Every finding on record at The William Breman Jewish Home

Based on observations, staff interviews, and review of the websites titled, Cozpalace.com and www.Thoracic.org, the facility failed to obtain a physician order for a CPAP (continuous positive airway pressure) unit, failed to properly label and store the CPAP supplies, and failed to document the nightly use of the CPAP unit for one of one resident (R) (R29), reviewed for CPAP use. Findings include:The facility failed to produce a policy related to the use of PAP (positive airway pressure) devices, including CPAP (continuous positive airway pressure) units.Review of the website titled, Thoracic.org, revealed distilled water should be used to humidify the pressurized air flowing through the CPAP unit.Review of the website titled, Cozpalace.com, revealed the shelf life of an opened container of distilled water for medical applications such as CPAP machines and nebulizers is one week. Review of the electronic medical record (EMR) revealed R29 was admitted with diagnoses to include, but not limited to, unspecified sleep apnea (periods of cessation of breathing during sleep).Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section GG, Functional Abilities and Goals: independent for eating; dependent for all other ADL (activities of daily living) care. The assessment was not coded for CPAP use.Review of the Care Plan revealed the following focus concerns:a. related to communication problem related to language barrier (Spanish)b. altered respiratory status/difficulty breathing related to sleep apnea. The goal was compliance with CPAP device at bedtime. The interventions were assist with applying CPAP mask at bedtime, clean CPAP mask with wipes in the am provided by family per their preference, clean CPAP weekly per manufacturer guidelines, and fill CPAP machine with distilled water before applying mask. The focus concerns, goals, and interventions were all initiated on 03/26/2026. There were no physician orders related to CPAP. Observation of R29 on 06/08/2026 at 12:27 PM revealed she did not speak English and that Spanish was her native language. Continued observation of her room revealed a CPAP unit and a half-full jug of distilled water, undated, on the nightstand, and the CPAP equipment/supplies were unbagged and undated. Subsequent observations on 06/10/2026 at 2:15 PM and 06/11/26 at 9:20 AM revealed the CPAP mask and the undated distilled water remained on the table with the CPAP supplies unbagged and undated.In an observation and interview with Licensed Practical Nurse (LPN) GG on 06/11/2026 at 2:00 PM, he confirmed that the CPAP equipment was unbagged and unlabeled and the opened jug of distilled water was undated when opened. He confirmed that respiratory supplies should be bagged and labeled when changed and that the distilled water should have been dated when opened and should not have been kept at room temperature for more than 72 hours before discarding. In a follow-up interview with LPN GG on 06/11/2026 at 4:00 PM, he confirmed there was no documentation of CPAP supply changes because there was no physician's order for the unit which her family supplied. He stated that he or other staff sometimes assisted R29 with applying her CPAP mask, but other times she applied it herself without assistance. In an interview with the Director of Nursing (DON) on 06/11/2026 at 4:30 PM, she stated that the CPAP unit should have had a physician order, should have been documented when in use, and the CPAP mask should have been bagged and labeled with the date of setup or change out. In addition, the distilled water should have been dated when opened. Finally, she confirmed that the facility did not have a policy related to CPAP use.

Based on observations, interviews, and review of facility's policies titled, Food Storage, Date and Label, and Cleaning Instructions: Ice Machine and Equipment, the facility failed to ensure proper food labeling, dating, and storage in the reach in cooler, failed to discard dry storage food items by the expiration date, and failed to maintain sanitary condition of the ice machine. The facility census was 85 residents. Findings include: Review of the facility policy titled Food Storage dated [DATE] revealed in section Refrigerated food storage: F. All foods should be covered, labeled, and dated. All foods will be checked to ensure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of the facility policy titled Date and Label dated [DATE] revealed in section Dry Storage: 7. Discard food that has expired or passed the used by date. Review of the facility policy titled Cleaning Instructions: Ice Machine and Equipment dated [DATE], revealed the purpose to ensure that ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. Procedures explained: 2. Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. 6. Clean the exterior of the machine with detergent solution daily. Rinse and allow to air dry. Clean the area underneath and around the machine. Observation on [DATE] at 9:45 am during the initial kitchen tour with the Chef/Dietary Manager (DM) revealed the following: Uncleaned ice machine with brown/red like substance found inside. Three fruit cups of yellow sliced peaches found in the cooler, unwrapped and not labeled or dated. Two one-gallon pitchers of brown liquid found in the cooler, not labeled or dated. A one-gallon pitcher of orange liquid found in the cooler, not labeled or dated. Ten single serving condiment cup/with lids found in the cooler, not labeled or dated. One wrapped plate with assorted fruits and a scoop of white like substance in center of the assortment found in the cooler, not labeled or dated. Three packages of 24 count flour tortillas found in dry storage were expired. Interview on [DATE] at 1:05 pm with Dietary Supervisor/Cook HH revealed he followed procedure, checked temperatures, cleaned, conducted labeling/dating, cooked food, or whatever the resident needed. Dietary Supervisor HH confirmed labeling and dating was everyone's responsibility, but supervisors did a walk through to catch errors. Dietary Supervisor HH confirmed maintenance was responsible for cleaning the ice machine. Interview on [DATE] at 1:55 pm with Facility Tech II revealed her kitchen responsibilities included cleaning vents, painting, fixing leaks, making sure hot water comes through, drainage, etc. Facility Tech II mentioned she also cleaned the ice machine which was usually cleaned on the first of every month or within the first week of the month. Facility Tech II explained how she would clean the ice machine by taking all the ice out, using chemicals, wiped the inside/outside boarder and seals, and discarded the first batch of ice. Facility Tech II confirmed she cleaned the ice machine this Tuesday and in November, but probably did not get into those seals properly, maybe due to rushing. Interview on [DATE] at 2:20 pm with DM revealed he checked for products with labeling/dating every day after the supervisor. The DM confirmed the labeling/dating/expiration of food items identified during the survey and shared that one of the servers was responsible for the reach in refrigerator items.

Based on observations, record review, staff interviews, and review of facility's policy titled, Advanced Directives, the facility did not properly maintain record of and the correct orders for one of 47 sampled residents (R) (R12) related to Advanced Directive choice. The deficient practice had the potential to result in the residents' wishes not being honored in the event of a medical emergency or end-of-life situation. Findings include: A review of the facility's policy titled Advanced Directives revealed under the section titled Policy Statement: Advanced Directives will be respected in accordance with the state law and facility policy. Under the section titled Policy Interpretation and Implementation revealed: Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the electronic medical record. a. Residents electronic medical record, including advanced directives must be audited on a quarterly basis. b. If the resident has a Do Not Resuscitate directive, it must be displayed at the front of the resident Chart. Review of the electronic health record (EHR) for R12 revealed he was admitted to the facility with diagnoses including but not limited to dementia, psychotic and mood disturbance, chronic lymphocytic leukemia of B-Cell type in remission, and major depressive disorder. Review of R12's quarterly Minimum Data Set (MDS) dated [DATE] documented in section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 14, indicating R12 was cognitively intact. Review of the R12's EHR profile revealed he had an advanced directive for Cardiopulmonary Resuscitation (CPR). Further review revealed the following documents related to Advance Directives: [DATE]: Advance Directives - Do Not Resuscitate (DNR) Physician Orders for Life-Sustaining Treatment (POLST) [DATE]: Advance Directive and DNR Order [DATE]: Advance Directive Review of R12's EHR revealed a Physician Order for Advanced Directive: CPR with an order date of [DATE]. On [DATE] at 01:09 pm, RN (Registered Nurse) AA confirmed that she created the order. An interview conducted on [DATE] at 1:09 pm with RN AA, she stated that typically the Social Worker provided the POLST forms, uploaded them, and sent a message to the nursing team. Once the information was received, they created an order in their EHR system for the physician to sign. RN AA explained that when patients were transferred from the hospital, they initially came in as a full code. The facility updated the code status as needed. RN AA acknowledged that she forgot to update the code status from CPR to DNR in this instance, taking full responsibility for the oversight. RN AA stated that this was a mistake and should not have happened. RN AA stated a potential negative outcome was that the resident's wishes could be disregarded, such as performing CPR against their DNR order. An observation and interview were conducted on [DATE] at 9:17 am with the Director of Nursing (DON) and revealed that Social Services typically communicated with the family to complete the POLST form, which was then forwarded to the nursing team for entry into the EHR system. The DON reviewed the incorrect advanced directive orders and confirmed that the information should be entered accurately according to the orders. The DON stated that a potential negative outcome could be resuscitating a patient who does not wish to be resuscitated, which would go against their expressed wishes. An interview on [DATE] at 9:26 am with the Administrator, she emphasized that her team's protocol was to obtain a copy of the patient's POLST form, determine the patient's wishes, and ensure the appropriate orders (DNR or full code) were entered into the chart and profile. The Administrator stated that the goal was to ensure the patient's wishes were honored, and that a negative outcome could occur if the orders were not accurately followed, potentially resulting in actions that did not align with the patient's preferences.

Based on observations, record review, staff interview, and review of the facility policy titled, Medication Administration, the facility failed to ensure the medication error rate was less than five percent (%). There were three medication errors of 30 opportunities made by two of four nurses for a medication error rate of 10 %. Findings include: Observation on 12/11/2024 at 9:37 am with Licensed Practical Nurse (LPN) BB during medication administration for Resident (R) (R50) morning medications revealed R50 had several medication in the prefilled pharmacy pouch which included acetaminophen 650 mg (milligrams) one tab and aspirin 81 mg. LPN BB proceeded to take two 325 mg acetaminophen and one aspirin 81 mg from the floor stock medication drawer and placed them in the medication cup. LPN BB proceeded and attempted to administer the incorrect medications before intervention by the surveyor. This action resulted in two medication errors. Review of the December 2024 Physician Orders for R50 revealed to administer aspirin 81 mg daily and acetaminophen 650 mg daily. During an interview on 12/11/2024 at 10:00 am with LPN BB, she reviewed the order for the acetaminophen 650 mg and aspirin 81 mg and verified the order stated R50 should receive aspirin 81 mg and acetaminophen 650 mg daily. LPN BB confirmed that there were three extra pills in the medication cup. Observation on 12/12/2024 at 9:19 am of LPN DD giving R19 his morning medications revealed LPN DD giving vitamin C 500 mg daily. Vitamin C was already in the prefilled medication pouch when LPN DD pulled another vitamin C from the floor stock medications. LPN DD proceeded to attempt to administer the vitamin C to R19 until the surveyor intervened. Review of the December 2024 Physician Orders for R19 revealed a medication order for vitamin C 500 mg daily. An interview on 12/12/2024 at 9:45 am with LPN DD, she verified that she had too many pills in the medication cup. LPN DD confirmed that she had one too many vitamin C tablets in the medication cup. An interview on 12/12/2024 at 9:50 am with the Administrator and the Director of Nursing (DON) revealed their expectations were that medication would be given according to physician's orders. They expect staff to abide by the five rights of medications. They also expect nurses to compare what was in the prefilled medications to the Medication Administration Record (MAR) before administrating medications.

Based on observations, interviews, and review of facility policies, the facility failed to maintain sanitary conditions of the cookware by not stacking wet cookware (wet nesting) to prevent bacterial growth; failed to ensure food items were labeled and dated; failed to discard leftover food by discard date; failed to maintain sanitary conditions of the stand-up mixer to prevent cross contamination; and failed to properly use the 3-compartment sink correctly to prevent food borne illness. This deficient practice had the potential to effect 81 residents receiving an oral diet. Findings include: 1.Review of the policy titled Cleaning Dishes with Dish Machine, dated 8/21 revealed procedure 9. Dishes should be air dried on the dish racks. Procedure 10. Inspect for cleanliness and dryness and put dishes away if clean. Dishes should not be nested unless they are completely dry. Observation on 7/29/22 at 9:05 a.m. during initial tour in the Meat Kitchen, revealed a drying rack, with several inverted stacks of metal steam table pans. Pans in three separate stacks were turned over revealing visible moisture (wet nesting). Interview on 7/29/22 at 9:10 a.m. with the Director of Dining Services (DDS) stated that he knows there is a problem with staff stacking the pans and wet nesting. During further interview, he stated he has been working with staff regarding not stacking pans when wet. 2. Review of policy titled Food Safety and Dining Service Sanitation dated 8/21, revealed 4. Food Storage-all time and temperature control for safety foods (including leftovers) should be labeled, covered, and dated when stored. When a food package is opened the food item should be marked to indicate the open date. This date is used to determine when to discard the food. Review of the policy titled Use of Leftovers revealed: Leftovers must be covered, labeled, and dated. Observations on 7/29/22 at 9:20 a.m. during initial tour of the Meat kitchen walk-in refrigerator revealed a one gallon opened container of Sweet Onion Salad Dressing with no open or use by date, a rectangle steam table pan containing a red food item labeled Hotdogs revealed a discard date of 7/23. Another rectangle steam table pan containing a red food item was labeled ketchup with a discard date of 7/27. Further observation of the Meat kitchen walk-in refrigerator revealed a rectangle steam table pan with chicken salad and another similar pan with chopped eggs, there was no label or date on either pan. Interview on 7/29/22 at 9:20 a.m. with the DDS, confirmed that the Sweet Onion Salad Dressing was opened and did not have an open date and that the red food items in the steam table pans had discard dates of 7/23 and 7/28. The DDS stated that he expects staff to date items after opening and expects them to look at labels and discard opened items by use by dates. The DDS confirmed that the steam table pan of chicken salad and chopped eggs had no label or date. 3. Observation on 7/29/22 at 9:45 a.m. of the Dairy kitchen walk-in refrigerator revealed two, three-pound opened containers of chocolate frosting with no open or use by date. Continued observation revealed an opened one-gallon container of mayonnaise with no open or use by date. Interview on 7/29/22 at 9:45 a.m. with the DDS, confirmed the chocolate frosting and mayonnaise were opened and not dated. The DDS stated that he expects staff to date items after opening. 4. Observation on 7/29/22 at 9:55 a.m. in the Dairy kitchen, revealed a stack of square metal steam table pans inverted on a rack. When a pan was turned over, it revealed moisture and food debris that was red and off white in color. Interview on 7/29/22 at 9:55 a.m. with the DDS revealed that he expects staff to stack pans once they are clean and dry. 5. Review of policy titled Cleaning Instructions: Food Preparation Appliances dated 8/21, revealed the purpose is to ensure that small appliances such as mixers and food processors will be cleaned and sanitized after each use. Procedure 6. Clean the outer surface of the appliance with a clean cloth that has been moistened with hot soapy water. Observation on 7/29/22 at 10:00 a.m. of the stand mixer in the Dairy kitchen revealed it was covered with a white plastic bag. When the bag was lifted it revealed a dried white substance on the beater arm and metal backsplash. Interview on 7/29/22 at 10:00 a.m. with the DDS revealed that when staff place a plastic bag over kitchen equipment, it indicates that the equipment is clean. He confirmed that the stand mixer had a dried white substance on the beater arm and backsplash. He stated that he expects staff to clean after use and before placing plastic bag over the equipment. 6. Review of the policy titled Cleaning Manual Dishwashing, dated 8/21 revealed in sink one-Wash: wash dishes in detergent and warm water to remove all soil. Sink two-Rinse: rinse dishes in clean warm water. Sink three-Sanitize: sanitize dishes by placing the dishes in the sanitizing sink, allow to stand according to the manufacturer's guidelines for sanitizer. Allow dishes to air dry. Check all dishes to be sure they are clean and dry prior to storing. Observation on 7/29/22 at 10:05 a.m. of Dietary Aide AA wash steam table pans in the three-compartment sink. He washed a rectangle steam table pan with soapy water, rinsed the pan with water then dipped and swished the pan in the sink with sanitizing solution for two seconds and placed the pan on the shelf above the three-compartment sink for drying. Continued observation revealed Dietary Aide AA took another rectangle steam table pan and washed in soapy water, rinsed, and again dipped and swished the pan in the sanitizing solution for a few seconds and placed the pan on the shelf above the sink for drying. Further observation revealed the facility uses a quaternary sanitizing solution in the three-compartment sink. Interview on 7/29/22 at 10:05 a.m. with Dietary Aide AA stated that is the way he usually washes dishes in the three-compartment sink. Interview on 7/29/22 at 10:05 a.m. with the DDS revealed that he expects staff to use the three- compartment sink correctly and stated the pans/dishes need to be in the sanitizing solution for sixty seconds.

Based on observations, interviews, record review, and policy review, the facility failed to evaluate the effectiveness of prescribed pain medications for one resident (R) (R #63) out of 24 sampled residents. Findings include: Review of the facility policy Core Components: Skilled Nursing Observation and Assessment User's Guide Pain Management dated 1/12/22 revealed under Daily Nursing Skills: Skilled assessment of pain symptoms including duration, frequency, intensity, factors that exacerbate complaints of pain and factors that relieve pain symptoms. Impact pain has on mobility, mood, sleep, relationships with others. Response to pharmacology and non-pharmacological interventions. Inadequate pain control can contribute to [CONDITION(S)], anxiety, depression, and hostility. Daily Nursing notes should address one or more of these areas of skilled nursing. A comprehensive weekly note should include all the identified nursing skills plus any periodic appropriate for the patient's Plan of Care. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the significant change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status Score (BIMS) of 6, indicating severe cognitive impairment. Resident had been on a scheduled pain management regimen and received opioids one of seven days. Review of the care plan for R#63 initiated 4/18/22 revealed R#63 has chronic hip pain. Interventions to care include administer analgesics as ordered, anticipate need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, monitor/record/report to nurse residents' complaints of pain or requests for pain treatment, and notify physician if interventions are unsuccessful. Care plan initiated on 6/28/22 revealed resident has been admitted to Hospice with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician orders for R#63 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/29/22 from 9:10 a.m. to 12:30 p.m. on the 3rd floor, R#63 was exhibiting continuous behaviors of yelling out for help. She yelled out that she cannot move her legs and that her left leg hurts so bad. R#63 continued yelling out frequently for Licensed Practical Nurse (LPN) BB asking for help stating she was having pain in her left leg. LPN BB was observed to address R#63 when he wasn't assisting other residents but he, nor any other staff were observed to reposition her or offer her pain medication. Interview on 7/29/22 at 11:50 a.m. with LPN BB, revealed this is a daily behavior for R#63 of yelling out and complaining she is in pain. He stated she has already had her [MEDICATION(S)] and it is too soon to give it to her again. Observation on 7/30/2022 beginning at 11:35 a.m. to 1:00 p.m. on the 3rd floor, R#63 was yelling out that her left leg hurts so much. She was yelling that her left leg and left thigh was killing her and was yelling out asking would someone please help her. The resident yelled out continuously. During this observation staff was observed to try and calm the resident down but no one offered to reposition her or give her pain medication. Interview on 7/30/22 at 11:50 a.m. with LPN BB, reviewing the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #63's daughter does not want her to have the additional [MEDICATION(S)] for pain. He revealed resident gets [MEDICATION(S)] 5mg every eight hours as needed for pain and it does not help. He stated they have spoken with the Doctor about this, and stated the daughter wants to be called before anything else is given to her mother for pain. He further stated the daughter is very hard to get in touch with. LPN BB revealed R#63 yells out all day most every day related to pain in her legs. Interview on 7/30/22 at 3:00 p.m. with the Assistant Director of Nursing (ADON), revealed R#63 has behaviors of yelling out. During this time the ADON reviewed the medical record and confirmed R#63 did not receive pain medication for breakthrough pain until 2:54 p.m., three hours after the 11:50 a.m. interview with LPN BB. During further interview, she stated that R#63 had not been given any breakthrough pain medications during the entire month of July. Attempt on 7/31/22 at 11:42 a.m. to contact Nurse Practitioner (NP) for R#63 was made. A voicemail message was left asking for a return call. A return call had not been received.

Based on observations, interviews, record review, and policy review, the facility failed to implement the person-centered comprehensive care plan for one resident (R) (R #63) related to pain management out of 24 sampled residents. Findings include: Review of the undated policy titled Care Plans, Comprehensive Person-Centered, revealed the policy is that a comprehensive, person-centered care plan include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 8.b. describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being. K. Reflect treatment goals, timetables, and objectives in measurable outcomes M. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of 6, indicating severe cognitive impairment. Section (E) revealed R#63 exhibited verbal behavioral symptoms directed toward others that included threatening others, screaming at others, cursing at others that occurred 4 to 6 days but less than daily. Section (J) revealed resident has been on a scheduled pain management regimen, has received as needed (PRN) pain management, and has not received non-medication intervention for pain. Section (M) Medications revealed R#63 received an antipsychotic, antidepressant, diuretic, and an opioid. Review of the care plan initiated 4/18/22 revealed R#63 has chronic hip pain. Interventions to care include anticipate need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions and review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, monitor/record/report to nurse residents' complaints of pain or requests for pain treatment. Care plan initiated on 6/28/22 revealed resident has been admitted to Hospice with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 7/29/22 from 9:10 a.m. to 12:30 p.m. on the 3rd floor, R#63 was exhibiting continuous behaviors of yelling out for help. She yelled out that she cannot move her legs and that her left leg hurts so bad. R#63 continued yelling out frequently for Licensed Practical Nurse (LPN) BB asking for help stating she was having pain in her left leg. LPN BB was observed to address R#63 when he wasn't assisting other residents but he, nor any other staff were observed to reposition her or offer her pain medication. Interview on 7/29/22 at 11:50 a.m. with LPN BB, revealed this is a daily behavior for R#63 of yelling out and complaining she is in pain. He continued to state that she has already had her [MEDICATION(S)] and it is too soon to give it to her again. Observation on 7/30/2022 beginning at 11:35 a.m. to 1:00 p.m. on the 3rd floor, R#63 was yelling out that her left leg hurts so much. She was yelling that her left leg and left thigh was killing her and was yelling out asking would someone please help her. The resident yelled out continuously. During this observation staff was observed to try and calm the resident down but no one offered to reposition her or give her pain medication. Interview on 7/30/22 at 11:50 a.m. with LPN BB, reviewing the July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #63's daughter does not want her to have the additional [MEDICATION(S)] for pain. He revealed resident gets [MEDICATION(S)] 5mg every eight hours as needed for pain and it does not help. He stated they have spoken with the Doctor about this, but the daughter wants to be called before anything else is given to her mother, and stated the daughter is very hard to get in touch with. LPN BB revealed R#63 yells out all day most every day related to pain in her legs. Interview on 7/30/2022 at 2:00 p.m. with the daughter of R#63, stated the nursing home is continuously calling her about her her mother yelling out. During further interview, she stated she does not have a problem with her mother receiving additional pain medications but stated that she does not want her to be out of it all the time. She further stated she does not want her mother to be in pain. Interview on 7/30/22 at 3:00 p.m. with the Assistant Director of Nursing (ADON), revealed R#63 has behaviors of yelling out. During this time the ADON reviewed the medical record and confirmed R#63 did not receive pain medication for breakthrough pain until 2:54 p.m., three hours after the 11:50 a.m. interview with LPN BB. During further interview, she stated that R#63 had not been given any breakthrough pain medications during the entire month of July. Interview on 7/30/22 at 3:31 p.m. with LPN CC, confirmed R#63 was yelling out all morning and afternoon stating she was having pain in her left leg. She revealed she spoke with LPN BB, and he had not given any PRN pain medication to R#63. LPN CC stated she checked the orders and noted that R#63 had liquid [MEDICATION(S)] ordered PRN and gave her a dose. During an observation on 7/30/22 at 3:40 p.m. of R #63 with the ADON revealed the resident was resting in bed with her eyes closed and no behaviors observed/noted. Attempt on 7/31/22 at 11:42 a.m. to contact Nurse Practitioner (NP) for R#63 was made. A voicemail message was left asking for a return call. A return call had not been received. Cross refer F697

Based on staff and family interviews, and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents, for one of two residents (R) reviewed for falls. Actual harm was identified on 1/11/19 when R#67 was transferred improperly by one Certified Nursing Assistants (CNA) when the resident required assistance of two staff resulting in a fracture to the left arm. Findings included: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. On 1/16/19 [DIAGNOSES REDACTED].#67 [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer and toilet use. The resident was assessed as total dependence for care. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 revealed impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. Review of the progress note dated 1/11/19 at 10:40 a.m. revealed: Writer was notified by Certified Nursing Assistant (CNA) during transferring of resident from bed to wheel chair, resident knees gave out and was going down. CNA broke fall by supporting her arm under resident left armpit and ease her into wheel chair. ROM (range of motion) performed. Able to move RT (right) arm. HEX (history) old FX (fracture) to LT (left) shoulder and muscle weakness. C/O (complained of) discomfort to LT shoulder. NP (Nurse Practitioner) notified and ordered X - Ray LT shoulder. Review of the Physician orders [REDACTED]. Review of the x-ray of the left shoulder dated 1/11/19 revealed: no acute fracture or other acute abnormality Review of the progress note dated 1/13/19 at 05:08 it is documented in part c/o (complain of) pain in the left shoulder, medicated for pain x 1. There is no evidence that the nurse assessed the resident's left shoulder. Review of an Progress Note dated 1/15/19 at 02:24 it was documented in part by an Licensed Practical Nurse; Resident was assessed, to observe left upper arm and shoulder swollen and purple color discoloration. .An interview was conducted on 2/27/19 at 11:46 a.m. with the Assistant Director of Nursing (ADON) revealed the sister of R#67 called the ADON from the resident's eye appointment on 1/15/19 and requested that the ADON look at Resident # 67 arm because the resident was still complaining of pain and the resident had swelling and bruising. The ADON revealed on 1/16/19 she assessed R#67 and the left arm was swollen and bruising and called the Physician. The Physician gave an order to x-ray the left clavicle, left shoulder and left humerus. The x-ray was completed on 1/16/19 and the results of the x-ray revealed a [MEDICAL CONDITION] humerus. An Encounter note written by a Physician dated 1/22/19 documented R#67 was seen for a proximal humerus fracture that occurred while she was in care at the (Name) home. She was not using the lift but was being lowered to the floor and a pop was felt. She was initially told that her arm was not broken, but subsequently a fracture was determined to be present. The onset date of 1/11/19, lowered to the floor, CNA said she heard a snap. She is right-hand dominant. She also has limited hand functions and a moderate amount of pain. An interview was conducted on 2/27/19 12:01 p.m. with Registered Nurse Supervisor DD regarding the incident with R#67. Supervisor DD stated when she arrived at the floor, she assessed the resident. The resident verbalized pain and there was no swelling at the time of her assessment. The Supervisor asked the CNA why she was transferring the resident alone and the CNA responded she was helping another CNA, and this was not her assigned resident. Supervisor DD revealed the CNA should have had another staff person to assist her with the transfer. Supervisor DD revealed the CNA should have checked the resident's Kardex (guide on how to take care of the residents) prior to the transfer. Supervisor BB revealed that the Kardex was located at the end of each residents' bed on a clip board. The CNA's are in-serviced on using the Kardex as a resource. An interview was conducted on 2/27/19 at 12:30 p.m. with R#67 and her sister/Responsible Party (RP). Resident #67 family revealed on 1/16/19 she met R#67 at the eye doctor and when R#67 arrived she was crying. The resident expressed that she was in pain and her left arm hurt. The family member looked under R#67 clothes and seen that the arm was swollen and black and blue. The RP called the facility and spoke with the Assistant Director of Nursing (ADON) and asked her to assess the resident's arm. The next day when she arrived at the facility, she was informed by the ADON that R#67 had a [MEDICAL CONDITION]. The RP made an appointment for the resident to be seen by and orthopedic physician on 1/17/19. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor the CNA stood in front of the resident. The CNA revealed she placed her left arm under the resident's right armpit and her right arm went under the residents left arm pit. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up the CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistant from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. Review of the Radiology report dated 1/16/19 revealed Impression: Acute displaced proximal humeral fracture. Review of the orthopedics History and Physical report dated 1/17/19 revealed the following, R#67 seen today for a left proximal humerus fracture. She has moderate amount of pain. An interview was conducted on 2/28/19 at 11:40 a.m. with the Director of Staff Development regarding if CNA EE received any in-service training for using the Kardex. The Staff Development Director revealed in-services are done but she has no documentation to support that CNA EE was in-service on using the Kardex.

Based on staff interviews and review of the facility documents the facility failed to follow the care plan/ Nursing Kardex related to two staff assistance for transfers for one resident (R) #67 of two residents reviewed. Actual harm was identified when R#67 sustained a left arm fracture from an improper transfer. Findings include: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could she stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up. The CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistance from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. An Interview was conducted on 02/27/19 at 11:46 a.m. the Assistant Director of Nursing (ADON) regarding R#67 transfers. The ADON revealed that R#67 is care plan transfer with two people or two people and a lifting device. The ADON revealed that each resident has a Kardex hanging at the end of the resident bed on a clip board that gives the CNA guidance on how to care for the residents. Refer to F689

Based on observation, staff interviews, and record review the facility failed to ensure that one resident (R), # 296 out of 2 residents reviewed was free from restraints from a sample of 39 residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#296 with a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was cognitively impaired. Further review of R#296 MDS provided evidence that R#296 required two-person extensive assistance with transfers and no documented evidence for use of restraint. Further review of resident R#296 clinical records shows that resident (R#296) was not assessed for the use of restraints. Additionally, there were no Physician order, plan of care or progress notes to show the needed use of restraints. Multiple observations were made of resident R#296 with a seatbelt around his torso area while sitting in his wheelchair. On 2/26/19 at 1:00 p.m., observed resident in the garden room involved in activities. Resident in wheelchair while seatbelt around his torso area. On 2/27/19 at 12:45 p.m., observed resident in dining room area eating his lunch, resident in a wheelchair with a seatbelt fasten around his torso currently. On 2/27/19 at 2:02 p.m. an interview was conducted with Registered Nurse FF, she stated that R#296 has a seat around him while he is in the wheelchair because he has problems with [MEDICAL CONDITION] activity and the seatbelt is being used to keep him for falling out wheelchair. On 2/28/19 at 3:05 p.m. an interview was conducted with the Director of Nursing (DON), she stated that R#296 should not have a seatbelt around his torso. The DON stated she believes that the daughter brought the wheelchair for R#296 to have but at this time the resident does not have a Physician order for [REDACTED].

Based on record review and staff interviews, the facility failed to accurately document the Advance Directive status for one Resident (R) R#18 from a sample of 17 residents reviewed for Advance Directives. Findings include: Review of the record for R#18 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. A review was conducted of the physician orders [REDACTED]. Review of the facility form titled, Order Summary Report for R#18 documented Advanced Directive: CPR, order date [DATE]; order status active and documented active orders as of [DATE]. Review of the resident's care plan, provided by MDS Coordinator A for R#18, documented two Advance Directive (AD) code status determinations. The care plan focus area reflects a code status as Full Code with a date initiated of [DATE], revision on [DATE]. Another care plan focus area reflects a code status as Do not Resuscitate (DNR) with a date initiated of [DATE], revision on [DATE]. Further record review for R#18 revealed a form titled, Physician order [REDACTED]. The POLST was signed by the resident and dated [DATE]. The section for discussion and signatures was blank for the physician's name and signature. The POLST was found at the front of the record in a clear document sleeve with a bright orange DNR sticker positioned at the top of the clear plastic document sleeve. On [DATE] at 10:38 a.m. an interview was conducted with the Social Worker (SW), she explained that the process to obtain Advance Directive information for a resident begins in admission; they work with the long-term care and rehab residents. Those residents receive an admission packet that starts with an Advance Directive checklist where residents can choose options. If they can sign for themselves, they must have a good BIMS score, meaning no impairment cognitively. If they have a Power of Attorney or a Living Will, that will be requested. The SW stated that it is the Social Worker's responsibility to discuss those options on the form with the resident and family. The SW further stated that the Unit Secretary will scan and upload the forms into the electronic record and place a copy of the original in the hard copy medical record. On [DATE] at 9:30 a.m. an interview was conducted with MDS Coordinator A in the MDS office with MDS Coordinator B and the Director of Nursing (DON) present. A review and confirmation of the quarterly and annual MDS was conducted. A printed copy of the resident's quarterly care plan was provided, dated [DATE]. When MDS Coordinator A was asked where the nursing staff would look for the Advance Directive information and preference, she stated that in an emergency they run to the hard copy chart to find the code status located at the front of the chart. After review of the provided documents with the MDS Coordinators with the DON present, the MDS Coordinators stated that the POLST form signed by the resident on [DATE] is an error. They revealed that the POLST forms have not been officially initiated in the facility yet; they confirmed the POLST form located in the front of the resident's record that is signed by the resident, is not signed by the Physician, and should not have been in the record. They confirmed the care plan indicating a DNR code status is in error. The DON explained that the POLST has not been initiated yet, because another Social Worker that is planning to initiate the POLST form for all residents that choose a DNR determination has been on maternity leave. No documentation was found in the record from the Social Worker regarding a change in the resident's Advance Directive status. In addition, the MDS Coordinator A and the DON explained that once an order is received by the Physician, the nursing staff will have the Unit Secretary scan in the AD into the electronic system and the original copy is placed in the hard copy record. The DON stated the plan now was to get a hold of the Physician's Nurse Practitioner, the resident and family to sort out the wishes of the resident, then get an order if there is a change. On [DATE] at 4:00 p.m. the DON provided a copy of a monthly follow-up visit conducted by the Nurse Practitioner for R#18, dated [DATE]. The note documents: POLST is reviewed with resident on day of exam. No acute changes or concerns per staff. On the bottom of page 5 of the follow-up exam, there is a hand-written note dated [DATE] and signed by the Nurse Practitioner that documents: reviewed POLST election and resident continues to desire elections charted on POLST form ,[DATE]. The DON also provided a printed copy of the original POLST form with the Physician's signature added and dated [DATE]. The DON confirmed that the POLST form is the form the facility has decided to use but confirmed that it has not been initiated yet.

Based on record review and staff interview, the facility failed to indicate the need to extend orders for as needed (PRN) antianxiety medications for two residents (R#31 and R#25) beyond 14 days, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 22 residents. Findings include: Review of the clinical records for Resident (R) #31 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment of 11/21/17 revealed the resident had evidence of mood symptoms, behaviors directed at others occurred 1-3 days during the assessment period, had active [DIAGNOSES REDACTED]. Review of the most recent physician order [REDACTED]. Further review of the clinical records for R#31 revealed no documentation that the PRN anxiolytic should continue beyond 14 days, the period during which it should be continued, or a rationale for its continued use. Interview with the Medical Director on 2/08/18 at 2:37 p.m. revealed the resident has had significant trauma in recent months and was placed on hospice soon after admission due to declining health. The resident has since been discharged from hospice, but continues to experience anxiety and needs the antianxiety medication on an as needed basis. He was not aware that he should have documented the ongoing need for this medication, but will do so going forward. 2. Review of clinical record for Resident (R) #25 revealed he was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Review of February 2018 Physician order [REDACTED].#25 was prescribed Klonopin 0.5 milligrams (mg) at bedtime as needed (PRN) for anxiety, with original order date of 8/8/17. Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician, for continued use. Interview on 2/8/18 at 1:58 p.m., with Medical Director, stated that he has not been evaluating the continued need for PRN antipsychotic medications. He stated that if he wrote an order for [REDACTED]. He stated he has not been addressing orders for PRN antipsychotic's, but will start, because the government regulations have changed.

Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an Advanced Directive, for five residents (R) observed. R# 11, R# 72, R#255, R# 84 and R#254. The sample size was 22 residents. Findings include: 1. Medical Record review revealed that Resident (R) #72 review of the medical record for R#72 revealed that there was not any evidence that an Advance Directive was completed. Further review of the admission file for R#72 revealed that the form, Responsible/Legal Guardian & Advanced Directive Checklist (no date) was incomplete. No response were checked for choice and there was not any evidence that an Advance Directive checklist was documented. 2. Medical Record review for R #255 reveals that there was not any evidence that the resident had an Advance Directive. Further review of the Acknowledgement of Receipt of Admission for Rehabilitation form reveals that there is not a check mark next to the Georgia Advance Directive for Healthcare. 3. Medical Record review for R #84 reveals that there was not any evidence that the resident had an Advance Directive. Further review revealed that R #84 does have a completed Acknowledgement of Receipt of Admission for Rehabilitation Information form in the resident's Admission Folder. 4. Medical Record review for R # 254 revealed that there was not any evidence that the resident had an Advance Directive on their medical record or in their admission folder. Further review of theAcknowledgement of Receipt of Admission for Rehabilitation information form revealed that R#254 does not have a check mark next to Georgia Advance Directive for Healthcare. 5. Medical record review for resident R#11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated no cognitive impairment. Further review on clinical record on 2/6/18 lacked evidence that the resident had been offered options to formulate an advance Directive. Document titled Responsibility/Legal Guardian & Advanced Directive Information was provided by Social Services Director on 2/6/18. The form revealed that resident was responsible for self, but no other information was documented on the form as to her choice to formulate or not formulate Advanced Directives. Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an advanced directive, for seven residents (R) observed. R# 11, R#76, R# 38, , R# 72, R#255, R# 84 and R#254; out of a sample of 22 Findings include: For all resident's in the sample, a form titled Responsibility/Legal Guardian and Advanced Directive Checklist were missing information regarding resident's response to an offer of formulating an advanced directive. On 2/6/18 11:31 a.m. an interview with Social Services Director (SSD) was able to provide a folder evidencing a form titled Responsibility/Legal Guardian and Advanced Directive Checklist. This document shows where the facility provided information to the resident and/or family member on legal guardianship, and Power of Attorney (POA) along with an advanced directives checklist. The checklist included a decision made by the resident to formulate an advance directive or not. This document did offer a decision. No decision was noted. Further interview by the SSD indicated the facility no longer uses the form as it was becoming confusing for the staff. When asked how does the facility know what the resident's decision was in the event of an emergency, SSD stated they use a form titled Acknowledgement of Receipt of Admission for Rehabilitation information. This document lists the Georgia Advanced Directive for Healthcare. A check by the document name indicates the resident and /or family member received the document. When asked what the time frame is for return of the document SSD stated we asked they return it within 24 hours. When the time frame runs out there is no follow up done. SSD was once again asked what is done if there is no documentation of resident's preference regarding advanced directives. SSD stated if there is no information on the record the resident the resident is considered to be a full code. On 2/7/18 11:23 a.m. an interview with Director of Health Services (DHS) and Administrator revealed that the form titled Responsibility/Legal Guardian & Advanced Directive Checklist is no longer used because their attorney stated it was not a legal document. When asked where is the resident's response to advance directives education documented, DHS stated that it should be in the admission noted or on the dashboard of the Electronic Medical Record (EMR). On 2/7/18 01:06 p.m. further interview with the DHS revealed the facility does not have any documentation as to resident's preference to execute an advance directive. A review of facility policy titled Advance Directives, no date, states information about whether or not the resident has executed an advanced directive, shall be displayed prominently in the medical record. Also, if the resident indicates that he or she has not established advance directive, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline.

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one resident (R) #9 for the use of injectable's and insulin. The sample size was 22 residents. Findings Include: Record review revealed R#9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three, which indicates cognitive impairment. Section I-Active [DIAGNOSES REDACTED]. Review of MDS dated [DATE], section N-Medications, N0300 Injections: indicated that resident received 0 injections in last 7 days; NO350 Insulin was left blank. Review of a care plan initiated on 2/8/18, revealed that resident has potential for hyperglycemic or hypoglycemic episodes secondary to diabetes: resident uses insulin. Interview on 2/8/18 at 3:11 p.m., with MDS Coordinator, stated she gets information for the MDS assessments by having a face to face interview with the residents and information is obtained from the direct care staff caring for the residents. She stated information about medications is obtained from the electronic Medication Administration Record [REDACTED]. She verified that the 8/1/17 MDS did not reflect that the resident has received insulin injections 7 out of 7 days. She further stated that she would go ahead and modify the MDS assessment to indicate resident received insulin injections 7 out of 7 days.

Based on observation, record review and staff interview the facility failed to follow the care plan for one resident (R) #47 related to not placing a fall mat at the bedside post fall on 1/9/18. The sample size was 22 residents. Findings include: A review of the clinical record for R#47 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated cognitive impairment. Review of the care plan dated 1/9/18, revealed that R#47 had impaired physical mobility related to a fall from the bed. Interventions to be implemented included bed in low position and fall mat at bedside. Observation on 2/7/18 at 12:05 p.m., 2/8/18 at 9:19 a.m. and 2/8/18 at 4:11 p.m. revealed no fall mat at bedside, nor stored in the closet or under the bed. A review of facility policy titled Fall Management Program with effective date October 25, 2010, revealed that the date and time of each fall and new intervention will be added to the care plan. Interview on 2/8/18 at 2:51 p.m., with Licensed Practical Nurse (LPN) AA, revealed that the procedure for when residents have a fall is to do a complete head to toe assessment, assessing for any injuries. She then notifies the Shift Supervisor, the residents Physician and family member. The residents nurse and the Supervisor discuss possible interventions and collaborate together what intervention is best suited for the situation. Supervisor inputs the intervention into electronic medical record (EMR) and the floor nurse is responsible for follow-up on implementation. She further stated the residents are observed for 72 hours post fall. She stated she did not know why R#47 didn't have a fall mat at the bedside. Interview on 2/8/18 at 4:06 p.m., with Assistant Director of Nursing, revealed that she and the floor Charge Nurse confer together discussing possible interventions to put in place after residents experience a fall. She further revealed that it is the facility's policy to implement interventions after each fall. She stated that when fall mats are ordered, the Certified Nursing Assistant (CNA) or the Charge Nurse are responsible for getting floor mats and placing them at bedside.

Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of two medication carts; and failed to discard expired biological's and medical supplies prior to expiration date in one of two medication storage rooms. The sample size was 22 residents. Findings include: 1. Observation on 2/6/18 at 4:25 p.m., third floor medication cart revealed one opened and used [MEDICATION NAME] respiratory inhaler. The inhaler had a sticker from the pharmacy that indicated the medication should be discarded 90 days after opening. The inhaler did not have a date when opened. Further observation, on the same medication cart, was [MEDICATION NAME] Propionate liquid, approximtely 1/2 of 16 ounce bottle, with expiration date of 12/17. 2. Observation on 2/6/18 at 4:25 p.m., in the third floor medication storage room revealed two catheter irrigation trays with expiration date of 1/18. 3. During medication pass on 2/7/18 at 12:28 p.m., with Licensed Practical Nurse (LPN) AA, revealed an opened multiple-dose vial of [MEDICATION NAME] Insulin with opened date of 1/2/18. A label on the vial read discard after 28 days. Review of the facility policy titled, Pharmacy Services and Procedures policy, revised January 2013, indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further indicated the facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Review of the policy titled, Recommended Minimum Medication Storage Parameters, revised September 29, 2016, indicated that multiple-dose vials for injection, are to be dated when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. The parameters for [MEDICATION NAME] Inhalation Spray, indicated after initial priming, discard after 120 sprays or three months after first use. Interview on 2/6/18 at 4:25 p.m., Licensed Practical Nurse (LPN) AA stated that she doesn't know when the inhaler was opened. She stated that she puts open dates on all the medications that she opens. She stated that each of the med nurses are supposed to check the medication carts and storage rooms daily for expired medications and supplies. Interview on 2/7/18 at 12:40 p.m., LPN AA stated the policy for opened injectable medications is 30 days. She verified the opened bottle of [MEDICATION NAME]had 1/2/18 open date and the pharmacy sticker indicated to discard 28 days after opening.

Based on observations, record review, policy and procedure review, and staff interviews the facility failed to maintain clean inlet filters on oxygen concentrators for five residents (R) receiving oxygen therapy ( R#80, R#182, R#181, R#111, R#96). The sample size was 7 residents receiving oxygen therapy via oxygen concentrators. Findings include: 1. Observation on 3/28/17 at 2:47 p.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen at 3 liters by nasal cannula every shift. Observation on 3/29/17 at 9:47 a.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 2. Observation on 3/28/17 at 3:22 p.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen 2 - 5 liters as needed by nasal cannula to keep oxygen level above ninety (90) percent. Observation on 3/29/17 at 9:48 a.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 3. Observation on 3/28/17 at 3:35 p.m. revealed R # 111 seated in recliner chair at bedside receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 3 liters by by nasal cannula at night and 3 liters as needed during the day. Observation on 3/29/17 at 10:26 a.m. revealed R # 111 asleep in bed, private sitter at bedside. R # 111 is receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 4. Observation on 3/28/17 at 3:38 p.m. revealed R # 96 lying in recliner chair at bedside receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 2 liters by nasal cannula or face mask to keep saturation above ninety (90) percent. Observation on 3/29/17 at 10:06 a.m. revealed R # 96 in bed, CNA at bedside providing morning care. R # 96 is receiving oxygen by nasal cannula at 2 liters per minute(LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Observation with the Director of Nursing (DON) on 3/29/17 from 4:35 p.m. to 4:58 p.m. confirmed the oxygen concentrators for R # 181, R # 182, R # 111, R # 207 had one filter on the right side of the machine coated with dust. Facility Policy on Departmental (Respiratory Therapy) - Prevention of Infection stated that filters from oxygen concentrators should be washed every 7 days with soap and water, rinse and squeeze dry, allow filter to dry prior to replacing back into machine. Telephone interview with LPN AA on 3/30/17 at 10:45 a.m. Stated that she works 3rd shift on the 3rd floor, and part of her duties include cleaning the oxygen concentrator filters on that floor weekly every Thursday, but she was off last week Thursday and Friday. Stated also that she did not follow up on 3/27/17 to ensure the oxygen concentrator filters were cleaned after resuming her normal work schedule. Telephone interview with LPN BB on 3/30/17 at 11:19 a.m. stated that she works 3rd shift on the 2nd floor and part of her duties include cleaning the oxygen concentrator filters on that floor with soap and water, air dry, and replace them every Thursday of every week, but forgot to clean them last week. Telephone interview with LPN CC on 3/30/17 at 3:00 p.m. stated that she started working on the 5th floor 3rd shift Wednesday last week, but did not clean the oxygen concentrator filters on that floor because she was not told during orientation that it was part of her duties to get the filters cleaned every week. Stated that she was only given that information yesterday by her supervisor. Interview with DON on 3/30/17 at 11:05 a.m. stated that there was no flow sheet or documentation to show when the oxygen concentrator filters were cleaned. However, she stated that as of yesterday she added a flow sheet to the Treatment Administration Record for all residents receiving oxygen. 5. On 3/27/17 at 12:53 p.m., the filter on the back of R #80's oxygen concentrator was observed to be covered with a thick coating of a white, dust-like material. Further observation at this time revealed that the tubing for the nasal cannula that delivered the oxygen to the resident was dated 3/21. During observation on 3/27/17 at 4:15 p.m. and 3/28/17 at 9:10 a.m., the nasal cannula tubing was dated 3/27/17, 7-3 (7:00 a.m. to 3:00 p.m. shift). Further observation revealed that there was still a thick coating of a white dust-like material on the oxygen concentrator filter.

Based on record review, facility policy review, and staff interviews, the facility failed to follow physician's orders for the administration of insulin per sliding scale. Findings include: Record review for R#17 revealed that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Physician Orders dated 1/20/17 revealed an order for [REDACTED]. Review of the Medication Record (MR) for January 2017 revealed one incorrect dose of insulin administered at bedtime (HS) on 1/21/17, which was documented at 212. During further review, the MR revealed that four u of insulin were given; however, two u ordered. Review of the Physician Orders for February 2017 revealed order for [MEDICATION NAME] 100 u/ml per sliding scale for BG greater than 160 mg/dl; give via subcutaneous injection before meals and at bedtime at 7:00 a.m., 12:00 p.m., 5:00 p.m. and 9:00 p.m. Continued review revealed that the sliding scale is as follows: 161-200, give one u, 201-250, give three u, 251-300, give five u, 301-350, give seven u; greater than 351, give 10 u. Review of the MR for February 2017 revealed a total of seven (7) occasions when insulin coverage had no evidence of documentation for the following dates: 7:00 a.m. administration: 2/6/17 BG=174, 2/12/17 BG=162; bedtime administration: 2/4/17 BG=198, 2/5/17 BG=176, 2/11/17 BG=213, 2/12/17 BG=189, and 2/18/17 BG=187. Review of the March 2017 MR revealed four (4) incorrect doses given, which includes the following: on 3/2/17 at 5:00 p.m. the BG was 232, and the resident was given two u instead of five units. Then on 3/8/17 BG=380, five u given, not 10 u as ordered; and on 3/13/17 BG=262-three (3) u given, instead of five (5) units. Review of the March 2017 Physician Orders continued the same sliding scale insulin orders as February 2017. Interview with Licensed Practical Nurse (LPN) DD on 3/29/17 at 11:15 a.m., she stated that inservices are held for all new medications, including how to draw up, if applicable, and administer. Continued interview revealed that annual inservices are held related to general medication administration. The procedure for self-reported medication errors is to contact the nursing supervisor, monitor the resident for any adverse reactions, complete the appropriate medication error paperwork and contact the physician and/or family. During an interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed the discrepanceies on the Medication Records from January 2017 through March 2017. Continued interview revealed that she was unable to give an explanation for the medication discrepancies. Review of the Facility Policy and procedures titled, Administering Medications Version 2.0, Accucheck Blood Sugar Testing and Insulin Administration revealed that all detail the steps for correct documentation of the testing and administration processes: 1.) Date, time, blood glucose level. 2.) Type and amount of insulin administered and the injection site. 3.) If blood glucose level is above or below normal range, document the time the physician was notified. 4.) Any results achieved and when those results were observed. 5.) Signature and file.

Based on observation, record review and staff interviews, the facility failed to follow the care plans related to the monitoring of blood glucose levels and the treatment of [REDACTED].#17) from a total sample of 35 residents. Findings include: Record review for resident (R) #17 revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the care plan dated 1/9/17 stated R#17 has the potential for hypoglycemic and hyperglycemic episodes secondary to DM with the goal to provide relief of hypo/hyperglycemic episodes within 30 minutes of interventions. Continued review revealed to monitor blood sugar (glucose) levels per physician's orders [REDACTED]. Review of the Physician Orders for March 2017 revealed order for [MEDICATION NAME] 100 Unit per milliliter (u/ml) per sliding scale for Blood Glucose (BG) greater than 160 milligrams (mg/deciliter (dL); give via subcutaneous injection before meals and at bedtime at 7:00 a.m., 12:00 p.m., 5:00 p.m. At bedtime, 9:00 p.m.: 161-200, give one (1) u, 201-250, give three (3) u, 251-300, give five (5) u, 301-350, give seven (7) u; greater than 351, give 10 u. Review of the Medication Record for January 2017 revealed no evidence of blood glucose (bg) level documentation at bedtime for 1/6/17, 1/7/17, 1/8/17, and/or 1/24/17. Review of the The Medication Record for March 2017 revealed no evidence of BG level documentation for 3/18/17. During interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed that the care plan was not followed regarding blood sugars. 2.) During observation on 3/30/17 at 7:00 a.m. with Registered Nurse (RN) EE, she cleaned the pressure ulcer to the sacral wound with Dakins solution, then applied an oil [MEDICATION NAME] dressing to the wound bed and applied the calcium alginate to the tunneling area. Continued observation revealed that a sponge was applied to the site and a new canister applied to the wound. Review of the care plan for R#17 dated 1/9/17 revealed that resident has a pressure ulcer and the intervention included to treatment per current physician orders. Review of the March 2017 Physician Orders revealed that R#17 was for a wound vac, and change every 72 hours. Interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 10:30 a.m., revealed that wound care for the resident's treatment is to apply the black sponge, which is the deriding agent and the application of the suction to the wound vac.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (R#109) taking a diuretic out of a total sample of 35 residents. Findings include: Resident #109 was admitted [DATE] with a [DIAGNOSES REDACTED]. Record review of the Admission MDS assessment dated [DATE] revealed in section N: medications that resident received two of the seven days of a diuretic in the last seven days. Review of the March 2017 Physician Orders revealed that [MEDICATION NAME] 25mg was ordered, but held due to the resident's condition, and then discontinued, showing no evidence that a diuretic was given during the past seven days. Interview with the MDS Coordinator on 3/30/17 at 12:30 p.m. confirmed that the MDS was miscoded during that time