Every finding on record at The Inn at Freedom Village

Based on interview and record review, the facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 3 of 12 residents (Resident #11, #47, and #48), reviewed for nursing professional standards of practice.Findings:Resident #11 (R11)Review of an admission Record revealed R11 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R11's Order Summary dated 2/16/26 revealed, cloNIDine HCl Oral Tablet 0.1 MG Give 1 tablet by mouth three times a day.HOLD IF SBP (systolic blood pressure [top number]) LESS THAN 110. To be administered at 8:00 AM, 2:00 PM, and 8:00 PM.Review of R11's Blood Pressure Summary revealed:On 2/17/26 R11's Blood Pressure (BP) was assessed at 7:22 AM with a result of 152/77. R11's BP was not assessed again prior to the 2:00 PM clonidine administration.On 2/25/26 R11's BP was assessed at 7:35 AM with a result of 157/75. R11's BP was not assessed again prior to the 2:00 PM clonidine administration.During an interview on 03/03/2026 at 7:40 AM, Registered Nurse (RN) F reported that vital signs are to be assessed prior to the administration of a medication when parameters are ordered.Review of R11's February Medication Administration Record revealed:On 2/17/26 R11's BP assessment from 7:22 AM was documented for the 2:00 PM clonidine administration and the clonidine was administered.On 2/25/26 R11's BP assessment from 7:35 AM was documented for the 2:00 PM clonidine administration and the clonidine was administered.Review of R11's Order Summary dated 2/14/26 revealed, Daily Weight- notify med staff of 2 lb (pound) weight gain in 24 hrs (hours) and/or 5 lb weight gain in 1 week.Review of R11's Weight Summary revealed that on 2/17/26 R11's weight was 144.6 lbs. On 2/18/26 R11's weight was 148.4. The physician was not notified of the weight gain of approximately 4lbs.Review of R11's Electronic Medical Record revealed no documentation for the lack of blood pressure assessments prior to the medication administration or documentation that the provider was notified of the weight gain from 2/17/26 to 2/18/26.Resident #47 (R47)Review of an admission Record revealed R47 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R47's Order Summary dated 2/18/26 revealed, Daily Weight- notify med staff of 2 lb weight gain in 24 hrs and/or 5 lb weight gain in 1 week.Review of R47's Weight Summary and February Treatment Administration Record revealed:On 2/21/26 R47's weight was 143.3 lbs. On 2/22/26 R47's weight was 151 lbs. The physician was not notified of the weight gain of approximately 7.5lbs.On 2/27/26 R47's weight was 145.4 lbs. On 2/28/26 R47's weight was 149 lbs. The physician was not notified of the weight gain of approximately 3.5lbs.Resident #48 (R48)Review of an admission Record revealed R48 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: congestive heart failure.Review of R48's Order Summary dated 2/21/26 revealed, Daily Weight- notify med staff of 2 lb weight gain in 24 hrs and/or 5 lb weight gain in 1 week.Review of R48's Weight Summary and February Treatment Administration Record revealed:On 2/25/26 R48's weight was 163.2 lbs. On 2/26/26 R48's weight was 167.2 lbs. The physician was not notified of the weight gain of approximately 4 lbs.During an interview on 03/03/2026 at 11:20 AM, The Director of Nursing (DON) confirmed R11's blood pressure was not reassessed prior to the clonidine administration. The DON confirmed the physician was not notified of R11, R47, and R48's weight increase of greater than 2 lbs in 24 hours. The DON reported that it is the expectation for the nurses to follow the physician orders for notification of weight gain and to assess vitals prior to the administration of medications if indicated. Review of the facility policy Administering Medication last revised January 2026 revealed, .4. Medications are administered in accordance with prescriber orders .11.The following information is checked/verified for each resident prior to administering medications .b. Vital signs, if necessary .Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost.Weigh patients with heart failure daily. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1059). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the failed to maintain the kitchen/facilities equipment and fixtures in proper working order potentially affecting all residents that receive food from the kitchen. Findings include: The following observations were observed on 01/28/25 from 9:15 AM to 10:25 AM, during the initial tour of the kitchen/facility with Dining Manager (DM) A and Kitchen Supervisor (KS) B. Observation of the paper towel dispenser located above the hand sink (on the wall closest to the hood system) was out of paper towels. Review of the FDA 2017 Food Code Section, 6-301.12 Hand Drying Provision. Reflects the following, Each HANDWASHING SINK or group of adjacent HANDWASHING SINKS shall be provided with: (A.) Individual, disposable towels; . Observation of the inside of the True Refrigerator Unit revealed a build-up of food residue, debris and grime on the sides, bottom, and door seal. Review of the FDA 2017 Food Code Section, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. Reflects the following, . (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Observation of the large 2 Door [NAME] Cooler was found to be out of order. The unit is needed for cold holding food storage and ensuring safe food service operations. During the observation DM A and KS B revealed that the cooler had quit working a couple of weeks ago and were waiting to see if the facility was going to repair or replace the unit. Review of the FDA 2017 Food Code Section, 4-501.11 Good Repair and Proper Adjustment. Reflects the following, (A) Equipment shall be maintained in a state of repair and condition that meets the requirements under 4-1 and 4-2. Review of the FDA 2017 Food Code Section, 4-301.11 Cooling, Heating, and Holding Capacities. Reflects the following, EQUIPMENT for cooling and heating FOOD, and holding cold and hot FOOD, shall be sufficient in number and capacity to provide FOOD temperatures as specified under Chapter 3. Observation of the hand sink located the in the dish washing area needed to be recalked/resealed to the wall. Review of the FDA 2017 Food Code Section, 4-402.11 Fixed Equipment, Spacing or Sealing. Reflects the following, (A) Equipment that is fixed because it is not EASILY MOVEABLE shall be installed so that it is: . (3) SEALED to adjoining EQUIPMENT or walls, if the EQUIPMENT is exposed to spillage or seepage. Observation of the 3 Compartment Sink Area revealed the nozzle of the spray arm was submerged in the first sinks basin that contained soiled soaking dishes. Further observation of the area revealed that the plumbing fixture the spray arm was attached to (including the water lines, pipes, the hot and cold-water handles) were no longer attached to the wall, sink, or plumbing. The disconnected plumbing fixture was resting on drain board to the left of the soiled dish sinks basin. Review of the FDA 2017 Food Code Section, 5-205.15 System Maintained in Good Repair Reflects the following, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Observation of the dish machine area revealed hot water was continuously leaking from the hot water handle for the spray arm fixture. The hose on the spray arm was worn/stretched-out an allowed the spray arms nozzle to be just above the flood rim of the spray basin. Resulting in the potential that the nozzle on the spray arm could easily become submerged in any pots and pans were being stored below the spray arm, causing a potential back-siphonage concern with the fresh water supply line. Review of the FDA 2017 Food Code Section, 5-205.15 System Maintained in Good Repair Reflects the following, A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Review of the FDA 2017 Food Code Section, 5-202.13 Backflow Prevention, Air Gap. Reflects the following, an air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Observation of the Walk In Freezer revealed the flooring was buckling up and down along the seams and would move while walking on them. Review of the FDA 2017 Food Code Section, 6-501.11 Repairing. Reflects the following, PHYSICAL FACILITIES shall be maintained in good repair. Observation of the door leading to the dumpster area reflected a large gap along the bottom of the door and the flooring. Review of the FDA 2017 Food Code Section, 6-202.15 Outer Openings, Protected. Reflects the following, (A) Except as specified in paragraph (B), (C), and (E) and under paragraph (D) of this section, outer openings of FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors.

Based on interview and record review, the facility failed to document vital signs before witholding a medication with parameters ordered for 1 resident (Resident #83) out of 12 residents reviewed for professional standards. Findings: Resident #83 (R83) Review of an Admission Record indicates R83 admitted to the facility with diagnoses that included hypertensive (high blood pressure) chronic kidney disease, supraventricular tachycardia (an irregular heart rhythm), and nonrheumatic mitral valve insufficiency (a condition affecting blood flow in the heart). Review of the January 2025 Medication Administration Record (MAR) reflected an order for Midodrine HCl Oral Tablet 5 MG (milligram) Give 2 tablets by mouth two times a day for low blood pressures Hold if SBP (systolic blood pressure) is more than >140 -Start Date- 01/28/2025 0800 (8:00 AM). The document reflected R83 did NOT receive a dose of the prescribed medication on 1/28/25 at 8:00 AM or 5:00 PM as evidenced by a 4 in the dose record which indicates Vital sign out of parameter. Review of all Progress Notes dated 1/28/25 did not reflect a record of blood pressures that exceeded the parameter set by the prescribing physician. Review of a Blood Pressure Summary reflected that on 1/28/2025 at 5:54 AM, R83's blood pressure was 133/72 mmHg (millimeters of column mercury, a unit of pressure measurement). No other blood pressure readings were documented on this day. During an interview on 1/30/2025 at 9:53 AM, the Director of Nursing (DON) reviewed the clinical record and said the blood pressure recorded in the morning of 1/28/2025 would have indicated the Midodrine could have been given as ordered. The DON reported that it is the professional standard that a vital sign should be recorded in the clinical record when there are parameters set by the physician. Review of the Fundamentals of Nursing revealed, The health care provider is responsible to provide accurate, complete, and understandable medication orders .also responsible for documenting any preassessment data required of certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. For example, errors in documentation about insulin often result in negative patient outcomes. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 609). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to implement its Hot Liquid Protocol for one resident (Resident #85) at risk for injury from hot liquids, out of 2 residents reviewed for accidents. Findings: Resident #85 (R85) Review of an Admission Record reflected R85 admitted to the facility from a hospital for rehabilitation. Review of a Hot Liquid Safety Data Collection dated 1/27/2025 reflected R85 had observed tremors in upper extremities and weakness/paresis in upper extremities which placed R85 at risk for hot liquid injuries. Review of a Care Plan initiated on 1/27/2025 indicated R85 was at risk for hot liquid injury. Interventions identified to prevent hot liquid injuries included Assist resident with hot liquids; (R85) to use cup with lid; (R85) to use splint for wrist stability; (R85) to wear clothing/lap protector; Encourage resident to drink hot liquids while sitting at the table. During an observation on 1/28/2025 at 1:52 PM, R85 was given a cup of coffee by a dietary aide. R85 had removed the lid and was drinking the coffee with a straw while in bed. R85 did not have a clothing protector in place and was not wearing a splint on his wrist for stability. Review of a dietary menu reflected R85 was to follow the Hot Liquid Protocol. Review of the Safety of Hot Liquids policy last revised 10/2014 reflected Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change of condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. During an interview on 1/30/2025 at 9:27 AM, the Director of Nursing (DON) reported that it is her expectation that all staff follow the care plan and hot liquid protocol.

Based on interview and record review, the facility failed to perform a facility-wide assessment to identify and determine the necessary resources to provide competent care for its residents, resulting in inadequate knowledge of the facility population and inadequate resources to care for residents and unmet care needs potentially affecting all 19 residents of the facility. Findings include: During the Entrance Conference interview conducted at the start of the annual recertification survey on 2/20/24 at 9:27 a.m., Information Needed from Facility Within Four Hours of Entrance was reviewed and included a request for the Facility Assessment. The facility assessment was not provided to the survey team prior to the end of the first day of the survey. The Nursing Home Administrator (NHA) submitted a facility assessment for review on 2/21/24 at 9:30 AM. The Facility Assessment Tool was dated 2/21/24 and had not been reviewed by the QAPI (Quality Assurance Process Improvement) committee for approval. Any record of a previous Facility Assessment was requested from the staff member E on 2/21/23 at 10:23 AM. Review of a Community Functional Assessment Binder reflected a facility assessment was last reviewed and updated on 11/5/2021. The assessment details did not reflect the current NHA or Director of Nursing (DON) and the average daily census was 10 (ten) residents. During a telephone interview on 2/21/24 at 2:10 PM, the NHA reported that she did not know she had to complete an annual facility assessment or update a facility assessment when necessary, and had not completed one since she started working at the facility. Review of Administration details in the ASPEN Central Office (ACO) database reflected the current NHA had been in place at the facility since 1/26/2022.

Based on interview and record review, the facility failed to implement an effective and current system of surveillance of staff and resident illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected. Findings: On 2/20/24 at 2:35 PM the last 3 months of infection surveillance/tracking for staff and residents was requested. Review of the resident illness tracking revealed a spreadsheet of residents that were prescribed antibiotics. There was a line list for residents that had tested positive for COVID. There was no other illness tracking for residents not prescribed antibiotics but had symptoms of infection (respiratory, integumentary, gastrointestinal, genitourinary, etc.) Review of the documentation received regarding employee illness tracking revealed Call-In Sheets and a line list for employees that had tested positive for COVID. The Call-In Sheets were not all thoroughly completed. During an interview on 2/21/24 at 11:00 AM, Director of Nursing (DON) and Clinical Support Nurse (CSN) F reported DON was the Infection Control Preventionist for the facility. DON reported that only residents that were ordered antibiotics were placed on the tracking tool. DON confirmed that the only other illness for staff and residents that was tracked/trended was COVID. DON reported that when an employee called off of work the Call-In Sheet would be completed by the staff member taking the call and would then be submitted to the scheduler. DON did not receive a copy of the slip and did not follow up with the employee to ensure they were symptom free with a date the employee could safely return to work (without exposing other residents and staff members to communicable disease and/or infection). DON confirmed that early identification of an outbreak and the prevention of the spread of an outbreak would require not only resident infections to be tracked but also employee illness. Employee illness tracking would require information such as the department worked, symptoms, symptom onset, testing if applicable, return to work date, etc. Review of the facility Infection Control Program revealed no policies and/or procedures for employee illness tracking/surveillance. Following the interview with DON and CSN F a policy for employee illness tracking/surveillance was requested. On 2/21/24 at 12:27 PM a copy of the Employee Health Program and Illness policy were received. Review of the facility policy Employee Health Program last revised January 2012 and the Illness policy last revised January 2008 did not contain an employee illness surveillance/tracking procedure. Review of the Facility Assessment Tool dated 11/5/21 did not include a system for surveillance for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents and staff. Review of the Facility Assessment Tool dated 2/21/24 (to be reviewed and/or adopted by the Quality Assessment and Performance Improvement in March 2024) revealed, 3.11 The infection prevention and control program at The Inn at Freedom Village [NAME] applies effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. Policies and Procedures follow accepted national standards. Education occurs one-to-one, through staff huddles, in-services, and monthly meetings. Infection surveillance is kept through tracking, reporting, and managing infections, as evaluated by McGreers criteria. Staff surveillance on appropriate infection control measures is closely monitored for compliance and further education needs. Through the antibiotic stewardship program, we apply protocols for monitoring to prevent antibiotic resistance and C-diff. Infection trends are reported at monthly QAPI meetings. For policies and procedures specific to COVID-19, refer to these binders. Review of the State Operations Manual revealed the facility Establishes facility-wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases and infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable disease or infections.

Based on interview and record review, the facility failed follow professional standards of nursing practice for medication administration for 1 resident (Resident #226) out of 8 residents reviewed, resulting in a medication error (incorrect dose of medication administered). Findings: Resident #226 (R226) Review of an Admission Record revealed R226 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: polyneuropathy (nerve pain). Review of R226's Order Summary revealed: *Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth in the morning related to POLYNEUROPATHY (start date 2/10/24). *Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth at bedtime related to POLYNEUROPATHY (start date 2/11/24). Review of R226's Controlled Substances Proof of Use form for the evening gabapentin (600mg) administration revealed that on 2/12/24 the gabapentin was not signed out/administered but was documented as administered in the electronic Medication Administration Record. Review of R226's Controlled Substances Proof of Use form for the morning gabapentin (300mg) administration revealed that on 2/12/24 at 11:15 PM, 1 capsule of gabapentin 300mg was administered to R226 (indicated by the licensed nurse's signature.) During an interview on 2/21/24 at 7:30 AM, Registered Nurse (RN) A reported that when administering controlled medications/narcotics, the Controlled Substance Proof of Use form should be compared to the order summary/electronic Medication Administration Record to confirm the correct dose/time prior to the administration of the controlled medication. RN A reported that R226 had recently had multiple medication changes to control his pain. RN A reported that it was important to ensure that R226's morning dose of gabapentin and/or evening dose of gabapentin was obtained from the correct blister pack to avoid a medication error. During an interview on 2/21/24 at 1:11 PM, Director of Nursing (DON) confirmed the medication error for R226. DON reported that on the evening of 2/12/24, R226 received the morning dose of gabapentin (300mg) and not the evening dose of gabapentin (600mg) due to the facility nurse obtaining the gabapentin from the incorrect blister pack (contains medication) and R226 was underdosed. DON reported that all staff would be educated on properly administering medications. Review of Fundamentals of Nursing ([NAME] and [NAME]) 10th edition revealed, The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 672). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview and record review, the facility failed to provide food served at a palatable temperature for 3 of 19 residents (Resident #10, #14 and #225) reviewed for dining, resulting in dissatisfaction with the food served and the potential for decreased intake and weight loss. Findings Include: During an interview with Dietary Aide G, at 11:55 AM on 2/20/24, it was found that staff prefer hot food on the steam table be 140F or higher, preferably in the 160's. At 12:22 PM on 2/20/24, a test tray was plated and placed on the expediting cart as the last tray out. The surveyor followed the cart and waited for all eight resident trays to be passed out before heading to the conference room. At 12:35 PM on 2/20/24 the following temperatures were taken with a rapid read digital thermometer: Patty melt was 149F and Fries 115F. 29073 Resident #10 (R10) Review of an Admission Record reflected R10 admitted to the facility on [DATE] with diagnoses that included a muscle weakness and gastro-esophageal reflux disease without esophagitis (GERD). Review of an annual Minimum Data Set (MDS) assessment dated [DATE] reflected R10 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15/15. During an interview on 2/20/24 at 11:00 AM, R10 reported that she took her meals in her room and the hot food selections were not very warm. R10 also reported that the meat selections were not very tender and she would often order chicken rather than beef or pork because of this. 39056 Resident #225 (R225) Review of an Admission Record revealed R225 was an [AGE] year-old male, originally admitted to the facility on [DATE]. R225 was his own responsible party/decision maker (cognitively intact) and able to make needs known. During an interview on 02/20/24 at 10:11 AM, R225 reported that the meals served to the residents were cold, all of them (breakfast, lunch, and dinner). Resident #14 (R14) Review of an Admission Record revealed R14 was a [AGE] year-old female, originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for R14, with a reference date of 12/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R14 was cognitively intact. During an interview on 02/20/24 at 09:51 AM, R14 reported that the meals served to the residents were cold, not even warm, just cold. On 2/21/2024 at 7:10 AM, a test tray for the lunch service was requested from Dietary Aide (DA) G. On 2/21/24 at 12:41 PM, DA G delivered a test tray to the conference room. DA G said the tray was plated at 12:31 PM. DA was told a surveyor was looking for the test tray along with the resident meals on the unit. DA G reported she did not want to make the surveyor wait for all the trays to be delivered on the unit and brought the test tray directly to the survey team, contrary to the survey process of obtaining a test tray once the last resident meal was served. During an observation on 2/21/24 at 12:48 PM, a surveyor was on the unit looking for the test tray that had been requested. No test tray was on the expediting cart (a metal rack that was not covered or insulated and held resident meal trays). The last tray was taken from the cart at this time and the surveyor requested a meal be prepared for the resident who was last to be served. During an observation on 2/21/24 at 12:50 PM, the temperature of the resident meal of 2 soft shell tortillas filled with seasoned ground beef was measured with an instant read thermometer. The internal temperature of the ground beef mixture was 108F. The tortilla was cool to touch and not warm when tasted. During an observation on 2/21/24 at 12:50 PM, the temperature of the test tray brought directly to the conference room by DAG was tested . The temperature of the shrimp enchilada was 155F. The temperature of the soup served with the meal was 160F. During an interview on 2/21/24 at 12:51 PM, Dietary Manager (DM) H reported the difference between the resident meal and the test tray was significant. DM H was informed at this time the food served to the residents was cold.

Based on interview and record review, the facility failed to treat 1 of 3 residents (R1) with respect and dignity and care for the resident in a manner that promotes maintenance or enhancement of his or her quality of life, resulting in R1 being treated in a disrespectful and undignified manner that caused embarrassment, fear, and/or emotional distress. Findings include: A review off the facility's Resident Rights policy, revised December 2016, revealed, Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation . e. self-determination . A review of R1's Admission Record, dated 8/9/23, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R1's Admission Record revealed multiple diagnoses that included a right femur (leg bone) fracture, a history of falling, difficulty walking, generalized muscle weakness, right hip pain, and left hip pain. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/4/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed she was cognitively intact. A review of the facility's self-reported Intake Information, dated 8/4/23, revealed on 7/30/23 at 5:10 AM, R1 pushed the call light to use the restroom. After several attempts to get R1 out of bed, R1 requested to use the bedpan because she was feeling too weak to stand. Instead of getting R1 the bedpan to use, the staff member (a certified nursing assistant) told her she could wet herself in her brief and then she could be changed. A review of R1's Nurse Practitioner note, dated 7/31/23, revealed R1 has been painful and not wanting to get up to use the bathroom, instead using bed pan. A review of the facility's investigative documentation revealed the following: - Certified Nursing Assistant (CNA) B's written statement, dated 7/30/23, revealed she answered R1's call light and R1 requested to use the bathroom. CNA B stated at about that time she heard yelling in the common area and asked R1 if she could wait while she went to see what the yelling was about. R1 told her that was fine. CNA B stated when she went into the hallway, she saw CNA A and asked him to help R1 while she assisted the nurse [with whoever was yelling]. CNA B stated a short time later, CNA A told her he gave R1 three times to stand up without his help. She stated CNA A told her after three unsuccessful tries for R1 to stand up on her own, he told R1 then you can just pee in your brief and then he left her room. - Registered Nurse (RN) C's written statement, dated 7/30/23, revealed at 5:10 AM, he and a female CNA went to R1's room to check on her. R1 told him that a male [CNA] had left her in bed, would not let her use a bed pan, and told her to just pee your pants. RN C stated he assured R1 she could always use a bed pan, if needed. He then assured R1 that the male CNA would not take care of her again and R1 was thankful. RN C stated both he and the female CNA then changed R1's brief and he reassured her again that the male CNA would not take care of her again. RN C asked R1 if she felt safe and she said she did as long as the male CNA did not come back into her room. After the brief change, RN C called the house supervisor and reported R1's allegation to her. RN C stated when the house supervisor came to talk to R1, he (RN C) was also present. He stated R1 told the house supervisor that the male CNA had said, If you can't get up you will have to wet [your]self. R1 told the house supervisor and RN C that the male aide did not offer her the bed pan. R1 told them after this happened she was scared to call and just laid in bed. RN C stated he and the house supervisor then reassured R1 that she could use the bed pan, if she needed, and that she was safe. RN C stated 10 minutes later, R1 called to use the bed pan and he and a female CNA assisted her. - Registered Nurse House Supervisor (RNHS) E's written statement, dated 7/30/23, revealed she received a call from RN C at 5:10 AM regarding an allegation of possible neglect for R1. She stated she spoke with R1 and R1 told her that a male aide was helping her to go to the bathroom. R1 told her when she could not get up, the male aide told her to just wet herself in the bed. At this point, R1 started crying and stated she had held it all night. RNHS E asked R1 if the aide had offered her a bed pan. R1 stated he had not, but she would have used one if he had. R1 stated she did not report the incident earlier when it happened because she was scared. RNHS E stated she and RN C assured R1 that she could use a bed pan, if she wanted to. RNHS E stated she went to get a bed pan for R1 to use, if she needed to. When RNHS E was returning to R1's room with the bed pan, CNA A saw her and asked where was she going with the bed pan. RNHS E stated she told him she was taking it to R1 and CNA A told her that R1 could not use one. RNHS E stated about 5 to 10 minutes later, R1 called for assistance and used the bed pan. - CNA A's typed statement, dated 7/30/23 at 3:22 PM, revealed CNA B had told him that R1 was sitting up with a gait belt (a belt used by staff to assist residents get get up and walk) and she needed assistance getting her up. CNA A stated he was watching another resident at the time. He stated the resident he was watching became confused, got angry, and tried to stand up. CNA A stated he and CNA B sat the other resident down and he then went into R1's room. CNA A stated he apologized to R1 for it taking so long to assist her. He stated he tried to get RN C or CNA B to help him transfer R1 to the restroom, but they were both busy. CNA A stated he told R1 that RN C and CNA B were busy and we can sit and wait for them to not be busy and I will stay here with you till then or I can lay you back down and check and change (check to see if the resident is wet and/or soiled and change them if they are) you or when you call. He stated CNA B then came in the room and he asked R1 if she wanted to get up to the bathroom. He stated R1 told him to lay her back down and she stated she understood she could call when she needed to be changed. He stated after this he left the room and did not go back into R1's room for the rest of the shift. - CNA A's, second typed statement, dated 7/30/23 at 3:35 PM, revealed he told R1 that using a bed pan was not an option. He stated he had been told by the previous shift staff that therapy had said R1 was not to use the bed pan and that she needed to either use the bathroom with an extensive assist of two staff members and her wheelchair or she was to just be a check and change. CNA A stated R1 was upset and angry when he told her this. He stated he apologized, but said the instructions for her to not use a bed pan came from therapy. CNA A stated he told R1 that he could leave a note for the therapists and they could come and talk to her about it. - Physical Therapist (PT) D's written statement, dated 7/31/23, revealed she had evaluated R1 on 7/29/23. She stated during her evaluation she assessed R1's bed mobility, transfer ability, and gait skills. She also stated R1 needed encouragement and rest breaks during the evaluation. PT D stated R1 could transfer from the bed to the wheelchair with two staff members assistance using her wheeled walker and could transfer to the toilet using one staff member's assistance and the grab bar next to the toilet. She stated she educated R1 on getting out of bed to use the bathroom with staff assistance to prevent skin breakdown. PT D stated she also told R1 that getting up with staff to use the bathroom would be therapeutically beneficial and would help her to work towards her goals. She stated she also instructed staff to use two people to help R1 transfer to the toilet for safety reasons and to encourage her to use the toilet, as able. - R1's typed interview, dated 7/31/23 and conducted by the Nursing Home Administrator (NHA), revealed, A conversation was had with [name of R1] in regards to last night's events with the aide on duty. [Name of R1] stated that the male aide who responded to her call light was not kind to her and told her that he would not get her the bed pan. She also stated that the male aide told her that once she went in her brief he would then change her. Administrator apologized to [name of R1] for the individuals (sic) actions and explained that this was inappropriate and assured [name of R1] that the individual would not be in her room again. [Name of R1] was thankful. A review of CNA A's Behavioral Change Notice, dated 8/1/23, revealed he was terminated because on 7/30/23, he refused to give a resident (R1) a bed pan and instead insisted that they use a brief. You stated that you would change that brief instead of using the bedpan. This violated the resident's (R1's) rights and does not corelate (sic) with [name of facility company's policies].

Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 3 residents (R1), resulting in incomplete medical records and inaccurate medical records; the potential for providers not having an accurate and complete picture of the resident's stay at the facility; and for providers not being aware of possible changes to the resident's mental, emotional, and/or physical well-being. Findings include: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice . Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines. It is how nurses create a record of their services for use by payors, the legal system, government agencies, accrediting bodies, researchers, and other groups and individuals directly or indirectly involved with health care. It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . Documentation is sometimes viewed as burdensome and even as a distraction from patient care. High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings . (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care- Assessments; Clinical problems; Communications with other health care professionals regarding the patient . Patient responses and outcomes, including changes in the patient's status; and Plans of care that reflect the social and cultural framework of the patient . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org). A review of R1's Admission Record, dated 8/9/23, revealed R1 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R1's Admission Record revealed multiple diagnoses that included a right femur (leg bone) fracture, a history of falling, difficulty walking, generalized muscle weakness, right hip pain, and left hip pain. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 8/4/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed she was cognitively intact. A review of the facility's self-reported Intake Information, dated 8/4/23, revealed on 7/30/23 at 5:10 AM, R1 pushed the call light to use the restroom. After several attempts to get R1 out of bed, R1 requested to use the bedpan because she was feeling too weak to stand. Instead of getting R1 the bedpan to use, the staff member (a certified nursing assistant) told her she could wet herself in her brief and then she could be changed. A nurse and another certified nursing assistant on the unit attended to R1's needs per her request and assisted her. R1 was assured that the staff member would not be back in her room and she stated she felt safe at the facility. The facility then began an investigation for possible neglect. A review of R1's electronic medical record (or electronic health record- EHR), dated 7/23/23 to 8/9/23, failed to reveal any mention of this incident and/or any follow-up to the incident (except possibly a Social Services Progress Note on 8/1/23 that refers to a second follow-up for a grievance without any indication of what the grievance was). During an interview on 8/9/3 at 2:50 PM, Registered Nurse (RN) F stated if a resident makes an allegation of abuse/neglect (e.g., a certified nursing assistant refused to help them with toileting or told them to just wet their brief and they would change them later), she would write a progress note, immediately address the allegation, talk to the certified nursing assistant to get their side of the story, and report it to Director of Nursing (DON) and Nursing Home Administrator (NHA), or whoever is on-call if it is after hours. RN F stated she would also make sure the resident was taken care of (changed, placed on a bedpan, or assisted to the toilet). During an interview on 8/9/23 at RN H stated if she was told by a resident that a staff member refused to change them or help them to the bathroom and told them to wet their pants and the staff member will change them later, she would apologize to the resident, talk to the staff member to get their side of the story, and notify her supervisor. She stated she would also document the accusation/incident in a progress note and that she notified the administrator and/or her supervisor in that same progress note. During an interview on 8/9/23 at 5:15 PM with the NHA and DON, they both stated that staff should have put a note in R1's progress note at least documenting that an allegation was made on 7/30/23 (even if it was in general terms), who was notified, and what was done (e.g., ensured R1 was safe and her needs were met). They both verbally acknowledged that it was concerning that a progress note was not entered into R1's electronic medical record and stated they would be educating staff on the expectation of documenting all incidents and/or allegations.

This citation pertains to intake MI000131154 Based on interview and record review, the facility failed to report an allegation of misappropriation of prescription medication to the State Agency, resulting in the potential for ongoing diversion, abuse and neglect. Findings: Review of a facility policy Abuse Investigation and Reporting revised July 2017 reflected All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The policy specified that the Administrator or designee was responsible for making the appropriate reports and specified the timeframe for reporting according to the regulation. During an interview on 11/21/22 at 1:45 PM, the Nursing Home Administrator (NHA) along with Assisted Living Director (ALD) J confirmed that in May or June 2022, insulin pens belonging to residents who lived in the Skilled Nursing Facility (SNF) had been discovered in a refrigerator in a basement employee lounge by House Supervisor (HS) K. According to ALD J, HS K was cleaning the employee fridge when she found a plastic grocery bag wrapped around 5 insulin pens belonging to at least 3 different residents. ALD J reported the plastic grocery bag was labeled with Certified Nurse Aide (CNA) L's name. ALD J said that when HS K brought the prescription medication to her she was able to identify that the drugs belonged to residents who lived in the SNF portion of the facility and never in the Assisted Living or Independent Living areas, thus reported the discovery to the SNF NHA. The NHA said that when she was first made aware of the discovery, she intended to make a report to the State Agency but was ultimately told not to do so by the Regional Clinical Operations Specialist, Registered Nurse (RN) O. The NHA said that CNA L had resigned long before the insulin pens were discovered, and she did not have a documented investigation related to the discovery of prescription drugs in an unauthorized area. During a telephone interview on 11/22/22 at 9:17 AM, RN O said she vaguely recalled the discovery of insulin pens belonging to residents who lived in the SNF in an employee refrigerator. According to RN O, she reviewed the matter with the NHA and advised her not to report to the State Agency because she was somehow able to determine that the residents did not miss doses of medication and the SNF had paid for the drugs, therefore no harm had come to residents. RN O said she did not have any documentation related to the drug diversion and assumed the NHA had completed an investigation.

This citation pertains to intake MI000131154 Based on interview and record review, the facility failed to investigate an allegation of misappropriation of prescription medication to the State Agency resulting in the potential for ongoing diversion, abuse and neglect. Findings: Review of a facility policy Abuse Investigation and Reporting revised July 2017 reflected All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The policy specified the actions necessary to facilitate and conduct investigations and ensure further potential abuse, neglect, exploitation or mistreatment is prevented. During an interview on 11/21/22 at 1:45 PM, the Nursing Home Administrator (NHA) along with Assisted Living Director (ALD) J confirmed that in May or June 2022, insulin pens belonging to residents who lived in the Skilled Nursing Facility (SNF) had been discovered in a refrigerator in a basement employee lounge by House Supervisor (HS) K. According to ALD J, HS K was cleaning the employee fridge when she found a plastic grocery bag wrapped around 5 insulin pens belonging to at least 3 different residents. ALD J reported the plastic grocery bag was labeled with Certified Nurse Aide (CNA) L's name. ALD J said that when HS K brought the prescription medication to her she was able to identify that the drugs belonged to residents who lived in the SNF portion of the facility and never in the Assisted Living or Independent Living areas, thus reported the discovery to the SNF NHA. The NHA said that when she was first made aware of the discovery, she intended to report the discovery to the State Agency but was ultimately told not to do so by the Regional Clinical Operations Specialist, Registered Nurse (RN) O. The NHA said that CNA L had resigned long before the insulin pens were discovered, and she did not have any documentation related to investigating the discovery of prescription drugs in an unauthorized area. The NHA explained that she did not note who the residents were, did not recall investigating whether the residents were given prescription medication as ordered and did not interview the former employee or other staff at the facility related to the diversion. The NHA also confirmed that she did not direct anyone to audit the medication storage or prescription accounting systems that may have been breached. During a telephone interview on 11/22/22 at 9:17 AM, RN O said she vaguely recalled the discovery of insulin pens belonging to residents who lived in the SNF in an employee refrigerator. According to RN O, she reviewed the matter with the NHA and advised her not to report to the State Agency because she was somehow able to determine that the residents did not miss doses of medication and the SNF had paid for the drugs, therefore no harm had come to residents. RN O said she did not have any documentation related to the drug diversion and assumed the NHA had completed an investigation.

This citation pertains to intake MI000130760 Based on interview and record review, the facility failed to ensure physician orders received after an outside appointment were reviewed and implemented as directed for one resident (Resident #3), resulting in discontinuity of care and potentially avoidable death. Findings: Resident #3 (R3) Review of an Admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure (CHF), orthostatic hypotension (low blood pressure), chronic kidney disease, pleural effusion, permanent atrial fibrillation, shortness of breath, muscle weakness and difficulty in walking. Review of a Care Plan initiated on 7/11/22 reflected R3 had orthostatic hypotension (low blood pressure). The goal of the care plan was for R3 to remain free from complications related to the condition through the next review date (10/06/2022). Interventions specified on the care plan to meet the goal included: Encourage (R3) to get up slowly, sit on side of bed before standing; Give medications as ordered, Monitor for side effects and effectiveness; Monitor labs, radiologic studies, cardiac testing results and other studies to determine causative factors of hypotension and report abnormal findings to physician; Monitor vital signs as ordered and record. Report significant abnormalities to MD (physician); Monitor/document/report to MD any s/sx (signs/symptoms) of hypotension: dizziness, Fainting, Syncope, blurred vision, lack of concentration, nausea, fatigue, cold, clammy, pale skin. Review of a provider Progress Notes dated 7/11/22 reflected [R3] who has had multiple hospitalization s recently due to CHF (congestive heart failure). Most recently admitted ,d+[DATE]-[DATE] at (name of local hospital) with acute hypoxic respiratory failure and acute on chronic CHF. She has had a long history of low blood pressures and difficulty tolerating her diuretics. She had significant orthostatic hypotension with systolic blood pressures down in the 60s and near syncope, so severe she was unable to stand, she was started first on Midodrine (a drug used to treat low blood pressure), and then Fluorinef (a corticosteroid used to treat postural hypotension) was added. Ultimately her diuretics were held and she was given IVF (Intravenous fluid) bolus x3 in attempts to improve her orthostasis without success. She is very dizzy with standing and is only able to transfer briefly to BSC (bedside commode). Previously independent with using her walker. She was started on continuous oxygen to maintain sats. Plan to hold off diuretics until her weight begins to climb and resume on a prn (as needed) basis. However this was tried in assisted living and was not very successful. Today patient is seen in her room at SAR (sub-acute rehab). Able to give hx (history), report no cough, is still on O2 (oxygen) NC (nasal cannula). Exam with crackles on the left lung field. Weight remains stable at 120 pounds. BP (blood pressure) remains lower due to her hx of orthostatic. Instructions in the note were for R3 to follow up with cardiology. Review of an After Visit Summary reflected R3 had an outside appointment with a cardiologist on 7/14/22. The instructions on the document directed R3 to CHANGE how you take midodrine (proamatine); STOP taking fludrocortisone 0.1 MG tablet (FLORINEFF); CONTINUE taking your other medications. Review of a Telephone Order (a triplicate paper form used to write physician orders) for R3 dated 7/14/22 reflected Stop (d/c discontinue) Floinef (sic) Increase Midodrine to 10 mg TID (three times a day) BMP (basic metabolic panel) and NT-proBNP (N-terminal pro hormone brain natriuretic peptide) in 1 week. The order form was signed by the cardiologist R3 had visited on 7/14/2022. No other notations were made on the telephone order indicating the order had been noted by nurses. Review of the July 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) reflected the following pertinent orders: Midordrine HCl Tablet 2.5 MG Give 1 table by mouth three times a day for orthostatic hypotension-Start Date 7/08/2022 1700 (5:00 PM)-D/C Date-7/17/2022 1237 (12:37 PM); Fludrocortisone Acetate Tablet 0.1 MG Give 1 tablet by mouth one time a day related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA (J96.01) for 10 Days-Start Date-07/09/2022 0800 (8:00 AM)-D/C Date-7/17/2022 1237 (12:37 PM). Further review of the July 2022 MAR/TAR did not reflect that the cardiologist prescribed medication changes written out on the telephone order form dated 7/14/2022 had been made. Review of an Order Recap Report for R3 for the date range 07/01/2022 - 11/30/2022 did not reflect the cardiologist prescribed medication changes written out on the telephone order form dated 7/14/2022 had been made. Review of a Late Entry Comprehensive Nursing Note dated 7/14/2022 at 16:13 (4:13 PM) documented by Licensed Practical Nurse (LPN) C reflected [R3] limited one person assist to standby assist, no current c/o pain, continues to work with therapy. The note did not indicate R3 had been out to a cardiology appointment that day and did not reflect new orders had been received. Review of a Nursing Narrative Note dated 7/17/2022 at 7:47 AM reflected At 0633 (6:33 AM) resident (R3) vitals were taken 82/55 (blood pressure), 60 HR (heart rate), 16 respirations, 97.7 temp, 87% on 1L of O2 via NC. Resident was encouraged to sit up and told staff she wanted to use bathroom. Resident then ambulated to the bathroom. She then stated she wanted to lay down and take a nap. No SOB (shortness of breath) reported but she was tired. After good deep breaths was able to bring oxygen up to 88%. Res stated she felt comfortable. Nurse left and later brought in medicine but resident did not wake up. Code status was confirmed and 911 was called. [Name of physician], administrator and family. [Name of R3's son and daughter-in law] stated for me to call [name of funeral home]. During a telephone interview on 11/22/22 at 10:50 AM, LPN C said she could not recall R3's cardiology appointment from 7/14/2022. According to LPN C, when a resident leaves the facility for an appointment, they are handed a packet of information that includes the admission record, current medication list, a physician order form and a blank physician progress note. When a resident returns from an appointment, the nurse is to receive any paperwork as soon as possible for processing. LPN C described a filing system to ensure every order is triple checked. LPN C said that if there were no nurse signatures on the telephone order form that had been scanned into R3's electronic health record, she likely never saw it or any other paperwork after R3's cardiology appointment. LPN C reported the system in place for collecting documentation after outside appointments varies depending on circumstances.

Based on observation, interview, and record review, the facility failed to implement and operationalize their COVID-19 vaccination policy for staff, potentially affecting all facility residents, resulting in the facility not being aware of the vaccination and/or exemption status of contractual staff who are providing care and services to facility residents and the potential for the spread of illness and disease (COVID-19) among facility residents. Findings include: A review of the facility's Skilled Nursing Facility COVID-19 Vaccine-Employees/Staff policy, revised 2/7/22, revealed, Staff refers to any individuals that work or volunteer in the facility, regardless of clinical responsibility or resident contact. This includes: Facility employees; Individuals who may not be physically in the LTC facility for a period (e.g., illness, disability, or scheduled time of), but are expected to return to work.; Individuals under contract or arrangement (e.g., medical directors, hospice and [CONDITION(S)] staff, therapists, mental health professionals, students, trainees, agency or temporary staff, or volunteers) who provide services to the facility on a regular basis . Employee is defined as an individual who is directly hired and employed by the employer/facility. A review of the facility's Skilled Nursing Facility COVID-19 Vaccine-Employees/Staff policy, revised 2/7/22, revealed, 2. Staff may obtain their COVID-19 vaccines from their personal physicians or at other community locations. Documentation of previous vaccination will be provided to the facility. 3. Staff may be eligible for medical or religious exemption but must meet the criteria for the exemption to qualify . 4. If a medical exemption is granted documentation signed and dated will be provided by the licensed practitioner indicating which of the authorized vaccines are clinical contraindicated, the reason for the contraindication, and a statement that the employee be exempted from the COVID-19 vaccination requirements . A review of the facility's COVID-19 Staff Vaccination Matrix (the facility's list of all staff and their vaccination status), undated but provided soon after entrance on 3/29/22, failed to reveal vaccination/ exemption status of any staff members that provided services under contract or arrangement (e.g. hospice companies, physicians, physician assistants, nurse practitioners, etc.). The matrix only listed facility staff that were employees of the facility. During an interview on 3/29/22 at 12:15 PM, the Nursing Home Administrator (NHA) confirmed the matrix that was provided soon after entrance included only facility employees and did not include any staff that provided services under contract or arrangement to facility residents. She stated they only had employee immunization information from one hospice company because that company automatically provided them with that information. She stated they do not have COVID vaccine information for their other hospice company or their other providers (e.g. medical director, physicians, physician assistants (PA), nurse practitioners (NP), etc.). She stated she spoke with the facility's human resources person and they said they were not aware that they needed the immunization/exemption information from their vendors (i.e. physicians, PA's, NP's, hospice companies). Therefore, the facility did not have an accurate number of staff who provide care and services under contract to their residents. During an interview on 3/29/22 at 12:15 PM, the NHA stated that their exemptions (the hospice company's that automatically provided them with their staff immunization information) only state that they were approved. She stated they do not have any information of the reason for hospice company staff's medical exemptions or any other documentation besides the exemption was approved/granted. She stated the hospice company had 57 staff members and six (6) of them have exemptions. However, she does not know if the hospice staff members' exemptions are medical or non-medical (i.e. religious) because the paperwork they sent us does not say. Therefore, since the facility employee list has only two employees with medical exemptions, no employees with non-medical exemptions, and the hospice company staff list did not include the categories of the exemptions approved/granted (i.e. medical and/or non-medical), there was no way for the surveyor to randomly select a complete sample of staff members to check for compliance with the mandatory COVID-19 immunization requirement under the federal regulations. During an interview on 3/29/22 at 1:45 PM, Registered Nurse (RN) C stated she had a medical exemption. She stated because she is not vaccinated she has to wear whatever the next level above a surgical mask is while at the facility. RN C stated she has to be tested for COVID-19 twice a week. During an interview on 3/29/22 at 1:45 PM, RN C was wearing a KN95 mask. She verified that this was the mask she had been wearing, instead of an N95 respirator. A review of the facility's Skilled Nursing Facility COVID-19 Vaccine-Employees/Staff policy, revised 2/7/22, revealed, Staff who receive an exemption to the COVID-19 vaccine, will be subject to additional precautions to mitigate the transmission and spread of COVID-19. Some examples may include: . Use of NIOSH approved N95 respirator or higher at all times regardless of community transmission . A review of the article What's the Difference Between N95 Masks and KN95 Masks? N95 Masks vs. KN95 Masks: Similarities and Differences, dated 3/1/21, revealed, Both N95 masks and KN95 masks are made from multiple layers of synthetic material (typically a polypropylene plastic polymer) and are designed to be worn over the mouth and nose. Straps behind your ear help to hold the mask in place. Both masks must filter out and capture 95 percent of tiny 0.3 micron particles in the air (hence the 95 in the names). N95 masks offer protection against particles as small as 0.3 microns in size, and while the Coronavirus itself is around 0.1 microns in size, it ' s usually attached to something larger, such as droplets that are generated by everyday activities like breathing and talking, explains [name of founder of an internet supply company]. Due to the multiple layers of non-woven fabric and melt blown fabric in the N95 masks, the strong material makeup of these masks are great at preventing airborne particles from entering through your mouth and nose. (https://www.msn.com/en-us/health/medical/what-s-the-difference-between-n95-masks-and-kn95-masks/ar-BB17WaR1, retrieved on 3/30/22) A review of the article What's the Difference Between N95 Masks and KN95 Masks? N95 Masks vs. KN95 Masks: Similarities and Differences, dated 3/1/21, revealed, But how are N95 masks different from KN95 masks? The main difference lies in how the masks are certified. In general, says [name of founder of a personal protection equipment (PPE) company] N95 is the U.S. standard, and the KN95 is the China standard. Because of this, only N95 masks are approved for health-care use in the United States, even though KN95 masks have many of the same protective properties. (https://www.msn.com/en-us/health/medical/what-s-the-difference-between-n95-masks-and-kn95-masks/ar-BB17WaR1, retrieved on 3/30/22) A review of the Centers for Disease Control and Prevention's (CDC) Types of Masks and Respirators guidelines, updated 1/28/22, revealed, Some respirators are designed and tested to meet international standards. The most widely available respirators that meet an international standard are KN95 respirators Poor quality KN95 respirators: About 60% of KN95 respirators NIOSH evaluated during the COVID-19 pandemic in 2020 and 2021 did not meet the requirements that they intended to meet. Using a poor-quality product may not provide the level of protection indicated Do NOT wear international respirators . As a replacement for NIOSH-approved respiratory protection when required by your job. NIOSH-Approved Respirators . NIOSH approves many types of filtering facepiece respirators. The most widely available are N95 respirators, but other types (N99, N100, P95, P99, P100, R95, R99, and R100) offer the same or better protection as an N95 respirator What to know about NIOSH-approved respirators: When worn consistently and properly, they provide the highest level of protection from particles, including the virus that causes COVID-19. Additionally, they contain your respiratory droplets and particles so you do not expose others Respirators approved by NIOSH are evaluated against a specific US standard that includes a quality requirement. They filter at least 95% of particles in the air when approved by NIOSH and when you have a proper fit. During an interview on 3/29/22 at 3:30 PM, the NHA stated they were still waiting on receiving complete information from their physician medical group and hospice companies. She stated the information was coming in slowly, was incomplete at times (not everything they needed), and she has had to get some additional information (e.g. reasons for exemptions). However, there was not any mention of acquiring staff COVID-19 vaccination/exemption information for staff other than their hospice companies and physician medical group (e.g. podiatrist company, dental company, and entertainers) who provide services on a regular basis, if applicable.

Based on observation, interview, and record review, the facility failed to properly label medications and maintain control of medications for 1 medication room and of 1 of 7 residents (Resident #2) observed during the medication pass observation, potentially affecting all facility residents, resulting in the potential for expired [MEDICATION(S)] Protein Derivative being administered, the potential for misappropriation, and the potential for Resident #2 not safely taking/not taking medications without the facility's knowledge, and the potential for residents receiving the wrong medications. Findings include: During an observation on [DATE] at 04:00 PM, the medication room was inspected with Licensed Practical Nurse (LPN) E. The following observation and interview were made: - A vial of [brand name] [MEDICATION(S)] (TB) Purified Protein Derivative (PPD) with a date of [DATE] on the box, but no legible date listed on the vial was observed (it looked like someone had written a date (possibly [DATE]) on the vial when the vial was enlarged and it smudged off). - LPN E stated she did not see a date written on the vial when asked to look at the TB PPD vial. - LPN E stated usually they label the vials and the boxes. She stated the vials are good for twenty-eight (28) days after they are first used. During an interview on [DATE] at 9:10 AM, the Nursing Home Administrator (NHA) stated she looked at the TB vial and saw what looked like a smeared date on the vial. She stated, It looks like the date was written with a gel pen and smeared. If you look at it real close, it looks like the date was ,d+[DATE] (2021). I know that doesn't match the date of ,d+[DATE] (2021) that's on the box. We are going to discard the vial and get a new one. It's almost been 28 days since ,d+[DATE] (2021). She showed the surveyor the vial and the date (if a date is looked closely for) appeared it could have been [DATE] or [DATE]. During an interview on [DATE] at 2:00 PM, another surveyor was asked if they could read the writing that was smudged on the TB vial. The other surveyor stated it looked like a series of numbers and letters. When the surveyor was told the smudged writing was supposed to be a date, the surveyor stated, It looks like it is [DATE] or [DATE]. But it's difficult to read. A review of the manufacturer's instructions for the TB PPD vial, dated ,d+[DATE], revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Due to the fact that the nurse administering medications (LPN E) could not see/read a date of the TB vial, the date was smudged and could be read several different ways (if at all by the person trying to read it), and the date (if read) did not match the date written on the box ([DATE]), the vial could have been expired and still used without the nurse's knowledge it was expired. R2 According to the Minimum Data Set (MDS) assessment, R2 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R2 was independent or required supervision of one staff member for most all cares including eating and transferring. Staff assessed R2 as cognitively intact and R2 was their own responsible party. During a medication pass observation on [DATE] at 8:42 AM, Registered Nurse (RN) C prepared three medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C took the medicine cup containing these medications into R2's room and placed them next to R2's breakfast. RN C stated that R2 prefers to take the medications at her own pace during breakfast. RN C then exited the room, leaving the medications out of the nurse's sight and unsecured.

Based on observation and interview the facility failed to thoroughly clean and maintain facility in two of three common areas, and properly store sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living, affecting residents who use the common areas. Findings include: During a tour of the facility, at 2:40 PM on 12/7/21, observation of the mission west clean linen closet found three boxes of plastic gowns stored on the floor. During an environmental tour of the facility, at 2:45 PM on 12/7/21, a review of the mission west lounge area found a stick of deodorant, two string cheese wrappers, a candy wrapper, and accumulations of dirt and crumb debris under furniture cushions. During an environmental tour of the facility, at 3:15 PM on 12/7/21, with Maintenance P, it was observed that seven storage racks in the central supply area were found to be made of press board shelving that is not smooth and easily cleanable. At this time, it was observed that clean and sanitary nursing items were stored on the shelves of these racks. During a review of the mission east lounge area, at 3:45 PM on 12/7/21, with the Nursing Home Administrator and Maintenance P, it was observed that an old a food item wrapped in tin foil was found stuck between the left couch cushion and the back of the couch. It was also observed that a used glove, a gauze packet, and accumulations of crumbs and debris were evident under furniture cushions.

Based on observation, interview, and record review, the facility failed to assess one Resident (R2) of seven residents reviewed, during medication pass observations, for self-administration of medications. This deficient practice resulted in Resident #2 not having a current assessment for safe medication administration and the potential for Resident #2 to self-administer the wrong medication dose. Findings include: According to the Minimum Data Set (MDS) assessment, R2 had multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This same assessment indicated that R2 was independent or required supervision of one staff member for most all cares including eating and transferring. Staff assessed R2 as cognitively intact and R2 was their own responsible party. During a medication pass observation on 12/8/21 at 8:42 AM, Registered Nurse (RN) C prepared three medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C took the medicine cup containing these medications into R2's room and placed them next to R2's breakfast. RN C stated that R2 prefers to take the medications at her own pace during breakfast. RN C then exited the room, leaving the medications out of the nurse's sight and in reach of R2. Review of R2's Electronic Medical Record (EMR) including physician orders, care plans, and progress notes revealed no Self-Assessment of Medication evaluation. On 12/8/21 at 10:00 AM, the Director of Nursing stated that there were no residents in the facility assessed to self-administer medications. Review of facility policy, Administering Medications, revised 12/2012, read, in part, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

This citation pertains to: MI 400 Based on observation, interview, and record review, the facility failed to develop and/or implement comprehensive person-centered care plans for one resident (Resident #4) of 6 residents reviewed for care plan development/implementation, resulting in care provided that was inconsistent with identified resident needs and preferences, and the potential for unmet physical, mental, and psychosocial needs. Findings include: R4 Review of R4's Admission Record dated 12/8/2021 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 9/30/21, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) assessment which revealed a score of 10 Resident #4 was moderately impaired. In addition, Resident #4's MDS revealed that in Activities for Daily Living (ADL's) Resident #4 required extensive assistance of Two (plus) persons physical assistance with bed mobility, transfers, dressing, toileting and personal hygiene and was totally dependent on Two (plus) persons for bathing. Review of R4 ADL Care Plan revealed the following ADL Intervention/Tasks - Two caregivers while providing resident care Date Initiated: 11/11/2021 Revision on: 11/12/2021. - (Name of R4) requires dep 2 assist with transfers. Date Initiated: 11/11/2021 Revision on: 11/19/2021. -Allow (Name of R4) sufficient time for dressing and undressing. Date Initiated: 10/21/2021 Revision on: 11/12/2021 - Assist (Name of R4) to choose simple comfortable clothing that maximized her ability to dress self. Date Initiated: 10/21/2021 Revision on: 11/12/2021 Review of R4's medical record under Certified Nurse's Aide (CNA) Tasks revealed that as of 9/24/21 2 PERSON CAREGIVER AT ALL TIMES. The following was documented on 11/12/21 by the current Director of Nursing (DON) 2-person caregiver with personal cares. Review of residents record revealed resident was signed onto (Name of) Hospice on 11/9/21. Review of Hospice POC Report dated 12/9/21 at 2:21:05 PM, reflected, REVIEW HOSPICE PLAN OF CARE WITH FACILITY STAFF. 11/9/21 Further review revealed that NEED FOR HOSPICE AIDE SERVICES (removed 11/12/21) During an interview on 12/8/21 at around 9:30 AM, NHA revealed R4 does not have hospice aides caring for her after 11/11/21 incident. Stated between family, staff, and hospice they felt it was better if facility staff do cares on her because they know the resident best. During an interview on 12/9/21 at 1:42 PM, Certified Nurse's Aide (CNA) K revealed the following, I went in that day hospice aide come in at 6 am, resident is not a morning person. Stated I warned the aide before she went in that she was not a morning person, but the aide stated it was the time she could come and fit her in. I told her we usually give her (R4) a bath/bed bath about 1pm but she was instant, I tried to offer my help, since we always go in two's, but she did not want my help. I had to respect the Hospice aide because they are in charge once they sign on to hospice. CNA K stated then 20-30 minutes later she the hospice aide came out and wrote report. CNA K revealed the resident was upset that day and since that day the resident has not had any more hospice aides, and that was the first and last time. CNA K stated that R4 had always been a 2 person's for care since she got here. During an interview an 12/9/21 at 1:50 PM, Certified Nurse's Aide (CNA) R revealed, she knew that day R4 was upset, resident is always 2 persons for cares, she does make accusations. CNA R confirmed that R4 is not early riser, and revealed resident liked to pick her own clothes, takes her time doing it, takes a while to get resident dressed. Review of facility interview with Hospice Aide dated 11/12/21 at around 10:30 AM, reflected the following information, She stated she came to community on 11/11/21 at around 7:00 AM to provide care to (Name of Resident). She did check in with staff to get a quick overview of resident and was told about the residents history of behaviors. (Name of Hospice CNA) stated that the resident was awake and that she got the supplies ready for a bath. (Name of Resident) became verbally and physically aggressive, so the CNA was only able to do a quick bed bath, change the brief and put a shirt on the resident. During the interview NHA asked the CNA if she got any of the staff to come assist but she said she knew these behaviors were normal, so she did not and only reported upon leaving that she has never worked with a resident like that before. During an interview on 12/9/21 at 1:53 PM, Registered Nurse (RN) C revealed that the hospice aide came in and said I'm going to get (Name of R4) ready for the day, asked if she knew (Name of R4), but she went in and she came out a short time later and said she was a hard resident. RN C revealed she asked hospice aide if she knew (R4) because of her behaviors, not a morning person, confirmed done before 7 AM. Revealed she went into residents room after hospice aide left found the resident dressed and stated that she had not been dressed in a couple of days prior (didn't want to get dressed.) Stated that the resident picky on clothes not something she'd choose, and that she was distressed that day.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to maintain a consistent physical level of comfort for one resident (R5) out of 6 sampled residents. This deficient practice resulted in unmet care needs leaving R5 with itchy dry skin. Findings include: R5 Review of R5's Admission Record dated 12/8/2021 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R5's Brief Interview of Mental Status (BIMS) dated 11/19/21 revealed he scored 8/15 (moderately impaired cognition). During a care observation on 12/7/21 at 12:38 PM, with Certified Nurse's Aide K, R5 was rolled onto his left side and pillows were placed under the right side of the resident's body for repositioning. During that time resident started moaning, CNA K was scratching residents back, and revealed that he was not in any pain he is just itchy and likes his back scratched. On 12/07/21 at 12:45 PM, R5 complained of having itchy skin, Resident stated, it itched all the time and everywhere. On 12/08/21 at 12:12 PM, Director Of Nursing (DON) stated she would look into concerns about (Name of R5's) skin. DON stated she did not know about him having dry skin. On 12/09/21 at 10:55 AM, Certified Nurse's Aide (CNA) R revealed that (Name of R5) always complains about his back being itchy daily and that we scratch his back for him daily, it's always been a thing with him. CNA R stated that she would sometimes take a towel to his back to get off some of the dead skin, and she would put lotion on sometimes too. CNA R further revealed that, as of today DON brought it to our attention that we are to put lotion on him 2x a day once morning and at night as part of his care plan, so it's official. On 12/09/21 at 11:07 AM, CNA K revealed that Resident 5 only complains when we reposition him, like today when we repositioned him, we scratched his back, just like the other day when you were observing us. Then we also put lotion on him today to. Review of R5's Care Plan for skin integrity reflected the following Intervention/Task with a Date Initiated of 10/21/21, Keep skin clean and dry. Use lotion on dry skin. Do not apply to area of skin breakdown, wound or between toes. Review of Nursing Progress Note on 12/9/2021 at 07:54, reflected, This nurse notified NP (Nurse Practitioner) about (Name of Resident 5) comments to staff about his back feeling itchy and requesting they scratch it. Per NP offer lotion to back with morning and HS cares. Review of R5's Care Plan noted following Intervention/Task with Date Initiated of 12/09/21, for skin impairment, (Name of R5) reports itchy back at times. Offer to apply lotion to (Name of R5's) back with morning and HS cares. On 12/09/21 at 11:15 AM, DON stated, I talked to NP last night, mentioned something to her because I remembered our conversation. I have gone in to help and reposition him (Resident 5) and he wanted his back scratched, didn't think about it, just thought he wanted his back scratched at the time, it wasn't until you said something yesterday that I thought about it. DON further revealed that, the resident had put lotion on as needed in care plan, but now we just made it more direct care to have staff do it daily. They (staff) were educated on it this morning. Review of R5's COMS - Skin Only Evaluation with a Signed Lock Date: 11/7/2021 at 09:05, reflected, Skin color is WNL. Mucous membranes are moist. Skin warm/dry to touch. Skin is dry/cracked. Skin is fragile. Normal skin turgor. Resident has current skin issues. Review of 11/4/21 Nurse Practitioner progress notes from R5's appointment at (Name) of Hospital Wound Clinic, reflected the following treatment, Once daily, apply fragrance-free lotion to intact skin at the legs, feet, hands, arms and back. Review of 12/2/21 Nurse Practitioner progress notes from R5's appointment at (Name) of Hospital Wound Clinic, reflected the following treatment, Once daily, apply fragrance-free lotion to intact skin at the legs, feet, hands, arms and back. During an interview on 12/09/21 at 12:21 PM, R5 stated my skin is always itchy, they put lotion on me today, but it didn't really help. R5 revealed that staff would put it (lotion) on him sometimes, but not daily.

Based on observation and interview, the facility failed to serve palatable and attractive food for 1 of 10 facility residents (Resident #113), resulting in food that was non-palatable, unattractive, and Resident #113 not wanting to eat it. Findings include: A review of Resident #113's Admission Record, dated 12/9/21 revealed Resident #113 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included a right femur (leg) fracture, depression, and anxiety. A review of Resident #113's progress notes, dated 12/3/21 to 12/9/21, revealed Resident #113 was alert x 4 (oriented to person, place, time, and situation) able to communicate her needs (Nursing Progress Note, dated 12/8/21 at 10:16 AM). During an interview on 12/07/21 at 11:24 AM, Resident # 113 stated the food is terrible. I was here maybe two or three years ago. The food was wonderful. You had all sorts of choices and the desserts were great. Not so much this time. Resident #113 further stated, I had raw french toast yesterday and the waffles this morning were cold and about the same (raw). She stated she sent the french toast back to the kitchen and just decided to eat the oatmeal. You really can't mess up oatmeal. When asked about her other meals, she just shook her head and stated, I pretty much have been sticking with soup and crackers. During an observation on 12/08/21 at 9:00 AM, a breakfast test tray was requested. The tray consisted of a fried egg sandwich, two pieces of bacon, a pork sausage patty, a glass of milk, a glass of orange juice, and a bowl of cream of wheat. The half of the sausage was pink in the middle and pink/red on the surface, the egg on the fried egg sandwich was runny (both yolk and white parts), and the cream of wheat was overcooked and without texture. During an interview on 12/8/21 at 9:10 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were shown the breakfast test tray. The DON agreed that the pork sausage and fried egg sandwich did not look appetizing. They stated they would notify the kitchen of the concern with the breakfast test tray.

Based on interview and record review, the facility gave an unordered anticoagulant medication to a resident (Resident #101) for at least six days, resulting in a significant medication error and hospitalization . Findings include: Review of a Face Sheet revealed Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #101 had a Brief Interview for Mental Status (BIMS) indicating she was cognitively intact and required extensive assistance of 2 staff for transfers. Review of an Admission Assessment revealed Resident #101 was a Fall Risk. Review of an Order Summary Report for Resident #101 revealed: -[MEDICATION NAME] (anticoagulant) Tablet 5 mg, Give 1 tablet by mouth one time a day every Mon (Monday), Wed (Wednesday), Fri (Friday), Sat (Saturday), Sun (Sunday) related to ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE, ordered 4/30/19, start date 5/1/19. -[MEDICATION NAME] Tablet 6 mg, Give 1 tablet by mouth in the evening every Tue (Tuesday), Thu (Thursday) related to ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE, ordered 4/30/19, start date 4/30/19. -[MEDICATION NAME] (anticoagulant) Tablet 5 mg (milligrams), Give 1 tablet by mouth one time a day every Mon, Wed, Fri, Sat , Sun related to ACUTE ON CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE, ordered 5/3/19, start date 5/3/19. -Aspirin Tablet 81 mg (interferes with blood clotting), Give 1 tablet by mouth one time a day for [MEDICATION NAME], ordered 4/22/19, start date 4/23/19. -[MEDICATION NAME] HCL Tablet 50 mg, Give 1 tablet by mouth as needed for pain BID (twice daily), ordered 4/22/19, start date 4/22/19. -[MEDICATION NAME] HCL Tablet 50 mg, Give 1 tablet by mouth three times a day for Moderate pain, ordered 4/30/19, start date 4/30/19. -[MEDICATION NAME] HCL Tablet 50 mg, Give 1 tablet by mouth every 6 hours for Moderate pain, ordered 5/2/19, start date 5/2/19/19. -[MEDICATION NAME] ([MEDICATION NAME]) HCL Tablet 50 mg, Give 1 tablet by mouth one time a day related to MAJOR [MEDICAL CONDITION], ordered 4/22/19, start date 4/23/19. -[MEDICATION NAME] ([MEDICATION NAME] HCL) Tablet 25 mg, Give 1 tablet by mouth one time a day related to MAJOR [MEDICAL CONDITION], ordered 5/7/19, start date 5/8/19. -[MEDICATION NAME] Tablet 500 mg, Give 1 tablet by mouth every 4 hours as needed for pain, ordered 4/23/19 and changed to [MEDICATION NAME], Give 1 tablet by mouth three times a day for moderate pain, ordered 4/30/19. -PT/INR ([MEDICATION NAME] time/international normalized ratio (INR) labs that monitor coagulation in blood.) 5/3/19 every shift related to ACUTE ON CHRONIC (CONGESTIVE) HEART FAILURE until 5/3/19 23:59 (11:59 p.m.), ordered 4/30/19, end date 5/3/19. Review of the Medication Administration Record [REDACTED]. -Aspirin 81 mg given as ordered 4/23/19 to 5/1/19. -[MEDICATION NAME] 50 mg given as ordered from 4/23/19 to 5/8/19. -[MEDICATION NAME] HCL ([MEDICATION NAME]) Tablet 50 mg given as ordered 4/23/19 to 5/8/19. -[MEDICATION NAME] Tablet 500 mg given as ordered 4/23/19 to 5/8/19. -ANTICOAGULANT MEDICATION-MONITOR FOR DISCOLORED URINE, BLACK TARRY STOOLS, SUDDEN SEVERE HEADACHE, N&V (nausea and vomiting), DIARRHEA, MUSCLE JOINT PAIN, LETHARGY, BRUISING, SUDDEN CHANGES IN MENTAL STATUS AND/OR V/S (vital signs), SOB (shortness of breath), NOSE BLEEDS. Document: Y if monitored and ANY of the above were observed. N if monitored and NONE of the above was observed, select chart code Other/See Nurses Notes' and progress note findings every shift for MONITOR. Start date 4/22/19, D/C Date 5/8/19. Entries for all shifts from 5/1/19 to 5/8/19 documented as n for no. -PT/INR-5/3/19, start date 5/2/19, documented done on 5/3/19 day shift only, evening shift coded 1 indicating Away from home, night shift coded 3 indicating absent from home. Review of Pharmacy recommendations dated 4/30/19 for Resident #101 revealed: -[MEDICATION NAME] Sodium 5 mg tablet, Interacts with [MEDICATION NAME] HCL 50 mg tablet Severity Level 3 (indicating low risk) Patients maintained on [MEDICATION NAME] who begin therapy with [MEDICATION NAME] or [MEDICATION NAME] containing medication should be monitored closely for signs of increased [MEDICATION NAME] effects If concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin, hematocrit, . when applicable, perform agent - specific laboratory test (e.g. INR, aPTT) to monitor efficacy and safety of anticoagulation Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding . unusual bruising, red or black tarry stools, red, pink or dark brown urine; acute abdominal or joint pain and/or swelling. The time of highest risk for a coumarin-type drug interaction is when the precipitant drug is initiated or discontinued -[MEDICATION NAME] Sodium 6 mg tablet, Interacts with [MEDICATION NAME] HCL 50 mg tablet . Severity level 3 -[MEDICATION NAME] Sodium 5 mg tablet, Interacts with [MEDICATION NAME] HCL 50 mg tablet (Selective Serotonin Reuptake Inhibitor (SSRI)) Severity level 3 . For all anticoagulant/SSRI or SNRI (Serotonin-[MEDICATION NAME] reuptake inhibitors) combinations, if concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loos, including decreased hemoglobin and/or hematocrit . When applicable, perform agent-specific laboratory test (e.g. INR, aPTT) . Instruct patients to report any signs and symptoms of bleeding . unusual bruising Acute abdominal or joint pain and/or swelling . -[MEDICATION NAME] Sodium 6 mg tablet, Interacts with [MEDICATION NAME] HCL 50 mg tablet Severity level 3 . -[MEDICATION NAME] Sodium 5 mg tablet, Interacts with [MEDICATION NAME] 500 mg caplet Severity level 3, Patients receiving greater than 2 grams/day with coumarin anticoagulants should be closely monitored for changes in anticoagulant effects. The dosage of the anticoagulant may need to be adjusted. All pharmacy recommendations were acknowledged and signed by the physician. Review of an unsigned Physician Discharge Note dated 5/8/19 for Resident #101 revealed: . mental status changes over past few days. Med list review discovered pt (patient) has been receiving [MEDICATION NAME] 5-6 mg daily in error since 4/30 (4/30/19). Pt refusing INR (lab to detect coagulation) and unable to get P[NAME] inr. Refusing vit K (vitamin K helps blood clotting). Discussed hospice inform (information) meeting- But since cannot get through to DTR (doctor) and she is full code- sending to the ED (emergency department). Pt agitated and yells with any care not her baseline . Active Problems and Plans: . #10 Butt PU (pressure ulcer), #11 Mental Status changes, BIMS 14 down to 6, ED for eval, [MEDICATION NAME] d/c'd (discontinued) pt ref (refused) vit K and INR . (sic) Review of Hospital History and Physical report revealed Resident #101 was admitted to the hospital on [DATE] Apparently she has developed a sacrococcygeal ulcer and wound which is now draining foul-smelling material . details are unclear but apparently the patient has been receiving [MEDICATION NAME] over the past week although she was not supposed to . Urinalysis showed 3+ blood and 6-10 RBCs (red blood cells). Laboratory studies show . hemoglobin 8.0 and hematocrit 24.6, INR greater than 16.6, PT greater than 145.0, and PTT 61 . There is a firm area of ecchymosis (subcutaneous spot of bleeding) at the right mid to lower abdomen and mild tenderness to palpation of the abdomen . Multiple areas of ecchymosis noted including at the extremities and abdomen. Sacrococcygeal area draining wound present. Back: There is an approximate 3 x 4 cm ulceration at the sacrococcygeal area draining fluid that is not obviously pus . Assessment/Plan: 1. Altered mental status/metabolic [MEDICAL CONDITION] . 3. Iatrogenic coagulopathy with INR greater than 16.6 . Lab results: PT: > 145.0 seconds High, INR: > 16.6 Critical, PTT: 61 seconds Abnormal . Review of labs for Resident #101 revealed there were no labs that monitored the [MEDICATION NAME] levels for the duration the resident was taking the medication. Review of Resident #101's chart revealed there were no skin assessments documented that monitored or indicated bruising. In an interview on 5/23/19 at approximately 12:00 p.m., Licensed Practical Nurse (LPN) B reported a new medication ordered and put into the computer, goes directly to the pharmacy who receives it immediately. Then the nurse on the following shift checks the orders to verify accuracy. LPN B was not sure what had happed to Resident #101's order. In an interview on 5/23/19 at 12:56 p.m., Registered Nurse (RN) C reported the facility implemented [MEDICATION NAME] log checks for residents who were prescribed [MEDICATION NAME]. Before a resident receives [MEDICATION NAME], the PT and INR labs need to be in the logbook and checked. Once the orders received and put into the computer on day shift, the second shift nurse checks the orders for accuracy, then the third shift nurse checks for accuracy. If a resident needed a medication right away, another nurse on the day shift can verify as well. In an interview on 5/23/19 at 2:48 p.m., Nurse Practitioner (NP) F reported she was filling out the discharge summary for Resident #101 and noticed the [MEDICATION NAME] on her orders. NP F realized there were no routine labs for [MEDICATION NAME]. Upon further investigation, NP F did not order [MEDICATION NAME] for Resident #101, nor did the physician. NP F reported Resident #101 refused medications and labs to check coagulation status and decided to send the resident to the hospital since she had an altered mental status as well. NP F could not elaborate how this error occurred. When queried about the Pharmacy Recommendations for Resident #101, NP F reported the physician signed them but would usually get so many and just sign them unless there was something significant that needed attention. In an interview on 5/23/19 at 3:25 p.m., RN D reported she put the orders for another resident into Resident #101's chart. RN D reported the process was that the night shift would review new orders and that was how the other residents' orders were corrected and received. But since Resident #101 did not have written orders to compare and directly put into the computer, the following nurse did not know to check Resident #101's orders. RN D reported the new process for all residents who received [MEDICATION NAME] are in the logbook and checked for PT/INR orders before administration. In an interview on 5/23/19 at 4:33 p.m., Consultant Pharmacist (CP) H reported the only thing that would alert a pharmacist about Resident #101's [MEDICATION NAME] order is that the dose was higher than what one would usually start on, but even then, the physician can start a resident on that dose. CP H reported he attends QUAPPI every 3 months and surprised to hear about the [MEDICATION NAME] medication error when it happened. Review of the Davis's Drug Guide Thirteenth Edition revealed [MEDICATION NAME] ([MEDICATION NAME]) . Contraindicated in: Uncontrolled bleeding; Open wounds; active ulcer disease; . severe kidney disease; uncontrolled hypertension . Route/Dosage: 2-5 mg/day for 2-4 days, then adjust daily dose by results of INR. Initiate therapy with lower doses in geriatric or debilitated patients . Nursing Implications: Assessment: Assess for signs of bleeding and hemorrhage . Patients over 60 yr (year) exhibit greater than expected PT/INR response . Lab Test Considerations: Monitor PT, INR and other clotting factors frequently during therapy . monitor stool and urine for occult blood .High Alert: Medication errors involving anticoagulants have resulted in serious harm or death from internal or intracranial bleeding. Before administering, evaluate recent INR/PT results and have second practitioner independently check original order .Because of the large number of medications capable of significantly altering [MEDICATION NAME]'s effects, careful monitoring is recommended when new agents are started, or other agents are discontinued . Review of a Policy titled Oral Anticoagulant Monitoring Policy dated 9/2016 revealed: The charge nurse shall monitor resident [MEDICATION NAME] (PT)/International Normalized Ration (INR) per physician/health care provider order using the CoagChek or other anti-coagulation monitoring device as indicated for administering anticoagulant medication. Additionally, the charge nurse shall: 1. Notify the physician/health care provider of the PT/INR 2.Promptly report abnormal lab results to the physician/health care provider 3. Document the PT/INR values in the resident record. 4. Observe and notify the physician/health care provider of signs/symptoms of bleeding that may include, but are not limited to: a. Hemorrhage or uncontrolled bleeding, b. Blood in urine or stools, . f. Frequent, severe bruising or tiny or purple spots on the skin, g. Numerous large bruises, h. The pharmacist has notified the community of a drug interaction that would affect bleeding time, i. Head injury while taking anticoagulant medications. Note: Most bleeding events are associated with INR values > 3.0 IU's. Review of a Policy titled Transcription of Orders dated 8/2000 revealed: The Nurse is responsible for the accurate transcription of all physician/healthcare providers' orders within the documentation system . 1. New physician/healthcare provider orders received in the community will be reviewed by the Nurse or designee and transcribed to the appropriate locations within the community will be reviewed by the Nurse or designee and transcribed to the appropriated location within the Resident's paper and/or Electronic Medical and Medication Record. 2. The designated staff will sign and date . 3. The Nurse will review the transcription for accuracy . 4. New orders should be added to the current Physician order [REDACTED].

This citation pertains to intake MI 1803 Based on observation, interview, and record review, the facility failed to ensure appropriate assistive devices (a gait belt) was used during transfer/ambulation for 1 resident (Resident #100), of 4 residents reviewed, resulting in a fall with a fracture. Findings include: Review of a facility policy for Gait/Transfer/Walking Belts last reviewed 10/2018 reflected Gait/transfer/walking belts are safety devices used for assisting a resident with transfer and/or ambulation with mobility needs. These devices are used with residents who may have unsteady gait, are at risk for falls, or other health conditions that affect ambulation. For infection control purposes, gait belts are assigned to individual residents and should not be for general use. Resident #100 Review of a facility Admission Record dated 3/04/19 reflected Resident #100 was a [AGE] year-old man originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #100 was readmitted to the facility from a hospital on [DATE] after sustaining a fall on 3/2/19 resulting in a displaced intertrochanteric [MEDICAL CONDITION] femur that required surgical intervention. Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] (prior to fall with fracture) reflected Resident #100 was cognitively intact and needed extensive assistance from one person for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. Review of an MDS 5-Day assessment dated [DATE] (after the fall on 3/2/19 and return from the hospital) reflected Resident #100 remained cognitively intact and now required extensive assistance from 2 people for bed mobility, transfers, dressing, and toilet use. Review of a Fall Risk assessment dated [DATE] indicated Resident #100 was a high risk for falls with a score of 20 based on risk factors. The Fall Risk Assessment specified that any resident that scored a 10 or greater was at greater risk for falls and required prompt implementation of interventions to prevent a fall. Review of a Kardex (a guide used by nurse aides that specifies individual care needs), printed on 3/4/19 reflected Resident #100 needed to be ambulated with assistance and be reminded to wear gait belt around his waist and not his chest. The Kardex also directed staff that Resident #100 needed extensive assistance with transfers and a 4-wheeled walker. Review of a Progress Note dated 3/2/19 at 22:23 (10:23 p.m.) reflected (Resident #100) was sent to (Local Hospital) emergency department for evaluation and treatment after a witnessed fall in his room. Pain to his left hip. Resident hit his head. Neuros WNL (within normal limits) at this time . Review of an Incident Report dated 3/2/19 reflected (Certified Nurse Aide (CNA A) was assisting (Resident #100) to get ready for bed. She assisted resident to stand with walker, helped him steady himself then proceeded to walk with the resident. Resident started to remove his shirt and lost his balance and fell backwards hitting his head and landing more on his left side. When CNA A was interviewed, she stated that she was not using a gait belt. Attempts were made to contact CNA A via telephone on 3/15/19. Messages were left and no return call was received as of the writing of this report. Review of a written statement signed by CNA A reflected I walked into (Resident #100's) room and he was sitting in his reclining chair. I asked him if he was ready for bed. He said yes. I grabbed his walker and brought it to him. He stood up. I waited a minute to let him get steady. (Resident #100) and I started walking to the bathroom. When we reached the end of his bed he realized he hadn't taken off his shirt. He started to take off his shirt and lost his balance. That is when he fell . During an observation and interview on 3/15/19 at 11:00 a.m., Resident #100 said he recalled the fall on 3/2/19. When asked, Resident #100 said he was trying to get to the bathroom and stopped to get his shirt off; when he took his hand off his walker, he lost his balance and just went down. Resident #100 said the nurse aide did not put a gait belt on him at the time and that was an isolated incident. Resident #100 said the staff always put a gait belt on him while assisting him to transfer. A gait belt was observed in Resident #100's room, resting on the arm to his walker. During an interview on 3/15/19 at 8:45 a.m., the Director of Nursing (DON) reported that every resident has their own gait belt and that is stored in their room. During an interview on 3/15/19 at 9:20 a.m., Certified Nurse Aide (CNA) D reported that every resident has their own gait belt and that the belts are stored in the resident rooms. CNA D said it was nice because you didn't have to worry about losing or forgetting to bring a gait belt. During an interview on 3/15/19 at 10:50 a.m., CNA B reported that gait belts are to be used with every single transfer. CNA B said she could review a resident's Kardex (a reference for aides to know how to care for residents) to determine transfer status or review a worksheet that is printed daily with specific resident interventions. Review of the Care Guide that CNA B was using revealed consistency with observations and review of sampled resident Care Plans and Kardex findings in the clinical record. During an interview on 3/15/19 at 11:05 a.m., CNA D said a gait belt is to be used with every transfer and that a CNA could always give more assistance than was care planned but was never allowed to offer or allow less assistance than was care planned without authorization by therapy evaluations. CNA D also had a printed care guide for residents on the unit she was assigned to which was consistent with observations and records reviewed for sampled residents.

This citation pertains to MI 232 Based on interview and record review, the facility failed to honor one resident's rights when she became unresponsive and the the facility failed to perform cardiopulmonary resuscitation (CPR), failed to obtain resident advance directives, and failed to deem one resident (Resident #105) incompetent to make her own medical decisions, out of 9 residents reviewed for advance directives and code status, resulting in an immediate jeopardy when Resident #105 did not recieve CPR per her last known code status. Findings include: According to a facility face sheet dated [DATE] at 8:34 p.m., Resident #105 was a [AGE] year-old female admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. Review of a Minimum Data Set Assessment (MDS) brief interview for mental status (BIMS) on [DATE] was 15 out of 15 indicating Resident #105 was cognitively intact. Resident #105 was found in bed with no heart rate or lung sounds by the Registered Nurse (RN) W on [DATE] at approximately 5:30 P.M., and did RN W did not perform cardiopulmonary resuscitation on Resident #105. According to a progress note dated [DATE] at 5:35 p.m. by Registered Nurse (RN) W for Resident #105 reflected, Res(ident #105) pronounced dead by RN. No apical heart rate or lung sounds. Family present at time. Another progress note for Resident #105 dated [DATE] at 5:35 p.m. reflected, Res(ident #105) passed away at 1730 (5:30 PM). During an interview with Registered Nurse (RN) W on [DATE] at 2:49 p.m. she revealed that Resident #105 had a Do Not Resuscitate order and no cardiopulmonary resuscitation was performed on [DATE]. Review of a facility document for Resident #105 titled, (Name of facility) Code Category and Resuscitation Directives dated signed on [DATE] (no time noted) by Resident #105 and signed by Physician X on [DATE] (no time noted) reflected, Category B - A Full code but no ventilator directive. On [DATE] at approximately 12:40 p.m., when according a facility document for Resident #105 reflected a change in a cardiopulmonary order to, Category D by family member (FM) V indicating no code or Do not resuscitate directive without preventative medications dated [DATE] (no time noted) by FM V and signed by Physician X on [DATE] (no time noted). During an interview with Director of Nursing (DON) B on [DATE] at 4:13 p.m., she revealed that Resident #105 had not been deemed incompetent to make her own decisions by two physicians. During an interview with DON B on [DATE] at 9:52 a.m., she revealed that the family stated they had paperwork for Durable Power of Attorney naming FM V power of attorney for health decisions but this document had not been given to the facility. DON B also confirmed during this interview that no cardiopulmonary resuscitation had been performed on Resident #105, on [DATE] at approximately 5:30 p.m., upon finding her without a heart rate or lung sounds. During an interview on [DATE] at 9:52 AM with DON B, she revealed that Resident #105 did not have any Advance Directives papers on file at the facility but the family of Resident #105 had said the Advance Directives had been done naming FM V as durable power of attorney (DPOA) for medical decisions. Review of a check sheet provided by the facility on [DATE] at approximately 12:00 PM reflected, Admission Meet and Greet: .(assess) POA's (Power of attorneys), Code Status . Review of a progress note for Resident #105 dated, [DATE] at 10:37 PM reflected, Admission Meet and Greet held. Resident (#105 present with staff from therapy, nursing, dietary and social services. Reviewed projected length of stay, nursing plan including medication review and pain management, and dietary overview regarding menus and nutritional options. Emergency contact is (name of family member) and (name of FM V). POA's have not been completed. SS (social services) informed resident (#105) POA information is available if needed. Code A (full resuscitation) .PCP (primary care provider/physician) is (name of FM V). Care plan was reviewed and signed by resident (#105). During an interview and record review on [DATE] at 10:14 AM with Hospice Admissions Manager (HM) P, she revealed that upon admission to the facility, Resident #105 was competent to make her own decisions. Resident #105 was admitted to hospice care [DATE] and according to hospice documentation dated [DATE] at 3:30 PM, it reflected, Body systems Self Esteem Mental Status Finding? Oriented x 1 (times one, to self) . Patient (Resident #105) very briefly opens eyes to her name, only responded 'hi' with a smile when asked any question .Discuss preference regarding DNR (do not resuscitate) status with patient and/or responsible party? Yes .Patient has been a code C (full resuscitation, no mechanical ventilation), family requested code D (do not resuscitate) , they signed paperwork and (name of long term care facility) faxed to (name of Physician X for signature. MSW (Master of Social Work) please obtain physician signed form .Was patient asked about CPR? Yes and discussion occurred. Date asked about CPR? [DATE] Consent/Election of Benefits signed and witnessed? Yes (Patients FM V) signed consents. Review of a hospice document dated [DATE] at 12:45 PM reflected, (FM V has health care DPOA (durable power of attorney) .but do realize that it is a short prognosis. Review of a hospice document dated [DATE] at 12:00 PM reflected, Care Plan Problem Update: Deficit related to advance directives .family stated the paperwork is complete. Resident #105 had experienced a change of condition and was oriented only to herself and was possibly unable to make medical decisions for herself. During an interview and record review on [DATE] at 10:14 AM with Hospice Admissions Manager (HM) P, she revealed that hospice had a verbal confirmation from the family of an Advance Directive with medical DPOA for Resident #105 and that copies of this was requested by hospice. HM P stated on [DATE] the process to deem Resident #105 incompetent to make her own decisions was started. HM P confirmed that the Do Not Resuscitate order of Code D was signed by FM V on [DATE] (before Resident #105's process for incompetency determination had begun. According to a hospice document titled Certification of Incapacity To Give Informed Consent and Make Health Care Decisions for Resident #15 dated [DATE] by Physician R reflected, A hospice patient (Resident #105) who has lost the ability to understand the full details of the situation and use judgement and reason to make care decisions. One physician had deemed Resident #105 incompetent to make decisions on [DATE], one day before Resident #105's death on [DATE]. According to a facility policy titled, Advance Directives dated ,[DATE] reflected, Policy Overview: On admission the Admissions Department or designee will notify and provide information to each resident or resident representative, regarding his/her right to make an Advance Directive. Advance Directives are a written method through which a resident or resident's legal representative may provide directions or wishes as to their medical care. Advance Directives are used when a resident is unable to make or communicate his/her decisions about medical treatment. It is prepared before any condition or circumstances occurs which causes the resident to be unable to actively participate in decisions about his/her medical care. If a written Advance Directive does not exist and the resident or resident representative is unable to make a health care decision, the community will take such action as is consistent with applicable laws and the policies of the state in which the community is located 2. Each resident or resident representative should be asked at the time of admission if he/she has executed an Advance Directive. If the resident or resident representative answers 'yes', a copy of the Advance Directive should be obtained and placed in the resident's medical record. The resident's physician should be informed of the Advance Directive so that appropriate orders can be obtained in the resident's medical plan of care. Obtain state specific out of hospital DNR (do not resuscitate) as indicated. According to a facility policy dated ,[DATE] titled, Capacity/Decision Making) reflected, Policy overview: this community shall follow the Patient Self Determination Act (PSDA) and applicable State law to support the right of residents to make his or her own health care decisions when possible. The Physician or other acceptable practioner as designated under State law, shall determine the resident's capacity upon admission, with any significant change of condition and during the monthly review of orders .5. The resident's capacity to make health care decisions shall be reviewed with any significant change of condition. The health care provider shall review the capacity statement in the resident's medical record and affirm agreement with the capacity statement by signing the orders or change the capacity statement. The Interdisciplinary Team (IDT) shall review the resident's capacity during each quarterly review and as needed to make recommendation to the physician if any change is noted in the resident's ability to make sound decisions. If there is a change, a member of the IDT shall be designated to inform the physician who will make determination of the resident's capacity at the time. According to a facility policy dated ,[DATE] titled, Do Not Resuscitate reflected, Policy overview: Resident have the right to make choices about their care. They are encouraged to document their wishes and provide the appropriate directives to their families/legal representative, and physician/healthcare provider. (Name of facility) will honor Do Not Resuscitate (DNR) orders. Physician order [REDACTED]. A. Upon admission to the community or soon thereafter, the community admission coordinator or designee will obtain a copy of resident advance directives, when applicable. the community representative will very and confirm the resident/legal representative's desire for resident code status, obtain appropriate documentation and identify resident's desire according to the community's procedure. B. DNR orders must be signed by the residents health care provider on the physician's orders [REDACTED].C. Advance Directive Information and DNR Order/POLST for (if appropriate) must be completed and signed by the licensed health care provider and resident (or resident's legal representative as permitted by State law) and placed in the resident's medical record .D. Social services or designee shall discuss and provide information regarding advance directives to the resident/legal representative shortly after admission, significant change of conditions and periodically for routine updating of care plans .F. A DNR Order will remain in effect until resident or legal representative provides the community with a verbal and/or written request to end the DNR order . On [DATE] at 4:15 PM, the Administrator A and DON B were notified of an Immediate Jeopardy that began on [DATE] at approximately 5:30 P.M On [DATE] the State Agency verified the facility completed the following to removed the immediacy: 1) Resident #105 is deceased as of [DATE]. No further action to be completed for this resident. 2) An audit was completed on [DATE] by the DON B and Social Worker U on all current resident's code status to determine what the code status is, does the resident/responsible party verify that the code status is correct, is there a doctor's order matching the resident's wishes, does the care plan match the resident wishes, and is there a Durable Power of Attorney (DPOA) that is activated and is the code status signed by the correct person. There were no discrepancies found. 3) Starting on [DATE], nursing staff were re-inserviced on resident rights, code status recognition, appropriate procedures in responding to a code, and procedure to be used if a code status is changed and who has legal authority to sign the code status. Nursing staff will receive this re-inservice education prior to beginning of shift worked. Nursing associates CPR (Cardiopulmonary Resuscitation) status will be verified and only associates that are current in their certification will be allowed to work on the floor. Re inservicing will be completed by the Education Coordinator and designee. Associates involved in DPOA paperwork and activation will be re inserviced on obtaining proper DPOA paperwork, in absence of this paperwork, education resident/responsible party on completing DPOA, in cases where resident declines to complete this paperwork, associates will document resident wishes on who would make decisions if they were unable to. This re inservicing will begin on [DATE] and continue until these associates have received this training prior to returning to work. Re inservicing will be completed by Education Coordinator or designee. 4) Compliance will be monitored by the DON B and Administrator A or designees with weekly random audits of current residents for 4 weeks and then monthly to review accuracy of new resident code status and accurate DPOA paperwork as necessary. Advance directive paperwork will be reviewed upon admission by Social Services. Current resident's code status will be reviewed at care conference or change of condition. Human Resource Director (HRD) Y or designee will monitor nursing associate CPR status by monthly audits. these audits will be reported to the Quality Assurance Performance Improvement Committee (QAPI) for 3 months or as determined by the Committee. DON B will be responsible for sustained compliance. Although the immediate jeopardy was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency and all education had not yet been completed.

This citation pertains to MI 705, MI 989 and MI 632 This citation contains 2 deficient practices DPS #1). Based on observation, interview and record review, the facility failed to administer oxygen at the ordered rate for one resident (Resident #104), out of 9 residents reviewed for quality of care, resulting in change of consciousness and hospitalization . Findings include: Resident #104 Oxygen According to a facility face sheet dated 7/26/18 at 12:39 PM, Resident #104 was an [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. On 7/24/18 at 10:35 AM, during an interview and observation of Resident #104 in her room, Resident #104 was observed to be dressed in her wheelchair to the left side of her bed. Resident #104 was observed to be covered by a blanket over her shoulders. Oxygen was on per nasal cannula hooked to a concentrator at 4 liters. Resident #104 stated she remembered an incident where she needed her portable oxygen tank changed and she was taken off her concentrator and brought to the room with the portable tanks and the tank was replaced and she was returned to her oxygen. Resident #104 revealed she didn't think it was over a few minutes. Review of a facility document for Resident #104 titled, Treatment Administration Record dated 3/1/18 to 3/31/18 reflected the treatment order, O 2 (oxygen) at 2 L (liters) per nasal cannula every shift. Start 3/23/18 at 6:00 AM and d/c 3/24/18 at 4:30 PM. Review of a progress note dated 3/23/18 at 9:49 PM reflected, Resident is a/o (alert and oriented) x (times) 4. Resident takes pill whole. Resident presents with Foley cathteter (sic). this nurse re set catheter securement device this evening. Resident continues on 3 lpm (liters per minute) of oxygen . During an interview with PT (Physical Therapist) E on 7/24/18 at 11:08 AM, she revealed she went to get Resident #104 for a PT evaluation. Resident #104 was on oxygen per her concentrator. When PT E stated she went to hook up Resident #104 to her portable oxygen, she realized the portable tank was empty so she took Resident #104 in her wheelchair to go to the room where the portable tanks are stored. As soon as PT E and Resident #104 was out of the room PT E revealed that Resident #104's family member was outside of the room and stopped them and asked if it was ok for Resident #104 to sign a paper. As soon as they were finished, PT E took Resident #104 by wheelchair quickly to the room where the portable oxygen was stored and put Resident #104 on portable oxygen, 4 L per nasal cannula. PT E revealed Resident #104 was off of oxygen 3 to 4 minutes tops. PT E stated she put Resident #104's oxygen at 4 L. PT E stated she looked at Resident #104's concentrator to see how many liters of oxygen she had been using and placed her on 4 L to match the oxygen concentrator. PT E stated this was Resident #104's first time in physical therapy and Resident #104 was tired. PT E stated she checked Resident #104's oxygen level with an oximeter and it was 97% (normal range). PT E revealed Resident #104 was fine then said she wasn't feeling well so PT E took her back to her room and told the nurse. PT E stated Resident #104 stopped talking and a hoyer mechanical lift was used to place Resident #104 back into bed. PT E stated when Resident #104 was back in bed, she was awake. PT E stated Resident #104 was out of it but wasn't sure if she lost consciousness. PT E was asked if she had to do it over would she do anything differently. PT E stated she would have gone and got the tank and left Resident #104 in her room on the oxygen concentrator. Review of a facility document titled, In Service Record dated 4/10/18 (no time noted) Topic: O 2 Management by Nasal Cannula. This document was signed by PT E and reflected, Provided training, team member provided return demonstration for change O2 (oxygen) cylinder and turning on O2 per (name of facility) competency protocol. Review of a facility document titled, Oxygen Therapy by Nasal Cannula Competency reflected, Change the Oxygen Cylinder .Turn on Oxygen .Adjust the flow knob on the regulator clockwise until the gauge reaches the flow rate the physician has prescribed. This document was signed by PT E on 4/10/18. During an interview with Minimum Data Set Nurse (MDS) Z filling in for absent Director of Nursing (DON) B, she revealed the facilities expectation when switching from an oxygen concentrator to portable oxygen to find out what level of oxygen the resident needed, orders needed to be consulted. MDS Z confirmed that settings on an oxygen concentrator should never be assumed as correct. Review of the hospital History and Physical report, printed on 3/26/18, for Resident #104 from her admission to the hospital from 3/24/18 through 3/27/18 reflected, Pt (patient) comes from (name of long term care facility). Was in a wheelchair about to do PT (physical therapy) when she became unconscious. On 4 L (liters) all time. Was not on O 2 (oxygen) when she had syncopal episode. A & O (alert and oriented) x 4 now. Denies pain, Denies SOB (shortness of breath). History of present illness: .Family reports just did not have the patient's home oxygen in place. She typically needs 4 L of oxygen continuously. She had a brief episode (apparently [MEDICATION NAME] seconds) of fatigue increased consciousness where she was not answering her name. There was no witnessed [MEDICAL CONDITION] activity. Patient denies any preceding chest pain or palpitations. She was feeling short of breath when this occurred .Assessment/Plan: [MEDICAL CONDITION]. Like secondary to dehydration, orthostatsis due to position change as well as [MEDICAL CONDITION] developing from nasal cannula not being in place .Hospitalist attending note: The patient (Resident 3104) was seen and examined independently. charts and relevant laboratory and imaging studies were reviewed personally. Case was discussed in detail with APP. medical decision making was collaborative. I agree with assessments and plans as noted in the notes above. [AGE] year old female presented after syncopal episode. Likely secondary to dehydration and orthostatsis due to position change as well as [MEDICAL CONDITION] developing from nasal cannula not being in place . During review of a facility policy titled Oxygen Management dated reviewed 11/2017 reflected, Policy overview: This policy will provide associates guidelines for the safe storage and use of oxygen .2. Oxygen Administration: Verify that there is a physician's order for this procedure. Review the health care provider's orders or community protocol for oxygen administration. Review the resident's care plan to evaluate for any special needs of the resident. 3. i) If the resident requires oxygen during transport, small oxygen canisters may be utilized. DPS #2). Based on observation, interview and record review, the facility failed to answer call lights timely for two residents (Resident #100 and 106), out of 3 residents reviewed for call lights, resulting in frustration and the potential for residents' needs not to be met. Resident #100 Call light According to a facility face sheet dated 10/11/17 at 7:52 AM, Resident #100 was a [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Review of a facility investigation summary dated 10/11/17 (no time noted) reflected, Resident (#100) son made complaint to LPN (Licensed Practical Nurse) on 10/10/17 .that his call light times were long and he had been incontinent 3 to 4 times because of it. He said that his care was good. Facility review call light times for resident (#100) and also the bowel and bladder log to check for incontinence. Resident (#100) had one documented incontinence episode. he did have several long wait times AEB (as evidenced by greater than 10 minutes. the one incontinent episode was not related to a long wait time. Staff was interviewed to verify documentation accuracy. Staff states resident is continent of bowel and bladder and does not sue his urinal. Resident cognitive status is documented as A&O (alert and oriented) x 2 to 4. His (Resident #100) BIMS (Brief interview for mental status score) was 11 indicating moderate impairment Facility does have to substantiate call light wait time but can not substantiate incontinence . Review of a an MDS Admission Assessment (Minimum Data Set Assessment) for Resident #100 dated 11/11/17 reflected, 3/2 (extensive assistance of one) for transferring and a 2/2 (limited assistance of 1) for ambulation and 3/2 (extensive assistance of one) to toilet. Always continent of bowel and occasionally incontinent of bladder. Review of a document titled Activities Report for room Resident #100 resided in presented as call light times dated from 10/7/17 to 10/13/17 reflected: 10/12/17 at 11/23 PM to 11:37 PM - 12 minutes 10/12/17 at 9:5 AM to 10:09 AM - 13 minutes 10/11/17 at 6:01 PM to 6:12 PM - 11 minutes 10/10/17 at 8:58 PM to 9:09 PM - 11 minutes 10/8/17 at 8:05 AM to 8:22 AM - 17 minutes 10/7/17 at 3:54 PM to 4:11 PM - 17 minutes 10/7/17 at 8:13 AM to 8/29 AM - 16 minutes 10/7/17 at 7:05 AM to 7:34 PM - 29 minutes 10/6/17 at 7:09 AM to 7:31 AM - 22 minutes 10/6/17 at 7:15 PM to 7:34 PM - 19 minutes 10/6/17 at 8:07 PM to 8:19 PM - 12 minutes During an interview on 7/26/18 at 9:59 AM, with MDS (Minimum Data Set Nurse) Z, she revealed the expectation for answering call lights was at 10 minutes for call lights, 5 minutes for bathroom call lights. Resident #106 Call light According to a facility document for Resident #106 titled, Medication Administration Record [REDACTED]. Review of an incident dated 7/9/18 at 4:00 AM reflected, Resident (#106) complaint that the CNA (certified nurses aide) did not return to assist her . Review of call light activity for Resident #106's room presented by the facility as call light times reflected on 7/9/18 at 2:12 AM it took 18:20 minutes to answer Resident #106's call light. This document also reflected, 7/8/18 at 8:47 AM to 9:09 AM - 22 minutes 7/8/18 at 2:59 PM to 3:17 PM - 17:52 minutes Review of a facility policy dated last revised 10/2016 titled, Resident Call system and Door Alarm Response reflected, Policy overview: Associates shall respond to resident call system alerts and door alarms in a reasonable and timely manner. If the resident call system has capacity for data storage, data will be maintained for no longer than 90 days. If applicable, data may be utilized as part of performance improvement and tracking and trending for customer satisfaction and may not be shared unless state-required. Background: 1) Residents may use various means to request assistance including: a) resident call systems. these systems allow resident to activate the system by pushing an accessible button on the wall or pendant or pulling a cord. The may include equipment such as central call panels and caregiver pagers .B) Responding to resident call system alerts 1) follow these directions for responding to resident call system alerts: a) When an associate receives a resident call system alert, he or she should respond within a timely manner. b) If the associate is unable to respond in a timely manner, he or she should request assistance from another associate .

This citation pertains to intake number MI 179 Based on interview and record review, the facility failed to ensure that nurses provided care in keeping with the professional standards of quality care for 1 of 11 sampled residents (#804) sampled for medication practices, from a total of 11 sampled residents, resulting in the potential for the exacerbation of physical, mental and psychosocial conditions and the potential for medication overdose. Findings Include: Documentation within a client medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track (resident) outcomes, and reflect current standards of nursing practice .Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors .The record is a means by which health care team members communicate (resident) needs and progress .The record should be the most current and accurate source of information about a client's health care status .High-quality documentation .(is) necessary to enhance efficient, individualized (resident) care. Quality documentation .(has) five important characteristics: they are factual, accurate, complete, current, and organized (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). According to Creighton in Law Every Nurse Should Know 5th edition, (pg. 13), The collection of data about the health status of the patient is systematic and continuous. These data are communicated to appropriate persons, recorded and stored in a retrievable and accessible system. Nursing assessment is the deliberate and systematic collection of data of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). Resident #804 Review of a Face Sheet revealed Resident #804 was a [AGE] year old male readmitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment, with a reference date of 05/11/16, revealed Resident #804 was cognitively intact and required assistance to transfers, get dressed, feed himself and bathe. Review of a hospital Patient Discharge Instructions medication list dated 12/01/16, page 2, found in Resident #804's medical chart, listed [MEDICATION NAME] ([MEDICATION NAME]-12 [MEDICATION NAME] film, extended release) 1 patch(es), every 72 hours, Refills:0, Last Dose: 11-28 at 1800. Review of Nursing Progress notes dated 12/01/16 found no documentation that a nurse had done a complete head to toe assessment on Resident #804 when he was admitted to the facility on [DATE] and no documentation was found describing the location of the [MEDICATION NAME] Patch that Resident #804 was admitted with from the hospital. Review of a conversation between Director Of Nursing (DON) B and Registered Nurse (RN) J, dated 12/06/16 at 2:45 P.M., revealed that RN J indicated that she did assess the [MEDICATION NAME] Patch on Resident #804 when he was admitted to the facility and passed along the information to the next shift nurse RN K. That information was not found on any nursing assessments in Resident #804's medical chart. In an interview on 06/20/17 at 11:45 A.M., RN K indicated that she remembers the [MEDICATION NAME] was supposed to come in on 3rd shift and it did not arrive. RN K also reported that at shift exchange on 12/01/16, she was not told by RN J that Resident #804 already had a [MEDICATION NAME] on his person. RN K stated she did not do a skin assessment on Resident #804 because she had not admitted the resident nor did she place a [MEDICATION NAME] on his person during her shift. In an interview on 06/20/17 at 11:05 A.M., Licensed Practical Nurse (LPN) L indicated that when she received 3rd shift report on the morning of 12/02/16, from RN K, Resident #804 had not yet gotten the [MEDICATION NAME] Patch that was ordered and was told that when the [MEDICATION NAME] Patch did come in, it needed to be placed on Resident #804. LPN L stated that she was not told that Resident #804 already had a [MEDICATION NAME] Patch on his person but that she did do a quick skin check on his back and arms to see if Resident #804 already had a patch on his person, because that's what should be done. LPN L stated that she did not have a chance to check the chart to see if it was a new order and that she did have the ability to check the chart. LPN L also indicated that she remembered they were trying to get him up and it was rushed a bit. It was lunch time. It was really busy and I didn't get a chance to check the chart to see if there was [MEDICATION NAME] Patch already on Resident #804.

This citation pertains to intake # MI 179. Based on interview and record review, the facility failed to prevent a significant medication error for 1 of 11 sampled residents (#804) sampled for medication errors, from a total sample of 11 residents, resulting in the need for urgent and immediate medical attention and the potential for death. Findings include: Review of a Face Sheet revealed Resident #804 was a [AGE] year old male readmitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of Post Acute Care Transfer Instructions, found in Resident #804's medical chart, dated 12/01/16 at 11:39 A.M., page 2, lists an order for [REDACTED].). The order also indicated the date and time the [MEDICATION NAME] had been placed on Resident #804 while at the hospital; 11/28/16 at 17:57 EST (5:57 P.M.). Page 2 of the instructions had a check mark and was initialed by Registered Nurse (RN) K. Review of a hospital Patient Discharge Instructions medication list dated 12/01/16, page 2, found in Resident #804's medical chart, listed [MEDICATION NAME] ([MEDICATION NAME]-12 [MEDICATION NAME] film, extended release) 1 patch(es), every 72 hours, Refills:0, Last Dose: 11-28 at 1800. Review of Nursing Progress notes dated 12/01/16 revealed no documentation to indicate a facility nurse had done a complete head to toe assessment on Resident #804 when he was admitted to the facility on [DATE] and no documentation was found describing the location of the [MEDICATION NAME] Patch that Resident #804 was admitted with from the hospital. Review of Medication Administration Record [REDACTED]. Further review of MAR indicated [REDACTED].M. and one [MEDICATION NAME] Patch 12 MCG/HR on 12/2/16 at 1:10 P.M. No additional order to remove the previously placed [MEDICATION NAME], applied at the hospital on [DATE] was located on the MAR. Review of Treatment Administration Record (TAR) dated 12/01/16 to 12/31/16 indicated that Resident #804 was ordered to receive 2 ounces of Gin with lemon twist three times daily: during the day, during the evening, and at night. Further review of TAR revealed that Resident #804 received the 2 ounce Gin cocktail during the evening and night of 12/02/16 and the evening of 12/03/16. Review of BD SBAR Communication Form and progress note dated 12/03/16 at 2100 (9:00 P.M.) indicated the following: Writer at 2040 (8:40 P.M.) was attempting to administer HS (bedtime) medications and observed resident having episode of apnea (not breathing) of 20 sec (seconds). Upon further immediate assessment writer attempted to arouse resident in bed and noted was unresponsive with stimulation. Writer immediately assessed VS (vital signs) and noted B/P (blood pressure) 80/52, temp (temperature) 99.2, o2 on RA (oxygen saturation in the blood on room air) 71%, Resp (respirations/breaths) 6 (per minute) shallow and labored, Apical Pulse ( Pulse checked by listening directly to heart beats) of 45 and faint. Right eye pupil was noted with [MEDICATION NAME]. 2nd nurse immediately responded and code status was assessed Crash cart and AED ( automatic electronic defibrillator) at bedside. 2nd nurse immediately called 911 for emergency transport at 2042 (8:42 P.M.). Writer immediately place O2 (oxygen) per mask running at 5L (Liters). AMR (local ambulance service) arrived at 2053 (8:53 P.M.). Res (Resident #804) left (the facility) at 2059 (8:59 P.M.) via AMR. Review of Hospital Progress Note dated 12/05/16, page 18, revealed The patient was found by the staff at (facility name) unresponsive with a heart rate in the low to mid 30's (heart rate for Resident #804 had been 55 to 71 in past 36 hours). He was given IV (intravenous/ through a vein) [MEDICATION NAME] (medication used to reverse the affects of an overdose) en route with some improvement in his neurological status. Patient again became unresponsive and a CODE BLUE was called in the emergency department. Patient was given IV [MEDICATION NAME] and started on a [MEDICATION NAME] drip with some improvement in his mental status. Patient was found with 2 [MEDICATION NAME]es on his back. In an interview on 06/20/17 at 11:05 A.M., Licensed Practical Nurse (LPN) L indicated that when she received 3rd shift report on the morning of 12/02/16, from Registerd Nurse (RN) K, Resident #804 had not yet gotten the [MEDICATION NAME] Patch that was ordered and was told that when the [MEDICATION NAME] Patch did come in, it needed to be placed on Resident #804. LPN L stated that she was not told that Resident #804 already had a [MEDICATION NAME] Patch on his person but that she did do a quick skin check on his back and arms to see if Resident #804 already had a patch on his person, because that's what should be done. LPN L stated that she did not have a chance to check the chart to see if it was a new order and that she did have the ability to check the chart. LPN L also indicated that she remembered they were trying to get him up and it was rushed a bit. It was lunch time. It was really busy and I didn't get a chance to check the chart to see if there was [MEDICATION NAME] Patch already on Resident #804. During an interview on 06/22/17 at 8:00 A.M., Director of Nursing (DON) B indicated that the incident involving Resident #804 and the second [MEDICATION NAME] being placed without removing the previously applied [MEDICATION NAME], was totally our fault and could have been lethal.

Based on interview and record review the facility failed to ensure the safety and prevent a fall with injury in 1 of 3 sampled residents (Resident #1) reviewed for falls, from a total sample of 3 residents, resulting in Resident #1 having a second fall which resulted in a fractured femur (large upper leg bone) and increased pain. Findings include: Review of the Face Sheet revealed Resident #1 was an [AGE] year old female admitted to the facility on [DATE] and diagnosed with [REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 was an extensive assist of 1 person for transfer and had severely impaired cognition. Review of the Nursing Admission Data Collection dated 7/16/16 at 9:32 pm, revealed Resident #1 ambulates with problems and with devices (gait is unsteady, slow, lurching) and Resident #1's balance was not steady, only able to stabilize with physical assistance. The Nursing Admission Data Collection further revealed, Yes Resident #1 was at risk for falls. Review of the Falls Investigation Worksheet dated 7/24/16 at 11:00 am, revealed Resident #1 attempted a self transfer from her recliner and had an Unwitnessed fall. Review of the Care Plan at risk for falls dated 7/16/16 and updated 7/24/16 revealed Resident #1 fall intervention after her unwitnessed fall from her recliner on 7/24/16 was to be offered to lay down in bed after meals. Review of the Fall Risk Data Collection dated 7/24/16 at 3:17 pm, revealed Resident #1 was easily distracted; periods of altered perception or awareness of surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varies over the course of the day . and Resident #1 was at risk for falls related to weakness, confusion. Review of the Facility Reported Intake dated 7/29/16 revealed on 7/28/16, Resident #1 was found alone in room observed on floor sitting on buttocks and Hospital x-ray results of left femur show a fracture .appears the resident attempted to self transfer from recliner in her room. In an interview on 8/11/16 at 2:06 pm, Registered Nurse (RN) E stated on 7/28/16, she took Resident #1 to the bathroom. RN E stated Resident #1 was a 1 assist with toilet use before the fall on 7/28/16. RN E stated after Resident #1 used the toilet she brought Resident #1 to the dining room and then back to Resident #1's room. RN E stated Resident #1 was in her recliner chair .she likes the recliner. RN E stated, on 7/28/16 that Resident #1 refused to go in her bed and stated she (Resident #1) wanted to be in my recliner. RN E stated Resident #1 wanted to lay back in her recliner and put the controls (for the recliner) under her left arm. RN E stated she was at the nursing desk and heard loud noise, got up and found Resident #1 sitting on the floor on her butt, saying it hurt everywhere. RN E stated Resident #1's recliner was all the way up and that Resident #1 had made it a couple of feet from the recliner. RN E stated she contacted the ambulance which took Resident #1 to the emergency department In an interview on 8/11/16 at 2:40 pm, Certified Nurse Aide (CNA) C stated before the fall on 7/28/16 Resident #1 was in her recliner, her feet were slightly up (elevated). CNA C stated Resident #1 frequently requested to be in the recliner. CNA C stated the only time she (Resident #1) would lay in bed would be after the 11 o'clock news. In an interview on 8/11/16 at 3:00 pm and 4:35 pm, Director of Nursing (DON) B stated Resident #1 made the choice to get up from her recliner on 7/24/16. DON B stated Resident #1 still had use of the recliner after fall on 7/24/16. DON B stated Resident #1 normally didn't get up from the recliner. DON B was asked by the surveyor why increased supervision was placed on Resident #1 after the second fall with fracture on 7/28/16. DON B stated, because she (Resident #1) had gotten up twice there was evidence she had gotten up a second time from her recliner. Review of the Kardex, undated/un-timed revealed Resident #1's pain is aggravated by movement and weight bearing status: NWB (non weight bearing) bed rest. Review of the Progress Notes dated 7/23/16 at 12:12 am, revealed Resident #1 was given Tylenol 325 MG (milligram) by mouth every 4 hours as needed for pain. Review of the Progress Notes dated 7/30/16 at 8:48 pm revealed Resident #1 had Morphine Sulfate (narcotic prescription pain medication) solution 20 mg/ml (milliliter). Give 0.25 ml by mouth every 2 hours as needed for left femur fx (fracture) .PRN (as needed) Administration was: Effective. Review of the Progress Notes dated 7/30/16 at 10:51 pm revealed Resident #1 had Morphine Sulfate solution 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for left femur fx .6/10 leg pain. Review of the Progress Notes dated 7/31/16 at 1:14 am revealed Resident #1 had Morphine Sulfate solution 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for left femur fx .6/10 pain. Review of the Progress Notes dated 7/31/16 at 5:28 am revealed Resident #1 had Morphine Sulfate solution 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for left femur fx .resident in pain at 8 on 0-10 scale. Review of the Progress Notes dated 7/31/16 at 11:19 am revealed Resident #1 had Morphine Sulfate solution 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for left femur fx .resident having pain at 8 on 0-10 scale and requesting medication. Review of the Progress Notes dated 7/31/16 at 1:56 pm am revealed Resident #1 had Morphine Sulfate solution 20 mg/ml. Give 0.25 ml by mouth every 2 hours as needed for left femur fx .resident has leg pain AEB (as evidenced by) facial grimacing. ( )