Every finding on record at Stonehenge of South Jordan

Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Specifically, the previous Director of Nursing (DON) was the facilities designated IP and did not work at least part time at the facility. Findings included: On 12/18/24 at 10:54 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was the facility DON. The CRN stated the previous DON was the IP. On 12/18/24 at 10:55 AM, an interview was conducted with the facility Administrator. The Administrator stated the previous DON was at the facility less than 10 hours per week. On 12/18/24 at 11:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the previous DON was the IP. LPN 1 stated that she was unsure how often the previous DON came to the facility. LPN 1 stated that she had not done the training to be the IP even though she signed and completed the infection surveillance for the facility. 30563

Based on observation, interview or record review it was determined, for 1 of 15 sampled resident, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered plan, the residents' goals and preferences. Specifically, a residents was assisted to bed and his oxygen was not turned on. Resident identifier: 74. Findings include: Resident 74 was admitted to the facility on [DATE] with diagnoses which included right pubis fracture, congestive heart failure (CHF) and chronic respiratory failure. On 12/16/24 at 12:53 PM, an interview was conducted with resident 74. Resident 74 stated he needed oxygen all the time. Resident 74 stated he did not think his oxygen was on. Resident 74 stated he needed to have his oxygen turned on. At 1:05 PM, an observation was made of Certified Nurses Assistant (CNA) 1. CNA 1 was observed to place a pulse oximeter on resident 74 and then went into resident 74's bathroom and turned on his oxygen concentrator. Resident 74's oxygen was at 88% after a minute. Resident 74's medical record was reviewed. A physician's order dated 12/7/24 revealed O2 [oxygen] 1-4 L [liters] per NC [nasal cannula] PRN [as needed] to keep Sat [saturations] > [greater than] 90% until stable RA [room air] every shift. A care plan dated 12/7/24 revealed I use Oxygen Therapy: CHF, Respiratory illness. The goal was I will have no s/sx [signs and symptoms] of poor oxygen absorption during my stay. The interventions included Change oxygen cannula and humidification bottle (if used) weekly; Give medications as ordered; Monitor for s/sx of respiratory distress and report to MD [medical doctor] PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color; Position resident to facilitate ventilation/perfusion matching: Use upright, high Fowlers position when possible to allow for optimal diaphragm use, When on side, the good side should be down (e.g., damaged lung should be up); and Provide reassurance and allay anxiety if in distress. Stay with patient during episodes of respiratory distress. On 12/17/24 at 2:38 PM, an interview was conducted with CNA 2. CNA 2 stated resident 74 was on continual oxygen using 3 to 4 liters. CNA 2 stated when a resident required oxygen a portable oxygen tank was used when the resident was being transported. CNA 2 stated resident 74 was not able to go without oxygen. CNA 2 stated when a resident was connected to a different oxygen tank or concentrator, she always checked to make sure the tubing was hooked up and the oxygen was on. On 12/17/24 at 3:25 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated if a resident required oxygen, then she would expect that the resident had the oxygen on at all times. The CRN stated a resident used a portable oxygen tank when the resident was not in their room. The CRN stated a resident used an oxygen concentrator when the resident was in their room. On 12/17/24 at 12:35 PM, an interview was conducted with CNA 1. CNA 1 stated she was not aware resident 74's oxygen concentrator was off. CNA 1 stated if she knew the oxygen concentrator was off she would have turned in on. CNA 1 stated the oxygen concentrator was usually turned off when a resident was not using it. CNA 1 stated she did not realize the concentrator was off.

Based on observation, interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications. Specifically, a resident fed by enteral means only did not have their nutrition and hydration requirements met, as identified by the Registered Dietitian (RD), which resulted in the resident being transferred to the hospital for dehydration. This resulted in a finding of harm. Resident identifier 24. Findings include: Resident 24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/21 at 11:23 AM, an observation was made of resident 24 lying in bed supine with the head of the bed (HOB) elevated greater than 30 degrees. The resident had a tube feed (TF) at the side of the bed. The TF was observed not connected to the resident and was not infusing. The bag of formula was labeled Vital AF 1.2 via percutaneous endoscopic gastrostomy (PEG) tube and was dated 6/13/21 at 12:30 PM. Resident 24 stated that the TF runs in the morning and she did not like it. It's hard to breathe with it running. At 11:38 AM an observation was made of Licensed Practical Nurse (LPN) 2 reconnecting the TF tubing to resident 24's peg tube at a rate of 48 milliliters (ml)/hour (hr) with the water flush set at a rate of 20 ml/hr. The water flush bag did not have a label with the resident information or the date and time it was hung. Resident 24 complained of pressure in the abdomen and was able to point to the area of concern. LPN 2 stated she would go get a stethoscope to listen. LPN 2 was observed to give a 30 cubic centimeter (cc) water flush with the medication administration. On 6/16/21 at 11:41 AM, an observation was made of resident 24's TF infusing at a rate of 49 ml/hr. with a water flush set at a rate of 20 ml/hr. The bag of formula was labeled Vital AF 1.2 and was dated 6/14/21 at 7:30 PM. The TF bag was observed to have approximately 250 ml of formula remaining. An interview was conducted with resident 24 and their family member. Resident 24 was still complaining of stomach pain and stated that the TF was causing the pain and tightness. Resident 24 stated she had a bowel movement Monday and it somewhat relieved the pressure and pain. Resident 24's family member reported that the TF caused fullness and difficulty with breathing. Resident 24 stated that the pain was currently an 8/10 (on a scale of 1 to 10 with 10 being the highest), was located in the stomach, was described as pressure and tightness, and with reports of hard to breathe. The resident pushed the call light and at 12:16 PM it was answered by Registered Nurse (RN) 2. The resident reported the pain to RN 2. RN 2 assessed resident 24's pain and stated that she would inform Nurse Practitioner (NP) 1 as he was still in the building. On 6/15/21 resident 24's medical records were reviewed. Review of resident 24's census revealed that the resident was admitted to the facility on [DATE], transferred to the hospital on 6/3/21 with an expected stay of less than 24 hours, and returned to the facility on [DATE]. Review of resident 24's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Enteral Feed, every shift CONTINUOUS FEED: Tube Feeding Vital AF Run at 40 ml/hr; flush 17 cc/hr. The order was initiated on 5/31/21 and discontinued on 6/3/21. b. Enteral Feed, every shift CONTINUOUS FEED: Tube Feeding Vital AF Run at 55 ml/hr (Goal Rate); flush 20 cc/hr. The order was initiated on 6/3/21. c. Enteral Feed, every shift Flush tube with 20-30 ml(cc) of water before and after administration of medication pass. The order was initiated on 5/31/21. d. Enteral Feed at bedtime Graduate cylinder and 60 cc syringe change out, add date at bedtime. The order was initiated on 5/31/21. e. Elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after the feeding is stopped. The order was initiated on 5/31/21. f. NPO (nothing by mouth). The order was initiated on 5/31/21. Review of resident 24's weights revealed the admission weight (wt.) on 6/1/21 was 105 lbs (pounds), and current wt. on 6/15/21 was 98.4 lbs. This was a 6.29% wt loss in 15 days. Resident 24's progress notes were reviewed and revealed the following: a. On 6/1/21 at 1:31 AM, the note documented, Pt (patient) is new admit to facility for failure to thrive, pt is thin and skin is fragile. Pt is alert and oriented x 3 to person, place and situation but not time. Pt has intermittent confusion during shift. Pt wears glasses. Pts heart sounds were WNL (within normal limits), no evidence of irregular heart rate noted during assessment, no peripheral [CONDITION(S)] and CRTS (capillary refill times) to extremities less than 3 seconds. Lung sounds clear throughout, HOB (head of bed) maintained at least 30 degrees once feeding initiated. No cough present. Bowel sounds active in all quadrants and LBM (last bowel movement) was 5/28, no distention noted and pt is continent of bowel. Pt is incontinent of bladder and needed brief change upon admit. SN (skilled nurse) performed this while assessing skin. Blanching redness to bottom and groin. Pt has PEG tube to LUQ (left upper quadrant), PEG line is patent and flushing well, Sn (skilled nurse) changed dressing to peg tube site upon admission. Blanching redness to bilateral heels, heels floated. Bp (blood pressure) -140/73, P (pulse) -89, O2 (oxygen saturation) -94%2l (liters), temp (temperature) -97.8F (Fahrenheit), R (respirations) -16. pt was stretcher admit last reported weight and height from hospital was 105lbs and 5'4 (inches). Pt adjusting to room well and utilizes call light/voices concerns. VSS (vital signs stable), WCTM (will continue to monitor). b. On 6/1/21 at 12:00 PM, the note documented that the resident was seen by NP 1 for initial assessment. History of present illness documented that resident 24 was a [AGE] year old female with a past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physical exam documented a&o (alert and oriented) x 2, well-nourished elderly _male lying comfortably in bed. The assessment and plan of care documented for protein calorie malnutrition to continue with TF and obtain weekly complete blood counts (CBC), comprehensive metabolic panel (CMP), magnesium (mag), and [MEDICATION(S)] (Phos.) levels. COVID-19 vaccine was documented as given on 2/13/21 and 3/13/21. c. On 6/1/21 at 5:04 PM, the note documented, Last Recorded Vitals of: T (temperature) 97.7 - 6/1/2021 11:07 Route: Temporal Artery , P 96 - 6/1/2021 11:08 Pulse Type: Regular , R 18.0 -6/1/2021 11:10, BP 112/50 - 6/1/2021 11:04 Position: Lying r/arm , , O2 89.0 % - 6/1/2021 11:11 Method: Oxygen via Nasal Cannula ,Liters of Oxygen:2, W 105.0 lb - 6/1/2021 01:24 Scale: Bath . The Capillary Refill was documented as less than 3 seconds. Patient's nutritional intake requires use of feeding tube. Isolation is required for active infection with all services provided within room. J-Peg LLQ (left lower quadrant). It should be noted that the resident did not have an active infection and was not on isolation precautions. COVID vaccination status was addressed in NP 1 progress note and resident 24 did not require quarantine. d. On 6/1/21 at 9:52 PM, the note documented that the lab results were received and NP 1 was made aware. e. On 6/1/21 at 11:58 PM, the note documented that NP 1 ordered for resident 24 to have a basic metabolic panel (BMP) drawn in the morning. f. On 6/2/21 at 1:46 PM, the note documented that the BMP was drawn. g. On 6/2/21 at 3:54 PM, the note documented, Last Recorded Vitals of: T 98.2 - 6/2/2021 10:19 Route: Temporal Artery , P 104 - 6/2/2021 10:22 Pulse Type: Regular , R 16.0 -6/2/2021 10:24, BP 100/45 - 6/2/2021 10:15 Position: Lying r/arm , , O2 90.0 % - 6/2/2021 10:25 Method: Oxygen via Nasal Cannula ,Liters of Oxygen:2, W 105.0 lb - 6/1/2021 01:24 Scale: Bath Patient's nutritional intake requires use of feeding tube. Isolation is required for active infection with all services provided within room. J-Peg LLQ The progress note was authored by the same nurse on 6/1/21 at 5:04 PM. h. On 6/3/21 at 2:09 PM, the note documented, Per Dietitian: enteral feeding rate goal is 55 ml/hr, pt is currently at 47 ml/hr and is tolerating rate well at this time. if pt continues to tolerate rate of 47 ml/hr for the rest of the day, will attempt to increase rate up to 55 ml/hr on 6/4/21. pt is tolerating h2o (water) rate of 20 ml/hr without issue i. On 6/3/21 at 2:13 PM, the note documented to discontinue the [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. j. On 6/4/21 at 3:03 AM, the note documented, Last Recorded Vitals of: T 98.4 - 6/4/2021 00:42 Route: Forehead (non-contact) , P 91 - 6/4/2021 00:42 Pulse Type: Regular , R 18.0- 6/4/2021 00:44, BP 78/34 - 6/4/2021 00:41 Position: Sitting r/arm , , O2 95.0 % - 6/4/2021 00:44 Method: Room Air , Liters of Oxygen:2, W 103.2 lb - 6/3/2021 15:09 Scale: Wheelchair Capillary Refill < 3 seconds: Normal. k. On 6/4/2021 at 3:09 AM, the note documented, Upon Sn (skilled nurse) arriving to shift, CNA (certified nurse assistant) reported pt having low BP, SN went and performed manual BP and noted Bp was 100/20 diastolic was difficult to hear/note. Pt was lethargic and only alert and oriented to person. Sn called and notified Oncall NP who gave order for NS (normal saline) at 200 ml/hr via IV (intravenous), SN placed 22g (gauge) IV to right inner wrist and started fluid replacement. SN changed tubing and feed and assured pt was receiving tube feed as well. Oncall NP stated to call around 2200 (10:00 PM) with update of vitals after NS had been running for a few hours. SN rechecked BP at 2200 and found it to be 78/34, Pt continuing to be lethargic and was now diaphoretic and clammy. Sn notified oncall NP who stated to send pt out via emergent transport, SN called 911 and sent pt to [local hospital], SN notified pts husband [name omitted] and called DON (Director of Nursing) [name omitted] for update. SN received call from [local hospital] around 0200 (2:00 AM) and MD (medical doctor) stated would continue pt on fluids at hospital and would be sending pt back within the next 5 hours or so after fluids completed. Sn will continue to watch for update and notify next shift. b. On 6/4/2021 at 3:46 AM, the note documented, Pt came back from ED (emergency department) with no report from hospital besides MD calling at 0200 stating she would be back in 5 hours after fluids complete. Hospital stated pt was dehydrated. vitals completed upon pt arrival to facility BP-102/56, P-81, O2-99%3L, temp-98.4F, R-16. SN received orders from oncall NP to continue [MEDICATION(S)] with .45 sodium IV at 100ml/hr. Sn placed pt back on tube feed and WCTM. Sn texted oncall DON with update on pt and pt need for social work refferal (sic) due to decline/no improvement in pt condition since admit. WCTM Review of resident 24's vital signs revealed the following: a. On 5/31/21 at 11:32, the BP 140/73, P 89, R 16. b. On 6/1/21 at 1:31 AM, the BP 140/73, P 89, R 16. Results were obtained from the progress notes. c. On 6/1/21 at 11:04 AM, the BP 112/50, P 96, R 18. d. On 6/1/21 at 10:26 PM, the BP 101/56, P 95, R 1(sic). e. On 6/2/21 at 10:15 AM, the BP 100/45, P 104, R 16. f. On 6/2/21 at 9:11 PM, the BP 93/47, P 92, R 16. g. On 6/3/21 at 9:20 AM, the BP 116/68, P 92, R 20. On 6/3/21 at 2:13 PM the [MEDICATION(S)] and [MEDICATION(S)] were discontinued. Review of the June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . h. On 6/4/21 at 12:41 AM, the BP was 78/34, P 91, R 18. i. On 6/4/21 at 3:09 AM, progress note documented BP 100/20 when arrived on shift. The progress note was entered at 3:09 AM by the night shift nurse. Night shift starts at 6 PM until 6 AM. The next documented BP 78/34 and was at 10:00 PM. j. On 6/4/21 at 3:46 AM, the BP 102/56, P 81, R 16. Results were obtained from the progress notes. Review of the Nutritional Risk Assessments on 6/2/21 by the facility Registered Dietitian (RD) documented the resident ht. was 64, admission wt. was 105 lbs, Ideal Weight Range (IWR) was 108-132, and Body Mass Index (BMI) was 18. Enteral Nutrition Order documented the formula as Vital AF at a rate of 40 cc/hr with a H2O flush at a rate of 17 cc/hr. The formula documented calories at 1152 and protein at 72. The free water was documented as 778+408 with a total volume of 1323. It should be noted that the actual total volume calculated was 778 + 408 =1186 total water and not 1323. The assessment documented that the resident was confused and disoriented but able to make needs known. Medications with nutritional implications were documented as [MEDICATION(S)]. The assessment documented that the calorie needs for the current body wt. were adjusted for weight gain, and the percentage of caloric needs were between 1432-1670 with a 30-35 factors. Hydration needs were documented for current body weight and adjusted for normal, ml were >1500 and the needs were documented as met and as min (minimum) req.(requirement). The RD did not document how she calculated the resident's hydration needs. Protein needs for current body weight were adjusted for normal and repletion at 48-57 grams with a 1.0-1.2 factor. The assessment documented a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] <18.5 and TF. The diet order stated to increase TF to 55 cc/hr and change flush to 18 cc/hr. The summary of review documented, 74 yo resident at nutritional risk r/t weakness, FTT (Failure to Thrive) w/ (with) malnutrition, [CONDITION(S)], AKF (acute kidney failure), CKD (chronic kidney disease) , TIA/CVA ([CONDITION(S)]/[CONDITION(S)]), [CONDITION(S)] (hypertension), PEG tube, [CONDITION(S)] obstruction, GERD (gastro-[CONDITION(S)] reflux disease). 97% IWR/BMI 18.0. Needs based on CBW (current body weight) for wt gain - 105# 1432-1670 kcal (30-35/kg) >1500 ml (min req) 48-57 gm Pro (1.0-1.2/kg for repletion) NPO att (and) tolerating TF of Vital AF @ 40 cc/hr x 24 hrs w/ flush 17 cc/hr x 24 hrs providing 1152 kcal, 72 gm Protein and 778+408=1323 cc fluid/day as ordered. Suggest increasing TF to 55 cc/hr and flush to 18 cc/hr to provide 1584 kcal/day, 99 gm protein and 1069+432=1526 cc/day to help meet nutritional needs and aid in weight gain. Resident is self directed with food choices. Dietary available to cater to needs and preferences. Monitor per POC (plan of care). Will follow as needed. Review of resident 24's lab results revealed the following: a. On 6/2/21 the BMP documented the sodium as 135 normal, potassium as 5.1 normal, Chloride 101 normal, BUN 71 high, creatinine 1.54 high. The Lab report was noted and signed by NP 1 on 6/3/21. b. On 6/7/21 the CMP documented abnormal values for the following; glucose 135 high, BUN (Blood Urea Nitrogen) 47 high, BUN/Creatinine ratio 64 high, Sodium 131 low, Potassium 5.4 high, [MEDICATION(S)] 3.4 low. The Lab report was noted and signed by NP 1 on 6/8/21. A written note next to NP 1 signature stated Dietary - re check BMP on 6/9/21. It should be noted that the dietary note was written in a different script than the NP 1 and did not contain a signature or initial. c. On 6/9/21 the BMP documented abnormal values for the following; glucose 112 high, BUN 48 high, BUN/Creatinine Ratio 61 high, Sodium 130 low, Chloride 95 low. The Lab report was noted and signed by NP 1 on 6/11/21. d. On 6/14/21 the CMP documented abnormal values for the following; glucose 103 high, BUN 36 high, BUN/Creatinine Ratio 63 high, Sodium 132 low, Chloride 95 low. The Lab report was noted and signed by NP 1 on 6/15/21. Review of the Dietary Recommendation sheets for 6/2/21 revealed that resident 24 was identified and documented by the RD with nutritional concerns of increased needs. The recommendations were to change the TF rate to 55 cc/hr and flush to 18 cc/hr. The nursing follow-up was not signed or dated. The weekly weights dated 6/4/21 for resident 24 listed a weight of 105 that was dated on 6/2/21, IWR 108-132, %IWR 97, and BMI 18. [Note: The RD did not address resident 24's hydration needs while resident 24's formula rate was being adjusted.] Review of resident 24's Hospital History and Physical (H & P) on 5/26/21 documented that the resident was found to have [CONDITION(S)] dysmotility and stricture and failed a swallow study which resulted in a PEG tube placement on 5/25/21. The resident presented to the emergency department on 5/26/21 with complaints of tingling (left side) and weakness. The patient reported nothing to eat or drink since 5/23/21. PEG tube balloon placement was determined to be in the stomach. Lab results were documented as Sodium 141, Chloride 105, Potassium 4.5, BUN 25 high, Creatinine 1.75 mg/dl (deciliter) high, and glucose 103 high. The history of present illness documented that resident 24 received IV fluids in the ED, type and amount unknown. The exam documented a thin female, dry mucous membranes with skin that was well perfused. Vital signs on 5/26/21 at 3:00 PM were BP 100/40, P 90, and R 15. The impression was documented as toxic metabolic [CONDITION(S)] likely due to dehydration, malnutrition, toxic side effects of chronic meds in the setting of AKI (acute kidney injury). The plan for severe protein calorie malnutrition was to have a nutrition consult, TF, and monitor for refeeding syndrome. The plan for the AKI due to the dehydration was to monitor Creatinine and TF. On 5/27/21 at 8:01 AM, the VS were documented as BP 119/42, P 87, and R 16. The exam documented a frail cachectic female. No documentation of dry mucous membranes were noted on the 5/27/21 exam. IV [MEDICATION(S)] was ordered for malnutrition, and TF were documented as having begun. Lab results were documented as Sodium 138, Chloride 109, Potassium 3.8, BUN 33 high, Creatinine 1.32 high, and glucose 118 high. On 5/27/21 at 12:06 PM the BP was 130/46, P was 92, and R was 16. On 5/27/21 at 2:26 PM, the provider note recommended [MEDICATION(S)] 500 mg IV daily for 3 days. Resident 24's medication list on 5/26/21 at 1:11 PM documented [MEDICATION(S)] [MEDICATION(S)] in Sodium Chloride 105 ml at 200 ml/hr IV daily, and Sodium Chloride 500 mls @ 999 ml/hr IV Q (every) 31M (minutes) SCH (scheduled). On 5/31/21 at 11:49 AM, resident 24's Hospital Discharge orders documented a TF order for Vital AF at a rate of 40 cc/hr. with a free water flush at 65 cc every 4 hours. The hospital discharge paperwork listed a past and present condition of dehydration, protein calorie malnutrition, acute dehydration, and acute renal failure. The principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lab results on date of discharge 5/31/21 were Sodium 136, Chloride 106, Potassium 5.3 high, BUN 30 high, and Creatinine 0.94. On 6/3/21 at 11:00 PM, resident 24's Hospital H & P documented that the resident was noted to have [CONDITION(S)] at the facility and received 1 liter of fluid. Vital signs were documented as BP 92/34, P 87, and R 31. Lab results were documented as Sodium 139, Chloride 107, Potassium 5.0, BUN 81 high, Creatinine 1.12 H. The orders documented that resident 24 received [MEDICATION(S)]/Sodium Chloride 1,000 mls @ 200 ml/hr IV every 5 hrs., and the IV fluids were documented as stopped on 6/4/21 at 6:59 AM. The narrative documented that the BUN creatinine ratio significantly elevated suggesting dehydration Patient needs IV hydration. She received a L (liter) fluid normal saline plus a L of D5 ([MEDICATION(S)] 5%) half normal saline. The nursing facility where she resides is a (sic) will to (sic) continue IV hydration as well. For this reason I do not think the patient needs readmission to the hospital and they can continue hydration at the nursing home. Patient's blood pressures were improved upon discharge. On 6/16/21 at 1:08 PM, an interview was conducted with RN 2. RN 2 stated that NP 1 assessed the resident and ordered to increase the Tylenol to 1000 milligram three times a day, and to add [MEDICATION(S)] 5 ml two times a day. RN 2 stated that the TF was running at 48 ml/hr with water at 20 ml/hr. RN 2 stated that the TF was a continuous feed, but it was taken off for therapy and sometimes taken off to give her tummy a break. At 1:13 PM RN 2 was observed to obtain a new bottle of TF formula and entered resident 24's room. The TF formula was observed as Vital AF 1.2 formula and came in a 8 fluid ounce or 237 ml bottle. RN 2 stated that the TF was running at a rate of 48 ml/hr, but when viewed was observed to be running at a rate of 49 ml/hr. They turned it up and didn't tell me, it wasn't me. It was probably night shift. RN 2 was observed to view the date and time stamp on the bag and stated that the bag was hung on 6/14/21 and should be changed every 24 hours. RN 2 stated she would obtain a new bag and tubing. RN 2 stated that the risk of having the same bag and tubing used past 24 hours was that it could get bacteria in it. On 6/16/21 at 2:49 PM, a telephone interview was conducted with the RD. The RD stated that the resident was on a TF with a BMI of 18 and 97% of IWR. The RD stated that she utilized charts with recommendations based on IDW and if the resident was underweight she would multiply by a certain number to give more calories. The RD stated that the resident was on 1.2 calorie formula, and the goal rate was 55 cc/hr. The RD stated that the wt. loss that had occurred was because the resident was not tolerating what she needed to gain wt. The RD stated that the total volume that was calculated was based on 778 from the formula and 408 was base of the 17 cc/hr water flush. The RD confirmed that the calculated total water was miscalculated and was 1186 and not 1323 as documented in the assessment. The RD stated that was the orders that was received from the hospital for resident 24's TF. The RD stated that she determined that resident 24 required more to meet her nutritional needs and recommended to increase the TF rate to 55 cc/hr with a water flush of 18 cc/hr and that this was stated in the summary of the assessment that was completed on 6/2/21. The RD further stated that she recommended a total water of 1526 cc per day based on the 1069 from the formula + 432 from the free water to equal 1526 cc/day. It should be noted that 1069 + 432 = 1501 and not the 1526 cc/day that was documented. The RD stated that the chart utilized for water needs stated not less than 1500 ml/ day, and based on the assessment she wasn't getting her water needs from the orders coming from the hospital. The RD stated that resident 24 needed 1432 to 1670, or 30-35 cal per kilogram for wt gain. The RD stated that when she had recommendations for residents' nutritional or hydration needs she provided a form to the DON and diet manager. The RD stated that the nurses usually check with the doctor and place the orders in the chart, but that nursing was responsible for updating orders in the medical records. The RD stated that she made recommendations, but did not change any orders in the medical records. The RD stated that they could increase resident 24's free water but did not want to dilute the sodium as resident 24's sodium levels were really low and didn't want to dilute them out further. The RD stated that she discussed this with the nursing staff. Don't want to do a water overload. So, yes at some point that is a nursing order or a doctor order and not a RD order. The RD stated that she discussed this with LPN 1, but did not discuss this with the DON or the physician or NP. The RD stated, they don't think she can eat. If she can't meet her needs with the TF then maybe hospice would be the option. I've been waiting to see how she tolerates it and hear back as to what they want to do. The RD stated that she was not aware that resident 24 went to the hospital for dehydration, and did not have a note that this had happened. The RD stated that her recommendations would be the same. If it's fluids that's a medical call. Dehydration would be a medical issue and not a dietary issue. The RD stated she had not seen resident 24 since 6/2/21. The RD stated she had talked to the DM this morning and resident 24 was still NPO, and there was nothing they can do until the rate could be increased. The RD stated that she was in the building one time per week and communicated with nurses and providers by text or phone. The RD stated that if the resident remained at the facility long enough then she would recheck them in a month or two. If the resident had wt. changes the DM would notify her. The RD stated that she could not change a diet order without a physician order. The RD stated that she made recommendations and the nurse or facility contacted the MD to make those changes to the diet. The RD stated that she did not have a lot of contact with the MD and that communication went through the nursing staff. On 6/16/21 at 4:05 PM, an interview was conducted with the DON. The DON stated that the RD filled out recommendation forms when she visited. The DON stated that she would update the resident orders based on the recommendation sheets, talk to the patient, and if it coincided with the weekly weight/nutrition meting or nutrition at risk meeting then it would be added to the skin and wt. assessment. Otherwise, it would be located in the RD assessment only. The DON stated that those recommendations did not get uploaded into each resident's records as multiple residents were located on a form, but that they were kept with the Nutrition at Risk (NAR) notes. The DON stated that she communicated those recommendations to the physician, and it was documented in the order in the electronic medical records. If the recommendations were not given to the DON then the Assistant Director of Nursing (ADON) would get those recommendations. The DON stated that dietary received a copy so they could update the meal tickets, but either the DON or ADON put the orders into the electronic medical records. The DON stated that the floor nurse would document a progress note on any communication with the RD recommendations, would notify the MD, and notify the DON. On 6/17/21 at 9:05 AM, an interview was conducted with LPN 1. LPN 1 stated that the RD was in the building one time a week and could be contacted by telephone. LPN 1 stated that anytime they had a TF resident the RD took over that resident's care. She is really involved with their rates. LPN 1 stated that the recommendations were communicated on T.O. (telephone order) forms or if she was out in a room she would send a message through the secure system in the electronic medical records. Most the time we just give her a phone call, its just quicker that way. LPN 1 stated that he communicated with the RD 1-2 weeks ago about resident 24. LPN 1 stated that resident 24 was having some GI distress and they discussed maybe using a different formula. They decided to stick with the current formula because there was only one other option, and to start some gas medications. LPN 1 stated that resident 24's pain had been pretty good. She had general pain and was now on scheduled gas-x that seemed to be helping with the discomfort. LPN 1 stated that resident 24 had a KUB (kidney, ureters, and bladder x-ray) that revealed no impaction but a high fecal load. LPN 1 stated that they gave her some laxatives and she cleared that out. Review of the diagnostics results revealed the KUB was obtained on 6/7/21. LPN 1 stated that they tried to reduce resident 24's TF rate due to the complaints of discomfort. LPN 1 stated that resident 24 was at a rate of 48 ml/hr last week this week she was at 49 ml/hr, so it's not going down and she seem to be tolerating it fairly well. LPN 1 stated that he talked to the RD initially about the TF rates with the GI problems and with different formula options. LPN 1 stated that there was no discussion about the free water or increasing the water flush rate. LPN 1 stated that the TF was a continuous feed 24/7 and was turned off for transfers, toileting, and therapy. On 6/17/21 at 9:22 AM, an observation was made of resident 24 in her room. Resident 24's TF was running at a rate of 55 ml/hr with a water flush at a rate of 20 ml/hr. The tube feed bag was observed dated 6/16/21 at 11:30 PM, and the bag was observed full with formula to 1000 ml line. The water bag was not labeled and was filled to the 800 ml line. On 6/17/21 at 12:16 PM, an interview was conducted with NP 1. NP 1 stated that communication with the RD was by a written order or just let the nurse know that nutrition needed to see the resident. NP 1 stated that he relied on the RD's recommendations with TF. I just take it and agree with it most of the time. Go based off what they calculate the residents needs are. I collaborate with the MD on the resident. I will let the nurse know with a VO (verbal order) to place them on a night time feed. NP 1 stated he had called the RD a couple of times over the years but nothing recently. Not very good at knowing all the nutritional needs of the residents that was why I rely on her. Don't know off the top of the head what the recommendations were but would go based on them. Usually they come out of the hospital on a rate and a goal. I don't generally write new orders for a TF when they get here. NP 1 stated that if the nutritional needs were not being met for a TF he would expect the RD to let them know. NP 1 stated that he did not recall the RD notifying him that the nutritional needs were not being met by the hospital orders and that she recommended something else. NP 1 stated that he did not review the RD assessment. NP 1 stated that it was usually a nurse who wrote the recommendations and he signed them or the RD wrote the order and he signed them. NP 1 stated that the TF rate was currently at 55 cc/hr. NP 1 stated that yesterday it was reported that resident 24 had abdominal pain. Last week resident 24 also complained of abdominal pain. NP 1 stated that they did a KUB, she had some fecal matter, ordered gas-x and stool softener. NP 1 stated that yesterday he was informed of pain and he assessed her. She has some kidney stones that needs to be assessed and might be the pain source. NP 1 stated that he was trying to schedule her for a stone protocol, but first they needed to determine if the resident was going to go the hospice route or not. NP 1 stated that on Monday the labs for magnesium, [MEDICATION(S)], and creatinine looked okay. NP 1 stated that today in rounds with the MD they determined to switch resident 24's PEG tube to a smaller tube to attempt to ease the discomfort. NP 1 stated that he was informed a couple of times that the residents rate was slowed down due to it causing her some discomfort. NP 1 stated that resident 24 went to the hospital for dehydration, she got fluids and then came back. I was keeping track of her labs to see where her fluid status was. I did tell the nurse that she was hyponatremic and to reach out to the RD and see if there was something that needed to be changed with the formula or water intake. It was at the end of last week by phone. NP 1 [TRUNCATED]

Based on observation and interview it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, dry food was outdated in the dry food storage room and still being given to residents. Resident identifiers: All. Findings include: 1. On [DATE] at 8:30 AM, an initial tour of the facility kitchen was conducted. The following was observed: a. A package of frozen vegetables was open and exposed to air, no expiration date was on the package. b. A Blendtec mixer bottle was uncovered in the freezer with frozen fruit in the bottom of the blender, it was not labeled or dated. c. A box of single use soy sauce packets with an expiration date of [DATE] was located in the dry storage. d. Six individual serve boxes of Cheerios with an expiration date of [DATE] was in the kitchen and 38 individual serve boxes of Cheerios with an expiration date of [DATE] was located in the dry storage room. e. A metal container full of sugar free assorted jams with an expiration date of [DATE] was in the kitchen and a box of single use sugar free assorted jams with an expiration date of [DATE] was in the dry storage room. f. A half empty bottle of peanut butter with an expiration date of [DATE] was on a shelf in the kitchen and 4 bottles of peanut butter with an expiration date of [DATE] was in the dry storage room. g. Two coconut pecan frosting containers with an expiration date of [DATE] was in the dry storage room. h. An opened, undated bottle of Med pass 2.0 Butter Pecan nutritional shake was found in the small fridge with no open or use by date. On [DATE] at 8:45 AM, an interview was conducted with the dietary cook (DC). The DC stated the fruit in the mixer was for a resident and could be discarded. The DC stated the peanut butter and jam were given to the residents almost daily. On [DATE] at 8:45 AM, an observation was made of the DC removing the mixer containing frozen fruit from the freezer and setting it on the counter. On [DATE] at 11:43 AM, an interview was conducted with the Dietary Manager (DM). The DM stated there was no need to put an expiration date on freezer items because the freezing stops everything from growing. The DM stated that the staff just know that items expired after they were removed from the freezer. We only keep something for at most a week after it's open. The DM stated there was not an itemized list of when things were pulled and when they expired, so no there isn't a way employees would know the exact expiration date. The DM stated she does not know why expiration dates were an issue, we go through things so fast here. On [DATE] at 12:05 PM, an observation was made of the expired peanut butter and expired sugar free jams being used in the kitchen. On [DATE] at 12:55 PM, a follow-up interview was conducted with the DM. The DM stated that they placed the date on an item when an item was recieved. The DM stated that they go through food items so fast, that there was not a need to put the expiration date on the item also. On [DATE] at 1:50 PM, an interview was conducted with Dietary Aide (DA) 1. The DA 1 stated if something was opened in the small fridge it was the nurse's stuff, and they watch it. The DA 1 stated that dietary would place food items in there but do not watch when it was opened. DA 1 stated the sugar free jams in the kitchen were used for the residents and was unsure who was responsible for checking the expiration dates. On [DATE] at 2:00 PM, an interview was conducted with registered nurse (RN) 1. The RN 1 stated when a drink or food was opened in the small fridge that they needed to use for med pass, they were supposed to date it if it was a multi-use bottle. If it was applesauce or something like that we just throw it away. On [DATE] at 2:40 PM, an observation was made of the peanut butter removed from the kitchen. The expired sugar free assorted jams were observed still available for use in the kitchen. On [DATE] at 11:50 AM, an interview was conducted with the DC. The DC stated things were only left in the kitchen for 4 days at the most before they were used. The DC stated that she did not know about the expiration dates of food items. We just know they are ok if they are in the kitchen. On [DATE] at 7:35 AM, an observation was made of the expired sugar free syrup, soy sauce, cheerios, and frosting still available for use in the downstairs pantry. The Peanut butter was observed removed. On [DATE] at 7:40 AM, an observation was made of the expired sugar free individual packets being used in kitchen. On [DATE] at 9:30 AM, an observation was made of the expired sugar free individual packets available for use in the downstairs pantry with the expiration date of [DATE]. On [DATE] at 10:55 AM, a follow-up interview was conducted with the DC. The DC stated the food was rotated and they used what comes first. The DC stated that the snacks and foods from the pantry were used so fast, and the snacks were consumed usually within 5 days. The DC stated they did not check the expiration dates when they bring an item up from the pantry. On [DATE] at 11:56 AM, a follow-up interview was conducted with the DM. The DM stated there was no process for determining when something expired first. It was a first in first out method with the food in the pantry. We go through food really fast here, like weekly and my staff is really good. The DM stated staff just get food from the pantry, they did not check the expiration dates.

Based on observation, interview, and record review it was determined, for 1 of 23 sample residents, that the facility did not maintain an infection prevention and control program designed to provide a sanitary environment and to prevent the development and transmission of communicable diseases and infections, including [CONDITION(S)]-CoV-2 (COVID-19). Specifically, staff did not utilize appropriate PPE when entering isolation rooms for 2 residents on contact and droplet precautions. Additionally, a resident on contact isolation precautions did not have the cautionary signs posted alerting staff and visitors of Transmission Based Precautions (TBP) and Personal Protective Equipment (PPE) was not located outside the resident's door. Resident identifiers: 80, 81, and 83. Findings include: 1. Resident 81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/21 at approximately 11:00 AM an observation was made of room [ROOM NUMBER]. Resident 81 was residing in room [ROOM NUMBER] on a new admission quarantine with contact/droplet isolation precautions. room [ROOM NUMBER] had signage posted on the door that stated new admit/quarantine 14 days leave your surgical mask in place, gown - washable, eye protection/face shield or goggles, gloves, door to remain closed - unless otherwise noted. room [ROOM NUMBER] had a start date of 6/4/21 with an end date of 6/24/21. A Personal Protective Equipment (PPE) cart was located outside of the door and contained washable gowns, gloves, and biohazard bags. On 6/15/21 resident 81's medical records were reviewed. Review of resident 81's physician orders revealed no order for quarantine with contact/droplet isolation precautions. Review of resident 81's June 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of COVID-19 monitoring every shift for signs and symptoms (s/sx.) consistent with COVID-19. Review of resident 81's progress notes revealed that monitoring for s/sx consistent with COVID-19 was not documented as conducted every shift. Additionally, the following progress notes documented an active infection. It should be noted that resident 81 did not have an active infection requiring isolation during the entire stay while at the facility. a. On 6/6/21 at 3:40 PM, the note documented, Isolation is required for active infection with all services provided within room. b. On 6/7/21 at 1:23 PM, the note documented, Isolation is required for active infection with all services provided within room. c. On 6/8/21 at 10:56 PM, the note documented, Isolation is required for active infection with all services provided within room. d. On 6/12/21 at 10:27 PM, the note documented, Isolation is required for active infection with all services provided within room. e. On 6/15/21 at 1:11 AM, the note documented, Isolation is required for active infection with all services provided within room. No lab results were found for a COVID-19 test that was ordered or obtained by the facility. No documentation could be found of a COVID-19 immunization. 2. Resident 83 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/21 at approximately 11:00 AM an observation was made of room [ROOM NUMBER]. Resident 83 was residing in room [ROOM NUMBER] on a new admission quarantine with contact/droplet isolation precautions. room [ROOM NUMBER] had signage posted on the door that stated new admit/quarantine 14 days leave your surgical mask in place, gown - washable, eye protection/face shield or goggles, gloves, door to remain closed- unless otherwise noted. room [ROOM NUMBER] had a start date of 6/9/21 with an end date of 6/23/21. A Personal Protective Equipment Cart (PPE) was located outside of the door and contained washable gowns, gloves, and biohazard bags. On 6/15/21 resident 83's medical records were reviewed. Review of resident 83's physician orders revealed no order for quarantine with contact/droplet isolation precautions. Review of resident 83's June 2021 MAR and TAR revealed no documentation of COVID-19 monitoring every shift for s/sx. consistent with COVID-19. Review of resident 83's progress notes revealed that monitoring for s/sx consistent with COVID-19 was not documented as conducted every shift. No lab results were found for a COVID-19 test that was ordered or obtained by the facility. No documentation could be found of a COVID-19 immunization. Review of the facility policy and procedures for COVID-19 documented under Infection Precautions that TBP were implemented when a resident develops signs and symptoms of a transmissible or communicable infection ('suspected case') or has tested positive for a communicable infection by a laboratory ('confirmed case'). Transmission-based precautions are additional measures taken to protect healthcare workers, other residents and visitors. Depending on how the infection is spread, one or more of the following precautions may be implemented: Contact Precautions - Contact precautions are used when the infection can be spread by touching an infected person (direct contact), or by indirect contact with items that the infected person has touched. - COVID-19 can be spread by touching an infected person or object and then touching one's own mouth, nose or eyes. - Droplets infected with CoV-2 can land on surfaces and survive for unknown periods of time. - Environmental cleaning, hand hygiene and the proper use of PPE are all important for contact precautions. Droplet Precautions - Droplet precautions are implemented to control the spread of infections by droplets through short distances in the air. Droplets are large particles (greater than 5 microns) that can be inhaled when an infected person coughs, sneezes, or talks. Respiratory procedures like suctioning can also generate droplets. - The COVID-19 coronavirus is primarily spread through droplets. - Facemasks should be placed on anyone suspected or confirmed to have COVID-19. - In addition, facemasks should be worn when coming within six feet of suspected or confirmed COVID-19 infected individuals in order to protect from respiratory droplets. - Masks, gowns, gloves and goggles should be worn during procedures that expose healthcare personnel to splashes or sprays of secretions. It should be noted that the facility policy and procedures did not address the process for implementing source control measures with new admissions. The guidance provided in the facility policy and procedures for COVID-19 was last updated on April 6, 2020. On 6/14/21 at 11:09 AM, an observation was made of dietary aide (DA) 1 exiting room [ROOM NUMBER] quarantine/new admit room. No hand hygiene was observed upon exit of the room. DA 1 was observed to enter room [ROOM NUMBER] and exit immediately. An immediate interview was conducted with DA 1. DA 1 stated she was taking food orders from the residents for the following day meals. DA 1 stated that if a room was on precautions she would donn gloves. DA 1 stated that for room [ROOM NUMBER] the required PPE was just goggles and a mask. DA 1 stated that for room [ROOM NUMBER] she walked in, talked to the resident, and walked out. DA 1 stated that for new admissions on quarantine she just put on goggles, and the glasses she wore had sides so they were technically a goggle. Immediately following our interview DA 1 was observed to enter room [ROOM NUMBER]. DA 1 did not donn any additional PPE or perform hand hygiene prior to entering room [ROOM NUMBER]. DA 1 was observed to perform hand hygiene upon exit of room [ROOM NUMBER]. DA 1 was observed to wear a surgical mask and glasses only in room [ROOM NUMBER] and room [ROOM NUMBER]. On 6/14/21 at 2:08 PM, an observation was made of Certified Nurse Assistant (CNA) 5. CNA 5 was observed to enter room [ROOM NUMBER], picked up the lunch meal tray from the bedside table, and removed it. CNA 5 did not donn any additional PPE and was observed to wear a surgical mask only. The meal tray was not bagged for transport. On 6/14/21 at 2:12 PM, an interview was conducted with CNA 5. CNA 5 stated that room [ROOM NUMBER]'s meal tray should be bagged in a biohazard bag for transport to the kitchen and the bags were located in the PPE cart outside the resident room. CNA 5 stated, I forgot to bag it. CNA 5 stated just to enter the room we don't have to gown. CNA 5 stated that if the sign on the resident door stated additional PPE was required then he would donn it. CNA 5 stated I didn't look [at the sign] because the door was open. On 6/16/21 at 7:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the nurse on shift would do the admission paper work and determine the resident's COVID-19 vaccination status. LPN 2 stated that if the resident did not have the vaccine they would be quarantined on contact/droplet precautions for 14 days. LPN 2 stated that they would place a sign on the door alerting the type of TBP and a PPE cart would be placed outside the resident door. LPN 2 stated that the floor sheet would show the COVID vaccine status for each resident. LPN 2 stated that the nurse brains would say quarantine 14 days due to new admit, no COVID vaccine. LPN 2 stated that if a resident was on quarantine for new admission with contact/droplet precautions the PPE worn would be a N95 mask, goggles, gloves and a gown. LPN 2 stated that they conduct COVID-19 monitoring every shift for every resident and they assess for cough, shortness of breath, nausea and vomiting, fever, and changes in oxygen saturation. LPN 2 stated that this was documented in the progress notes. On 6/16/21 at 10:03 AM, a follow-up interview was conducted with DA 1. DA 1 stated that meal trays from the quarantine or vaccine precaution rooms were placed in a biohazard bag and kept separate from the meal cart. DA 1 stated that those trays were processed separately form the rest of the dishes. On 6/16/21 at 10:32 AM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN). The DON stated that new admissions were quarantined for 14 days on contact/droplet precautions. The DON stated that signs on the resident door stated PPE was required for any close contact for greater than 15 minutes and while providing cares. If we are just dropping off trays then we don't need full PPE. Meal trays that go out of quarantine rooms should be placed in a biohazard bag so kitchen staff can identify that they are from those rooms. The DON stated that it was addressed that the meal tray was taken to the kitchen without being bagged and they were aware of it. On 6/17/21 at 11:18 AM, an observation was made of CNA 7. CNA 7 was observed entering room [ROOM NUMBER] wearing only a surgical mask, no other PPE was observed donned. CNA 7 exited room [ROOM NUMBER] and performed hand hygiene. An immediate interview was conducted with CNA 7. CNA 7 stated that she did not wear a gown or gloves in room [ROOM NUMBER], because she just went in to say hi. On 6/17/21 at 11:50 AM, a follow-up interview was conducted with CNA 7. CNA 7 stated she should wear a mask, gown, goggles, and gloves when entering room [ROOM NUMBER]. But was told by the other nurse lady, not sure who, that I didn't have to wear all that if I wasn't giving patient cares. Review of the Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes stated under New Admissions and Residents who Leave the Facility that In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance for recommended PPE use when caring for resident in quarantine referred back to, and was described in, the section Manage Residents who have had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. The PPE guidance further stated, HCP (healthcare personnel) should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 3. Resident 80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 resident 80's medical records were reviewed. Review of resident 80's orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 6/14/21. Review of resident 80's hospital History and Physical on 6/4/21 documented that resident 80 had microbiology results that showed positive for MRSA in the Shin Superficial Wound Culture on 6/1/21 and MRSA in the Blood Culture on 5/31/21. Review of resident 80's progress notes revealed the following: a. On 6/8/21 at 3:52 PM, the note documented, patient is on [MEDICATION(S)] for MRSA in RLE (right lower extremity). b. On 6/8/21 at 4:41 PM, the note documented, Isolation is required for active infection with all services provided within room. c. On 6/9/21 at 4:07 AM, the note documented, Contact precautions utilized. d. On 6/11/21 at 12:51 AM, the note documented, Isolation is required for active infection with all services provided within room. e. On 6/11/21 at 10:17 AM, the note documented, Isolation is required for active infection with all services provided within room. f. On 6/15/21 at 1:08 AM, the note documented, Isolation is required for active infection with all services provided within room. Review of resident 80's care plan revealed a focus area for Infection MRSA in RLE that was initiated on 6/14/21. The interventions documented included, but were not limited to, Educate both the resident and the direct care staff that the infection is contagious., and Maintain universal precautions when providing resident care. Review of the facility Policy and Procedures for Isolation - Categories of Transmission-Based Precautions documented under Contact Precautions .may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The policy further stated that staff and visitors should wear gloves when entering the room, and a gown should be donned upon entering the room and doffed before exiting the room. The guidance was last revised in October 2018. On 6/14/21 at approximately 11:15 AM, an observation was made of room [ROOM NUMBER]. No cautionary signs were posted on the door alerting staff to any TBP, and no PPE cart was located outside of the resident room. On 6/14/21 at 2:55 PM, an observation was made of room [ROOM NUMBER]. A cautionary sign was observed posted on room [ROOM NUMBER] door that stated contact precautions, wear a gown, gloves when providing direct care, clean hands with alcohol based hand rub (ABHR). An interview was conducted with CNA 3. CNA 3 stated that resident 80 was on contact precautions for MRSA in her wound. On 6/16/21 at 7:50 AM, an interview was conducted with CNA 6. CNA 6 stated that she worked for an agency and this was the first day working at the facility. CNA 6 stated that for any isolation precautions there was usually a sign posted on the door. CNA 6 stated that since this was the first day at the facility she was unsure of how they did things here. 06/16/21 07:55 AM, an interview was conducted with CNA 7. CNA 7 stated that she was a agency aide and was not aware that room [ROOM NUMBER] was on TBP. CNA 7 stated that she was informed of TBP by signs that were posted on a resident door or she would ask a nurse. CNA 7 stated that if there was not a sign posted on a resident door alerting her to the TBP then she was unaware of how she would be informed of this information. CNA 7 was observed to shrug her shoulders when asked how she would know if a room had TBP without a sign posted. On 6/16/21 at 10:32 AM, an interview was conducted with the DON and CRN. The DON stated that resident 80 was admitted on [DATE] and contact precaution signs were placed on 6/15/21. The DON stated that the delay in implementing the TBP signs was a miscommunication between staff. The DON stated that the licensed nursing staff were responsible for placing signs and the PPE carts outside of the residents rooms when they were on TBP. The DON stated that resident 80 has had the shin wound since admission, but was made aware of the MRSA in the wound on 6/8/21. The DON stated that initially upon admission they were trying to determine if the MRSA infection was located in the residents blood or wound. The DON stated that the MRSA infection was communicated to staff verbally by her on 6/8/21 and for them to update their perspective communication sheets. The DON further stated that they communicated in morning meeting that there was an infection and that they were trying to clarify the location. The DON stated that she instructed staff in the morning meeting that there was an infection that it was in either the wound or blood, and if providing treatment or care to put on the necessary PPE (gloves, gowns and universal mask, and eye protection). On 6/17/21 at 10:47 AM, an interview was conducted with laundry aide (LA) 1. LA 1 stated that the laundry from the isolation was usually bagged for transport and to identify that it needed to be handled and processed differently. LA 1 stated that if he went into a room to get laundry he would wear all the required PPE. LA 1 stated that he would know about the TBP and required PPE based on the signs on the door.

Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not immediately notify the physician when there was an accident that involved the resident and had the potential for physician intervention, a significant change in the resident's status, or a need to alter treatment. Specifically, the physician was not notified when the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/21 at 10:34 AM, an interview was conducted with resident 7. Resident 7 reported bilateral weakness in the lower extremities, and stated that he falls all the time. Review of resident 7's incident reports revealed 9 fall since admission. The following incident reports revealed no physician notification of the incident: a. On 5/7/21 at 7:00 PM, the report documented that the resident was found on the floor next to the bed. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed, no notes were documented prior to 5/13/21. b. On 5/20/21 at 7:30 PM, the report documented that the resident was found on the floor next to the side of the bed with their buttocks on the floor and legs crossed side ways extending under bed. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed and no documentation could be found for physician notification of the 7:30 PM fall. c. On 6/7/21 at 8:00 PM, the report documented that the resident was found on the floor in front of the wheelchair with legs crossed underneath him. The report did not document that notification was made to the physician of the fall. Nursing progress notes were reviewed and no documentation could be found for physician notification. On 6/17/21 at 8:51 AM, Licensed Practical Nurse (LPN) 1. LPN 1 stated that they notify the provider with each resident fall along with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the family. LPN 1 stated that documentation of notification was under risk management in the electronic medical records and would also be documented in a nursing progress note. The LPN stated that the Nurse Practitioner (NP) 1 was in the facility 5 days a week and the physician was there 1 day a week. LPN 1 stated that they either call the provider or the the on call provider when notification needed to be made. On 6/17/21 at 10:36 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that physician notification was noted in risk management. If we notified it could be there. The CRN stated that the nurses should notify the physician after each fall. On 6/17/21 at 1:00 PM, a follow-up interview was conducted with the CRN. The CRN stated that NP 2 provided copy of a note with documentation showing that notification was made of the fall on 5/7/21. It should be noted that the note did not document the time of notification. The CRN stated that there was no documentation of physician notification for the falls that occurred on 5/20/21 and 6/7/21.

Based on interview and record review it was determined, for 2 out of 23 sampled residents, that the facility did not ensure that the baseline care plans were developed and implemented within 48 hours of a resident's admission and included instructions needed to provide effective and person-centered care. Specifically, two resident's baseline care plans were not developed within 48 hours of admission. Resident identifiers were 75 and 81. Findings include: 1. Resident 81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 resident 81's medical records were reviewed. Review of resident 81's care plan revealed a focus area for emotional, intellectual, physical, and social needs related to physical limitations with interventions that were initiated on 6/8/21, and a focus area for potential for altered mood/behavioral and social isolation related to facility quarantine with interventions that were initiated on 6/14/21. All other care plan focus areas with interventions were initiated on 6/15/21. It should be noted that the resident was discharged from the facility on 6/16/21. On 6/16/21 at 9:58 AM, an interview was conducted with the Director of Nursing (DON) and Corporate Resource Nurse (CRN). The DON stated that the admission paperwork was completed by herself, the Assistant Director of Nursing, or a floor nurse and they complete the care plan as well. Once the care plan was completed it was given to the nurse and a copy was provided to the resident. The DON stated that a signed sheet was retained in the resident's medical record indicating that they received a copy of the care plan. The DON stated that the baseline care plan would be included in the comprehensive care plan and would show the date that the focus area was initiated. The DON stated that the baseline care plans contained and covered (if applicable) the admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the completion goal for the baseline care plan was the date of admit, but was not aware of the regulatory guidelines. The DON stated that resident 81 only had one care area or focus area for emotional, intellectual, spiritual needs that was initiated on 6/8/21. All other care plans were initiated on 6/15/21. The DON agreed that the nursing staff did not have the benefit of the care plan as it was not available until yesterday, but that they could have read through all of the resident documentation to see the history. 2. Resident 75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 resident 75's medical records were reviewed. Review of resident 75's care plan revealed that all focus areas with interventions were initiated on 6/14/21. On 6/17/21 at 1:52 PM, a follow-up interview was conducted with the DON. The DON stated that resident 75 was admitted on [DATE] and the baseline care plan was completed on 6/14/21.

Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose, excessive duration, without adequate monitoring, without adequate indication for its use, in the presence of adverse consequences or any combination of these reasons. Specifically, a resident's medication was administered when it should have been held per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident 20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/21 resident 20's medical records were reviewed. Review of resident 20's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initiated on 5/21/21. Resident 20's May 2021 Medication Administration Record (MAR) was reviewed. The [MEDICATION(S)] was administered when it should have been held per the physician ordered parameters on the following dates: a. On 5/22/21 at bedtime (HS) the blood pressure was (BP) 92/54 and the [MEDICATION(S)] was documented as administered. b. On 5/23/21 at 7:00 AM, the BP was 134/72 and the [MEDICATION(S)] was documented as administered. c. On 5/23/21 at 2:00 PM, the BP was 134/72 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. d. On 5/24/21 at 7:00 AM, the BP was 109/56 and the [MEDICATION(S)] was documented as administered. e. On 5/31/21 at 7:00 AM, the BP was 131/60 and the [MEDICATION(S)] was documented as administered. f. On 5/31/21 at 2:00 PM, the BP was 131/60 and the [MEDICATION(S)] was documented as administered. Resident 20's June 2021 MAR was reviewed. The [MEDICATION(S)] was administered when it should have been held per the physician ordered parameters on the following dates: a. On 6/1/21 at 7:00 AM, the BP was 118/54 and the [MEDICATION(S)] was documented as administered. b. On 6/1/21 at 2:00 PM, the BP was 118/54 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. c. On 6/1/21 at HS the BP was 105/55 and the [MEDICATION(S)] was documented as administered. d. On 6/2/21 at 7:00 AM, the BP was 114/53 and the [MEDICATION(S)] was documented as administered. e. On 6/2/21 at 2:00 PM, the BP was 114/53 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. f. On 6/6/21 at 7:00 AM, the BP was 122/60 and the [MEDICATION(S)] was documented as administered. g. On 6/6/21 at 2:00 PM, BP was 122/60 and the [MEDICATION(S)] was documented as administered. h. On 6/6/21 at HS the BP was 121/60 and the [MEDICATION(S)] was documented as administered. i. On 6/7/21 at 7:00 AM, the BP was 112/65 and the [MEDICATION(S)] was documented as administered. j. On 6/7/21 at 2:00 PM, the BP was 122/60 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. k. On 6/8/21 at 7:00 AM, the BP was 114/58 and the [MEDICATION(S)] was documented as administered. l. On 6/8/21 at 2:00 PM, the BP was 114/58 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. m. On 6/8/21 at HS the BP was 111/53 and the [MEDICATION(S)] was documented as administered. n. On 6/9/21 at HS the BP was 137/55 and the [MEDICATION(S)] was documented as administered. o. On 6/11/21 at 2:00 PM, the BP was 114/82 and the [MEDICATION(S)] was documented as administered. p. On 6/12/21 at HS the BP was 93/56 and the [MEDICATION(S)] was documented as administered. q. On 6/13/21 at 7:00 AM, the BP was 116/61 and the [MEDICATION(S)] was documented as administered. r. On 6/13/21 at 2:00 PM, the BP was 116/61 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. s. On 6/14/21 at 7:00 AM, the BP was 126/63 and the [MEDICATION(S)] was documented as administered. t. On 6/14/21 at 2:00 PM, the BP was 126/63 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as 7:00 AM reading and documented by the same licensed nurse. u. On 6/15/21 at 7:00 AM, the BP was 134/72 and the [MEDICATION(S)] was documented as administered. v. On 6/15/21 at 2:00 PM, the BP was 134/72 and the [MEDICATION(S)] was documented as administered. It should be noted that the BP was the same reading as the 7:00 AM reading and documented by the same licensed nurse. On 6/16/21 at 7:53 AM, and interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the Certified Nurse Assistants (CNAs) obtained the BP readings for the nurse one time per shift and when BP medications were administered. The LPN stated that if the CNA was not available she would obtain a BP reading prior to administering a BP medication. LPN 2 stated that she would document the blood pressure readings in the MAR and verify any medications with parameters. On 6/16/21 at 10:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility does not have standing orders to hold BP medications for parameters. The DON stated that providers would put parameters on each individual order or if the nurse identified a trend with BP readings they would inform the provider. The DON stated that there should be a BP reading obtained either by a CNA or a licensed nurse (LN) and the LN should verify the reading prior to administering the BP medication. The DON stated that the LN should have obtained a new BP reading for each medication administration and they should have held the medication per the physician parameters.

Based on interview and record review, it was determined that for 5 of 14 sample residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, multiple medications were not available for resident administration. Resident identifiers: 2, 13, 70, 72, and 73. Findings include: 1. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19, resident 13's Medication Administration Record [REDACTED]. a. [MEDICATION NAME] tablet. Give 500 milligrams (mg) by mouth three times a day for Rt (right) foot ulcer infx (infection) until 5/17/2019 23:59 (11:59 PM). -Start Date 4/24/2019 1900 (7:00 PM). On 5/8/19 at 1400 (2:00 PM), the MAR indicated [REDACTED]=Other / See Progress Notes). On 5/8/19 at 4:01 PM, an Orders-Administration Note revealed the following: [MEDICATION NAME] Tablet. Give 500 mg by mouth three times a day for Rt foot ulcer infx until 05/17/2019 23:59. Waiting on pharmacy. Provider notified. b. Latanoprost [MEDICATION NAME] 0.005%. Instill 1 drop in both eyes at bedtime for diabetic retinopathy. -Start Date 4/23/19 1900. On 5/12/19 at 19-22 (Flex time 7:00-10:00 PM), the MAR indicated [REDACTED] On 5/13/19 at 1:26 AM, an Orders-Administration Note revealed the following: Latanoprost [MEDICATION NAME] 0.005%. Instill 1 drop in both eyes at bedtime for diabetic retinopathy. Pt (Patient's) eye gtt (drops) have to be re order unable to locate in the cart. On 5/21/19 at approximately 12:03 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated she did not know why the two medications listed above were unavailable to administer to resident 13. On 5/21/19 at approximately 12:51 PM, an interview conducted with the Assistant Director of Nursing (ADON) and the Corporate Resource Nurse (CRN). The ADON and CRN stated they did not know why the medications were unavailable to administer to resident 13. 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 2's MAR indicated [REDACTED]. On 5/10/19 at 1559 (3:59 PM), the MAR indicated [REDACTED]=Other / See Progress Notes). An Orders - Administration Note progress note, dated 5/10/19 at 3:59 PM, documented the following information: . Note Text: [MEDICATION NAME] Sodium Solution . Use 1 gram intravenously every 24 hours for UTI until 05/12/2019 23:59 . Pharmacy has not delivered medication yet . On 5/22/19 at approximately 1:30 PM, an interview was conducted with the CRN. The CRN stated she contacted the pharmacy for additional information related to the availability of residents' medications. The CRN further stated she did not have any additional information related to the availability of resident 2's unavailable medication. 3. Resident 72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 72's MAR indicated [REDACTED] a. Started 5/18/19 at 1900; [MEDICATION NAME] Tablet 324 (37.5 Fe (iron)) Give 1 tablet by mouth two times a day for [MEDICAL CONDITION]. On 5/18/19 at 19-22, the MAR indicated [REDACTED]=Other / See Progress Notes). An Orders - Administration Note progress note, dated 5/18/19 at 11:20 PM, documented the following information: . Note Text: [MEDICATION NAME] Tablet . Give 1 tablet by mouth two times a day for [MEDICAL CONDITION] . pharmacy notified, med (medication) on order. b. Started 5/18/19 at 1900; [MEDICATION NAME] Tablet 20 MG Give 20 mg by mouth two times a day [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). On 5/22/19 at 7-10 (Flex time 7:00-10:00 AM), the MAR indicated [REDACTED]=Other / See Progress Notes). An Orders - Administration Note progress note, dated 5/22/19 at 10:46 PM, documented the following information: . Note Text: [MEDICATION NAME] Tablet . Give 20 mg by mouth two times a day [MEDICAL CONDITION]. Waiting on pharmacy . On 5/22/19 at approximately 1:30 PM, an interview was conducted with the CRN. The CRN stated she contacted the pharmacy for additional information related to the availability of residents' medications. The CRN further stated the pharmacy did not deliver resident 72's [MEDICATION NAME] because the pharmacy believed the facility already had them. 4. Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 70's MAR indicated [REDACTED]. On 5/17/19 at 19-22 and 5/18/19 at 7-10, the MAR indicated [REDACTED]=Other / See Progress Notes). Resident 70's Orders - Administration Note progress notes documented the following two entries: a. 5/17/19 at 9:51 PM; Note Text: [MEDICATION NAME] HCl Tablet . Give 20 mg by mouth two times a day for anorexia . med not available. Pharmacy notified and they need a signed rx (prescription) from the MD (physician). MD notified . b. 5/18/19 at 7:34 AM; Note Text: [MEDICATION NAME] HCl Tablet . Give 20 mg by mouth two times a day for anorexia . Med on order at pharmacy. On 5/22/19 at approximately 1:30 PM, an interview was conducted with the CRN. The CRN stated she contacted the pharmacy for additional information related to the availability of residents' medications. The CRN further stated she did not have any additional information related to the availability of resident 70's unavailable medication. 5. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/21/19, resident 73's MAR indicated [REDACTED]. 2 puff inhale orally two times a day for hypoxemic resp (respiratory) failure. On 5/16/19 at 19-22, the MAR indicated [REDACTED]=Other / See Progress Notes). An Orders - Administration Note progress note, dated 5/16/19 at 2:24 AM, documented the following information: . Note Text: [MEDICATION NAME] Aerosol Solution . 2 puff inhale orally two times a day for hypoxemic resp failure . Pharmacy notified. Drug not available and will be delivered tonight or in the am (morning) . On 5/22/19 at approximately 1:30 PM, an interview was conducted with the CRN. The CRN stated she contacted the pharmacy for additional information related to the availability of residents' medications. The CRN further stated the pharmacy did not deliver resident 73's [MEDICATION NAME] because it was a more expensive medication that was typically sent the day after a resident's initial medication delivery. On 5/21/19 at approximately 12:03 PM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that when a medication was unavailable, she called the pharmacy to request it. RN 3 stated pharmacy will deliver the medication within 2 hours. RN 3 further stated she will also contact the resident's provider to let him/her know that the medication was unavailable. RN 3 stated if the resident's provider wanted the unavailable medication given prior to the 2-hour pharmacy delivery time, he/she would request that the pharmacy deliver it STAT (as soon as possible) and the pharmacy would deliver the unavailable medication sooner. RN 3 stated that when she identified a medication card had only 2-3 doses left, she would remove a reorder sticker from the medication card and send it to the pharmacy so a new card of medications can be delivered before the old card of medications ran out. On 5/21/19 at 2:25 PM, an interview was conducted with RN 1. RN 1 stated sometimes the pharmacy did not send all of a resident's medications upon admission. RN 1 further stated if a medication was unavailable, she would document that it was unavailable in a progress note and call the pharmacy to follow up. In addition, RN 1 stated some of the nurses were new and may not have known the process to follow up on medications that were unavailable. On 5/22/19 at 7:05 AM, an interview was conducted with RN 2. RN 2 stated the pharmacy was typically good about delivering medications, but sometimes waited until after a resident was admitted to deliver the resident's medications. RN 2 further stated if a medication was unavailable, she would document that it was unavailable in a progress note, call the pharmacy, and notify the provider. On 5/22/19 at 8:42 AM, an interview was conducted with the CRN. The CRN stated timeliness of medication delivery depended upon the time of day a resident admitted to the facility, and the pharmacy tried to get medications to the facility as fast as they can. The CRN further stated the facility had a good variety of medications available within the medication storage area, but deliveries of specialized medications could have taken longer. In addition, the CRN stated the facility should have had every medication at all times.

Based on interview and record review it was determined that for 1 of 14 sample residents, the facility did not maintain medical records on each resident that were accurately documented. Specifically, there was one resident that had a resolved pressure sore, but subsequent nurse notes stated the resident still had a pressure ulcer. Resident identifier: 13. Findings include: Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/20/19 at approximately 8:11 AM, an interview was conducted with resident 13. Resident 13 stated he had not slept well the night prior because he had a sore area on his bottom. Resident 13 stated he had a hard time positioning himself in the recliner, which made it hard to sleep. On 5/21/19, resident 13's Nurse Note progress notes were reviewed and documented the following three entries: a. 4/25/19 at 10:41 AM; Pt (patient) was admitted to Stonehenge Rehab of South(NAME)for [MEDICAL CONDITION], Foot [MEDICAL CONDITION], Stage II pressure sore on L (left) buttock. Pt is A&O x3 (alert and oriented to person, place, and time), Pleasant and cooperative with cares provided, able to make needs and wants known to staff. Pt states he is Limx1 assist (requires assistance from one person) with a cane or walker for toileting, transfers, bed mobility, and independent grooming, WBAT (weight bearing as tolerated). HRR (heart rate regular), Lungs clear, BSx 4q (bowel sounds in four quadrants) Last BM (bowel movement) 4/22, Pt has +1 [MEDICAL CONDITION] in BLE (bilateral lower extremities) and LUE (left upper extremity), Compression stocking placed on arm and pt states the swelling is baseline for him. VSS (vital signs stable), Pt stated he has no pain at this current time, Pt has ulcer on foot and L buttock has pressure sore, left chest has [MEDICATION NAME] port for IV (intravenous) meds (medications) and blood draws. Pt is cont (continent) of B&B (bowel and bladder), Takes meds whole with water no difficulties. Pt is on IV ABX (antibiotics) [MEDICATION NAME] for wound infection, no ASE (adverse side effects) noted or s/s (signs or symptoms) of side effects noted. Pt is on RA (room air) and sating (oxygen saturation level) 95%. Pt did bring some home meds that are marked with his name and room number locked in nurses cart. Pt is able to use call light and it was within reach. WCTM (will continue to monitor) b. 5/2/19 at 11:38 AM; Pt was admitted to Stonehenge Rehab of South(NAME)for [MEDICAL CONDITION], Foot [MEDICAL CONDITION], Stage II pressure sore on L buttock. Pt is A&O x3, Pleasant and cooperative with cares provided, able to make needs and wants known to staff. Pt states he is Limx1 assist with a cane or walker for toileting, transfers, bed mobility, and independent grooming, WBAT. HRR, Lungs clear, BSx 4q Last BM 4/22, Pt has +1 [MEDICAL CONDITION] in BLE and LUE, Compression stocking placed on arm and pt states the swelling is baseline for him. VSS, Pt stated he has no pain at this current time, Pt has ulcer on foot and L buttock has pressure sore, left chest has [MEDICATION NAME] port for IV meds and blood draws. Pt is cont of B&B, Takes meds whole with water no difficulties. Pt is on IV ABX [MEDICATION NAME] for wound infection, no ASE noted or s/s of side effects noted. Pt is on RA and sating 95%. Pt did bring some home meds that are marked with his name and room number locked in nurses cart. Pt is able to use call light and it was within reach. WCTM c. 5/16/19 at 11:28 AM; Pt was admitted to Stonehenge Rehab of South(NAME)for [MEDICAL CONDITION], Foot [MEDICAL CONDITION], Stage II pressure sore on L buttock. Pt is A&O x3, Pleasant and cooperative with cares provided, able to make needs and wants known to staff. Pt states he is Limx1 assist with a cane or walker for toileting, transfers, bed mobility, and independent grooming, WBAT. HRR, Lungs clear, BSx 4q Last BM 5/16, Pt has 3+ [MEDICAL CONDITION] in BLE and LUE, Compression stocking placed on arm and pt states the swelling is baseline for him. VSS, Pt stated he has no pain at this current time, Pt has ulcer on foot and L buttock has pressure sore, left chest has [MEDICATION NAME] port for IV meds and blood draws. Pt is cont of B&B, Takes meds whole with water no difficulties. Pt is on IV ABX [MEDICATION NAME] for wound infection and PO (by mouth) [MEDICATION NAME] with no S or S (signs or symptoms) or adverse reactions noted. pt remains afebrile and wound appears to be healing. WCTM no ASE noted or s/s of side effects noted. Pt is on 2L (liters) nasal canula and sating 95%. Pt ate 100% of breakfast and tolerated well. Pt is able to use call light and it was within reach. WCTM On 5/22/19 at approximately 9:03 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she had cared for resident 13. CNA 1 stated she had applied barrier cream to his bottom but could not remember when. CNA 1 stated when she had applied the barrier cream to resident 13's bottom that the area was red but there was not an open wound. CNA 1 further stated that resident 13 was also applying barrier cream to his own bottom. On 5/22/19 at approximately 9:55 AM, an interview conducted with Registered Nurse (RN) 4. RN 4 stated she had not treated resident 13's pressure sore on his bottom. RN 4 stated the facility had wound care nurses, who treat the residents' pressure ulcers. On 5/22/19 at approximately 11:08 AM, an interview conducted with the Assistant Director of Nursing (ADON), who was responsible for wound care in the facility and the Corporate Resource Nurse (CRN). The ADON provided a document from the Wound/Skin Log binder, which revealed the stage 2 pressure ulcer on resident 13's left buttock had resolved on 4/30/19. The ADON and CRN did not know why the Nurse Notes documented on 5/2/19 at 11:38 AM and 5/16/19 at 11:28 AM indicated resident 13 had a pressure sore on his left buttock. The Nurse Notes documented on 5/2/19 at 11:38 AM and 5/16/19 at 11:28 AM were identical word-for-word to the Nurse Note documented on 4/25/19 at 10:41 AM with the exception of the last few sentences. The ADON and CRN concluded that the Nurse Notes from 5/2/19 and 5/16/19 were copied and pasted from the 4/25/19 Nurse Note. The ADON and CRN further stated that the information about resident 13's pressure sore documented in the 5/2/19 and 5/16/19 Nurse Notes were inaccurate.

Based on interview and record review, it was determined that for 1 of 16 sample residents, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug includes any drug when used in excessive dose; for excessive duration; without adequate monitoring; without adequate indications for its use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, one resident did not have an increase in monitoring of vital signs, side effects or sedation when her narcotic medication had been increased. The deficient practice identified was found to have occurred at a harm level. Resident Identifiers: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] resident 1's medical record was reviewed. A nursing progress note dated [DATE] at 9:40 AM revealed, At approximately 0540 (5:40 AM) this morning staff went in to administer medication and draw INR (International Normalized Ratio). Patient was lethargic and difficult to arouse. She was slurring her words. INR was drawn and was 6.9. Staff redrew INR and it was 6.1. Vital signs were taken. BP (blood pressure) ,[DATE], R (respirations) 24, T (temperature) 97.6, O2 (oxygen saturation) 98 on RA (room air). Her pulse on the monitor read 230. Could not get a radial pulse. Asked another nurse to assist in assessing the patient. NP (Nurse Practitioner) was notified and ordered to given (sic) [MEDICATION NAME] and Vitamin K. Both medications were administered by other nurse. Decision was made to call EMS (Emergency Medical Services). Daughter was notified. DON (Director of Nursing) was notified. EMS arrived and upon lowering her bed patient stopped breathing and CPR (Cardio-Pulmonary Resuscitation) was initiated. EMS took her to (name of an acute care hospital) ER (emergency room ) for further evaluation. A nursing progress note dated [DATE] at 9:55 AM revealed, Nurse contacted (hospital) and was informed of pt (patient) passing shortly after arriving at the ED (Emergency Department). Family and MD (Medical Doctor) aware. A typed note dated [DATE], from Registered Nurse (RN) 1 revealed the following: On [DATE] at around 06:20 (6:20 AM), I went into (Resident 1's) room to see how she was doing, as the previous shift nurse and CNAs (Certified Nursing Assistant's) mentioned she had been in a lot of pain throughout the night. I asked (Resident 1) how she was doing, and she was in tears. She stated her right leg was really hurting. I asked her where on her leg she was having pain, and she pointed to her right leg distal from the incision dressing that was in place. I looked at her leg where she was pointing, and there was no redness, heat, or swelling present. I palpated the area and asked if touching her leg made the pain worse. She stated my palpating did not cause more pain, and said the pain was sharp and deep. From the appearance of her leg, I did not suspect a new infection or fracture to the leg. At that point I told (Resident 1) I would go call (Physician 1) to see about helping with pain control. I called (Physician 1) @ (at) 06:37 (6:37 AM) and told him exactly what the patient was describing, and what I saw upon evaluating her leg. (Physician 1) stated her pain medication was increased over the weekend. Prior to the increase she was on 5 mg of [MEDICATION NAME] every 4 hours for pain. After the increase she was on ,[DATE] mg of [MEDICATION NAME] every 4 hours as needed for severe pain. At the time of the call, (Physician 1) ordered an additional one-time dose of 20 mg [MEDICATION NAME] for breakthrough pain, as well as 60 mg [MEDICATION NAME] IM (intramuscular) injection. (Resident 1) was given both new ordered medications. About an hour later, (Resident 1) stated her pain was coming down, but it was still pretty bad. At this point (Resident 1) vomited a large amount of clear vomit. Due to her nausea, I gave her 4 mg [MEDICATION NAME] every 4 hours to help with her nausea. She stated she did not want to eat anything because she did not feel well. I then went to the kitchen and got (Resident 1) a glass of milk and took it back to her. I told her that if she did not have something in her stomach, the pain medication may continue to make her sick. (Resident 1) drank the milk without any issues. She continued to receive her ordered [MEDICATION NAME] throughout the day. I went into (Resident 1's) room multiple times throughout the day to check on her. I even spoke to her daughter (Resident 1's Daughter's Name) both times she called. I explained that (Resident 1) was nauseated and had vomited once, but that we were treating the nausea and working to keep her pain under control. Her daughter (Resident 1's Daughter's Name) said thank you for taking care of her mother, and she would call back later to check on her. The last dose of pain medication (Resident 1) received was 10 mg [MEDICATION NAME] at 1745 (5:45 PM). At this time she was completely coherent and had asked for the pain medication. A typed email dated [DATE] at 10:30 PM regarding room [ROOM NUMBER] report (resident 1's room), from CNA 1 revealed the following: Saturday Graveyard Shfit (sic): -Started my shift at 10 PM and was in her room every five to ten minutes. -She was having a lot of pain in her leg. -Changed her every two hours or when she called and asked. -Conversated (sic) with her for about 30 minutes around 3 or so to calm her down while she waited for pain pill -Left work at 6 AM Monday morning and she had finally calmed down and relaxed. Sunday Graveyard Shift: -Got into work at 6 PM and got her vitals around 6:30. -All vitals were normal and her behavior was her karnal (sic) self. -She didn't call as much so as I would check on another patient every two hours of my shift I would walk in and make sure everything was okay with her. -No signs of abnormal behavior. Her eyes were closed and she was sleeping most of the time. -I offered to changed (sic) her multiple times but she had refused saying that she didn't want to move, she just wanted to not be bothered. -Around 5:45 is when I went in with the nurse. I went to get her INR and nurse went to give her the pain pills that she takes. -She was not herself. I told the nurse that she hadn't been like this all night and that it was something new. -Her INR was 6.9. When I went back out to tell the nurse she told me to go back in and get her vitals. -As I was in there getting her vitals I was asking her if she wanted to be changed because her room wasn't smelling too good. She just said she didn't want to be moved or touched. (CNA 2) came in and helped me get another INR on her while I did her vitals. With the results of her vitals I was worried because they were so out of range. I told the nurse immediately. -After that the nurse took over things. They called the ambulance and that was the last time that I had seen her. -(name of CNA 1) A typed email dated [DATE] at 3:04 PM regarding report, revealed the following: On (MONTH) 19th, (YEAR) I was working the night shift on South Hall. The other CNA working North Hall, asked me to come help assist at 0545 (5:45 AM) in room [ROOM NUMBER]. When I walked into the room the patient was breathing heavy and very quiet. The CNA asked me to check her INR while she rechecked her vital signs. Her pulse was up in the 200's. I communicated with the patient asking her if I could poke her finger for the INR, and she communicated back to me telling me it was okay. The INR result was 6.1. We then proceeded to ask the patient if we could change her or make her more comfortable, and she refused the care saying that she didn't want to be touched. I then took the INR equipment out of the room, and we informed the nurse at 0600 (6:00 AM). The day shifts were just walking in, and the last I heard was that they were sending her out to the hospital. That was the only time I interacted with her. (name of CNA 2) physician's orders [REDACTED]. a. [DATE], [MEDICATION NAME] 600 mg (milligrams), 600 mg oral at bed time. b. [DATE], Duloxetine 20 mg, 20 mg oral daily. c. [DATE], Aripiprazole 5 mg, 5 mg oral daily. d. [DATE], [MEDICATION NAME] ([MEDICATION NAME]) XL (extended release) 300 mg, 300 mg oral daily. e. [DATE] until [DATE], [MEDICATION NAME] 100 mg, 100 mg oral at bed time. f. [DATE], [MEDICATION NAME] 100 mg, 300 mg oral at bed time. g. [DATE] until [DATE], [MEDICATION NAME] 5 mg, 5 mg oral every four hours as needed. h. [DATE] until [DATE], [MEDICATION NAME] 5 mg, ,[DATE] mg oral every three hours as needed. i. [DATE], [MEDICATION NAME] 5 mg, 20 mg oral once for breakthrough pain. j. [DATE], [MEDICATION NAME] 5 mg ,[DATE] mg oral every three hours as needed. (NOTE: Nursing considerations in the Nursing (YEAR) Drug Handbook revealed to Carefully monitor vital signs, pain level, respiratory status, and sedation level in all patients receiving opioids . The facility Controlled Drug Record revealed the following: a. [DATE] at 1930 (5:30 PM), [MEDICATION NAME] 5 mg 3 tablets administered. b. [DATE] at 2300 (11:00 PM), [MEDICATION NAME] 5 mg 2 tablets administered. c. [DATE] at 0211 (2:11 AM), [MEDICATION NAME] 5 mg 3 tablets administered. d. [DATE] at 0505 (5:05 AM), [MEDICATION NAME] 5 mg 3 tablets administered. e. [DATE] at 0650 (6:50 AM), [MEDICATION NAME] 5 mg 4 tablets administered. (NOTE: The [MEDICATION NAME] 20 mg was administered to resident 1 approximately 1 hour and 50 minutes after the administration of the [MEDICATION NAME] 15 mg at 5:05 AM.) f. [DATE] at 0830 (8:30 AM), [MEDICATION NAME] 5 mg 4 tablets administered. (NOTE: The [MEDICATION NAME] 20 mg was administered to resident 1 approximately 1 hour and 40 minutes after the administration of [MEDICATION NAME] 20 mg at 6:50 AM.) g. [DATE] at 1210 (12:10 PM), [MEDICATION NAME] 5 mg 4 tablets administered. h. [DATE] at 1505 (3:05 PM), [MEDICATION NAME] 5 mg 3 tablets administered. (NOTE: The [MEDICATION NAME] 15 mg was administered to resident 1 approximately 2 hours and 55 minutes after the administration of [MEDICATION NAME] 20 mg at 12:10 PM.) i. [DATE] at 1850 (6:50 PM), [MEDICATION NAME] 5 mg 4 tablets administered. (NOTE: Resident 1 received a total of 30 [MEDICATION NAME] 5 mg tablets within an approximate 23 ,[DATE] hour time period.) The Medication Administration Record [REDACTED] a. [DATE] between 7:00 AM and 10:00 AM, Duloxetine 20 mg administered. b. [DATE] between 7:00 AM and 10:00 AM, [MEDICATION NAME] ([MEDICATION NAME]) XL 300 mg administered. c. [DATE] between 7:00 AM and 10:00 AM, Aripiprazole 5 mg administered. d. [DATE] between 7:00 PM and 11:00 PM, [MEDICATION NAME] 600 mg administered. e. [DATE] between 7:00 PM and 11:00 PM, [MEDICATION NAME] 300 mg administered. The facility Vital Parameters Snapshot Report revealed the following: a. [DATE] at 8:15 AM, no vitals recorded. b. [DATE] at 12:43 PM, no vitals recorded. c. [DATE] at 18:32 (6:32 PM), no vitals recorded. d. [DATE] at 22:37 (10:37 PM), BP - ,[DATE], P (Pulse) - 100, R - 28, T - 97.9, O2 Saturations - 99%. e. [DATE] at 8:02 AM, no vitals recorded. f. [DATE] at 10:44 AM, BP - ,[DATE], P - 100, R - 16, T - 97.6, O2 Saturations - 97%. g. [DATE] at 12:16 PM, no vitals recorded. h. [DATE] at 16:28 (4:28 PM), no vitals recorded. i. [DATE] at 21:47 (9:47 PM), BP - ,[DATE], P - 94, R - 12, T - 98.3, O2 Saturations - 91%. Documentation of vital signs in resident 1's medical record, revealed that resident 1's vital signs had not been monitored for 7 hours and 53 minutes. No other documentation could be located in the medical record to show that facility staff had increased monitoring of resident 1's vital signs, side effects nor for sedation of resident 1 after the increase of the [MEDICATION NAME]. An autopsy report obtained by the facility Director of Nursing (DON) from the Office of the Medical Examiner revealed the following: (Resident 1) Date and Time of Death [DATE] - 06:58 (6:58 AM) (Case Number) Date and Time of Exam [DATE] - 10:30 AM Manner of Death: Accident Immediate Cause of Death: Toxic Effects of [MEDICATION NAME], Duloxetine, [MEDICATION NAME], and Aripiprazole complicating therapy for [MEDICAL CONDITION]. Other Significant Conditions: Hypertensive and [MEDICAL CONDITION] cardiovascular disease. Opinion: (Resident 1) died from the toxic effects of [MEDICATION NAME], duloxetine, [MEDICATION NAME], and aripiprazole complicating therapy for a [MEDICAL CONDITION] sustained during a fall. Hypertensive and [MEDICAL CONDITION] cardiovascular disease was a contributory condition. The manner of death is accident. (NOTE: The autopsy report indicated that resident 1 had [MEDICATION NAME] in her system. It was not known where the [MEDICATION NAME] came from since resident 1 did not have a physician's orders [REDACTED]. On [DATE] at 11:07 AM, an interview was conducted with the facility DON. The facility DON stated that she as well as RN 1 was extremely concerned when resident 1 passed away. The DON stated, Definitely a mistake was made and they (the nursing staff) should have been contacting the doctor every single time, referring to each time an [MEDICATION NAME] was needed. The facility DON stated she was unaware that [MEDICATION NAME] 20 mg had been administered to resident 1 so many times, nor was she aware so many [MEDICATION NAME] 5 mg tablets had been administered to resident 1 in approximately 23 ,[DATE] hours. On [DATE] at 12:38 PM, a telephone interview was conducted with resident 1's physician; Physician 1. Physician 1 stated he had been made aware that resident 1 was writhing in bed in pain therefore he had ramped up on the pain medication for resident 1. Physician 1 stated resident 1 had taken [MEDICATION NAME] ([MEDICATION NAME]) at home and was no stranger to narcotics. Physician 1 stated that while he certainly wanted resident 1 out of pain, he would not have expected she needed [MEDICATION NAME] 20 mg each time she was administered pain medication. Physician 1 stated he had not been made aware that resident 1 had received [MEDICATION NAME] 5 mg, 30 tablets in approximately 23 ,[DATE] hour time period. Physician 1 stated he had been made aware that resident 1 had requested to go to the hospital and that he had given the nurse the option for sending resident 1 out to the hospital or to administer a [MEDICATION NAME] injection. On [DATE] at 1:50 PM, a telephone interview was conducted with the facility Pharmacist. The facility Pharmacist stated that the normal dosing of [MEDICATION NAME] would have been ,[DATE] mg every ,[DATE] hours. The facility Pharmacist stated that 30 pills in approximately 23 ,[DATE] hours would have been on the higher end and that increased monitoring would have been appropriate due to the additive effects and interactions with other medications. Additional information provided by facility staff on [DATE], included a spreadsheet which included Pain Scale Observation, Medication Administration and vital signs. Per documentation on the spreadsheet, facility staff had monitored resident 1 eleven times on [DATE], twelve times on [DATE], thirteen times on [DATE], twenty one times on [DATE], and three times on the morning of [DATE]. Although the frequency of staff entering resident 1's room may have increased, the additional infomation provided did not demonstrate a coordinated staff approach to assess the resident's response to pharmacologic attempts to control her pain or to monitor the substantial risk for an adverse side effect related to the increased dose of narcotics.

Based on interview and record review, it was determined for 1 of 16 sample residents, that the facility did not ensure that its residents are free of any significant medication errors. Specifically, one resident was not receiving her scheduled narcotic on time. Resident identifier: 5. Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/11/18 resident 5's medical record was reviewed. physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. The Controlled Drug Record for resident 5 revealed that resident 5 had received the [MEDICATION NAME] 10 mg at the following times: a. 4/9/18 at (YEAR) (8:15 PM). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 7:00 PM and was administered to resident 5 approximately 1 hour and 15 minutes after it was due.) b. 4/10/18 at 0015 (12:15 AM). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 11:00 PM and was administered to resident 5 approximately 1 hour and 15 minutes after it was due.) c. 4/10/18 at 3:15 AM. (NOTE: The [MEDICATION NAME] 10 mg was administered per physician's orders [REDACTED]. physician's orders [REDACTED].) d. 4/10/18 at 20:18 (8:18 PM). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 7:00 PM and was administered to resident 5 approximately 1 hour and 18 minutes after it was due.) e. 4/10/18 at 0000 (Midnight). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 11:00 PM and was administered to resident 5 approximately 1 hour after it was due.) f. 4/11/18 at 0400 (4:00 AM). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 3:00 AM and was administered to resident 5 approximately 1 hour after it was due.) g. 4/11/18 at 0815 (8:15 AM). (NOTE: The [MEDICATION NAME] 10 mg was due to be administered at 7:00 AM and was administered to resident 5 approximately 1 hour and 15 minutes after it was due.) On 4/11/18 at 11:07 AM, an interview was conducted with the facility Director of Nursing (DON). When the facility DON was asked if it was a possibility to overmedicate a resident if the scheduled narcotic was administered an hour late and then the next dose administered on time. The facility DON did not address the question but stated that's an easy fix, we'll adjust the times that the medication should be administered.

Based on interview and record review it was determined, for 8 of 16 sample residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care within 48 hours of a resident's admission. Specifically, eight residents' baseline care plans did not include information necessary to properly care for the resident including; initial goals based on admission orders [REDACTED]. The baseline care plan summaries were not written in a language that the residents and/or representatives could understand nor did the facility provide residents and/or representatives with a written copy. Additionally, 2 resident's baseline care plans were incomplete. Resident identifiers: 1, 70, 71, 73, 74, 121, 125, and 126 Findings include: 1. Resident 121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 121's medical record was completed on 2/22/18. Resident 121's Baseline Care Plan Summary (BCP) was reviewed. (Note: The facility used the Baseline Care Plan for the Baseline Care Plan Summary.) Resident 121's BCP included the problem of weakness with a plan of approach to have physical therapy (PT)/occupational therapy (OT) evaluate and treat resident 121. There were no orders on the BCP indicating frequency or duration for PT or OT. The Dietary Care plan section of resident 121's BCP indicated that resident 121 was on a Renal, CCHO diet. The BCP did not explain the diet terms and abbreviations in common language. On 2/22/18 at 1:00 PM, the Director of Nursing (DON) was interviewed. The DON stated that facility staff met with residents or their representative on the day of admit to review the care plan and the responsible party would then sign the BCP. The DON stated that the BCP then went to the resident's paper chart. The DON stated that if the responsible party asked for a copy of the BCP or other care plan that she would gladly make them a copy. The DON stated that she did not provide the responsible party with a copy of the BCP. The DON stated that specific information related to PT and OT, including frequency and duration, were indicated on PT and OT's care plan. The DON stated that this is a separate care plan from their BCP, because the BCP was a nursing care plan. The DON stated that PT and OT evaluated residents on their first day of admission and created their plans at that time. The DON stated that if a resident or their representative asked for this care plan, then they could receive a copy. The DON acknowledged that the facility's BCP's did not indicate specific medications and did not explain all abbreviations. 2. Resident 125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 125's medical record was completed on 2/22/18. Resident 125's Baseline Care Plan Summary (BCP) was reviewed. Resident 125's BCP included the problem of influenza with a plan of approach to have physical therapy (PT)/occupational therapy (OT) evaluate and treat resident 125. There were no orders on the BCP for PT or OT indicating duration or frequency. Resident 125's BCP included a Medication Order Summary, which indicated the classification of medications that resident 125 received. The BCP did not indicate specific medications or physician's orders [REDACTED]. 3. Resident 70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/18 at 1:04 PM, resident 70 was interviewed and observed. She was observed to have nasal cannula for oxygen in her nose and her breathing appeared labored. Resident 70 stated that she never used to wear oxygen mask or cannula before she got sick few weeks ago. Resident 70 stated that since she came to the facility she had the oxygen cannula in her nose all the time. A review of resident 70's medical record was completed on 2/22/18. Resident 70's physician's orders [REDACTED]. Resident 70's BCP was reviewed. Resident 70's PT/OT orders were not included on the BCP. In addition, the resident 70's problem with occasional shortness of breath and order for [MEDICATION NAME] HFA 0.09 MG/1 Actuation were not listed in BCP. 4. Resident 71 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of resident 71's medical record was completed on 2/22/18. Resident 71's physician orders [REDACTED]. Resident 71's BCP was reviewed. Resident 71's care plan addressing PT/OT did not indicate specific therapies or frequency. Resident 71's BCP indicated that resident 71's diet was CCHO, thin. The BCP did not explain the diet terms and abbreviations in common language. Resident 71's BCP indicated that resident 71's medications included [MEDICATION NAME], narcotic (pain medication, Antidepressants, and Oral hypoglycemic (diabetic medication). Resident 71's BCP did not indicate what specific medications resident 71 was receiving. In addition, resident 71's physician's orders [REDACTED]. There was no indication on resident 71's BCP that she received this medications. 5. Resident 73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 73's medical record was completed on 2/22/18. Resident 73's physician's orders [REDACTED]. a. Change nasal cannula and tubing every Sunday, b. Oxygen (O2): Change O2 humidifier and filter every month, c. Notify primary care physician for increased oxygen needs and oxygen SATs less than 90%, d. Nebulizer mask and tubing to be changed every week on Sunday, e. Incentive Spirometer at bedside; encourage hourly use, f. O2 1-4 Liter (L) per nasal cannula as needed to keep oxygen saturation greater than 90% until stable on room air, 7. PT/OT skilled services 5-7 times per week for 12 weeks to address residents functional decline and weakness. Resident 73's BCP was reviewed. Resident 73's care plan addressing PT/OT did not indicate specific therapies or frequency. The Medication Order Summary of the BCP neglected to indicate that resident 73 was receiving Oxygen Therapy. Additionally, resident 73's BCP indicated categories of medications that resident 73 was receiving but did not include specific medications. 6. Resident 74 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 74's medical records were reviewed on 2/22/18. Resident 74's physician's orders [REDACTED]. a. PT/OT skilled services 5-7 times per week for 12 weeks to address resident 74 functional decline and weakness. b. Monitor Surgical Incision site to lower back for signs and symptoms of infection. Resident 74's BCP was reviewed. Resident 74's care plan addressing PT/OT did not indicate specific therapies or frequency. On the skilled services to be provided section of resident 74's BCP, the facility did not indicate that resident 74 was receiving wound care monitoring and dressing changes. Additionally, resident 74's BCP indicated categories of medications that resident 74 was receiving but did not include specific medications. On 2/22/18 at approximately 1:00 PM, the DON was interviewed. The DON stated that staff did care plan audits on Tuesdays and that they did not have chance to update residents 74 care plan since resident 74 was admitted on [DATE]. 7. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/21/18, a medical record review was completed for resident 1. Resident 1's BCP was reviewed. Resident 1's BCP included the problem of R (right) humerus fracture with a Plan of Approach for PT/OT evaluation and treatment, and for medications to be given as ordered. There were no orders on the BCP for PT or OT; or indication of frequency or duration for therapies. The Medication Order Summary listed on the BCP included basic drug classifications such as [MEDICATION NAME], narcotic, but no specific medication orders were listed. 8. Resident 126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/21/18, a medical record review was completed for resident 126. Resident 126's BCP was reviewed. Resident 126's BCP included the problem of Falls with a Plan of Approach for PT/OT evaluation and treatment, and for medications to be given as ordered. There were no orders on the BCP for PT or OT; or indication of frequency or duration for therapies. The Medication Order Summary listed on the BCP included basic drug classifications such as Antidepressants, but no specific medication orders were listed.

Based on observation, interview, and record review, it was determined for 1 of 16 sample residents, that the facility failed to provide a comfortable and homelike environment. Specifically, the maintenance of comfortable sound levels was prevented by the use of audible pressure alarms for a resident with dementia who was deemed to be at high risk for falls. Resident identifier: 126. Findings include: Resident 126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/21/18, resident 126's medical record was reviewed. A review of resident 126's physician's orders [REDACTED]. a. On 2/8/18, Low bed with protective mat at all times. Bed to be pushed up against wall. Nurse to check Q (every) shift. b. On 2/14/18, Clarification order for 2/08: Alarms to bed and wheelchair at all times r/t (related to) dementia. Assess that alarms are in place and that they are functioning appropriately. Resident 126's Minimum Data Set (MDS) assessment dated [DATE] was reviewed. Resident 126's MDS assessment revealed that the resident had scored 7 of 15 on the Brief Interview for Mental Status. A score of 7 is indicative of severe cognitive impairment. On 2/21/18 at approximately 7:30 AM, resident 126's paper chart was reviewed. It was observed that a Position Change Alarm Assessment was not present in resident 126's chart. The Position Change Alarm Assessment indicated that silent pressure alarms had been ordered and that the assessment was to serve as the facility's policy on audible alarms until the silent alarms were in place. The policy included the following components: a. Less restrictive measures should be evaluated before audible alarms were put into place. (NOTE: Resident 126's alarms were put in place on 2/8/18, the day she was admitted to the facility.) b. The use of audible alarms should be evaluated to ensure that the sound of the alarms does not: i. Startle the resident ii. Embarrass the resident iii. Restrict movement. A section was designated for staff to indicate that the evaluation had been completed. On 2/21/18 at 8:08 AM, a bed alarm speaker was observed to be on the floor on the left side of the bed in resident 126's room. The speaker was attached to a cord which extended between the top surface of the bed frame and the bottom surface of the mattress. The right side of the bed was observed to be against the wall between the bedroom and the bathroom. A sign with the words Call don't fall was observed to be secured on the wall on the right side of the bed. The bed was observed to be in the lowest position with a thick fall mat on the left side of the bed on the floor. On 2/21/18 at 8:10 AM, resident 126 was observed to be eating breakfast in the dining area. A pressure alarm was observed to be attached to the left side of the resident's wheelchair. On 2/21/18 at 9:50 AM, Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated that the bed and chair alarm for resident 126 had been in place since she was admitted . CNA 1 stated that the alarms were in place because (the resident) is a little confused, so it is a safety measure for all of us. On 2/22/18 at 7:21 AM, CNA 2 was interviewed. CNA 2 stated that resident 126 tried to get out of bed several times towards the beginning of her admission. CNA 2 stated that resident 126 is very confused, and constantly has to be reminded of facts regarding her family. CNA 2 stated that when the bed alarm sounds, resident 126 usually stops moving. On 2/22/18 at 7:23 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated that the severity of resident 126's dementia varies from day to day. RN 1 stated that when resident 126's dementia was more severe, she heard the resident's bed alarm sound more frequently. RN 1 stated that sometimes after hearing the alarm go off, she would enter the resident's room and find her on the mat next to her bed. On 2/22/18 at 12:30 PM, CNA 3 was interviewed. CNA 3 stated that resident 126's bed alarm was pretty sensitive. CNA 3 stated that if the resident moved from one side of of the bed to the other, the bed alarm would sound. CNA 3 stated that the alarm stays on till someone goes in. On 2/22/18 at approximately 1:00 PM, the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that she purchased two silent alarms for the facility. (NOTE: There were five residents identified with audible alarms.) The CRN stated that she did not have a purchase order for the silent alarms since she purchased them over the phone. No documentation verifying the purchase of the silent alarms was provided. On 2/22/18 at approximately 1:30 PM, the Director of Nursing (DON) and the CRN were interviewed. The surveyors asked the DON and the CRN why the audible alarms were being used concurrently with other fall prevention measures. The DON stated that audible alarms were traditionally part of fall prevention and that audible alarms had been around so long. The DON stated that she had been trying to facilitate a mindset shift regarding audible alarms. The CRN stated that audible pressure alarms had not been effective as a fall prevention measure. The DON further stated that they must have just missed the Position Change Alarm Assessment for resident 126.

Based on observation, interview, and record review, it was determined for 2 of 16 sample residents, that the facility did not ensure that its residents were free of any significant medication errors. Specifically, facility staff did not discontinue a resident's anticoagulant medication according to the physician's orders [REDACTED]. Resident identifier: 6 and 20. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20 was discharged from the facility to the hospital on [DATE] and expired shortly after arriving at the Emergency Department (ED). On [DATE], resident 20's medical record was reviewed. The Nursing Progress Notes for resident 20 were reviewed. A note dated [DATE] at 1:29 PM documented that resident 20 was experiencing increased [MEDICAL CONDITION] in her upper extremities. The Nurse Practitioner (NP) ordered an ultrasound to evaluate resident's right upper arm. On [DATE] at 5:51 PM, a nurse documented, Results from R (right) upper arm ultrasound received and sent to (name of NP). Results show occlusive venous [MEDICAL CONDITION] of the right jugular vein in the mid-portion of the jugular with 80% occlusion. Resident 20's Electronic Medication Administration Report (eMAR) was reviewed. The eMAR revealed that the resident had an order for [REDACTED]. The following entry was documented under resident 20's physician progress notes [REDACTED]. continue [MEDICATION NAME], follow-up with vascular clinic at (name of hospital). The following entry was documented under resident 20's Nursing Progress Notes. On [DATE], (Name of hospital) [MEDICAL CONDITION] clinic called and agreed with the [MEDICATION NAME] dosing. Recommended Eliquis or Xarelto or [MEDICATION NAME] based on patient preference. Pt (patient) wanted to continue [MEDICATION NAME] until DC (discharge) to home, then start [MEDICATION NAME]. [MEDICAL CONDITION] clinic preferred she begin [MEDICATION NAME] now, and get stabilized prior to DC. Recommended [MEDICATION NAME] 5 mg PO (by mouth) QHS (at bedtime) and house MD to adjust dose. DC [MEDICATION NAME] when INR (International Normalized Ratio) > (greater than) 2.0. The [MEDICATION NAME] log for resident 20 was reviewed. Instructions on the log stated, If no specific instructions: Dr. (name of doctor) standing order is INR (greater than or equal to) 2.0 = d/c (discharge) any order [MEDICATION NAME]. On [DATE], under INR Results, the INR was listed as 3.7. Resident 20's eMAR for the month of (MONTH) (YEAR) was reviewed. The following medication administrations were documented on the eMAR: a. On [DATE], the morning dose of [MEDICATION NAME] was administered between 7:00 AM and 10:00 AM and the evening dose was administered between 7:00 PM and 10:00 PM. (NOTE: Since INR was recorded to be 3.7 on [DATE], per the physician's orders [REDACTED].) b. On [DATE], the morning dose of [MEDICATION NAME] was administered between 7:00 AM and 10:00 AM and the second dose was administered between 7:00 PM and 10:00 PM. (NOTE: Since INR was recorded to be 3.7 on [DATE], per the physician's orders [REDACTED].) c. On [DATE], the documentation for the morning dose of [MEDICATION NAME] indicated that the dose had been missed. (NOTE: Since INR was recorded to be 3.7 on [DATE], per the physician's orders [REDACTED].) On [DATE] at 10:13 AM, the Corporate Resource Nurse (CRN) was interviewed. The CRN confirmed that the [MEDICATION NAME] should have been discontinued on [DATE]. 2. Resident 6 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. On [DATE] a review of resident 6's medical record was completed. Resident 6's eMAR was reviewed from [DATE] through [DATE]. Resident 6's physician's orders [REDACTED]. a. On [DATE], 18 units of insulin were documented as given for the afternoon dose. b. On [DATE], 8 units of insulin were documented as given for the afternoon dose. c. On [DATE], 30 units of insulin were documented as given for the afternoon dose. d. On [DATE], 10 units of insulin were documented as given for the afternoon dose. e. On [DATE], 30 units of insulin were documented as given for the afternoon dose. f. On [DATE], 10 units of insulin were documented as given for the afternoon dose. On [DATE] at 12:20 PM, the Director of Nursing (DON) was interviewed. The DON stated that the facility had another resident admitted on [MEDICATION NAME]yesterday. The DON stated that she had identified the [MEDICATION NAME] errors on the eMAR as transcription errors. The DON stated that when transcribing the orders she realized that there was room for a potential transcription order on the [MEDICATION NAME]. The DON stated that she had completed a Quality Assurance (QA) for Intermediate Acting Insulin Clarifications. The DON stated that she trusted her nurses and had assumed that her nurses would not give the incorrect dose of an intermediate acting insulin; or adjust the insulin without documenting the rationale and notifying the physician. The QA for Intermediate Acting Insulin Clarifications dated [DATE], documented that the Problem Area Discussed was When putting in orders for new admit receiving any intermediate acting insulin, we noticed that there is still potential for transcription error and needing clarification on when to hold an intermediate insulin. The QA documented the Reason Problem Occurred as When there is an order for [REDACTED]. The QA documented that the Plan of Correction was to On all insulins to be administered at a set amount, nurse entering admission orders [REDACTED]. Nurse to re-select injection set, and BG manually; All admitting nurses, and floor nurses to be in-serviced on [DATE] and [DATE] regarding parameters to hold intermediate insulin, and changing (name of EMR) set order; Clarified with (Medical Director) on when to hold an intermediate insulin. And created a standing order to correlate with. On [DATE] at 1:20 PM, The DON was re-interviewed. The DON stated that she interviewed one of the nurses who made the insulin errors. The DON stated that that nurse stated he had made a transcription error and did not give an incorrect dose of insulin. The DON had not interviewed the four other nurses who documented giving the incorrect insulin dose.

Based on observation and interview, it was determined that the facility did not ensure a safe, sanitary environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to post proper signage for two residents who required isolation precautions. Findings include: On 2/20/18, during the initial tour of the building, it was observed that rooms [ROOM NUMBERS] had Isolation Boxes in the front of their doors. Each box contained gowns, gloves, sanitizing wipes and hazardous bags. There were no signs posted on the outside of them room to alert staff and visitors that the residents were on isolation precautions. There were no signs indicating to see the nurse before entering the rooms. Appoximatley 2 hours later, rooms [ROOM NUMBERS] were observed to have signage posted indicating to staff and visitors to see the nurse before entering the residents' rooms. On 2/20/18 at approximately 8:00 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident in room [ROOM NUMBER] had shingles and that resident in room [ROOM NUMBER] had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her Peripherally Inserted Central Catheter (PICC) line and Urinary Tract Infection [MEDICAL CONDITION]. RN 2 stated that in both cases, facility staff and visitors should wear proper contact precaution items, such as gown and gloves. She stated, that the items used while in the rooms, should be disposed into hazardous bags while in the room and everyone who provided care or touched anything in the room, should wash hands thoroughly before taking care of another resident or doing any other task. On 2/21/18 at approximately 2:05 PM, the Director of Nursing (DON) was interviewed. The DON stated that she expected all of her staff to follow infection control policies and procedures. The DON stated isolation rooms should have a STOP sign on the door or closest part of the wall with the sentence see the nurse before entering. The DON stated that her expectation was for all staff and visitors to follow the infection control protocol. The DON stated that staff and visitors should wear proper protection such as gloves, gowns, etc.; which would depend on the type of isolation. The DON stated that she expected kitchen and housekeeping staff to follow the same infection control protocol and procedures when disposing of used items from isolation rooms. On 2/22/18 at 1:52 PM, RN 2 stated that the isolation signs were stored in the isolation boxes and that they would only need to be put up on the door or on the wall when a resident was placed on isolation. RN 2 stated that whoever admitted the residents in rooms [ROOM NUMBERS], did not post the sings. RN 2 stated that this morning, when she arrived to work, she started working on medication administration and did not see if the signs were posted or not.

Based on interview and medical record review, it was determined for 3 of 20 sample residents, that the facility did not consult with the resident's physician and/or notify the resident representative when there were incidents that had the potential for requiring physician intervention. Specifically one resident with a [MEDICAL CONDITION] and staples was noted to have wound dehiscence without physician notification for three days and two residents had insulin held for low BS (blood sugars) without physician notification. Resident identifiers: 17, 79 and 135. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 resident 17's medical record was reviewed. A physician's orders [REDACTED].< (less than) 120. On 1/4/17, Resident 17's MAR (Medication Administration Record) for December 2016 and January 2017 was reviewed. The MAR for December 2016 revealed the following: a. On 12/18/16 at 2:00 AM, resident 17 had a BS of 142. Facility staff documented that resident 17's BS was too low and resident 17 did not receive the Humalog Insulin 5 units. b. On 12/25/16 at 2:00 PM, resident 17's BS had not been monitored and that resident 17 did not receive the Humalog Insulin 5 units. No documentation could be located in the medical record to show that resident 17's physician had been notified that the Humalog Insulin 5 units had not been administered to resident 17 or that resident 17's BS had not been monitored. On 1/5/17 at approximately 9:50 AM, an interview was conducted with the facility DON. The facility DON stated that she needed to research the concerns. On 1/5/17 at approximately 12:05 PM, the DON stated she was not able to determine why the facility nurse documented the insulin was held for resident 17 on 12/18/16 due to the BS being too low. The DON further stated that resident 17 went out on an LOA (leave of absence) on 12/25/16. The DON stated that was the reason resident 17's BS and insulin, (if indicated) was not completed. (NOTE: The DON provided a document that showed resident 17 leaving the facility at 3:00 PM for his LOA. The BS and insulin (if indicated) was scheduled for 2:00 PM.) 2. Resident 135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 135's medical record was reviewed. A. A physician's orders [REDACTED]. On 1/5/17 Resident 135's MAR for December 2016 and January 2017 was reviewed and revealed the following: a. 12/11/16 at 8:30 AM, resident 135 received 15 units of [MEDICATION NAME]. b. 12/19/16 at 8:30 AM, resident 135 received 2 units of [MEDICATION NAME]. c. 12/22/16 at 8:30 AM, resident 135's [MEDICATION NAME] was held for a low BS of 122. No documentation could be located in the medical record that resident 135's physician had been notified of the [MEDICATION NAME] dosage changes nor of the low BS resulting in the [MEDICATION NAME] being held. B. A physician's orders [REDACTED].=0 units, BS of 176-250=2 units, BS of 251-300=4 units, BS of 301-350=6 units, BS of 351-400=8 units, BS of 401-450=10 units, BS of 451-500=12 units, BS of 501 or >(greater), Notify MD (Medical Doctor) or NP (Nurse Practitioner) on call. The MAR for resident 135 for December 2016 revealed the following: a. 12/9/16 at 8:00 AM, resident 135 had a BS of 238. Resident 135 received 4 units of Humalog Insulin. Resident 135 was to receive 2 units of the sliding scale insulin per physician orders. b. 12/9/16 at 12:00 PM, resident 135 had a BS of 8. Resident 135 received 35 units of insulin. Resident 135 was to receive 0 units of insulin per physician orders. c. 12/20/16 at 8:00 AM, resident 135 had a BS of 147. Resident 135 received 2 units of insulin. Resident 135 was to receive 0 units of the sliding scale insulin per physician orders. d. 12/27/16 at 7:00 PM, Resident 135 had a BS of 200. Resident 135 received 5 units of insulin. Resident 135 was to receive 2 units of the sliding scale insulin per physician orders. On 1/5/17 at approximately 12:05 PM, the DON stated she was not able to determine why a facility nurse documented that the sliding scale Humalog insulin doses were different than had been ordered by the physician. The DON stated that she did not know why facility nurses did not contact the physician as needed or simply give the sliding scale according to the physician order. 2. Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 79's medical record was reviewed. A. A nurse's note dated 11/21/16 at 22:19 (8:19 PM) revealed that resident 79 admitted to (facility) for strengthening and rehab after a [DIAGNOSES REDACTED]. A nurse's note dated 11/24/16 at 13:11 (1:11 PM), revealed that resident 79 Wound is starting to open at 3rd staple down. New orders to clean out wound tunnel thoroughly with NS (normal saline) and gauze, apply triple ABX ointment, and a new DRSG. Note put in 24 hour book to notify surgeon on Monday. A nurse's note dated 11/24/16 at 15:15 (3:15 PM) revealed that resident 79 Wound RN (Registered Nurse) cleansed incision and applied triple ABX (antibiotic) with a new DRSG (dressing). Orders have been updated by wound RN. Incision is not fully closed at 3rd staple and has tunneled 0.2 cm (centimeter) deep A nurse's note dated 11/26/16 at 11:42 AM, revealed that resident 79 Wound cleansed at incision and applied triple ABX with a new DRSG. Incision is not fully closed at 3rd staple and has tunneled 0.2 cm deep A nurse's note dated 11/27/16 at 11:10 AM, revealed that resident 79 Treatment held: May remove staples if no s/s (signs/symptoms) of infection or drainage noted from laceration. Held due to still draining with area of dehisence (sic). A nurse's note dated 11/27/16 at 11:27 AM, revealed Laceration to the posterior head has staples in place that were to be removed today. There is an are (sic) of dehiscence that is 0.5 cm round and 0.1 cm deep and is draining moderate serosanguinous/purulent drainage that is non-odorous. Staples were not removed and area cleansed. Triple ABX ointment and clean dressing applied. MD notified and ordered Keflex 500 mg (milligrams) PO (by mouth) TID (three times daily) X (times) 5 days. Wound MD was also notified to assess the pt A physician progress notes [REDACTED]. Small opening in scalp where staples were not intact. Opening 0.8 cm x 0.2 cm x 0.2 cm On 1/5/16 at 2:35 PM, an interview was conducted with the facility DON. The facility DON stated that her expectation was that the nurse's would notify the physician immediately whenever there was a problem with a wound such as dehiscence and infection. The DON stated that she did not know why the facility nurse's waited three days before notifying the MD of the wound dehiscence. A review of the nurse's notes for resident 79 revealed multiple entries that resident 79's sliding scale insulin had been held for low blood sugars. B. A physician's orders [REDACTED].=2 units (HS=0 units), 151-180=4 units (HS=0 units), 181-200=4 units (HS=0 units), 201-250=6 units (HS 2 units), 251-300=8 units (HS=4 units), 301-350=10 units (HS=5 units), 351-400=14 units (HS=7 units), > (greater than) 400=call physician. The MARs for resident 79 for November 2016 and December 2016 revealed the following: a. On 11/22/16 at 8:00 AM, resident 79 had a BS of 119. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. b. On 11/22/16 at 1600 (4:00 PM), resident 79 had a BS of 106. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. c. On 11/24/16 at 8:00 AM, resident 79 had a BS of 111. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. d. On 11/25/16 at 8:00 AM, resident 79 had a BS of 122. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. e. On 11/26/16 at 12:00 PM, resident 79 had a BS of 94. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. f. On 11/28/16 at 8:00 AM, resident 79 had a BS of 96. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. g. On 11/30/16 at 12:00 PM, resident 79 had a BS of 110. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. h. On 12/4/16 at 12:00 PM, resident 79 had a BS of 144. Resident 79 was administered 4 units of sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. i. On 12/9/16 at 12:00 PM, resident 79 had a BS of 89. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. C. A physicians order dated 11/20/16 revealed that resident 79 was to receive [MEDICATION NAME] 8 units QHS (every hour of sleep). The MAR for resident 79 for November 2016 revealed that resident 79 did not receive the [MEDICATION NAME] 8 units on 12/25/16. D. A physicians order dated 11/21/16 revealed that resident 79 was to receive [MEDICATION NAME] 500 mg BID (twice daily). The MAR for resident 79 for November 2016 revealed that resident 79 did not receive the [MEDICATION NAME] 500 mg on 11/26/16. No documentation could be located in the medical record to show that resident 79's physician had been notified that the sliding scale insulin had been held for the low BS or administered incorrectly. No documentation could be located in the medical record to show that resident 79's physician had been notified that the [MEDICATION NAME] 8 units and [MEDICATION NAME] 500 mg had been held for the low blood sugars. On 1/5/17 at 12:35 PM, an interview was conducted with the facility DON. The facility DON stated that the [MEDICATION NAME] and [MEDICATION NAME] should never be held and that she did not know why the sliding scale insulin had been held or administered incorrectly. The DON stated that she would expect that the facility nurses would call resident 79's physician and notify him of the low blood sugars and that the insulin's had been held and notified of the insulin error.

Based on interview and medical record review, it was determined for 7 of 20 sample residents, that the residents were not free of significant medication errors. Specifically, facility staff did not administer multiple resident's insulin's with the correct dose and oral diabetic medications had been held. One resident did not receive the stat Vitamin K that had been ordered by the physician. Resident identifiers: 17, 27, 79, 123, 132, 135 and 147. Findings include: 1. Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 79's medical record was reviewed. A review of the nurse's notes for resident 79 revealed multiple entries that resident 79's sliding scale insulin had been held for low blood sugars. A. A physician's orders [REDACTED].=2 units (HS=0 units), 151-180=4 units (HS=0 units), 181-200=4 units (HS=0 units), 201-250=6 units (HS 2 units), 251-300=8 units (HS=4 units), 301-350=10 units (HS=5 units), 351-400=14 units (HS=7 units), > (greater than) 400=call physician. The MAR (Medication Administration Record) for resident 79 for November 2016 and December 2016 revealed the following: a. On 11/22/16 at 8:00 AM, resident 79 had a BS of 119. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. b. On 11/22/16 at 1600 (4:00 PM, resident 79 had a BS of 106. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. c. On 11/24/16 at 8:00 AM, resident 79 had a BS of 111. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. d. On 11/25/16 at 8:00 AM, resident 79 had a BS of 122. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. e. On 11/26/16 at 12:00 PM, resident 79 had a BS of 94. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. f. On 11/28/16 at 8:00 AM, resident 79 had a BS of 96. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. g. On 11/30/16 at 12:00 PM, resident 79 had a BS of 110. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. h. On 12/4/16 at 12:00 PM, resident 79 had a BS of 144. Resident 79 was administered 4 units of sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. i. On 12/9/16 at 12:00 PM, resident 79 had a BS of 89. Resident 79 did not receive any sliding scale insulin. Resident 79 was to receive 2 units of sliding scale insulin per physician orders. B. A physicians order dated 11/20/16 revealed that resident 79 was to receive [MEDICATION NAME] 8 units QHS (every hour of sleep). The MAR for resident 79 for November 2016 revealed that resident 79 did not receive the [MEDICATION NAME] 8 units on 12/25/16. C. A physicians order dated 11/21/16 revealed that resident 79 was to receive [MEDICATION NAME] 500 mg BID (twice daily). The MAR for resident 79 for November 2016 revealed that resident 79 did not receive the [MEDICATION NAME] 500 mg on 11/26/16. On 1/5/17 at 12:35 PM, an interview was conducted with the facility DON. The facility DON stated that the [MEDICATION NAME] and [MEDICATION NAME] should never be held and that she did not know why the sliding scale insulin had been held or administered incorrectly. On 1/5/17 at 1:09 PM, an interview was conducted with the facility ADON (Assistant Director of Nursing). The facility ADON stated that she thought that the facility nursing staff were confused with the orders for the sliding scale insulin and that they were not looking at the day orders versus the hour of sleep orders. 2. Resident 132 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 resident 132's medical record was reviewed. A nurse's note dated 12/23/16 at 10:42 AM, revealed that resident 132 had a INR (international normalized ratio - is a lab value for thinning the blood) 6.6, MD (medical doctor) ordered 5 mg (milligrams) Vit (vitamin) K STAT (immediately) DC (discontinue) [MEDICATION NAME], recheck INR at 1600 (4:00 PM) today, hold all therapy, orders noted. A physician's orders [REDACTED]. The MAR for December 2016 revealed that resident 132's Vitamin K 5 mg had not been administered. On 1/5/17 at 8:00 AM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that the Vitamin K had been pulled from the cubex but did not know why it had not been signed out on the MAR indicated [REDACTED] 3. Resident 147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 147's medical record was reviewed. Resident 147's physician orders [REDACTED]. A. Resident 147's MARs were reviewed for December 2016 and January 2017. Resident 147's MARs revealed the following: a. On 12/11/16, resident 147 received [MEDICATION NAME] 4 u. b. On 12/31/16, resident 147 received [MEDICATION NAME] 20 u. B. Resident 147's physician orders [REDACTED]. Resident 147's December 2016 MAR indicated [REDACTED] a. On 12/22/16 at 4:00 PM, resident 147 received 10 units of Humalog Insulin. C. Resident 147's physician orders [REDACTED]. Resident 147's December 2016 MAR indicated [REDACTED] a. On 12/30/16 at 7:00 PM, resident 147 received 3 units of Humalog Insulin. D. Resident 147's physician orders [REDACTED].=1 unit, 156-180=2 units, 181-205 = 3 units, 206-230 = 4 units, 231-255 = 5 units, 256-280 = 6 units, 281-305 = 7 units, 306-330 = 8 units, 331-355 = 9 units, 356-380 = 10 units, 381-405 = 11 units, 406-430 = 12 units, 431-455 = 13 units, and >456 call medical doctor (MD). Resident 147's December 2016 MAR indicated [REDACTED] a. On 12/15/16 at 8:00 AM, resident 147 had a blood sugar (BS) of 173 and received 3 units of Humalog Insulin. Resident 147 was to receive 2 units of Humalog Insulin. b. On 12/17/16 at 8:00 AM, resident 147 had a BS of 384 and received 10 units of Humalog Insulin. Resident 147 was to receive 11 units of Humalog Insulin. c. On 12/19/16 at 7:00 PM, resident 147 had a BS of 307 and received 7 units of Humalog Insulin. Resident 147 was to receive 8 units of Humalog Insulin. d. On 12/23/16 at 8:00 AM, resident 147 had a BS of 205 and received 4 units of Humalog Insulin. Resident 147 was to receive 3 units of Humalog Insulin. e. On 12/23/16 at 4:00 PM, resident 147 had a BS of 213 and received 1 unit of Humalog Insulin. Resident 147 was to receive 4 units of Humalog Insulin. f. On 12/23/16 at 7:00 PM, resident 147 had a BS of 314 and received 5 units of Humalog Insulin. Resident 147 was to receive 8 units of Humalog Insulin. g. On 12/26/16 at 12:00 PM, resident 147 had a BS of 317 and received 11 units of Humalog Insulin. Resident 147 was to receive 8 units of Humalog Insulin. h. On 12/27/16 at 12:00 PM, resident 147 had a BS of 247 and received 8 units of Humalog Insulin. Resident 147 was to receive 5 units of Humalog Insulin. On 1/5/17 at 11:56 AM, an interview was conducted with the DON. The DON stated that they have discovered there are some clerical errors in charting insulin and that they have been working on ways to eliminate errors. The DON had no other information on the insulin errors. 4. Resident 123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 123's medical record was reviewed. Resident 123's physician orders [REDACTED]. Resident 123's November 2016 and December 2016 MAR indicated [REDACTED]. A progress note on 11/28/16 revealed that the medication was not available and that the pharmacy was contacted. No documentation was available to indicate that resident 123 received the [MEDICATION NAME] before the next scheduled patch on 12/5/16. On 1/5/17 at 11:56 AM, an interview was conducted with the DON. The DON stated she did not know when resident 123 received her [MEDICATION NAME] from the pharmacy. 5. Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/4/17 resident 17's medical record was reviewed. A. Resident 17's physician orders [REDACTED]. Resident 17's MAR for December 2016 and January 2017 were reviewed. Resident 17's MAR indicated [REDACTED] a. On 12/8/16 resident 17 received 5 u of [MEDICATION NAME]. B. Resident 17's physician orders [REDACTED].< (less than) 120. Resident 17's December 2016 MAR indicated [REDACTED] a. On 12/7/16 at 2:00 AM, resident 17's insulin was held. (NOTE: No documentation could be located in the medical record as to why the insulin was held. No documentation could be located in the medical record to show that resident 17's BS had been obtained.) b. On 12/18/16 at 2:00 AM, resident 17's insulin was held. (NOTE: No documentation could be located in the medical record as to why the insulin was held. A nurse's note dated 12/18/16 at 2:15 AM indicated the blood sugar was 142 and insulin was held due to a low BS of 142.) c. On 12/25/16 at 2:00 PM, resident 17's insulin and BS were not done due to resident 17 not being available. On 1/5/17 at approximately 9:50 AM, an interview was conducted with the facility DON. The DON stated she needed to research the concerns. On 1/5/17 at approximately 12:05 PM, the DON stated she was not able to determine why the facility nurse documented the insulin was held for resident 17. The DON further stated that resident 17 went out on an LOA (leave of absence) on 12/25/16 and that was the reason resident 17's BS and insulin, (if indicated) was not completed. (NOTE: The DON provided a document that revealed that resident 17 signed out of the facility at 3:00 PM for his LOA. The BS and insulin (if indicated) was scheduled for 2:00 PM.) C. A physician's orders [REDACTED]. On 1/4/17 Resident 17's MAR for December 2016 and January 2017 revealed the following: a. On 12/7/16, no documentation could be located in the medical record to show that resident 17 received the [MEDICATION NAME] 1000 mcg IM (intramuscular) injection. b. On 12/14/16, no documentation could be located in the medical record to show that resident 17 received the [MEDICATION NAME] 1000 mcg IM injection. c. On 12/21/16, no documentation could be located in the medical record to show that resident 17 received the [MEDICATION NAME] 1000 mcg IM injection. d. On 12/28/16, no documentation could be located in the medical record to show that resident 17 received the [MEDICATION NAME] 1000 mcg IM injection. On 1/5/17 at 12:05 PM, an interview was conducted with the facility DON. The facility DON stated that the reason that the [MEDICATION NAME] 1000 mcg had not been administered, was because whoever transcribed the order, did not put a time to be administered into the electronic medical record, thus, never alerting the nursing staff to administer the ordered medication. 6. Resident 135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 135's medical record was reviewed. A. Resident 135's physician orders [REDACTED]. Resident 135's MAR's were reviewed for December 2016 and January 2017. Resident 135's MAR indicated [REDACTED] a. On 12/11/16 at 8:30 AM, resident 135 received 15 u of [MEDICATION NAME]. b. On 12/19/16 at 8:30 AM, resident 135 received 2 units of [MEDICATION NAME]. c. On 12/22/16 at 8:30 AM, resident 135's insulin was held by facility nurse. On 1/5/17 at approximately 12:05 PM, an interview was conducted with the facility DON. The DON stated she was not able to determine why a facility nurse documented the insulin dose administered to resident 135 was 15 units instead of the ordered 14 units nor why a facility nurse documented that 2 units of [MEDICATION NAME] was administered instead of the ordered 14 units. The DON stated that she did not know why a facility nurse held [MEDICATION NAME] due to the BS being to low at 122 for resident 135. B. A physician's orders [REDACTED].=0 units, BS of 176-250=2 units, BS of 251-300=4 units, BS of 301-350=6 units, BS of 351-400=8 units, BS of 401-450=10 units, BS of 451-500=12 units, BS of 501 or >= Notify MD (Medical Doctor) or NP (Nurse Practitioner) on call. a. 12/9/16 at 8:00 AM, resident 135 had a BS of 238. Resident 135 received 4 units of Humalog Insulin. Resident 135 was to receive 2 units of the sliding scale insulin per physician orders. b. 12/9/16 at 12:00 PM, resident 135 had a BS of 8. Resident 135 received 35 units of insulin. c. 12/20/16 at 8:00 AM, resident 135 had a BS of 147. Resident 135 received 2 units of insulin. Resident 135 was to receive 0 units of the insulin per physician orders. d. 12/27/16 at 7:00 PM, Resident 135 had a BS of 200. Resident 135 received 5 units of insulin. Resident 135 was to receive 2 units of the sliding scale insulin per physician orders. On 1/5/17 at approximately 12:05 PM, the DON stated she was not able to determine why a facility nurse documented the incorrect dosages of the sliding scale insulin nor the sliding scale insulin according to the physician order. 7. Resident 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 27's medical records was reviewed. A physician's orders [REDACTED]. <60 call MD and <70 begin hypoglycemic protocol. (Glucose less than 60 AC (before a meal)=0 units HS (at bedtime)=0 units) (Glucose 61-80 AC=0 HS=0) (Glucose 81-150 AC=0 HS=0) (Glucose 151-180 AC=0 HS=0) (Glucose 181-200 AC=2 HS=2) (Glucose 201-250 AC=2 HS=2) (Glucose 251-300 AC=4 HS=3) (Glucose 301-350 AC=6 HS=4) (Glucose 351-400 AC=8 HS=5) Greater than 400 call physician. Medical record review of the electronic medication record (eMAR) for the above order indicated that the medication was to be administered at the following times: 8:00 a.m., 12:00 p.m., 4:00 p.m. and 7:00 p.m. A physician's orders [REDACTED].**Only treat with insulin sliding scale if pt (patient) received did not receive insulin at HS (2100)** for DM <50 call MD, <70 hypoglycemic protocol, 141-170=1unit, 171-200=2 units, 201-230=3 units, 231-260=4 units, 261-290=5 units, 291-320=6 units, 321-340=7 units, >340= call MD (physician). Medical record review of the eMAR for the above order indicated that the medication was to be administered at 2:00 a.m. per the sliding scale. On 12/28/16 at 7:00 p.m. the eMAR indicated that the insulin sliding scale was held due to a blood sugar of 160. On 12/29/16 at 2:00 a.m. the eMAR indicated that the Humalog 100 U/1 ML was held. According to the eMAR the residents blood sugar at this time was 245. Per the physician's orders [REDACTED]. On 1/5/17 at approximately 2:00 p.m. an interview was conducted with the DON (director of nursing). Resident 27's insulin sliding scale and Humalog sliding scale were reviewed. The DON clarified the Humalog order as Only treat with insulin sliding scale if patient did not receive insulin HS the night before. The DON further confirmed that according to the physician's orders [REDACTED].

Based on observation, staff interview, and medical record review it was determined that the facility did not ensure that it was free of medication error rates of less than 5 percent. Observations of 30 medication opportunities revealed 3 medication errors resulting in a 10 percent medication error rate. Specifically one resident received medications 1 hour and 15 minutes before the scheduled administration time, and one resident had two capsules opened and administered with other crushed medications. Resident identifiers: 27 & 60. Findings include: 1. On 1/4/17 at 7:15 a.m. RN (Registered Nurse) 1 was observed to administer medications to resident 60. The observed medications administered to resident 60 included the following; Magnesium Oxide 400 mg (milligrams) tablet, [MEDICATION NAME] Acetate 30 mg, [MEDICATION NAME] 0.025-2.5 mg tablet, Fludrocortisone Acetate 0.1 mg tablet, [MEDICATION NAME] 100 mg capsule, DHEA (Dehydroepiandrosterone) 10-47 25 mg tablet, Aspirin 81 mg CTB (chewable tablet), [MEDICATION NAME] HCL ([MEDICATION NAME]) 2.5 mg tablet, [MEDICATION NAME] 300 mg, and [MEDICATION NAME] 40 mg capsule. On 1/4/17 resident 60's medical records was reviewed for the reconciliation of medications. According to resident 60's Medication Administration Record [REDACTED]. 2. On 1/4/17 RN 1 was observed to administer medications to resident 27. The following medications were observed to be administered to resident 27, [MEDICATION NAME] 110-0.5 mg capsule and [MEDICATION NAME] 60 mg ECC ([MEDICATION NAME] coated capsule). All morning tablets, with the exception of [MEDICATION NAME], were crushed. All morning capsules were opened and the contents were emptied into the crushed medication mixture, including the medications [MEDICATION NAME] and [MEDICATION NAME]. On 1/4/17 a review of the physician orders [REDACTED]. According to the website webhealthnetwork.com, Ferrocon capsules should not be crushed or chewed, but instead swallowed whole. Source: www.drugs.com/. The following website, http://www.rxzone.us/product.cfm/rx/[MEDICATION NAME]-Capsules-10-Capsules- 2.html provides the directions for use of [MEDICATION NAME] Capsules as Swallow it whole. Do not crush or chew. 3. On 1/4/17 a review of the PO and eMAR was conducted for the reconciliation of medications. According to Wolters Kluwer. (2017) 37th Edition Nursing 2017 Drug Handbook. Philadelphia, PA:(NAME)Abramovitz., the administration of oral [MEDICATION NAME] revealed Give whole; don't crush or open capsules, p 507. On 1/4/17 an interview was conducted with RN 1. RN 1 stated that she crushed resident 27's medications because he chews them otherwise. She further stated that he had no difficulties with swallowing.

Based on record review and interview, it was determined for 2 of 20 sample residents, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, one resident did not receive a hormone patch or calcium supplement and one resident missed a dose of an anti-depressant due to it being unavailable from the pharmacy. Resident identifiers: 123 and 147 Findings include: 1. Resident 123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17, resident 123's medical record was reviewed. A. Resident 123's physician orders [REDACTED]. Resident 123's November 2016 and December 2016 Medication Administration Records (MAR) were reviewed. The November 2016 MAR indicated [REDACTED]. A nurses note dated 11/28/16 revealed that the medication was not available and that the pharmacy was contacted. No documentation was available to indicate that resident 123 received the Estradiol patch before the next scheduled patch on 12/5/16. B. Resident 123's physician orders [REDACTED].>Resident 123's December 2016 MAR indicated [REDACTED]. A nurses note dated 12/15/16 and 12/16/16 revealed that resident 123 did not receive the Calcium Citrate due to waiting on pharmacy to deliver. A nurses note dated 12/17/16 revealed that resident 123 did not receive the Calcium Citrate due to the medication not being available. On 1/5/17 at 8:21 AM, the DON was interviewed. The DON stated that if a medication was unavailable from the pharmacy the staff should have called the pharmacy and it should be delivered as soon as possible. On 1/5/17 at 11:56 AM, the DON was interviewed. The DON stated that she did not know when resident 123 received the Estradiol patch from the pharmacy. The DON stated that she did not have any additional information on related to resident 123's missed doses of Calcium Citrate. 2. Resident 147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/5/17 resident 147's medical record was reviewed. Resident 147's physician orders [REDACTED].>Resident 147's December 2016 MAR indicated [REDACTED]. A nurses note dated 12/23/16 revealed that resident 147's Bupropion was held due to reordered from pharmacy. not here. On 1/5/17 at 11:56 AM, the DON was interviewed. The DON stated that she did not have any additional information related to the missed dose of the Bupropion.