Every finding on record at Tri-Community Nursing Center

Based on record review, policy review, and interviews, the facility failed to ensure:Resident #1's grievance was documented and prompt efforts were made to investigate the voiced grievance, andResident #2's grievance for clothing that was lost by facility was satisfactorily resolved. Findings:Review of the facility's policy titled, Grievance Policy with a revision date of 05/15/2026, read in part, Purpose: 1. To ensure each resident has the right to voice grievance with respect to .care.2. To ensure resident grievance will be followed up by prompt efforts to resolve grievance that the resident have.all grievances will be investigated thoroughly and appropriate corrective action taken.The Facility administrator or designee will act as the grievance official.4. Grievances made by a residents family .are to be documented on the grievance form.The grievance form will include: the date the grievance was received, b. A summary statement of the grievance, c. The steps taken to investigate the grievance, e. A statement as whether the grievance was confirmed or not confirmed, f. Any corrective action taken or to be taken by the facility as a result of the grievance.Resident #1Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting his left non-dominant side, polyneuropathy, benign prostatic hyperplasia, insomnia, pain, and peripheral vascular disease. Resident #1's sister was his responsible party.On 07/23/2026 at 2:15 p.m., an interview with Resident #1's responsible party confirmed she had called the facility and talked to a nurse at the station on 07/19/2026 and complained that the staff were not waking up Resident #1 and getting him out of bed. She stated S1ADM had returned her call the next day and she complained to S1ADM that staff were not waking Resident #1 up and getting him out of bed.On 07/28/2026 at 8:45 a.m., an interview with S2DON confirmed there was no documentation that Resident #1's responsible party had called in a complaint on 7/19/2026 that the staff were not waking the resident up or getting him out of bed. On 07/28/2026 at 10:12 a.m., an interview with S5SSD confirmed there was no documentation that Resident #1's responsible party had called in a complaint on 07/19/2026 that the staff were not waking the resident up or getting the resident out of bed.On 07/28/2026 at 12:00 p.m., an interview with S1ADM confirmed he had talked to Resident #1's responsible party on Monday, 07/20/2026, after she had called in a complaint on 07/19/2026. S1ADM stated Resident #1's responsible party complained to S1ADM that staff were not getting Resident #1 up early and that the facility must be short staffed over the weekend. S1ADM further confirmed he did not document the complaint voiced by Resident #1's responsible party nor did the facility investigate the complaint.Resident #2Review of the facility's policy titled Resident Personal Belongings, dated 05/15/2026, read in part, It is the policy of this facility to protect Residents right to possess personal belongings such as clothing.The facility will ensure that personal belongings and/or possessions are rightfully returned to the resident, or the residents representative.1. All resident possessions, regardless of their apparent value will be treated with respect.5.The facility will exercise reasonable care for the protection of the resident's property for loss or theft.Review of Resident #2's record revealed she was admitted to the facility on [DATE]. She was her own responsible party. Her current diagnoses included in part, multiple sclerosis, spinal Stenosis, and chronic pain. Her Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed her BIMS (Brief Interview of Mental Status) score was 15, indicating she was cognitively intact.On 07/27/2026 at 11:37 a.m., an interview with Resident #2 revealed she was her own responsible party and made her own decisions. She stated at the beginning of June 2026, the facility packed a bag of 3 days of her clothes and evacuated her and the other residents to a sister facility due to potential flooding. She stated she returned to this facility on 06/29/2026. She stated her bag of clothing was missing. She complained to S5SSD that her clothes were missing and S5SSD said they would look for her clothes. Resident #2 stated these were her clothes that made her feel comfortable to wear to get out of bed and go do things, like going outside to get some sun. She stated she felt not having her clothes was preventing her from getting out of bed. She stated the only clothes she had in the facility were fall clothes that were too hot to wear. She stated she wanted her summer clothes that were in the bag. She stated S1ADM offered her hospital gowns and used clothing, and she didn't feel good about going around in hospital gowns and used clothing that he offered. She stated that was not very dignified. Resident #2 further stated it had been a month since she returned to the facility and they had not found her clothing.Record review of Resident #2's grievance dated 07/02/2026 revealed the following in part: S5SSD wrote: Resident#2 reported her bag with clothing during evacuation was missing. She reported 2 shirts, 2 pants, 1 Dress, 1 Sock, and 2 sports bras. Summary of investigation read: S5SSD checked laundry room, did not find bag or clothing, S5SSD spoke with S3HKS about Resident #2's missing clothes and made S1ADM aware of the missing clothing. S3HKS and staff will look in other closets for possible mix up of clothing. Bag with clothing was not left in trailer upon transport back to the facility. The Outcome/Corrective action was staff will continue to look for garments at this time.On 07/28/2026 at 10:26 a.m., an interview was conducted with S5SSD. She stated Resident #2 returned to the facility on [DATE] and complained to her on 07/02/2026 that she was missing 2 shirts, a dress, 2 pairs of pants, 1 pair of socks, and 2 sports bra that was in her bag the staff had packed to evacuate. S5SSD stated she checked Resident #2's room and laundry and then talked to S3HKS and informed S1ADM that Resident #2's clothes were missing. She stated, I have been looking and it has been a month since we have been back in the facility and we still have not found her bag. She stated it was up to S1ADM to replace her clothing.On 07/28/2026 at 12:30 p.m., an interview with S3HKS revealed Resident #2 had been back in the facility for about a month. She stated that the clothes that Resident #2 complained were missing were the clothes that was brought to our sister facility during the evacuation. She stated all the residents had a green bag with 3 days of clothing, and when they returned, she passed the green bag of clothes back out to all the residents. Resident #2 did not have a bag. S3HKS stated she looked around and couldn't find Resident #2's bag or the clothes that were in the bag. S3HKS stated the resident's clothing was either left at the sister facility or lost in transfer. S3HKS stated she remembered washing Resident #3's clothing at the sister facility. She stated that all the residents' names were labeled in their clothing, and Resident #2's clothes were not in this facility. On 07/28/2026 at 12:00 p.m., an interview with S1ADM confirmed they had returned to the facility after evacuation on 06/29/2026, and Resident #2 had complained on 07/02/2026 that she was missing her 3 days of clothes that were in the green bag that was packed to evacuate to their sister facility. He confirmed it was the facilities responsibility to ensure Residents' clothing was packed in the bag and was returned to the facility after the evacuation. He stated he should have replaced Resident #2's clothing that was in the bag.

Based on observations, record reviews, and interviews, the facility failed to provide supervision and protective apron to unsafe smoking residents while smoking for 1 (#1) of 3 sampled residents. Findings:Review of the facility's policy titled, Residents Smoking Policy with a review date of 05/15/2026, read in part, The facility shall establish and maintain safe resident smoking practices.1. Facility shall designated a formalized smoking area.7. The resident will be evaluated on admission to determine if he is a smoker or non-smoker. If a smoker, the evaluation will include.d. Ability to smoke safely with or without supervision.9. The resident ability to smoke safely will be re-evaluated quarterly, upon significant changes and as determined by the staff.The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with available levels of support and supervision.Review of Resident #1's record revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting his left non dominant side, chronic obstructive pulmonary disease, polyneuropathy, and peripheral vascular disease. The resident's quarterly Minimum Data Set, dated [DATE] revealed his BIMS (Brief Interview of Mental Status) score was 15, indicating he was cognitively intact.Record review of Resident #1's quarterly Smoking Safety Screen dated 5/26/2026 read in part, Decision: Unsafe Smoker. History of dozing off while smoking and dropping ashes on clothing resulting in holes. Smoking apron to be worn when smoking.Record review of Resident #1's care plan with a revision date of 04/07/2026 read in part, Focus: Resident # is at risk for injury when smoking r/t (related to) falling asleep while sitting in Wheel Chair under front breezeway with lite cigarette. Ashes noted on his pants. Goal: He will be compliant with wearing smoking apron when smoking. Interventions: Smoke apron to be worn while smoking.Record review of Resident #1's June 2026 TAR (Treatment Administration Record) revealed an order which read, Smoking apron to be worn while smoking every shift. Start Date 5/1/2026. S6ADON/Tx Nurse had signed off on 07/27/2026 the 6AM-6PM shift indicating she had supervised Resident #1 to ensure he was wearing his apron.On 07/27/2026 at 11:27 a.m., an observation of Resident #1 and interview with S4HK was conducted. Resident #1 was observed sitting in his wheelchair on the front breezeway. His pants were observed with old burned holes. He lit a filter-less cigarette and smoked it without wearing a smoking apron. Resident #1 stated that he smoked anytime he wanted. He stated that most of the time no one is out there to supervise him to ensure he wore his apron. S4HK was observed sitting in the breezeway. She was asked if she was supervising Resident #1. She stated she was newly hired and was not there to supervise any of the residents while they smoked or to ensure they wore an apron. On 07/27/2026 at 3:13 p.m., an observation of Resident #1 and interview with S4HK was conducted. Resident #1 was observed on the front breezeway smoking a filter-less cigarette. He was not wearing a smoking apron over his clothes. A smoking apron was observed on the resident's right side between his right hip and the right arm rest of his wheel chair. S4HK was observed smoking a cigarette. She confirmed the resident had been smoking without an apron and that the resident had old holes on the left side of his pants. She confirmed she was not out there to supervise any of the residents while they smoked or ensure they were wearing an apron. On 07/27/2026 at 3:22 p.m., record review and interview with S7MDS Coordinator confirmed Resident #1 was assessed as an unsafe smoker. She stated he was care planned to wear an apron when he smoked. She stated S6ADON/Tx Nurse was to supervise the resident and ensure he wears his apron when he smoked and document this on the residents TAR (Treatment Administration Record). S7MDS Coordinator went to the front breezeway of the facility and observed Resident #1 sitting outside under the breezeway smoking a cigarette without a smoking apron. S4HK was observed sitting under the breezeway and informed S7MDS Coordinator that Resident #1 was smoking his cigarette without wearing an apron and there was no one supervising him. At this time, S7MDS Coordinator observed the burn holes in Resident #1's pants with the apron on his side. S7MDS Coordinator confirmed Resident #1 should be wearing his apron and S6ADON/Tx Nurse should have supervised him.On 07/28/2026 at 8:10 a.m., an interview with S5ADON/Tx Nurse confirmed she was given the task of supervising Resident #1 when he went out to smoke and to ensure he wore a smoking apron. She stated the resident was assessed as an unsafe smoker; non-compliant with wearing his apron; and needed someone to supervise him while smoking. She stated that she didn't have the time to ensure Resident #1 wore his apron every time he decided to go out and smoke.

Based on record reviews and interviews, the facility failed to maintain an effective infection control program. The facility failed to: 1. Analyze the cause of resident's repeat facility acquired infections; and2. Follow its system for identifying potential infections The facility's census was 45 residents.Findings: Record review of the facility's policy titled, Infection Prevention and Control Program with a revision date of 04/28/2025 read in part, The facility has established and maintains an infection prevention and control program.to help prevent the development and transmission of communicable diseases and infections.1. The designated Infection Preventionist (IP) is responsible for oversight of the program.and surveillance.and investigations of exposures of infectious diseases.3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents.b. The infection Preventionist serve as the leader in surveillance activities, maintains documentation of.findings, and any corrective actions made by the facility. 1. On 03/24/2026 at 11:01 a.m., a record review of the facility's monthly tracking and trending binder with S4MDSIP for the months of December 2025, January 2026 and February 2026 revealed the facility's floor plan with color coded dots on the rooms of residents that had an infection for these months. She revealed a resident had a repeat PEG (Percutaneous endoscopic gastrostomy) infections and 2 residents had a repeated UTIs (Urinary Tract Infection). At this time S4MDSIP, was asked if she had analyzed the cause of these repeated infections. She stated that she did not determine the cause of the infections or develop a plan for preventing future infections. On 03/24/2026 at 10:42 a.m., a review of the facility's monthly tracking and trending binder for December 2025, January 2026 and February 2026 was conducted with S2DON. She confirmed that 1 resident had a repeated PEG infection and 2 residents had repeated UTIs for these months. She confirmed S4MDSIP should be analyzing these infections monthly to determine the causes and develop a plan to prevent future infections. 2. Review of the resident's medical record revealed he was admitted to the facility on [DATE]. The resident's diagnoses included cerebrovascular disease affecting right dominant side, aphasia, dysphagia, retention of urine, urinary catheter, incomplete bladder emptying, acute hepatitis C, and benign prostatic hyperplasia. Review of the physician orders dated 02/12/2026 read in part: U/A (Urinalysis) with C&S (Culture and Sensitivity). Review of Resident #50's lab urinalysis with culture and sensitivity read in part: Microbiology – collected date/time: 02/13/2026 at 12:39 P.M. Final report – verified date/time: 02/16/2026 at 6:16 A.M. Pseudomonas aeruginosa with 70,000 CFU/ML (colony-forming unit/Milliliters) and Providencia stuartii 70,000 CFU/ML Further review of the document revealed the facility obtained the results on 03/04/2026 at 7:44 a.m. Further review of the physician orders dated 03/04/2026 read in part: Rocephin 1 gram (Gram) IM (Intermuscular) for 5 days related to urinary tract infection. Cipro 250 mg (Milligrams) twice daily for 7 days related to urinary tract infection. Review of the facility communication log dated 02/12/2026 read in part: Resident #50 U/A C&S (cloudy urine/foul odor). Further review of the communication log failed to reveal any further information related to Resident #50's urine test or the consistency and/or smell of the urine after 02/12/2026. Review of the nurse's progress notes dated 02/12/2026 – 03/04/2026 read in part: On 02/12/2026 at 9:01 a.m., S11RN documented physician contacted at this time related to urine cloudy, foul odor, and amber. New order noted and carried out for urine u/a with c&s at this time. Further review of the nurse's progress notes failed to show additional documentation of the staff addressing the resident's urine or his microbiology/urinalysis test until 03/04/2026. On 03/04/2026 at 3:49 a.m., S7LPN documentation read in part. resident lying in bed noted with bloody bowel movement and coke colored urine with blood noted. On 03/04/2026 at 8:31 a.m., S4IP documentation read in part. resident's orders this am, noted with order for UA C&S on 02/12/2026, no results found in chart. Call placed to local hospital lab, results sent. Results of C&S shows Pseudomonas aeruginosa and Providencia stuartii (bacteria). Nurse practitioner made aware of when UA was collected and of results. New order given to start Rocephin 1 gram IM x 5 days and cipro 250 mg twice daily x 7 days. On 03/24/2026 at 3:45 p.m., an interview was conducted with S11RN. S11RN stated she had observed Resident #50's foley catheter bag with cloudy urine. She stated upon further inspection, she noted the urine had a foul smell. S11RN stated on 02/12/2026 she obtained an order from the physician to collect a U/A C&S. She confirmed she collected the urine sample from the resident's indwelling catheter bag and sent it to the lab for analysis. S11RN stated she did not follow up with the nurse or with S4MDSIP about the results of the test. On 03/25/2026 at 1:28 p.m., an interview was conducted with S4MDSIP. S4MDSIP stated she had not been made aware that Resident #50's urine was cloudy and had a foul odor. She stated the nurses would collect the urine and leave her a sticky note on top of her desk letting her know the sample had been collected. She added from there she would follow up with lab to retrieve the results. She added she was not aware that a U/A C&S had been ordered and collected on 02/12/2026. S4MDSIP stated staff should have made her aware of the order so that she could follow up with lab to obtain the results. On 03/25/2026 at 1:30 p.m., an interview was conducted with S5MDS who stated she was responsible for reviewing the communication log for labs on Resident #50's hall and all other events that occurred on the previous shift. She stated she does not review the communication log daily consistently. S5MDS stated if she sees a lab order written in the communication log, she will verbally notify S4MDSIP of the order so S4MDSIP could follow up with the results. On 03/25/2026 at 1:58 p.m., an interview was conducted with S2DON. S2DON stated when the nurses take a phone order for labs or cultures from the physician, the order is to be written in the communication log, and on the physician order sheet. She stated whoever completed the orders was supposed to leave a note on S4MDSIP's desk, notifying her of the order and the collection of that particular lab. S2DON stated S4MDSIP should have been made aware of the lab order and followed up with lab in order to obtain the results of the lab in a timely manner.

Based on observation, record review, and interview, the facility failed to ensure all drugs and biologicals remained locked in stored compartments as evidenced by medication left unattended on top of a medication cart. Findings: Review of the facility's policy and procedure for Medication Storage that was not dated revealed, Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the Medication storage area/cart.On 03/24/2026 at 11:08 a.m. during the medication pass, S9LPN (Licensed Practical Nurse) was observed leaving medication blister packets of Baclofen and Hydralazine on top of the medication cart that was in the hall next to Resident #26's room. S9LPN was then observed entering Resident #26's room to administer medications. The medication cart was not in direct observation of S9LPN's vision. Upon exiting the resident's room, S9LPN observed the 2 blister packets of medication on the top of the medication cart. S9LPN confirmed the medication cart was not in her view. She confirmed the medications should not have been left on top of the cart and should have been locked in the medication cart.

Based on record reviews and interviews, the facility failed to have a policy/process in place to ensure that collected specimens were sent to the lab for processing in a timely manner to prevent delay of care for 1 (Resident #11) of 25 sampled residents.Findings:Review of Resident #11's electronic record revealed she was admitted to the facility on absence epileptic syndrome, intractable without status epilepticus; major depressive disorder, recurrent; and iron deficiency anemia. Review of Section H of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she was always incontinent of urine and bowel.Review of Resident #11 progress notes revealed the following entries:11/20/2025 at 5:24 p.m. by S9LPN revealed the resident was exhibiting signs and symptoms of confusion and S8MD was notified and a new order noted for UA (urinary analysis) and C&S (culture and sensitivity). 11/21/2025 at 5:09 a.m. by S7LPN revealed she attempted urine collection and the resident was incontinent of bowel and bladder, and no urine was obtained. 11/21/2025 at 2:43 p.m. by S6LPN revealed she obtained the urine specimen from the resident, placed it in the specimen refrigerator and supervisor was notified. 11/24/2025 at 5:40 a.m. by S7LPN revealed the urine obtained on 11/21/2025 was discarded because it had been obtained over 24 hours, and a new sample was collected and sent to the lab.Review of urinalysis report on urine collected on 11/24/2025 revealed the following in part:UA color: yellow; UA appear: cloudy; UA WBC (white blood cells): 10-15 (normal is 1-2); UA Bacteria: Moderate (normal is 0).Microbiology final report verified 11/25/2025 at 6:15 a.m. > (greater than) 100,000 cfu (colony forming units)/ml (milliliter) Escherichia coli (normal is less than 10,000).Microbiology preliminary report verified 11/25/2025 at 8:06 a.m. > 100,000 cfu/ml Gram Negative Bacilli (a large group of bacteria).The facility did not receive the results for the urinalysis until Resident #11 was sent out to the hospital for a swollen knee.On 03/24/2026 at 1:15 p.m., a request for a policy regarding urine collection, transportation to lab, and receiving results was made to S2DON. She stated that she did not have a written policy that addressed urine collection and transportation to the lab.On 03/25/2026 at 8:49 a.m., an interview was conducted with S6LPN. She stated she collected the urine from Resident #11 on 11/21/2025. She stated she placed the sample in the refrigerator, and notified the ward clerk and S2DON. S6LPN stated when she placed a specimen in the refrigerator she would usually check at the end of her shift to ensure it was sent. She confirmed that she did not check the refrigerator before she left her shift to know if the urine sample had been sent to the lab. On 03/25/2026 at 10:10 a.m., S1ADM was asked if the facility had a policy on the process for implementing an order for urine cultures which addressed collection of sample and submitting it to the lab. He reported back at 10:20 a.m. and confirmed that the facility had no policy addressing the above.On 03/25/2026 at 1:28 p.m. an interview was conducted with S4MDSIP who is responsible for infection control in the facility. She stated the urine should have been collected the day it was ordered and the facility's transporter called to take it to the lab. She was asked if there was a process in place to ensure that collected urine specimens were removed from the refrigerator and sent to the lab in a timely fashion. She confirmed that the facility had no process in place for specimen collection and transportation to the lab in a timely fashion.On 03/25/2026 at 1:58 p.m., an interview was conducted with S2DON. She re-confirmed the facility did not have a written policy that addressed urine collection and transportation to the lab in a timely fashion. She stated that when a doctor ordered a urinalysis, the nurse is supposed to ensure it is collected and sent out to the lab. She stated that the maintenance/transportation staff member takes all specimen to the lab when he is called by staff. She stated that even if maintenance is not in the facility, he lived close by and staff can call him anytime to take specimen to the lab. She stated that there was no reason for the urine to be ordered on 11/20/2025 and not collected and sent to the lab until 11/24/2025.

Based on observations, record review, and interviews, the facility failed to ensure residents who are unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for 3 (#13, #15, #35) of 4 residents reviewed for ADL care.Findings: Record review of the facility's policy with a revision date of 04/28/2025, titled, Nail Care read in part, Provide guidelines for the provision of care to a resident's nails for good grooming and health.3. Routine cleaning and inspection of nails will be provided during ADL (Activities of Daily Living) care on an ongoing basis.6. Procedure: c. gently clean underneath nails with orange stick. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, vascular dementia, delusional disorder, type 2 diabetes mellitus and anxiety. Her MDS (Minimum Data Set) dated 02/03/2026 indicated her BIMS (Brief Interview for Mental Status) score was 7, meaning her cognition was severely impaired. Review of Resident #13's care plan dated 11/25/25 read in part, Her usual functional ability performance with personal hygiene is partial/moderate assist. On 03/23/2026 at 9:00 a.m., an observation of Resident #13's fingernails revealed a dark substance under her fingernails on both hands. On 03/24/2026 at 12:05 p.m., S2DON observed Resident #15's fingernails and confirmed they were dirty. She stated the CNAs (Certified Nursing Assistant) were supposed to clean the resident's nails when they bathe the residents. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, dementia with agitation, major depressive disorder and cognitive communication deficit. Her MDS (Minimum Data Set) dated 02/06/2026 indicated her BIMS score was 3, meaning her cognition was severely impaired. Review of Resident #15's care plan dated 1/29/26 read in part, Her functional ability performance is dependent x 2 assist with personal hygiene. On 03/23/2026 at 9:20 a.m., an observation of Residents #15 fingernails on her left hand revealed a black substance under her fingernails. On 03/24/2026 at 11:45 a.m., an observation with S14CNA (Certified Nursing Assistant) confirmed Resident #15's fingernails on her left hand were dirty with a black substance under her nails. S14CNA stated the CNAs were to clean the resident's nails when showering and as needed. S14CNA stated Resident #15 had her bath yesterday. Resident #35 Resident #35 was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, cerebral infarction, hemiplegia and hemiparesis, aphasia, Type 2 diabetes mellitus and Parkinsonism. Her MDS (Minimum Data Set) dated 03/10/2026 indicated her BIMS score was 6, meaning her cognition was severely impaired. Review of Resident #35's care plan dated 11/25/25 read in part, Her functional ability performance is substantial/maximal assist with personal hygiene. On 03/23/2026 at 9:15 a.m., an observation of Resident #35's fingernails revealed a thick build-up of grime under her fingernails on both hands. On 03/24/2026 at 12:06 p.m., S13LPN (Licensed Practical Nurse) stated she was Resident #13's, #15's and #35's nurse. During this time she observed all three residents and confirmed Resident #13's, #15's, and #35's fingernails were dirty and needed to be cleaned. S13LPN stated the CNAs were supposed to clean the resident's nails when providing hygiene care.

Based on record review and interview, the facility failed to ensure the resident's MDS (Minimum Data Set) was completed accurately for 2 (#32, #44) out of 25 sampled residents. Findings:Review of Resident #32's quarterly MDS dated [DATE] revealed the resident was coded for taking anticoagulants. Review of Resident #32's physician's orders for March 2026 revealed there was no order noted for an anticoagulant (a drug that inhibit clotting factors in the blood to prevent stable blood clots). Review of Resident #44's quarterly MDS dated [DATE] revealed the resident was coded for taking anticoagulants. Review of Resident 44's physician's orders for March 2026 revealed there was no order noted for an anticoagulant. On 03/24/2026 at 8:50 a.m., an interview was conducted with S4MDSIP and S5MDS. They both reviewed the resident's electronic clinical record. S4MDSIP stated the residents were on Plavix and that was the anticoagulant. S5MDS corrected her and stated that Plavix was an antiplatelet medication. Both then confirmed that the residents were not on an anticoagulant. Both confirmed the resident's MDS were coded inaccurately to reflect anticoagulant use.

Based on interview and review of the facility's Resident Personal Funds policy, the facility failed to provide quarterly personal funds statements for 1 (#12) out of 1 (#12) resident investigated for personal funds.Findings:An interview was conducted on 03/23/2026 at 09:24 a.m. with Resident #12. Resident #12 stated he had not received a quarterly statement for several months. On 03/23/2026, a review of the facility's policy titled Resident Personal Funds with no date revealed in part, Accounting and Records .3. The individual financial record must be available to the resident through quarterly statements and upon request .An interview was conducted on 03/24/2026 at 12:45 p.m. with S10PFS. She stated that she was responsible for providing quarterly personal funds statements to the residents with a personal funds account. S10PFS stated had been out of the facility from January 2025 to September 2025 and confirmed that Resident #12 had not received quarterly statements during that time.

Based on interviews and record reviews, the facility failed to ensure a resident's right to be free from financial exploitation for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility's census was 49.Findings:On 08/05/2025, a review of the facility's undated policy titled Abuse, Neglect and Exploitation, read in part: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Review of Resident #1's Electronic Health Record (EHR) revealed an admission date of 05/31/2023, with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; alcohol use, unspecified with withdrawal with perpetual disturbance; and major depressive disorder. Review of Resident #1's last quarterly Minimum Data Set (MDS) revealed he had a brief interview for mental status (BIMS) of 14, indicating his cognition was intact.Review of the facility's investigative report dated 07/08/2025 at 4:00 p.m., revealed in part: Resident #1's family member reported to S2DON (Director of Nursing) that she had reviewed the resident's bank statements and noted several transactions in which the resident transferred money to S3LPN (Licensed Practical Nurse) via a peer to peer payment service. The dates and amount listed were: 06/03/2025-$103.96; 06/04/2025 -$206.00, $104.00, and $106.00; 06/09/2025 - $410.00 and $50.00; and in May 2025 $50.00 and $25.00. Further review revealed S2DON and S4SSD (Social Services Director) spoke to S3LPN on 07/09/2025, and she confirmed receiving the money from Resident #1, and stated the money was used to purchase clothes and several pairs of shoes for the resident.Review of a police report dated 07/14/2025 at 11:17 a.m., revealed a complaint was made by Resident #1's family member that she had reviewed the resident's May 2025 bank statement and noticed several peer to peer transfers to S3LPN. The family member further stated that after questioning Resident #1 about the transactions, he stated S3LPN had asked him for $400 because her son was in the hospital.Review of Resident #1's bank statements dated 01/28/2025 to 02/26/2025 revealed the following in part: On 02/08/2025 a payment of $258.00 was sent to S3LPN's Card.On 02/11/2025 an overdraft fee of $34.00 was posted for the $258.00 payment sent to S3LPN's Card.Review of Resident #1's bank statements dated 04/24/2025 through 05/23/2025 revealed the following:On 05/07/2025, a payment of $50.00 was sent to S3LPN's Card.On 05/07/2025, a payment of $25.00 was sent to S3LPN's Card.On 05/08/2025, an overdraft fee of $34.00 was posted for the $50.00 payment sent to S3LPN's Card.On 05/08/2025, an overdraft fee of $34.00 was posted for the $25.00 payment sent to S3LPN's Card.Review of Resident #1's bank statements dated 05/24/2025 to 06/25/2025 revealed the following:On 06/03/2025, a payment of $103.96 was sent to S3LPN's Card.On 06/04/2025, a payment of $206.00 was sent to S3LPN's Card.On 06/04/2025, a payment of $104.00 was sent to S3LPN's Card.On 06/04/2025, a payment of $106.00 was sent to S3LPN's Card.On 06/09/2025, a payment of $410.00 was sent to S3LPN's Card.On 06/09/2025, a payment of $50.00 was sent to S3LPN's Card.Review of Resident #1's bank statements dated 06/26/2025 through 07/24/2025 revealed the following:On 07/03/2025 an ATM (Automated Teller Machine) withdrawal of $400.00.On 08/04/2025 at 10:07 a.m., a phone interview was conducted with S5PInv (Police Investigator). She stated she reviewed Resident #1's bank statements and discovered the peer to peer payments to S3LPN. She stated she interviewed Resident #1, and he stated to her that S3LPN requested money from him in June of 2025 because her son was in the hospital. The payment of $410 showed as a payment to S3LPN on 06/09/2025. S5PInv stated Resident #1 told her prior to that, he sent S3LPN money to purchase shoes and clothes for himself. She stated S3LPN had purchased the items and had them at her house. When S3LPN was asked to bring the items in, there was a pair of shoes that were not the resident's size. S5PInv also stated S3LPN was not able to provide receipts for any of the purchases.On 08/04/2025 at 12:12 p.m., a phone interview was conducted with Resident #1's family member. She stated she discovered the peer to peer payment service transactions on Resident #1's bank statements. The family member stated she reported it to the facility in July of 2025. She stated the facility did an investigation and S3LPN stated she used the money to make purchases the resident asked her to make, but when asked she was not able to provide receipts for the purchases, so she (the family member) reported it to the police.During a telephone interview with Resident #1 on 08/04/2025 at 12:47 p.m., the resident confirmed that he had sent money via Cash App to S3LPN.On 08/04/2025 at 1:20 p.m., an interview was conducted with S2DON. She stated the facility started investigating the allegation of financial abuse on 07/08/2025. Resident #1 and S3LPN both stated the money was to purchase groceries, clothes, and shoes for Resident #1. S2DON stated that on 07/14/2025 when S5PInv came to conduct her investigation, Resident #1 confirmed sending $400.00 to S3LPN for her personal use and also sent her money to purchase groceries, clothes and shoes for himself. S2DON stated that S3LPN was not able to produce receipts for the purchases. She further stated S3LPN should have known better and should not have accepted any money from Resident #1. On 08/05/2025 at 9:08 a.m., an interview was conducted with S1ADM (Administrator). S1ADM stated she was notified of the financial abuse allegation between S3LPN and Resident #1 on 07/08/2025. She stated on 07/14/2025, she sat in on separate interviews conducted by S5PInv with Resident #1 and S3LPN. S1ADM stated S3LPN told S5PInv that she received money via the peer to peer payment service from Resident #1 to purchase groceries, clothes and shoes for him, and did not have receipts for the purchases. S1ADM also stated she heard when Resident #1 told S5PInv that he sent S3LPN $400 for personal use because she told him her son was sick. S1ADM stated S3LPN should not have accepted any payments from Resident #1, should not have told Resident #1 her personal story because that's exploitation, and should not have accepted cash from Resident #1.On 08/05/2025 at 10:08 a.m., an interview was conducted with S3LPN. She confirmed receiving the above payments from Resident #1, and stated they were used to purchase food, cigarettes and clothing items for the resident. When asked if she had provided receipts for the purchases, S3LPN stated I think so. S3LPN stated she did not report that Resident #1 had asked her to make purchases, or that she received payments from the resident to the resident's family, S4SSD, S2DON, or S1ADM. She confirmed that she was trained on abuse and exploitation and the facility's policy. S3LPN further stated she should not have accepted the peer to peer payment service payments from Resident #1.

Based on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required. This deficient practice had the potential to affect any of the 51 residents residing in the facility. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for Fiscal Year 2024, Quarter 1 (October 1- December 31) revealed the following: -One star staffing rating, triggered. -Excessively low weekend staffing, this metric is suppressed for this facility and quarter. -Failed to have licensed nursing coverage 24 hours/day, triggered. On 02/26/2025 at 9:22 AM, an interview was conducted with S1ADM (Administrator). She stated she reviewed her entries to PBJ for Quarter 1, and realized she had two licensed practical nurses coded as a regular staff member versus a licensed practical nurse that was providing direct care to the residents. S1ADM confirmed she did not submit accurate payroll information to PBJ.

Based on record review, observations and interview, the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#48) of 4 (#16, #17, #32 and #48) residents that were reviewed for urinary catheter or UTI (urinary tract infection). The facility failed to ensure Resident #48's urinary catheter drainage bag was secured properly off of the floor. Findings: On 02/26/2025 a review of the facility's policy with a review date of 12/31/2024 titled Catheter Care read in part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Resident #48 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, anxiety disorder and retention of urine. Review of Resident #48's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/21/2025 revealed in Section H - Bladder and Bowel she was coded for an indwelling catheter. On 02/24/2025 at 9:30 AM, an observation was made of Resident #48's indwelling urinary drainage bag lying on the floor beneath her bed. On 02/24/2025 at 11:24 AM, a second observation was made of Resident #48's indwelling urinary drainage bag in the same position lying on the floor beneath her bed. On 02/24/2025 at 11:46 AM, an observation and interview was conducted with S2CNA (Certified Nursing Assistant). She confirmed that Resident #48's indwelling urinary drainage [NAME] was lying on the floor beneath the bed. She stated that the drainage bag should have been clipped to the bed below the resident's bladder and not on the floor. On 02/26/2025 at 9:30 AM, an interview was conducted with S3LPN/IP (Licensed Practical Nurse/Infection Preventionist). She stated appropriate catheter care for indwelling urinary drainage bags were that they should be hung on the resident's bed or wheelchair with a privacy covering and should not be on the floor.

Based on observations, record review and interviews, the facility failed to supervise and monitor assistive devices to prevent accidents. This occurred in 1 (#35) out of 1 (#35) residents who were investigated for Accidents out of 19 sampled residents. Findings: Record review of the facility policy titled Resident Alarms and dated 12/31/2024 read in part, Alarms are to be utilize in accordance with the resident's needs .to maintain highest .level of well-being .when movement is detected .The use of alarms does not eliminate the need for adequate supervision of the resident .Each resident shall be assessed for fall .and periodically thereafter as part of the comprehensive assessment process .When alarms are used .monitoring shall be provided .to .verify alarms are working properly. Review of Resident #35's record revealed he was admitted to the facility on [DATE]. His diagnoses were in part, Bipolar, Major Depression, Seizures, Paralytic Syndrome, Anoxic brain damage, Cerebral Vascular Disease, and Hemiplegia affect left dominant side. Resident had a BIMS (Brief Interview of Mental Status) score of 13 meaning his cognition was intact. Record review of Resident #35's Fall Risk assessment dated [DATE] revealed a total score 50 meaning he was at a High Risk for falls. Record review of Resident #35's care plan dated 05/03/2024, under problem area, read in part Resident #35 is at risk for falls due to CVA (Cerebrovascular Accident or Stroke) with left side hemiplegia, paralytic syndrome .weakness .unsteadiness . Under approaches read in part, Monitor for falls q (every) 1/2 hours .Bed alarm while in bed .Staff to observe more closely when resident coming back from smoking and assist to bed .Staff to offer resident transfer assist more often. Record review of Resident #35's February 2025 physicians orders read in part, Monitor for falls q 1/2 hours .Bed alarm while in bed. On 02/24/2025 at 11:23 AM, an observation was made of Resident #35 lying in bed with his bed alarm pad located under his torso and attached to the alarm monitor hanging from his bed rails. Resident #35 stood up on one leg and transferred himself into his wheelchair. At this time, the bed alarm was not alarming. On 02/25/2025 at 2:57 PM, an observation was made of Resident #35 lying in bed. His bed alarm pad was not observed under his torso. The alarm monitor was hanging from the bed rails. There was no light on to indicate that the alarm was working. On 02/25/2025 at 3:02 PM, an observation was made with S4CNA (Certified Nursing Assistant) who confirmed Resident #35 was lying in bed with the alarm pad by his feet. She stated the nurses and CNA were to ensure the alarm pad was located under the resident's torso and the monitor was working. She stated the bed alarm monitor for Resident #35 was not working at this time. On 02/25/2025 at 3:08 PM, S5LPN (Licensed Practical Nurse) stated the batteries in Resident #35's bed alarm monitor was dead. She stated the alarm pad was not under the resident and if the monitor was working it would alarm. On 02/25/2025 at 3:10 PM, S6LPN entered the room and stated she was Resident #35's nurse. She stated the staff were to ensure Resident #35's alarm pad was located under his body and were to ensure that the alarm monitor was working. On 02/26/2025 at 10:01 AM, an observation was made of Resident #35 lying in his bed and his alarm monitor was hanging from the side rails. The alarm pad was under the resident's bed sheet at the foot of the bed. The monitor was not alarming. On 02/26/2025 at 10:03 AM, S7CNA confirmed Resident #35's bed alarm pad was not under his body. At this time, S7CNA placed the pad under Resident #35's body and turned on the monitor. She then had the resident stand up and the alarm sounded. She stated it was the nurses and the CNA's responsibility to ensure the pad was under the resident's body and that the alarm monitor was working properly. On 02/26/2025 at 12:30 PM, S8MDS (Minimum Data Set) Coordinator confirmed the nurses should be monitoring the resident and the nurses and CNA should be ensuring the Resident's bed alarm pad was correctly placed under the resident as well as ensuring the alarm monitor was working every shift.

Based on record review and interviews, the facility failed to electronically submit payroll information for direct care staffing as required. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2023 from 07/01/2023 - 09/30/2023 revealed triggers for the following: failed to submit accurate data for the quarter- One Star Staffing Rating. On 01/18/2024 10:10 a.m., S1ADM (Administrator) stated that she was unaware that the facility's PBJ had not been submitted. She stated that the nursing facility had a third-party company that submitted the facility's PBJ information. At 10:35 a.m., S1ADM contacted the HR (Human Resource) Director with the company. During the phone interview, the HR Director confirmed that the company only complied the data sent by the nursing home and create the PBJ, but the nursing home was responsible for submitting their data. S1ADM confirmed that the PBJ information was not submitted into the system.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service by failing to ensure all stored food items in the facility's walk in freezer were labeled and dated. This deficient practice had the potential to affect the 52 residents who consumed meals prepared and/or served from the facility's kitchen. Findings: Review of the facility's policy and procedure titled Food Storage revealed in part: . Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination . 16. Frozen foods . c. Foods should be covered, labeled and dated . On 01/15/2024 at 9:15 a.m., during the initial walk through of the facility's kitchen, an observation was made of the facility's walk in freezer with S9DS (Dietary Supervisor). There were a total of 6 individual clear storage bags containing food items without dates or labeling. S9DS verified the contents of the unlabeled bags were 2 bags of frozen meat pies; 1 bag of frozen crab cakes; 1 bag of frozen chicken nuggets; and 2 bags of frozen seasoning blend. S9DS confirmed all food items in the freezer should be labeled and dated and were not.

Based on observations and interviews the facility failed to maintain a homelike environment for 4 (#6, #20, #26 and #38) out of 6 (#6, #20, #26, #28, #38 and #50) residents investigated for a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all the residents residing in the facility. The facility's census was 54. Findings: Review of the facility's policy, Maintenance Inspection revealed, in part, the following: Policy Statement: It is the policy of this facility . to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Resident #6: Review of Resident #6's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Essential Hypertension, Cerebrovascular Disease, and Pain. Review of Resident #6's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating his cognition was moderately impaired. An observation on 01/15/2024 at 10:07 a.m. revealed Resident #6's headboard was half way detached from the resident's bed. Resident #6's bedside table had splintered wood exposed to the outside of the bedside table. A follow up observation on 01/17/2024 at 12:35 p.m. revealed Resident #6's headboard was half way detached from the resident's bed. Resident #6's bedside table had splintered wood exposed to the outside of the bedside table. Resident #20: Review of Resident #20's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebrovascular disease, Chronic Diastolic Heart Failure, and Muscle Wasting and Atrophy. Review of Resident #20's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 8 indicating his cognition was moderately impaired. An observation on 01/15/2024 at 11:15 a.m. revealed Resident #20's bedside nightstand had plastic edging unattached and nails exposed and his overhead light was not working. A follow up observation on 01/17/2024 at 12:32 p.m. revealed Resident #20's bedside nightstand had plastic edging unattached and nails exposed and his overhead light was not working. Resident #26: Review of Resident #26's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Transient Cerebral Ischemia Attack, Polyneuropathy, and Heart Failure. Review of Resident #26's Annual Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating the resident was unable to participate. An observation on 01/17/2024 at 12:41 p.m. revealed Resident #26's bedside nightstand had plastic edging unattached and nails exposed. Resident #38: Review of Resident #38's record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Dementia, Other Lack of Coordination, and Other Abnormalities of Gait and Mobility. Review of Resident #38's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating the resident was unable to participate. Section GG Functional Abilities and Goals, revealed toilet transfer: partial/moderate assistance. An observation on 01/15/2024 at 9:15 a.m. revealed baseboards were missing from the wall and a small hole noted in the wall where the baseboards were missing and Resident #38's toilet was easily moveable. A follow up observation on 01/17/2024 at 12:43 p.m. revealed baseboards were missing from the wall and a small hole noted in the wall where the baseboards were missing and Resident #38's toilet was easily moveable. On 01/17/2024 at 12:47 p.m., an interview was conducted with S8LPN (Licensed Practical Nurse). S8LPN confirmed that Resident #38 used the toilet sometimes. On 01/17/2024 at 12:49 p.m., an interview and observation was conducted with S1ADM (Administrator) and S4MS (Maintenance Supervisor). S4MS stated that his responsibility was to maintain the building for the facility and fix any issues for the residents. S4MS stated he has a maintenance log and completes a daily maintenance inspection in each room in the facility and checks the electrical outlets, any leaks, plumbing, bed control, call button, bathroom, and the overall environment making sure it is homelike for the resident. Observations of Resident #6, #20, #26, and #38's room was conducted with S1ADM and S4MD who confirmed multiple findings: Resident #6's bedside table had splintered wood exposed to the outside of the bedside table, Resident #20's bedside nightstand had plastic edging unattached and nails exposed and his overhead light was not working, Resident #26's bedside nightstand had plastic edging unattached and nails exposed, and Resident #38's revealed baseboards were missing from the wall and a small hole noted in the wall where the baseboards were missing and her toilet was easily moveable. S1ADM and S4MS confirmed that these issues needed to be repaired and did not provide a homelike environment for Resident #6, #20, #26, and #38.

Based on record review and interview, the facility failed to inform Resident #254 and his RP (resident representative) of the resident's rights by failing to complete an admission packet during the admission process for 1 (#254) out of 29 final sampled residents. This deficient practice had the potential to effect all the resident's that reside in the nursing facility. The facility census was 54. Findings: A review of Resident #254's medical record revealed an admitted [DATE]. Further review of the medical record revealed there was no admission packet completed, which contained documents that informed the resident and/or the resident's RP of the resident's rights and of all rules and regulations governing the resident conduct and responsibilities during his or her stay. On 01/18/2024 at 11:30 a.m., an interview was conducted with S5SSD (Social Services Director). She confirmed that she was responsible for completing the admission packet with resident's and the resident's RP upon admission. She confirmed that Resident #254 did not have a completed and signed admission packet. On 01/18/2024 at 3:20 p.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed that the SSD was responsible for having the resident and/or the resident's RP sign the admission packet documents within 3-5 days after admission. She confirmed that because the admission packet documents had not been signed by the resident and/or the resident's RP during the admission process, they had not received written notification of the resident's rights and of all rules and regulations governing the resident conduct and responsibilities during his or her stay.

Based on record review and interview, the facility failed to ensure the nurse informed the physician of low blood pressure readings for 1 (#37) resident out of 29 sampled residents. Findings: Resident #37. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cerebral Infarction, Dysphagia, Hypertension, Anxiety Disorder, and Atrial Fibrillation. Review of the resident's quarterly MDS (Minimum Data Set) dated 1/9/2024 revealed the resident's BIMS (Brief Interview Mental Status) score was 13 which meant the resident was cognitive. Review of the resident's nurse's notes dated 1/14/2024 at 3:31 p.m. revealed, 11 a.m.: Called into room by CNA (Certified Nursing Assistant) due to low blood pressure reading on vs (vital sign) machine. VS machine had BP (blood pressure) of 77/33, re-checked with manual cuff BP 80/40 . Placed in Trendelenburg (position elevating the feet and legs of the resident above the level of the heart while resident is lying on back) at this time. 12:20 p.m.; Resident sitting up in bed, re-checked BP now 90/44 . Placed back in Trendelenburg at this time. 1:30 p.m. re-checked BP 96/48 2 p.m. re check BP 104/52. There was no evidence the physician was informed concerning the resident's low blood pressure. On 1/18/2024 at 10:15 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She confirmed that on 1/14/2024, the resident did have low blood pressure readings. S3LPN stated that the resident was placed in Trendelenburg position to help raise the resident's blood pressure. S3LPN confirmed that she could not provide evidence in the resident's clinical record she notified the physician concerning the resident's low blood pressure. On 1/18/2024 at 10:25 a.m., an interview was conducted with S2DON (Director of Nursing). She confirmed that there should have been evidence in the resident's clinical record the nurse notified the physician concerning the low blood pressure readings.

Based on record review and interviews, the facility failed to accurately assess Resident #4's dental status out of a sample of 29 residents. Findings: Record review of Resident #4's care plan dated 07/31/2023 read in part, Resident #4 has natural teeth with some missing and broken. Record review of S5SSD (Social Service Director) progress notes dated 08/01/2023 read in part, New Admit: Resident #4 is a new admit to the facility on [DATE] .Resident #4 has natural teeth with some missing. Record review of Resident #4's MDS (Minimum Data Set) dated 08/07/2023 under Section L, Oral/Dental Status, B. No natural teeth or tooth fragments., D. Obvious or likely cavity or broken natural teeth. were not checked. Further review of this document revealed Z None of the above were present was checked On 01/15/2024 at 12:48 p.m., observation revealed Resident #4 had missing, broken and decayed teeth. On 01/18/2024 at 8:07 a.m., an interview and record review was conducted with S5SSD (Social Service Director). She reviewed her progress notes dated 08/01/2023 and Resident #4's MDS dated [DATE]. She confirmed she had documented that Resident #4 had natural teeth with some missing and had incorrectly coded the dental section of his MDS. On 01/18/2024 at 11:26 a.m., record review of S5SSD (Social Service Director) progress notes dated 08/01/2023 and Resident #4's MDS dated [DATE] was conducted with S7MDS (Minimum Data Set) Coordinator. She confirmed S5SSD had documented in her progress notes on 08/01/2023 that she had assessed Resident #4's oral cavity and observed that he had natural teeth with some missing. S7MDS reviewed Resident #4's MDS Admission assessment dated [DATE] and confirmed S5SSD had chosen Z. None of the above were present. S7MDS stated this was an inaccurate. S5SSD should have chosen D. Obvious or likely cavity or broken natural teeth.

Based on record review and interviews, the facility failed to reassess the resident's pain level after administering pain medication as required by the facility's policy for 2 (#4, #21) of 3 (#4, #21, #304) residents investigated for pain management out of 29 sampled residents. Findings: Record review of the facility's policy titled Pain Management read in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice . Resident #4 Record review of revealed Resident #4 was admitted to the facility on [DATE] with current diagnoses of, Pain, Weakness, Type 2 Diabetes mellitus, Muscle wasting and Atrophy, Atrial Fibrillation, and Cardiac Pacemaker. Record review of Resident #4's care plan read in part, Resident #4 has episodes of generalized pain to left shoulder. X-rays shows probability of chronic rotator cuff tear. Give PRN (as needed) medication for pain as ordered. Monitor the effectiveness of PRN medication. Record review of Resident #4's Physicians Orders dated from 1/1/2024 to 1/31/2024 read in part, Ibuprofen 600 milligram tablet every day PRN Norco 7.5-325 milligrams give 1 tablet PO (Orally) every 8 hours PRN for shoulder pain. On 01/18/2024 at 9:55 a.m., record review of Resident #4's MAR (Medication Administration Record) with S8LPN confirmed that on 1/5/2024, Resident #4 was given Norco 7.5 milligram table for moderate pain at 8:20 a.m. He was not reassessed for pain medication effectiveness until 10:00 a.m. Further review of the MAR revealed that on 1/7/2024 at 8:18 a.m., Ibuprofen 600 milligram tab was administered for shoulder pain. The resident's pain level was not reassessed until at 1:51 p.m. She stated the nurses were not reassessing the pain medication effectiveness timely. She confirmed it was the facility's policy to reassess the resident pain one hour after administering pain medication. On 01/18/2024 at 10:53 a.m., an interview with S2DON (Director of Nursing) confirmed the facility's policy was for nurse to recheck the resident's pain an hour after administering pain medication for the effectiveness. At this time S2DON reviewed Resident #4's MAR dated 1/01/2024 and confirmed S11LPN gave Resident #4 Ibuprofen 600 mg at 8:06 a.m., and reassessed his pain at 1:07 p.m. S2DON also confirmed that on 1/5/2024 at 8:20 a.m., S12LPN gave Norco 7.5 mg-325 mg to Resident #4 for complaint of right shoulder pain and didn't reassess until 10:00 a.m. S2DON stated the nurses were not following facility policy and reassessing the resident pain in a timely manner. Resident #21 Record review revealed Resident #21 was admitted to the facility on [DATE] with current diagnoses of Chronic Pain, Restless legs syndrome, Hypertension, Cerebrovascular diseases, Peripheral Vascular Disease, Chronic Obstructive Pulmonary disease, Arthropathy, and Primary Arthritis. Record review of Resident #21's care plan read in part, Resident has chronic pain to his bilateral lower extremities secondary to Osteoarthritis, Neuropathy, Restless Leg Syndrome .and Spinal Stenosis .Give pain mediation as ordered .Monitor effectiveness of pain medication. Record review of Resident #21's Physicians Orders dated from 1/1/2024 to 1/31/2024 read in part, Norco 7.5-325 milligram tablets take one orally every 8 hours as needed for pain and Tramadol 50 milligrams tablet take one orally every 8 hours for pain. On 01/18/2024 at 9:55 a.m., S8LPN reviewed Resident #21's MAR dated 1/17/24 and confirmed a nurse gave Norco 7.5-325 milligram tablet at 7:57 PM. The resident's pain was not reassessed until 4:57 a.m. on 1/18/24 for effectiveness. She also confirmed that on 1/18/2024 at 7:49 a.m., a nurse gave the resident Tramadol 50 milligram tablet and wasn't reassessed for the medication's effectiveness until 9:48 a.m. on 1/18/2024. S8LPN stated the nurses were not following the facility's policy to reassess the resident's pain an hour after giving pain medication. On 01/18/2024 at 10:53 a.m., S2DON reviewed Resident #21's MAR and confirmed the nurses were not following the facility's policy to reassess residents within an hour of giving pain medication to ensure pain medications were effective.

Based on observation, interview, and record review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by kitchen staff failing to: 1) Have knowledge of recipes to be followed when preparing pureed foods and 2) Ensure the appropriate sized scoops were used to serve pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 3 residents who consumed pureed diets. Findings: Record review of a form titled, Tuesday Week 3 Diet Spreadsheet, provided by S10Cook revealed column 3 of 6 that was titled Puree with the menu items that were divided into the three meals of the day: breakfast, lunch and supper. The corresponding scoop sizes served for an individual portion size were listed before the menu item. Review of the Puree lunch meal revealed #10 sc (scoop) for pork chop. There was also a separate chart noted at the bottom of the spreadsheet that listed the different scoop sizes (No. 6, 8, 10, 12 and 16) and the converted measurements of each scoop in cup and oz (ounces). The #10 scoop had a capacity of 3/8 of a cup or 3.75 oz and the #12 scoop had a capacity of 1/3 cup or 2.6 oz. Review of a form titled, Substitution Record, revealed the lunch meal served on 01/18/2024 was initially chicken and sausage gumbo and was being substituted for hot dogs and pork chops with the reason for the change being that the chicken did not come per S9DS (Dietary Supervisor). On 01/18/2024 at 10:27 a.m., a follow up visit was conducted of the facility's kitchen. S10Cook was observed preparing food items on the steam table that were to be served for the lunch meal. S10Cook was interviewed and stated she was responsible for preparing pureed and mechanical chopped meats diets. S10Cook was unable to recall or show evidence of recipes used and followed when preparing pureed foods. S10Cook stated she followed a diet spreadsheet that included the meals of the day that were separated by the weekday and the week of the month. S10Cook explained that the Tuesday, Week 3, Diet Spreadsheet was being used for the substituted lunch meal which included pureed pork chop. On 01/18/2024 at 10:40 a.m., an observation was made of a green handled scoop in the pureed meat container on the steam table. S10Cook reviewed the Diet Spreadsheet for Tuesday, Week 3 and confirmed a #10 scoop was to be used. S10Cook stated the #10 scoop was a white handled scoop. S10Cook confirmed the green handled #12 scoop that was observed on the steam table line inside the pureed meat container was the incorrect scoop for the pureed pork chop that was going to be served for lunch.

Based on record review, and interview; the facility failed to administer its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to: 1. ensure the safety of Resident #3 during van transport, 2. ensure staff were properly trained and competent to secure wheelchair residents in the van according to manufacturer's instructions for use, and; 3. ensure all transportation staff were retrained on proper wheelchair restraint after Resident #3's incident and develop policies and procedures for safe tranportation to prevent future incidents. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. when the facility failed to develop policies and procedures after staff placed Resident #3, who utilized a wheelchair, in the facility's transport van with the j-hook of the van strap applied to the wheel instead of the frame of Resident #3's wheelchair. The driver made a turn and the resident flipped backward and hit her head which resulted in 3 lacerations to the back of her head. The resident was sent to the ER (emergency room ) for scalp laceration repair that required 7 skin staples. The facility also failed to retrain all transportation staff on the correct procedure for utilizing the van's restraint system to prevent future incidents. S1ADM was notified of the Immediate Jeopardy on 11/30/2022 at 2:50 p.m. The IJ was removed on 12/1/2022 at 3:15 p.m., when the facility presented an acceptable POR (plan of removal) prior to the survey exit, which by observation, record review, and interview, the survey team verified was in progress. The POR read: To assure all staff members have an understanding on the vehicle policies and procedures of van operation. As of 12/01/22, S1ADM will update policy to include training of the proper application of safety straps to secure wheelchairs. On 11/30/22 13 residents who are in wheelchairs were identified for potential risk of improper use of brake and safety strap usage on transportation van. On 11/30/22 S10Maintenance checked all straps on the van to ensure they were properly working. Ford Sprinter van will be used for residents that do not require to be transported by wheelchair/lift. Supervision Facility will develop and implement a policy on safe transporting of residents in wheelchairs. Policy will be completed on 12/01/22. S1ADM will randomly monitor transportation drivers S6CNADriver, S7MaintDriver, and S5CNATransport. Day shift CNA's (Certified Nursing Assistants) will also be in serviced on proper application of safety straps to assure residents are free of accident hazards, three times a week for four weeks (January 4, 2023). Administrator will instruct if any deficient practice noted. Training On 12/01/2022 S1ADM will review policies on Safe Transport of Wheelchair Residents with drivers and ensure a copy of the policy will be placed in the van. New hires with potential to drive the van or potential to assist in loading a wheelchair bound resident will be trained on proper placement of straps and wheelchair brakes ensuring that the chair is placed correctly and secured per manufacture instruction. Evaluation On 12/01/2022 for Quality Assurance purposes and to ensure staff members are in compliance with application of safety straps (J-Hook), Administrator will meet with transportation drivers on a weekly basis, review and discuss monitoring/findings, and provide direction, guidance, and recommendation in area of concern. Quality Assurance Coordinator S11ADON and or S2DON will monitor drivers and S1ADM randomly three times a week for four weeks (January 4, 2023). Quality Assurance will instruct if any deficient practice noted. Compliance will be met on January 4, 2023. This deficient practice continued at a potential for more than minimal harm for the 13 wheel-chaired residents who had the potential to be transported in the facility's van. Findings: Cross reference findings at F689 Review of the facility's policy, Company Vehicles failed to include procedures for safe transportation of residents and proper use of the van straps and lift. On 11/30/22 at 9:36 a.m., S1ADM stated that the only policy she had on transportation was the one given on yesterday Company Vehicles. She further stated that the facility did not have any other policies regarding resident transportation or safe resident transport. She stated that staff should transport residents according to their training. On 11/30/22 at 10:41 a.m., an interview and review of in-service records dated 8/25/22 and 11/2/22 was conducted with S1ADM. S1ADM stated that she conducted the in-services where she demonstrated the proper placement of straps to staff. She stated that S5CNATransport, S6CNADriver, and S7MaintDriver were the facility's designated transportation staff, but that any CNA could transport residents. She confirmed that S5CNATransport, S6CNADriver, and S7MaintDriver were not retrained on 8/25/22 after Resident #3's incident. On 11/30/22 at 10:55 a.m., another interview and record review was conducted with S1ADM. She confirmed that Resident #3 fell in the van because S4CNADriver hooked the straps to the wheel not to the frame of the resident's wheelchair as stated in the manufacturer's instructions. S1ADM stated she conducted the QA after Resident #3's fall in which she directly observed staff for proper placement of the straps on the wheelchair for 4 weeks. She reviewed the QA forms and confirmed it stated proper placement of straps on wheel. She stated that it was an error. On 11/30/22 at 5:27 p.m., S3Owner stated that he was responsible for training staff on the proper way to strap residents' wheelchairs in the van. He had the van lift and straps installed after purchasing the gray Ford Sprinter van which did not come with manufacturer's instructions for the straps and lift. He stated that a shoulder strap was not installed and that the van never had a shoulder strap. He confirmed that the QRT-360 belt system was installed in the gray van. He reviewed manufacturer's instructions which noted that strap system should have included a shoulder strap and J hooks should be attached to the frame of the wheelchair. He confirmed he was not aware of the information stated in the instructions regarding the shoulder strap. He further stated that the manufacturer's instructions provided to surveyors on yesterday were printed off of the internet to provide us with what we requested because the facility did not have the manufacturer's instructions onsite. He confirmed S5CNATransport did not strap the resident according to manufacturer's instructions as observed on 11/29/22.

Based on observation, record review, and interview, the facility failed to ensure residents' environment were as free of accident hazards by failing to: 1. properly secure wheelchairs in the facility's van for 1 (#3) of 8 (#1-#5, #R1-#R3) sampled residents who utilized wheelchairs during facility transport; and 2. train transportation staff on the correct procedure for utilizing the van's restraint system. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/24/22 at 4:45 p.m. when S4CNADriver placed Resident #3, who utilized a wheelchair, in the facility's transport van with the j-hook of the van strap applied to the wheel instead of the frame of Resident #3's wheelchair. The driver made a turn and the resident flipped backward and hit her head which resulted in 3 lacerations to the back of her head. The resident was sent to the ER (emergency room ) for scalp laceration repair that required 7 skin staples. S1ADM was notified of the Immediate Jeopardy on 11/30/2022 at 2:50 p.m. The IJ was removed on 12/01/22 at 3:15 p.m., when the facility presented an acceptable POR (plan of removal) prior to the survey exit, which by observation, record review, and interview, the survey team verified was in progress. The POR read: Immediate Action To assure resident #3 and all wheelchair bound residents identified (13) with potential to be affected by improperly securing of safety straps; facility has implemented the following to assure residents are as free from accident hazards. As of 12/01/22, S1ADM will update Company Vehicle Policy to include Safe Vehicle, Safe Wheelchairs, Safe Procedures (unloading and loading wheelchairs), Safe Planning(wheelchair placement), and Emergency Safety Procedures to ensure proper application of safety straps are being used in accordance with policy. On 11/30/22, S10Maintenance inspected all safety straps on Eco line Van and Sprint Van for proper functions- Ford Sprint Van is not equipped with shoulder strap and as of this date (11/30/22) will only be utilized for non-wheelchair bound residents. Ford Eco-line Van is fully equipped with functioning safety straps, including shoulder strap. Supervision To ensure resident (#3) and all wheelchair bound residents are secured properly with all straps per manufactures instructions. Training Residents who are wheelchair bound will use the Ford Hi Top van with pelvic and shoulder attachment on transports. On 11/30/22 an immediate in service was held with facility van drivers. The instructor was S3Owner and participants were S6CNADriver, S7MaintDriver, and S5CNATransport. These three employees listed will be the only staff allowed to transport residents; unless a new employee is trained on driving, loading, and securing residents. In service on the Ford Eco Line will include Step 1: Position the wheelchair, Step 2: Attach the front tie downs, Step 3: Attach rear tie downs, Step 4: S-Hook placement on solid part of wheelchair frame, Step 5: Attach the lap belt, Step 6 Attach shoulder belt per manufacture instructions for securing wheelchair bound residents. In service will also include once resident is placed on lift when to lock and unlock wheelchair brakes. Staff will be educated on how to keep one hand on the resident's wheelchair during operation of the lift for Ford Eco-Line. Repeat demonstration was performed immediately by drivers S6CNADriver, S7MaintDriver, and S5CNATransport on 11/30/22. As of today, 12/01/22 the following employees performed repeat demonstration: S12CNA, S13CNA, S14CNA, S11ADON, S15CNA), S16Clerk, S10Maintenance, S2DON, and S1ADM. New hires with potential to drive or assist with loading the van will be trained on proper placement of straps and wheelchair brakes ensuring that the chair is placed correctly and secure per manufactures instructions. Evaluation All day shift CNA's (Certified Nursing Assistants) will start in servicing on 12/01/22 for the Ford Eco Line Van with proper lift and strap use by S3Owner with return demonstration by all dayshift CNA's. For Quality Assurance purposes to ensure staff members are in compliance with application of safety straps (J-Hook), S1ADM will meet with transportation drivers on a weekly basis, review and discuss monitoring/findings, and provide direction, guidance, and recommendation in area of concern three times a week. This will last up to 4 weeks January 4, 2023 or until compliance is met. Quality Assurance S2DON and S11ADON team will monitor drivers and S1ADM weekly of proper operation of safety straps and brake usage of wheelchair residents. Quality Assurance will last up until 4 weeks or until compliance is met. Compliance will be met on January 4, 2023. Findings: Review of the facility's policy, Company Vehicles failed to include procedures for safe transportation of residents and proper use of the van straps and lift. Review of manufacturer's instructions for van straps, Q'Straint Use and Care Manual QRT-360 4-point wheelchair securement system, read in part: J-Hooks must be attached to the WC19 compliant chair securement points or a solid wheelchair frame for all other wheelchairs (no spokes or movable components) at an approximate 45 degree angle with floor .Compliant Shoulder and Pelvic Belt Restraint must go across occupant's shoulder and pelvis (lap), and not be worn twisted or held away from occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance of the system. The QRT-360 4-Point wheelchair securement system should not be operated by anyone who does not have fully comprehension of how the system works or if the system is not working properly. Further review revealed illustrations of the equipment with labeled parts. Review of the entire system with depictions with wheelchair placement revealed straps/J-hooks secured to wheelchair frame (not wheel spokes) with two in front and two in back. A lap and shoulder belt was also illustrated in the completed setup. Resident #3: Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with diagnoses including Complete Traumatic Amputation at level between left hip and knee, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Generalized Muscle Weakness, and Muscle Spasm. Review of Resident #3's quarterly MDS (Minimum Data Set) dated 10/04/22 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. Further review revealed the resident used a wheelchair. Review of Resident #3's nursing notes revealed in part: 08/24/22 4:45 p.m., S4CNADriver FaceTime called and advised that while transporting resident, wheelchair overturned with resident in it .[Local ambulance service] called and advised location to transport resident to hospital for assessment .ER doctor via FaceTime informed nurse that resident had a small cut on the back of head. 08/24/22 7:45 p.m., ER nurse reports resident will be returning to facility, laceration to back of head with staples, .9:15 p.m., RFH (returned from hospital) .staples to back of head noted and intact . Review of S4CNADriver's handwritten statement dated 08/25/22 revealed in part: took Resident #3 to the __ in (city name) .After her appointment we loaded up, traveled to (city name). Stopped at the store __ to pick up items for the nursing home. I loaded Resident #3 up in the van, hooked all 4 straps, seat belted her down, shook the chair (as I did each time I loaded her) for securing her. All was well, closed the doors, got in the van and pulled off. I exited the parking lot, took off down the street __ leading to the interstate. I looked in my rear view mirror and shouted (Resident #3's name). She hollered and I said, what happened? How did you do that? I was in my turning lane. I had to get all the way over in order to assist her. Once I was in a safe place I got out the van, got to the back of the van and phoned 911 at 4:39 p.m. I recognized my mistake #1 exiting the parking lot on a slant. #2 hooking the hooks to the wheels instead of the bars under the chair. Review of an attached page read in part: when I opened the back doors to the van, Resident #3 was lying flat on her back at an angle .She had bleeding from the back of her head. Review of Resident #3's hospital records revealed in part: 08/24/22 17:21 (5:21 p.m.) resident presented to the emergency department for evaluation due to fall from her wheelchair. The patient was in an agency van just prior to ED (emergency department) evaluation when the wheelchair fell backward and the patient hit her head on the floor of the van. The patient has a scalp laceration. Laceration repair: occipital linear superficial wounds. Laceration #1- length 3 cm (centimeters), closed with 3 staples. Laceration #2- length 2 cm, closed with 2 staples. Laceration #3- length 2 cm, closed with 2 staples. A total of 7 staples. On 11/29/22 at 10:07 a.m., an interview was conducted with Resident #3 who was asked to recall the incident. She stated that S4CNADriver took her to her appointment. After the appointment, they stopped to a store. After shopping, S4CNADriver loaded her into the van in her wheelchair and strapped her down. Everything seemed fine so S4CNADriver got into the driver's seat and began driving out the parking lot. When S4CNADriver made a left turn, the back wheels on the left side of the van hit a curb causing the van to jump up. When this happened, she fell backward in her wheelchair hitting her head on the van's floor. She stated that there was a lot of blood from her head. The ambulance transported to the hospital where it took 7 skin staples to repair the laceration to her head. She then parted the hair behind her head and stated she had scars behind her head. Three scars observed in a disrupted pattern to left posterior skull. At this time resident began to cry and stated that since the fall it seemed like everything hurts and she has occasional headaches that she did not experience prior to the fall. On 11/29/22 at 10:32 a.m., a phone interview was conducted with S4CNADriver who stated she was no longer employed at the facility. She was asked to recall the incident involving Resident #3 and explained it in detail as was documented in her witness statement. She stated that she hooked the straps to the residents chair and shook the chair to make sure it was sturdy. She was driving down the road after pulling out the store driveway when she looked in her rear view mirror and saw that the resident was not visible. She yelled out to the resident and the resident began yelling so she pulled over to a safe area on the side of the road, called 911, and video called the nurse at the nursing home. She stated the resident fell backward in her wheelchair and was bleeding from the back of her head. The ambulance took Resident #3 to the hospital. S4CNADriver stated, I made a mistake .I hooked the straps to the wheels, not the cross bar. She stated that the straps of the j hooks should have been placed on the frame of the wheelchair not the wheels. She further stated she had been transporting residents for many years and knew better. On 11/29/22 at 11:59 a.m., an observation was conducted of S5CNATransport and S6CNADriver loading Resident #3 into the facility's gray Ford Sprinter van. S3Owner was present during the observation. Once the resident was lifted into the van, S6CNADriver began securing the J hook straps to Resident #3's wheelchair. S6CNADriver hooked two front straps and two rear straps onto the wheels of the resident's wheel chair. The hooks were observed as the same hooks illustrated in the operator's manual as the J hook. The hooks did not have a secure closing on the ends. S6CNADriver then stepped out to allow closer observations. At this time, S3Owner was standing next to S6CNADriver at the side doors in view of the resident. All 4 straps were observed on the wheelchair wheel. There were no straps observed on the frame of the wheelchair. When asked if these were all the straps required for transport, S6CNADriver stated yes. S6CNADriver then secured the resident's lap belt, a shoulder strap was not applied. S6CNADriver was asked if this was how staff secured the straps, to the wheels of the wheelchair, and she replied yes. She was again asked if any other straps needed to be applied to the frame of the wheelchair, and if these were the only straps required to secure the resident, and she said yes. At this time S3Owner confirmed this was the proper placement of the straps, 4 J hooks applied to the wheel with a strap across the resident's lap. S6CNADriver confirmed she was done securing the resident's wheelchair and that the resident was ready for transport. S6CNADriver and S5CNATransport entered the driver and passenger seats respectively and drove off with the resident. On 11/29/22 at 3:20 p.m., Resident #3 had returned to the facility. An observation was conducted of Resident #3 was still loaded inside the van with straps in place. S1ADM, S5CNADriver, and S6CNADriver were present. The straps of the J hooks were now observed to the frame of the resident's wheelchair. There was no shoulder belt in place, only a lap belt. No shoulder strap attachments were observed in the back of the van where Resident #3 was located. S5CNATransport and S6CNADriver were asked why the straps were placed differently. Resident #3 then replied, to satisfy the state. Both CNAs confirmed straps were placed on wheels this morning as previously observed. They were asked which way was the correct placement, on the wheels or frame? S5CNATransport stated that both methods were correct. S6CNADriver stated she was not sure why, but that staff placed them on the wheels. S6CNADriver confirmed the straps of the J hooks should have been secured to the frame of the resident's wheelchair. Resident #3 stated that staff normally hooked the straps to her wheels and that today on her return trip hooked it to the frame. S5CNATransport and S6CNADriver then stated that Resident #3 preferred that staff strap the hooks on the wheels, so that's what they did, and it was the resident's preference. S1ADM confirmed Resident #3 fell on [DATE] because S4CNADriver hooked the straps to the wheel. She confirmed staff did not follow the manufacturer's instructions and that resident was not properly secured during transport. On 11/30/22 8:09 a.m., an interview was conducted with S7MaintDriver who stated that he normally drives the white high top van and does not drive the gray Ford Sprinter van (the one observed on 11/29/22.) He stated he straps the resident across the lap and hooks the straps to the frame of the chair. When asked about a shoulder strap he stated, I think that maybe there is one that goes across the shoulder but he wasn't sure. Interviews conducted with residents who had been transported in the facility's van from August 2022-November 2022 revealed the following: Resident #1 Review of the resident's Admission MDS dated [DATE] revealed she had a BIMS score of 15, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 11/02/22 and 11/10/22. During an interview on 11/29/22 at 2:30 p.m., Resident #1 confirmed she had been transported to medical appointments via the facility van in her wheelchair. She stated that whenever they transport her the staff strap the safety belts to the wheels of her wheelchair and then one strap goes across her waist. Resident #2 Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 12, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/22/22 and 11/21/22. During an interview on 11/29/22 at 3:20 p.m., Resident #2 confirmed she had been transported to medical appointments via the facility van in a wheelchair. She stated that staff hooked straps onto to the wheels of her wheelchair for transport. Resident #5 Review of the resident's admission MDS dated [DATE] revealed she had a BIMS score of 14, indicating she was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/19/22, 10/06/22, and 11/02/22. During an interview on 11/29/22 at 2:30 p.m., Resident #2 confirmed she had been transported to appointments via the facility van in a wheelchair. He stated that whenever they transport him, the staff secure the safety belts to the wheels of his wheelchair with one strap across his waist. Resident #R1 Review of the resident's admission MDS dated [DATE] revealed she had a BIMS score of 14, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/27/22. During an interview on 11/30/22 at 11:00 a.m., Resident #R1 confirmed he had been transported in a wheelchair in the facility van. He stated that whenever he is transported, the staff hook the safety belts to the wheels of his wheelchair using 4 straps to the wheels plus a lap belt. Resident #R2 Review of the resident's annual MDS dated [DATE] revealed she had a BIMS score of 14, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 09/13/22, 09/27/22, and 10/20/22. During an interview on 11/29/22 at 2:30 p.m., Resident #R2 stated he was transported regularly in the facility van in his wheelchair. He stated that whenever staff transport him, the staff strap 4 safety belts to the wheels of his wheelchair and apply a lap belt; no mention of a shoulder strap. Resident #R3 Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 15, indicating he was cognitively intact. Review of the Transport Logs revealed the resident was transported in the van via wheelchair on 10/08/22. During an interview on 11/30/22 at 10:30 a.m., Resident #R3 confirmed she had been transported to via the facility van in a wheelchair. She stated that staff hooked straps onto to the wheels of her wheelchair for transport. He stated staff hook the straps to the wheels of his wheelchair and apply a lap belt. On 11/29/22 at 2:07 p.m., in an interview with S8CNA, she stated she was trained on the van about 3 weeks ago after Resident #4's fall. S1ADM conducted the training and demonstrated to staff to strap the wheelchair down by attaching each strap to each wheel. She further stated that each CNA (Certified Nursing Assistant) at the training had to perform a return demonstration. On 11/30/22 at 9:40 a.m., in an interview with S9CNA, she stated S1ADM trained her 3 weeks ago on van transportation. She stated she was taught to hook the straps front straps on the front of each wheel and the back straps on the back wheels. On 11/30/22 at 10:55 a.m., an interview and record review was conducted with S1ADM. She stated that the facility owned a white high top Ford van and a gray Ford Sprinter van. She stated that shoulder straps were used as needed and if the resident can wear it. She was asked to explain what can meant and under what circumstance a shoulder strap would be used. She stated that it depended on which van the resident rode and was also based on resident's needs/condition. She was informed a shoulder strap was not observed in the gray van used to transport Resident #3, nor was there any shoulder strap attached to the van frame. She stated that a shoulder strap was not required in the gray van, but it was required in the white van. She stated that both vans were equipped with the same QRT-360 strapping system. The QRT-360's manufacturer's instructions were reviewed with S1ADM at this time. She then confirmed that a shoulder strap was required to ensure integrity of the strapping system. She then stated that the gray Sprinter van used to transport Resident #3 on 11/29/22 was borrowed from a sister facility after it was wrecked sometime after Resident #3's incident. She stated that the facility had not inspected the van or the van's strapping system to ensure the van was in proper working order before transporting residents. She further stated that it was her error that she failed to do this. On 11/30/22 at 4:35 p.m., S1ADM observed the gray Ford sprinter van and confirmed the van was not equipped with shoulder straps for wheelchair residents. On 11/30/22 at 5:27 p.m., S3Owner stated that when he purchased the gray Ford Sprinter van it did not come with lift and straps. Another company installed the lift and straps and a shoulder strap was not installed. He further stated that the van never had a shoulder strap. He confirmed that the QRT-360 belt system was installed in the gray van. He reviewed manufacturer's instructions which noted that strap system should have included a shoulder strap. There were no instructions to use the system as a lap strap only although he continued to insist that it could be used without a shoulder belt. He further stated that the manufacturer's instructions provided to surveyors on yesterday were printed off of the internet to provide us with what we requested, and that the facility did not have any manufacturer's instructions onsite. He confirmed he was not aware of the information stated in the instructions because the van did not come with manufacturer's instructions for the straps after install. He confirmed S5CNATransport did not strap the resident according to manufacturer's instructions as observed on 11/29/22.

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to follow standard infection control precautions during the performance of conducting blood glucose checks when they failed to decontaminate the facility's blood glucose meters with an appropriate germicidal solvent that was effective against Blood Borne Pathogens for 15 (Resident #15, 17, 24, 25, 26, 29, 39, 42, 43, 46, 47, 48, 52, 206, and #49) residents that the shared blood glucose devices were used, on out of total census of 56 residents. This resulted in an Immediate Jeopardy was discovered to exist on 02/03/2020 at 11:20 AM, when it was observed that the facility's blood glucose monitoring system meters were not being cleaned and disinfected with a germicide effective against [CONDITION(S)] and other potentially infectious diseases. The blood glucose monitoring meters were shared and used among 15 residents in the facility including one resident (#49) who had been diagnosed with [CONDITION(S)]. FINDINGS: Cross Reference at F880 On 2/06/2020 at 4:00 PM, S5ADON presented the facility's Policy and Procedure on Cleaning and disinfecting of Resident-Care Equipment. The Policy included: resident care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. On 2/07/2020 at 9:05 AM, an interview was conducted with S5ADON. She stated that she was the head of Infection Control for the facility. She stated that S1ADM ordered the Clorox wipes, which the nurses used to clean the glucometers with. On 2/07/2020 at 11:07 AM, interviews were conducted with S1ADM and S5ADON. S5ADON confirmed that she was in charge of the infection control program in the facility and it was her responsibility to ensure proper disinfecting of the glucometers. She made an observation of the label on the bottle of Clorox Disinfecting Wipes that were made available to clean the glucometers. S5ADON confirmed that the disinfectant did not include that it was effective on any blood borne pathogens. S1ADM confirmed that she ordered Clorox Disinfectant Wipes for the facility and that she was aware that there were germicidal wipes effective against blood borne pathogens. She confirmed that the Clorox wipes that the nurses had been provided to use were not germicidal wipes and were not effective in decontaminating glucometers against blood borne pathogens. On 2/10/2020 at 10:10 AM, an interview was conducted with S2DON. S2DON stated that Resident #49 had been a resident in the facility for over [AGE] years and confirmed that he had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that blood glucose monitoring was conducted on Resident #49 and that the glucometer that was used on the resident was also used on other residents to obtain their blood glucose checks. She confirmed that she was aware that the nurses were cleaning the facility's shared glucometers with alcohol after conducting blood glucose checks on the residents. She stated that nurses used alcohol swabs to clean residents' skin and that they should be able to clean the blood glucose meters with alcohol also.

Based on observation, interview, and record review, the facility failed to ensure an effective Infection Control Program designed to prevent the transmission of infectious diseases was in place for 15 (#15, #17, #24, #25, #26, #29, #39, #42, #43, #46, #47, #48, #52, and #206) of 15 residents who required blood glucose monitoring/testing with the facility's blood glucose monitoring meters. The facility failed to ensure their staff: 1. Cleaned and disinfected the facility's Blood Glucose Monitoring System meters with an appropriate germicidal solvent per the manufacturer's instructions after use, 2. Did not carry a blood glucose meter in their pockets, and 3. Disinfected the fingers of residents pricked to conduct a blood glucose check on for 3 of 3 (48, 25, and 28's) residents whose blood glucose checks were observed on 2/10/2020. An Immediate Jeopardy was discovered on 02/03/2020 at 11:20 AM, that the facility's blood glucose monitoring system meters were not being cleaned and disinfected with a germicide effective against [CONDITION(S)] and other potentially infectious diseases. The blood glucose monitoring meters were shared and used among 15 residents in the facility including one resident (#49) who had been diagnosed with [CONDITION(S)]. S1ADM was notified of the Immediate Jeopardy on 2/7/2020 at 2:30 PM. The Immediate Jeopardy was removed on 2/10/2020 at 1:07 PM. The facility presented an acceptable Plan of Removal. Through observations, interviews, and review of documentation of the nurse re-training on appropriate decontamination of the glucometers, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. - Supervision: Immediate provision to the nursing staff of an appropriate solvent that was effective on [CONDITION(S)], B, and the HIV virus to disinfect/decontaminate the blood glucose meters that were being used to assess blood sugars on multiple residents; - Infection Control (S5ADON) will conduct random checks of medication carts twice a week for 3 months to assure that each medication cart is supplied with appropriate disinfectant/decontaminate solvent (wipes) - Nurses are appropriately cleaning glucometers after each resident use to prevent cross contamination or blood borne pathogens, including HIV, [CONDITION(S)] B & C. - Training: As of 2/7/2020, S15TXRN began in-servicing training nurses with return demonstration on appropriate disinfect/decontamination of glucometers after each resident use. To assure in-service training of nurses with return demonstration from 2/7/2020 at 6PM through 2/10/2020 at 6AM nurse training will be as follows: - S3LPN will train S20LPN and S11LPN; S20LPN will train S8LPN, S14LPN, and S13LPN. Nurse training (on nurses not trained between 2/7/2020 and 2/10/2020) will be complete by 2/11/2020. - Evaluation: For Quality Assurance purposes, to assure staff compliance with appropriate disinfect/decontamination of glucometers between each resident use, Administrator will meet with Infection Control Preventionist on a weekly basis; review and discuss monitoring and findings; provide direction, guidance, and recommendation of areas of concern. The deficient practice continued at a potential for more than minimal harm for the 15 residents identified by the facility as requiring blood glucose monitoring with the facility's blood glucose monitoring meters. FINDINGS: A review of CMS Code of Federal Regulations Universal Infection Control Standard Precautions revealed in part: Infection Prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. properly clean and disinfect or sterilize reusable equipment including blood glucose meters, before use on another patient). Blood glucose meters, can become contaminated with blood and, if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer's instructions for multi-patient use. Additionally, staff must not carry blood glucose meters in pockets. An excerpt from FDA guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters reads: The disinfection solvent you choose should be effective against HIV, [CONDITION(S)], and [CONDITION(S)] B virus. Outbreak episodes have been largely due to transmission of [CONDITION(S)] B and C viruses. Please note that 70% [MEDICATION(S)] (alcohol) solutions are not effective against [CONDITION(S)] Bloodborne pathogens. A review of the CDC Website revealed that following information regarding decontamination of Blood Glucose Monitors and the [CONDITION(S)] Virus: Infectious agents, such as the [CONDITION(S)] Virus, can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is defined as the transfer of an infectious agent from one patient to another through a contaminated intermediate object (e.g., blood glucose meter). With some blood glucose meters that require pre-loading of the test strip, the device may come into direct or close contact with the patient's fingerstick wound. If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. For these reasons, blood glucose meters should be cleaned and disinfected after each use, unless they are dedicated to a single patient and appropriately stored to prevent inadvertent contamination. A review of the OSHA Bloodborne Pathogen Standards included that all equipment should be cleaned and decontaminated with an appropriate disinfectant after contact with blood or other potentially infectious materials. EPA-registered disinfectants labeled as effective against Bloodborne Pathogens should be used. A review of the facility's user guide for the glucometer being utilized by the facility to conduct blood glucose monitoring presented by S4MD was conducted and revealed Cleaning and Disinfection on page 21. Information on this page included: To mitigate the risk of blood borne pathogen transmission (e.g. [CONDITION(S)] [CONDITION(S)]) the meter must be properly cleaned and disinfected. Disinfecting removes most of the organisms present on the surface which can cause infection or disease. It is useful against a number of bacterial and [CONDITION(S)] microorganisms. The following disinfectant product (brand name) Germicidal Wipes has been shown to be safe for use with the (brand name) Meter, but a disinfectant product with EPA registration number of -12 may be used on this device. On 2/3/2020 at 11:20 AM, an observation of S8LPN using Glucometer #2 to perform a blood glucose check on Resident #46 was conducted. S8LPN pricked the resident's finger with a lancet, held a monitoring strip in her fingers to collect the blood from the resident's finger, and then inserted the strip into the glucometer. S8LPN cleaned the glucometer with an alcohol swab after collecting the blood sample. She then put the glucometer into the top right drawer of the medication cart, where she stated she had retrieved it from initially. On 2/5/2020 at 11:20 AM, an observation of S8LPN using Glucometer #1 to perform a blood glucose check on Resident #48 was conducted. S8LPN pricked Resident #48's finger with a lancet, held a monitoring strip with her fingers, collected the sample of blood from the resident's finger, and inserted the strip into the glucometer. S8LPN cleaned the glucometer with an alcohol swab and returned the device into the top right drawer of the medication cart. S8LPN confirmed that she used alcohol swabs to clean the glucometer after using it to collect blood from the residents for the glucose checks, and further stated this is how I clean the glucometer all the time. On 2/5/2020 at 1:45 PM, an observation of S9LPN using Glucometer #2 to perform a blood glucose check on Resident #24 was conducted. S9LPN took the glucometer from a drawer in the medication cart, and cleaned glucometer with an alcohol wipe. S8LPN pricked Resident #24's finger with a lancet, collected the sample of blood from the resident's finger with a monitoring strip, and inserted the strip into the glucometer. She cleaned the glucometer with an alcohol wipe and returned the device to the drawer in the medication cart. S9LPN confirmed that she used an alcohol wipe to clean the glucometer, and further stated that this is how she cleaned the device every time she used it to collect blood samples for the residents' glucose checks. On 2/6/2020 at 10:30 AM, an observation of S3LPN using Glucometer # 1 to perform a blood glucose check on Resident #48 was conducted. S3LPN took the glucometer from a drawer in the medication cart and cleaned it with an alcohol wipe. She pricked Resident #48's finger with a lancet, collected the sample of blood on the finger with a monitoring strip that she held with her fingers, and inserted the strip into the glucometer. After completing the glucose check she cleaned the glucometer with an alcohol swab and returned the device to the drawer in the medication cart. S3LPN stated that this is how she cleaned the glucometer every time she used it to collect blood for the blood glucose monitoring on the residents. On 2/6/2020 at 10:55 AM, an observation of S10LPN using Glucometer #2 to perform a blood glucose check on Resident #46 was conducted. S10LPN cleaned the glucometer with an alcohol wipe, and pricked the resident's finger with a lancet, collected the sample of blood on the finger with a monitoring strip that she held with her fingers, and inserted the strip into the glucometer. After completing the blood glucose check she cleaned the glucometer with an alcohol wipe and stated that alcohol wipes were used to clean the glucometers. On 2/6/2020 at 1:45 PM, an inspection of the medication cart used by S3LPN was made with the nurse. During the inspection, she stated this medication cart (Cart #1) was used for residents on Hall #1, Hall #2, and some residents on Hall #3. She confirmed that there was only one glucometer (Glucometer #1) on this medication cart, and that this glucometer was used for the residents requiring blood glucose monitoring on these halls. S3LPN presented a bottle of (Brand name) Disinfecting Wipes that she had taken out of the bottom right drawer of the medication cart. She stated that these wipes were used to wipe down the medication cart and were also available to clean the glucometer. An observation of the bottle of wipes revealed (Brand name) Disinfecting Wipes. Kills staph, E. coli, MRSA, Salmonella, Strep, kleb. Kills Cold and Flu viruses. Further review of the label did not reveal that the disinfecting wipe was effective against blood borne pathogens including the [CONDITION(S)] viruses or HIV. The EPA Registration Number on the bottle was 5813-79. On 2/6/2020 at 2:00 PM, an inspection of the medication cart used by S10LPN. During the inspection she stated the medication cart (Cart #2) was used for residents on Hall #4 and some residents on Hall #3. She confirmed that there was only one glucometer (Glucometer #2) on this medication cart, and that it was used for the residents requiring blood glucose monitoring on these halls. An observation of the same brand of disinfecting wipes stored on the medication cart was made. S10LPN stated that she used only alcohol wipes to clean the glucometer. On 2/07/2020 at 9:00 AM, interviews were conducted with S9LPN and S10LPN. Both nurses stated that they had only used alcohol wipes for cleaning the glucometers, had done so for multiple years, and further stated they had not been instructed to use any other solvents on the glucometers. On 2/07/2020 at 11:07 AM, interviews were conducted with S1ADM and S5ADON. S5ADON stated that she was in charge of the infection control program in the facility and it was her responsibility to ensure the proper cleaning and disinfecting of the glucometers. She made an observation of the label on the bottle of (Brand name) Disinfecting Wipes that were made available to clean the glucometers. S5ADON confirmed that the disinfectant did not include that it was effective on any blood borne pathogens. S1ADM confirmed that she was aware that there were germicidal wipes effective against blood borne pathogens and that the facility was not using them. Both S1ADM and S5ADON confirmed that the facility was not using a germicidal solvent that was effective in decontaminating glucometers of blood borne pathogens. On 2/7/2020 at 11:20 AM, S5ADON presented a list of the residents that the facility conducted blood glucose monitoring on. A review of this list revealed the following: Resident #15's blood glucose was checked daily; Resident #17's blood glucose was checked on the 15th of each month; Resident #24's blood glucose was checked ACHS (before meals and within an hour of sleep - 4 times every day); Resident #25's blood glucose was checked ACHS; Resident #26's blood glucose was checked q day (every day); Resident #29's blood glucose was checked q week-Monday (weekly every Monday); Resident #39's blood glucose was checked bid (twice a day); Resident #42's blood glucose was checked ACHS; Resident #43's blood glucose was checked q week (every week); Resident #46's blood glucose was checked ACHS; Resident #47's blood glucose was checked bid (twice a day); Resident #48's blood glucose was checked ACHS; Resident #52's blood glucose was checked q AM (every morning); Resident #206's blood glucose was checked q day; and Resident #49's blood glucose was checked every Monday. A review of Resident #49's record revealed that he had been admitted to the nursing home on 9/21/2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed that on 9/26/2013 the facility received an order to conduct an Accu check (blood glucose check) every Monday on the resident. A review of Resident #49's January 2020 MAR (Medication Administration Record) revealed that his blood glucose checks had been conducted as ordered. On 2/07/2020 at 11:57 AM, an interview was conducted with S9LPN. She confirmed that the medication cart she was using (Cart #1) had only one glucometer on it, and this was the glucometer used to conduct blood glucose monitoring on residents from Hall #1, Hall #2, and some of Hall #3, including Resident #49. S9LPN confirmed that there was no other device used specifically on Resident #49 to conduct his blood glucose checks, and that there were no specific instructions on how to clean the device. On 2/07/2020 at 1:09 PM, an interview was conducted with S5ADON. She confirmed that Glucometer #1, from Medication Cart #1 was used to conduct their blood glucose monitoring on Residents #25, #42, #206, #47, #48, #26, #4, and Resident #49. She further confirmed that Resident #49 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/07/2020 at 2:30 PM, a telephone interview was conducted with S11LPN. She confirmed that she conducted blood glucose checks on Resident #49. She stated that she obtained a blood sample from Resident #49's finger and then inserted the glucose strip with the blood sample into the glucometer. S11LPN stated that she cleaned the glucometer with an alcohol swab after completing the blood glucose check on Resident #49 and further stated that she only used alcohol to clean the device, and had never been instructed otherwise. On 2/10/2020 at 10:10 AM, concurrent interviews were conducted with S1ADM, S2DON, and S5ADON. S5ADON stated that she was the head of infection control program for the facility, and confirmed that the nurses had been using alcohol or the (Brand name) Disinfectant Wipes to clean the glucometers. S1ADM confirmed that the wipes that had been made available to the nurses by the facility were not effective on blood borne pathogens, including [CONDITION(S)]. S2DON stated that nurses used alcohol swabs to clean residents' skin and that they should be able to clean the blood glucose meters with alcohol also. S2DON stated that Resident #49 had been a resident in the facility for over [AGE] years and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . S2DON confirmed that the glucometer that was used on Resident#49 was also used on other residents to obtain their blood glucose checks, and confirmed that the nurses had been cleaning the glucometer with alcohol. S2DON confirmed that she failed to ensure that her nursing staff had been using an EPA approved germicidal solvent to clean and disinfect the glucometers between resident uses, including before and after blood glucose monitoring had been conducted on Resident #49. On 2/10/2020 at 11:25 AM, an interview was conducted with S14LPN. She stated that she had been working as a nurse in the facility since 2011 and had been using either alcohol swabs or the (Brand name) Disinfecting Wipes that were stored on the medication carts to clean the glucometers. She stated had never used a Germicidal Wipe to clean the blood glucose monitors until today. On 2/10/2020 at 12:51 PM, an interview was conducted with S13LPN. She stated that she had been a nurse in the facility for over 5 years and initially used alcohol swabs to clean the blood glucose monitors. She stated that at some point that changed and she began using the (Brand name) Disinfectant Wipes, which had been provided by the facility, but had never used a Germicidal Wipe to clean the blood glucose monitors until today. On 2/6/2020 at 12:20 PM, at interview was conducted with S3LPN. An observation of the nurse removing the glucometer from her uniform pocket was made. S3LPN confirmed that she had put the glucometer in her uniform pocket. On 2/10/2020 at 11:01 AM, an observation of S14LPN conducting a blood glucose check on Resident #48 was made. S14LPN loaded the blood glucose monitoring strip into the glucometer and did not clean Resident #48's finger before she pricked it with the lancet. She collected the blood from the resident's finger onto the monitoring strip. On 2/10/2020 at 11:10 AM, an observation of S14LPN conducting a blood glucose check on Resident #25 was made. S14LPN loaded the blood glucose monitoring strip into the glucometer and did not clean Resident #25's finger before she pricked it with the lancet. She collected the blood from the resident's finger onto the monitoring strip. On 2/10/2020 at 11:20 AM, an observation of S14LPN conducting a blood glucose check on Resident #28 was made. She stated that an order was received yesterday to begin blood glucose monitoring for Resident #28. S14LPN loaded the blood glucose monitoring strip into the glucometer and did not clean Resident #28's finger before she pricked it with the lancet. She collected the blood from the resident's finger onto the monitoring strip. On 2/10/2020 at 11:25 AM, an interview was conducted with S14LPN. She stated that she was supposed to clean residents' fingers with an alcohol wipe before pricking them with the lancet for a blood sample. She confirmed that she should have disinfected Resident #48, #25, and #28's fingers before pricking them fingers with a lancet to conduct their blood glucose checks and had failed to do so.

Based on record review and interview, the facility failed to ensure that one (#55) of five (#5, #26, #31, #32, #55) residents who received [MEDICAL TREATMENT] received services consistent with professional standards of practice. The facility failed to: 1. Ensure there were ongoing assessments, monitoring and oversight of the resident after [MEDICAL TREATMENT] treatment to prevent the resident from taking the caps off of her external catheter used for [MEDICAL TREATMENT], 2. Ensure the resident's care plan addressed and identified appropriate interventions/measures to stop the resident from pulling her external catheter (a Tesio) used for [MEDICAL TREATMENT], 3. Ensure that communication received from the facility in which the resident received [MEDICAL TREATMENT] treatments was addressed and communicated with staff working with the resident, 4. Ensure nursing staff was trained on the care and services of residents who received [MEDICAL TREATMENT] treatments including appropriate measures and interventions and 5. Develop and implement written policies/procedures as related to residents in the facility who received [MEDICAL TREATMENT] treatments. This failed practice resulted in an Immediate Jeopardy on [DATE] at 10:45 pm when Resident #55, an [AGE] year old cognitively impaired resident appeared in the hall without a shirt bleeding from her [MEDICAL TREATMENT] catheter. The resident unclamped the external catheter and removed the caps causing blood to freely flow from the port. A facility CNA (Certified Nursing Assistant) attempted to assist the resident when she passed out and was eased to the floor according to the record. CPR (Cardiopulmonary Resuscitation) was initiated and EMS (Emergency Medical Services) called to transport the resident to the hospital. The facility was aware that the resident had been pulling her external catheter used for [MEDICAL TREATMENT] and did not implement interventions/measures to try to prevent the resident from pulling at it. The resident was admitted to ICU (Intensive Care Unit) and diagnosed with [REDACTED]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 11:20 am. The Immediate Jeopardy was removed on [DATE] at 3:30 pm when the facility presented an acceptable plan of removal which included the following: IJ Plan of Removal Goal/Expected Outcome: To assure all [MEDICAL TREATMENT] residents are free of harm secondary to shunt site tampering as evident by pulling, tugging, unclamping and/or uncapping CVC tubing, self-removal of shunt site bandages, picking/digging at AV graft site; facility has initiated the following to assure at risk residents have been identified and appropriate monitoring systems are in place: Supervision: 1. As of [DATE] all current [MEDICAL TREATMENT] residents have been evaluated for potential safety risks of shunt site tampering. Based upon Safety Risk Assessment for [MEDICAL TREATMENT] Residents, these residents present no safety risk at this time. For these residents: * Nurses will monitor and document shunt site assessment q shift on eTAR; * Nurses will monitor and document shunt site for self-tampering q shift Etar; * CNAs will observe q shift during daily care for shunt site tampering and will immediately notify the nurse; * Nurses will notify [MEDICAL TREATMENT]/physician of self-tampering of shunt site behavior and document notification; * Registered Nurse will re-evaluate monthly for safety risk. * Registered Nurse will adjust frequently of monitoring as indicated. 2. All new [MEDICAL TREATMENT] residents will be evaluated for potential safety risk beginning day 1 of the first 14 days of admission or new [MEDICAL TREATMENT]. Evaluations will be as follows: * Nurses will monitor and document hourly for 2 weeks for indications of shunt site tampering; * CNAs will observe hourly and during daily care and will notify nurse immediately of any self-tampering behavior noted; * Nurses will notify [MEDICAL TREATMENT]/physician of self-tampering of shunt site behavior and document notification; * Upon completion of evaluation period, Registered Nurse will review nursing documentation to determine if safety risks are present and frequency of monitoring/documentation needed; * Registered Nurse will re-evaluate monthly for safety risk; * Registered Nurse will adjust frequency of monitoring as indicated * Safety monitoring/documentation frequencies are as follows: 1. No behavior concerns = q shift 2. Potential behavior concerns = hourly 3. Actual shunt tampering behaviors = every 30 minutes (Nurse will notify [MEDICAL TREATMENT]/physician of shunt site tampering and document notification) 4. Increased/worsening shunt tampering behaviors = every 15 minutes and/or one on one supervision (Nurse will notify [MEDICAL TREATMENT]/physician of shunt site tampering and document notification) 3. Upon each resident's return from [MEDICAL TREATMENT], assigned nurse will review [MEDICAL TREATMENT] communication form for any noted behavior concerns and/or condition changes during [MEDICAL TREATMENT]. If documentation is present, nurse will contact [MEDICAL TREATMENT] for further information pertaining to: what occurred, what measures were taking and further recommendations. Such communication is to be documented in the nurses notes. 4. Registered Nurse will review [MEDICAL TREATMENT] communication form daily (Monday-Friday), to assure nurse has followed proper procedures for noted behaviors and/or concerns during [MEDICAL TREATMENT]. Director of Nurses will be notified of any failure to follow proper procedure; 5. Registered Nurse will review daily nursing monitor documentation for completion and indicators of safety concerns and documentation of [MEDICAL TREATMENT]/physician notification (if indicated.) Training: 1. As of [DATE], Director of Nurses, Registered Nurse and designated LPN, began in-service training of all nurses and CNAs on the following: (Nurse and CNA in-servicing will be completed as of [DATE] * Safety Risk Assessment for all [MEDICAL TREATMENT] residents; * Behavior Tracking for [MEDICAL TREATMENT] residents; * Monitoring and documentation per policy guidelines; (see below for [MEDICAL TREATMENT] policy) 2. Each Nurse and CNA completed a post-test, to assure staff knowledge, retention and understanding of [MEDICAL TREATMENT] policy and procedures, importance of monitoring for actual and/or potential safety risks for [MEDICAL TREATMENT] residents, [MEDICAL TREATMENT]/physician notification in condition and/or safety concerns. 3. Upon each resident's return from [MEDICAL TREATMENT], assigned nurse will review [MEDICAL TREATMENT] communication form for any noted behavior concerns and/or condition changes during [MEDICAL TREATMENT]. If documentation is present, nurse will contact [MEDICAL TREATMENT] for further information pertaining to: what occurred, what measures were taking and further recommendations. Such communication is to be documented in the nurses notes. The deficient practice continued at a potential for more than minimal harm for the remaining four residents in the facility who received [MEDICAL TREATMENT] treatments. Finding: Resident #55. Review of the resident's electronic clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a Tesio [MEDICAL TREATMENT] catheter to the right chest wall. Review of the resident's MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 2, which was severely impaired for cognition. Review of the resident's nurses notes dated [DATE] at 3:12 pm revealed, 2:25 pm New admit arrived per stretcher via (ambulance). Resident with Dx. of Acute [MEDICAL CONDITION], Protein Malnutrition, [MEDICAL CONDITION], Weakness, [MEDICAL CONDITION](hypertension) . HD ([MEDICAL TREATMENT]) tessio cath to right chest wall . Review of the resident's nurse's note by S5LPN (Licensed Practical Nurse) dated [DATE] at 10:14 pm revealed,Daily Nursing Assessment. Completed assessment done at 7pm. Resident at nurse's station. Confused. Not easily redirected. Picking at [MEDICAL TREATMENT] cath to right chest wall. Area covered with 4x4 and secured with paper tape . Review of the resident's nurse's note by S6RN (Registered Nurse) dated [DATE] at 11:27 am revealed, . Resident noted pulling at Rt chest wall [MEDICAL TREATMENT] port. Attempted to educate resident on importance of not pulling at port. Attempted to cover port to prevent resident from pulling at site. Resident refused and begin swinging at me. Review of the resident's nurses note by S8LPN dated [DATE] at 10:32 pm revealed, . resident pulling at [MEDICAL TREATMENT] port several times, [MEDICAL TREATMENT] port covered with dressing in order to distract resident . Review of the resident's nurse's note dated [DATE] at 4:04 pm revealed, Dr. ___ here on rounds, made aware of resident's episodes of being combative, disruptive, aggressive, resisting care and wandering in others rooms and belongings. Review of the resident's nurse's note by S14LPN dated [DATE] at 5:28 pm revealed, . RCW (right chest wall) cath intact, res pulled off dressing, applied new dressing, no active bleeding at this time, wm (will monitor). Review of the resident's nurse's note by S8LPN dated [DATE] at 5:45 pm revealed, Late entry for [DATE] . Resident pulling at [MEDICAL TREATMENT] catheter, redirected several times for this behavior. Review of the resident's [MEDICAL TREATMENT] Vital Signs sheet from the [MEDICAL TREATMENT] center revealed documentation under comments that read on [DATE] Please monitor CVC (central venous catheter) daily. Pt (patient) arrived c (with) catheter unclamped & end caps removed. On [DATE] revealed, catheter unclamped and end cap missing please monitor. On [DATE] revealed, Catheter dressing missing please monitor. There was no documentation that the facility addressed the information communicated to them from the [MEDICAL TREATMENT] center. Review of the resident's care plan dated [DATE] revealed that it was not updated or revised to address the resident pulling on the [MEDICAL TREATMENT] catheter and unclamping and removing the cap from the ports. Review of the resident's nurse's note by S11LPN dated [DATE] at 12:50 am revealed, 10:45 PM CNA (Certified Nursing Assistant) . saw resident standing at the end of green hall without a shirt on. I went to the end of the hall to assist resident and noticed blood on the floor. (CNAs) came to assist and resident lost consciousness, (CNAs) eased resident to the floor. I yelled out for assistance. S5LPN and CNA . came to assist. Upon assessment found that resident had unscrewed port and was bleeding out. (CNA) pinched off port. Resident's breathing became shallow. 10:48 CPR (cardiopulmonary resuscitation) administered to resident while waiting on EMS (Emergency Medical Service) to arrive. 11:30 pm EMS arrived and took over care of resident. 11:32 Daughter . was contacted via phone and she voiced understanding that resident had passed out and was to be transported to (hospital emergency room ) for eval (evaluation) and Tx (treatment) 11:35 pm Dr. _____ notified. 11:40 pm EMS left with resident for transport to (hospital emergency room ) . Review of the resident's nurses note dated [DATE] at 1:33 pm revealed, Report of incident: Date: [DATE] Time: 10:45 pm Description: Resident standing at door at the end of green hall without shirt on. When I went to assist resident, found that she was bleeding out of her [MEDICAL TREATMENT] port. CNA . attempted to assist resident and she passed out. They eased her down to the floor, pinched off the port & CPR was administered . Interventions: resident was admitted to the hospital . Resident Statement: resident was standing at the end of hall with no shirt on and resident herself had un-clamped ports to her [MEDICAL TREATMENT] ports when the nurse went to help her . Review of the resident's hospital emergency room documentation report dated [DATE] at 4:25 revealed that the resident was transferred from another hospital (local hospital) with report of ([MEDICAL TREATMENT] catheter) uncapped and bled profusely. Pt arrived intubated. The ambulance personnel reported profuse bleeding on scene. Review of the resident's hospital history and physical report dated [DATE] revealed, .Patient's condition is critically ill. The patient is an [AGE] year old lady with dementia who was admitted to the ICU (Intensive Care Unit) with acute [MEDICAL CONDITION], the story we're being told is that she was able to remove one of the caps from her [MEDICAL TREATMENT] catheter, leading to a large amount of bleeding as well as what looks like an air embolism to the brain. She also has acute [MEDICAL CONDITION] due to air emboli in the lungs .Shortly after arrival to the ICU (intensive care unit) she had a [MEDICAL CONDITION] . Further review revealed that the resident's critical care [DIAGNOSES REDACTED]. Further review of History of Present Illness revealed, According to the EMR (electronic medical record), the nursing staff saw the patient ambulating with blood pouring from her [MEDICAL TREATMENT] catheter and she collapsed shortly thereafter . On [DATE] at 2:15 pm, S6RN (Registered Nurse) stated that she observed the resident pulling on the [MEDICAL TREATMENT] catheter ports and that she attempted to cover it with a dressing and that the resident removed the dressing. Also, S6RN stated that she tried to redirect the resident and educate the resident about not pulling on the [MEDICAL TREATMENT] catheter ports. S6RN stated that the only time she was aware that the resident was pulling on the [MEDICAL TREATMENT] catheter ports was the time she observed the resident pulling on them on [DATE] at 11:27 am. S6RN stated that the incident that occurred on the night the resident was transferred to the hospital was tragic. S6RN stated that she did not inform the physician that the resident was pulling on the [MEDICAL TREATMENT] catheter ports on [DATE]. On [DATE] at 2:30 pm, S7LPN confirmed that the resident's behavior of pulling on her [MEDICAL TREATMENT] catheter ports was not addressed in the care plan. S7LPN stated that she did not inform the physician that the resident was pulling on her [MEDICAL TREATMENT] catheter ports. On [DATE] at 2:40 pm, S8LPN stated that she did observe the resident pulling on the [MEDICAL TREATMENT] catheter ports several times but that she adjusted her clothing, tried to redirect her, and covered her [MEDICAL TREATMENT] catheter to distract her attention to something else. S8LPN stated that she did not inform the physician that the resident was pulling on the [MEDICAL TREATMENT] catheter ports. On [DATE] at 3:45 pm, a telephone interview was conducted with one of the RNs who cared for the resident at the [MEDICAL TREATMENT] center. The RN stated that the resident would arrive there with the dressing missing from the chest wall area of the [MEDICAL TREATMENT] catheter. The RN stated that the resident needed to be monitored closely because the resident would mess with her [MEDICAL TREATMENT] catheter while being dialyzed and needed to be monitored closely. On [DATE] at 3:50 pm, a telephone interview was conducted with another RN who cared for the resident at the [MEDICAL TREATMENT] center. The RN stated that the resident would arrive there with the [MEDICAL TREATMENT] catheter uncovered and with the end caps of the catheter ports removed. The RN stated that she spoke to the nurses at the facility about monitoring the resident's [MEDICAL TREATMENT] catheter caps being on and having a dressing in place. Also, the RN stated that notes were written on the resident's [MEDICAL TREATMENT] vital signs sheet that was sent with the resident to the facility to inform them that the caps on the [MEDICAL TREATMENT] catheter were removed and that the [MEDICAL TREATMENT] catheter did not have a dressing upon arrival to the [MEDICAL TREATMENT] center. The RN stated that the resident arrived to the [MEDICAL TREATMENT] center with only the transportation driver. On [DATE] at 4:25 pm, S2DON (Director of Nurses) stated that she was only aware that the resident was pulling on the [MEDICAL TREATMENT] catheter one time when she was having behaviors of combativeness and aggression. S2DON stated that she was not aware of any other incidence when the resident was pulling on the [MEDICAL TREATMENT] catheter. S2DON stated that no one reported to her of any other incidence. Also, S2DON stated that she was not aware that the nurses from the [MEDICAL TREATMENT] center had called and sent notes concerning the resident removing the dressings and unclamping and uncapping the [MEDICAL TREATMENT] catheter ports. S2DON stated that the resident was being transported by the facility. S2DON stated that the resident was transported with the driver and if the resident had behaviors of aggression then the ward clerk would go with the resident during transport. On [DATE] at 5:05 pm, S11LPN stated that she was sitting at the nurse's station when the CNA noticed that the resident was standing in the hall without a shirt on. S11LPN stated that she went down the hall to assist the resident and noticed blood on the floor. S11LPN stated that she noticed that the resident had unscrewed both caps from the [MEDICAL TREATMENT] catheter and one port of the catheter was unclamped and that was where she noticed the blood flowing from the unclamped port. S11LPN stated that she noticed that a substantial amount of blood was on the floor in the hall. S11LPN stated that the resident collapsed and she instructed the CNAs to pinch off the catheter and to hold pressure so that CPR could be started. S11LPN stated that she called 911 and began CPR and continued until EMS came. S11LPN stated that she was not aware of the resident pulling on the [MEDICAL TREATMENT] catheter ports until this incident. S11LPN stated that the resident was on 1 hour checks to keep an eye on the whereabouts of the resident to make sure the resident was in her room sleeping because of all her behaviors. S11LPN stated that she did not discuss anything further with S2DON concerning the incident. On [DATE] at 9:10 am, S2DON stated that she felt that the nurse did what she needed to do and took care of the resident and did not feel that anything else needed to be done. Also, S2DON stated that no in-services or trainings were done after the incident. On [DATE] at 12:15 pm, S12ADON (Assistant Director of Nurses) stated that the facility did not have written policies and procedures for [MEDICAL TREATMENT] or for caring for residents on [MEDICAL TREATMENT] because the facility did not perform [MEDICAL TREATMENT] in the facility. On [DATE] at 12:20 pm, S2DON stated that the facility did not have written policies and procedures for external catheters, [MEDICAL TREATMENT] catheters or for [MEDICAL TREATMENT]. Also, S2DON stated that the facility did not have a policy for caring for residents on [MEDICAL TREATMENT] because the facility did not perform [MEDICAL TREATMENT]. On [DATE] at 2:55 pm, S1Admin (Administrator) stated that she was only aware of one incident when the resident was pulling on her [MEDICAL TREATMENT] catheter and it was when she was combative and having aggression with staff. S1Admin stated that she was concerned about the resident wandering around the facility and that she had a wander guard. S1Admin stated that she was not aware that the [MEDICAL TREATMENT] center informed the facility that the resident was arriving to the [MEDICAL TREATMENT] center with the [MEDICAL TREATMENT] caps removed and the catheter unclamped. On [DATE] at 4:30 pm, S13CNA stated that she has seen the resident touch her [MEDICAL TREATMENT] catheter and would ask what that was on her chest. S13CNA stated that she did not report it to the nurse because the nurse saw her messing with her [MEDICAL TREATMENT] catheter. S13CNA stated that the resident was messing with the [MEDICAL TREATMENT] catheter while S6RN was in the room. S13CNA stated that S6RN told her to watch the resident to make sure that she did not mess with the catheter too much. S13CNA stated that she did not receive training on caring for patients with [MEDICAL TREATMENT] or external catheters. On [DATE] at 4:35 pm, S15CNA stated that she has seen the resident pulling on her [MEDICAL TREATMENT] catheter on several occasions. S15CNA stated that S14LPN was there when the resident was pulling on the [MEDICAL TREATMENT] catheter. S15CNA stated that she did not receive training on caring for patients with [MEDICAL TREATMENT] or external catheters. On [DATE] at 4:45 pm, S16LPN stated that she has not received training on caring for residents with an external catheter. She stated that she did basic nursing by assessing for signs of infection, bleeding, and checking the dressing for being dry and intact. On [DATE] at 4:50 pm, S17LPN stated that she has not received training on caring for residents with an external catheter. On [DATE] at 5:00 pm, S2DON confirmed that she could not provide documentation that the nursing staff was trained on caring for residents with [MEDICAL TREATMENT] or external catheters.

Based on record review and interview, the facility was not administered in a manner that enabled its resources to effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (#55) of five residents (#5, #26, #31, #32, #55) receiving [MEDICAL TREATMENT] treatments. The facility failed to: 1. Develop and implement written policies/procedures as related to residents in the facility who received [MEDICAL TREATMENT] treatments, 2. Ensure there were ongoing assessments, monitoring and oversight of the resident after [MEDICAL TREATMENT] to prevent the resident from taking the caps off of her external catheter used for [MEDICAL TREATMENT], 3. Ensure the resident's care plan addressed and identified appropriate interventions/measures to stop the resident from pulling her external catheter (a Tesio) used for [MEDICAL TREATMENT], 4. Ensure that communication received from the facility in which the resident received [MEDICAL TREATMENT] treatments was addressed and communicated with staff working with the resident, and 5. Ensure nursing staff was trained on the care and services of residents who received [MEDICAL TREATMENT] This failed practice resulted in an Immediate Jeopardy on [DATE] at 10:45 pm when Resident #55, an [AGE] year old cognitively impaired resident appeared in the hall without a shirt bleeding from her [MEDICAL TREATMENT] catheter. The resident unclamped the external catheter and removed the caps causing blood to freely flow from the port. A facility CNA attempted to assist the resident wehn she passed out and was eased to the floor according to the record. CPR was initiated and EMS called to transport the resident to the hospital. The facility was aware that the resident had been pulling her external catheter used for [MEDICAL TREATMENT] and did not implement interventions/measures to try to prevent the resident from pulling at it. The resident was admitted to ICU and diagnosed with [REDACTED]. The Administrator was notified of the Immediate Jeopardy on [DATE] at 11:20 am. The Immediate Jeopardy was removed on [DATE] at 3:30 pm when the facility presented an acceptable plan of removal which included the following: IJ Plan of Removal Goal/Expected Outcome: To assure all [MEDICAL TREATMENT] residents are free of harm secondary to shunt site tampering as evident by pulling, tugging, unclamping and/or uncapping CVC tubing, self-removal of shunt site bandages, picking/digging at AV graft site; facility has initiated the following to assure at risk residents have been identified and appropriate monitoring systems are in place: Supervision: 1. As of [DATE] all current [MEDICAL TREATMENT] residents have been evaluated for potential safety risks of shunt site tampering. Based upon Safety Risk Assessment for [MEDICAL TREATMENT] Residents, these residents present no safety risk at this time. For these residents: * Nurses will monitor and document shunt site assessment q shift on eTAR; * Nurses will monitor and document shunt site for self-tampering q shift Etar; * CNAs will observe q shift during daily care for shunt site tampering and will immediately notify the nurse; * Nurses will notify [MEDICAL TREATMENT]/physician of self-tampering of shunt site behavior and document notification; * Registered Nurse will re-evaluate monthly for safety risk. * Registered Nurse will adjust frequently of monitoring as indicated. 2. All new [MEDICAL TREATMENT] residents will be evaluated for potential safety risk beginning day 1 of the first 14 days of admission or new [MEDICAL TREATMENT]. Evaluations will be as follows: * Nurses will monitor and document hourly for 2 weeks for indications of shunt site tampering; * CNAs will observe hourly and during daily care and will notify nurse immediately of any self-tampering behavior noted; * Nurses will notify [MEDICAL TREATMENT]/physician of self-tampering of shunt site behavior and document notification; * Upon completion of evaluation period, Registered Nurse will review nursing documentation to determine if safety risks are present and frequency of monitoring/documentation needed; * Registered Nurse will re-evaluate monthly for safety risk; * Registered Nurse will adjust frequency of monitoring as indicated * Safety monitoring/documentation frequencies are as follows: 1. No behavior concerns = q shift 2. Potential behavior concerns = hourly 3. Actual shunt tampering behaviors = every 30 minutes (Nurse will notify [MEDICAL TREATMENT]/physician of shunt site tampering and document notification) 4. Increased/worsening shunt tampering behaviors = every 15 minutes and/or one on one supervision (Nurse will notify [MEDICAL TREATMENT]/physician of shunt site tampering and document notification) 3. Upon each resident's return from [MEDICAL TREATMENT], assigned nurse will review [MEDICAL TREATMENT] communication form for any noted behavior concerns and/or condition changes during [MEDICAL TREATMENT]. If documentation is present, nurse will contact [MEDICAL TREATMENT] for further information pertaining to: what occurred, what measures were taking and further recommendations. Such communication is to be documented in the nurses notes. 4. Registered Nurse will review [MEDICAL TREATMENT] communication form daily (Monday-Friday), to assure nurse has followed proper procedures for noted behaviors and/or concerns during [MEDICAL TREATMENT]. Director of Nurses will be notified of any failure to follow proper procedure; 5. Registered Nurse will review daily nursing monitor documentation for completion and indicators of safety concerns and documentation of [MEDICAL TREATMENT]/physician notification (if indicated.) Training: 1. As of [DATE], Director of Nurses, Registered Nurse and designated LPN, began in-service training of all nurses and CNAs on the following: (Nurse and CNA in-servicing will be completed as of [DATE] * Safety Risk Assessment for all [MEDICAL TREATMENT] residents; * Behavior Tracking for [MEDICAL TREATMENT] residents; * Monitoring and documentation per policy guidelines; (see below for [MEDICAL TREATMENT] policy) 2. Each Nurse and CNA completed a post-test, to assure staff knowledge, retention and understanding of [MEDICAL TREATMENT] policy and procedures, importance of monitoring for actual and/or potential safety risks for [MEDICAL TREATMENT] residents, [MEDICAL TREATMENT]/physician notification in condition and/or safety concerns. 3. Upon each resident's return from [MEDICAL TREATMENT], assigned nurse will review [MEDICAL TREATMENT] communication form for any noted behavior concerns and/or condition changes during [MEDICAL TREATMENT]. If documentation is present, nurse will contact [MEDICAL TREATMENT] for further information pertaining to: what occurred, what measures were taking and further recommendations. Such communication is to be documented in the nurses notes. The deficient practice continued at a potential for more than minimal harm for the remaining four residents in the facility who received [MEDICAL TREATMENT] treatments. Findings: Cross reference findings at F698 Resident #55. Review of the resident's electronic clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted with a Tesio [MEDICAL TREATMENT] catheter to the right chest wall. Review of the resident's MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 2, which was severely impaired for cognition. Review of the resident's [MEDICAL TREATMENT] Vital Signs sheet from the [MEDICAL TREATMENT] center revealed documentation under comments that read on [DATE] Please monitor CVC (central venous catheter) daily. Pt (patient) arrived c (with) catheter unclamped & end caps removed. On [DATE] revealed, catheter unclamped and end cap missing please monitor. On [DATE] revealed, Catheter dressing missing please monitor. There was no documentation that the facility addressed the information communicated to them from the [MEDICAL TREATMENT] center. Review of the resident's nurse's note by S11LPN dated [DATE] at 12:50 am revealed, 10:45 PM CNA (Certified Nursing Assistant) . saw resident standing at the end of green hall without a shirt on. I went to the end of the hall to assist resident and noticed blood on the floor. (CNAs) came to assist and resident lost consciousness, (CNAs) eased resident to the floor. I yelled out for assistance. S5LPN and CNA . came to assist. Upon assessment found that resident had unscrewed port and was bleeding out. (CNA) pinched off port. Resident's breathing became shallow. 10:48 CPR (cardiopulmonary resuscitation) administered to resident while waiting on EMS (Emergency Medical Service) to arrive. 11:30 pm EMS arrived and took over care of resident. 11:32 Daughter . was contacted via phone and she voiced understanding that resident had passed out and was to be transported to (hospital emergency room ) for eval (evaluation) and Tx (treatment) 11:35 pm Dr. _____ notified. 11:40 pm EMS left with resident for transport to (hospital emergency room ) . On [DATE] at 2:15 pm, S6RN (Registered Nurse) stated that she observed the resident pulling on the [MEDICAL TREATMENT] catheter ports and that she attempted to cover it with a dressing and that the resident removed the dressing. Also, S6RN stated that she tried to redirect the resident and educate the resident about not pulling on the [MEDICAL TREATMENT] catheter ports. S6RN stated that the only time she was aware that the resident was pulling on the [MEDICAL TREATMENT] catheter ports was the time she observed the resident pulling on them on [DATE] at 11:27 am. S6RN stated that the incident that occurred on the night the resident was transferred to the hospital was tragic. S6RN stated that she did not inform the physician that the resident was pulling on the [MEDICAL TREATMENT] catheter ports on [DATE]. On [DATE] at 4:25 pm, S2DON (Director of Nurses) stated that she was only aware that the resident was pulling on the [MEDICAL TREATMENT] catheter one time when she was having behaviors of combativeness and aggression. S2DON stated that she was not aware of any other incidence when the resident was pulling on the [MEDICAL TREATMENT] catheter. S2DON stated that no one reported to her of any other incidence. S2DON stated that she was not aware that the nurses from the [MEDICAL TREATMENT] center had called and sent notes concerning the resident removing the dressings and unclamping and uncapping the [MEDICAL TREATMENT] catheter ports. S2DON stated that the resident was being transported by the facility. S2DON stated that the resident was transported with the driver and if the resident had behaviors of aggression then the ward clerk would go with the resident during transport. On [DATE] at 9:10 am, S2DON stated that she felt that the nurse did what she needed to do and took care of the resident and did not feel that anything else needed to be done. S2DON stated that no in-services or trainings were done after the incident. On [DATE] at 12:15 pm, S12ADON (Assistant Director of Nurses) stated that the facility did not have written policies and procedures for [MEDICAL TREATMENT] or for caring for residents on [MEDICAL TREATMENT] because the facility did not perform [MEDICAL TREATMENT] in the facility. On [DATE] at 12:20 pm, S2DON stated that the facility did not have written policies and procedures for external catheters, [MEDICAL TREATMENT] catheters or for [MEDICAL TREATMENT]. Also, S2DON stated that the facility did not have a policy for caring for residents on [MEDICAL TREATMENT] because the facility did not perform [MEDICAL TREATMENT]. On [DATE] at 2:55 pm, S1Admin (Administrator) stated that she was only aware of one incident when the resident was pulling on her [MEDICAL TREATMENT] catheter and it was when she was combative and having aggression with staff. S1Admin stated that she was concerned about the resident wandering around the facility and that she had a wander guard. S1Admin stated that she was not aware that the [MEDICAL TREATMENT] center informed the facility that the resident was arriving to the [MEDICAL TREATMENT] center with the [MEDICAL TREATMENT] caps removed and the catheter unclamped. On [DATE] at 5:00 pm, S2DON confirmed that she could not provide documentation that the nursing staff was trained on caring for residents with [MEDICAL TREATMENT] or external catheters.

Based on observation and interview, the facility failed to ensure adequate supervision to prevent accident hazards as evidenced by 1.the facility failing to secure room R6 which contained potentially harmful chemicals and maintenance tools. 2. the facility failing to provide supervision for 1 of 4 confused wandering residents who was observed wandering into a room located across the hall from room R6. (#24) As a result of this observation, it placed resident #24 and the other 3 confused wanderers at a potential risk for injury, harm or impairment which places them in an immediate jeopardy. The administrator was informed of the Immediate Jeopardy on 8/8/11 at 4:40 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 8/8/11 at 5:25 pm when the facility installed a lock on the door of room R6. The deficient practice was reduced to a pattern for the potential for more than minimal harm for residents #18, #20, #24, and #66. Findings: An observation was made on 8/8/11 at 11:28 am of Room R-06 in which the door was observed to be ajar and the room was unattended. Upon entering the room it was noted that there were 3 buckets labeled paint with one bucket open with a liquid white substance noted inside. There were also multiple tools located laying on a bed including a cordless drill, hammer, metal spatula with pointed end, 3 pairs of wire cutter pliers, 1 wire cutter, 3 screwdrivers, old paint roller with a wooden handle, 1 paint brush, 1 can of Stomp Insecticide Spray, and tool box, 1 box of dry wall screws, 1 box of wire connectors, 1 container of super glue, 1 flashlight, 1 can caulk in a caulk gun, 1 sheet sandpaper, 1 sandpaper block, 1 receptacle with 2 loose screws, and 1 white roller shade with 7 loose screws noted. The room was located down the end of Red Hall and was noted to be 3 doors down from R-03. An observation was made on 8/8/11 at 11:22 am of Room R-03 (Red Hall). The door was tied shut from the outside with a clear plastic bag. The bag was tied from the outside of the resident's doorknob to the hand rail in the hall. An interview was conducted with S3, LPN, Treatment Nurse on 8/8/11 at 11:23 am S3,LPN, Treatment Nurse stated that the door to Room R-03 was tied shut to prevent other wandering residents from entering the room as the resident in Room R-03 was out on pass and the room was unoccupied. S3, LPN, Treatment Nurse stated that there were a few residents that were known wanderers that ambulated throughout the facility. An interview was conducted with S2, RN, DON on 8/8/11 at 11:55 am who provided a list of the wanderers in the facility. She stated that there were several residents that wandered throughout the facility. She stated that there were 4 identified wandering residents that were, " very confused all of the time, " and were known to enter other resident ' s rooms in the past, which were Resident #24, #20, #66 and #18. An observation and interview was conducted on 8/8/11 at 3:40 pm with Resident #24, who opened the door and wandered into R-08 where the surveyors were located at this time. Resident #24 stated that she was, "just looking for what I can find, been here lots of times." Noted was the fact that the R-06 was located directly across the hall from R-08 and the items in question remained in Rm-06 unattended and the door remained unlocked. An interview was conducted with S4, Maintenance Manager on 8/8/11 at 12:15 pm. S4, Maintenance Manager stated that Room R -06 was being remodeled and that the room was being worked on by S5, Maintenance Worker. S4, Maintenance Manager confirmed that the room (R-06) was unlocked and unattended at this time. S4, Maintenance Manager stated that the white substance in the paint bucket was water and paint mixture that the Maintenance worker had used to clean his paint brush with. S4, Maintenance Manager stated that S5, Maintenance Worker, should have had the room locked and/or the paint and tools should have been removed from the room to be secured. S4, Maintenance Manager stated that the paint substance and the tools were a danger to confused residents and that confused residents could have consumed the paint substance and the tools could have been a safety hazard to themselves and other residents. The door to R-06 leading to the hallway did not have locks. S4, Maintenance Manager stated that he was unaware that the tools and paint were left in Room R-06 unlocked and unattended. He stated that he last entered the room on Friday 8/5/11 but was unsure of the time. At 12:25 pm, after this interview, S4, Maintenance Manager exited the room with this surveyor and walked away from the room which remained unlocked and unattended. An interview was conducted on 8/9/11 at 4:05 pm with S4, Maintenance Manager who stated that the incident was a mistake on the facility ' s behalf and that he usually cleaned up rooms when work was being done in the room. An interview was conducted on 8/9/11 at 4:15 pm with S5, Maintenance Worker. S5, Maintenance Manager stated that he worked in Rm-06 doing remodeling work on 8/5/11. S5, Maintenance Worker stated that he left the paint buckets and tools in Rm -06 unsecured and that they must have remained there since 8/5/11. An interview was conducted on 8/8/11 at 12:30 pm with S2, RN, DON who stated that the facility had security camera system in place with 7 operating cameras throughout the facility used to monitor wandering residents. S2, RN, DON stated that all of the security cameras were connected to a monitoring device in the Administrator's office. S2,RN, DON denied that staff were monitoring the camera at all times. An observation was made of the Administrator at this time in the dining room awaiting his food tray. An interview was conducted on 8/8/11 at 12:37 pm with S1, Administrator after he returned to his office. S1, Administrator stated that he monitored the 7 cameras when he is in his office and that S2, RN, DON is the only other person that has access to the monitor located in his office for the security cameras. S1, Administrator stated that he, " does not devote a lot of time, " viewing the monitor and that it is not monitored at all times. An observation was made of a white computer terminal labeled Systemax that was not on at this time. S1, Administrator stated that the monitor located in his office was currently broken and he was unaware of how long it had been broken. S1, Administrator stated that he did not contact the company that managed and repaired the computer terminal for the cameras as of yet. ********************************************************************** Based on observation and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible to prevent accidents as evidence by the following: FINDINGS: 1) An observation was made on 8/8/11 at 10:30 am on the back outdoor breezeway. The observation revealed a wooden rack with 5 green bottles of Oxygen (3 large/2 small) labeled Lincare 6. The rack was located on the floor between 2 doors labeled Dry Food and Mechanical Electrical. The 2 smaller O2 bottles were not secured to the top of the rack and were easily tilted over. An interview was conducted on 8/8/11 at 10:32 am with S4, Maintenance Manager who confirmed that the two smaller O2 bottles were not secured to the wooden rack and could, " fall over easy. " S4, Maintenance Manager stated that the facility was in the process of rebuilding the wooden rack in order to hold the top of the smaller bottles but the new rack was not yet available. He stated that the smaller O2 bottles were not secure and were unsafely stored. An interview was conducted on 8/8/11 at 10:33 am with S1, Administrator who confirmed that the 2 smaller O2 bottles were unsecure on the top of the wooden rack. S1, Administrator stated that the 2 smaller bottles could have fallen over easily and would pose a hazard to any resident in the area. He removed the O2 bottles and brought to another area for securing. 2) On the initial tour of the facility on 8/8/11 an observation of the resident's room was made. Upon entering the room, the ceiling tile near the door of the bathroom was observed. The tile, with the water sprinkler in it was noted to be torn and wet with the center of the tile missing. There was noted also a portion hanging down with black wires by the sprinkler system and a metal rod was noted in the bathroom. On 8/11/11 at 10:31 am, S1 Administrator observed the resident's room and the tile. The tile was replaced by the facility but there was a wet brown spot noted in the middle of the tile. S1 Administrator confirmed that there was a leak in the ceiling and that the facility was aware of the leak and the potential for the wet tile to possibly fall on the resident in the room. S4 Maintenance Manager also confirmed that the metal rod had been in the bathroom but that he had removed it. 3) On the initial tour of the facility on 8/8/11 an observation was made in Resident 61's bathroom. On 8/11/11 at 11:02 am with S4 Maintenance Manager another observation of the resident's bathroom was made. The toilet was noted to have loose screws on both sides of the toilet and where the tubing for the water line was connected, there was a large opening noted in the wall around the tubing. This was confirmed by the S4 Maintenance Manager and when asked if he felt if this was a safety hazard for the resident, he confirmed that the loose toilet was a hazard for the resident. 4) On the initial tour of the facility done on 8/8/11, the 2 door on the green hall was noted at the bottom of the door, on the left and right, to have a metal portion at the bottom of both doors that was loose from the door and protruded out 3-4 inches. On 8/11/11 at 10:31 am, the S1 Administrator, the owner and the S4 Maintenance Manager was notified of the metal protruding and confirmed that it was a safety issue. 5) On the initial tour of the facility on 8/8/11, in Resident # 70's room, a small box was observed on the floor in the resident's. Upon further observation the box was noted to contain 2 metal spatulas that the maintenance workers would use to fix the wall in the resident's room. On 8/11/11 the S 4 Maintenance Manager was questioned concerning this box and he confirmed that he had left the box in the resident's room after doing repairs to the wall of the bathroom. 6) On 8/11/11 at 11:13 am, an observation of Resident #49 was made. On the wall next to the bathroom at the bottom of the wall the baseboard was missing and there was a metal piece sticking out of the wall about 3-4 inches from the wall. This was confirmed at this time by S4 Maintenance Manager and he stated that after repairing another room in the facility, that this was the next room that his staff was going to work on.

Based on observation and interview, the facility failed to use its resources effectively and efficiently to ensure that the environment was safe for wandering residents in the facility. The facility administration failed to use its resources to ensure adequate supervision to prevent accident hazards as evidenced by 1. the facility administration failing to secure room R6 which contained potentially harmful chemicals and maintenance tools. 2. the facility failing to provide supervision for 1 of 4 confused wandering residents who was observed wandering into a room located across the hall from room R6. (#24) As a result of this observation, it placed resident #24 and the other 3 confused wanderers at a potential risk for injury, harm or impairment which places them in an immediate jeopardy. The administrator was informed of the Immediate Jeopardy on 8/8/11 at 4:40 pm. The plan of removal was received and the Immediate Jeopardy was lifted on 8/8/11 at 5:25 pm when the facility installed a lock on the door of room R6. The deficient practice was reduced to a pattern for the potential for more than minimal harm for residents #18, #20, #24, and #66. Findings: An observation was made on 8/8/11 at 11:28 am of Room R-06 in which the door was observed to be ajar and the room was unattended. Upon entering the room it was noted that there were 3 buckets labeled paint with one bucket open with a liquid white substance noted inside. There were also multiple tools located laying on a bed including a cordless drill, hammer, metal spatula with pointed end, 3 pairs of wire cutter pliers, 1 wire cutter, 3 screwdrivers, old paint roller with a wooden handle, 1 paint brush, 1 can of Stomp Insecticide Spray, and tool box, 1 box of dry wall screws, 1 box of wire connectors, 1 container of super glue, 1 flashlight, 1 can caulk in a caulk gun, 1 sheet sandpaper, 1 sandpaper block, 1 receptacle with 2 loose screws, and 1 white roller shade with 7 loose screws noted. The room was located down the end of Red Hall and was noted to be 3 doors down from R-03. An observation was made on 8/8/11 at 11:22 am of Room R-03 (Red Hall). The door was tied shut from the outside with a clear plastic bag. The bag was tied from the outside of the resident's doorknob to the hand rail in the hall. An interview was conducted with S3, LPN, Treatment Nurse on 8/8/11 at 11:23 am S3,LPN, Treatment Nurse stated that the door to Room R-03 was tied shut to prevent other wandering residents from entering the room as the resident in Room R-03 was out on pass and the room was unoccupied. S3, LPN, Treatment Nurse stated that there were a few residents that were known wanderers that ambulated throughout the facility. An interview was conducted with S2, RN, DON on 8/8/11 at 11:55 am who provided a list of the wanderers in the facility. She stated that there were several residents that wandered throughout the facility. She stated that there were 4 identified wandering residents that were, " very confused all of the time, " and were known to enter other resident ' s rooms in the past, which were Resident #24, #20, #66 and #18. An observation and interview was conducted on 8/8/11 at 3:40 pm with Resident #24, who opened the door and wandered into R-08 where the surveyors were located at this time. Resident #24 stated that she was, "just looking for what I can find, been here lots of times." Noted was the fact that the R-06 was located directly across the hall from R-08 and the items in question remained in Rm-06 unattended and the door remained unlocked. An interview was conducted with S4, Maintenance Manager on 8/8/11 at 12:15 pm. S4, Maintenance Manager stated that Room R -06 was being remodeled and that the room was being worked on by S5, Maintenance Worker. S4, Maintenance Manager confirmed that the room (R-06) was unlocked and unattended at this time. S4, Maintenance Manager stated that the white substance in the paint bucket was water and paint mixture that the Maintenance worker had used to clean his paint brush with. S4, Maintenance Manager stated that S5, Maintenance Worker, should have had the room locked and/or the paint and tools should have been removed from the room to be secured. S4, Maintenance Manager stated that the paint substance and the tools were a danger to confused residents and that confused residents could have consumed the paint substance and the tools could have been a safety hazard to themselves and other residents. The door to R-06 leading to the hallway did not have locks. S4, Maintenance Manager stated that he was unaware that the tools and paint were left in Room R-06 unlocked and unattended. He stated that he last entered the room on Friday 8/5/11 but was unsure of the time. At 12:25 pm, after this interview, S4, Maintenance Manager exited the room with this surveyor and walked away from the room which remained unlocked and unattended. An interview was conducted on 8/9/11 at 4:05 pm with S4, Maintenance Manager who stated that the incident was a mistake on the facility ' s behalf and that he usually cleaned up rooms when work was being done in the room. An interview was conducted on 8/9/11 at 4:15 pm with S5, Maintenance Worker. S5, Maintenance Manager stated that he worked in Rm-06 doing remodeling work on 8/5/11. S5, Maintenance Worker stated that he left the paint buckets and tools in Rm -06 unsecured and that they must have remained there since 8/5/11. An interview was conducted on 8/8/11 at 12:30 pm with S2, RN, DON who stated that the facility had security camera system in place with 7 operating cameras throughout the facility used to monitor wandering residents. S2, RN, DON stated that all of the security cameras were connected to a monitoring device in the Administrator's office. S2,RN, DON denied that staff were monitoring the camera at all times. An observation was made of the Administrator at this time in the dining room awaiting his food tray. An interview was conducted on 8/8/11 at 12:37 pm with S1, Administrator after he returned to his office. S1, Administrator stated that he monitored the 7 cameras when he is in his office and that S2, RN, DON is the only other person that has access to the monitor located in his office for the security cameras. S1, Administrator stated that he, " does not devote a lot of time, " viewing the monitor and that it is not monitored at all times. An observation was made of a white computer terminal labeled Systemax that was not on at this time. S1, Administrator stated that the monitor located in his office was currently broken and he was unaware of how long it had been broken. S1, Administrator stated that he did not contact the company that managed and repaired the computer terminal for the cameras as of yet.