completed when a resident was discharged and a written notification of a transfer and a copy of the bed hold policy, including the daily rate, be provided to the resident and/or the resident's representative when transferred out of the facility.

Based on observation, interview, and record review, the facility failed to provide showers for six residents (Residents #5, #7, #19, #31, #41 and #61) out of 18 sampled residents. The facility's census was 71. Review of facility policy titled, Bath, Shower/Tub, dated February 2018, showed: - Staff to document the following: the date and time the shower or bath was performed; all assessment data obtained during the shower or bath; how the resident tolerated the shower or bath; and if the resident refused the shower or bath, the reason why, and the intervention taken. 1. Review of Resident #5's medical record showed: - admission date of 12/15/23; - Diagnoses of chronic kidney disease, stage 1 (early mild kidney disease), type 2 diabetes mellitus (DM - high blood sugar related to insulin resistance), malleolus without complications (ankle bone injury without complications), thoracic aortic aneurysm without rupture (enlarged area of the main artery in the chest that has not ruptured), morbid obesity (severely elevated body weight that increases health risks), anxiety disorder (ongoing excessive worry or anxiety), muscle weakness (reduced muscle strength), generalized dysphagia, (difficulty swallowing), unsteadiness on feet (balance problems when standing or walking), and weakness (generalized lack of strength). Review of the resident's significant change Minimum Data Set (MDS - a mandatory assessment completed by the facility) assessment, dated 05/20/25, showed: - Cognitive impairment; - Partial or moderate assistance from staff for dressing, personal hygiene, and showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Tuesday, Thursday and Saturday. Review of the resident's shower documentation for 12/11/25 - 01/06/26 showed: - December had nine opportunities for receiving a shower. The resident failed to receive a shower on 12/18/25, 12/23/25, and 12/27/25. Three showers were missed out of nine opportunities; - January had three opportunities for receiving a shower. The resident failed to receive a shower on 01/01/26 and 01/03/26. Two showers were missed out of three opportunities. 2. Review of Resident #7's medical record showed: - admission date of 03/16/22; - Diagnoses of Parkinson's disease (a movement disorder of the nervous system that worsens over time), polyneuropathy (damage to multiple peripheral nerves, causing symptoms like numbness, tingling, weakness, and burning pain, often starting in the feet and hands), dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), bipolar disorder (a mental health condition causing extreme shifts in mood, energy, and activity levels), post-traumatic stress disorder (PTSD - a mental health condition that can develop after a person experiences or witnesses a traumatic event), anxiety disorder (mental health conditions causing intense, excessive, and persistent fear or worry that disrupts daily life), polyarthritis (inflammation and pain affecting five or more joints simultaneously), osteoarthritis (a degenerative joint disease where cartilage wears down, causing joint pain, stiffness, and swelling), right foot drop ( difficulty in lifting the front part of the foot), and spondylolisthesis (a condition where a vertebra in the spine slips forward over the one below it, which can cause back pain, stiffness); Review of the resident's quarterly MDS assessment, dated 12/17/25, showed: - Cognitive impairment; - Dependent on staff for dressing, personal hygiene, and showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Monday, Wednesday, and Friday night shift. Review of the resident's shower documentation for 12/09/25 to 01/08/26 showed: - December had ten opportunities for receiving a shower. The resident failed to receive a shower on 12/12/25, 12/19/25, 12/22/25, 12/24/25, 12/26/25, 12/29/25, and 12/31/25. Seven showers were missed out of ten opportunities; - January had three opportunities for receiving a shower. The resident failed to receive a shower on 01/05/26 and 01/07/26. Two showers were missed out of three opportunities. 3. Review of Resident #19's medical record showed: - admission date of 02/25/11; - Diagnoses of hemiplegia affecting unspecified side (paralysis or severe weakness on one side of the body), aphasia following cerebral infarction (difficulty speaking or understanding language after a stroke), dysphagia (difficulty swallowing), schizophrenia (chronic mental health disorder affecting thinking and behavior), epilepsy (seizures), moderate intellectual disabilities (moderate limitations in intellectual functioning and adaptive behavior), and sequelae following unspecified cerebrovascular disease (lasting effects from a disease affecting blood flow to the brain). Review of the resident's quarterly MDS assessment, dated 05/02/25, showed: - Severe cognitive impairment; - Dependent on staff for dressing, personal hygiene, and showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Tuesday, Thursday and Saturday. Review of the resident's shower documentation for 12/11/25 - 01/06/26 showed: - December had nine opportunities for receiving a shower. The resident failed to receive a shower on 12/18/25, 12/23/25 and 12/27/25. Three showers were missed out of nine opportunities; - January had three opportunities for receiving a shower. The resident failed to receive a shower on 01/01/26 and 01/03/26. Two showers were missed out of three opportunities. 4. Review of Resident #31's medical record showed: - admission date of 11/04/24; - Diagnoses of depression (loss of interest in activities) and fracture of the left tibia (leg bone). Review of the resident's significant change MDS assessment, dated 11/02/25, showed: - No cognitive impairment; - Partial/moderate assist from staff for upper body dressing; - Substantial/maximal assist on staff for lower body dressing, personal hygiene, and showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Tuesday, Thursday and Saturday with Sunday a makeup shower day. Review of the resident's shower documentation for 12/11/25 - 01/06/26 showed: - December had nine opportunities for receiving a shower. The resident failed to receive a shower on 12/11/25, 12/16/25, 12/18/25, 12/20/25, 12/25/25, 12/27/25, and 12/30/25. Seven showers were missed out of nine opportunities; - January had three opportunities for receiving a shower. The resident failed to receive a shower on 01/03/26. One shower was missed out of three opportunities. 5. Review of Resident #41's medical record showed: - admission date of 12/16/22; - Diagnoses of epilepsy, acute transverse myelitis in demyelinating disease of central nervous system (disorder causing sudden inflammation across sections of the spinal cord), osteoarthritis (breakdown of cartilage causing bones to rub leading to pain, stiffness, and impaired range of motion) of both knees, and lymphedema (excess fluid buildup in parts of body). Review of the resident's significant change MDS assessment, dated 12/28/25, showed: - No cognitive impairment; - Supervision or touching assistance from staff for upper body dressing and toileting hygiene; - Partial or moderate assistance on staff for lower body dressing; - Substantial/maximum assistance on staff for showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Tuesday, Thursday and Saturday with Sunday a makeup shower day. Review of the resident's shower documentation for 12/11/25 - 01/06/26 showed: - December had nine opportunities for receiving a shower. The resident failed to receive a shower on 12/16/25, 12/20/25, and 12/25/25. Three showers were missed out of nine opportunities. - January, had three opportunities for receiving a shower. The resident failed to receive a shower on 01/03/26. One shower was missed out of three opportunities. During an interview on 01/06/26 at 11:45 A.M., Resident #41 said he/she sometimes only received one shower a week or went long stretches without a shower. 6. Review of Resident #61's medical record showed: - admission date of 11/14/24; - Diagnoses of Alzheimer's disease (progressive brain disease affecting memory and thinking), age-related osteoporosis (bone thinning that increases fracture risk), hyperlipidemia (high cholesterol or elevated blood fats), dementia, essential hypertension (chronic high blood pressure), and depression. Review of the resident's quarterly MDS assessment, dated 05/23/25, showed: - Minimal cognitive impairment; - Independent for dressing and personal hygiene; - Partial or moderate assistance from staff for showering/bathing. Review of the resident's shower schedule showed: - The resident scheduled for Tuesday, Thursday and Saturday. Review of the resident's shower documentation for 12/11/25 - 01/06/26 showed: - December had nine opportunities for receiving a shower. The resident failed to receive a shower on 12/18/25, 12/25/25 and 12/27/25. Three showers were missed out of nine opportunities. During an interview on 01/08/26 at 2:20 P.M., Certified Nurse Assistant (CNA) F and CNA G said showers were done by the CNA on each hall. There were assigned shower days to the residents with at least two to three showers offered each week and Sunday being a makeup shower day for those who missed a shower or refused a shower earlier in the week. Showers were documented in the electronic medical record and on paper. The paper shower sheets were discarded after a week. During an interview on 01/08/26 at 2:00 P.M., the Director of Nursing (DON) said they do not keep completed showers sheets for more than seven days. The showers were documented in the resident's electronic medical record. However, the system will only allow a 30-day look back period for record review of showers. During an interview on 01/08/26 at 4:15 P.M., the Administrator and DON said they would expect residents to be given or offered a minimum of two showers a week and the showers should be documented in the resident's electronic medical record.

Based on observation, interview and record review, the facility failed to use proper infection control techniques during wound care for two residents (Resident #7 and #14) out of three sampled residents and during blood glucose (blood sugar) test for four residents (Residents #3, #61, #66, and #75) out of five sampled residents. The facility census was 71. Review of the facility's policy titled, Hand Hygiene, not dated, showed: - All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors; - The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to putting on gloves, and immediately after removing gloves; - Hand hygiene is indicated and will be performed: between resident contacts; after handling items potentially contaminated with body fluids, secretions, or excretions; when, during resident care, moving from a contaminated body site to a clean site. Review of facility policy titled, Glucometer (a portable device used to measure the amount of sugar in the blood) Disinfection, dated September 2022, showed: - Obtain needed equipment and supplies including gloves, glucometer, alcohol pads, single-use lancet (a device to collect blood from the fingertips for blood glucose testing), blood glucose testing strips (small, disposable strips used with a glucometer to check sugar levels from a tiny blood drop), and disinfecting wipes; - Wash hands; - Explain the procedure to the resident; - Provide privacy; - Put on gloves; - Obtain a capillary (a small thin-walled vessel of the body) blood glucose sampling; - Remove and discard gloves, perform hand hygiene prior to exiting the room; - Reapply gloves if there is visible contamination of the device or if the resident is human immunodeficiency virus (HIV - a virus that attacks the body's immune system) or Hepatitis B or C (viral infections that causes the liver to swell) positive; - Retrieve two disinfectant wipes from the container; - Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; - After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacture's instructions. Allow the glucometer to air dry; - Discard disinfectant wipes in a waste receptacle; - Perform and hygiene. Review of the Assure Prism Multi Blood Glucose Monitoring System's User Instruction Manual for showed: - The meter should be cleaned and disinfected after use on each resident; - Wear appropriate protective gear such as disposable gloves; - Open the towelette container and pull out one towelette and close the lid; - Wipe the entire surface of the meter three times horizontally and three times vertically using one towelette to clean blood and other body fluids; - Dispose of the used towelette in a trash bin; - Pull out one new towelette and wipe the entire surface of the meter three times horizontally and three times vertically to remove blood-borne pathogens; - Dispose of the used towelette in a trash bin; - Allow exteriors to remain wet for the appropriate contact time and then wipe the meter using a dry cloth; - Contact time for Super Sani-Cloth Germicidal Disposable Wipe is two minutes; - After disinfection, the user's gloves should be removed and thrown away; - Wash hands before proceeding to the next resident. 1. Observation on 01/07/26 at 9:30 A.M., of Resident #14's sacral (the area above the tailbone) wound care showed: - Enhanced Barrier Precautions (EBP) signage in place; - Licensed Practical Nurse (LPN) A and Registered Nurse (RN) E entered the resident's room, performed hand hygiene, put on gloves, and did not put on gowns; - LPN A cleaned the resident's buttocks with a wipe; - LPN A changed gloves and did not perform hand hygiene; - LPN A cleaned the resident's sacral wound with gauze soaked with Dakin's solution (an antiseptic); - LPN A did not change gloves, did not perform hand hygiene, and applied skin prep (a barrier product) to the skin surrounding the wound; - LPN A did not change gloves, did not perform hand hygiene, and applied Iodosorb (iodine gel used to treat chronic wounds) to the wound bed using a cotton-tipped swab; - LPN A did not change gloves, did not perform hand hygiene, and applied Collagen powder (a topical wound therapy that promotes healing) to the wound; - LPN A did not change gloves, did not perform hand hygiene, covered the wound with calcium alginate (a highly absorbent wound dressing made from seaweed) and secured it with an island dressing (a sterile, all-in-one bandage with a central absorbent pad and a surrounding adhesive border); - LPN A did not change gloves, did not perform hand hygiene, and applied Calmoseptine cream (a multi-purpose skin protectant and moisture barrier) to the resident's buttocks; - LPN A did not change gloves, did not perform hand hygiene, and put a clean brief on the resident; - LPN A removed his/her gloves and did not perform hand hygiene; - LPN A touched the resident's call light, bed control, and blankets; - LPN A performed hand hygiene and exited the room. 2. Observation on 01/07/26 at 11:29 A.M., of Resident #75's blood glucose testing showed: - Certified Medication Technician (CMT) H removed the glucometer from his/her scrub pocket, did not clean and disinfect the glucometer, and placed it on top of the medication cart without a clean barrier; - CMT H gathered the supplies; - CMT H did not perform hand hygiene and put on gloves; - CMT H entered the resident's room, performed the blood glucose test, did not change gloves, did not perform hand hygiene, and exited the room; - CMT H placed the glucometer on top of the medication cart without a clean barrier; - CMT H removed gloves, did not perform hand hygiene, and removed the blood glucose testing strip from the glucometer with his/her bare hands; - CMT H did not clean and disinfect the glucometer and placed it in his/her scrub pocket. 3. Observation on 01/07/26 at 11:34 A.M. of Resident #61's blood glucose testing showed: - CMT H removed the same glucometer from his/her scrub pocket, did not clean and disinfect the glucometer, and placed it on the top of the medication cart without a clean barrier; - CMT H gathered the supplies; - CMT H did not perform hand hygiene and put on gloves; - CMT H entered the resident's room, performed the blood glucose test, did not change gloves, did not perform hand hygiene, and exited the room; - CMT H placed the glucometer on top of the medication cart without a clean barrier; - CMT H removed gloves, did not perform hand hygiene, and removed the blood glucose testing strip from the glucometer with his/her bare hands; - CMT H did not clean and disinfect the glucometer and placed it in his/her scrub pocket. 4. Observation on 01/07/26 at 11:40 A.M. of Resident #3's blood glucose testing showed: - CMT H removed the same glucometer from his/her scrub pocket, did not clean and disinfect the glucometer, and placed it on the top of the medication cart without a clean barrier; - CMT H gathered the supplies; - CMT H did not perform hand hygiene and put on gloves; - CMT H entered the resident's room, performed the blood glucose test, did not change gloves, did not perform hand hygiene, and exited the room; - CMT H placed the glucometer on top of the medication cart without a clean barrier; - CMT H removed gloves, did not perform hand hygiene, and removed the blood glucose testing strip from the glucometer with his/her bare hands; - CMT H did not clean and disinfect the glucometer and placed it in his/her scrub pocket. 5. Observation on 01/07/26 at 11:46 A.M. of Resident #66's blood glucose testing showed: - CMT H removed the same glucometer from his/her scrub pocket, did not clean and disinfect the glucometer, and placed it on the top of the medication cart without a clean barrier; - CMT H gathered the supplies; - CMT H did not perform hand hygiene and put on gloves; - CMT H entered the resident's room, performed the blood glucose test, did not change gloves, did not perform hand hygiene, and exited the room; - CMT H placed the glucometer on top of the medication cart without a clean barrier; - CMT H removed gloves and did not perform hand hygiene, removed the blood glucose testing strip from the glucometer with his/her bare hands; - CMT H did not clean and disinfect the glucometer and placed it in his/her scrub pocket. During an interview on 01/08/26 at 2:15 P.M., CMT H said he/she performed hand hygiene between every task and every resident. Gloves were worn during the blood glucose testing and when the strip was removed from the glucometer. He/She wiped the glucometer off with the Super Sani-Cloth Germicidal Disposable Wipe and let it sit for two minutes. A towel placed on a surface as a barrier before the glucometer was set down. 6. Observation on 01/08/26 at 9:21 A.M., of Resident #7's coccyx (the tailbone) wound care showed: - EBP signage in place; - LPN A put on a gown and mask; - LPN A performed hand hygiene and put on gloves; - LPN A removed the resident's brief, did not change gloves, and did not perform hand hygiene; - LPN A cleaned the resident's wound with wound cleanser spray and gauze; - LPN A did not change gloves, did not perform hand hygiene, and applied Collagen powder to the wound bed using a cotton-tipped swab; - LPN A did not change gloves, did not perform hand hygiene, and applied Calmoseptine cream to the buttocks around the wound; - LPN A did not change gloves, did not perform hand hygiene, and touched the resident's blankets and bed control; - LPN A removed the gloves and gown, performed hand hygiene, and exited the room. During an interview on 01/08/26 at 9:30 A.M., LPN A said hands should be cleaned before and after wound care, and gloves should be changed when they were soiled. During an interview on 01/08/26 at 4:20 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to perform hand hygiene when they enter a resident's room, after they perform care, between glove changes, when they exit a resident's room, and when their hands were visibly dirty. They would expect the glucometer to be cleaned and disinfected between every resident.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required competency of Abuse Prevention and Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions). This affected one Certified Nurse Assistant (CNA) (CNA B) out of two sampled CNAs. The facility's census was 71.Review of the facility's policy titled, Required Training and Continuing Education of Nurse Aides, dated September 2022, showed:- The facility will provide at least 12 hours of in-service training annually, based on the employment date, not the calendar year;- Minimum training will include: dementia management and care of the cognitively impaired, abuse, neglect, and exploitation prevention. Review of CNA B's in-service record showed:- A hire date of 01/16/19;- CNA B did not attend an annual competency in-service training on Abuse and Neglect Prevention;- CNA B did not attend an annual competency in-service training on Dementia Care;- CNA B did not attend any in-service training for January 2025 through January 2026. During an interview on 01/08/26 at 2:45 P.M., the Administrator said she would expect CNAs have at least 12 hours of in-service education per year which included the mandatory annual competency trainings.

Based on interview and record review, the facility failed to follow the resident's care plan, dated 8/30/24, to ensure staff utilized safe transfer techniques for one resident (Resident #1) when staff failed to transfer the resident via a mechanical lift out of one sampled resident. The resident sustained a hematoma (a collection of blood that pools outside of a blood vessel in an organ, tissue, or body space) to the chest area. The facility census was 72. The Administration was notified on 12/11/24 of the Past Non-Compliance citation. On , 12/06/24 and 12/09/24, the facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered the use of care plans, policy and procedure for transfers, and proper use of a gait belt and Hoyer lift. The deficiency was corrected on 12/09/24. Review of the facility's policy titled, Using the Care Plan, revised October 2018, showed: - The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident; - Care plans are used to develop daily care practices for staff. Review of the facility's policy titled, Safe Lifting and Movement of Residents, revised July 2017, showed: - In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; - Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; - Staff will document resident transferring and lifting needs in the care plan; - Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary; - Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. 1. Review of Resident #1's medical record showed: - An admitted [DATE]; - Diagnoses of fracture of sixth cervical (neck) vertebra (bones in the spine), hemiplegia (paralysis of one side of the body), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), dysphagia (difficulty swallowing), and muscle weakness. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 11/27/24, showed: - Moderately cognitively impaired; - Total dependence of one staff for bed mobility, dressing, personal hygiene, and bathing; - Total dependence of two staff for transfers and toilet use; - Always incontinent of bowel and bladder. Review of the resident's Care Plan, dated 08/30/24, showed: - Resident required assist per staff with Activities of Daily Living (ADL) and mobility; - Resident used a wheelchair for locomotion; - Resident required mechanical lift transfers with assistance of two staff for the transfers. Review of the resident's Progress Notes, dated 12/06/24 at 10:41 A.M., showed: - Resident had a soft, swollen pocket to the right upper chest/breast area and the area below the breasts and upper rib cage appeared to be bruised; - Resident complained of pain to the area; - Resident sent to the emergency room via ambulance for evaluation. Review of the resident's Computed Tomography (CT - a medical imaging procedure that uses rays and a computer to create detailed pictures of the inside of the body) scan of the chest, dated 12/06/24, showed: - A probable hematoma within the anterior (the front) right chest wall measured 8.7 centimeters (cm) wide by 5.2 cm deep by 10.2 cm in height. Review of the facility's investigation, dated 12/11/24, showed: - Certified Nurse Assistant (CNA) B and CNA C did not transfer Resident #1 according to his/her care plan; - During an interview CNA B said he/she and CNA C transferred Resident #1 without using a mechanical lift on 12/05/24. The resident said it was okay to transfer him/her without a mechanical lift; - During an interview, Resident #1 said he/she did not tell CNA B and CNA C that it was okay to transfer him/her without a mechanical lift; - During an interview, CNA C said he/she helped CNA B transfer Resident #1 without a mechanical lift on 12/05/24; - CNA B and CNA C were suspended pending the investigation; - Nursing staff were in-serviced regarding the use of care plans, policy and procedure for transfers, and proper use of a gait belt and Hoyer lift on 12/06/24 at 1:00 P.M., and on 12/09/24 at 1:30 P.M. Observation of Resident #1 on 12/11/24 at 11:30 A.M., showed the resident had a large raised purple area to his/her right mid-chest. During an interview on 12/11/24 at 11:22 A.M., Resident #1 said two Certified Nurse Aides (CNA's) moved him/her from a shower chair to his/her wheelchair in the shower room last week. The CNA's bear-hugged him/her, lifted him/her up, and put him/her in the wheelchair. He/She was bruised all over from it. The bruising was painful at times, but that he/she had pain medication that controlled the pain. During an interview on 12/11/24 at 2:29 P.M., Licensed Practical Nurse (LPN) A said he/she was on duty when Resident #1 was found with a hematoma. LPN A was called to the the resident's room by a CNA on duty and found the resident had a small raised bruised area to his/her right chest. Within 30 minutes, the area had doubled in size and he/she notified the Administrator and sent the resident to the emergency room . During an interview on 12/11/24 at 2:45 P.M., the Administrator said on 12/06/24, she was notified Resident #1 had an injury and began investigating immediately. It was found that two CNA's had transferred the resident without using the mechanical lift per the resident's care plan. She expected staff to transfer a resident according to his/her care plan. During an interview on 12/17/24 at 1:51 P.M., CNA C said around lunch time on 12/05/24, Resident #1 asked him/her and another CNA to stand him/her up and transfer him/her to his/her chair. After the resident had been transferred, he/she did not complain of pain, injury, or show any signs of pain. CNA C left to go on break and when he/she returned, the resident was already back in bed. He/She did not know how the resident was injured. During an interview on 12/17/24 at 1:57 P.M., CNA B said on 12/05/24, Resident #1 requested he/she and another CNA transfer him/her without a mechanical lift. He/She and another CNA lifted the resident under the arms and did a two person transfer to the shower chair. The resident did not say anything about having pain or an injury. He/She did not know how the resident was injured. Complaint #MO00246204

Based on interview and record review, the facility failed to allow one resident (Resident #1) to return to the facility after being sent out to the hospital for an evaluation. The facility census was 76 residents. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed-hold policy within 24 hours of such transfer; - If the facility determines that a resident who was transferred cannot return to the facility, the facility will comply with the facility's Discharge Policy. Review of the facility's policy titled, Transfers and Discharges (Including Against Medical Advice (AMA), dated September 2022, showed: - If a Notice of Discharge is given the facility will send a copy of transfer or discharge notice to the Ombudsman. The facility will also provide to the resident and/or resident representative additional information in the notice regarding the process for appealing transfer or discharge; - If the facility has made the decision that a resident cannot return to the facility following a hospital discharge the facility must discharge the resident according to the policy. The medical record should show documentation of the reason the resident cannot return to the facility. A discharge notice must be presented to the resident or resident's representative in the case that a resident is not returning to the facility as decided by the facility; - Provide the resident with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address and phone number of the State long term care ombudsman; - For developmentally disabled individuals the appeal rights notice must include the name, address and phone number of the agency responsible for advocating for the developmentally disabled; - The physician should document medical reasons for transfer or discharge in the medical record. A copy of the physician's order for discharge should be attached to the discharge notice. 1. Review of Resident #1's medical record showed: - admitted [DATE]; - Diagnoses of spina bifida occulta (a gap formed in the spine at birth), pressure ulcer of the sacral region (a wound caused from limited mobility to the spine that connects to the pelvis), colostomy (when the colon is diverted through the abdomen), dysphagia (difficulty swallowing), schizophrenia (a chronic mental illness that affects a person's thoughts, feelings and behaviors), bipolar disorder (extreme mood swings, along with changes in thinking and behavior), type 2 diabetes mellitus (a chronic disease when the body doesn't produce enough insulin or use it properly), attention-deficit hyperactivity disorder (a chronic mental disorder that affects a person's behavior and ability to focus and control impulses), anxiety (excessive fear, dread, or uneasiness), and depression (persistent low mood and loss of interest); - Resident is his/her own responsible party; - An entry on the resident's Electric Medical Record (EMR) assessments page, dated 09/26/24, for the completion of a transfer form for discharge to the hospital; - No official discharge notice to the resident or resident's representative. Review of the resident's Preadmission Screening and Resident Review (PASARR - an evaluation guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) Level I screening, dated 11/15/23, showed: - The resident with a diagnosis of spina bifida and schizophrenia that would qualify as a related condition; - A PASRR Level II screening was indicated for intellectual disability or related condition. Review of resident's Level II PASARR dated, 11-21-23, showed resident had auditory hallucinations, schizophrenia, psychotic disorder, anxiety disorder, MDD, personality disorder, adjustment disorder, bi-polar disorder, obsessive-compulsive disorder, spina bifida, hydrocephalus, paraplegia, suicidal ideations; - The PASRR Level II Evaluation, dated 11/30/23, showed the residents' needs could be met in a nursing facility. Review of the resident's discharge Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 09/26/24, showed: -Resident was discharged with return anticipated; - Able to make consistent and reliable decisions independently. Review of the resident's nurse's note, dated 09/26/24, at 4:07 A.M., showed: - The resident was returned from the hospital at approximately 9:00 P.M., on 09/25/24, via ambulance; - The resident complained of chest pain. Vital signs obtained; - The resident was able to answer questions appropriately but then began to switch the conversation to family deaths and his/her role in them; - The resident said he/she was going to do something stupid and requested to go to the hospital; - The on-call provider was contacted and order obtained to send the resident to the hospital for a thorough psychiatric evaluation and treatment; - Emergency Medical Services (EMS) arrived and departed facility with resident en route to the emergency room (ER). Review of the resident's hospital records, dated 09/26/24, showed: - On 09/26/24, the resident was seen by a telepsychiatry physician; - On 09/26/24, the psychiatrist recommendations were for medication adjustments and supportive psychotherapy (a variety of treatments that aim to help a person identify and change troubling emotions, thoughts, and behaviors); - On 09/26/24, the resident was cleared by psychiatry to return to the facility. The resident wanted to return to the facility; - On 09/26/24, the facility reported to the hospital staff they would not take the resident back until he/she has had an inpatient psychiatric stay with medication adjustments; - On 09/26/24, the hospital continued to search for placement. The resident was never admitted to the hospital, but remained in the ER; - On 10/08/224, the resident continued to be stable for discharge from the ER back to the facility; - On 10/09/24, the resident was accepted for admission to another skilled nursing facility from the ER; - The resident remained in the ER from 09/26/24 - 10/09/24, without admission to the hospital. During an interview on 10/08/24, at 10:20 A.M., the Director of Nursing (DON) said: - On the morning of 09/26/24, the resident complained of chest pain. The resident said he/she was going to do something stupid. The on-call provider was notified and the staff received an order to send the resident out for a psychiatric evaluation; - The facility did not discharge the resident, they were waiting for the resident to receive in-patient psychiatric services; - The medical director said the resident was not safe at the facility and the staff were not able to provide care to the resident. Therefore, they could not accept the resident back to the facility. Review of a letter from the facility's Medial Director, dated, 10/08/24, showed: - Based on the psychiatric evaluation, the staff at the facility would need to do 1:1 suicidal watch care for Resident #1, which the facility is not equipped or staffed to provide. After speaking with the DON and the Psychiatric Nurse Practitioner, the decision to not readmit the resident at this time was made for the resident's safety. It was advised that the resident be admitted to a behavioral psychiatric unit for acute care. During an interview on 10/08/24 at 11:35 A.M., the Registered Nurse Case Manager (RN CM) at the ER said: - The resident was brought into theER on the morning on 09/26/24; - The resident underwent a psychiatric evaluation on 09/26/24. The resident was deemed able to return to the facility with medication modifications; - The facility medical director refused to accept the resident back to the facility until the resident had an inpatient psychiatric stay with medication adjustments; - He/She sent over 50 referrals to other long-term care facilities and received 25 denials. Due to the medical complexities of the resident, in-patient psychiatric facilities were not equipped to manage the resident's medical needs; - The facility did not issue the resident a discharge notice and did not assist with finding placement; - The resident was not admitted to the hospital due to being medically stable. The resident had been in the ER for two weeks. During an interview on 10/15/24 at 2:21 P.M., the DON said she went to the ER and interviewed the resident. The resident said he/she didn't want to live in a facility anymore. The resident wanted to live on his/her own in an apartment. She said the resident still had a 1:1 sitter at the ER. She went to the ER to do an assessment, not to discharge the resident, but the resident was not better. The resident was still hearing voices. The DON said the facility did not issue a discharge notice at that time. During an interview on 10/15/24 at 2:30 P.M., the Administrator said the DON went to the ER and saw the resident on 10/09/24. The hospital found placement for the resident at another long-term care facility. The Administrator said the facility did not begin the discharge process at any time for Resident #1. No discharge process had been started, but the resident would not be allowed back to the facility without an in-patient psychiatric stay. MO00242905

Based on interview and record review, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer, for seven residents (Resident #8, #21, #31, #33, #35, #36, and #55) out of 10 sampled residents. The facility's census was 82. The facility did not provide a policy for transfer/discharge notification. 1. Review of Resident #8's medical record showed: - The resident transferred to the hospital on 03/06/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 03/16/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 03/27/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/18/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 03/06/24, 03/16/24, 03/27/24, and 07/18/24. 2. Review of Resident #21's medical record showed: - The resident transferred to the hospital on 03/14/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/08/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/22/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/27/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 03/14/24, 04/08/24, 04/22/24, and 05/27/24. 3. Review of Resident #31's medical record showed: - The resident transferred to the hospital on 08/30/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfer to the hospital on 08/30/24. 4. Review of Resident #33's medical record showed: - The resident transferred to the hospital on 10/03/23, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 10/26/23, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 11/14/23, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 10/03/23, 10/26/23, and 11/14/23. 5. Review of Resident #35's medical record showed: - The resident transferred to the hospital on 05/01/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/09/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/12/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/23/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/09/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/18/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 05/01/24, 05/09/24, 05/12/24, 05/23/24, 07/09/24, and 08/18/24. 6. Review of Resident #36's medical record showed: - The resident transferred to the hospital on 08/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/22/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 08/02/24 or 08/22/24. 7. Review of Resident #55's medical record showed: - The resident transferred to the hospital on 06/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/19/24, and readmitted to the facility on [DATE]; - No documentation of written notification provided to the resident and/or the resident's representative for the transfers to the hospital on 06/03/24 or 07/19/24. During an interview on 09/12/24 at 4:00 P.M., the Administrator said she would expect notice of a resident's transfer or discharge to the hospital to be given to the resident and/or the resident's representative in writing. She would also expect it to be documented in the resident's medical record that the notice was given to the resident or their representative. 49150 49152 49999

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of their bed hold policy at the time of transfer to the hospital for five residents (Resident #21, #31, #33, #36, and #55) out of 10 sampled residents. Facility census was 82. Review of the facility's policy titled, Bed Holds, dated March 2022, showed: - Upon admission and when a resident is transferred to hospitalization or for therapeutic leave, the facility will provide information regarding the bed-hold policy to the resident or representative in a written format that is understood by the resident or representative; - When emergency transfers are necessary, the facility will provide the resident or representative with information concerning the bed-hold policy within 24 hours of such transfer. 1. Review of Resident #21's medical record showed: - The resident transferred to the hospital on 03/14/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/08/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 04/22/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 05/27/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 2. Review of Resident #31's medical record showed: - The resident transferred to the hospital on 08/30/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 3. Review of Resident #33's medical record showed: - The resident transferred to the hospital on 10/26/23, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfer. 4. Review of Resident #36's medical record showed: - The resident transferred to the hospital on 08/02/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 08/22/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 5. Review of Resident #55's medical record showed: - The resident transferred to the hospital on 06/03/24, and readmitted to the facility on [DATE]; - The resident transferred to the hospital on 07/19/24, and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. During an interview on 09/12/24 at 4:00 P.M., the Administrator said she filled out the Bed Hold Notice form, mailed it to the resident's representative, and then made a note in the resident's chart. 49150 49152 49999

Based on interview and record review, the facility failed to develop and implement comprehensive care plans for two residents (Resident #33 and #35) out of 18 sampled residents. The facility's census was 82. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated October 2017, showed: - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care; - Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; - Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The IDT must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS - a federally mandated assessment to be completed by facility staff). 1. Review of Resident #33's medical record showed: - A diagnosis of Parkinsonism (a disease of the central nervous system that affects movement, often including tremors); - admitted to hospice for Parkinson's Disease on 11/08/23. Review of the resident's care plan, dated 09/09/24, showed Parkinsonism, including risks, goals, and interventions were not addressed. 2. Review of Resident #35's medical record showed: - A computed tomography (CT - a medical imaging scan used to obtain detailed internal images of the body) scan report, dated 06/02/22, showed a right-sided mediport (medical device put just below skin for access if blood needs drawn or intravenous medications need given) catheter; - No documentation for assessments of the mediport, an order to access the mediport, or and order/protocol to maintain the mediport. Review of resident's care plan, dated 08/04/24, showed the mediport, including risks, goals, and interventions were not addressed. Observation on 09/13/24 at 1:45 P.M. showed a right side upper chest mediport on Resident #35. The mediport had three small bumps for identification to access the mediport in the proper place. During an interview on 09/13/24 at 1:45 P.M., Resident #35 said he/she had a mediport because of poor veins and was a very hard person to stick for blood or intravenous (IV) access. He/She had the mediport for years. During an interview on 09/13/24 at 3:00 P.M., the DON and MDS Coordinator said the interdisciplinary team was in charge of developing the care plans. The DON and MDS Coordinator said that if a resident's condition changed, then the care plan would be revised. During an interview on 09/13/24 at 3:00 P.M., the Administrator said the interdisciplinary team was in charge of developing the care plans. The care plan should accurately reflect the resident's current condition.

Based on observation, interview, and record review, the facility failed to have an order for and a process in place for accessing, maintaining, and assessing a mediport (medical device put just below skin for access if blood needs drawn or intravenous medications need given) for one resident (Resident #35) out of one sampled resident. The facility did not provide a policy on mediport care/maintenance. 1. Review of Resident #35's medical record showed: - A computed tomography (CT - a medical imaging scan used to obtain detailed internal images of the body) scan report, dated 06/02/22, showed a right-sided mediport catheter; - No order for the mediport; - No orders and/or protocols to access and maintain the mediport; - No documentation for assessments of the mediport. Review of resident's care plan, dated 08/04/24, showed the mediport, including risks, goals, and interventions, not addressed. Observation on 09/13/24 at 1:45 P.M. showed a right side upper chest mediport on Resident #35. The mediport had three small bumps for identification to access the mediport in the proper place. During an interview on 09/13/24 at 1:45 P.M., Resident #35 said staff accessed his/her mediport on 09/11/24, to draw lab work. He/She had the mediport for years because of poor veins and was a very hard person to stick for blood or intravenous (IV) access. Only one staff person knew how to access the mediport at the facility. During an interview on 09/13/24 at 2:00 P.M., the Director of Nursing (DON) said she was the only person in the facility who knew how to access and draw blood from Resident #35's mediport. She would expect there to be orders for the mediport and care/maintenance for the mediport. She would also expect assessments to be completed for the mediport.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of five percent (%) or less. There were six errors out of 43 opportunities for errors, resulting in an error rate of 13.95%. This affected six residents (Resident #17, #20, #24, #33, #44 and #46), out of 10 sampled residents. The facility census was 82. The facility did not provide a policy for insulin pens. Review of Novolog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) manufacturer instructions, revised February 2023, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing: remove the cap; attach the needle; prime the pen by turning the dose selector to select two units; press and hold the button and make sure a drop of insulin appears; select the dose; and give the injection. Review of Humalog (a fast acting insulin injected just below the skin) Kwik Pen (insulin in a pen-type device) manufacturer instructions, revised August 2023, showed: - Remove the cap; - Attach the needle; - Prime the pen before each injection. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin; - To prime the pen: turn the dose knob to select 2 units; push and hold the button and make sure a drop of insulin appears; - Select the dose; - Give the injection. Review of Fiasp (a rapid acting insulin injected just below the skin) Flextouch (insulin in a pen-type device) manufacturer instructions, dated July 2023, showed: - Remove the cap; - Check the liquid in the pen; - Attach the needle; - Prime the pen. Prime the pen by turning the dose selector to select two units; press and hold the button and make sure a drop of insulin appears; - Select the dose; - Give the injection. 1. Review of Resident #17's Physician's Order Sheet (POS), dated September 2024, showed: - An order for Humalog Kwikpen inject six units subcutaneously ((an injection just beneath the skin) before meals, dated 09/04/24; - An order for Humalog Kwikpen inject per sliding scale (progressive increase in the pre-meal or nighttime insulin dose based on pre-defined blood glucose ranges) for a blood sugar of 351-400, give six units, dated 09/04/24. Observation of the resident on 09/12/24 at 10:45 A.M., showed: - The resident's blood sugar was 384; - Certified Medication Technician (CMT) A administered Humalog Kwikpen 12 units to the resident; - CMT A failed to prime the Humalog Kwikpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 2. Review of Resident #46's POS, dated September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 05/01/24. Observation of the resident on 09/12/24 at 11:08 A.M., showed: - The resident's blood sugar was 162; - CMT A administered Novolog Flexpen two units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 3. Review of Resident #20's Physician Order Sheet (POS), dated September 2024, showed: - An order for Novolog Flexpen inject 12 units subcutaneously before meals, dated 08/19/24; - An order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 08/19/24. Observation of the resident on 09/12/24 at 11:19 A.M., showed: - The resident's blood sugar was 185; - CMT A administered Novolog Flexpen 14 units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 4. Review of Resident #24's POS, dated September 2024, showed an order for Fiasp Flextouch Pen inject per sliding scale for a blood sugar of 181-220, give four units, dated 06/17/24. Observation of the resident on 09/12/24 at 11:27 A.M., showed: - The resident's blood sugar was 214; - CMT A administered Fiasp Flextouch Pen four units to the resident; - CMT A failed to prime the Fiasp Flextouch Pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 5. Review of Resident #44's POS, dated September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 150-199, give three units, dated 03/01/23. Observation of the resident on 09/12/24 at 11:41 A.M., showed: - The resident's blood sugar was 184; - CMT A administered Novolog Flexpen three units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 6. Review of Resident #33's POS dated, September 2024, showed an order for Novolog Flexpen inject per sliding scale for a blood sugar of 151-200, give two units, dated 10/31/23. Observation of the resident on 09/12/24 at 11:41 A.M., showed: - The resident's blood sugar was 155; - CMT A administered Novolog Flexpen two units to the resident; - CMT A failed to prime the Novolog Flexpen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. During an interview on 09/12/24 at 11:50 A.M., CMT A said that he/she was not aware that insulin pens needed to be primed. During an interview on 09/12/24 at 4:30 P.M., the Administrator said she would expect the manufacturer's guidelines to be followed when administering insulin with an insulin pen.

Based on interview and record review, the facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an antibiotic stewardship program. This deficient practice had the potential to affect all residents in the facility. The facility census was 82. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2018, showed: - The facility's Infection Prevention and Control Program (IPCP) follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible; - The Infection Prevention and Control Program includes an antibiotic stewardship program. Review of the facility's policy titled, Infection Prevention and Control Manual Antibiotic Stewardship and Multidrug Resistant Organisms (MDROs), dated 2017, showed the Director of Nursing (DON) or designee will track antibiotic use and monitor adherence to evidence-based criteria. The facility did not provide documentation for the antibiotic stewardship program. During an interview on 09/10/24 at 9:30 A.M., the Administrator said the former DON/Infection Preventionist quit suddenly in August 2024, and he/she had been responsible for the antibiotic stewardship program. During an interview on 09/13/24 at 2:45 P.M., the DON said she was unable to find the antibiotic stewardship program documentation. The former DON quit suddenly and took all of the antibiotic stewardship program information.

Based on observation, record review and interviews, the facility failed to ensure all residents were kept free from possible accident hazards when the facility staff failed to monitor one resident (Resident #12) outside the sample for self administration of dietary supplements bought on the Internet and for giving the same supplements to another resident (Resident #49) out of a sample of 18. The facility census was 73. Record review of the facility policy titled Medications Brought to the Facility by the Resident/Family, revised April 2007, showed: -The facility shall ordinarily not permit residents and families to bring medications into the facility; -Residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility; -The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy, as well as applicable laws and regulations; -If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: A) State law and regulations allow such use; B) The medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet; C) The contents of each container are labeled in accordance with established policies; D) The contents of each container have been verified by a licensed pharmacist. The facility did not provide a policy regarding residents having dietary supplements. The facility did not provide a policy regarding resident safety regarding purchasing medication/supplements online and sharing with other residents. 1. During an interview on 2/6/23 at 3:00 P.M., Significant Other (SO) A said Resident #12 gave Resident #49 a bottle of Cannabidiol (CBD, a compound found in cannibas) gummies. Review of Resident #49's medical record showed: -An admitted [DATE]; -Diagnoses included Alzheimer's dementia (progressive mental deterioration), Type 2 diabetes, anxiety, major depressive disorder, delusional disorders (a mental disorder marked by false beliefs) and chronic pain; -The Minimum Data Set (MDS-a federally mandated assessment, required to be completed by the facility) for significant change, dated 1/19/23, identified Resident #49 as severely cognitively impaired with a Cognition Score of 5; -The Physician order sheet, current as of 2/9/23, no order for self administration of CBD gummies; -The Medication Administration Record (MAR) from 12/1/22 through 2/9/23, showed no documentation of CBD gummies administration; -The nursing notes from 12/1/22 through 2/7/23 showed no documentation regarding resident receiving CBD gummies from Resident #12, nor the physician being notified Resident #49 took two CBD gummies. Record review on 2/7/ 2022 at 10:00 A.M., showed Resident #49's care plan did not address: - The use of CBD gummies for self-administration; - The resident taking a bottle of supplements from another resident; - Any interventions for monitoring. Review of Resident #12's medical record showed: -admitted [DATE]; -Diagnoses included Chronic obstructive pulmonary disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar), anxiety (a feeling of worry, nervousness, or unease), and depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); -The significant change MDS, dated [DATE], identified Resident #12 as cognitively intact, with a cognition score of 15 (highest); -The current Physician order sheet, as of 2/9/23, showed no order for self administration of CBD gummies; -The Medication Administration Record (MAR) from 12/1/22 through 2/9/23, showed no documentation of CBD gummies administration; -No documentation of notification to the doctor regarding CBD gummy use; -No documentation of an investigation as to how the resident acquired the CBD Record review on 2/7/ 2022 at 10:00 A.M., showed Resident #12's care plan did not address: - The use of CBD gummies for self-administration; - The resident purchasing dietary supplements off of the Internet; - The resident giving other residents bottles of dietary supplements for self administration; - Any interventions for monitoring. During an interview on 2/7/23 at 10:00 A.M., Resident #12 said he/she ordered CBD gummies from the Internet and had them delivered to the facility. Resident #12 said the CBD gummies are the only supplement he/she has ordered. He/she ordered five bottles of the CBD gummies and gave one bottle to Resident #49 because he/she thought it might help with Resident #49's pain. Resident #12 said he/she takes two of the CBD gummies every day and had consumed at least one entire bottle. Resident #12 said he/she did not consult a doctor prior to taking and did not know of any possible side effects or interactions with other medications. Resident #12 did not know what other medications Resident #49 took. Resident #12 said he/she still had a bottle at her bedside. Resident #12 found the packing slip for the CBD gummies. The order for five bottles was placed on 12/5/2022 and delivered to the resident at the facility on 12/15/2022. Resident #12 said he/she gave Resident #49 a bottle, and he/she had one bottle left so he/she guessed she had gone through three bottles. Observation showed a bottle of Proper CBD Gummies 300 MG Pure Organic Hemp Extract, THC Free Formula, labeled as a dietary supplement, which had directions to take 1 to 2 gummies once a day, stored in a plastic storage cart next to the resident's bed. Review of the manufacturer's website for the Proper CBD gummies showed the following advisory: While CBD is generally considered safe, it can cause side effects like dry mouth, diarrhea, and reduced appetite. Additionally, CBD can interact with other medications you're taking, so it's important to talk to your doctor before using it. During an interview on 2/7/23 at 1:05 P.M., the DON said he/she was aware that Resident #12 had CBD gummies and had given some to Resident #49. The DON said the gummies were removed from Resident #49's refrigerator. The DON said the facility does not allow residents to keep medications or supplements in their room. The DON said he/she did not address the issue with Resident #12 or contact Resident #49's doctor with the information. He/She did not know if Resident #12 had any supplements in his/her room currently. He/She said the administrator said he/she would address the situation with Resident #12. The DON did not know if there was any documentation regarding the incident in either resident's medical record, or if any interventions had been put in place. During an interview on 2/7/23 at 1:20 P.M., the Administrator said he/she had been made aware that Resident #12 gave Resident #49 CBD gummies on 12/29/2022. The Administrator said she confirmed the bottle had been removed. Staff counted the gummies in the bottle and found two missing. The administrator thought staff had contacted Resident #49's Nurse Practitioner, but did not know if anyone had contacted Resident #12's doctor. The Administrator said she had talked with Resident #12 about giving the gummies to Resident #49, but could not find any documentation of that conversation or any other interventions taken. The Administrator thought the conversation with Resident #12 took place around the first week of January 2023. The Administrator was not aware Resident #12 currently had more CBD gummies in his/her room. The Administrator did not know if either residents' care plan had been updated. During a phone interview on 2/7/23 at 1:38 P.M., the Medical Nurse Practitioner (MNP) said residents are not supposed to have medications or supplements in their rooms. The MNP would have expected the CBD gummies to have been removed and both residents to be monitored. He/she said the primary physician should have been contacted to see if an order needed obtained for the resident to take CBD gummies. He/she was not aware that Resident #12 still had CBD gummies in his/her room. During interview on 2/8/23 at 8:45 A.M., the Administrator said she and the DON, the Social Services Director and the MDS coordinator held a care plan meeting last evening with Resident #12 regarding buying medications or supplements off the Internet, without letting the facility know and giving supplements to other residents. The Administrator said Resident #12 informed them that he/she kept the gummies where no one could get to them in her purse. Resident #12 was to have surrendered all the gummies to staff, but she would make sure Resident #12 wasn't hiding more gummies in a drawer as was seen the day before. 46460

Based on observation, interview and record review, the facility failed to utilize proper technique during incontinent care for one resident (Resident #3) when staff touched the trash can during care and dropped the box of wipes on the floor three times. Staff did not change gloves, perform hand hygiene after touching the trash can and the box of wipes that he/she picked up from the floor. During wound care staff failed to use a barrier for supplies, disinfect the bandage scissors, used for multiple residents, before and after use, and perform appropriate hand hygiene and glove changes for one resident (Resident #14), outside of 18 sampled residents. The facility failed to maintain infection control practices to prevent the development and transmission of infection when staff did not wash or sanitize hands and wear gloves during medication administration for one resident (Resident #69) out of 18 sampled residents and nine residents (Resident #1, #3, #11, #15, #27, #36, #39, #48, and #58) outside of the sample. The facility's census was 73. Record review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2015, showed: - The facility considers hand hygiene the primary means to prevent the spread of infections; - Wash hands with soap and water for the following situations: * Hands are visibly soiled; * After contact with a resident with infectious diseases; - Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: * Before and after coming on duty; * Before and after direct contact with residents; * Before preparing or handling medications; * Before moving from a contaminated body site to a clean body site during resident care; * Before handling clean or soiled dressings, gauze pads, etc; * After contact with resident's intact skin; * After removing gloves. - Hand hygiene is the final step after removing and disposing of personal protective equipment. 1. Observation on 2/5/23 at 1:39 P.M. showed: - Resident #3 lay in bed on a mechanical lift sling wearing pants which were visibly wet. Certified Medication Technician (CMT) G and Certified Nurses Aide (CNA) H removed the resident's pants, brief, and sling, then placed the soiled sling in the resident's wheelchair. CMT G and CNA H then provided peri care for the resident; - CMT G picked up the trash can with bare hands and handed it to CNA H who held the trash can with his/her forearms and set it onto the floor; - CMT G applied gloves without sanitizing hands; - CNA H, with forearms that were used to hold the trash can, repositioned the resident while CMT G provided peri care; - An open wipe container fell from the bed three times during care, and CMT G picked it up and placed it back onto the bed without changing gloves; - CMT G did not to change gloves after providing peri care. During an interview on 2/5/23 at 1:50 P.M., both CMT G and CNA H said hands should be sanitized when going into a room, with every glove change and when going from dirty to clean. Hands should be washed before exiting the room and in between glove changes if gloves are soiled. Both said the Hoyer sling should have been taken to be cleaned and a new sling obtained. CNA H said he/she knew the minute he/she had picked the trash can up with his/her arms, that they should have been sanitized before repositioning the resident with his/her arms. Both said they did not sanitize with every glove change. 2. Observation on 2/7/23 at 9:33 A.M. showed: - Licensed Practical Nurse (LPN) I and Registered Nurse (RN) J performed wound care for Resident #14; - LPN I did not provide a barrier for supplies that had been placed on the resident's nightstand; -LPN I cut off the old bandage with scissors and did not clean scissors prior to removing the bandage; -LPN I sat the scissors on the nightstand with no barrier after cutting the bandage; -LPN I removed gloves and applied new gloves without washing or sanitizing hands; -LPN I sprayed gauze with wound cleanser, then removed Xeroform from the resident's wound; -LPN I removed gloves and washed hands, then applied gloves and cleansed wound with wound cleanser; -LPN I removed gloves and washed hands and opened rolled gauze and Xeroform and applied to the resident's wound; -LPN I removed gloves and washed hands, then applied gloves and applied tape to gauze and wrote the date; -LPN I removed gloves and washed scissors with soap and water and put scissors in pocket of scrub pants. During an interview on 2/7/23 at 11:36 A.M., LPN I said he/she should have placed a barrier between supplies and a dirty surface. Hands should be washed or sanitized before wound care wash, sanitize from dirty to clean, and wash hands after care. Scissors should be cleaned with a Sanicloth wipe or soap and water before and after use. 3. Observation of medication pass by CMT K on 2/7/23 at 11:48 A.M. through 12:49 P.M. showed: - CMT K did not wash or sanitize hands prior to or after providing medication to Resident #36; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #11; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #3; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #39; - CMT K did not wash or sanitize hands prior to or after providing medications to Resident #69; - CMT K did not wash or sanitize hands prior to providing medications to Resident #27; - CMT K did not wash or sanitize hands after providing medication to Resident #15; - CMT K did not wash or sanitize hands prior to inserting eye drops into both eyes of Resident #48 with ungloved hands; - CMT K did not wash or sanitize hands prior to providing medication for Resident #1; - CMT K removed a straw from a package for Resident #58 and touched the end of the straw that would go into the resident's mouth with his/her bare hand. During an interview on 2/7/23 at 12:49 P.M., CMT K said he/she can't wash hands in between each person, but tried to sanitize. Hands should be washed when going into rooms and sanitized when leaving. Hands should be washed before and after eye drops and gloves worn when touching someone's eye, and should not touch anything that goes into a resident's mouth without gloves. 4. Observation on 2/9/23 at 1:05 P.M. showed: - RN F removed a bandage from the elbow of Resident #54; - RN F pulled scissors from his/her pocket and cut new dressing to fit; - RN F placed scissors on sink without placing a barrier; - RN F removed gloves and placed the scissors back into his/her pocket before washing hands. During an interview on 2/9/23 at 1:50 P.M., RN F said a barrier should have been laid down prior to providing wound care, and scissors should have been sanitized before and after use. During an interview on 2/9/23 at 5:35 P.M., the Director of Nursing said she would expect scissors to be sanitized before and after each use. She would expect hand hygiene to be performed between clean and dirty while providing care. 46460

Based on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #7) out of 18 sampled residents and two residents (Resident #31 and #32) outside of the sample. The facility's census was 73. Record review of the facility's policy, End-Stage Renal Disease, Care of a Resident With revised September 2010, showed: - Agreements between this facility and the contracted end stage renal disease facility (ESRD) include all aspects of how the resident's care will be managed including: a) How the care plan will be developed and implemented; b) How information will be exchanged between the facilities. 1. Review of Resident #7's medical record showed: - Diagnoses of chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and dependence on renal dialysis; - Started dialysis 1/23/23; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. 2. Review of Resident #31's medical record showed: - Diagnoses of chronic kidney disease, and dependence on renal dialysis; - Started dialysis 11/29/19; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. 3. Review of Resident #32's medical record showed: - Diagnoses of chronic kidney disease, and dependence on renal dialysis; - Started dialysis 1/11/21; - Goes to dialysis three times a week; - No documentation to assess and monitor the resident's condition before and after dialysis treatments; - No documentation of on-going communication between the facility and dialysis staff. During an interview on 02/9/23 at 10:35 A.M., the Administrator said they use two centers for the three residents that receive dialysis. The Administrator said they talk with the centers as needed, but do not talk routinely with them for every appointment and no documentation is shared routinely with the centers. She said the nurses do not do assessments when their dialysis residents come back and do not have coordinated plans of care. She said they coordinate transportation when residents come back from their appointments. She said staff will lay eyes on the dialysis residents and take them to dinner when they arrive back at the facility. During an interview on 02/9/23 at 12:31 P.M., the Infection Preventionist said they just look at the ports and the area surrounding the port, as well as labs and vital signs. The labs are usually drawn and the nurse who gets the labs off the fax sends it to the doctor, but that is really it as far as checking the dialysis residents. He/she denied having a coordinated plan of care. He/she said sometimes the dialysis center will give a heads up if something is concerning for them to look for, but otherwise the residents will often go straight to the dining room to eat or to their room when returning from dialysis. He/she said they do not always document information about the dialysis or resident's condition in the chart.

Based on interview and record review, the facility failed to ensure the physician responded to the pharmacist's recommendations in regard to the resident's antidepressant medications for two residents (Resident #14 and #22) out of 18 sampled residents. The facility's census was 73. Record review of the facility's policy titled, Gradual Dose Reduction of Psychotropic Drugs, updated September 2022, showed: - Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who use psychotropic drugs; - GDR's will be documented on the psychotropic Dose Reduction History form; - The GDR may be clinically contraindicated for reasons that include, but not limited to, returned or worsened after most recent attempt at a GDR within the facility and the physician has documented rationale for why any additional attempted dose reduction at that time would likely impair the resident's function or increase distressed behavior. 1. Record review of Resident #14's Physician's Order Sheet (POS), dated February 2023, showed: - Orders for Citalopram (antidepressant medication) 40 milligrams (mg) daily for depression; - Orders for Mirtazapine (antidepressant medication) 30 mg at bedtime for major depressive disorder. Record review of the monthly Pharmacist's Review, dated 5/19/22, showed: - Recommendation to decrease Citalopram 40 mg daily to 30 mg daily; - Recommendation to decrease Mirtazapine 30 mg to 22.5 mg at bedtime; - Not addressed by physician. 2. Record review of Resident #22's POS, dated February 2023, showed: - Orders for Citalopram 10 mg daily for major depressive disorder. Record review of the monthly Pharmacist's Review, dated 8/10/22, showed: - Recommendation to decrease Citalopram 10 mg daily if appropriate; - Not addressed by physician due to Resident being out to hospital on the date received. During an interview on 2/8/23 at 4:25 P.M., the Psychiatric Nurse Practitioner (NP) said rounds are made every other week. The facility is able to fax or call reports in if they have a gradual dose reduction (GDR) that needs addressed. Once reviewed, the new order will be added to point click care (PCC), sign and return the GDR recommendation. During an interview on 2/8/23 at 4:51 P.M., the Administrator said she would expect the physician/NP to respond within 30 days. The facility tries to get the GDR recommendations to the physician/NP within 48-72 hours. The Director of Nursing (DON) is the one who will follow up with responses. During an interview on 2/9/23 at 5:35 P.M., the DON said she would expect all medications on a GDR to be addressed. During an interview on 2/9/23 at 5:35 P.M., the Administrator said she would have expected a GDR from August, 2022 to have already been addressed with some kind of reply.

Based on observation, record review and interview, the facility failed to label and store drugs in accordance with currently accepted professional principles and had potential to affect all residents. The facility's census was 73. Review of the facility's policy titled, Storage of Medications, last revised April 2007, showed: - Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; - The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner; - Medications requiring refrigeration must be stored in a refrigerator located in the drug room at nurse's station or other secure location. Medications must be stored separately from food and must be labeled accordingly. 1. Observation of the Certified Medication Technician (CMT) medication room on 2/7/23 at 1:28 P.M. showed: - Floor debris including several rubber bands and torn paper; - Refrigerator temperature was 40 degrees and no log found; - Refrigerator had a long, dark hair in bottom of refrigerator shelf along with a puddle of water; - A wet, dripping box containing 50 individually wrapped acetaminophen (pain and fever reducer) suppositories 650 milligrams (mg); - A red plastic container with 83 individually wrapped 650 mg acetaminophen suppositories; - One unopened Lantus (long-acting insulin) pen 3 milliliters (ml); - Seven unopened Levemier (insulin) pens 3 ml each; - One unopened Aspart (short acting insulin) Flexpen 3 ml; - Two unopened Novolog (fast acting insulin) pens 3 ml each; - Five unopened Toujeo pens (Insulin glargine injection); - Three unopened Basaglar (long acting insulin) pens 3 ml each; - Five unopened Novolog vials 10 ml each; - Two unopened Humolog (fast acting insulin) vials 3 ml each; - One unopened Humulin R (short acting insulin that lasts several hours) vial 3 ml; - One unopened Levemier vial 10 ml. 2. An observation on 02/08/23 at 9:03 A.M. of the CMT medication room showed: - The refrigerator temperature was 32 degrees, no log found; - Above medications remained in refrigerator; - Two small containers of pudding; - One small container of applesauce; - Floor debris including several rubber bands, torn paper and two clear plastic squeezable vials with unknown medication. During an interview on 2/8/23 at 9:03 A.M., the Director of Nursing (DON) said the applesauce and pudding were placed in there for the next med pass and she could not find the refrigerator temperature log. 3. An observation on 2/09/23 at 4:43 PM of the CMT Medication room showed: - Refrigerator temperature was 40 degrees, no log found; - Above medications remained in refrigerator; - One small container of pudding; - One small container of applesauce; - Floor debris including several rubber bands and torn paper. During an interview on 2/9/23 at 4:43 P.M., the DON said they still had not found the temperature log. During an interview on 2/9/23 at 5:35 P.M., the Administrator said she would expect the medication storage room to be clean and free of debris, the refrigerator to have a temperature log and food not be stored in the medication refrigerator. According to product labels from insulin manufacturers, the recommended storage temperature for unopened insulin is approximately 36 to 46 degrees Fahrenheit. According to manufacturer's recommendation for acetaminophen suppositories, they may be stored at room temperature or in the refrigerator, but must not be frozen.

Based on interview and record review, the facility failed to ensure the quality assessment and assurance (QAA) committee attendees included an Infection Preventionist (IP). This failure had the potential to affect all 73 residents who reside at the facility. The facility's census was 73. Record review of the QAA Committee Members did not show the Infection Preventionist as a committee member. Record review of the QAA committee attendance records, dated July 2022 through December 2022, provided by the facility, showed the Infection Preventionist did not attend the meetings as required. During an interview on 2/9/23 at 5:35 P.M., the Administrator said their Infection Preventionist is new and recently certified. She said the Infection Preventionist needs to be put on the list. She said the previous IP attended meetings. Record review of the facility's policy titled, Quality Assurance and Performance Improvement, dated November 2016, regarding QAA did not include a list of required committee members.

Based on observation, interview and record review, the facility failed to ensure safe transfers using a mechanical Lift (a mechanical device used to transfer a resident from one place to another) which resulted in injuries for one resident (Resident #40) out of the 18 sampled residents. The facility's census was 73. The administrator was notified of the Past-Noncompliance on 1/23/20. The non-compliance started on 11/15/19 and corrected on 11/17/19 when staff were counseled, inservices provided and the mechanical lift inspected. Record review of the facility's policy, Using a Mechanical Lifting Machine, revised (MONTH) (YEAR), showed: - At least two nursing assistants are needed to safely move a resident with a mechanical lift; - Attach sling straps to sling bar, making sure sling is securely attached to the clips and it is properly balanced; - Before resident is lifted, double check the security of the sling attachment; - Examine all hooks, clips or fasteners; - Check the stability of the straps - Ensure that the sling bar is securely attached and sound; - Lift resident two inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Record review of Resident #40's Face Sheet (a document which gives a patient/resident's information at a quick glance) showed the resident to have the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION], atrophy (wasting away or shriveling up) and muscle wasting. Record review of the resident's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by the facility), dated 11/14/19, showed total dependence of two staff for transfers. Record review of the resident's comprehensive care plan, updated 11/15/19, showed: - Continue mechanical lift transfers x 2 assist; - Resident is dependant for mobility and transfers; - Ensure resident is positioned appropriately per staff x 2; - Fall risk, assist per staff, fatigues, weakness and unsteady. Record review of the resident's progress notes, dated 11/15/19, at 10:51 [NAME]M. showed: - Nurse was walking down hall and heard commotion come from the resident's room; - Upon entering room, the resident was noted to be lying on floor under mechanical lift; - Mechanical sling had three straps attached and the right strap was hanging; - Certified Nurse Aide (CNA) B said he/she was lifting resident with the mechanical lift, the right lower strap came unhooked and the resident fell to floor landing on right side; - Resident noted to have redness to right hip and soft hematoma (a solid swelling of clotted blood within the tissues) to right side of head; - Resident complained of pain to head, right arm and right hip; - Vital signs obtained and neurological exam (neuro checks; an evaluation of the nervous system) initiated and are with in normal limits; - Director of Nursing (DON) notified, fax sent to physician requesting X-rays, message left with guardian's deputy. Record review of the resident's progress notes showed: - On 11/15/19 at 12:00 P.M., nurse spoke with Family Nurse Practitioner (FNP) due to resident's complaints of increasing pain and received order for one time dose of [MEDICATION NAME] (pain medication); - On 11/15/19 at 5:34 P.M., FNP notified of X-ray results and order received to monitor, scheduled [MEDICATION NAME] ordered; - On 11/15/19 at 8:39 P.M., neuro checks within normal limits for resident, continues to complain of pain in different places, able to reposition to alleviate pain, resident using foul language and yelling; - On 11/16/19 at 4:41 P.M., order for X-ray of right ribs, resident continues to complain pain all over and specifically indicates right side of ribs, [MEDICATION NAME] order changed to four times daily; - On 11/16/19 staff entered room to give medication and witnessed dark emesis ( bloody vomit) on bed and resident, Registered Nurse (RN) was notified at 8:15 P.M., resident had dark brown, coffee ground emesis in large amount on bed and self, resident cleaned and vital signs obtained, resident complained of pain everywhere. Notified Administrator, FNP, order given to send to hospital at 8:35 P.M. Power of Attorney (POA) notified at 8:21 P.M. and gave permission to send to hospital. Resident transported to ambulance at 8:55 P.M. - On 11/17/19 at 3:13 [NAME]M., staff calls hospital for update on resident and was told resident was being admitted to the Intensive Care Unit (ICU), for rib fractures, pneumothorax (a condition which air is leaked into the space between the lung and chest wall from a [MEDICATION NAME] or penetrating chest injury) and femoral head fracture (broken hip). Record review of the facility's counseling form, completed by the facility staff, dated 11/15/19, showed: - CNA B violated facility safety rules: - CNA lifted resident with mechanical lift and strap came off; - CNA used lift without second person and policy reads to use two people for safety. Record review of the facility's investigation dated 11/18/19 showed: - On 11/15/19 CNA was getting resident in bed with mechanical lift and the strap slipped off hook; - Resident fell to the floor = 3 feet 3 inches; - Two fractured ribs; - In-service given for two person assist of lift; - Mechanical lift inspected by maintenance. Record review of the hospital records dated 11/17/19 showed resident had a fall with closed fracture of multiple ribs of right side, pneumothorax on right, closed fracture of neck of right femur, coffee ground emesis, contusion of right lung and femoral neck fracture. During an interview on 1/23/20 at 11:15 [NAME]M., CNA F and CNA G said they always use two staff for a mechanical lift. On occasion, they use a third staff member if the resident is complaining of pain that day. During a telephone interview on 01/23/2020 at 3:39 P.M. Licensed Practical Nurse (LPN) J said CNA B was in the resident's room and said the the strap had slipped off the mechanical lift. Resident #40 was on the floor. LPN J said he/she assessed the resident, called the physician, gave the resident medication and got an order for [REDACTED].>During an interview on 01/23/2020 at 4:15 P.M., the Administrator said she would expect two staff to assist with the mechanical lift during transfer although she doesn't think the policy says to do so. During a telephone interview on 01/29/2020 at 2:16 P.M., CNA B said he/she had brought Resident #40 back to the room to be changed and put to bed. The resident was very impatient and CNA B's hall partner was in the shower room with another resident at the time. CNA B said the straps were hooked but the one must have moved during the lift. CNA B said the hall partners work together now for showering and laying residents back down. They are required by the facility to use two people for all mechanical lifts.