Every finding on record at Tennova Lafollette Health and Rehab Center

Based on the Association for Professionals in Infection Control (APIC) and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention review, medical record review, observation, and interviews, the facility failed to use appropriate hand hygiene practices when providing wound care to 1 resident (Resident #10) of 1 resident reviewed with an in-house pressure wound. The findings include:Review of the Association for Professionals in Infection Control [APIC] and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention, dated 6/2015, revealed .Hand hygiene is widely recognized as the most important measure to prevent the spread of infection .Hand hygiene is one of the cornerstones of reducing healthcare-associated infections and preventing occupationally acquired infections .patient care .recommendations for hand hygiene .Gather supplies .Enter .room .HH [hand hygiene] .Don [apply] gloves and remove dressing .Discard old dressing and gloves .HH .Don gloves .clean site .Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus with Diabetic Neuropathy, Heart Failure, Peripheral Vascular Disease, and Pressure Ulcer of Left Heel Stage 3. Review of an annual Minimum Data Set assessment dated [DATE], revealed Resident #10 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Physician's Orders for Resident #10 dated 5/18/2026, revealed .Left heel .clean .pat dry .apply .cover with border foam .Review of a comprehensive care plan for Resident #10 dated 6/26/2026, revealed .Stage 3 to left heel .Follow treatment orders per MD . During an observation on 7/1/2026 at 9:35 AM, revealed the Wound Care Nurse prepared wound care supplies for Resident #10. Further observation revealed the Wound Care Nurse sanitized the hands, applied gloves, and removed Resident #10's elastic bandage and soiled border foam dressing from the left heel. Continued observation revealed without performing hand hygiene or changing gloves after removal of the soiled dressing, the Wound Care Nurse cleansed Resident #10's left heel with wound cleanser and clean gauze and used the same gloved hands she had used to remove the elastic bandage and foam dressing. The Wound Care nurse removed her gloves, performed hand hygiene, applied new gloves, and placed a new dressing to the resident's left heel. Resident #10's left heel revealed no signs of infection. During an interview on 7/1/2026 at 9:50 AM, the Wound Care Nurse confirmed she failed to follow proper infection control practices when she removed the elastic bandage and the old dressing from Resident #10's left heel, did not remove her gloves, did not perform hand hygiene, or apply new gloves prior to cleansing the wound. During an interview on 7/1/2026 at 1:22 PM, the Director of Nursing confirmed the Wound Care Nurse did not follow infection control practices when she provided wound care to Resident #10. The facility was unable to provide a wound care procedure related to handwashing and wound dressing change upon surveyor request.

Based on medical record review, observations, and interviews, the facility failed to ensure a call light was available at the bedside for 2 residents (Resident #63 and Resident #43) of 63 residents reviewed for call lights at the bedside. The findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Unspecified Dementia, Type 2 Diabetes, Insomnia, Major Depressive Disorder, and Anxiety. Review of a comprehensive care plan dated 2/23/2024, revealed Resident #63 .at risk for falls .Keep call light .within reach . Review of a comprehensive care plan dated 3/4/2024, revealed Resident #63 .resident [Resident #63] has an ADL [Activities of Daily Living] self-care performance deficit .Encourage the resident [Resident #63] to use bell [call light] to call for assistance . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #63 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation and interview on 6/29/2026 at 12:50 PM, in Resident 63's room revealed the resident did not have a call light at the bedside. Resident #63 stated .it [call light] has been gone . (unable to give an exact date). The resident also stated he used his roommates call light when he needed assistance from staff. During an observation on 6/30/2026 at 3:15 PM, in Resident 63's room revealed the resident did not have a call light at the bedside. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Type 2 Diabetes, and Generalized Anxiety Disorder. Review of a comprehensive care plan dated 9/25/2023, revealed Resident #43 .limited mobility .Keep call light .within reach . Review of a quarterly MDS assessment dated [DATE], revealed Resident #43 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 6/30/2026 at 9:23 AM, in Resident #43's room revealed the resident did not have a call light at the bedside. The resident stated .it [call light] tore up and I use hers [roommates call light] . The resident was unsure how long he had been without a call light. During an observation on 6/30/2026 at 12:48 PM, in Resident #43's room revealed the resident did not have a call light at the bedside. During an interview on 6/30/2026 at 3:20 PM, Certified Nursing Assistant (CNA) A stated she was the routine caregiver for Residents #63 and #43 and was unaware the residents did not have a call light at the bedside. CNA A stated Resident #63 had informed her the surveyor questioned him about the call light on 6/30/2026 (unsure of the exact time), informed CNA A he did not have a call light, and CNA A placed a call light at the resident's bedside around 2:45 PM. During an observation and interview on 6/30/2026 at 3:28 PM, in Resident #63's room revealed the resident had a call light at the bedside. The resident stated he informed CNA A he did not have a call light after talking with the surveyor. CNA A placed a call light at the bedside .a little while ago .[6/30/2026] . During an interview on 6/30/2026 at 3:36 PM, Licensed Practical Nurse (LPN) B stated she cared for Resident's #43 and #63 routinely. LPN B was unaware the resident's did not have a call light at the bedside. During an interview on 7/1/2026 at 5:30 PM, the Administrator confirmed the facility failed to ensure Residents #63 and #43 had call lights in reach at the bedside.

Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, observations, medical record review, and interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for oral/dental status for 1 resident (Resident #28); failed to accurately code MDS assessments for Hospice services for 2 residents (Residents #32 and #3); and failed to accurately code a MDS assessment for Pre-admission Screening and Resident Review (PASRR) for 1 resident (Resident #10) of 19 residents reviewed for MDS assessments. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .A1500 .Preadmission Screening and Resident Review (PASRR) .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .L0200 .Dental .Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth .O0110K1 .Hospice Care .Code residents identified as being in a hospice program . 1. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Gastroesophageal Reflux Disease, and Heart Failure. Review of an admission MDS assessment dated [DATE], revealed Resident #28 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed .No natural teeth or tooth fragment(s) (edentulous) . was documented as no, which indicated Resident #28 had natural teeth. During an observation on 6/30/2026 at 1:02 PM, revealed Resident #28 was missing several upper and lower teeth. During an observation and interview on 7/1/2026 at 5:10 PM, the MDS Coordinator confirmed Resident #28 was missing several upper and lower teeth and confirmed the MDS assessment for Resident #28's oral/dental status dated 12/16/2025 was inaccurate. 2. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Hypothyroidism, and Anxiety Disorder. Review of a Physicians admission Order for Resident #32 dated 4/28/2026, revealed .Admit .Hospice Services . Review of a baseline care plan dated 4/29/2026, revealed Resident #32 .admitted under .hospice services . Review of an admission MDS assessment dated [DATE], revealed Resident #32 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Hospice care was not coded in Section O on the MDS. 3. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia without Behavioral Disturbance, Type 2 Diabetes Mellitus, and Anxiety. Review of the Physician's Orders for Resident #3 dated 8/28/2025 (order written prior to admission to facility) revealed .[named] Hospice to follow . Review of a Nursing admission Progress Note for Resident #3 dated 8/29/2025, revealed .Admit .services of [named physician] .Hospice . Review of a baseline care plan for Resident #3 dated 9/2/2025, revealed .admitted with [named] hospice services . Review of an admission MDS assessment dated [DATE], revealed Resident #3 scored a 99 on the BIMS assessment which indicated the resident was unable to complete the interview. Further review revealed Hospice care was not coded in Section O on the MDS. During an interview on 7/1/2026 at 4:55 PM, the MDS Coordinator stated she was responsible for completing the MDS assessments and confirmed Resident #32 and Resident #3 were admitted to the facility on Hospice services. The MDS Coordinator confirmed the admission MDS assessments for Resident #32 and Resident #3 were inaccurate. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Major Depressive Disorder, Unspecified Psychosis, and Epilepsy. Review of a Notice of PASRR Level II Outcome for Resident #10 dated 1/31/2025, revealed .You had a Level II PASRR evaluation .you need special services for your mental health, intellectual disabilities or related condition .your PASRR Level II evaluation remains good during your stay . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition .No . During an interview on 7/1/2026 at 5:03 PM, The MDS Coordinator confirmed the MDS for Resident #10 was coded inaccurately and did not reflect the resident's Level II PASRR status.

Based on Centers for Medicare & [and] Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual review, medical record review, and interview the facility failed to accurately code a Minimum Data Set (MDS) assessment for oral/dental status for 1 resident (Resident #162) of 25 residents reviewed. The findings include: Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual dated 10/2024, revealed .primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan .the assessment [MDS] accurately reflects the resident's status .registered nurse conducts or coordinates each assessment .SECTION L: ORAL/DENTAL STATUS .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth . Review of the medical record revealed Resident #162 was admitted to the facility on [DATE] with diagnoses including Dementia, Generalized Anxiety, Major Depressive Disorder, and Fracture for Lower End of Right Femur. Review of a nursing admission baseline health and history assessment for Resident #162 dated 12/31/2024, revealed the resident was edentulous (no natural teeth). Review of an admission MDS assessment for Resident #162 dated 1/7/2025, revealed .No natural teeth or tooth fragment(s) (edentulous) . was documented as .no ., which indicated Resident #162 had natural teeth. During an observation on 1/21/2025 at 11:00 AM, revealed Resident #162 was edentulous. During an observation and interview on 1/23/2025 at 2:20 PM, Licensed Practical Nurse (LPN) B confirmed Resident #162 was edentulous. During an interview on 1/23/2025 at 3:50 PM, the Director of Nursing (DON) confirmed the MDS assessment for oral/dental status was inaccurate for Resident #162.

Based on facility policy review, medical record review, observation, and interviews the facility failed to document post dialysis assessments for 1 resident (Resident #20) of 1 resident reviewed for dialysis. The findings include: Review of the facility's policy titled, Dialysis, revised 5/6/2021, revealed .The facility staff will provide immediate monitoring and documentation of the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Dependence on Renal Dialysis, Hypertension, Chronic Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Continued review revealed Resident #20 received dialysis. Review of a comprehensive care plan dated 12/20/2019, revealed Resident #20 had a care plan .dialysis r/t [related to] End Stage Renal Failure .I [Resident #20] have a central line for dialysis in my right carotid [artery-carries blood] .dialysis cares for shunt site, staff and dialysis monitors site .Observe/document/report to MD [medical doctor] PRN [as needed] any s/sx [signs/symptoms] of infection to access site: Redness, Swelling, warmth or drainage . Review of the nursing progress notes for Resident #20 from 1/1/2025-1/23/2025 revealed no documentation to show the resident's dialysis catheter site had been assessed/monitored for bleeding upon return to the facility after dialysis treatments. During an observation on 1/23/2025 at 2:40 PM, revealed Resident #20's dressing covering the dialysis catheter access site was dry and intact. During an interview on 1/23/2025 at 3:50 PM, the Director of Nursing (DON) stated staff were expected to assess dialysis catheter access sites for bleeding post dialysis treatment. The DON confirmed post dialysis assessments had not been documented when Resident #20 returned to the facility after dialysis.

Based on facility policy review, observations, and interviews the facility failed to ensure expired supplies were not available for resident use for 2 medication storage rooms of 4 medication storage rooms observed. The findings include: Review of the facility's policy titled, Medication Administration Guidelines, dated [DATE], revealed .The expiration/beyond use date .must be checked . During an observation on [DATE] at 9:55 AM, of the 2nd floor north medication storage room with Registered Nurse (RN) C revealed: *,d+[DATE] gauge (G) X (by)1 ,d+[DATE] inch intravenous (IV) catheter with expiration date of [DATE]. *,d+[DATE] G X 1 ,d+[DATE] inch IV catheter with expiration date of [DATE]. *,d+[DATE] G X 1 ,d+[DATE] inch IV catheters with expiration date of [DATE]. During an interview on [DATE] at 10:15 AM, RN C confirmed the IV catheters were expired. 49568 During an observation on [DATE] at 1:16 PM, of the 3rd floor medication storage room with RN A revealed: *,d+[DATE].97 ounce individual packets of nutrition powder with expiration date of [DATE]. *27-blue top lab tubes with expiration date of [DATE]. *,d+[DATE] G X 1 ,d+[DATE] inch IV catheters with expiration date of [DATE]. *,d+[DATE] G X 1 ,d+[DATE] inch IV catheters with expiration date of [DATE]. During an interview on [DATE] at 1:42 PM, RN A confirmed the nutrition powder, lab tubes, and IV catheters were expired. During an interview on [DATE] at 3:00 PM, the Director of Nursing (DON) confirmed the nutrition powder, lab tubes, and IV catheters were expired.

Based on facility policy review, medical record review, observation, and interviews the facility failed to follow infection control practices during resident care for 1 resident (Resident #8) of 3 residents observed for Enhanced Barrier Precautions. The findings include: Review of the facility's policy titled Infection Control Program, dated 1/18/2024, revealed .the facility will establish and maintain an infection prevention and control program designed to provide a safe sanitary .environment to help prevent the development and transmission of communicable diseases and infections . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Sepsis Unspecified Organism, Venous Insufficiency, Type 1 Diabetes Mellitus, and Anxiety Disorder. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Active Diagnoses included Septicemia. Review of a comprehensive care plan for Resident #8 dated 10/23/2024, revealed the resident is under Enhanced Barrier Precautions (EBP). Follow EBP guidelines: gloves and gown required during high-contact activities. Review of the Enhanced Barrier Precautions signage on Resident #8's door directed individuals entering the room to wash their hands before exiting the room. Providers and staff to wear gloves and gown for the following high-contact resident care activities, dressing bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting device care or use, central line, urinary catheter, feeding tube, tracheostomy, wound care any skin opening requiring a dressing. The signage directed staff not to wear the same gown and gloves for the care of more than one person. During an observation on 10/22/2024 at 8:15 AM, in Resident #8's room, revealed Certified Nursing Assistant (CNA) A entered the residents room with the sit to stand lift. The CNA made contact with the resident and hooked her to the sit to stand lift then the CNA washed her hands, put on gloves, and gown. During an interview on 10/22/2024 at 8:25 AM, CNA A stated she should have washed her hands and put on gloves and gown before touching Patient #8 .I was in a hurry to get her to the commode and I just didn't think .I knew better we have had education more than once on that .that is why I put them on before I transferred her . During the interview the CNA confirmed she had made physical contact with a resident on Enhanced Barrier Precautions without washing her hands or putting on a gown or gloves. During an interview on 10/30/2024 at 3:30 PM, the Infection Preventionist stated .my expectation would have been for the staff to have performed hand hygiene, put on gloves and a gown prior to physical contact with the resident.

Based on review of a facility policy, medical record review and interview the facility failed to develop a comprehensive care plan for placement of a midline catheter for one Resident (#8) of 3 residents reviewed. The findings included: Review of the facility's policy titled Care Plan, Comprehensive Person-Centered, dated 6/13/2022 revealed .the facility will ensure that a comprehensive, person-centered care plan that is consistent with the resident's rights, needs, and choices is developed and implemented . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Emphysema, Anxiety Disorder, and Chronic Respiratory Failure. Review of a comprehensive care plan dated 4/18/2024, revealed the midline catheter had not been included on the care plan. Review a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an interview on 10/31/2024 at 2:15 PM, the Administrator stated a care plan was not developed for [Resident #2] to include a midline placement, observation, and monitoring. The Administrator confirmed the facility failed to follow their policy for a comprehensive care plan.

Based on facility policy review, the Center for Disease Control (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections review, medical record review, and interview the facility failed to obtain a physician's order for dressing changes for a midline intravenous (IV) catheter, failed to ensure daily assessments of the midline IV site were completed, and failed to change the dressing for 1 resident (Resident #2 ) of 3 residents reviewed for IV therapy. The findings included: Review of the facility policy titled Midline Dressing Changes, revised 12/30/1899 [the Administrator confirmed revision date was error] revealed .To preform, using sterile technique, a Midline dressing change every 7 days and as needed if the dressing becomes soiled, loose, or saturated .Document in care manager [electronic medical record] the procedure, assessment of site, and how patient tolerated procedure. Review of the Summary of Recommendations Infection Control from the Center of Disease Control dated 2/28/2024, revealed replace dressings used on short-term CVC [central venous catheter]sites at least every 7 days for transparent dressings . Review of the Medication Administration Record for Resident #2 dated 4/1/2024-4/30/2024, revealed antibiotic 500 mg [milligrams] intravenously one time a day start date 4/18/2024 at 9:00 AM, stop date 4/22/2024. Antibiotic 1 gm [gram] intravenously two times a day start date 4/22/2024 at 9:00 PM, stop date 4/25/2024. Steroid (a medication used to treat inflammation) 40 mg intravenously two times a day start date 4/17/2024, end date 4/19/2024. Steroid 20 mg intravenously every 12 hours start date 4/19/2024, stop date 4/22/2024. Steroid 20 mg intravenously two times a day start date 4/22/2024, stop date 4/25/2024. Medications were documented administered as ordered. Review of the Treatment Administration Record for Resident #2 dated 4/1/2024-4/30/2024, revealed 4/18/2024 .Okay for midline . No entries for observation or monitoring midline catheter, and no entries for midline catheter dressing changes had been documented. Review of the Nurse's Note for Resident #2 dated 4/18/2024 at 11:45 PM, revealed .Continue on IV antibiotic and [steroid] for pneumonia. No signs of adverse effects noted. Midline right upper arm is patent and flushes well, no redness or swelling present, dressing dry and intact . Review of the Nurse's Note for Resident #2 dated 4/22/2024 at 10:40 AM, revealed .Conts [continue] IVABT [intravenous antibiotic treatment] for PNA [pneumonia]. Midline in right arm intact and flushes well . Review of the Nurse's Note for Resident #2 dated 4/23/2024 at 1:52 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/23/2024 at 10:59 AM, revealed . IV antibiotics and [steroid] for Pneumonia without adverse effects . Review of the Nurse's Note for Resident #2 dated 4/24/2024 at 4:38 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/25/2024 at 1:32 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Note for Resident #2 dated 4/26/2024 at 12:25 AM, revealed .Resident continues on IV antibiotic's and [steroid] for pneumonia. Midline right upper arm is patent and flushes well, dressing is dry and intact . Review of the Nurse's Notes for Resident #2 dated 4/27/2024-5/1/2024, revealed no documentation related to the midline catheter. Review of the Nurse's Notes for Resident #2 dated 5/3/2024-5/7/2024, revealed no documentation related to the midline catheter. During an interview on 10/30/2024 at 1:15 PM, the Physician stated .I would expect the facility to follow their protocol for dressing changes and monitoring .in this case the patient suffered no harm. There was no signs or symptoms of infection and no negative outcomes .I saw her on 4/22/2024 .if there had been any signs or symptoms of infection the nurses would have called me .the nurses were attentive to her care . During an interview on 10/30/2024 at 3:40 PM, he Infection Preventionist stated .I would have expected the nurse to document the observation and to follow their doctors' orders for dressing changes .best practice guidelines are for the midline dressing to be changed every 7 days or when soiled, however without a physician's order to change the dressing on the MAR there was no documentation the dressing had been changed . During an interview on 10/31/2024 at 2:15 PM, the Administrator stated the dressing should be changed every 7 days. During the nurses orientation/training they are given instruction/training that a midline is to be flushed every 12 hours and as needed. The Administrator confirmed there was no documentation the midline dress had been changed or monitored per policy.

Based on facility policy review, interview, review of personnel records, staff education, and staff competencies, the facility failed to ensure qualified staff completed tasks within their scope of practice for 1 of 7 staff reviewed for competency. The findings include: Review of a facility policy titled Blood Glucose Monitoring-Using the Accu-Check, dated 1/26/2023, revealed .testing is to be performed by trained personnel. Trained personnel may include a licensed nurse, perfusionist, laboratory personnel and ancillary staff members . Review of a facility document Position Description/Competency Based Evaluation Nursing Assistants, undated revealed no documentation or competency for preforming blood glucose level. Review of the Certified Nursing Assistant (CNA) E personnel file revealed no documentation of education/training for obtaining blood glucose level. The CNA had received a termination notice on 2/15/2024 for obtaining a patients blood glucose without proper training. Review of the Licensed Practical Nurse (LPN) F personnel file revealed the LPN had been terminated for asking a CNA to obtain a patient's blood glucose level. LPN F had not followed the facility policy. During an interview on 10/24/2024 at 8:10 AM, the Risk/Facility Compliance Officer stated the previous Administrator #2 was notified by a CNA that LPN F was allowing CNA E to perform blood sugars on residents. An investigation was conducted and a determination to terminate both employees was based on (LPN F's) own admission that she had allowed CNA E to perform duties out of her scope of practice. During an interview on 10/29/2024 at 8:30 AM, LPN F stated .I let her [CNA E] do one finger stick for me while I was in the room .I admitted to this .she did a finger stick for me one time, I was in the room with her . During an interview on 10/31/2024 at 2:40 PM, the Administrator stated .CNAs are not trained to obtain blood sugars. The nurse admitted to allowing the CNA to obtain a blood sugar and by doing so the CNA practiced outside of her scope of practice.

Amended 9/2/2022 to reflect change to Past Noncompliance. Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to implement interventions to prevent elopement for 1 resident (Resident #1) of 3 residents reviewed for wandering and elopement. The facility's failure placed Resident #1 in Immediate Jeopardy (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #1 exited the 2nd floor of the healthcare center via an elevator to the first floor, where she was then assisted by a staff member out of a set of locked doors that led to the adjacent hospital. The resident exited through the adjacent hospital, crossed a 4-lane highway and 2 two-lane roads, and was found by a family friend approximately 0.8 miles away from the facility at a grocery store. The resident was gone from the premises for approximately 39 minutes. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 7/28/2022 at 4:40 PM. The facility was cited F-689 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective 6/23/2022 and was removed 6/30/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 7/29/2022 at 4:13 PM and the corrective actions were validated onsite by the surveyors on 7/29/2022. The IJ was cited as Past Noncompliance and the facility is not required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Wandering, Unsafe Resident revised 9/16/2021, showed .The facility will take preventative measures to establish and maintain a safe environment for those residents identified as being at risk for elopement .elopement occurs when the resident leaves the premises . Resident #1 was admitted to the facility from an acute care hospital on 1/20/2022 for skilled therapy with diagnoses including Anxiety Disorder, Repeated Falls, Dementia without Behavioral Disturbance, Depression, and Dysphagia. Review of an admission Elopement Risk Assessment (ERA) dated 1/20/2022, showed the resident was not at risk for elopement. Review of a Nursing Progress Note dated 1/22/2022, showed Resident #1 placed all her clothes, sheets, and pillow in a bag and walked by the nurse's station confused. She said .guessed it was time to go home . The resident was redirected and placed on 30-minute checks. Review of an Elopement Risk assessment dated [DATE], showed the following factor was checked yes: .Resident verbally expresses the desire to leave the facility or shows signs of leaving by packing belongings .asking people to take them home or elsewhere . Continued review showed Resident #1 was assessed as High Risk for elopement with interventions that included .offer music, computer access games of interest .address any identified psychosocial concerns .address any verbalized concerns of leaving . Review of weekly Elopement Risk Assessment documentation from 1/22/2022 until 3/2/2022, showed Resident #1's Elopement Risk Assessments fluctuated from high risk for elopement to low risk for elopement dependent on the resident's behavior at the time of the assessment. Review of Resident #1's Comprehensive Care Plan updated 3/8/2022, showed the resident was care planned as Not at risk for elopement. Continued review showed the facility had implemented interventions which included .monitor for changes in medical conditions .monitor for the ability to redirect prn [as needed] and resident ability to follow thru [through] with the redirection. If resident is not redirectable for exit seeking type behaviors, staff will place on 1:1 [one-to-one supervision], call MD [physician], call RP [responsible party] and notify the DON . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. The resident required supervision and set-up for all activities of daily living (ADLs) except toileting and personal hygiene. The resident used a walker, was not steady, but was able to stabilize without staff assist during walking, turning, moving, and transfers, and the resident had no wandering behavior. Review of a Nurse Progress Note dated 5/3/2022, showed .resident was on 3rd floor of nursing home, she lives on 2nd floor. Resident was looking around on the floor in the rooms. Redirected back to second floor and to her room. New ERA tool completed. Resident is a low risk of elopement. Hourly checks put into place . Review of an Elopement Risk assessment dated [DATE], showed the resident was assessed as Low Risk for elopement and an intervention for hourly rounding was put into place. Medical record review showed hourly rounding was documented from 5/3/2022 through 5/24/2022 when the intervention had been discontinued. Review of a Nurse Progress Note dated 6/1/2022, showed Resident #1 .seems to be anxious tonight. She keeps pacing up and down the hallway and to the day room. This nurse asked if she was sleepy and she stated that she was but was waiting to go home because she didn't want to sleep in that bed anymore. I asked her why and she stated she didn't like her new roommate. Resident redirected and eventually went back to her room and is currently resting . Continued record review showed the resident was not reassessed for elopement risk and remained low risk for elopement. Review of a House Call Progress Note dated 6/8/2022, showed .referred by PCP [Primary Care Physician] r/t [related to] Dementia, [CONDITION(S)] .when asked how her mood has been she says .I wish I could be with my mother though .she complains she can't get out of this hospital to anybody . Medical record review showed from 6/8/2022 until 6/23/2022, the facility continued to assess Resident #1 as Low Risk for elopement. Review of the facility elopement investigation witness statement provided by Certified Nurse Assistant (CNA) #1 dated 6/23/2022, showed .I was in the dayroom around 5:05 PM .[Resident #1] was sitting in the dayroom watching [television show] . Review of the facility elopement investigation witness statement provided by Licensed Practical Nurse (LPN) #1 dated 6/23/2022, showed .was in the hall about [4:30 PM], when I saw [Resident #1] ambulating with her walker, headed toward the North nurse's station, as she had been ambulating with her walker, several times today .A little before [6:00 PM] this nurse checked on the third floor [and] found her outside the doors by the fish pond [with] her walker [and] a woman .they said they found her walking by [named grocery store] . Review of the facility elopement investigation witness statement provided by the Patient Access Specialist (PAS) dated 6/23/2022, showed .clocked out [at] 5:56 PM. I then came through the double doors [on the third floor] and saw [LPN #1] [at] the door with [the family friend] bringing [Resident #1] back . Review of the facility elopement investigation Event Timeline and Investigative Summary dated 6/23/2022, showed Resident #1 entered the 2nd floor elevator and when she arrived on the first floor, she was met by an Environmental Services (EVS) associate (Floor Tech #1) at 5:14 PM, who used his proxy badge to unlock the double doors at the end of the therapy hallway, where Resident #1 entered the long hallway that led to the hospital. The resident exited the healthcare facility through the adjacent hospital, crossed a 4-lane highway with a center turning lane and 2 separate 2-lane roads using a walker. Resident #1 was found in a parking lot of a grocery store by a family friend who returned the resident to the facility in their private vehicle. The resident was gone from the premises for approximately 39 minutes. Review of the facility elopement investigation witness statement provided by a family friend of Resident #1 dated 6/23/2022, showed .dropped by [named grocery store] and saw [Resident #1] walking up the hill toward the store .asked her what she was doing there. [Resident #1] stated she was coming to get a few things and that it was her mom's birthday .store manager came out to check on [Resident #1] .brought her to . [facility's] front door . Review of historical data showed the weather on 6/23/2022 was clear and 91 degrees. Review of BIMS score documentation dated 6/23/2022, showed Resident #1 scored a 14, which indicated she was cognitively intact. Review of Resident #1's skin assessment dated [DATE], showed no skin issues were present when Resident #1 was returned to the facility. Review of a Nurse Progress Note dated 6/23/2022, showed Resident #1's family and physician were notified of the elopement. The resident was sent to the emergency room for evaluation and returned to the facility with no injuries noted. Upon return to the facility, the resident was provided dinner and hydration and was placed on 1:1 supervision. Review of Resident #1's Comprehensive Care Plan showed the care plan was updated on 6/24/2022, 1:1 supervision had been discontinued, and new interventions including courtyard activities and one-on-one reminiscing as needed were initiated. During an observation on 7/13/2022 at 12:01 PM, signage was posted at the main entrance, in front of and inside the main elevator on the first, second, and third floors, and at all exit doors, that indicated only a Registered Nurse (RN), LPN, or designee was to allow visitors or residents in or out of the nursing home and/or elevator. Continued observation showed the elevator required a code to operate. During an interview on 7/13/2022 at 12:01 PM, the Administrator stated Resident #1's cognition and BIMS varied and on the day of the elopement the resident was alert. The Administrator stated the resident was last seen in the Day Room on the second floor, which was just around the corner from the elevator, at approximately 5:00 PM. She revealed the elevator requires a code to move between floors, however, if the elevator is called from another floor, the elevator will move to that floor. The Administrator stated Floor Tech #1 called the elevator to the 1st floor, seen the resident, and used his badge to let the resident out the double doors into the main hallway between the nursing home and the hospital. The Administrator stated the hospital exit doors were not locked. During an interview on 7/13/2022 at 3:11 PM, the Facility Compliance Officer (FCO) stated she received a call from the Quality Analyst and arrived at the facility within 10 minutes after Resident #1 returned. The FCO stated it was her understanding a code white had not been called because at the time the staff realized the resident was missing, the resident had returned to the facility. The FCO stated her role was .to implement immediate necessary actions .consulting role .supporting role .Re-education .increase elopement precautions .immediate education for everyone present that night .pulled code white policy .following day measures implemented anyone appearing to be a resident to not let through into the hospital .packets made and sent out .did not just educate the nursing home .hospital staff as well .we share ancillary departments .facility staff as a whole .reassessed elopement risk . During an interview on 7/13/2022 at 3:20 PM, the Administrator stated she had no knowledge of Resident #1 having had exit seeking behaviors previously .she can move freely .from this main entrance .what is considered the nursing home .my understanding .she went to the hospital .from there .went out the side door .crossed at the Methodist Church .went to where she used to live [resident's address] .she checked for traffic .watched and waited for the traffic light .crossed the main highway .4-lane .lowest point of hospital .she had on slacks and dress shirt .shoes . During an interview on 7/13/2022 at 3:33 PM, the PAS stated .I was getting ready to leave .passed [LPN #1] who was searching for [Resident #1] .it was almost time for supper . The PAS could not recall exact time, but stated supper was served between 5:00 PM-6:00 PM. The PAS stated . kept doing my thing .came back upstairs .clocked out .opened double door .saw [LPN #1] at the door with [Resident #1] .asked [family friend] .where did you find her .said she was at [named grocery store] .they have a driveway that meets [resident's home street] .that is the street her house is on .approximately .0.5 miles . The PAS continued .the [family friend] stated Resident #1 said she was .'getting some groceries' .that it was 'nearing her mom's birthday' . When asked about the resident immediately after the resident returned, the PAS stated .[Resident #1] was laughing .thought her outing was funny .but she was glad to be back . The PAS stated the resident was wearing a pair of slacks, a blouse, and a pair of shoes. During an interview on 7/13/2022 at 3:58 PM, Floor Tech #1 stated his job duties were to dust mop and buff hallway floors in the hospital and nursing home. The Floor Tech stated he was cleaning the first-floor hallway of the nursing home .leading up to the elevator .was going up to the nursing home next .before I even hit the elevator button .[Resident #1] came down .she greeted me .[Resident #1] started walking over to the [double-doors] .it was closing in on her .opened it back up for her . The Floor Tech stated when Resident #1 greeted him at the elevator .she looked like a visitor .seen visitors come down there before with canes and walkers .[Resident #1] was in her right mind .had a walker .wasn't wearing a gown .was wearing regular clothes like you and I . Further interview confirmed the Floor Tech was trained on the facility's Code White (elopement) policy in orientation and stated he was to report to his supervisor .if somebody looked confused .seemed suspicious .person not doing what they are supposed to be doing .when I know there is a code white .I inform security .maintenance .go to phone .tell someone .stay with that patient .only if they were patients .not supposed to let patients out .nothing about visitors .I thought she was a visitor .visitors are supposed to have tags on them .there have been a couple times visitors didn't have tags .can't go into the nursing home without a tag .so I just let her go through . The Floor Tech stated he did not recall receiving training regarding residents with dementia but stated .I have a better idea now .they may act like they are in their right mind .[it is] part of their condition . The Floor Tech stated after the incident he .signed something .I had went over that situation of what not to do .signs all over the building .even if we think they are a visitor not supposed to let them out .if I see someone coming from an elevator .I let someone know .even if they are a visitor .prior to that I was not told to not let anyone out of the building . During an interview on 7/13/2022 at 4:24 PM, RN #1 stated Elopement Risk Assessments were completed prior to admission, on admission day, on day 7, day 14, quarterly, and as needed. RN #1 stated at the request of the former Regional Corporate Nurse Consultant, weekly Elopement Risk Assessments were started for high-risk residents sometime in February 2022. RN #1 stated it was hers and the DON's responsibility to complete them. She stated the reason Elopement Risk Assessments were completed weekly was to reevaluate if the resident was still at risk for elopement and to get a .true picture of the patient during that week .to try to establish whether or not they were going to be high [risk] forever . RN #1 stated weekly assessments were completed for a total of 12 weeks and on 6/23/2022, Resident #1 was assessed as a low risk for elopement. RN #1 stated after Resident #1 eloped, it was determined by leadership to stop the weekly Elopement Risk Assessments because .once a resident is high risk for elopement, they are always high unless they become bedfast . Further interview confirmed when Resident #1 returned to the facility on [DATE], there was .no physical sign this woman had been outside or even walked an extended distance .did a BIMS .14 .sat with her while she ate .wasn't left unattended .1:1 . The RN stated the weather on 6/23/2022 was .nice cool breezy day .high 80's .didn't break a sweat . During an interview on 7/14/2022 at 1:21 PM, LPN #1 stated it was a typical day and staffing was appropriate on 6/23/2022. She stated Resident #1 was not at risk for elopement and had not experienced any exit seeking behaviors during her shift .one mood one day .another mood another day .[Resident #1] is happy go lucky .helping person .used to be an aid here .she knows the building .likes to walk a lot .don't ever recall her going to the door .shaking it .trying to get out .the day she ended up outside .was up and down the hallway with her walker .stops in rooms .talks to them [other residents] .social butterfly . LPN #1 stated .had my cart .between dispensing medicines .helping set up supper trays .my aid comes over and says I can't find [Resident #1] to come eat .I said 'I'll go find her' .not unusual for her to be on south side .looking for her for maybe 5 minutes .fully expected to find her somewhere on the second floor .sometimes a staff member will [take the resident to the fish pond on the 3rd floor] to give them something else to look at .not unusual for that to happen .checked the lobby .as I walked through the entrance doors .I seen people getting out of a car .I got to the front door .I was going to help them .I see [Resident #1] .with her walker .smile on her face .I was stunned .see [PAS] coming in .[family friend] confirmed they had found her walking with her walker near [named grocery store] .just that she was walking .that is all I can tell you what happened .[Resident #1] used to live down there . During an observation and interview on 7/14/2022 at 4:50 PM, Resident #1 was observed in her room working on a word puzzle. The resident appeared clean, well groomed, and pleasantly confused. The resident was very hard of hearing and stated she was happy with her care. During an observation and interview on 7/27/2022 at 1:35 PM, Resident #1 was dressed in street clothing and shoes and was observed ambulating in the hallway with her rolling walker. The resident told the surveyor she had left the facility and went to visit her mother because it was a couple of weeks before her mother's birthday and stated this happened last fall before Christmas because it was still warm outside. She stated she had to cross the street, waited for the traffic light to catch the cars, then went up 1 block. The resident stated she worked at the facility for years, but after her mother got sick, she had quit work to care for her. During an interview on 7/27/2022 at 3:20 PM, Resident #1's Physician stated he was made aware of Resident #1's elopement on 6/23/2022 .I was out of town .she never mentioned she wanted to go home .had dementia .never mentioned she would leave by herself .many times they are confused .most don't attempt .they can say .I want to go home .most are demented .can't go by themselves .now every month .changing codes .signs .don't assist anyone .signs in Spanish .English .all doors are locked .doing everything possible to ensure everybody is safe and nobody gets out . During an interview on 7/27/2022 at 5:17 PM, the DON stated she accepted the role of DON this week. When asked about the facility's documentation on Elopement Risk Assessments, the DON stated unless the resident was no longer able to ambulate, residents cannot be assessed as low risk for elopement if they had previously been assessed as a high risk for elopement. Observation on 7/28/2022 at 1:30 PM, the surveyor drove the assumed route Resident #1 had taken when she eloped from the facility. The resident exited the facility through the emergency department door of the adjacent hospital. Traveled across the parking lot, crossed a 4-lane highway with a center turn lane, walked down the sidewalk 2 blocks, traveled down a sidewalk one block, crossed a 2-lane road, traveled down a sidewalk, crossed another 2-lane road to the home she used to live in. Resident #1 then traveled down the street beside her former home and was discovered in the parking lot of the grocery store. During an interview on 7/28/2022 at 1:45 PM, the Store Manager (of the named grocery store) stated he was alerted by a customer there was a lady with a walker in the parking lot and she seemed confused. He stated by the time he got to the parking lot, another customer was assisting Resident #1 into the backseat of her car. The Store Manger stated the customer used to help Resident #1 before she moved to the nursing home, so she knew where to take her. During an interview on 7/28/2022 at 2:46 PM, Certified Nursing Assistant (CNA) #1 stated 6/23/2022 .was just like any other day .last time saw her .she was headed to Day Room .before supper time . The CNA stated the resident had not displayed exit-seeking behaviors or anxiety prior to the resident's elopement and stated the resident seemed to be happy and in a good mood. During an interview on 7/28/2022 at 2:55 PM, the nursing home main entrance Screener #1 revealed she had never given visitors stickers to wear while visiting the nursing home. She stated when Covid first started in 2020 everyone, including employees and visitors, had to enter through the hospital and received a sticker that indicated they had been screened for that day. Facility Corrective Actions included: 1. On 6/23/2022, staff on duty checked all facility exit doors as well as the courtyard doors and gate and conducted two complete head counts to ensure no other residents were impacted. All exit doors, as well as the courtyard gate, were verified by surveyors as locked on 7/29/2022. 2. An Elopement Risk Assessment was performed on 6/23/2022, which placed Resident #1 at high risk and 1:1 supervision, along with additional interventions, were implemented. Review of Resident #1's Care Plan and Elopement Risk Assessment showed on 6/23/2022, the interventions were documented. During interviews conducted with staff on 7/29/2022, 2 CNAs and 1 LPN confirmed the interventions for Resident #1 were implemented. 3. On 6/23/2022, nursing home and ancillary staff on duty were re-educated on the facility's Code White (elopement) and Wandering, Unsafe Resident policy. Review of facility documentation and interviews with 2 LPNs, 3 CNAs, and 1 Environmental Service employee confirmed they were re-educated on the facility polices for Code White and wandering residents at risk for elopement on 6/23/2022. 4. On 6/24/2022, staff completed Elopement Risk Assessment's on all residents in the facility and added applicable interventions to at risk resident care plans. Review of facility documentation showed all residents' Elopement Risk Assessments and care plans were updated with appropriate interventions on 6/24/2022. Observations by surveyors on 7/29/2022 verified interventions were implemented by staff for residents at risk for elopement. 5. On 6/24/2022, the Quality Assurance and Performance Improvement (QAPI) committee held a meeting to discuss the root cause of the elopement. The QAPI Committee discussed and developed signage in English and Spanish that was to be placed at all exit doors and elevators that alerted all staff and visitors only LPNs and RNs were allowed to assist anyone in or out of the facility or elevator. Posted signage was verified onsite by surveyor observations conducted on 7/29/2022. 6. On 6/24/2022, the facility updated their Wandering, Unsafe Resident policy to include the signage with the approval of the Medical Director. Surveyors verified the facility policy for Wandering, Unsafe Resident had been revised on 6/24/2022. Interview with the Medical Director on 7/29/2022 confirmed he approved the update. 7. On 6/24/2022, daily signage audits were initiated on 6/24/2022. Review of facility documentation verified audits were conducted beginning 6/24/2022 and were ongoing. Interview with the Administrator confirmed she was responsible for the audits and had been completed by her. 8. On 6/28/2022, monthly interview audits to confirm understanding and acknowledgement of signage were initiated. Review of facility documentation verified audits were initiated on 6/28/2022 and were ongoing. Interviews with 3 LPNs, 5 CNAs, the DON, the Rehab Director, and 1 EVS employee verified the education was completed and understood. 9. On 6/29/2022, the facility completed education for all nursing home and ancillary staff regarding the updated Wandering, Unsafe Resident policy. The education was added to orientation for new employees. Review of facility documentation and interviews with 3 LPNs, 5 CNAs, the DON, the Rehab Director, and 1 EVS employee verified the education was completed and understood.

Based on facility policy review, temperature log review, observation, and interview, the facility failed to maintain an appropriate temperature in the freezer and failed to ensure temperature logs were maintained for the refrigerator and freezer in 1 of 2 nourishment rooms which had the potential to affect 55 of 56 residents in the facility. The findings include: Review of the facility's policy titled, NURSING UNIT STOCK, dated 1/2022, showed .Nursing personnel are responsible for the once daily temperature monitoring of unit refrigerator(s) on a posted temperature sheet .If the refrigeration unit includes a freezer, the temperature in the freezer is also recorded once daily (ideal temperature is 0 [degrees] F [Fahrenheit], but may go as high as 10 [degrees] F in the nursing pantries if food remains solid to touch . Review of the 2nd North Nourishment Room FREEZER TEMPERATURE LOGS dated 4/2022, showed .Please place an X in the appropriate box for freezer temperature readings daily. If temperatures fall outside the gray zone, corrective actions must be taken .Dietary action steps .Check product for thawing and remaining ice crystals. If frozen, move to a working freezer unit. If thawed .discard as appropriate (ice cream, etc [etcetera]) .If the temperature is out of range discard the product and place a sign on the freezer OUT OF ORDER . Further review showed the gray zone included temperatures between -10 degrees F and 10 degrees F. The FREEZER TEMPERATURE LOGS showed an entry on 4/1/2022 of 4 degrees F. Continued review showed no temperature was recorded on 4/2/2022, 4/3/2022, and 4/4/2022. Review of the 2nd North Nourishment Room REFRIGERATOR TEMPERATURE LOGS dated 4/2022, showed .Please place an X in the appropriate box for cooler temperature readings daily . Further review showed an entry on 4/1/2022 of 37 degrees F. Continued review showed no temperature was recorded on 4/2/2022, 4/3/2022, and 4/4/2022. Observation and interview on 4/5/2022 at 10:09 AM, with the Dietary Director, in the 2nd North Nourishment Room, showed the freezer temperature was 16 degrees F. The freezer contained 21- 3 fluid ounce orange sherbet containers. The orange sherbet containers were soft to touch, not frozen solid, and availabel for resident use. The Dietary Director stated the nursing staff was responsible for obtaining and recording daily temperatures for the nourishment room refrigerator and freezer. Nursing staff was to notify the dietary department and maintenance for any freezer temperature reading out of the gray zone (above 10 degrees F). The Dietary Director confirmed no temperature reading had been obtained for the 2nd North Nourishment Room refrigerator or freezer from 4/2/2022 - 4/4/2022 and the current temperature reading in the freezer was 16 degrees F. Further interview with the Dietary Director confirmed the dietary department was unaware of the 2nd North Nourishment Room freezer temperature above 10 degrees F. During an interview on 4/5/2022 at 3:33 PM, the Registered Nurse (RN) Supervisor stated she was unaware who was responsible for obtaining and documenting refrigerator and freezer temperatures on the temperature log. During an interview on 4/6/2022 at 11:05 AM, the Administrator confirmed nursing staff were responsible for obtaining and recording nourishment room refrigerator and freezer temperatures daily. The Administrator confirmed temperatures had not been recorded for the 2nd North Nourishment Room refrigerator and freezer for 3 days from 4/2/2022 - 4/4/2022.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide water flushes for a resident who received tube feeding (nutrition provided by a tube placed directly into the stomach) per the Physician's order for 1 resident (Resident #42) of 2 residents review for tube feedings. The findings include: Review of the facility policy titled, Feeding, tube feeding, revised 6/14/2016, showed .Dietician will .determine .nutritional needs .The physician will be notified of any recommendations and any orders will be followed . Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was rarely or never understood and had severe cognitive impairment. Continued interview showed the resident received nutrition by tube feedings. Review of Resident #42's Physician's Telephone Order dated 3/16/2022, showed .[increase] auto flush [water flush of the feeding tube] to 35cc [cubic centimeters]/ [per] hr [hour] . Review of Resident #42's Supplements Record dated 3/2022, showed .SUPPLEMENTS .Glucerna [type of nutrition provided by a feeding tube] .[with] 30ml [milliliters- equivalent to cubic centimeters] H2O [water] flush . Further review showed no documentation of an update to reflect the 3/16/2022 physician's telephone order to increase the water flush to 35 cc/hour. Review of Resident #42's care plan updated on 3/27/2022, showed .Maintain rate of Glucerna .w/ [with] 35 ml/hour free water [flush] . Review of Resident #42's Supplements Record dated 4/2022, showed .SUPPLEMENTS .Glucerna .[with] 30 ml H2O flush . During an observation on 4/4/2022 at 10:36 AM, showed Resident #42 lying on the bed with Glucerna tube feeding infusing at 80 ml/hour and the water flush infusing at 30 ml/hour. During an observation on 4/5/2022 at 2:08 PM, showed Resident #42 lying on the bed with Glucerna tube feeding infusing at 80 ml/hour and the water flush infusing at 30 ml/hour. During an observation and interview on 4/5/2022 at 2:12 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #42's water flush was infusing at 30 cc/hour. The LPN stated if the facility received a new order, the nurse who received the order was responsible to update the order on the supplement record and change the rate on the feeding pump. LPN #1 confirmed Resident # 42's Supplement Record showed the resident was to receive the water flush at 30 ml/hour. (the physician's order dated 3/16/2022 was for 35 cc/hour) During an interview on 4/5/2022 at 2:23 PM, the Clinical Case Manager (CCM) confirmed Resident #42 had an order dated 3/16/2022 to increase the auto flush to 35 cc/hour. Continued interview confirmed the resident was to receive 35 cc/hour water flush and the resident was not receiving receiving the appropriate amount of water flush.

Based on review of prior survey results, medical record review and interview, the facility failed to maintain compliance with prior plans of correction, in an effort to sustain accurate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's plans of correction dated 2/10/2020 included, .3. The DON [Director of Nurses] conducted education with the nursing staff regarding following physician orders, diabetic medication/sliding scale insulin, and treatment administration .random checks of treatment and medication administration orders to ensure compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .reported at the quarterly QAPI [quality assurance performance improvement] meeting with modifications made if indicated , to maintain substantial compliance. The facility defines substantial compliance as a rate of 100% compliance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During review of 19 resident's medical records, 4 residents were found with inaccurate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/5/2022 at 2:50 PM, the Director of Nursing (DON) confirmed Resident #1's medication for [MEDICATION(S)] 7.5 mg at bedtime was discontinued on 2/9/2022 and continued to be inaccurately listed on the current Physician's Recapitulation Orders. Record review showed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's telephone orders for Resident #6 showed a decrease in daily blood sugar checks, dated 12/10/2020, Decrease Fingersticks (to obtain a blood sugar value) to FBS (fasting blood sugar)/4 PM. Review of Resident #6's monthly Physician Recapitulation Orders, dated April 2022 and signed by the physician on 4/3/2022, showed [MEDICATION(S)] (fast acting insulin) 100 UNITS/ML VIAL INJECT 4-16 UNITS .BEFORE MEALS & AT BEDTIME PER MODERATE DOSE SLIDING SCALE. Continued review showed an order, [MEDICATION(S)] (long acting insulin) 100 UNITS/ML INJECT 46 UNITS .EVERY DAY. During an interview with LPN #3 on 4/5/2022 at 3:00 PM, she confirmed each month, when the Physician's Recapitulation Orders were reviewed, the order for blood sugar checks before meals and at bedtime inaccurately remained on the current orders. Continued interview confirmed the order was not being followed and revealed prior to the beginning of each month, she or another nurse checking recapitulation orders, created a handwritten Moderate Dose Sliding Scale Insulin Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview confirmed the decrease to 2 times a day fingersticks was on the Sliding Scale Insulin MAR, without a start date included. Continued interview confirmed the order for the long acting insulin every day on the recapitulation order was incomplete due to a morning or bedtime administration was not specified. During an interview with the Pharmacy Director on 4/6/2022 at 9:35 AM, he stated during the monthly pharmacy reviews medication administration records were checked .not currently auditing accuracy of recap (recapitulation) orders . Further interview confirmed the pharmacy wasn't aware of scanned telephone orders not always being entered into the monthly recapulation orders to maintain accurate and current orders. Record review showed Resident #32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022 did not include the 35 ml/hr water flush [used with tube feeding administration] as ordered by the physician on 2/18/2022. Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #42 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the facility had not placed the order on the resident's Physician's Recapitulation Orders for the months of 2/2022, 3/2022, and 4/2022. Interview with the Quality Director and the Clinical Case Manager, confirmed the facility's prior plans of correction related to accurate medication and treatment orders had not been sustained. Further interview confirmed the facility was aware of the ongoing problems with medication and treatment orders not being included, corrected, or updated on the monthly recapitulation orders. Continued interview confirmed the Quality Assurance program did not have an active plan to address incomplete or inaccurate physician orders.

Based on medical record review, observation, and interview the facility failed to maintain accurate and complete medical records for 5 residents (Residents #1, #2, #42, #6, and #32) of 19 residents reviewed for medical records. The findings include: Record review showed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Recapitulation Order dated 3/2022 for Resident #1 showed [MEDICATION(S)] 7.5 milligram (mg) at bedtime continued to be listed on the resident's active orders. During an observation an interview on 4/5/2022 at 2:45 PM, Licensed Practical Nurse (LPN) #1 showed the [MEDICATION(S)] for Resident #1 was not available for administration on the medication cart. LPN #1 further stated after a telephone order or a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .sometimes I'm not sure if it goes through . Continued interview showed the pharmacy generated the recapitulation orders each month and it was the nurse's responsibility to notify the pharmacy of any medication discrepancies identified on the monthly orders. LPN #1 confirmed the [MEDICATION(S)] had been discontinued on 2/9/2022, was incorrectly documented on the 3/2022 monthly recapitulation orders and was not given to the resident after the resident medication was discontinued. During an interview on 4/5/2022 at 2:50 PM, the Director of Nursing (DON) stated the [MEDICATION(S)] 7.5 mg at bedtime was discontinued on 2/9/2022 and continued to be listed on Resident #1's 3/2022 active Physician's Recapitulation Orders. Continued interview confirmed the documentation for the discontinued [MEDICATION(S)] on the active Physicians Recapitulation Orders was inaccurately documented and the resident did not receive the discontinued medication. Record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician's Telephone Order dated 1/6/2020, showed .May use seat belt on w/c [wheelchair] for safety and proper positioning . Review of Resident #2's care plan dated 1/6/2020, showed .I may use a seat belt while I am in wheelchair . Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. Continued review revealed the resident used a restraint in the chair daily. Review of Resident #2's Physician's Recapitulation Orders dated 1/1/2022-1/31/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 2/1/2022-2/28/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 3/1/2022-3/31/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. Review of Resident #2's Physician's Recapitulation Orders dated 4/1/2022-4/30/2022, showed no documentation of the order for the resident's seat belt use while in the wheelchair. During an observation on 4/5/2022 at 2:05 PM, showed Resident #2 seated in the wheelchair in the hallway with a seat belt in use. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #2 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the facility had not placed the order on Resident #2's Physician's Recapitulation Orders for the months of 1/2022, 2/2022, 3/2022, and 4/2022. Continued interview confirmed the physician recapitulation orders were inaccurate. Record review showed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Physician's Telephone Order dated 2/9/2021, showed .Glucerna [type of nutrition provided by feeding tube] .@ [at] 80 ml [milliliters]/ [per] hr [hour] [with] H2O [water] flush [flush of the feeding tube] 30 ml/hr Review of Resident #42's Physician's Recapitulation Orders dated 2/1/2022-2/28/2022, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .@ 80 ml Further review showed the orders were inaccurate and did not have documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #42's Physician's Recapitulation Orders dated 3/1/2022-3/31/2022, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .@ 80 ml . Further review showed the orders were inaccurate and did not have documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #42's Physician's Telephone Order dated 3/16/2022, showed .[increase] autoflush [water flush] to 35 cc [cubic centimeter] /hr . Review of Resident #42's Physician's Recapitulation Orders dated 4/1/2022-4/30/2022, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .@ 80 ml . Further review showed the orders were inaccurate and did not have documentation of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation and interview on 4/5/2022 at 2:12 PM, in Resident #42's room, Licensed Practical Nurse (LPN) #1 confirmed the resident had the water flush infusing with the tube feeding. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #42 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the facility had not placed the order on the resident's Physician's Recapitulation Orders for the months of 2/2022, 3/2022, and 4/2022. Continued interview confirmed the physician recapitulation orders were inaccurate. Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's telephone orders for Resident #6 showed a decrease in daily blood sugar checks, dated 12/10/2020, Decrease Fingersticks (to obtain a blood sugar value) to FBS (fasting blood sugar)/ [and] 4 PM. Review of Resident #6's monthly Physician Recapitulation Orders, dated 4/2022, showed [MEDICATION(S)] [fast acting insulin] 100 UNITS/ML [mililiter] VIAL INJECT 4-16 UNITS .BEFORE MEALS & [and] AT BEDTIME PER MODERATE DOSE SLIDING SCALE. Continued review showed an order, [MEDICATION(S)] [ long acting insulin] 100 UNITS/ML INJECT 46 UNITS .EVERY DAY. Review of Resident #6's monthly physician's recapitulation orders showed the orders were inaccurate from January 2021 through April 2022 and did not reflect the resident new order for blood sugar checks twice a day. During an interview with Licensed Practical Nurse (LPN) #3 on 4/5/2022 at 3:00 PM, she confirmed each month, when the physician's recapitulation orders were reviewed, the order for blood sugar checks before meals and at bedtime remained on the current recapitulation orders. Continued interview confirmed the inaccurate order was not being followed and the resident's blood sugar was being checked twice a day. Further interview revealed, prior to the beginning of each month, she or another nurse checking recapitulation orders. Continued interview confirmed the order for the long acting insulin every day on the recapitulation orders was incomplete because the order did not specify whether the insulin was to be given in the morning or at bedtime. Interview confirmed the order was incomplete and each month the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .we know the doctor administers long acting insulin in the morning. During an interview with LPN #1 on 4/5/2022, at 3:15 PM, revealed all telephone orders were scanned to the pharmacy when written. Further interview confirmed this order to reduce the blood sugar checks to 2 times a day was not included in Resident #6 monthly recapitulation orders and the monthly orders continued to inaccurately specify 4 blood sugar checks a day for the sliding scale insulin. Continued interview revealed the resident received 2 blood sugar checks daily. During an interview with LPN #1 and LPN #3 on 4/5/2022 at 3:20 PM, confirmed Resident #6's 2 orders for insulin administration on the Physician's Recapitulation Orders, dated 4/3/2022, were inaccurate. Continued interview confirmed the frequency of administration of the sliding scale insulin was inaccurate and the order was incomplete for the time of day the resident's long acting insulin was to be administered. During an interview with the Pharmacy Director on 4/6/2022 at 9:35 AM, he confirmed the order for Resident #6's long acting insulin administration on the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview confirmed the order to check the resident's blood sugar 4 times a day and to administer the moderate sliding scale insulin if needed was inaccurate and remained on the monthly Recapitulation Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview with Resident #6's physician on 4/6/2022 at 10:00 AM, he confirmed he understood the resident's monthly recapitulation orders he signed each month were inaccurate and stated, .Appreciate this, we will work on this and make sure it is taken care of properly . Record review showed Resident #32 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Peg tube (New) .Glucerna 1.2 tube feeding @ [at] 30 ml [milliliters]/hr [hour] [with] end goal rate 55 ml/hr, Flush 35 ml/hr . Review of the Care Plan dated 2/22/2022, showed .tube feeding r/t [related to] decreased oral intake that is insufficient to maintain my nutritional needs .I am dependent with tube feeding and water flushes .See MD [medical doctor] orders for current feeding orders . Review of the PHYSICIAN's TELEPHONE ORDERS dated 2/24/2022, showed an order to increase tube feeding 10 milliliters per shift until initial goal of 65 ml/hr was reached for 22 hours per day. Review of the Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022, showed .PEG Tube feeding Glucerna 1.2 . Further review showed the orders were incomplete and did not show the order for resident's water flushes. Review of the PHYSICIAN'S TELEPHONE ORDERS dated 3/31/2022, showed .Decrease tube feeding to Glucerna 1.2 @ 55 ml/hr . Review of the Physician Recapitulation Orders dated 4/1/2022 - 4/30/2022, showed .PEG T.F. [tube feeding] Glucerna 1.2 . Further review showed the orders were incomplete and did not show the order for the resident's tube feeding water flushes. Observation on 4/4/2022 at 11:06 AM, showed Resident #32 lying in bed with the head of the bed elevated. Resident #32 had Glucerna 1.2 at 55 ml/hr and water flush at 35 ml/hr infusing via PEG tube. During an interview on 4/5/2022 at 8:47 AM, LPN #2 stated Resident #32's current tube feeding orders were Glucerna 1.2 at 55 ml/hr and water flush at 35 ml/hr for 22 hours daily. The LPN confirmed there was no order for the 35 ml/hr water flush listed on Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022. LPN #2 stated the water flush order was listed in the dietary notes .that is what I have been told . During an observation and interview on 4/5/2022 at 3:14 PM, in Resident #32's room, the Clinical Case Manager confirmed Resident #32 had Glucerna at 55 ml/hr and water at 35 ml/hr infusing via PEG tube. The Clinical Case Manager confirmed there was no order for the 35 ml/hr water flush on the Physician's Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022. The Clinical Case Manager stated the 35 ml/hr water flush was ordered on Resident #32's readmission from the hospital on 2/18/2022 and confirmed the order was not placed on the monthly Physician's Recapitulation Orders. During an interview on 4/6/2022 at 2:46 PM, the DON confirmed Resident #32's Physician Recapitulation Orders dated 3/1/2022 - 3/31/2022 and 4/1/2022 - 4/30/2022 was not accurate and did not inlclude the 35 ml/hr water flush as ordered by the physician on 2/18/2022.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 5 residents (Resident #14, #27, #29, #15, and #24) of 56 residents reviewed for dignity. The findings include: Review of the facility's policy titled, ATTACHMENT I: Resident Rights Policy, revised 1/2014, showed .Every Facility Resident has the following minimum rights .respect and full recognition of his/her dignity .The Resident has a right to a dignified existence .The resident has the right to personal privacy and confidentiality . Record review showed Resident #14 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 was rarely or never understood and had severe cognitive impairment. During observation on 4/4/2022 at 10:28 AM, revealed signage on the nightstand read, .[Resident #14's initials] .[Resident's room number] .Aspiration [accidentally inhaling liquid or food into the lungs]/Reflux Precautions .feed pt [patient] .Sit upright at 90 deg [degrees] for all intake .Take pills crushed .Date: 9/30/21[2021] . The signage was visible to anyone who entered the residents's room. During observation on 4/4/2022 at 2:44 PM, revealed signage on the nightstand read, .[Resident #14's initials] .[Resident's room number] .Aspiration [accidentally inhaling liquid or food into the lungs]/Reflux Precautions .feed pt [patient] .Sit upright at 90 deg [degrees] for all intake .Take pills crushed .Date: 9/30/21[2021] . The signage was visible to anyone who entered the resident's room. During observation on 4/5/2022 at 9:00 AM, revealed signage was posted above Resident #14's bed that read, .[Resident #14's initials] .[resident's room number] .Aspiration/Reflux Precautions .feed pt .Sit upright at 90 deg for all intake .Take pills crushed .Date: 9/30/21 . The signage was visible to anyone who entered the resident's room. During observation on 4/6/2022 at 8:23 AM, revealed signage was posted above Resident #14's bed that read, .[Resident #14's initials] .[resident's room number] .Aspiration/Reflux Precautions .feed pt .Sit upright at 90 deg for all intake .Take pills crushed .Date: 9/30/21 . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:47 AM, in Resident #14's room, the Clinical Case Manager confirmed the signage was present above Resident #14's bed and was visible to anyone who entered the resident's room. Record review showed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Observation on 4/4/2022 at 10:32 AM, showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. Observation on 4/5/2022 at 8:35 AM showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. Observation on 4/6/2022 at 8:24 AM showed 2 signs posted above Resident #27's bed. The first sign read, . [Resident #27's initials] .[Resident's room number] .Aspiration/Reflux Precautions .Sit upright at 90 deg for all intake .Sit up for 30 minutes following intake .Small bites .Take pills crushed .Avoid meltables .Follow up speech services are recommended .Date: 3/10/22[2022] . The second sign read, CHANGE POSITION OF BED/CHAIR EVERY TWO HOURS . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 3:00 PM, the Clinical Case Manager confirmed the signage was present over Resident #27's bed and visible to anyone who entered the resident's room. Record review showed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's annual MDS assessment dated [DATE], showed the resident was rarely or never understood and had severe cognitive impairment. During an observation on 4/4/2022 at 10:30 AM, showed a sign posted above the head of the resident's bed .aspiration precautions .please do not lay flat . The signage was visible to anyone who entered the room. During an interview and observation on 4/4/2022 at 3:05 PM, Certified Nursing Assistant (CNA) #1, in Resident #29's room, stated the sign above the head of the resident's bed stated the resident required aspiration precautions and the head of the bed was to be raised at all times. The signage was visible to anyone who entered the room. During an observation on 4/6/2022 at 8:59 AM, showed a sign posted above the head of Resident #29's bed .aspiration precautions .please do not lay flat . The signage was visible to anyone who entered the room. During an interview and observation on 4/6/2022 at 11:00 AM, in Resident #29's room, the Clinical Case Manager confirmed the signage was present above Resident #29's bed and was visible to anyone who entered the room. Record review showed Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the admission MDS assessment dated [DATE], showed Resident #15 had a BIMS score of 7, indicating the resident was severely cognitively impaired. During observations on 4/4/2022 at 11:17 AM, 4/4/2022 at 2:10 PM, and 4/5/2022 at 8:47 AM, 1 sign was posted above Resident #15's bed that read, Hard of Hearing .Speak loud +[and] slow or write it down .Thanks! . The signage was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:55 AM, in Resident #15's room, the Clinical Case Manager confirmed the signage was present above Resident #15's bed and was visible to anyone who entered the resident's room. Record review showed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual MDS assessment dated [DATE], showed Resident #24 had a BIMS score of 8, inidicating the resident was moderately cognitively impaired. During an observation on 4/4/2022 at 11:02 AM, signage was posted above Resident #24's bed that read, 12/15/21 [2021] .[Resident #24's first inital and last name] .Bed position will be alternated to allow her to lay on a different side, to heal her shearing area and prevent more breakdown. Please DO NOT move bed back unless nurse management has instructed to do so . The signage was visible to anyone who entered the resident's room. During an interview on 4/4/2022 at 11:13 AM, Resident #24 stated she was unaware of any signage posted in her room and did not request any signage to be posted. During an observation on 4/5/2022 at 1:25 PM, signage was posted above Resident #24's bed that read, 12/15/21 .[Resident #24's first initial and last name] .Bed position will be alternated to allow her to lay on a different side, to heal her shearing area and prevent more breakdown. Please DO NOT move bed back unless nurse management has instructed to do so . The signsge was visible to anyone who entered the resident's room. During an observation and interview on 4/6/2022 at 10:54 AM, in Resident #24's room, the Clinical Case Manager confirmed the signage was present above Resident #24's bed and was visible to anyone who entered the resident's room. During an interview on 4/6/2022 at 10:44 AM, the Clinical Case Manager stated it was the expectation of the facility that resident medical information be communicated to staff members via verbal report and on the care plan. The Clinical Case Manager stated resident medical information was not to be visibly posted unless requested by the resident or family. During an interview on 4/6/2022 at 1:44 PM, the Administrator confirmed no documentation was available to show Residents #14, #27, #29, #15, and #24 or their families had requested any signage to be placed in their rooms.

Based on facility policy review, medical record review, interview, and observation, the facility failed to obtain a signed consent indicating the potential risks and benefits for the use of a restraint from the resident's representative prior to the use of a restraint and failed to document the monitoring and supervision provided during the use of a restraint to check ever 30 minutes and release and reapply every 2 hours for toileting and range of motion for 1 resident (Resident #2) of 1 resident reviewed for restraint use. The findings include: Review of the facility policy titled, Restraints, Use of, revised 2/17/2020, showed .The following safety guidelines shall be .documented while a resident is in restraints .A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel .Restrained residents must be repositioned at least every two (2) hours on all shifts .Residents and/or surrogate /sponsor shall be informed about the potential risks and the benefits of all options under consideration, including the use of restraints, and the alternatives to restraint use evidenced by signed consent .Documentation regarding the use of restraints shall include .Observation, range of motion and repositioning flow sheets .Direct monitoring and supervision during the use of restraints . Record review showed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Physician's Telephone Order dated 1/6/2020, showed .May use seat belt on w/c [wheelchair] for safety and proper positioning, [check] Q [every] 30 min [minutes] release Q 2 hrs [hours] and PRN [as needed] . Review of Resident #2's Nurse's progress note dated 1/6/2020, showed .Verbal Consent for seatbelt on wheelchair for safety, family consent obtained with witness . Record review showed no documentation the facility had obtained a signed consent including the potential risks and benefits of the use of the restraint from the resident's representative. Review of Resident #2's care plan dated 1/6/2020, showed .I may use a seat belt while I am in wheelchair . as the least restrictive means to provide safety and positioning .check seat belt every 30 minutes, release and reapply every 2 hours for toileting and rom [range of motion] and as needed . review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The resident used a wheelchair for mobility and used a restraint daily. Review of Resident #2's quarterly MDS assessment dated [DATE], showed a BIMS score of 00, indicating the resident had severe cognitive impairment. The resident used a wheelchair for mobility and used a restraint in the chair daily. Record review showed no documentation Resident #2 had been monitored or supervised during the use of the seat belt restraint. During an interview on 4/4/2022 at 2:17 PM, Certified Nursing Assistant (CNA) #4 stated she was unsure if the seat belt was used when Resident #2 was seated in the wheelchair was a restraint. The CNA stated the resident was able to self-release the seat belt at times, but she was unsure if the resident was able to self-release the seat belt upon command. The CNA stated the resident was checked frequently while up in the wheelchair and provided assistance with toileting every 2 hours. During an interview on 4/4/2022 at 2:28 PM, Licensed Practical Nurse (LPN) #2 stated Resident #2 did not have a restraint. The LPN stated the resident did use a seat belt when she was seated in her wheelchair, but it was not a restraint. The LPN confirmed she did not document monitoring or supervision provided to the resident while the seat belt was in use .I've never documented anything . but stated the resident was monitored frequently and assited with toileting. During an observation of Resident #2 and interview with the MDS Coordinator on 4/5/2022 at 2:05 PM, showed Resident #2 seated in the wheelchair in the hallway with a seat belt in use. The MDS Coordinator confirmed Resident #2 used a seat belt restraint when she was seated in the wheelchair and the resident was unable to release the seat belt upon command. During an interview on 4/6/2022 at 8:18 AM, the Administrator confirmed the facility did not have documentation of the monitoring or supervision the facility was providing for Resident #2 for the use of the seat belt restraint. The Administrator stated .the staff know to do it [monitor the resident] . During an interview on 4/6/2022 at 9:01 AM, CNA #5 stated she did not know if the seat belt Resident #2 used when she was seated in the wheelchair was a restraint. The CNA stated the staff did observe the resident when she was seated in the wheelchair .we just visually keep an eye on her . and stated incontinence care was provided every 2 hours or more often as needed. During an interview on 4/6/2022 at 9:11 AM, Registered Nurse (RN) #1 confirmed the resident was monitored when she was seated in the wheelchair, but the facility did not have documentation of the monitoring that was provided to the resident for the restraint. During an interview on 4/6/2022 at 1:58 PM, the Clinical Case Manager, confirmed the facility had not documented the restraint monitoring and supervision for Resident #2 and a signed consent had not been obtained prior to the use of the restraint for the resident.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Medication Administration, revised 10/14/2015, showed .be sure to observe any fluid restriction ordered by the physician . Review of the facility's policy titled, Intake & Output, revised 9/26/2013, showed .resident has a flow sheet maintained by the nurse. The purpose of which is to monitor fluid intake .C.N.A.s [Certified Nurse Assistants] record in cc's [cubic centimeter-equivalent to milliliters] the amounts of intake residents receive each meal .Nurses take the information .and record it on the flow sheet . Record review showed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Telephone Order dated 10/22/2021, showed .1500 fluid restriction . Review of Resident #12's Comprehensive Care Plan revised 10/23/2021, showed .resident has fluid overload or potential fluid volume overload r/t [related to] .[history of] [CONDITION(S)] .fluid restrictions of 1500 ml [milliliters] daily . Review of the intake and output record dated 1/1/2022-1/31/2022, showed 12 out of 31 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -1/1/2022- fluid intake exceeded by 140 cc -1/6/2022- fluid intake exceeded by 220 cc -1/7/2022- fluid intake exceeded by 500 cc -1/10/2022- fluid intake exceeded by 150 cc -1/11/2022- fluid intake exceeded by 120 cc -1/16/2022- fluid intake exceeded by 10 cc -1/17/2022- fluid intake exceeded by 60 cc -1/19/2022- fluid intake exceeded by 530 cc -1/20/2022- fluid intake exceeded by 420 cc -1/24/2022- fluid intake exceeded by 300 cc -1/29/2022- fluid intake exceeded by 540 cc -1/30/2022- fluid intake exceeded by 420 cc Review of the intake and output record dated 2/1/2022-2/28/2022, showed 17 out of 28 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -2/2/2022- fluid intake exceeded by 180 cc -2/3/2022- fluid intake exceeded by 500 cc -2/4/2022- fluid intake exceeded by 440 cc -2/6/2022- fluid intake exceeded by 300 cc -2/8/2022- fluid intake exceeded by 340 cc -2/9/2022- fluid intake exceeded by 240 cc -2/11/2022- fluid intake exceeded by 780 cc -2/12/2022- fluid intake exceeded by 540 cc -2/13/2022- fluid intake exceeded by 380 cc -2/14/2022- fluid intake exceeded by 360 cc -2/16/2022- fluid intake exceeded by 440 cc -2/17/2022- fluid intake exceeded by 420 cc -2/19/2022- fluid intake exceeded by 480 cc -2/21/2022- fluid intake exceeded by 160 cc -2/22/2022- fluid intake exceeded by 120 cc -2/23/2022- fluid intake exceeded by 100 cc -2/27/2022- fluid intake exceeded by 20 cc Review of the intake and output record dated 3/1/2022-3/31/2022, showed 2 out of 31 days, the resident's intake exceeded the 1500 cc fluid restriction by the amounts that follow: -3/7/2022- fluid intake exceeded by 540 cc -3/8/2022- fluid intake exceeded by 320 cc Review of the nurse's notes from 10/22/2021 to 4/6/2022, showed no documentation Resident #12 had any adverse outcome related to the increased fluid intake. Observation on 4/4/2022 at 10:49 AM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. Observation on 4/5/2022 at 3:12 PM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. Observation on 4/6/2022 at 2:00 PM, showed the Resident #12 sitting in a wheelchair. Further observation showed the resident had no visible swelling. During an interview on 4/5/2022 at 7:45 AM, Licensed Practical Nurse (LPN) #4 stated the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed the nurse documents the fluid intake percentage from all meals on the intake and output flowsheet then calculates how much more fluid the resident had remaining in a 24 hour period. During an interview on 4/5/2022 at 8:00 AM, LPN #1 stated when a resident had a fluid restriction order, CNA staff calculated the fluid intake from all meals, documented the percentages, and informed the assigned nurse how many cc's the resident consumed. She stated the nurse documented intake percentages from all meals on an intake monitoring sheet placed with the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview 4/5/2022 at 8:00 AM, CNA #2 stated when a resident was on a fluid restriction, the CNA staff were responsible for calculating fluid intake from all meals. She stated fluid intake percentages were documented and the assigned nurse was made aware of the totals. During an interview on 4/5/2022 at 2:45 PM, CNA #6 stated she was aware Resident #12 had a fluid restriction. She stated fluid intake percentages were calculated from all meals and reported to the nurse. Continued interview revealed the nurse informs the staff of how much fluid the resident has remaining. During an interview on 4/5/2022 at 3:00 PM, the Dietary Manager stated dietary employees were aware of Resident #12's 1500 cc fluid restriction. He also stated the resident was served 360 cc daily for breakfast, 480 cc daily for lunch, and 240 cc daily for dinner for a total of 1080 cc daily from dietary. During an interview on 4/5/2022 at 3:55 PM, the Director of Nursing (DON) stated her expectation was for the facility to follow physician orders. The DON confirmed the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 4/6/2022 at 10:52 AM, Resident #12's physician stated the resident had a fluid restriction and the physician expected the facility to follow his orders. He also stated he conducted an assessesment of the resident monthly and the resident had been stable while at the facility.

Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to follow their elopement policy, failed to implement interventions to prevent elopement, and failed to provide a safe environment to prevent an elopement for 1 of 4 sampled residents (Resident #3) reviewed for elopement. The facility's failure placed Resident #3 in Immediate Jeopardy (a situation in which a provider's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #3 was able to enter the security code into the keypad and exit through an egress door to the facility's courtyard, and through the fence of the courtyard. The facility was unaware of the exact time the resident eloped from the building. The resident was found across the street, 1800 feet from the facility, at a family friend's house. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Facility Compliance Officer were notified of the Immediate Jeopardy on 4/27/2021 at 4:45 PM, in the conference room. The Chief Executive Officer, Chief Operating Officer, Chief Nursing Officer, Quality Assurance Director, Vice President Nursing Informatics, Survey Manager, Director of Operations, and Director of Clinical Operations teleconferenced into the meeting. The facility was cited F-689 at a scope and severity of J, which constitutes Substandard Quality of Care. The Immediate Jeopardy was effective 4/17/2021- 4/21/2021 and was removed 4/22/2021. The findings include: Review of the facility's policy titled, Policy Emergency Codes - Code White - Elopement, revised 8/20/2019, showed, .To prevent elopements from occurring and if elopements occur, to return the patient/resident quickly and safely .to assure a safe and secure environment .Every effort shall be made to prevent elopements from happening. This may be in the form of security systems .Procedure .Code white will alert staff of an elopement .Should an elopement occur, staff should immediately announce over the PA system the above code .If the patient/resident is not located within 15 minutes the [Police Department] will be contacted to assist in the search . Resident #3 was admitted to the facility on [DATE] and was readmitted on [DATE] from an Acute Care hospital with diagnoses including [CONDITION(S)], Dysphagia following Cerebral Infarction, Aspiration Pneumonia with Acute Respiratory Failure, [MEDICATION(S)] Induced [CONDITION(S)], and [CONDITION(S)]. Review of the Elopement Risk assessment dated [DATE], showed Resident #3 was not at risk for elopement. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], showed Resident #3 was cognitively intact, required limited assistance of 1 to walk in the corridors, used a walker for mobility, and did not exhibit wandering behaviors. Review of an initial Psychotherapy Evaluation dated 2/26/2021, showed, .Orientation: AOX [alert and oriented] .not fully oriented to time .Judgement and Insight poor .mild confusion .monitor for .anxiety, impulsivity, mood lability, change in behaviors, change in cognition . Review of the Elopement Risk assessment dated [DATE], showed Resident #3 was at low risk for elopement due to cognitive impairment and being able to ambulate independently. The assessment showed no interventions were implemented for risk of elopement. Review of a Social Worker's progress note dated 3/10/2021, showed, .Resident [#3] asking about going to a health and rehab, could not seem to express where he was wanting to go. When asked if it was in our town, he said no . Review of a Social Worker's progress note dated 3/17/2021, showed, .alert and is usually able to communicate needs. He [Resident #3] has been upset thinking about some land taxes .talking about his son who has not been involved .still thinks he can leave here and care for himself . Review of the Elopement Risk assessment dated [DATE], showed Resident #3 was at risk for elopement due to cognitive impairment and being able to ambulate independently. The assessment showed no interventions were implemented for risk of elopement. Review of the Falls Risk assessment dated [DATE], showed, .Ambulatory aid .walker .weak gait .short steps .knows own limits . The assessment showed Resident #3 scored Moderate Risk. Review of the care planned interventions for fall risk showed interventions implemented were to remind the resident to use call light when in need of assistance and nonskid socks. Review of the facility's investigation revealed a written statement provided by Certified Nursing Assistant (CNA) #1 dated 4/17/2021, At 8:00 pm [Resident #3] was in the central dayroom . The resident was last seen by CNA #1 and he was in bed, but the time was unknown. Review of the Incident Report filed by Licensed Practical Nurse (LPN) #1 dated 4/17/2021, showed, While rounding at 11:45 pm, checked room [resident's room number] - [Resident #3] was not in bed. I checked the bathrooms and the other rooms. After checking all the rooms on South, went over to Central and North to get the other nurses. We began looking both upstairs and down, then the courtyard and out the door on South. Called Security and the House supervisor, called the code to ER [emergency room ] registration . There was no indication in the Incident Report that a Code White was initiated or that the police were called, as indicated in the facility policy. Review of the facility's elopement investigation dated 4/18/2021, showed Resident #3 had left the premises of the nursing home. The resident entered the security code that was posted next to the keypad to exit an egress door to the courtyard, dismantled the facility fence, crossed a street, and went to a friend's house approximately 600 yards (1,800 feet) from the facility. Review of a written statement provided by Licensed Practical Nurse (LPN) #2 dated 4/18/2021, showed, .Nurse [LPN #1] came to me around 12:08 am and asked if I had seen resident [Resident #3] .I told [LPN #1] to call security at 12:15-12:30 am .police called around 12:40 am [approximately 55 minutes after LPN #1 noticed Resident #3 was missing] .friend [emergency contact] called notified of absence .police arrived at 1:00 am .friend called back around 1:15 am stating resident had walked to her house .police informed .resident in ER [transferred by police] at 1:35 am . Review of a progress note dated 4/18/2021, showed a family friend called and informed the facility of Resident #3's location. The progress note showed, .he is on my porch and his foot is hurt . Review of a progress note from LPN #3 dated 4/18/2021 at 8:54 AM, showed, .arrived back to nursing home from ER via wheelchair with CNA from hospital at 7:45 [AM]. CNA from hospital is to stay with patient [Resident #3] all day and watch him .no new orders .Resident complains of left foot hurting. X-ray was performed in ER . Review of a progress note from Registered Nurse (RN) #1 dated 4/18/2021 at 9:10 AM, showed, .I went to speak to the resident [Resident #3] and ask him what happened. He stated he had decided last night that he was going to leave. He said he went out the back door and to [took] fence apart. I asked him how, he said he unscrewed bolts and then pushed the fence down. He then reached in his pocket and showed me a washer which appeared to come from the fence . Review of a written statement by LPN #3 dated 4/19/2021, showed, .I did see him near the courtyard door once when it was in the process of closing .I made night shift aware [night shift on 4/17/2021] of that . Observation on 4/26/2021 at 11:00 AM, revealed the security code was not posted at the exits leading out of the facility to the courtyard, and the fence had been repaired. An interview with the Administrator on 4/26/2021 at 3:00 PM, in the conference room, showed, .Keypad code [code used by Resident #3 on 4/17/2021] had been posted since before the time I came .about 5 years ago . The Administrator stated Resident #3 had one to one (1:1) supervision after his return to the facility from the hospital on 4/18/2021 at 7:45 AM, until his discharge on 4/19/2021. During an interview with the DON on 4/26/2021 at 3:15 PM, in the conference room, she stated Resident #3 had progressed from being no elopement risk to a low risk due to his improved ability to walk independently. A telephone interview on 4/27/2021 at 9:30 AM, with Resident #3's Physician, showed, .I was told about the elopement but don't know the details personally .he [Resident #3] wanted to go home from the beginning of his stay [2019] and we worked with him about the need to regain his health . A telephone interview on 4/27/2021 at 9:50 AM, with LPN #1, showed, .he told me he wanted to go check on his dogs .His friend told me when she found him on her porch .he was complaining of his left foot hurting .Just by going out of the nursing home at night he put himself into an unsafe area . A telephone interview with LPN #3 on 4/27/2021 at 10:25 AM, showed Resident #3 was ambulating on his own over the last month and had begun to ambulate without his walker, slow but steady. She said maintenance and the nursing home staff could not believe he [Resident #3] was able to get the fencing apart. During a telephone interview on 4/27/2021 at 11:30 AM, Resident #3 confirmed he had used the security code posted at the exit door to the courtyard, partially dismantled the fence, and left the faciity on [DATE]. He stated he was able to get to the courtyard .easy . Resident #3 confirmed he crossed one street and went to his lady friend's house. A telephone interview with RN #1 on 4/27/2021 at 1:00 PM, showed the temperature on 4/17/2021 was .about 47 degrees . and Resident #3 was wearing jeans, a short sleeve shirt, and flannel shirt when he returned from the ER. Interview with the DON on 4/29/2021 at 12:10 PM, in the conference room, confirmed facility staff did not follow the policy for a resident elopement when Resident #3 left the facility.[Facility staff] didn't call the Code White as soon as they knew the resident [Resident #3] wasn't in the immediate vicinity .The Command Center wasn't set up timely .the police weren't notified within 15 minutes . An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 4/29/2021 at 12:30 PM, and the corrective actions were validated on-site by the surveyors on 4/29/2021 through interviews, observations, and review of documents. The Removal Plan presented to the survey team documented the following immediate corrective actions implemented. Staff on duty were re-educated on the facility's Code White (elopement) policy on 4/18/2021. On 4/18/2021, the courtyard fencing was repaired by the engineering department. On 4/18/2021, the courtyard keypad code was changed by a member of the engineering department and staff were educated. On 4/18/2021, the signage posted with the courtyard keypad code was removed. Staff on duty 4/18/2021 were educated on the elopement policy and door code. Elopement drills, tabletop drills and education were conducted 4/19/2021-4/22/2021. 1. The surveyors' interview with the DON on 4/29/2021 at 12:10 PM, in the conference room, confirmed the re-education of the facility's elopement policy and procedures after the 4/17/2021 elopement. The re-education emphasized the timing of the procedures. The surveyors reviewed the employee sign-in sheets on the re-education. All staff had been educated on policy and procedures by 4/22/2021. 2. The surveyors' observation on 4/29/2021 at 12:30 PM, showed the security code was no longer posted at the exits leading out to the courtyard. The fence had been repaired with the bolts turned away from the courtyard. An additional 5 wire brackets were on the left side to secure the end of fencing to a metal pole and 3 additional wire brackets placed to secure the top of the fence. 3. The surveyors' observation on 4/29/2021 at 12:30 PM, showed all the nursing home staff wore a badge buddy under their name tags, with the security codes for each of the exits. No codes were posted at the exits of the facility. 4. The facility conducted a virtual QAPI (Quality Assessment Performance Improvement) committee meeting on 4/18/2021 to address the elopement and completed a root cause analysis. 5. The surveyors interviewed the Maintenance person who confirmed he found the breach in the courtyard fencing, repaired it, and made an immediate change to the security code. 6. The surveyors' interviews of 3 LPNs and 5 CNAs on 4/29/2021, confirmed they received education on the Code White (elopement) policy. Review of attendance sheets confirmed all staff had received re-education and attended elopement drills by 4/22/2021. 7. During tours of the facility on 4/29/2021, the staff were all noted to be wearing their badge buddies under each one's name badge. Tours showed the courtyard fencing secured with the repairs done. The surveyors' interview with RN #1 confirmed he had removed the posted security codes by 8:00 AM on 4/18/2021. 8. On 4/19/2021, Elopement Risk Assessments were completed for 100% of the residents by the Nurse Managers and no residents were identified as high risk for elopement. 9. The surveyors reviewed the daily QA meetings and confirmed daily QA meetings concerning elopement were being done by the DON and Administrator. Noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on medical record review, observation and interview the facility failed to attempt a Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications for 1 resident (#14), and failed to provide a rationale for the continued use of an as needed (PRN) antianxiety and antipsychotic medication beyond 14 days for 1 resident (#40) of 5 residents reviewed for unnecessary medications. The findings include: Review of the medical record showed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 received antidepressant medications on all 7 days of the assessment look back period. Review of the Physician Recapitulation Orders for 1/1/2020 - 1/31/2020, showed [MEDICATION NAME] (antidepressant) 30 milligrams (mg) by mouth twice daily with an order date of 2/7/2018 and [MEDICATION NAME] (antidepressant) 50 mg 1and ½ tablets by mouth daily with an order date of 2/11/2019. Observation of the resident on 1/22/2020 at 10:16 AM, Resident #14 was seated outside of the beauty shop interacting with staff with no behaviors. During an interview on 1/23/2020 at 11:50 AM, the Director of Nursing (DON) confirmed that a GDR had not been attempted for [MEDICATION NAME] or [MEDICATION NAME] since the medications were first prescribed. Review of the medical record showed Resident #40 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] showed Resident #40 scored a 6 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The resident had no moods or behaviors and the resident received antianxiety, antidepressant and opioid medications. Review of the hospital Discharge Medication List dated 1/1/2020 showed [MEDICATION NAME] 0.5 mg (antianxiety medication) every 8 hours PRN with no stop date and [MEDICATION NAME] disintegrating tablet (antipsychotic medication) 5 mg every 6 hours PRN with no stop date. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Observation of Resident #40 on 1/22/2020 at 3:25 PM and 1/23/2020 at 8:40 AM revealed the resident lying in his bed with no behaviors exhibited. During an interview on 1/23/2020 at 11:50 AM, the DON confirmed the PRN [MEDICATION NAME] and the PRN [MEDICATION NAME] did not have a discontinue date or end date ordered and the medications continued beyond the 14 day time frame.

Based on facility policy review, medical record review, observation, and interview the facility failed to ensure nutritional interventions were implemented timely for 2 residents (#122, #7) of 3 residents reviewed for weight loss, of 26 sampled residents. This failure resulted in Harm to Resident #122. The findings included: Review of the facility policy for Unintended Weight Loss Protocol dated 9/25/15 revealed .Nursing services will weigh resident's .The dietitian reviews these weights and, in the event of an unintended weight loss (5% in one month), the resident will be reviewed and assessed with [REDACTED]. Medical record review revealed Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physician's admission orders [REDACTED].Weigh new residents weekly x 4, then monthly .11/19/15, 11/26/15, 12/3/15, 12/10/15 . Medical record review revealed the resident's weight was 81 pounds on admission and no further weights had been completed since admission. Medical record review of the Nutritional assessment Data Collection effective date 11/25/2015, revealed Resident #122 had a Body Mass Index (BMI) of below 18.5, indicating the resident was underweight. Continued review revealed an ideal body weight range of 94-116 pounds, with a usual body weight of 80 pounds, and an admission weight of 81 pounds. Continued review revealed the RD recommended .providing res (resident) w (with) Ensure TID (3 times per day) to increase caloric/protein intake in diet. res @ (at) high nutr (nutritional) risk . Interview with the Minimum Data Set (MDS) Coordinator and the Registered Dietitian (RD) on 12/1/15 at 3:32 PM, at the 200 north hall nurse's station, confirmed the 11/19/15 and 11/26/15 weights had not been obtained. Continued interview with the RD revealed the RD assessment was completed on 11/25/15, (13 days after admission), and the RD had recommended a nutritional supplement 3 times per day. Continued interview confirmed Resident #122 had not received the RD recommended supplement. Interview with the MDS Coordinator on 12/2/15 at 7:52 AM, at the 200 north hall nurse's station, confirmed the resident was weighed on 12/1/15, twelve days after 11/19/15, when the first weekly weight was to be obtained. Continued interview revealed the resident's weight was 75 pounds, a 7.4% weight loss. Interview with the Director of Nursing (DON) on 12/2/15 at 1:22 PM, in the DON office, confirmed the facility failed to ensure the physician ordered weekly weights had been acted upon timely, failed to provide Resident #122 with the nutritional supplement as recommended by the RD until 12/2/15, and failed to ensure the policy for Unintended Weight Loss was followed, resulting in a 7.4% weight loss and Harm to Resident #122. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance of 2 persons for bed mobility and transfers. Continued review of the MDS revealed the resident scored 3 out of 15 on the Brief Interview for Mental Status indicating severe cognitive impairment. Medical record review of the Monthly Weight Report revealed Resident #7 weighed 125 pounds on 10/1/15, and 117.8 pounds on 11/2/15, a difference of 5.8% weight loss in a 30 day period. Review of the Case Conference minutes dated week of 11/9 -11/13 (2015) provided by the Assistant Director of Nurses (ADON) revealed, the resident had been reviewed during the weekly Case Conference meeting for significant weight loss, and RD #2 had documented .Eating 25-50%; Recommend Ensure pudding BID (2 times daily) . Interview with RD #2 (with the DON and ADON present) on 12/02/15 at 1:16 PM, in the DON's office confirmed Resident #7 had a significant weight loss during a one month period. Continued interview confirmed the recommendation for Ensure pudding BID had been received during the weekly Case Conference meeting (11/9-11/13), and the recommendation had not been implemented until 12/1/15. Continued interview confirmed the facility failed to provide Resident #7 with the nutritional supplement as recommended by the RD.

Based on medical record review and interview, the facility failed to ensure Physician order [REDACTED].#122) of 3 residents reviewed for weight loss, of 26 sampled residents. The findings included: Medical record review revealed resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians admission orders [REDACTED].Weigh new residents weekly x4, then monthly .11/19/15, 11/26/15, 12/3/15, 12/10/15 . Interview and medical record review with the Minimum Data Set (MDS) Coordinator and the Registered Dietician (RD) on 12/1/15, at 3:32 PM, revealed the 11/19/15 and 11/26/15 weights had not been completed. Continued interview with the RD revealed the RD assessment had been completed on 11/25/15 and the 11/19/15 and 11/26/15 weights had not been completed. Interview with the MDS Coordinator on 12/2/15 at 7:52 AM, at the 200 north hall nurse's station, confirmed Resident #122 was weighed on 12/1/15, 12 days after 11/19/15, and 5 days after 11/26/15. Interview revealed the Resident #122's weight was 75 pounds, a 7.4% weight loss. Interview with the Director of Nursing (DON) on 12/2/15 at 1:22 PM confirmed Resident #122's physician's orders [REDACTED].#122. Refer to F325

Based on medical record review, observation, and interview, the facility failed to maintain hydration resulting in admission to the hospital with [DIAGNOSES REDACTED].#85) of twenty-seven residents reviewed. The findings included: Resident #85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation on September 29, 2014, at 11:30 a.m., revealed the resident sleeping in bed. Observation on September 30, 2014, at 8:15 a.m., revealed the resident remained asleep in the bed as residents were served breakfast trays. Interview with Licensed Practical Nurse (LPN #3), at the time of the observation confirmed the resident required full assistance to be fed and had not yet been served breakfast. Medical record review of the Monthly Summary dated July 29, 2014, revealed, "Mental Status: Alert...Confused...Wanders...Eating Habits: Fair Appetite...Feeds Self..." Medical record review of the Monthly Summary dated August 31, 2014, revealed, "...lies in bed...withdrawn...doesn't respond well...medications: [REDACTED] Medical record review of the nursing notes revealed the following: August 31, 2014, at 1:05 a.m., "...Very lethargic. Responds when moved or turned. Will not respond when spoken to...R.N. (Registered Nurse) notified." August 31, 2014, at 10:36 a.m., "...Holding everything in...mouth. Does not follow commands." August 31, 2014, at 6:15 p.m., revealed, "v.s. (vital signs) 102.8 (temperature) - 80 (pulse) - 22 (respirations) - 124/62 (blood pressure)...Dr. (name) notified...new orders...1 liter NS (normal saline) at 75 ml (milliliters) per hour..." September 2, 2014, at 10:00 a.m., revealed, "Resident is total care." September 3, 2014, at 8:45 a.m., "Gave Tylenol gr (grains) X (ten) for increased temp. to 100.5 ax. (axillary)." September 4, 2014, at 12:12 a.m., revealed, "Finished ABT (antibiotic) therapy...Continues to be very lethargic." September 7, 2014, at 9:00 p.m., revealed, "Resident had temp 102.4...Resident said...didn't feel good." September 8, 2014, at 10:38 a.m., revealed, "...Cont (continues) to be lethargic." September 8, 2014, at 11:00 a.m., revealed, "Faxed MD (physician) concerning resident...continues with temp and still won't eat..." Medical record review of the Intake Record for August 2014 revealed the resident's Total Intake for a twenty-four hour period was 240 ml (milliliters) or equal to one cup of fluid on August 30 and 0 intake on August 31, 2014. Medical record review of the Intake Record for September 2014 revealed the following Total Intake for each twenty-four hour period: September 5 - 540 ml, equal to two and one fourth cups; September 6 - 480 ml, equal to two cups; September 7 - 180 ml, equal to three-fourths of one cup; and September 8 - 60 ml, equal to one-fourth of one cup. Medical record review of the medication administration records for August through September 7, 2014, revealed [MEDICATION NAME], a diuretic (water pill), was given to the resident each morning. Interview with the Minimum Data Set (MDS) Coordinator, in the conference room on October 1, 2014, at 9:10 a.m., confirmed the resident had a marked decline in the months of August and September 2014. Interview confirmed the resident was treated for [REDACTED]. Continued interview confirmed Speech Therapy evaluated the resident on August 11, 2014, and treated the resident at three meals each week due to problems with pocketing and swallowing food. Further interview confirmed the following: The Physician was not contacted on August 30, 2014, when the intake equaled one cup of fluid; The Nurses Note dated August 31, 2014, at 8:45 p.m., recorded the initiation of one liter of Normal Saline to infuse intravenous (IV), when the resident had no intake of fluids, however, review of the medical record revealed no record of the total amount of I.V. fluids administered; The Physician was not contacted on September 5, 6, or 7, 2014, when the oral intake decreased each day, from 540 ml, to 480 ml, and 180 ml and; The diuretic medication [MEDICATION NAME] continued to be administered during and after the resident received IV fluids for dehydration from August 31 - September 1, 2014. During interview, the MDS Coordinator stated, "The nurses needed to contact the doctor and ask if the [MEDICATION NAME] should be continued." Interview with the Assistant Director of Nursing, in the conference room on October 1, 2014, at 1:55 p.m., confirmed the Physician "should have been contacted about continuing the diuretic" when it became difficult to maintain adequate fluid intake. Medical record review of the hospital physician's History and Physical dated September 9, 2014, revealed, "...In the ER (emergency room ) the patient was found to be severely dehydrated with [MEDICAL CONDITION] and pneumonia...having difficulty swallowing...Impression: 1. Left lower lobe pneumonia, probably aspiration. 2. Acute on [MEDICAL CONDITION]. 3. Volume Depletion...7. [MEDICAL CONDITION] with Severe Electrolyte Abnormality..." Interview by telephone with the resident's attending physician on October 2, 2014, at 2:30 p.m., confirmed the facility's failure to stop the administration of the diuretic contributed to the severe Dehydration and Electrolyte Abnormality, stating, "It should have been held."

Based on medical record review and interview, the facility failed to remove an indwelling catheter resulting in a Urinary Tract Infection requiring antibiotic injections (Harm) for one resident (#85) and failed to complete a bladder re-assessment and develop an individualized toileting plan for one resident (#84) of twenty-seven residents reviewed. The findings included: Resident #85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a urinalysis completed in the hospital emergency roiagnom on [DATE], revealed the urine was negative for [MEDICATION NAME] and leukocytes and a culture was not ordered. Interview with the Assistant Director of Nursing in the conference room on October 1, 2014, at 10:35 a.m., confirmed when a urinalysis did not indicate the presence of an infection, for example negative for [MEDICATION NAME] and leukocytes, the laboratory did not culture the urine. Medical record review of the Physician's admission orders [REDACTED] Medical record review of a nursing note dated September 17, 2014, at 8:00 p.m., (the date the resident had been readmitted from the hospital) revealed, "...bladder training to begin...9 AM and written guidelines/schedule placed in room..." Medical record review of the nursing notes revealed the bladder training was ongoing September 18, 19, and 20, 2014. Further review revealed no record of bladder training or notations concerning the indwelling urinary catheter until September 23, 2014, when a urine specimen was obtained. Medical record review of a nursing note dated September 25, 2014, revealed, "Foley catheter removed..." Medical record review of a urine culture completed September 25, 2014, obtained from the indwelling catheter on September 23, 2014, revealed the bacteria identified as [MEDICATION NAME] Cloacae and sensitive to [MEDICATION NAME] (an antibiotic known to be toxic to the kidneys). Medical record review of a physician's orders [REDACTED]. Medical record review of a physician's orders [REDACTED]." Interview with the Minimum Data Set (MDS) Coordinator, in the conference room on October 1, 2014, at 9:10 a.m., confirmed the resident had a marked decline in the months of August and September 2014. Continued interview confirmed the resident did not have a history of an indwelling urinary catheter and confirmed the resident was treated for [REDACTED]. Further interview withe MDS Coordinator confirmed the bladder training had begun on September 18, 2014, continued September 19 and 20, 2014, without any further mention of the training after September 20, 2014. Interview confirmed the catheter was removed five days later on September 25, 2014. Continued interview revealed the MDS Coordinator had been able to locate the schedule for bladder training mentioned in the September 17, 2014, nursing note. Further interview revealed the MDS Coordinator had brought a blank form "Schedule For Bladder Training Residents With Indwelling Catheters." Interview, as the bladder training schedule was reviewed, confirmed the bladder training schedule was ongoing for three days, followed by removal of the catheter. Interview confirmed the resident's catheter was not removed for five days after the bladder training period was scheduled to end resulting in a UTI requiring antibiotic injections (Harm). Interview by telephone with the resident's attending physician on October 1, 2014, at 2:30 p.m., confirmed the presence of an indwelling urinary catheter increased the likelihood of the Urinary Tract Infection and the physician stated, "That is why the admission order is there for bladder training and removal of the catheter." Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed resident always continent of bladder. Continued medical record review of a Quarterly MDS dated [DATE], revealed resident occasionally incontinent of bladder. Interview with the Director of Nursing (DON) on October 1, 2014, at 9:48 a.m., in the conference room confirmed the facility had failed to attempt a bladder program after a decline in bladder function.