Every finding on record at University Place Nursing and Rehabilitation Center

Based on observations and staff interviews, the facility failed to remove a dented can located on shelf ready for use and failed to reseal and label and date leftover food items stored for use. These practices occurred in 1 of 1 walk-in freezer and 1 of 1 dry storage room and had the potential to affect food served to residents. The findings included: An initial tour of the kitchen occurred on 7/21/25 at 10:09 AM. The following concerns were identified:a. Items in the walk-in freezer that were open to air and not resealed but labeled included: -one 15.33 pound (lb.) box of Texas Toast bread, dated 7/11/25-one 7.93lb box of churros, dated 10/24/25 Items in the walk-in freezer that were open to air, not resealed, and not labeled included:-one18.9lb box of [NAME] cheese omelets -one 20lb box of cookie dough ballsb. Items in the dry storage area that were opened and resealed but not dated included:-one bag of brown sugar-one 22.6-ounce (oz) bag of brown gravy mix -one 31oz bag of white sugar -one 160oz bag of elbow macaroni -one 57oz box of complete mashed potatoes d. One 105oz can of pears on the rack in the dry storage area for use was dented on the bottom sealAn interview with the Dietary Manager (DM) on 7/24/25 at 11:11 AM was conducted. She explained kitchen staff were instructed to rewrap items in the dry storage area after use and date them with a seven-day expiration date. The DM stated the food items in the freezer followed a guide with use by dates specific to the food. She stated the staff forgot to reseal and date the items. The DM stated the dented can was removed and sent back to the distributor for credit.An interview with the Administrator on 7/24/25 at 1:26 PM was conducted. She stated she had the expectation that kitchen staff follow the policies and procedures for proper food storage.

Based on observations, record review, resident, staff, and Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse when Resident #23 hit Resident #96 in the face with a closed fist resulting in a slightly swollen area to the outer aspect of Resident #96's left eye. This affected 1 of 8 residents (Resident #96) reviewed for resident-to-resident abuse. The findings included:Resident #23 was admitted to the facility on [DATE] with diagnoses which included mild vascular dementia without behavioral disturbance, psychotic disturbance or mood disturbance due to a previous cerebral infarction (a condition where brain tissue dies due to a lack of blood supply) and hypertensive heart disease with heart failure.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. Resident #23 was able to ambulate 10 feet with a rolling walker unassisted but generally self-propelled in a wheelchair.A review of the care plan revised on 4/10/2025 revealed that Resident #23 had focus areas regarding ineffective coping which resulted in Resident #23 acting out in a verbally or physically aggressive manner and Resident #23 having some aggressive behaviors toward other residents. Goals included Resident #23 would display a decrease in aggressive and angry outbursts through the next review period and staff would recognize and avoid behaviors that provoked aggressive outbursts from Resident #23. Interventions included allowing Resident #23 time to respond to requests, approaching Resident #23 slowly and from the front, being aware not to invade Resident #23's personal space and being sure to have Resident #23's attention before speaking or touching the resident.Resident #96 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, heart failure, and aphasia (a language disorder that affects a person's ability to communicate).A review of the quarterly MDS dated [DATE] indicated Resident #96 was moderately cognitively impaired. Resident #96 was not ambulatory and was mobile in a wheelchair for short distances.A review of the care plan dated 5/15/2025 revealed a focus area regarding refusal of care and showers but no aggressive behaviors noted.A review of a nursing note written by the Assistant Director of Nursing (ADON) on 7/16/2025 at 1:20 PM indicated nursing staff had entered the room shared by Resident #23 and Resident #96 and Resident #96 stated Resident #23 had hit her in the face. The residents were immediately separated and assessed for injury and pain. The Nurse Practitioner and Resident Representatives were notified.A review of a Wellness Nurse progress note dated 7/16/2025 indicated she assessed Resident #96 after the altercation and notified the Nurse Practitioner that Resident #96 had a slightly swollen area to the left outer eye. The note indicated an ice pack had been placed to the left outer eye area. The Nurse Practitioner ordered lab work, psychiatry and psychology referrals, and x-rays of Resident #96's face and hands. The Nurse Practitioner also ordered Resident #96's aspirin dose to be held for 3 days. The note indicated Resident #96 was angry and upset regarding the altercation with her roommate.A review of the Electronic Medical Record (EMR) for Resident #96 revealed a Nurse Practitioner order dated 7/16/2025 to hold the 81 milligram (mg) chewable aspirin tablet for 3 days. Resident #96 usually received one 81 mg chewable tablet once daily by mouth for antiplatelet therapy.A review of the initial allegation report dated 7/16/2025 at 2:15 PM stated the facility became aware of the incident on 7/16/2025 at 1:20 PM. Resident #23 hit Resident #96 in the face and both residents were placed on one to one supervision. Resident #96 had a bump on her cheek under the left eye. The initial report was signed by the Administrator.An interview on 7/24/2025 at 10:15 AM with Nurse #1 revealed she was walking down the hall on 7/16/2025 when she heard yelling and screaming coming from Resident #23's and Resident #96's room. She was the first staff member to enter the room within a few seconds of hearing the yelling and Resident #96 was screaming that Resident #23 hit her in the face. Nurse #1 observed Resident #23 standing up out of her wheelchair and leaning over Resident #96 who was seated in her wheelchair. Resident #23 was holding down Resident #96's arms by her wrists and pushing them down onto the wheelchair armrest. Resident #96 had both hands holding Resident #23's shirt which had been ripped on the side. Nurse #1 stated she had to physically removed Resident #96's hands from the shirt and asked Resident #23 to let go of Resident #96 which she did. She stated the residents were separated immediately. SW #1 had been notified and took Resident #96 out of the room to provide one to one supervision. Nursing Aide (NA) #1 provided one to one supervision for Resident #23. The Wellness Nurse was in the facility and assessed both residents. Nurse #1 stated that Resident #96 had a slight swelling to the left side of her face below her eye. Resident #23 had no injuries. Resident #23 was moved across the building to another room the same afternoon and stayed on one to one supervision that day. Nurse #1 indicated there had never been any issues between the two residents until that altercation. Nurse #1 stated Resident #23 had been verbally aggressive to staff in the past regarding medication administration. Nurse #1 revealed Resident #23 had cursed at her in the past when the order required medications to be crushed in applesauce because Resident #23 had wanted to take her medications whole.An interview on 7/24/2025 at 2:48 PM with Nursing Aide (NA) #1 indicated she arrived at the room on 7/16/2025 just after Nurse #1 and the nurse had already separated the residents. NA #1 provided one to one supervision for Resident #23. She stated she stayed with Resident #23 while the Wellness Nurse and local law enforcement conducted their assessments. NA #1 stated Resident #23 was moved to a different room and hallway. As far as she knew there had not been any more behavioral issues with Resident #23 or Resident #96. NA #1 stated she never had any problems with either resident.An interview on 7/24/2025 at 10:58 AM with Social Worker (SW) #1 revealed she was called to the unit shortly after the altercation. Resident #96 was out in the hall in her wheelchair. SW #1 took Resident #96 into the activity room to provide one to one supervision and emotional support. SW #1 stated after Resident #96 told her about being hit by Resident #23, and talked through the incident, Resident #96 calmed down and returned to her baseline mood. Resident #96 and SW #1 sat together and watched television while arrangements for Resident #23 to move to another room were being made. SW #1 stated Resident #96 indicated she felt safe after the incident. SW #1 indicated Resident #96 had not displayed any behavioral changes since the altercation.A social services note dated 7/16/2025 indicated Resident #23 and the Resident Representative were advised of the room change and both agreed.A social services note dated 7/16/2025 revealed social services interviewed Resident #96 later in the day after the incident, and she expressed she felt safe and had no other concerns.A Nurse Practitioner note dated 7/17/2025 indicated she had been contacted on 7/16/2025 by the Wellness Nurse who had assessed Resident #23, and no injuries were noted. The Nurse Practitioner also noted no injuries, and the lab results were reviewed without any significant findings. Resident #23 appeared to be at her baseline regarding her mood and physical assessment.A Nurse Practitioner note dated 7/17/2025 indicated she examined Resident #96 and found less swelling to her face. Resident #96 complained of left sided rib pain, so x-rays were ordered. Lab results were reviewed without significant findings and Resident #96 appeared to be at her baseline regarding her mood.A nursing note dated 7/18/2025 revealed that Resident #96 was alert and pleasantly confused. Denied pain and no discomfort noted. The x-rays of Resident #96's ribs showed normal ribs. The nurse contacted the Resident Representative with the results.A review of a Physician progress note dated 7/18/2025 indicated Resident #23 was assessed due to the altercation with another resident. Resident #23's agitation on 7/16/2025 appeared to be situational. The Physician encouraged Resident #23 to do breathing exercises when she was annoyed.A review of the investigation report dated 7/18/2025 revealed the incident had been reported to the County Department of Social Services and to local law enforcement on 7/16/2025. The investigation report stated an altercation began between Resident #23 and Resident #96 when Resident #96 grabbed Resident #23's shirt and would not release her grip. Resident #23, in response, struck Resident #96 in the face. Staff heard yelling and immediately responded. Upon entering the room, Resident #23 was observed standing over Resident #96 and was holding Resident #23's wrists down against the arms of the wheelchair. Resident #96 had a grip on Resident #23's shirt with both hands and there was a tear down the right side of Resident #23's shirt. Resident #96 had a raised nickel-sized bump under her left eye. Staff separated the residents, and both were assessed and supervised. Resident #23 stated Resident #96 had been bumping her wheelchair into Resident #23's wheelchair and then grabbed her shirt from behind. Resident #23 admitted she struck Resident #96 with a closed fist under the left eye resulting in the bump. The report stated within a couple of hours there was no bump to Resident #96's cheek and no bruising noted. The investigation report stated both residents had cognitive impairment and diagnoses of dementia. There was no documented history of conflict or aggression between the residents prior to the incident. The report indicated Resident #23 remained on one to one supervision after the event. The report stated follow up x-rays, lab work and psychiatry and psychology referrals were completed as ordered by the Nurse Practitioner. The report revealed the abuse was not substantiated as there was no evidence of willful infliction of injury with an intent to harm. The investigation report was signed by the Administrator. An interview on 7/22/2025 at 11:15 AM with Resident #23 revealed she had moved to another room, and she reported all was going well with the new roommate. She stated she moved as she did not like the previous roommate. Resident #23 denied any altercation with the previous roommate.An interview on 7/23/2025 at 9:40 AM with Resident #96 revealed Resident #96 was alert, pleasant but was unable to provide information as she answered questions in a nonsensical manner.An interview on 7/23/2025 at 1:15 PM with the Assistant Director of Nursing (ADON) indicated she did not witness the altercation between Resident #23 and Resident #96. She stated she arrived at the room after the residents had been separated. Resident #23 had no injuries and admitted she hit Resident #96 in the face because Resident #96 had grabbed her shirt and would not let go. The ADON stated Resident #96 had a small, raised area on her left cheek. She stated the x-rays were negative. The ADON stated there had never been any issues between Resident #23 and Resident #96 and they had been roommates for several months. She indicated Resident #23 had behavioral issues around refusing medications and needed encouragement to take her medication, but the ADON had never witnessed any aggressive behavior.A follow up observation and interview on 7/24/2025 at 10:08 AM with Resident #96 revealed the resident resting in bed and that she remained pleasantly confused and unable to answer questions in an understandable way.A follow up interview on 7/24/2025 at 11:05 AM with Resident #23 revealed she admitted to hitting Resident #96 in the face. Resident #23 indicated both residents were up in their wheelchairs in their shared room. Resident #23 stated Resident #96 bumped her wheelchair into Resident #23's wheelchair and then grabbed Resident #23's shirt and would not let go. Resident #23 stood up, faced Resident #96 and yelled for Resident #96 to let go of her shirt. Resident #23 indicated she hit Resident #96 on the left side of her face with a right hand closed fist. Resident #23 stated she was holding Resident #96's wrists trying to push her arms down onto the wheelchair armrests to get her to release her grip. At that point, the nurse arrived and separated them. Resident #23 stated local law enforcement was called, and she provided the Officer with a statement. Resident #23 stated she moved rooms and was very happy with her new roommate.An interview on 7/24/2025 at 1:48 PM with Nursing Aide (NA) #2 revealed Resident #23 was doing great in the new room and loved being on the new hall. Resident #23 and her new roommate got along and interacted well. NA #2 indicated Resident #23 had not been upset at all and was doing fine.An interview on 7/24/2025 at 11:37 AM with the Nurse Practitioner indicated she saw both Resident #23 and Resident #96 on 7/17/2025. The Wellness Nurse had assessed both residents on 7/16/2025 and notified the Nurse Practitioner. She provided lab orders and psychiatry and psychology referrals for both residents. For Resident #96, the Nurse Practitioner ordered the aspirin dose to be held for 3 days and facial and hand x-rays. She stated both residents appeared to be back to their baseline for mood. Resident #23 seemed to be settling into the new room easily. The Nurse Practitioner stated she ordered bilateral rib x-rays for Resident #96 on 7/17/2025 due to pain complaints. The x-rays were negative for any abnormality. The Nurse Practitioner did not know of any issues between the residents previously and felt Resident #96's behavior (bumping into Resident #23's wheelchair and grabbing the shirt) was related to the progression of Resident #96's dementia.An interview on 7/24/2025 at 12:54 PM with the Director of Nursing (DON) indicated she was not working the day of the altercation and heard about it when she returned to work.An interview on 7/24/2025 at 1:23 PM with the Administrator indicated she conducted the investigation and did not believe resident to resident abuse occurred as Resident #23 did not intend to harm Resident #96 when she hit her. The Administrator stated Resident #23 was trying to get Resident #96 to release her grip on the shirt. She stated both residents had cognitive impairment, and the Brief Interview for Mental Status (BIMS) was not a good scale for the type of dementia Resident #23 had. The Administrator stated The St. Louis University Mental Status Examination (SLUMS) was a more accurate assessment.A follow up interview on 7/24/2025 at 3:30 PM with the Administrator indicated she was requesting past noncompliance and provided the plan of correction. She also provided a SLUMS examination dated 7/24/2025 at 2:10 PM for Resident #23 which revealed a score of 11 which indicated dementia. The Administrator stated both Resident #23 and Resident #96 had skin checks after the altercation. She indicated all residents who were cognitively intact had been questioned about abuse with no concerns noted. All residents who were cognitively impaired had skin checks completed. The Administrator stated all staff had attended an abuse training. The facility provided the following corrective action plan: Address how corrective actions will be accomplished for those residents who have been affected by the deficient practice:Problem Statement: On 7/16/2025, at 1:20pm, the aides on the unit heard yelling coming from the room while passing meal trays. Upon entering the room, resident #23 was observed standing over resident #96 holding resident #96's wrists down against the armrests of her wheelchair. The aides immediately separated the 2 residents and placed them on 1:1 supervision. Both residents were interviewed concerning the incident along with staff members present. Resident #23 stated that resident #96 rolled up behind her and grabbed the back of her shirt, bumping her wheelchair and then struck her in the face. Resident #23 stated that she struck resident #96 on the left side of the face. No injury was noted at the time of the incident; however, the nurse completed an assessment for latent injury and noted a bump under the left eye. On 7/16/2025, at the time of the incident, the nursing staff separated the residents immediately and placed them on 1:1 supervision. Resident #23 was moved to a different room in another area of the facility. Resident #23's family was notified of the room move. Skin checks were completed on resident #23 and resident #96. Medical services, Adult Protective Services (APS), police, and responsible party were notified. An initial report was placed with the division of health and human services. Medical services were completed for resident #23 on 7/16/2025 with labs and psych referral completed. Medical services were completed for resident #96 on 7/16/2025 and 7/17/2025 with x-rays, labs and psych referral. No medication adjustments for either resident at the time of visits.How will the facility identify other residents having the potential to be affected by the same deficient practice:On 7/16/2025, skin checks were completed for 100% of all residents with a BIMS of 12 or below and interviews were completed for all residents with a BIMS of 13 or above. Any concerns were addressed immediately by the Administrator or Director of Nursing.What measures will be put into place or systemic changes made to ensure that the deficient practice will not occurAn in-service for abuse along with resident-to-resident physical interaction and behaviors was initiated with all staff to include agency and contract staff by the Administrator and the Administrator in Training on 7/16/2025 and was completed by 7/16/2025. The in-service education included an understanding of resident-to-resident interactions, causes and contributing factors, prevention strategies, documentation and reporting and promoting a culture of safety and respect. Any staff member to include agency and contract staff that had not completed the education as stated above by the completion date, received the education by their next scheduled shift. Any newly hired staff to include agency or contract staff received the above stated in-service education during orientation prior to their first shift. The training included: what is abuse and neglect, staff should intervene and protect the resident or residents by removing them from the situation if you feel abuse has occurred and who to report abuse to (immediate supervisor), and how the nurses should document and report a concern for abuse. How will the facility monitor its corrective actions to ensure that the deficient practice will not recur:On 7/17/2025, the Director of Nursing or the Assistant Director of Nursing will review all progress notes 5x/week for 4 weeks during Cardinal Interdisciplinary Team (IDT) Meeting to identify any behaviors. Any concerns will be addressed immediately by the Administrator and the Director of Nursing, medical services and Responsible party will be notified as appropriate. On 7/17/2025, the social workers will complete interviews with 5 residents a week for 12 weeks who have a BIMS of 13 or >. These interviews included the following questions: 1. How do you usually respond when another resident upsets or bothers you? 2. Are there any residents you don't get along with, or who make you feel uncomfortable? 3. If someone is bothering you or touches your things, who can you talk to about it before it becomes a problem?On 7/17/2025, licensed nurses will complete 5 staff interviews weekly for 12 weeks with direct care staff to ensure understanding of prevention for resident-to-resident altercations. The questions will include: 1. How do you identify when a resident with cognitive impairment is becoming agitated or overstimulated, and what steps do you take to de-escalate the situation. 2. Can you give an example of how you've successfully intervened to prevent a conflict between two residents? 3. How do you monitor and manage interactions between residents with different cognitive levels or behavioral triggers? 4. What communication strategies do you use when redirecting a resident with dementia who is entering another resident's space or becoming intrusive? The Nursing Home Administrator will review the responses weekly for 12 weeks. Any areas of concern will be addressed immediately by the Administrator or Director of Nursing. The Administrator or Director of Nursing will present the findings of the audit tools to the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. The Quality Assurance Performance Improvement Committee will meet monthly for 3 months and review the audit tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. QAPI meetings were held on 7/17/2025. Date of Compliance: 7/18/2025 The corrective action plan was validated onsite on 7/24/2025. The validation included review of the initial and follow up assessments of Resident #23 and Resident #96, the immediate separation of both residents, both residents placed on one-to-one supervision, Resident #23 being moved to another room and hallway. All skin checks were reviewed for completeness and all resident interviews regarding abuse were reviewed with no additional findings noted. The initial report and the investigation report were sent to the State Agency, local Law Enforcement and Adult Protective Services were notified on 7/16/2025. The Resident Representatives and MD/NP were notified of the incident on 7/16/2025. The handout regarding resident-to-resident abuse provided during the abuse training was reviewed. Interviews with staff revealed that they had received recent education on abuse and were able to verbalize types of abuse and the procedure for reporting. Signature sheets were reviewed to confirm all staff were educated. Social worker interviews with 5 residents regarding abuse concerns were reviewed with no concerns noted. Nursing staff interviews regarding understanding of resident-to-resident abuse were reviewed with no concerns noted.A compliance date of 7/18/2025 for the corrective action plan was validated.

Based on observations, staff interviews, and record reviews the facility failed to remove expired medications stored in 1 of 4 medication carts (Garden City).The findings included:An observation of the Garden City medication cart was conducted on 7/22/25 at 1:30 PM in the presence of Nurse #1. The following expired medications were found in the Garden City medication cart, a pack of Catapres 0.1 micrograms (medication to lower blood pressure) with an expiration date of 7/18/25 in the second drawer from the top; and a pack of Atarax 25 milligrams (treat anxiety and itching) with an expiration date 2/27/25 were in the second drawer from the top. An interview with Nurse #1 was completed on 7/23/25 at 1:50 PM. The Nurse stated that all staff who administer medication were responsible for checking medication expiration dates. The night shift had more down time and was expected to check the medication carts to restock and get rid of expired medications.An interview with the Unit Manager was completed on 7/23/2025 at 1:54 PM. The Unit Manager reported that expired medications were placed in a gray box, then scanned by the night shift nurse and returned to pharmacy daily. The interview with the Director of Nursing (DON) on 7/24/25 at 12.35 PM revealed that the nurses on the medication carts should check the medication cart and get rid of expired medication each shift. The DON stated that staff should follow the medication administration policy that included checking the medication expiration date prior to administration. An interview with the Administrator was completed on 7/24/25 at 1:23 PM. The Administrator stated that she expected the staff who administered medications to follow the medication administration policy and remove expired medication from the medication carts.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for hand hygiene when Nurse #3 failed to perform hand hygiene during medication administration after handling medication bottles and dispensed pills into her bare hand before placing the pills in a medicine cup. In addition, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse Aide (NA) #3 failed to wear personal protective equipment (PPE) during a high contact care activity that included transferring Resident #122 who had a chronic wound and an indwelling urinary catheter and when NA #3 and NA #4 transferred Resident #117 who had an indwelling urinary catheter. This was for 3 of 5 staff members observed for infection control practices (Nurse #3, NA #3 and NA #4). The findings included:1. A review of the facility's policy titled Medication Administration - Person Centered Care dated last revised on 6/2021 revealed in part the following: If breaking tablets was necessary to administer the proper dose, hands are washed with soap and water or alcohol gel prior to handling tablets.On 7/23/2025 at 8:41 AM a continuous observation for medication administration was conducted for Resident #18 with Nurse #3. Nurse #3 used hand sanitizer for both hands, opened the medication cart drawer with right hand. She then held a medication bottle with her left hand and removed the top with her right hand. Nurse #3 then poured one (1) pill from the medication bottle into her left hand and placed the pill in a clear medication cup. Nurse #3 then touched other medication bottles in the medication cart drawer looking for the next medication. Nurse #3 did not perform hand hygiene and proceeded to pour a second pill into her left hand and then placed the pill in the clear medication cup. The surveyor stopped Nurse #3 before dispensing further medications. On 7/23/2025 at 8:50 AM an interview with Nurse #3 was conducted outside of Resident #18's room. Nurse #3 stated that she thought that she could dispense pills in her hand if she used hand sanitizer prior to dispensing all medications. Nurse #3 indicated she was not aware that she was contaminating her hands when touching various unclean surfaces prior to dispensing the pills in her hand. An interview with the Director of Nursing (DON) was completed on 7/24/25 at 12:35 PM. The DON stated Nurse #3 should not dispense medications in her hands to prevent the spread of bacteria. The DON reported Nurse #3 should have followed the medication administration policy to wash hands with soap and water or alcohol gel prior to handling tablets/medications. She did use hand sanitizer prior to handling pills. The DON stated she would have dispensed the pill in the lid of the medication bottle and then into the medication cup. On 07/24/2025 at 1:23 PM an interview with the Administrator indicated Nurse #3 should have followed the medication administration policy as it pertained to hand washing. 2. A review of the facility's policy titled Enhanced Barrier Precautions dated last revised on 6/13/24 revealed in part the following: Enhanced Barrier Precautions are used in conjunction with standard precautions to reduce the risk of MDRO transmission during high-contact resident care activities. It includes the use of both gowns and gloves. Enhanced Barrier Precautions apply to residents with any of the following: Presence of an indwelling medical device with or without the presence of an MDRO infection or colonization. Example of indwelling device included urine drainage device. Resident care activities that are considered high contact included transferring a resident. An observation on 7/23/25 at 1:24 PM revealed NA #3 entered Resident #117's room. Signage for EBP was posted on the outside of Resident #117's door and indicated that staff performing high contact care that included transferring residents should wear a gown and gloves. PPE was observed hanging the door that included gowns, gloves and masks. NA #3 then exited the room and returned with a mechanical lift to transfer Resident #117. NA #3 entered Resident #117's room without donning a gown and gloves and began to place lift pad under Resident #117. The Surveyor intervened and inquired about the reason Resident #117 required EPB. NA #3 stated that Resident #117 had a chronic wound and indwelling urinary catheter and then donned a gown and gloves. An interview with NA#3 on 7/23/2025 at 2:44 PM was completed outside of Resident #117's door. NA #3 stated that she knew that she should wear PPE in Resident #117's room and was going to put on the gown and gloves after someone arrived to assist her with the transfer. b. An observation on 7/24/25 at 2:30 PM revealed EBP signage was posted on the outside of Resident #122's door that indicated staff performing high contact care that included transferring residents should wear gown and gloves. NA #4 was observed entering Resident #122's room without PPE and closed the door. The Surveyor knocked on Resident #122's door, then entered Resident #122's room. NA #3 and NA #4 had not donned a gown or gloves and were transferring the resident from the bed to the wheelchair using the mechanical lift. NA #3 was observed holding Resident #122's legs and NA #4 had her hands under Resident #122's armpits, while Resident #122 hovered over a wheelchair. Resident #122 had an indwelling urinary catheter. An interview with NA#3 on 7/23/2025 at 2:44 PM revealed she had completed the online computer training and hands on training for EBP during her employment orientation. NA #3 reported she was aware that Resident #122 required PPE; however, was focused on getting Resident #122 up in wheelchair and out to wound appointment on time. An interview was completed on 7/23/2025 at 2:35 PM with NA #4. NA #4 reported she saw NA #3 having a hard time preparing Resident #122 for a mechanical lift transfer and jumped in to assist NA #3. NA #4 stated that she knew to put on PPE for EBP rooms; however, she was rushing to assist NA #3 and forgot to don PPE. NA #4 reported she was more concerned about transferring Resident #122 safely and assisting Resident #122 to wound appointment. NA #4 confirmed that NA #3 was not wearing PPE.On 7/24/25 at 12:35 PM an interview with the Director of Nursing (DON) stated NA #3 had previously received education on the use of EBP precautions with online computer training and hands on training during new employee orientation. The DON reported that NA #3 and NA #4 should have been wearing the appropriate PPE listed on the EBP sign posted on Resident #117 and Resident #122's doors when providing high contact care for residents with chronic wounds and indwelling urinary catheters. On 07/24/2025 at 1:23 PM an interview with the Administrator indicated NA #3 should have followed EBP which included wearing a gown while performing high contact activity, such as transferring residents to prevent the potential spread of microorganisms.

Based on record review and staff interviews, the facility failed to maintain accurate records related to documentation of treatment to a pressure ulcer for 1 of 3 residents reviewed for accurate medical records (Resident #110). The findings included: A review of Resident #110's physician orders dated May 2025 revealed the following:- - Treatment to sacral wound: cleanse with sodium hypochlorite (wound cleaner), apply Drawtex (wound dressing) to wound bed, secure with 4-inch by 4-inch bordered foam daily and as needed until resolved. The order was dated 05/01/25. A review of Resident #110's May 2025 Treatment Administration Record (TAR) revealed the following order:- -Treatment to sacral wound: cleanse with sodium hypochlorite (wound cleaner), apply Drawtex (wound dressing) to wound bed, secure with bordered foam daily and as needed until resolved. The order was dated 05/01/25. The order was documented as completed and signed off by a nurse daily.A review of Resident #110's June 2025 Treatment Administration Record (TAR) revealed the following order:- - Treatment to sacral wound: cleanse with sodium hypochlorite (wound cleaner), apply Drawtex (wound dressing) to wound bed, secure with 4 inch by 4 inch bordered foam daily and as needed until resolved. The order was dated 05/01/25. The order was documented as completed and signed off by a nurse daily from 06/01/25 through 06/24/25. A wound care consultation report dated 06/25/25 revealed the wound care physician had ordered for Resident #110's dressing to be changed to the following:- -Cleanse the wound with wound cleanser. Apply calcium alginate with silver, apply a 2-inch by 2-inch gauze border foam dressing and change daily. A review of Resident #110's June 2025 Treatment Administration Record (TAR) revealed the following order:- -Treatment to sacral wound: cleanse with sodium hypochlorite (wound cleaner), apply Drawtex (wound dressing) to wound bed, secure with 4-inch by 4-inch bordered foam daily and as needed until resolved. The order was dated 05/01/25. The order was documented as completed and signed off by a nurse daily from 06/25/25 through 06/30/25. There was no documentation of the application of the calcium alginate with silver, apply a 2-inch by 2-inch gauze border foam dressing in the June TAR. A review of Resident #110's July 2025 Treatment Administration Record (TAR) revealed the following order:- - Treatment to sacral wound: cleanse with sodium hypochlorite (wound cleaner), apply Drawtex (wound dressing) to wound bed, secure with 4-inch by 4-inch bordered foam daily and as needed until resolved. The order was dated 05/01/25. The order was documented as completed and signed off by a nurse daily until 07/23/25. There was no documentation of the application of the calcium alginate with silver, apply a 2-inch by 2-inch gauze border foam dressing in the July TAR for the period of 07/01/25 through 07/23/25. On 07/24/25 at 10:13 AM an interview was conducted with Wound Nurse #1. During the interview Wound Nurse #1 stated she was the facility's weekend wound nurse and had worked in the facility for 2 years. She stated she completed all wound care on the weekends and would often look back through resident's charts from the previous week to ensure orders were placed into the electronic medical record (EMR). She stated she had not seen Resident #110's wound care consultation report from 06/25/25 or realized there was a different order on the consultation than what she had been completing for Resident #110. Wound Nurse #1 confirmed she had been treating the sacral pressure ulcer with the order dated 05/01/25. Wound Nurse #1 stated she would have to talk to Wound Nurse #2 about the order because she felt like it was just a documentation issue. Wound Nurse #1 stated Resident #110's wound was improving in size and appearance. On 07/24/25 at 10:37 AM an interview was conducted with Wound Nurse #2 via telephone. During the interview she stated she was out of town but typically completed all wound care during the week and Wound Nurse #1 completed the wound care on the weekends. During the interview she stated she had received the wound care consultation order on 06/25/25. However, she asked the Medical Director if they could keep Resident #110's treatment order the same as ordered on 05/01/25 because the wound was improving. The Medical Director told her it was fine to do so however she did not put a note into the EMR or a new physician order on the resident's Treatment Administration Record. On 07/24/25 at 10:50 AM an interview was conducted with the Medical Director. During the interview he stated any resident with a stage three or greater pressure ulcer was sent out to the wound care clinic. He stated the wound care clinic made recommendations for dressing changes and would send consultation reports back with the resident to the facility. The Medical Director stated he ultimately approved or denied them. He stated Wound Nurse #2 was good about coming to him about orders and if she felt an order was working better than the recommendation then he would have kept the treatment order the same. He stated he felt like he remembered Wound Nurse #2 coming to him about the new order on 06/25/25 and he told her it was okay to keep the treatment regimen the same. The Medical Director stated he just didn't write a note about it or an order for it. The interview revealed Resident #110's wound was improving in size and appearance. On 07/24/25 at 11:46 AM an interview was conducted with the Wound Care Clinic Staff Member #1. During the interview she stated they had received a call from the facility on 06/25/25 and they gave a verbal order that it was okay to continue with the treatment order from 05/01/25. She stated Resident #110 had been evaluated in the wound care clinic on 07/23/25 and her wound was improving. On 07/24/25 at 12:43 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Wound Nurse #2 should have written a note into the resident's EMR and there should have been documentation to show the consultation report from 06/25/25 was not missed. The DON stated the physician order should have been updated to reflect a new date and that it was appropriate to use sodium hypochlorite (wound cleaner), and Drawtex (wound dressing) to wound bed, instead of the calcium alginate with silver order from 06/25/25. On 07/24/25 at 3:35 PM an interview was conducted with the Administrator. During the interview she stated Wound Nurse #2 should have documented in Resident #110's EMR if an order was not followed or changed for Resident #110's wound care.

Based on observations, record review, and staff, Resident Representative, Physician Assistant and Pharmacist interviews, the facility failed to ensure a resident was free of significant medication errors when they failed to administer a daily dose of Cenobamate (seizure medication) from 9/05/24 through 9/18/24. Resident #1 was observed having a mild seizure (eyes rolled back and upper body twitching that lasted approximately 2 minutes) on 9/18/24. This deficient practice occurred for 1 of 3 residents reviewed for medication errors. (Resident #1) The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to continue Divalproex Sodium (seizure medication) 750 milligrams (mg) in the morning and 1000 mg at bedtime, Zonisamide (seizure medication) 400 mg at bedtime, decrease Lacosamide (seizure medication) to 200 mg twice a day and to start Cenobamate (seizure medication) once a day at bedtime with a gradual dose increase to 100 mg. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was severely cognitively impaired and was coded for having a seizure disorder. A review of Resident #1's physician orders revealed the following active orders as of 8/06/24: Divalproex Sodium 750 mg by mouth once a day (9:30 am). Divalproex Sodium 1000 mg by mouth at bedtime (8:30 pm). Zonisamide oral suspension (liquid) 100 mg/5 milliliters (ml) 20 ml by mouth at bedtime. Lacosamide oral solution 10 mg/ml 20 ml by mouth twice a day (9:00 am and 9:00 pm). Cenobamate 12.5 mg to be administered once a day at bedtime 8/08/24 through 8/21/24. Cenobamate 25 mg to be administered once a day at bedtime 8/22/24 through 9/04/24. Cenobamate 50 mg to be administered once a day at bedtime 9/05/24 through 9/18/24. Cenobamate 100 mg to be administered once a day at bedtime 9/19/24 and continue. A review of Resident #1's Medication Administration Record (MAR) from August 2024 through September 2024 revealed Cenobamate 12.5 mg was documented as given daily at bedtime from 8/08/24 through 8/21/24, Cenobamate 25 mg was documented as given daily at bedtime from 8/22/24 through 9/04/24 and Cenobamate 50 mg was documented as given daily at bedtime from 9/05/24 through 9/18/24. A phone interview conducted with Nurse #2 on 10/10/24 at 2:06 PM revealed she worked 2nd shift and was assigned to Resident #1. Nurse #2 indicated she was unaware Cenobamate was not on the medication cart and thought she had administered the medication to Resident #1. She stated she was unable to explain why she had not identified that the medication was not on the medication cart. She further stated she thought the 1st shift (7am-3pm) nurse and unit manager were responsible for monitoring the medications and notifying the pharmacy when a medication was needed. Nurse #2 revealed she received education on the 6 rights of medication administration and the process to follow when a medication was unavailable. A phone interview was conducted with Nurse #3 on 10/11/24 at 9:48 AM. Nurse #3 indicated she worked 2nd shift and was assigned to Resident #1. She stated she was notified by the ADON that there was no Cenobamate on the medication cart for Resident #1. Nurse #3 further stated she thought she was administering the medication to Resident #1 at bedtime and did not recall the medication being unavailable. She indicated if she had noticed the Cenobamate was not on the medication cart she would have contacted the pharmacy. Nurse #3 revealed she received education on the 6 rights of medication administration and the process to follow when a medication was not available. A review of the controlled substance count sheet for Cenobamate indicated the last pill was administered to Resident #1 on 9/04/24. A review of the nurse's note dated 9/18/24 indicated Resident #1 was sitting in her wheelchair and observed to have a seizure lasting approximately 2 minutes. Resident #1 was transferred to her bed and her vital signs were obtained. The Nurse Practitioner and Resident Representative were notified. The note was electronically signed by Nurse #4. A review of the Nurse Practitioner (NP) note dated 9/19/24 revealed Resident #1 was evaluated due to a breakthrough seizure on 9/18/24. Labs for Divalproex Sodium and Lacosamide levels were ordered, and a follow-up appointment was to be scheduled with the neurologist. New orders were given for a one-time dose of Cenobamate 50 mg to be administered 9/19/24 at bedtime and on 9/20/24 start Cenobamate 12.5 mg for 14 days and then 25 mg for 14 days. A review of Resident #1's laboratory report dated 9/24/24 indicated her Divalproex Sodium level was 90 micrograms per milliliter (ug/ml) with the therapeutic range being 50-100 ug/ml and her Lacosamide levels were 13.6 micrograms per milliliter (mcg/ml) with the therapeutic range being up to 15 mcg/ml. A review of the neurology visit note dated 9/25/24 revealed Resident #1 had a breakthrough seizure on 9/18/24 and was ordered to resume Cenobamate 50 mg daily at bedtime for 2 weeks and then increase and continue Cenobamate 100 mg daily at bedtime. A phone interview with the Resident Representative (RR) on 10/10/24 at 9:00 AM revealed she was notified on 9/18/24 that Resident #1 had a mild seizure with no residual effects and that did not require hospitalization . She stated on 9/19/24 she was notified by the Assistant Director of Nursing (ADON) that Resident #1 had not received her new seizure medication as ordered, and the facility had initiated an investigation into how the error occurred. The RR further stated Resident #1 had a follow-up appointment with the neurologist on 9/25/24 and orders were received to resume the new seizure medication. An interview conducted with Nurse #1 on 10/10/24 at 11:13 AM indicated that Resident #1 had a neurology appointment on 8/06/24 and returned with new orders for Cenobamate. She revealed the neurologist had sent the prescription to the pharmacy and she entered the orders in the electronic medical record (EMR). She stated she was aware that Resident #1 had a mild seizure on 9/18/24. She further stated on 9/19/24 during the narcotic count she noticed there was no Cenobamate on the medication cart and immediately notified the ADON. Nurse #1 revealed she was unsure if Resident #1 received the Cenobamate because she worked 1st shift (7am-3pm) and it was administered on 2nd shift (3pm -11pm) at bedtime. She stated she did recall Cenobamate being on the cart during the narcotic count before going on vacation 9/05/24 through 9/17/24. An interview with the ADON on 10/10/24 at 11:38 AM indicated Resident #1 had a mild seizure on 9/18/24 and she was notified by Nurse #1 on 9/19/24 that there was no Cenobamate on the medication cart. The ADON revealed she notified the Administrator, and they initiated an investigation. The ADON stated Resident #1 received Cenobamate 12.5 mg for 14 days and 25 mg for 14 days but, the 50 mg and 100 mg doses were never requested from pharmacy. She revealed the NP and RR were notified and a follow-up neurology appointment was scheduled. The ADON indicated they determined the error occurred because the 6 rights of medication administration were not followed. She revealed a performance improvement plan was initiated, and all licensed nurses and medication aides received training on the 6 rights of medication administration (verifying the right resident, right drug, right dosage, right route, right time and right documentation) as well as the process to follow when a medication was unavailable. The NP was no longer employed by the facility and unavailable for interview. An interview conducted with the Physician Assistant (PA) on 10/10/24 at 12:49 PM revealed the facility notified the NP on 9/18/24 that Resident #1 was observed having a mild seizure. He stated the NP evaluated Resident #1 on 9/19/24 and indicated she was at her baseline and had no residual effects from the seizure. He further stated the NP ordered labs for Divalproex Sodium and Lacosamide levels and for a follow-up appointment to be scheduled with the neurologist. He revealed he was unaware that Resident #1 was not administered Cenobamate from 9/05/24 through 9/18/24. The PA indicated the Cenobamate not being administered was a significant medication error and would explain why Resident #1 had a mild seizure on 9/18/24. Several attempts made to contact the Neurologist were unsuccessful. A phone interview conducted with the Pharmacist on 10/11/24 at 9:18 AM revealed the Neurologist sent a prescription on 8/06/24 for Resident #1 to start Cenobamate 12.5 mg for 14 days then increase to 25 mg for 14 days. She indicated the Neurologist also sent a prescription on 8/06/24 for Cenobamate 50 mg for 14 days and 100 mg for 14 days to start on 9/03/24 and to continue Cenobamate 100 starting 10/1/24. The Pharmacist revealed they dispensed Cenobamate 12.5 mg (14 tablets) and 25 mg (14 tablets) to the facility on [DATE]. She stated the 50 mg and 100 mg doses were not requested or dispensed. She further stated the facility should have notified the pharmacy when the 12.5 mg and 25 mg doses were completed and to send the 50 mg and 100 mg. The Pharmacist indicated that the Cenobamate not being administered would have caused Resident #1 to have a seizure. An interview with the Administrator on 10/10/24 at 1:50 PM indicated she was notified by the ADON on 9/19/24 that Resident #1's Cenobamate was not on the medication cart. She revealed they initiated an investigation and determined the Cenobamate was not requested from the pharmacy when the dose increased to 50mg. She stated the Cenobamate was ordered at bedtime, and they interviewed the 2nd shift (3pm-11pm) nurses (Nurse #2 and Nurse #3) that initialed the MAR that the medication was administered. She further stated Nurse #2 and Nurse #3 were unaware the medication was not in the medication cart and thought it was administered. She indicated if Nurse #2 and Nurse #3 followed the 6 rights of medication administration they would have noticed the Cenobamate was not in the medication cart and notified the pharmacy to send the medication. She stated a performance improvement plan was initiated, and all licensed nurses and medication aides received training on the 6 rights of medication administration and the process to follow when a medication was unavailable. The facility provided the following corrective action plan: Corrective Action that will be accomplished: On 9/18/24 Resident #1 was observed having a mild seizure. Nurse #1 identified on 9/19/24 there was no Cenobamate located on the medication cart for Resident #1 and notified the ADON. Through further investigation the ADON determined a medication error occurred. Resident #1 had not received 14 doses of Cenobamate 50 mg. The physician was notified, the medication was re-started, and a follow-up appointment was scheduled with the neurologist. Identification of other residents: On 9/19/24 the ADON initiated a 100% audit of all current residents with orders for anti-seizure medications and the physician would be notified of any areas of concern. The ADON verified that the anti-seizure medications for all residents audited were available on the medication carts. On 9/19/24 the ADON initiated an audit of all incident reports for the past 30 days to identify trends, and any incidents related to medication administration to ensure appropriate interventions were initiated, the physician was notified, and the resident was assessed as indicated. Measures for systemic changes: On 9/19/24 the Staff Development Coordinator, Unit Manager and Nursing Supervisors initiated and completed medication pass observations with Nurses and Medication Aides (MA) utilizing the medication pass audit tool. The observations were to ensure all medications were being administered per the physician orders. The Nurses and MAs with identified concerns during the observation received immediate training. After 9/19/24 any MA or Nurse that had not worked will complete the medication pass observation prior to their next scheduled shift. On 9/19/24 and 9/20/24 an in-service was initiated by the Staff Development Coordinator with 100% Nurses and MAs receiving education on the 6 rights of medication administration, reading the medication administration record, accurately administering medications as ordered by the physician, and the facility policy on steps to complete when medication was not available. After 9/20/24 all nurses and MAs that had not worked will receive the education prior to their next scheduled shift. How Corrective Action will be monitored: Beginning 9/20/24 the Unit Manager will audit all medication carts 3 times weekly for 2 months to ensure that residents have all controlled medications available. The Physician will be notified of any identified concerns. The nursing managers will complete 10% of medication passes with nurses and MAs once a week for 4 weeks and then once a month for one month utilizing the medication pass audit tool to ensure medications are being administered as ordered by the physician. Any areas of concern will be immediately addressed including staff retraining. New medication orders will be reviewed in the Cardinal Interdisciplinary Team meeting daily. The Administrator or Director of Nursing (DON) will review and initial the audits beginning 9/20/24 once a week for 4 weeks and then once a month for one month to ensure that all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools to Quality Assurance Performance Improvement (QAPI) Committee beginning 9/20/24 once a month for 2 months. The QAPI committee beginning 9/20/24 will meet monthly for 2 months and review the audit tools to determine trends and/or issues that may need further interventions and additional monitoring. Validation of the facility's corrective action plan was conducted 10/10/24 through record review, staff interviews, and medication administration observations. The licensed nurses and medication aides interviewed were able to recall the education on the 6 rights of medication administration and what steps to take when a medication was unavailable. They also confirmed that medication administration audits were completed. Medication administration observations conducted on 10/10/24 indicated a 0% medication error rate. The education of the 6 rights of medication administration and steps to take when a medication was unavailable was reviewed and contained staff signature sign in sheets. The corrective action plan's completion date of 9/20/24 was validated.

Based on record review, and staff interviews, the facility failed to accurately document the administration of 14 doses of a seizure medication in the medical record for 1 of 1 resident reviewed for accurate medical records (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included seizure disorder. The neurology visit note dated 8/06/24 revealed Resident #1 was experiencing persistent break through seizures. Resident #1 was ordered to start Cenobamate once a day at bedtime with a gradual dose increase to 100 mg. A review of Resident #1's physician orders revealed the following orders: Cenobamate 50 mg to be administered once a day at bedtime 9/05/24 through 9/18/24. Cenobamate 100 mg to be administered once a day at bedtime 9/19/24 and continue. A review of Resident #1's Medication Administration Record (MAR) from August 2024 through September 2024 revealed Cenobamate 50 mg was documented as given daily at bedtime from 9/05/24 through 9/18/24. A review of the controlled substance count sheet for Cenobamate indicated the last pill was administered to Resident #1 on 9/04/24. An interview with the ADON on 10/10/24 at 11:38 AM indicated she was notified by Nurse #1 on 9/19/24 that there was no Cenobamate on the medication cart for Resident #1. The ADON revealed she notified the Administrator, and they initiated an investigation. The ADON indicated Resident #1 received Cenobamate 12.5 mg for 14 days and 25 mg for 14 days but, the 50 mg and 100 mg doses were never requested from pharmacy. She stated the 50 mg dose was initialed on the MAR as given 9/05/24 through 9/18/24 by Nurse #2 and Nurse #3. She further stated Nurse #2 and Nurse #3 were unable to explain why they initialed administering a medication that was unavailable on the medication cart. A phone interview conducted with Nurse #2 on 10/10/24 at 2:06 PM revealed she worked 2nd shift and was assigned to Resident #1. Nurse #2 indicated she was unaware Cenobamate was not on the medication cart and documented administering the medication on the MAR because she thought she had. A phone interview was conducted with Nurse #3 on 10/11/24 at 9:48 AM. Nurse #3 indicated she worked 2nd shift and was assigned to Resident #1. She stated she was unaware there was no Cenobamate on the medication cart for Resident #1. Nurse #3 further stated she thought she was administering the medication and that was why she documented on the MAR that it was given. An interview with the Administrator on 10/10/24 at 1:50 PM indicated she was notified by the ADON on 9/19/24 that Resident #1's Cenobamate was not on the medication cart. She revealed they initiated an investigation and determined the Cenobamate was not requested from the pharmacy when the dose increased to 50mg. She stated the Cenobamate was ordered at bedtime and they interviewed the 2nd shift (3pm-11pm) nurses (Nurse #2 and Nurse #3) that initialed the MAR that the medication was administered. She stated Nurse #2 and Nurse #3 were unable to explain why they documented a medication was administered when it was unavailable on the medication cart. The Administrator further stated medication administration should be accurately documented in the resident record and on the MAR.

Based on record review, and resident, staff, and Physician Assistant interviews the facility failed to dispose of a plastic bag that had been used to crush medications for Resident #24 and the plastic bag ended up on Resident #23's breakfast tray. Resident #23 believed the crushed white substance was powdered sugar and sprinkled it on his breakfast. This affected 1 of 5 residents reviewed for medication errors. The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses that included chronic pain. A physician order dated 05/06/24 read, Acetaminophen 500 milligram (mg) by mouth give 2 tablets 3 times a day for chronic pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #23 was cognitively intact and had no behaviors. The MDS further revealed that Resident #23 frequently reported pain of a 9 on a pain scale. Resident #24 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia. A physician order dated 10/18/23 read, Acetaminophen 325 mg by mouth, give 2 tablets every 8 hours for pain. The quarterly MDS dated [DATE] revealed that Resident #24 was severely cognitively impaired and had no nonverbal signs of pain. Review of the Medication Administration Record (MAR) dated July 2024 revealed that Resident #24's acetaminophen had been initialed by staff indicating it had been administered as prescribed. Review of the MAR dated August 2024 revealed that Resident #24's acetaminophen had been initialed by staff indicating it had been administered as prescribed. Resident #23 was interviewed on 08/26/24 at 11:44 AM who stated about a month ago he received his breakfast tray, and he had French toast. Resident #23 stated he loved French toast and was excited that it was on his tray. He stated that on the side of his tray was a plastic bag that had a white powder in it, and he believed it was powdered sugar for his French toast. Resident #23 stated he sprinkled the white powder on his French toast and took a bite and the white powder was bitter and tasted like medication, so he spit the food out and did not eat anything else on his tray. Resident #23 stated he flipped the plastic bag over and it had another resident's name written on the bag and then he believed that the white powder was a medication but stated he did not ingest any because it was bitter, and he spit it out. He also did not know which resident's name was written on the plastic bag. Resident #23 stated he summoned Nurse Aide (NA) #1 to his room and told her what had occurred. Resident #23 stated that later he was interviewed by Unit Manager #1, the former Social Worker, and the Director of Nursing (DON). He also stated that Nurse #1 was giving meds that day and came back to him later and stated she had the plastic bag in her pocket, and it had accidentally fallen on his tray. Resident #23 was unable to quantify how much powder was in the bag but stated it was enough that I thought it was powdered sugar. He picked up a plastic sleeve that was on his lunch tray and approximated that the white powdered substance was one third of the plastic sleeve. Resident #23 also confirmed that nothing like that had happened since that day. Review of the facility's menu revealed that French toast was on the menu for breakfast on 07/09/24. NA #1 was interviewed on 08/26/24 at 12:42 PM. NA #1 stated that she recalled the incident but could not recall when it occurred. She stated that Resident #23 called her to his room and stated he had sprinkled powdered sugar on his French toast and when he put it in his mouth it was bitter, and he thought it was medication that was not his. NA #1 stated she told Resident #23 that they did not have powdered sugar and added that she did not see the white powder or bag on his tray at the time, but she had reported what he said to Nurse #1, and Nurse #1 went and talked to him. Nurse #1 was interviewed via phone on 08/27/24 at 10:15 AM. Nurse #1 stated that she recalled the incident but could not recall when it occurred. She stated she was working and passing medications, and she was asked to help pass out breakfast trays. She stated she had crushed 2 acetaminophen tablets for Resident #24 and administered them to her but the plastic bag that she crushed them in had Resident #24's name on it and she could not throw it in the trash. Nurse #1 stated she put the plastic bag in her pocket of her scrub top with the intention of throwing it in the shred box for destruction. Nurse #1 stated after she passed trays, she reached in her pocket to get the plastic bag out to dispose of it and it was gone. Nurse #1 stated she returned to each room that she had delivered trays to and found the bag in Resident #23's room. Nurse #1 stated that Resident #23 stated he thought it was sugar and she replied to Resident #23 you know that had a name on it and was not sugar but for my protection I reported to my supervisor which was Unit Manager #1. Nurse #1 stated Resident #23 did not report to her that he had tasted it only that he thought it was sugar. Nurse #1 again stated that there was no medication in the plastic bag that she had already given the acetaminophen to Resident #24 and could not explain how Resident #23 sprinkled it on his French toast. Unit Manager (UM) #1 was interviewed on 08/27/24 at 10:42 AM. She stated that she recalled walking up on a conversation between the DON and Nurse #1 about the incident but was not aware of what had occurred. UM #1 stated she had not been informed of the situation by anyone else and was not aware of any of the details, nor was she aware when it occurred or how the situation was handled. The former Social Worker (SW) was interviewed via phone on 08/27/24 at 10:07 AM. The SW explained that she used to be the full-time social worker and had switched to working evenings at the facility. She stated she came in one evening and NA #1 told her what had occurred and that she needed to go and speak to Resident #23. The SW stated she immediately went to talk to Resident #23 who stated that he got a breakfast tray and had French toast and when he was fixing his tray, he found a plastic bag that he thought was powdered sugar, and he had sprinkled it on his French toast and took a bite and it was bitter. Resident #23 stated he spit the food out and did not ingest the substance, but he looked at the plastic bag and it had a resident's name on it. The SW stated she reported the incident to Unit Manager #1 and to the DON and they were going to talk to him. The SW could not recall when the incident occurred but stated she thought it was reported to her on a Monday and the incident had occurred over the weekend, but she was not for sure. The DON was interviewed on 08/27/24 at 11:49 AM. The DON stated she could not recall when the incident occurred, but Nurse #1 had reported to her that she had dropped an empty pouch that had been used to crush medications on Resident #23's tray. The DON stated she asked Nurse #1 if the medication had been given to the correct resident and Nurse #1 replied yes so, the DON stated she did not think anything else about it. She added that she had instructed Nurse #1 to properly dispose of the packaging and to not put it in her pocket. The DON stated Resident #23 had not said anything to her about the situation and the former SW had not reported it to her. The DON stated she was not aware that Resident #23 had sprinkled the medication on his food which she found highly unlikely because Nurse #1 stated the plastic bag was empty. She added that it surprised her that Resident #23 would sprinkle that on his food. The Physician Assistant was interviewed via phone on 08/27/24 at 1:29 PM. He stated that Resident #23 took a lot of acetaminophen for his chronic pain but his dosage was within the acceptable parameters. The Physician Assistant stated if Resident #23 had ingested or taken an extra dose of acetaminophen 650 mg one time there would have been no adverse outcome to him. The facility provided the following corrective action plan with a completion date of 8/5/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: At the time of the incident Resident #23 spit out the food and did not consume it and sent the tray back to the kitchen. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 07/30/24 the DON did an audit of all resident rooms to ensure no medications were noted at bedside or in the room unless the resident had an order to keep medications at bedside including Resident #23. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur: From 07/30/24 through 08/05/24 all facility nurses and Medication Aides received a medication pass observation by the corporate clinic management team. From 07/24/24 through 08/05/24 all Nurses and Medication Aides received training from the facility DON or corporate clinical management team on the 6 rights of medication administration, medication storage, and limiting interruptions during medication pass for example not taking phone calls or text during medication pass times. The education included the facility's system for disposing of protected health information during medication pass. The system included that any medication packaging that contained protected health information was to be placed in a cardboard box on each medication cart and at the end of the medication pass and taken to the shred box for destruction. Any Nurses or Medication Aides that did not receive the education or medication pass observation were not permitted to work a shift until both had been completed. The education used for the Nurses and Medication Aides was included in the new hire orientation program. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Daily audits were completed by the Medical Records clerk from 08/05/24 through 08/08/24 observing for any medication at bedside or in the resident's room. Weekly audits continue until directed by the QAPI committee. The plan had been approved by the QAPI committee on 07/26/24. Facility date of compliance was 08/05/24. The plan of correction was validated on 08/26/24 through 08/27/24. Alert and oriented residents were interviewed about medications in their room or on their meal tray with no issues reported including Resident #23. A medication pass observation was completed with 30 opportunities and no errors, and no other concerns noted. Nursing staff were interviewed on the 6 rights of medication administration and how and where to dispose of resident's medication packaging that included protected health information. They were able to verbalize that the medication packaging that included protected health information was not placed in the trash can, it was placed in a small cardboard box that sat on top of the medication cart and after the medication pass was completed the box was emptied into the shred box for destruction. The new hire orientation packet was verified to include the medication administration education and medication pass observation. The daily and weekly audits were reviewed. Staff interviews revealed that they observed 10 different resident rooms to ensure there were no medications at bedside unless the resident had an order to keep medications at bedside. The compliance date of 08/05/24 was validated.

Based on observations, a resident interview, interviews with staff and record review, the facility failed to provide food in a form to meet the individual needs of a resident with a physician order for a regular diet with mechanical soft texture (Resident #19). This failure occurred for 1 of 3 sampled residents reviewed for mechanically altered diets. The findings included: A review of menus, recipes and the Diets policy, revised 9/2010 revealed residents with a physician order for a regular diet, mechanical soft texture should receive regular mechanical soft textured foods and meats from the regular menu would be ground, easy to chew and easy to swallow. Resident #19 was admitted to the facility on [DATE]. Diagnoses included dysphagia, oropharyngeal phase, dementia (mild) with mood disturbance, cognitive communication deficit, and psychosis. A review of the August 2024 Physician Order Summary revealed Resident #19 had a physician order for a regular diet with mechanical soft texture. A 8/7/24 quarterly Minimum Data Set assessment, recorded Resident #19's speech was clear, he was understood by others, able to understand, his hearing was adequate, his vision was impaired, he wore corrective lenses, his cognition was intact and he received a mechanically altered diet. A care plan, revised 8/16/24 recorded Resident #19 had a care deficit related to his dentures as he was edentulous, received a mechanically altered diet and that he was resistive to treatment/care (refused to wear his dentures). Interventions included providing his diet as ordered and referrals for dietary concerns related to any swallowing difficulties. A review of the medical record for Resident #19 revealed there was no documentation that he requested to receive crispy bacon or that he was educated on the risks of crispy bacon associated with a mechanically altered diet. Resident #19 was observed on 8/26/24 at 9:19 AM in the Activity Room with other residents and staff for the breakfast meal. Resident #19's breakfast tray was in front of him, but he was not eating. Resident #19 was not wearing dentures. His breakfast tray remained with a partially eaten cheese omelet, a small portion of grits, and crisp bacon that was cut into large pieces and was not ground. Resident #19 did not eat the bacon. The tray card recorded a mechanical soft diet, and the notes section recorded give crispy bacon daily. Resident #19 stated he did not finish eating because he did not like his food. He described that he did not eat the bacon because of his throat issues and stated that he could not eat food that was too hard or too big because if he did, the food got caught in his throat and caused him to cough. Resident #19 stated that every time bacon was on the breakfast menu, which was once or twice per week, he stated, This is what I get, and I can't eat it, so I don't. Resident #19 stated that They have been telling me they are going to fix it on my card for years and they never do, I'm supposed to get my meat ground up, I don't like this bacon because I can't chew it and I can't swallow it, but every time it's on the menu, I get it cut up like this, but I can't eat it, so I don't. Resident #19 further stated that he did not know why the crispy bacon daily was on his tray card, he stated I don't know where that came from, I never asked for bacon, I try not to eat pork/ham. Resident #19 stated that he was supposed to get his breakfast meat ground up, he did not know what kind of meat it was, but ground meat was what he needed and stated, that's what the doctor ordered and that's what I should get. He stated that he was told in therapy that he would receive ground meat and that he agreed to that. Resident #19 stated that Nurse Aide (NA) #1 knew that he was supposed to get ground meat, so when he received foods that he did not like or could not eat, if NA #1 was working that day, she took his tray back to the kitchen and brought him something he could eat. He stated that as many times as NA #1 took his tray back to the kitchen, he thought his card would get corrected, but that it never got fixed. A review of the Spring/Summer cycle breakfast menus revealed bacon was served three times in weeks one and four and twice in weeks two and three. An 8/26/24 interview at 12:00 PM with NA #1 revealed she worked at the facility for over a year and Resident #19 was on her regular assignment. NA #1 stated she did not set up his breakfast tray that morning (8/26/24) and did not know which staff member did, but that he was supposed to receive ground meat with his meals. NA #1 stated that when she did set up his breakfast tray, she made sure he received a mechanical soft diet with ground meat. NA #1 stated that sometimes she had to return his meal tray back to the kitchen, to get it fixed, but that she did not recall if that was because he did not receive something he wanted or if something else was wrong. NA #1 stated that as far as she knew, Resident #19 received a mechanical soft diet, and that she had not noticed before if he received bacon that was cut up and not ground, but that she did not always set up his tray. NA #1 stated that she was not sure why he received bacon that was in pieces too big for him to eat, but that his food came from the kitchen that way. NA #1 stated that on the days she worked, if she saw that he was not eating his food, she checked on him and if he said he did not want his food, she took his tray back to the kitchen to get him something else to eat. An 8/27/24 interview at 10:05 AM with Unit Manager (UM) #1 revealed she worked in the facility for the past four months. UM #1 stated she assisted another resident with his breakfast on 8/26/24 in the Activity Room when she noticed Resident #19 did not finish eating his breakfast. She described he was just looking ahead. UM #1 said she asked Resident #19 if he was okay, but he did not tell her what was wrong. UM #1 stated that since she was assisting another resident, she did not go over to Resident #19 to see what was wrong. UM #1 stated she did not work with Resident #19 that often, and that she was not familiar with his care needs. UM #1 stated she did not set up his breakfast tray on 8/26/24 so she did not notice that his diet order was mechanical soft but that he received large pieces of bacon. During an interview and observation on 8/26/24 at 9:26 AM of Resident #19 with his breakfast tray with the Speech Therapist (ST) and the Rehab Director, the ST stated that she worked in the facility for the past 18 months and Resident #19 discharged from ST caseload in 2023. The ST reviewed the tray card and observed the breakfast meal for Resident #19 and stated she saw on his tray card instructions to give crispy bacon daily and stated that the large pieces of bacon he received did not meet the requirement for ground meat texture for a resident with a diet order for mechanical soft foods. The ST stated that his diet recommendation from ST was for a mechanical soft diet with ground meat and that she assumed he requested the crispy bacon because it was on his tray card, but she wasn't sure. The ST stated that she saw the crispy bacon on his tray card today (8/26/24), but she did not talk to him previously about the risks of eating crispy bacon. The ST stated Resident #19 was his own responsible party and that he could have crispy bacon if he wanted but that he should be educated on the risks associated with receiving foods that were not part of his diet order. The ST stated that she educated Resident #19 on the risks associated with his difficulty swallowing when he was treated in 2023, but that she did not know when the crispy bacon was added to his tray card, and she did not know if he was educated on the risks of eating crispy bacon. The ST stated that Resident #19 refused to be evaluated for ST services since he was discharged from ST in 2023 and expressed at discharge that he would continue to receive a mechanical soft diet. During an interview on 8/27/24 at 2:00 PM with the Certified Foodservice Manager (CFM), he stated that he was the CFM for the past three weeks, he was familiar with Resident #19 because he attended Food Committee Meetings. The CFM stated he received bacon for breakfast that morning (8/26/24) because it was recorded on his tray card and that the bacon was cut up because of his diet order for mechanical soft foods. He reviewed the therapeutic spread sheet during the interview and confirmed that residents with diet orders for mechanical soft foods should receive ground meats. During an observation of Resident #19 on 8/26/24 at 9:25 AM with his breakfast meal and interview with the Registered Dietitian (RD), the RD stated she was not aware that Resident #19 received bacon with his breakfast meal, but that he attended Food Committee Meetings weekly and his concern with receiving bacon had not been discussed. The RD stated that at the Food Committee Meeting on Monday, 8/19/24, Resident #19 communicated that he wanted gravy biscuits, but because his tray card recorded no gravy he did not receive it, so that was corrected, but that he did not mention the bacon, nor had she been informed by staff that he did not want crispy bacon. The RD stated that she assumed Resident #19 must have told someone in the dietary department at some point that he wanted crispy bacon, in order for it to be recorded on his tray card, but she was not sure who because there had been several different dietary managers employed at the facility in just a few months. The RD stated she did not know if Resident #19 was educated on the risks associated with receiving crispy bacon with a diet order for mechanical soft foods, but that ground crispy bacon was impossible to make. The RD stated she had not spoken to Resident #19 about the risks associated with eating crispy bacon since his diet order was for mechanical soft foods. The RD stated Resident #19 should receive ground meat per his diet order and if he requested the crispy bacon, he should be educated on the risks. During an interview on 8/27/24 at 4:15 PM the Rehab Director reviewed the ST notes for Resident #19 and stated he was referred for ST services in 2023 from nursing when he was observed coughing repeatedly with his meal. The Rehab Director stated that nursing immediately downgraded his diet from a regular diet to a mechanical soft diet. The Rehab Director stated that after some time, ST offered to re-evaluate and treat him to upgrade his diet, but although he had dentures, he usually refused to wear them, and he never wore dentures with his meals. The Rehab Director stated that Resident #19 understood safe swallowing techniques, he was able to communicate the techniques, but that he did not implement safe swallowing techniques consistently. The Rehab Director stated that he had not received ST services since 2023, because he stated that he did not like the ST at the facility, so the Rehab Director asked another ST to eval him yesterday (8/26/24). The Rehab Director stated that Resident #19 expressed during the 8/26/24 evaluation that he still did not want to wear his dentures to eat, and if his food was not soft and ground up, he could not swallow it. He stated that he did not like pork and wanted to stay away from bacon. He declined ST treatment services and stated that he would continue with his current diet of mechanical soft foods with ground meats. The Rehab Director stated that since Resident #19 would not wear his dentures to eat, his diet order would remain mechanically soft for his safety. The Administrator stated in an interview on 8/26/24 at 11:45 AM that Resident #19 attended the weekly Food Council Meetings and had not brought up a concern about receiving bacon. The Administrator stated that Resident #19 was his own responsible party and since crispy bacon was recorded on his tray card, she assumed that it was per his request. She stated she was the Administrator at the facility since February 2024 and that in that time staff had not brought to her attention that Resident #19 did not want crispy bacon and that she was not aware if Resident #19 was educated on the risks associated with a diet order for mechanical soft foods and eating crispy bacon. The Nurse Consultant stated on 8/27/24 at 4:00 PM that she did not find documentation in the medical record for Resident #19 that he was educated on the risks associated with crispy bacon and his diet order, but that he should have been educated. She stated that she felt the education occurred, but since it was not documented, she could not be certain. She stated that residents should receive their diet as ordered.

Based on observations, a resident interview, interviews with staff and record review, the facility failed to provide a resident scrambled eggs for breakfast per his preference. This failure occurred for 1 of 3 sampled residents reviewed for food intolerances and preferences (Resident #19). The findings included: Resident #19 was admitted to the facility on [DATE]. Diagnoses included dementia (mild) with mood disturbance, cognitive communication deficit, major depressive disorder and psychosis. A review of the August 2024 Physician Order Summary revealed Resident #19 had a physician order for a regular diet with mechanical soft texture. A 8/7/24 quarterly Minimum Data Set assessment recorded Resident #19's speech was clear, he was understood by others, able to understand, his hearing was adequate, his vision was impaired, he wore corrective lenses, and his cognition was intact. A care plan revised 8/16/24 recorded Resident #19 was at risk for nutritional decline due to a history of weight loss, varying appetite and a diet order for a mechanically altered diet. Interventions included providing his diet as ordered, assessing for and providing food preferences. A review of the Spring/Summer cycle breakfast menus revealed cheese omelet was served once in weeks one, three, and four and cheese eggs was served once in weeks two and three. Resident #19 was observed on 8/26/24 at 9:19 AM in the Activity Room with other residents and staff for the breakfast meal. Resident #19's breakfast tray was in front of him, but he was not eating. His breakfast tray remained with a partially eaten cheese omelet, a small portion of grits, and bacon. The tray card recorded standing orders: 4 oz (ounces) scrambled eggs. Resident #19 stated he did not finish eating because he did not like his food. He described that he preferred scrambled eggs for breakfast, it was written on his tray card, but when the breakfast menu included cheese eggs or an omelet, which was about once or twice per week, this is what he got instead of the scrambled eggs. He stated, I don't like the omelet, but I have to eat something, so I ate it. I go to these meetings every week to talk about the food, but it does no good, nothing ever gets done, I don't mean any disrespect, but I don't expect anything to change, it hasn't in [AGE] years, so I just don't say anything anymore. Resident #19 stated that Nurse Aide (NA) #1 knew what he was supposed to get and knew what he liked, so when he received foods that he did not like or could not eat, if NA #1was working that day, she took his tray back to the kitchen and brought him something he could eat. A 8/26/24 interview at 12:00 PM with NA #1 revealed she worked at the facility for over a year and Resident #19 was on her regular assignment. NA #1 stated she did not set up his breakfast tray that morning (8/26/24) and did not know which staff member did. NA #1 stated that when she did set up his breakfast tray, she made sure he received the foods per his diet order and preferences. NA #1 stated that sometimes she had to return his meal tray back to the kitchen, to get it fixed, but that she did not recall if that was because he did not receive something he wanted or if something else was wrong. NA #1 stated that on the days she worked, if she saw that he was not eating his food, she checked on him and if he said he did not want his food, she took his tray back to the kitchen to get him something else to eat. A 8/27/24 interview at 10:05 AM with Unit Manager (UM) #1 revealed she worked in the facility for the past four months. UM #1 stated she assisted another resident with his breakfast on 8/26/24 in the Activity Room when she noticed Resident #19 did not finish eating his breakfast. She described he was just looking ahead. UM #1 said she asked Resident #19 if he was okay, but he did not tell her what was wrong. UM #1 stated that since she was assisting another resident, she did not go over to Resident #19 to see what was wrong. UM #1 stated she did not work with Resident #19 that often, and that she was not familiar with his care needs. UM #1 stated she did not set up his breakfast tray on 8/26/24 so she did not notice that he received a cheese omelet instead of scrambled eggs. During an interview on 8/27/24 at 2:00 PM with the Certified Foodservice Manager (CFM), he stated that he was the CFM for the past three weeks, he was familiar with Resident #19 because he attended Food Committee Meetings. The CFM reviewed the tray card for Resident #19 and stated that the tray card recorded his preference for scrambled eggs so as best he could tell it was just an oversight. During a 8/26/24 9:25 AM observation of Resident #19 with his breakfast meal and interview with the Registered Dietitian (RD), the RD stated Resident #19 received scrambled eggs with his breakfast meal on 8/26/24, due to an oversight. The RD stated that she assisted on the tray line often and if she saw an error with preferences, she would ask staff to correct it. The RD stated that Resident #19 attended Food Committee Meetings weekly and his concern with receiving scrambled eggs had not been discussed nor had she been informed by staff that he did not receive scrambled eggs. The RD stated that the facility had employed several different dietary managers in just a few months and that the current manager had been at the facility for three weeks. The Administrator stated in an interview on 8/26/24 at 11:45 AM that Resident #19 attended the weekly Food Committee Meetings and had not brought up a concern about receiving scrambled eggs. The Administrator stated that resident preferences should be provided as recorded on the tray cards.

Based on observation, record review, staff interviews, the facility failed to safely assist a resident without causing injury to 1 of 3 residents (Resident #1) reviewed for accidents. Resident #1 was documented to be transferred by a lift and was assisted by Nurse Aide #1 alone. The findings included: Resident #1 was originally admitted to the facility on [DATE] with diagnoses which included dementia and hypertension. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severally cognitively impaired and required extensive assistance with transfers. Review of Resident #1's care plan revised on 04/19/24 revealed the resident was care planned for Activities of Daily Living (ADL). The goal was for Resident #1's care to be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Interventions included chair to bed and to chair transfer required a mechanical life for Resident #1. Review of Resident #1's care guide revised on 04/19/24 revealed Resident #1 required a mechanical lift for transfers. An observation conducted on 07/09/24 at 12:35 PM revealed Nurse Aide (NA) #1 transferred Resident #1 by herself from the bed to the wheelchair to take the resident to the dining room for lunch. No injury or incident was observed. The observation further revealed no care guide was posted or lift present in Resident #1's room at the time of the transfer. An interview conducted with Nurse Aide (NA) #1 on 07/09/24 at 2:15 PM revealed she was an agency staff and had been working in the facility for two weeks. NA #1 further revealed she was not familiar with Resident #1 and assumed the resident was a one person assist because nursing staff had not educated her on Resident #1. NA #1 stated she transferred the resident from the bed to his wheelchair without any issues. NA #1 indicated she was not aware Resident #1 had a history of falls and had not been educated to look at the residents' care guide in the electronic chart for the residents ADLs. An interview conducted with Unit Manager (UM) #1 on 07/09/24 at 1:15 PM revealed Resident #1 had a history of falls. The UM further revealed she could not recall what Resident #1's status was for transfers but knew he was at least a two person assist. UM #1 indicated nursing staff was educated to follow the residents' care guide. UM #1 indicated NA #1 was agency staff and should have not transferred Resident #1 by herself. An interview conducted with Nurse #1 on 07/09/24 at 2:35 PM revealed Resident #1 was a mechanical lift for transfers from the bed to wheelchair. Nurse #1 further revealed nursing staff had been educated to review residents care guides for ADL assistance. Nurse #1 stated NA #1 should have not transferred Resident #1 without assistance due to the resident's history of falls. Interview conducted with the Director of Nursing (DON) on 07/09/24 at 3:20 PM revealed nursing staff had been educated to follow resident care guides and care plan. The DON indicated NA #1 and all staff who were agency had been educated to follow all residents care guides in the electric chart. The DON further revealed Resident #1 was documented to have a mechanical lift for transfers and should have been followed. An interview conducted with Administrator on 07/09/24 at 2:55 PM revealed nursing staff had been educated at orientation to follow resident care guides. Administrator further revealed NA #1 should not have transferred Resident #1 with one assist and followed what was reflected on Resident #1's care guide.

Based on observations, record reviews, staff and resident interviews, the facility failed to assess residents for the ability to self-administer medications for 2 of 2 residents (Resident #2 and #3) reviewed for self-administering medications. The findings include: 1. Resident #2 was admitted to the facility 10/29/20. A review of Resident #2's physician orders revealed orders for Gabapentin Capsule (to treat nerve pain) 300 milligram (mg) give one capsule by mouth three times a day for neuralgia (nerve pain) dated 02/10/22, and Hydrocodone-Acetaminophen (narcotic analgesic) 5/325 mg give one tablet by mouth three times a day for pain dated 02/10/22. There were no orders to self-medicate. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #2 was cognitively intact. A review of Resident #2's medical record revealed there was no assessment to self-administration of medications in the record. There was no care plan developed for the Resident to self-administer medications. A review of Resident #2's Medication Administration Record (MAR) for 05/2024 indicated Hydrocodone-Acetaminophen 5/325 mg was given at 12:30 PM on 05/29/24 and Gabapentin Capsule 300 mg was given at 1:00 PM on 05/29/24 and initialed by Nurse #1. On 05/29/24 at 2:46 PM an observation and interview were made of Resident #2. Noted on the Resident's over bed table was a medicine cup that had a yellow capsule and a white pill in the cup. The medication was dry and there was no indication that they were in contact with moisture. Resident #2 explained that Nurse #1 brought him the medications and he had not taken them yet, but he would take them in a little while. When asked what they were for the Resident stated one was for his legs and the other was his pain pill. An interview was conducted with the Director of Nursing (DON) on 05/29/24 at 2:50 PM who was looking for Nurse #1. The DON was asked if the Nurses were allowed to leave medications on the residents over bed table and she replied, absolutely not, there are no residents in house that are allowed to self-medicate. The DON was accompanied to Resident #2's room and the Resident was not in his room and the medicine cup was empty. During an interview with Nurse #1 on 05/29/24 at 3:05 PM the Nurse confirmed that she had medicated Resident #2 earlier and he put the medication in his mouth. She explained that he must have spit them out after he put them in his mouth. Nurse #1 continued to explain that she gave the Resident his medications at 12:45 PM and she thought he took them. On 05/29/24 at 3:45 PM during an interview with the Administrator she explained that the residents were not allowed to self-administer medications unless they had been assessed to be mentally and physically able to self-administer their medications. 38515 2. Resident #3 readmitted to the facility on [DATE]. Review of Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact with no psychosis, behaviors, or rejection of care. Review of Resident #3's medical record revealed no documentation that Resident #87 had been assessed to self-administer medications. Further review of Resident #3's medical record revealed no care plan for self-administration of medications. An observation of Resident #3 completed on 05/29/24 at 10:17 AM revealed her to be in her room, sitting in her wheelchair watching television. On Resident #3's overbed tray was a bottle of antacid chewable tablets. Additional observations made on 05/29/24 at 12:50 PM, 2:44 PM, and 3:00 PM all revealed the antacid chewable tablets remained on Resident #3's overbed table. An interview with Nurse #2 on 05/29/24 at 3:58 PM revealed she did not believe that the facility allowed residents to self-administer medications. She reported she knew that none of the residents she cared for on 05/29/23 self-administered medications. Nurse #2 verified she was assigned to care for Resident #3 on 05/29/24 and stated she had not noticed the bottle of antiacid chewable tablets on Resident #3's overbed table. She stated Resident #3 should not have had the bottle of antiacid chewable tablets in her room and reported she would go and remove them and store them on the medication cart where they belonged. Nurse #2 proposed that Resident #4's family had potentially brought the antacid chewable tablets to the facility earlier in the day. An interview with Resident #3 on 05/30/24 at 12:10 PM revealed a family member had brought in the antiacid chewable tablets for her the previous day because she complained about some indigestion. She stated she was unaware she was unable to keep them at her bedside and reported that someone had removed them from her room. Resident #3 verified she had taken some of the antacid chewable tablets. An interview with the Director of Nursing completed on 05/30/24 at 1:24 PM revealed if was not customary for staff to leave medications at resident bedsides. She reported, to her knowledge, there were no residents in the facility that currently had the ability to self-administer medications. She reported the facility's policy required residents to be screened and assessed to ensure they had the cognitive ability to safely administer the medication and keep the medication safe in their room. She indicated that Resident #3 should not have had the antacid chewable tablets in her room for self-administration. An interview with the Administrator on 05/30/24 at 1:1 PM revealed she was made aware that Resident #3 had the antacid chewable tablets in her room during a facility-wide audit that was completed after being informed of other medications being found left at resident bedsides. She reported Resident #3 did not have the authority to keep the antacid chewable tablets at her bedside and indicated that Resident #3 had not been assessed to self-administer medications. The Administrator reported the antacid chewable tablets had been removed from Resident #3's room and were being kept in a secure area until Resident #3's family could pick them up.

Based on record review, observations, and Resident Representative (RR) and staff interviews the facility failed to provide nail care for 2 of 3 dependent residents reviewed for activities of daily living (ADL) (Resident #4 and Resident #5). The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, and muscle weakness. Resident #4 did not have a diagnosis of diabetes. A review of the shower schedule for Resident #4 revealed he was scheduled to receive showers on Mondays and Fridays. The last documented nail care was on 3/8/2024 and was documented in a nursing progress note. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was severely cognitively impaired with impairment on both sides of the upper and lower extremities. Resident #4 was documented as maximum assist for personal hygiene. A review of the care plan dated 4/4/2024 revealed Resident #4 required staff support to achieve the highest practical level of function for activities of daily living with interventions which included Resident #4 required maximal assistance for personal hygiene. A review of a shower sheet dated 5/28/2024 revealed Resident #4 received a shower that was scheduled to be performed by NA #4. The space for intervention documentation was blank. There was no documentation regarding fingernails being cut or cleaned. An interview was conducted on 5/30/2024 at 9:42 am with NA #4. NA #4 reported she had given Resident #4 a shower on 5/28/2024. NA #4 stated she washed his hair and body but did not cut/clean his fingernails. NA #4 reported she performed nail care when she noticed nails were long and/or dirty but had not noticed Resident #4's nails. A telephone interview was conducted on 5/29/2024 at 9:52 am with Resident #4's RR. The RR stated Resident #4 always had long and dirty fingernails when she would come and visit weekly. She reported she had mentioned her concerns in March of 2024 to nursing staff, including the previous Director of Nursing, at the facility, but it continued to be an issue. An observation was conducted on 5/29/2024 at 9:57 am. Resident #4 was observed to have contractures of both the left and right hands and had quarter-inch long fingernails, on all ten fingernails on both the right and left hands, with a brown substance underneath. There were 4 of Resident #4's fingernails on the right side that touched his right palm and 4 fingernails on the left side that touched his left palm. There was no redness or open areas observed. An interview was conducted on 5/29/2024 at 2:43 pm with NA #3. NA #3 was assigned to care for Resident #4 on 5/29/2024. NA #3 reported he had not noticed Resident #4 had long, dirty fingernails. NA #3 stated the shower team usually performed nail care and that he had not cut and cleaned nails at the facility. NA #3 was asked to observe Resident #4's fingernails. NA #3 verbalized Resident #4's fingernails were long and dirty. An interview was conducted on 5/29/2024 at 2:25 pm with Nurse Aide (NA) #1. NA #1 reported she was on the shower team and was assigned to give showers to residents in the building on their assigned shower days. She reported she had not trimmed or cleaned any residents' fingernails because she was not comfortable cutting nails. NA #1 stated if she noticed a resident's fingernails were long while she was giving them a shower, she would write it down on the shower sheet and tell the hall nurse. An interview was conducted on 5/29/2024 at 2:38 pm with NA #2. NA #2 reported she was on the shower team and was assigned to give showers to residents according to their shower schedule. NA #2 stated she was not responsible for cutting fingernails or toenails and was unsure of who was. NA #2 reported if she noticed a resident had long nails she would report it to the Nurse. An interview was conducted on 5/29/2024 at 3:11 pm with the Staff Development Coordinator (SDC). The SDC reported nursing staff, both NAs and Nurses, were trained about nail care during orientation. The SDC stated both NAs and Nurses were responsible for cutting and cleaning fingernails unless the resident had a diagnosis of diabetes. The SDC stated all staff were trained to cut and clean dirty nails. The SDC reported nail care was to be performed whenever a resident had long or dirty nails regardless if it was the resident's shower day or not. The SDC was not aware if anyone audited nail care in the facility. An interview was conducted on 5/30/2024 at 8:30 am with the Unit Manager. The Unit Manager stated staff had been educated in March of 2024 regarding nail care, including cutting and cleaning. The Unit Manager stated NAs and Nurses could cut and clean nails unless the resident had a diagnosis of diabetes. She reported for residents with a diagnosis of diabetes a podiatry consultation would need to be placed. The Unit Manager was unsure if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:43 am with the Director of Nursing (DON). The DON reported nail care should be performed daily and as needed. The DON stated NAs usually cut and cleaned resident's fingernails. The DON reported she was not aware Resident #4 had long, dirty fingernails and reported they should have been cleaned and cut. The DON was unaware if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:51 am with the Administrator. The Administrator stated nail care should be performed daily by the hall NAs or as needed. The Administrator stated a lot of staff were not comfortable with cutting fingernails. The Administrator stated if an NA was not comfortable with cutting nails, they should let a Nurse know so someone would perform the task. The Administrator was not aware Resident #4 had long, dirty fingernails. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses which included vascular dementia. Resident #5 did not have a diagnosis of diabetes. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired and required substantial/maximum assistance for personal hygiene. A review of the shower schedule for Resident #4 revealed he was scheduled to receive showers on Tuesdays and Fridays. There was no documentation of nail care in the Electronic Medical Record or shower sheets. A review of the shower sheet dated 5/24/2024 revealed Resident #5 received a shower by NA #1. The space for intervention documentation was blank. There was no documentation of Resident #5's fingernails being cut or cleaned. A review of a care plan dated 5/27/2024 revealed Resident #5 required staff support to achieve highest practical level of function for activities of daily living with interventions which included Resident #5 required substantial/maximum assistance for personal hygiene. An observation was conducted on 5/29/2024 at 10:13 am. Resident #5 was observed to have quarter-inch long fingernails with brown substance underneath all 5 fingernails on the left hand and 4 fingernails on the right hand. Resident #5's right thumb fingernail was approximately a half-inch long, jagged, and had a brown substance underneath. An interview was conducted on 5/29/2024 at 2:25 pm with Nurse Aide (NA) #1. NA #1 reported she was on the shower team and was assigned to give showers to residents in the building on their assigned shower days. NA #1 reported she had given Resident #5 a shower on 5/28/2024 and she had not noticed that her fingernails were long and dirty. She reported she had not trimmed or cleaned any residents fingernails because she was not comfortable cutting nails. NA #1 reported she would clean resident's fingernails during a shower if she had noticed they were dirty. NA #1 stated if she noticed a resident's fingernails were long while she was giving them a shower, she would write it down on the shower sheet and tell the hall nurse. An interview was conducted on 5/29/2024 at 3:11 pm with the Staff Development Coordinator (SDC). The SDC reported nursing staff, both NAs and Nurses, were trained about nail care during orientation. The SDC stated both NAs and Nurses were responsible for cutting and cleaning fingernails unless the resident had a diagnosis of diabetes. The SDC stated all staff were trained to cut and clean dirty nails. The SDC reported nail care was to be performed whenever a resident had long or dirty nails regardless if it was the resident's shower day or not. The SDC was not aware if anyone audited nail care in the facility. An interview was conducted on 5/30/2024 at 8:30 am with the Unit Manager. The Unit Manager stated staff had been educated in March of 2024 regarding nail care, including cutting and cleaning. The Unit Manager stated NAs and Nurses could cut and clean nails unless the resident had a diagnosis of diabetes. She reported for residents with a diagnosis of diabetes a podiatry consultation would need to be placed. The Unit Manager was unsure if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:43 am with the Director of Nursing (DON). The DON reported nail care should be performed daily and as needed. The DON stated NAs usually cut and cleaned resident's fingernails. The DON reported she was not aware Resident #5 had long, dirty fingernails and reported they should have been cleaned and cut. The DON was unaware if anyone monitored nail care for the residents. An interview was conducted on 5/30/2024 at 11:51 am with the Administrator. The Administrator stated nail care should be performed daily by the hall NAs or as needed. The Administrator stated a lot of staff were not comfortable with cutting fingernails. The Administrator stated if an NA was not comfortable with cutting nails, they should let a Nurse know so someone would perform the task. The Administrator was not aware Resident #5 had long, dirty fingernails.

Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 4 of 5 residents reviewed for activities (Resident #17, 31, 35, and 110). The residents expressed not being able to leave the facility for over a year made them feel more dependent, less social, sad, and they missed getting out with the group to shop and socialize. The findings included: A review of the February 2024 activity calendar revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility. Review of resident council minutes from February 2023 through February 2024 revealed grievances for scheduled group activities outside of facility were discussed each month during meetings and the response given from the previous Administrator was one of the facility vans was broken and unable to provide transportation for residents and the other facility van was only available for short distances to resident medical appointments. Observation on 02/26/24 at 9:30 AM revealed the facility was located within a business and residential complex that contained sidewalks, pedestrian crosswalks and was within walking distance to numerous local and commercial shops, grocery stores, local and commercial coffee shops, fast food, and sit-down restaurants. a. Resident #17 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #17 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #17 was cognitively intact. An interview as conducted with Resident #17 on 2/28/24 at 2:00 PM during resident council meeting revealed there had not been a scheduled group activity outside of the facility in over a year and the resident council had requested one each month, made grievances, and met with the previous administrator about it and each time was told there was nothing they could do because the van was broken, and they had no other way to transport residents. She stated in her opinion group activities outside of the facility were important to the residents that were able to go and participate because it allowed them some lasting independence, socialization with the group and outside world, and helped with their mental and physical health, it made them feel normal and that they weren't just stuck in a facility. Resident #17 stated not being able to leave the facility in a year and participate in group activities outside the facility had sometimes made her feel as though she had lost some of her own independence and was having to rely on someone else to do her personal shopping instead of on her own. She revealed personally being able to do her own shopping and socializing with other people outside of the facility was very important to her. Resident #17 asked surveyor at the end of resident council meeting if she promised to share their concerns with administration about not being able to schedule activities outside of the facility over the past year and how important this matter was to all of them. b. Resident #31 was admitted to the facility on [DATE]. An Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #31 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #31 was cognitively intact. An interview was conducted with Resident #31 on 2/28/24 at 2:00 PM during resident council meeting revealed he had been told for the past year that they were not allowed to schedule any group activities outside of the facility because they did not have resident transportation due to the van being broken. He stated he asked about alternate transportation that the residents could pay for if they wanted to and was also told no due to insurance reasons. He also stated that for the past year they have not been able to leave the facility for any outings other than to a doctor's appointment and after a while they get tired of looking at the inside of the facility. Resident #31 began shaking his head and looking down towards the floor and revealed that going out to eat at a restaurant and talking with the group or going into a store and being able to shop for your own personal belongings made you feel independent and normal, and he felt that not being able to do those things over the past year had made him less independent and more reliant on staff and not as social as he used to be and he would just like the opportunity to have those things again. c. Resident #35 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #35 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #35 was cognitively intact. An interview was conducted with Resident #35 on 2/28/24 at 2:00 PM during resident council meeting revealed she knew for a fact that resident council had made numerous grievances to the Administrator about not being able to schedule group activities outside of the facility and each time was told that was not possible because the van was broken, and they had no way to transport residents. She revealed they were also told they would have to continue with activities inside of the building or on the grounds of the facility and there was never any discussion of finding a different way to help with transportation. Resident #35 stated being able to go outside of the facility for group activities was important to her because she enjoyed interaction with her friends, and it helped with her mental health and allowed her some independence. She revealed not being able to have group activities outside of the facility had made her sad at times and miss what the world outside the facility was like. d. Resident #110 was admitted to the facility on [DATE]. An Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #110 felt that it was very important to have activities that included going outside of the facility and doing things in a group setting. The assessment further indicated Resident #110 was cognitively intact. An interview was conducted with Resident #110 on 2/28/24 at 2:00 PM during resident council meeting revealed she along with the other residents in the meeting had been asking to schedule group activities outside of the facility for the past year at least and were always told by the previous Administrator the van was broken and they had no other way to transport residents. Resident #110 revealed being at the facility day in and day out sometimes made her feel sad and like she was always reliant on staff for her needs, but being able to get out of the facility and go out into the community for group activities allowed her to be more independent, socialize with her friends and the community in a different setting and gave her a break from being inside the building all the time and made her feel good. An interview was conducted with the Activity Director (AD) on 02/28/24 at 2:30 PM revealed she had been working as the AD at the facility for the past 2 years and part of her responsibilities was scheduling and implementing resident activities inside and outside of the facility for each month. She stated prior to this past year, she would schedule monthly outings for the residents to attend outside of the facility such as going to eat at a restaurant, shopping, or the movies, but for the past year she had not been able to schedule any resident group activities outside of the facility due to transportation issues. She revealed one of the facility vans had been broken for over a year and she was told by the previous administrator the other facility van could only be used for medical appointments and residents would just have to participate in activities inside of the facility or on facility grounds. The AD stated she had brought the issue to Administration monthly of the residents requesting to schedule activities outside of the facility and each time was told no due to the transportation and alternate transportation for the residents was never discussed. She revealed she had been doing personal shopping for residents so they could continue to receive their preferences but understood that was not the same as the residents being able to leave the facility and shop for themselves or eat a meal together at a restaurant or watch a movie outside of the facility. She stated she felt like activities outside of the facility for those residents who could participate were important for their overall mental and physical well- being and allowed them some independence. During an interview conducted with the Administrator on 02/29/24 at 5:15 PM she revealed this was her first week of work at the facility and she was unaware of the facility vans needing repair and residents not having been to participate in activities outside of the facility over the past year. She stated she would investigate the issue and see what alternative transportation methods were available that could be used to assist with the residents being able to participate in activities outside of the facility until the situation with the vans could be resolved.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents (Resident #41, #102, #84) reviewed for Preadmission Screening and Resident Review (PASRR), and 1 of 3 residents (Resident #110) reviewed for restraints. Findings Include: 1. Resident #41 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, anxiety, and psychosis. Review of PASRR Level II determination letter from July 2021 revealed Resident #41 had met the requirements for a level II PASRR due to having mental illness diagnosis with specialized services required. The annual MDS assessment dated [DATE] indicated Resident #41 was cognitively intact and was not coded as having a level II PASRR. An interview with the MDS Coordinator on 02/29/24 at 3:28 PM revealed she had begun working at the facility in October 2023 and was not aware that Resident #41had a level II PASRR or that it had been coded on his MDS. She stated Resident #41's MDS did not reflect him having a level II PASRR assigned and that was an oversight based on human error and a correction would need to be made. An interview with the Administrator on 02/29/24 at 4:08 PM revealed she had just begun at the facility on Monday 02/26/24 and was not aware of Resident #41 PASRR level not being reflected on his MDS. She stated their process would be for the MDS to reflect current PASRR level and to be accurate. She felt it was just an oversight based on human error on the part of the MDS Coordinator. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:45 PM revealed she was not aware of Resident #41 PASRR level was not reflected on his MDS and believed it was probably due to an oversight on the part of the MDS Coordinator. She stated MDS should reflect current PASRR level for all residents and a correction would need to be made. 2. Resident #102 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of PASRR level II determination letter from May 2021 revealed Resident #102 met the requirements for a level II PASRR due to diagnosis of dementia. The annual MDS assessment dated [DATE] indicated Resident #102 was moderately cognitively impaired and was not coded as having a level II PASRR. An interview with the MDS Coordinator on 02/29/24 at 3:28 PM revealed she had begun working at the facility in October 2023 and was not aware that Resident #102 had a level II PASRR or that it had not been coded on her MDS. She stated she believed Resident #102's MDS not reflecting her having a level II PASRR assigned was an oversight based on human error by the previous MDS Coordinator and a correction would need to be made. An interview with the Administrator on 02/29/24 at 4:08 PM revealed had just begun at the facility on Monday 02/26/24 and was not aware of Resident #102 PASRR level not being reflected on her MDS. She stated their process would be for the MDS to reflect current PASRR level and to be accurate and they felt it was just an oversight based on human error on the part of the MDS Coordinator. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:45 PM revealed she was not aware of Resident #102 PASRR level was not reflected on her MDS and believed it was probably due to an oversight on the part of the MDS Coordinator. She stated MDS should reflect current PASRR level for all residents and a correction would need to be made. 45358 3. Resident #84 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, and anxiety. The most recent annual Minimum Data Set assessment dated [DATE] indicated Resident #84 was not currently considered by the state level II PASRR process to have serious mental illness. Review of Resident #84's electronic medical record revealed a Halted level II PASRR identification number noted in the demographic information. During an interview on 2/29/24 at 3:34 PM MDS Coordinator #1 indicated it was the responsibility of the MDS coordinator to enter PASRR information onto the MDS assessment at admission and annually. She further indicated she initially understood Resident #84's PASRR to be halted and therefore Resident #84 was not considered to have a level II PASRR determination. However, she realized the PASRR section of the MDS should have been marked as having a level II PASRR, since the Resident was admitted with a PASRR number and mental health diagnoses. The Director of Nursing (DON) was interviewed on 02/29/24 at 4:58 PM revealed she was not aware of Resident #84's PASRR level was not reflected on her MDS. She believed it was probably due to an oversight on the part of the MDS Coordinator staff changes. She stated her expectation was that MDS should reflect current PASRR levels for all residents. An interview with the Administrator on 02/29/24 at 5:10 PM revealed had just begun at the facility on Monday 02/26/24 and she expected the MDS to be reviewed and coded correctly. 48684 4. Resident #110 was admitted to the facility on [DATE]. The quarterly Minimum Data Sheet (MDS) assessment dated [DATE] indicated Resident #110 was coded for the use of a limb restraint less than daily. The previous annual MDS dated [DATE] indicated no use of restraints. Review of Resident #110's current care plans dated 12/1/23 revealed Resident #110 had no restraint care plan. An interview was conducted with MDS Coordinator #1 and MDS Coordinator #2 on 2/29/24 at 3:56 PM. MDS Coordinator #1 explained Resident #110's MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed at the facility. The MDS Coordinator #2 confirmed Resident #110 did not use a limb restraint now and had not used one in the past. The MDS Coordinator #2 stated it was likely an entry issue and they would look into the entry. During an interview on 2/29/24 at 5:06 PM, the Administrator stated it was her expectation for MDS assessments to be completed accurately. The Administrator further stated that MDS entries should be checked before final submission.

Based on observations, record review, resident and staff interviews, the facility failed to provide sufficient nursing staff to ensure resident were administered medications per the physician orders for 8 of 16 residents reviewed for significant medication errors (Residents #7, #28, #47, #51, #73, #79, #88, and #110) and provide assistance with showers and hair washing for 1 of 10 residents reviewed for assistance with activities of daily living (Resident #94). The findings included: 1a. Resident #7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 was coded as received insulin 7 times during the assessment period. The active physician's orders for December 2023 for Resident #7 included an order dated 08/07/23 for Insulin Detemir solution 100 units per milliliter (ml), inject 13 units at bedtime for diabetes and an order dated 11/06/2023 for Novolog flex pen solution pen- injector 100 units/ml sliding scale insulin four times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Detemir Solution 13 units, scheduled for 8:00 PM, was not documented as given on 12/10/2023 and the Novolog flex pen sliding scale insulin scheduled for 8:30 PM was not documented as given on 12/10/2023. b. Resident #28 was admitted to the facility on [DATE] with a diagnosis of hypertension, anxiety, diabetes mellitus and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was noted to have received insulin 5 times during the assessment period. The MDS revealed Resident #28 received an antipsychotic medication during the assessment period. The active physician's orders for December 2023 for Resident #28 included an order dated 11/10/23 for Lantus Solostar pen-injector 100 units/ml, inject 10 units at bedtime for diabetes, an order dated 11/09/2023 for Carvedilol oral tablet 6.25 mg 1 tablet by mouth two times a day for heart failure and an order dated 11/09/23 for Seroquel 25 mg give 1 tablet by mouth two times a day for depression. A Medication Administration Record (MAR) dated December 2023 revealed the Lantus Solostar pen-injector 100 units/ml 10 units, Carvedilol oral tablet 6.25 mg and Seroquel 25 mg scheduled for 8:00 PM, were not documented as given on 12/10/2023. c. Resident #47 was admitted to the facility on [DATE] with a diagnosis of depression and schizophrenia and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Resident #47 was coded as receiving antipsychotic medication, antianxiety medication, antidepressant medication and opioids. The active physician's orders for December 2023 for Resident #47 included an order dated 02/19/22 for Seroquel 200 mg give 1 tablet by mouth at bedtime for mood, an order dated 03/10/22 for Lorazepam 1 mg by mouth two times a day for agitation, an order dated 08/25/22 for Trazodone 125 mg by mouth at bedtime for insomnia and an order dated 04/07/23 for Percocet oral tablet 10-325mg give 1 tablet by mouth three times a day for severe pain. A Medication Administration Record (MAR) dated December 2023 revealed the Seroquel 200 mg, Trazodone 125 mg, Lorazepam 1 mg and Percocet oral tablet 10-325mg scheduled for 8:00 PM were not documented as given on 12/10/2023. d. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 was coded as receiving insulin on 7 days during the assessment period. The MDS revealed Resident #51 had received an anticoagulant during the assessment period. The active physician's orders for December 2023 for Resident #51 included an order dated 11/15/22 Insulin Glargine solution 100 units/ml inject 12 units at bedtime for diabetes, an order dated 11/15/22 for Eliquis tablet 5 mg by mouth two times a day for anticoagulant therapy and an order dated 7/16/23 for Metformin 500 mg 1 tablet by mouth two times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 units/ml 12 units, Eliquis tablet 5 mg and Metformin 500 mg scheduled for 9:00 PM were not documented as given on 12/10/2023. e. Resident #73 was admitted to the facility on [DATE] with a diagnosis of depression. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was coded as received an antidepressant during the assessment period. The active physician's orders for December 2023 for Resident #73 included an order dated 06/20/23 for Trazodone 50 mg 1 tablet by mouth at bedtime for insomnia. A Medication Administration Record (MAR) dated December 2023 revealed the Trazodone 50 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. f. Resident #79 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired. Resident #79 was coded as received insulin on 7 days during the assessment period. The active physician's orders for December 2023 for Resident #79 included an order dated 11/14/23 for Insulin Glargine solution 100 units/ml inject 2 units at bedtime for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 unit/ml 2 units scheduled for 9:00 PM was not documented as given on 12/10/2023. g. Resident #88 was admitted to the facility on [DATE] with a diagnosis of hypertension, heart failure and coronary artery disease (CAD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. The active physician's orders for December 2023 for Resident #88 included an order dated 03/31/22 for Metoprolol Tartrate 25 mg give 0.5 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Metoprolol Tartrate 12.5 mg scheduled for 9:00 PM was not documented as given on 12/10/2023. h. Resident #110 was admitted to the facility on [DATE] with a diagnosis of hypertension and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. The active physician's orders for December 2023 for Resident #110 included an order dated 1/10/23 for Carvedilol 3.125mg 1 tablet by mouth two times a day for hypertension and an order dated 12/04/23 for Amoxicillin 500 mg give 1 tablet by mouth two times a day for a bacterial infection for 10 days. A Medication Administration Record (MAR) dated December 2023 revealed the Amoxicillin 500 mg and Carvedilol 3.125 mg scheduled for 8:00 PM were not documented as given on 12/10/2023. An interview was conducted on 02/28/24 at 4:00 PM with Nurse #1. She stated on 12/10/23 she was working the 7:00 AM to 7:00 PM shift assigned to Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88, and Resident #110. The interview revealed Nurse #2 had contacted her after 12:00 PM stating she would not be coming into work for the 7:00 PM to 11:00 PM shift to take over the resident assignment. She stated she told Nurse #2 she would need to contact management and let them know. The interview revealed she then told Unit Manager #1 that she did not think Nurse #2 would be coming into the facility for her assigned shift. She stated report on the residents was given to Nurse #3, Nurse #4 and Nurse #5 who were told by the Unit Manager #1 to split the medication cart. The interview revealed she had offered to stay over to cover the shift from 7:00 PM to 11:00 PM but was told it was necessary by the scheduler. She stated she left the facility at 7:00 PM. An interview conducted on 02/28/24 at 3:36 PM with Unit Manager #1 revealed on 12/10/23 she was notified later in the day by Nurse #1 that Nurse #2 was not going to come in for the scheduled 7:00 PM to 11:00 PM shift. She stated she called the scheduler who no longer works in the facility and Director of Nursing (DON) to let them know they were going to be a nurse short. The interview revealed the scheduler could not get in touch with Nurse #2 so Unit Manger #1 then notified Nurse #3, Nurse #4 and Nurse #5 they would need to split the medication cart for the 7:00 PM to 11:00 PM shift. She stated Nurse #4 told her she needed to get some food and would look at the medication cart when she returned, and Nurse #5 stated the medication cart had too many residents to split. She stated she then left the facility at 7:00 PM and did not know until 12/12/23 that the residents had never received their scheduled medication on the evening of 12/10/23. An interview was attempted with Nurse #2 on 02/28/24 and on 02/29/24 with no return phone call received. An interview was attempted with Nurse #3, Nurse #4 and Nurse #5 on 02/29/24 with no return phone call received. An interview conducted on 02/28/24 at 4:30 PM with the Director of Nursing (DON) revealed on 12/10/23 around 6:30 PM she was told by Unit Manager #1 that Nurse #2 had called out for the 7:00 PM to 11:00 PM shift. She stated Unit Manager #1 told her that Nurse #3, Nurse #4 and Nurse #5 were instructed to split the medication cart and had taken report on the residents. She stated she heard the next morning that some residents had not received their medication. The interview revealed that Nurse #5 had given half of the assigned residents their medication, but the other 8 residents Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 did not receive any scheduled medication. She stated Nurse #5 told her she had completed her assigned half and thought someone else was going to administer the rest of the residents' medication. The DON stated it was a communication error between the nurses. The interview revealed the residents' vital signs were obtained on 12/11/23 along with blood glucose levels for the diabetic residents. She stated no adverse outcomes had occurred from the incident and no residents needed medical treatment due to not receiving their medication. 2. Resident #94 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II, vitamin deficiency, dementia, and anorexia. Review of Resident #94's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired and required total assistance with showering and bathing. The assessment also revealed Resident #94 had no rejection of care behaviors. Review of Resident #94's care plan revealed a focus area for activities of daily living/personal care deficit related to dementia. The interventions included personal hygiene with substantial/maximal assistance and showering/bathing dependent on staff. An observation and interview with Resident #94 on 02/26/24 at 11:42 AM revealed the resident sitting in her wheelchair in her room, dressed for the day. The resident's hair appeared greasy and disheveled, and she stated she was not getting her showers as scheduled two times per week. Resident #94 further stated she preferred showers because she liked to get her hair washed when she was bathed. Review of the shower schedule for the hall on which the resident resided revealed Resident #94 was scheduled for showers on Tuesday and Friday on 1st shift (7:00 AM to 3:00 PM). Review of the documentation of showers in the electronic medical record for Resident #94 revealed for the month of February she had only received one shower on 02/27/24. On the other days she was scheduled for showers the following was documented: Tuesday 02/06/24 no indication or documentation Tuesday, 02/13/24 no indication or documentation Tuesday, 02/20/24 no shower or bed bath given Friday, 02/23/24 partial bed bath (not a complete bed bath) A telephone interview on 02/29/24 at 10:46 AM with Nurse Aide (NA) #8 who was assigned to care for Resident #94 on 02/06/24 and 02/13/24 stated if she were assigned to a resident and did not have time to give them a shower, she would wash them up in bed and document it as a partial bath but said it was not a complete bed bath. NA #8 stated she could not recall why she had not given Resident #94 a shower on 02/06/24 or 02/13/24 but said it was most likely due to staffing issues. An interview on 02/28/24 at 10:34 AM with NA #12 who was assigned to care for Resident #94 on 02/09/24 revealed if she was assigned to the resident and had given her a complete bed bath instead of a shower it was due to not having time to shower the resident. She stated they were short of help sometimes and it was less time-consuming to give residents a bed bath than shower. An interview on 02/29/24 at 1:45 PM with NA #7 who was assigned to care for Resident #94 on 02/23/24 revealed she could not recall why she had not given the resident a shower as scheduled. She stated there were days they worked short of help and that could have been one of those days when she did not have time to give the resident a shower and just bathed her in bed and documented it as a partial bath. NA #7 further stated when she showered residents, she tried to cut their nails and shave them as needed but did not always have time to do so due to staffing issues. An interview on 02/29/24 at 3:10 PM with Unit Manager #1 revealed she was not aware Resident #94 was not receiving her showers as scheduled and said no one had reported it to her. She indicated if the NAs were having difficulty completing their showers, they should have reported that to her so she could have provided them with additional staff to assist with showers. An interview on 2/29/23 at 12:30 PM with the Nursing Scheduler who has been in her position for the last two months. The Scheduler revealed that all call ins by nursing staff go to the Director of Nursing (DON) who then tells her what needs to be filled. The Nursing Scheduler stated she filled out the schedules in advance, so staff can pick up extra hours and staff were good about picking open shifts. She explained the problem was the call ins and trying to find someone to fill the opening. The scheduler further stated she was not on call and worked Monday through Friday 8:00 AM to 5:00 PM so after hours and on the weekends, it falls on nurse management to fill open positions. The scheduler stated she was not aware of a situation where there was not a nurse for a cart when other nurses did not step up and take care of the cart. The Nursing Scheduler indicated the following were the staffing levels she was expected to maintain. The Scheduler went on to say that it was hard to keep those levels of staffing in the building, but she tried hard to get positions filled so staff were not short, but that it happens at times and there is nothing that can be done about it. 1. 7:00 AM-3:00 PM shift 10-12 Nurse Aides (NAs) and 3 NAs on memory care. 2. 7:00 AM-3:00 PM shift 6 Nurses and 2 nurses on memory care. 3. 3:00 PM-11:00 PM shift 10-12 NAs and 2-3 NAs on memory care 4. 3:00 PM-11:00 PM shift 5 Nurses and 2 nurses on memory care 5. Memory care works 7:00 AM - 7:00 PM so this covers the third shift. 6. 11:00 PM -7:00 AM shift 9-10 NAs and 2-3 on memory care Interview on 02/29/24 at 4:46 PM with the Director of Nursing (DON) revealed she would expect nursing staff to communicate in a timely manner when they are not going to report to work so that the facility has time to try and fill the open position. They have been posting open positions on their website and have recently started using a staffing agency to assist with staffing levels. An interview on 02/29/24 at 4:53 PM with the Director of Nursing (DON) revealed they had struggled with getting the NAs to give and document showers and said it was a process they were currently working on with the NAs. She stated she expected residents to have their showers as scheduled and said if they did not receive their showers, she expected them to receive a complete bed bath not a partial bed bath and for it to be documented. The DON further stated if the resident refused their shower, she expected the nurse to document the refusal in their progress notes.

Based on record reviews, and family member, staff, and Medical Director interviews, the facility failed to prevent significant medication errors when Nurse #9 administered medications to Resident #83 prescribed for Resident #30 which included Lasix (fluid pill), Ativan (a medication used to treat anxiety, Seroquel (an antipsychotic), Celexa (an antidepressant), and Diltiazem (used to treat cardiac disorders). The facility also failed to prevent significant medication errors when medications were not administered as ordered by the physician. This deficient practice affected 9 of 16 residents reviewed for significant medication errors (Resident # 83, #7, #28, #47, #51, #73, #79, #88, and #110.) . The findings: 1. Resident #83 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA), high blood pressure, dementia, and diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 had moderate cognitive impairment. The MDS revealed Resident #83 was not receiving diuretics, anti-anxiety, or anti-psychotics. Review of the December 2023 physician orders for Resident #83 revealed the following medications: -Sertraline (antidepressant) 150 milligrams (mg) 1 tablet by mouth one time a day for depression. -Vimpat Oral Solution (anti-seizure) 250 mg by mouth two times a day for seizures. -Divalproex Sodium (anti-seizure) delayed release 250 mg 3 tablets by mouth twice a day for neurological disorder. -Xarelto (anticoagulant) 20 mg 1 tablet by mouth one time a day for deep vein thrombosis prevention. -Amlodipine Besylate 10 mg 1 tablet by mouth daily for high blood pressure. Resident #30 was admitted to the facility on [DATE]. A review of the physician orders dated December 2023 revealed Resident #30 had orders for: -Diltiazem (cardiac medication) 120 mg extended release 1 capsule by mouth one time a day for atrial fibrillation. -Citalopram Hydrobromide 10 mg one tablet by mouth daily for depression. -Lasix (diuretic/fluid pill) 20 mg by mouth one time day for fluid. -Seroquel (antipsychotic) 25 mg by mouth three times a day for schizoaffective disorder -Ativan (anti-anxiety) 0.5 mg by mouth twice a day for anxiety. An incident report dated 12/27/2023 written by Nurse #8 revealed Resident #83 had received Resident #30's medication which included: Lasix 20 mg, Ativan 0.5 mg, Seroquel 25 mg, Celexa 10 mg, and Diltiazem 120 mg at 10:00 AM in addition to her own morning medications. The incident was reported to the on-call provider at 1:20 PM after Nurse #8 realized Resident #83 had been given Resident #30's medications. Resident #83 was noted to be in no acute distress and at her baseline. Resident #83's responsible party (RP) was notified of the medication errors on 12/27/2023 at 1:35 PM. Resident #83's documented vital signs dated 12/27/2023 at 1:35 PM revealed the following: blood pressure123/74 (normal range systolic (top number) less than 120 and diastolic (bottom number) less than 80), temperature 97.2 (normal range 97 to 99), pulse 55 beats per minute (normal range 60-100), respirations 14 breaths per minute (normal range 12-20), oxygen saturation 94% (normal range 92% or greater) on room air. Review of the Nurse Practitioner (NP) acute visit note dated 12/27/2023 revealed Resident #83 was being seen due to a medication error. Resident #83 received Lasix, Ativan, Seroquel, Celexa, and Diltiazem in error. The NP visit note further revealed Resident #83 appeared at her baseline with stable vital signs and was awake and alert and offered no complaints. The NP's note also indicated Resident #83 was in no acute distress and no adverse reactions were noted. The provider ordered vital signs to be checked every shift for 24 hours and to closely monitor Resident #83 for low blood pressure and sedation. An interview was conducted on 02/26/2024 at 13:20 PM with Resident #83's RP. The RP stated the facility reported to her that a medication error had occurred. She further stated that a new nurse who was still being oriented gave Resident #83's the wrong medications. She also stated that the nurse in training should not have been allowed to administer medications without another staff member being present. She also indicated the facility contacted the pharmacy and Resident #83's doctor. Multiple unsuccessful attempts were made to contact Nurse #8 and Nurse #9 (the nurse in training). An interview was conducted on 03/05/2024 at 9:03 AM. The pharmacist stated there was no medication error report on file for Resident #83 for 12/27/2023. She further stated the concern with the Amlodipine and the Diltiazem would be for hypotension. She also stated hypotension would develop on the day of administration due to the short half-life of the drugs. An interview was conducted on 03/05/2024 at 09:36 with the Nurse Practitioner (NP) who evaluated Resident #83. The NP stated she was notified of the medication errors the morning of 12/27/2023 and she does not remember exactly what time she evaluated Resident #83, but she stated it was before 12:00 PM. She also indicated she was most concerned with the cardiac medications: Amlodipine and the Diltiazem and the potential for hypotension. She further added Resident #83 was stable during her evaluation and that she asked the nursing staff to monitor Resident #83 and notify her if the resident became hypotensive or had any other clinical concerns. An interview was conducted on 02/28/2024 at 11:40 AM with the Director of Nursing (DON). The DON revealed that during a medication pass, Resident #83 was given the incorrect medications. Nurse #9 (nurse in training) was being oriented by Nurse #8. Nurse #8 was standing at the medication cart and Nurse #9 went into the room to administer the medications. Nurse #9 got confused about the room numbers and got bed A and bed B mixed up. Nurse #8 went into the room when she saw Nurse #9 at Resident #83's bedside. Nurse #9 had already given Resident #30's medications to Resident #83. The DON also stated Nurse #8 and Nurse #9 were no longer employed by the facility. The DON further revealed Nurse #8 had immediately notified the physician, assessed the resident, and notified the RP following the incident. The DON stated the staff did everything they should have after the incident occurred. She further stated Nurse #8 should have stayed with the nurse in training throughout the entire medication pass especially when actually administering the medications at the bedside. She stated nursing staff should have provided the correct medication to the correct resident. 40476 2a. Resident #7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was severely cognitively impaired. Resident #7 was coded as received insulin 7 times during the assessment period. The active physician's orders for December 2023 for Resident #7 included an order dated 08/07/23 for Insulin Detemir solution 100 units per milliliter (ml), inject 13 units at bedtime for diabetes and an order dated 11/06/2023 for Novolog flex pen solution pen- injector 100 units/ml sliding scale insulin four times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Detemir Solution 13 units, scheduled for 8:00 PM, was not documented as given on 12/10/2023 and the Novolog flex pen sliding scale insulin scheduled for 8:30 PM was not documented as given on 12/10/2023. b. Resident #28 was admitted to the facility on [DATE] with a diagnosis of hypertension, anxiety, diabetes mellitus and heart failure. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact. Resident #28 was noted to have received insulin 5 times during the assessment period. The active physician's orders for December 2023 for Resident #28 included an order dated 11/10/23 for Lantus Solostar pen-injector 100 units/ml, inject 10 units at bedtime for diabetes, an order dated 11/09/2023 for Carvedilol oral tablet 6.25 mg 1 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Lantus Solostar pen-injector 100 units/ml 10 units, Carvedilol oral tablet 6.25 mg and Seroquel 25 mg scheduled for 8:00 PM, were not documented as given on 12/10/2023. c. Resident #47 was admitted to the facility on [DATE] with a diagnosis of depression, schizophrenia, anxiety and bilateral chronic lymphedema with lower extremity pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. Resident #47 was coded as receiving antipsychotic medication, antianxiety medication, antidepressant medication and opioids. The active physician's orders for December 2023 for Resident #47 included an order dated 02/19/22 for Seroquel 200 mg give 1 tablet by mouth at bedtime for mood, an order dated 03/10/22 for Lorazepam 1 mg by mouth two times a day for agitation, an order dated 08/25/22 for Trazodone 125 mg by mouth at bedtime for insomnia and an order dated 04/07/23 for Percocet oral tablet 10-325mg give 1 tablet by mouth three times a day for severe pain. A Medication Administration Record (MAR) dated December 2023 revealed the Seroquel 200 mg, Trazodone 125 mg, Lorazepam 1 mg and Percocet oral tablet 10-325mg scheduled for 8:00 PM were not documented as given on 12/10/2023. d. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Resident #51 was coded as receiving insulin on 7 days during the assessment period. The MDS revealed Resident #51 had received an anticoagulant during the assessment period. The active physician's orders for December 2023 for Resident #51 included an order dated 11/15/22 Insulin Glargine solution 100 units/ml inject 12 units at bedtime for diabetes, an order dated 11/15/22 for Eliquis tablet 5 mg by mouth two times a day for anticoagulant therapy and an order dated 7/16/23 for Metformin 500 mg 1 tablet by mouth two times a day for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 units/ml 12 units, Eliquis tablet 5 mg and Metformin 500 mg scheduled for 9:00 PM were not documented as given on 12/10/2023. e. Resident #73 was admitted to the facility on [DATE] with a diagnosis of depression. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 was cognitively intact. Resident #73 was coded as received an antidepressant during the assessment period. The active physician's orders for December 2023 for Resident #73 included an order dated 06/20/23 for Trazodone 50 mg 1 tablet by mouth at bedtime for insomnia. A Medication Administration Record (MAR) dated December 2023 revealed the Trazodone 50 mg scheduled for 8:00 PM was not documented as given on 12/10/2023. f. Resident #79 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was moderately cognitively impaired. Resident #79 was coded as received insulin on 7 days during the assessment period. The active physician's orders for December 2023 for Resident #79 included an order dated 11/14/23 for Insulin Glargine solution 100 units/ml inject 2 units at bedtime for diabetes. A Medication Administration Record (MAR) dated December 2023 revealed the Insulin Glargine solution 100 unit/ml 2 units scheduled for 9:00 PM was not documented as given on 12/10/2023. g. Resident #88 was admitted to the facility on [DATE] with a diagnosis of hypertension, heart failure and coronary artery disease (CAD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #88 was severely cognitively impaired. The active physician's orders for December 2023 for Resident #88 included an order dated 03/31/22 for Metoprolol Tartrate 25 mg give 0.5 tablet by mouth two times a day for heart failure. A Medication Administration Record (MAR) dated December 2023 revealed the Metoprolol Tartrate 12.5 mg scheduled for 9:00 PM was not documented as given on 12/10/2023. h. Resident #110 was admitted to the facility on [DATE] with a diagnosis of hypertension and atrial fibrillation. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #110 was cognitively intact. The active physician's orders for December 2023 for Resident #110 included an order dated 1/10/23 for Carvedilol 3.125mg 1 tablet by mouth two times a day for hypertension and an order dated 12/04/23. A Medication Administration Record (MAR) dated December 2023 revealed the Amoxicillin 500 mg and Carvedilol 3.125 mg scheduled for 8:00 PM were not documented as given on 12/10/2023. A facility investigation summary dated 12/12/23 revealed the facility interdisciplinary team was reviewing the Medication Administration Audit report for the previous 48 hours and noted the medication errors and Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 had not been administered their medication during the 7:00 PM to 11:00 PM shift. An investigation was then initiated, and the Medical Director was notified. The investigation was completed by the Regional Nurse Consultant who identified the cause of the incident was due to a nurse not reporting for the 7:00 PM to 11:00 PM shift. An interview was conducted on 02/28/24 at 4:00 PM with Nurse #1. She stated on 12/10/23 she was working the 7:00 AM to 7:00 PM shift assigned to Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110. The interview revealed Nurse #2 had contacted her after 12:00 PM stating she would not be coming into work for the 7:00 PM to 11:00 PM shift to take over the resident assignment. She stated she told Nurse #2 she would need to contact management and let them know. The interview revealed she then told Unit Manager #1 that she did not think Nurse #2 would be coming into the facility for her assigned shift. She stated report on the residents was given to Nurse #3, Nurse #4 and Nurse #5 who were told by the Unit Manager #1 to split the medication cart. The interview revealed she had offered to stay over to cover the shift from 7:00 PM to 11:00 PM but was told it was necessary by the scheduler. She stated she left the facility at 7:00 PM. An interview conducted on 02/28/24 at 3:36 PM with Unit Manager #1 revealed on 12/10/23 she was notified later in the day by Nurse #1 that Nurse #2 was not going to come in for the scheduled 7:00 PM to 11:00 PM shift. She stated she called the scheduler who no longer works in the facility and Director of Nursing (DON) to let them know they were going to be a nurse short. The interview revealed the scheduler could not get in touch with Nurse #2 so Unit Manger #1 then notified Nurse #3, Nurse #4 and Nurse #5 they would need to split the medication cart for the 7:00 PM to 11:00 PM shift. She stated Nurse #4 told her she needed to get some food and would look at the medication cart when she returned, and Nurse #5 stated the medication cart had too many residents to split. She stated she then left the facility at 7:00 PM and did not know until 12/12/23 that the residents had never received their scheduled medication on the evening of 12/10/23. An interview was attempted with Nurse #2 on 02/28/24 and on 02/29/24 with no return phone call received. An interview was attempted with Nurse #3, Nurse #4 and Nurse #5 on 02/29/24 with no return phone call received. An interview conducted on 02/28/24 at 4:30 PM with the Director of Nursing (DON) revealed on 12/10/23 around 6:30 PM she was told by Unit Manager #1 that Nurse #2 had called out for the 7:00 PM to 11:00 PM shift. She stated Unit Manager #1 told her that Nurse #3, Nurse #4 and Nurse #5 were instructed to split the medication cart and had taken report on the residents. She stated she heard the next morning that some residents had not received their medication. The interview revealed that Nurse #5 had given half of the assigned residents their medication, but the other 8 residents Resident #7, Resident #28, Resident #47, Resident #51, Resident #73, Resident #79, Resident #88 and Resident #110 did not receive any scheduled medication. She stated Nurse #5 told her she had completed her assigned half and thought someone else was going to administer the rest of the residents' medication. The DON stated it was a communication error between the nurses. The interview revealed the residents' vital signs were obtained on 12/11/23 along with blood glucose levels for the diabetic residents. She stated no adverse outcomes had occurred from the incident and no residents needed medical treatment due to not receiving their medication. On 02/29/24 at 11:20 AM an interview was conducted with the Medical Director. During the interview he stated he was notified by the facility that the residents had missed their medication on 12/10/23. The interview revealed he notified the Nurse Practitioner's that were in the facility of the incident and that nurses on the unit were monitoring the residents for any changes of condition. He stated no residents were having symptoms from not receiving their medication. The MD stated although medication such as anticoagulants, opioids, antipsychotics and insulin were significant, it would not be harmful to the residents to miss one dose. The interview revealed none of the residents identified to have missed their medication were sent to the hospital or experienced a change of condition.

Based on observations, staff interviews, and record review the facility failed to record an open date on multi-dose insulin pens, failed to discard an expired insulin pen and failed to store unopened insulin pens in the refrigerator for 2 of 4 medication carts (Garden City Cart #1 and Arboretum Cart #2) which were reviewed for medication storage. The findings: Review of the manufacturer's package insert for Glargine stated to store unopened Glargine insulin pens in a refrigerator and in-use (opened) insulin pens at room temperature for 28 days. 1a. An observation of the Garden City medication cart #1 was conducted on 02/28/2024 at 11:11 AM with Nurse #6 and the Director of Nursing. The observation revealed an opened Glargine insulin pen and an opened Novolin insulin pen that were not dated. The medication cart observation also revealed an opened insulin pen with an open date of 12/08/2023 which had passed the 28-day expiration date of 01/05/2024. An interview was conducted with Nurse #6 on 02/28/2024 at 11:26 AM who stated she thought 3rd shift (11:0 PM to 7:00 AM) nursing staff were responsible for checking the medications carts for expired medications and she did not realize the insulin pens were not dated and that one was expired. 1b. An observation of the Arboretum Cart #2 was conducted on 02/28/2024 at 12:03 PM with Nurse #7 and the Director of Nursing. The observation revealed 2 unopened insulin pens were stored in the medication cart and were labeled as refrigerate until opened and one Glargine insulin pen with an open date that was illegible. The ink had smeared, and the opening date was unidentifiable. An interview was conducted with Nurse #7 on 02/28/2024 at 12:24 PM who stated she did not realize there was no open date on the insulin pens, and she thought the pharmacy placed the open date on the insulin pens. She also stated she did not know the unopen insulin pens required refrigeration and she did know how long the insulin pens had been in the medication cart. She also added she did not realize the insulin pen open date was not legible. She further stated she did not know who was responsible for checking the medication carts. An interview was conducted with the Director of Nursing (DON) on 02/28/2024 at 1:12 PM. The DON revealed all insulin pens should have been labeled when opened for use with a 28-day expiration date sticker. She also indicated that all nurses were responsible for putting the date of opening on the insulin pens and checking all medications in the medication carts. She further stated that she expected all insulin pens to be labeled when opened and discarded 28 days after opening. She also stated that all unopened insulin pens should be stored in the refrigerator until ready for use and that no expired medications should be available for use in the medication carts.

Based on observation and staff interviews, the facility failed to remove expired food items and unlabeled items which belonged to staff for 1 of 3 resident's nourishment rooms. These practices had the potential to affect food served to residents. Findings included: An observation and interview was conducted with Nurse Aide (NA) #5 on [DATE] at 10:15 AM revealed an 8 oz. fat free milk with the best by date of [DATE] and three separate lunch bags not labeled in the memory care unit nourishment room. NA #5 indicated nursing staff on the memory care unit had stored their personal items in the nourishment room because the nursing staff break room was on the other side of the facility. NA #5 stated nursing staff had been educated to not store personal items in the nourishment room and to discard any expired items. An interview conducted with the Dietary Manager (DM) on [DATE] at 10:30 AM revealed dietary aides check nourishment rooms daily but could not recall if any staff had checked them over the weekend. It was further revealed nursing staff had been educated not to store personal items in the nourishment rooms refrigerators and to also throw away any expired items that were found. An interview conducted with the Director of Nursing (DON) on [DATE] at 4:55 PM revealed nursing staff were educated not to store personal belongings in the nourishment rooms because there was a staff break room available with a refrigerator. The DON further stated she was unaware staff had stored items in the memory care nourishment room refrigerator. The DON indicated dietary aides were responsible for checking nourishment rooms, but nursing staff was also responsible for throwing out items if found that needed to be discarded. An interview conducted with the Administrator on [DATE] at 5:10 PM revealed she expected staff to check nourishment rooms daily and to discard any expired or unlabeled items. The Administrator further revealed it was not appropriate for nursing staff to store personal items in the nourishment room refrigerator.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the focused infection control survey that occurred on [DATE], the recertification and complaint investigation surveys that occurred on [DATE] and [DATE]. This failure was for three deficiencies that were originally cited in the areas of Accuracy of Assessments (F641), Food Procurement, Store/Prepare/Serve Food Under Sanitary Conditions (F812) and Infection Prevention and Control (F880) and were subsequently recited on the current recertification and complaint investigation survey of [DATE]. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents (Resident #41, #102, #84) reviewed for Preadmission Screening and Resident Review (PASRR), and 1 of 3 residents (Resident #110) reviewed for restraints. During the recertification and complaint investigation survey conducted [DATE] the facility failed to accurately code the Minimum Data Set (MDS) assessment related to tobacco use for residents reviewed for smoking. F812: Based on observation and staff interviews, the facility failed to remove expired food items and unlabeled items which belonged to staff for 1 of 3 resident's nourishment rooms. These practices had the potential to affect food served to residents. During the recertification and complaint investigation survey conducted [DATE], the facility failed to remove expired food items in the refrigerator in 1 of 4 nourishments rooms and failed to label and date opened food items stored for use in 3 of 4 nourishment rooms. During the recertification and complaint investigation survey conducted [DATE], the facility failed to discard produce with signs of spoilage, remove expired food items and date leftover food stored ready for use in the walk-in cooler. F880: Based on observations, record reviews, and staff interviews, the facility failed to ensure staff implemented their handwashing/hygiene policy as part of their infection control policy when the Treatment Nurse did not perform hand hygiene and don clean gloves after cleaning two wounds with wound cleanser and one wound with normal saline and before applying treatment to the wounds for two residents (Resident #128 and Resident #43) and did not doff gloves, sanitize hands and don clean gloves after wound care and prior to touching the resident's (Resident #128) pillows and bedding. The Treatment Nurse was also observed during wound care on another resident (Resident #126) with Methicillin-Resistant Staphylococcus Aureus (MRSA) and Carbapenem-Resistant Enterobacterales (CRE) in the wound and she did not doff gloves, sanitize hands and don clean gloves after cleaning the wound which had brown colored drainage and before applying the treatment to the wound and with the same gloves on the Treatment Nurse used to clean the drainage from the wound was observed touching the bed controls to lower the resident's bed and touching the trash bag on the resident's bed. In addition, another staff member (Nurse Aide (NA) #1) was observed providing incontinence care of bowel movement to a resident (Resident #51), and with the same gloves on that he had cleaned the resident with touching the resident's closet door, bedside drawer and over bed table. These failures occurred for 3 of 3 residents reviewed for wound care and 1 of 3 residents reviewed for incontinence care. During the focused infection control survey conducted [DATE] the facility failed to ensure dietary staff implemented the facility's infection control measures when 2 staff members failed to wear a facemask covering their mouth and nose while working in the kitchen. During an interview on [DATE] at 5:19 PM with the Administrator she revealed the QAPI committee meets monthly with department heads, administrative staff, the Medical Director, and at least quarterly the Pharmacist and Registered Dietician attend and monthly attend by phone. She reported they currently had Process Improvement Plans (PIPs) addressing some of the issues she and the corporate advisors had identified at the facility. Some of the PIPs currently being addressed included grievances, care plan meetings, resident weights, and physician visits. She also reported they would be putting PIPs into place to address the current concerns addressed during the current recertification and complaint survey. The Administrator stated the PIPs would be ongoing and monitored to ensure ongoing and future compliance.

Based on observations, record reviews, and staff, resident, pest control technician and physician interviews, the facility failed to implement an effective pest control program to control the presence of flies in the room of 1 of 3 sampled residents (Resident #1). Resident #1 had live maggots develop in her right heel wound. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required total assistance with all activities of daily living. The MDS also indicated she had pressure ulcers on the sacrum, left heel and right heel which required treatments. Review of the August 2021 treatment record (TAR) revealed the right heel wound treatment included cleaning with normal saline, applying a gel used to debride and aid in wound healing and covering with a 6x6 dry dressing every Monday, Wednesday and Friday. The TAR revealed the wound care had last been completed on Friday 8/27/21 by the Treatment Nurse. A phone interview, conducted with Nurse Aide #1 on 9/5/21 at 11:00am, revealed on 8/29/21, she repositioned Resident #1 and observed maggots that fell out of her right heel wound dressing onto the bed. She reported the maggots to Nurse #1. Nurse #1 checked on Resident #1 then got Nurse #2 to help him address the maggots. A phone interview, conducted with Nurse #1 on 9/8/21 at 10:00am, revealed it was around noon on 8/29/21 when Nurse Aide #1 notified him of maggots in Resident #1's right heel wound. He immediately got Nurse #2 to go with him to look at the wound. He and Nurse #2 confirmed there were maggots in the wound, approximately 50-100 maggots. Nurse #2 notified the Director of Nursing (DON) on 8/29/21 around noon. A couple hours later the Assistant Director of Nursing (ADON) and the Treatment Nurse came into the facility to remove the maggots. An interview, conducted with Nurse #2 on 9/7/21 at 1:00pm, revealed on 8/29/21 around noon, Nurse #1 asked her to look at Resident #1's heel. She observed the right heel wound with a wound dressing that was partially on and observed maggots in the wound. She stated she immediately notified the DON. The DON stated she would notify the physician. The DON then notified her that the ADON and Treatment nurse were coming into the facility to clean the wound and remove the maggots. Resident #1 was in no acute distress, showing no signs of pain or discomfort. An interview, conducted with the DON on 9/7/21 at 4:00pm, revealed she received a call from Nurse #2 on 8/29/21 at 12:17pm. Nurse #2 informed her that Resident #1 had maggots in her right heel wound. The DON stated she immediately notified the Administrator and the physician. The physician gave an order for the wound to be cleaned with equal parts vinegar and water and remove the maggots. The DON notified the Assistance Director of Nursing (ADON) and the Treatment Nurse, both of whom lived close to the facility, with the physician orders to clean the right heel wound with vinegar and water and remove the maggots. The DON further stated she directed the Maintenance Director to have the pest control company treat Rooms 101, 103, 304, 305, 308, 314, 401, 407, 404, 602 which were rooms of residents with wounds. The DON stated the department heads make rounds daily to check for pests, open food, crumbs, spills on the floor and sticky floors. If found, this was reported to housekeeping for cleaning. A phone interview, conducted with the ADON on 9/9/21 at 9:00am, revealed he was contacted by the DON on 8/29/21 in the early afternoon, to go to the facility and assist the Treatment Nurse with removing maggots from Resident #1's right heel wound. He arrived at the facility the same time as the Treatment Nurse. Together they cleaned Resident #1's right heel wound with equal parts vinegar and water. The Treatment Nurse removed the approximately 50-100 maggots with tweezers and applied a clean dry dressing. An interview, conducted with the Treatment Nurse on 9/7/21 at 2:30pm, revealed Resident #1's right heel wound had been treated three times a week on Monday, Wednesday and Friday cleaning with normal saline, applying Medi-honey (a gel to treat chronic wounds) and covered with a dry dressing. The last treatment was completed on 8/27/21. She stated Resident #1 had contractures of her legs and was unable to reach the wound dressings on her heels. She stated she was contacted, by the DON on 8/29/21 in the early afternoon, to go to the facility and assist the ADON with removing maggots from Resident #1's right heel wound. She arrived at the facility the same time as the ADON. Together they cleaned Resident #1's right heel wound with equal parts vinegar and water and removed the maggots with tweezers. She applied a clean dressing over the right heel wound. She then assessed Resident #1's remaining pressure ulcers on the left heel and the sacrum. Those wounds were clean with no signs of maggots. Resident #1 tolerated the procedure without any signs of pain or discomfort. On 8/29 and 8/30, she conducted skin audits on all residents in the facility with wounds. None were found to have maggots in their wounds. The treatment nurse called Resident #1's Power of Attorney (POA) twice on 8/29/21 to notify him of the change in the resident's wound status. She left a message each time. The POA never returned her calls. On 8/30/21, the POA called the facility requesting the resident be sent to the hospital. Review of the emergency room (ER) record, dated 8/30/21, revealed Resident #1 was evaluated in the ER at the request of the POA. The ER report stated in part, No evidence of any infestation when dressings were removed. No concern over frank purulence or infection. At this point, there is no evidence of infestation, [CONDITION(S)] or other infection. Resident #1 was not returned to the facility at the request of the POA. A phone interview, conducted with the physician on 9/8/21 at 12:40pm, revealed he was notified by the DON on 8/29/21 early afternoon that Resident #1 had maggots in her right heel wound. He gave an order to clean the wound with equal parts vinegar and water and remove the maggots. He told the DON he would visit Resident #1 on Monday 8/30/21 to assess the wound. He stated he did not think Resident #1 needed to be sent to the emergency room as the maggots could be removed and the wound managed by the facility staff. He stated it was not appropriate for maggots to be in the wound. An interview conducted with the Maintenance Director on 9/7/21 at 3:00pm, revealed the facility had pest control treatments monthly, which included treatments for flies. The last two scheduled service calls occurred on 7/2/21 and 8/11/21. Recommendations were made during the 7/2/21 pest control service including unblocking the drain in the kitchen floor and removing debris from under the dishwasher in the kitchen. During the pest control service call on 8/11/21, recommendations included removing standing water in the kitchen and remove accumulated food from underneath the appliances. The Maintenance Director stated all of the recommendations had been corrected right after the pest control technician made the recommendation both times. An observation of the kitchen on 9/7/21 at 3:30pm revealed the floor drains in the kitchen were not blocked and were free of debris. In addition, there was no food accumulated underneath the appliances, no debris under the dishwasher and there was no standing water in the kitchen. There was no gap noted in the door going into the kitchen from the outside. A second interview with the Maintenance Director was conducted on 9/10/21 at 9:13am. He stated he felt that the smoking door was a source of entry for the flies. He identified the smoking door as a problem area as the door is held open for residents in wheelchairs who go out and come back in for smoking at 10:00am, 12:00pm, 2:00pm, 4:00pm and 7:00pm. He stated an air curtain (a device placed over a door that supplies a high velocity stream of air across a door opening that keeps pests like flies from entering the building) had been ordered to be placed over the smoking door. Review of the pest control reports provided by the pest control company indicated onsite services of inspections and chemical applications were conducted on 7/2/21, 8/11/21 and 8/31/21, which included perimeter bait, glue boards and chemical spray specifically for flies. A phone interview, conducted with the pest control technician on 9/10/21 at 7:55am, revealed he provided monthly maintenance visits and sprayed for flies each visit. He stated he had not seen a fly infestation at the facility. He stated he had made recommendations during the 7/2/21 and 8/11/21 visits, which had been resolved by the Maintenance Director. On 8/31/21, he treated Rooms 101, 103, 304, 305, 308, 314, 401, 407, 404, 602 and the common areas for flies at the request of the Maintenance Director. There was no fly activity except for a fly here and there. On 8/31/21, a gap in the door going into the kitchen from the outside had been identified. When he visited the facility on 9/7/21, he noted a sweep had been placed on the door which eliminated the gap. The Administrator signed a contract on 9/8/21 for the pest control company's Fly Program which included adding 11 fly lights throughout the facility and weekly inspections and treatments as long as needed. An interview with the Administrator was conducted on 9/7/21 at 4:30pm. She stated she was notified by the DON on 8/29/21 between noon and 1:00pm that Resident #1 had maggots in a wound. She stated she immediately began an investigation and implemented a performance improvement plan. A second interview, conducted with the Administrator on 9/10/21 at 12:00pm, revealed she wasn't sure what contributed to the increase in the number of flies in the facility. Immediately after staff observed maggots in Resident #1's wound, she started an investigation and implemented a performance improvement plan. She stated she ordered 2 air curtains on 8/29/21 and then ordered 3 additional air curtains on 9/2/21, which are scheduled to arrive and be installed week of 9/14/21. Air curtains will be placed on the smoking door, replace the air curtain outside kitchen door, 2 courtyard doors, and on the back door out to the dumpster. She further stated that flies were the root cause of the maggots. She stated it was a freak occurrence and she hated that it happened. It was not acceptable to have maggots in a wound. On 9/10/21 at 3:30pm, the Administrator was notified of the Immediate Jeopardy. The facility provided the following corrective action plan with a completion date of 9/6/21. Allegation of Compliance F925 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. All residents with wounds, dressings, and tube feedings were at risk from the failure to adhere to correct and adequate pest control policies. The facility had in place a pest control process for employees to follow prior to 8/29/21. The facility's pest control included: reporting system through the maintenance work orders, contracted pest control company servicing the facility monthly and as needed for any problems that arose between services. There was one air curtain positioned outside the kitchen door. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. CORRECTIVE ACTION THAT WILL BE ACCOMPLISHED: -On 8/29/21, the Administrator initiated a performance improvement plan which included the following: -8/29/21 Resident's 1's room #314 was deep cleaned. -8/29/21 Two air curtains were ordered 8/29/21 and 3 additional air curtains were ordered 9/2/21, all to be delivered and installed week of 9/13/21, to be placed at the back door leading to the dumpster, the 2 doors leading to the courtyard, the smoking door and replace the current air curtain at the kitchen door. -8/29/31 Uultraviolet mini fly/bug LED light lamps were ordered for all resident rooms with wounds. The mini lights were delivered 9/7/21 and placed in all resident rooms with wounds on 9/7/21. -8/30/21 All resident rooms with wounds were deep cleaned. Maintenance Director (MD) identified 4 outside doors that had gaps and those 4 doors were sealed with the rubber sweepers at the bottom of the doors on 8/30/21. -8/31/21 Maintenance Director and the pest control technician treated rooms 101, 103, 304, 305, 308, 314, 401, 407, 404, 602, where residents with wounds resided. Pest control treated all problem areas with chemical solution. There were no problem areas with flies noted. Treated specifically for flies. -8/31/21 Initiated the Fly Program which included: pest control tech applied bait around the dumpster and the smoking area, repeated on 9/8. Administrator signed a contract which included the same treatment weekly for 1 year. The contract included 11 additional ILT lights to be installed in the facility hallways and at the back door leading to the dumpster. -9/2/21 100% window screens audited, ordered approximately 42 screens for windows that had none. IDENTIFICATION OF OTHER RESIDENTS: - 8/29/31-8/30/21 Wound audits were conducted on all residents with wounds In-services Provided: - All staff: Conducted on 9/1/21 by the Director of Nursing (DON): Prevention and reporting of pest control concerns were to be entered into the TELS (computer work order) system and report to the supervisor. - Kitchen Staff: Conducted on 9/6/21 by the Dietary Managers: Back door to stay closed at all times. Alert a member of management of all pest control concerns and enter into TELS system. MEASURES FOR SYSTEMIC CHANGE - 8/29/21 Two air curtains were ordered. - 8/29/21 Ultraviolet mini fly/bug LED lights were ordered for all resident rooms with wounds. - 8/30/21 Maintenance Director identified 4 outside doors that had gaps. The doors were sealed with rubber sweepers at the bottom of the doors on 8/30/21. - 9/1/21 In-serviced staff to report flies and pest immediately in the TELS system and report to the supervisor. - 9/2/21 An additional 3 air curtains were ordered, with delivery planned week of 9/13/21. - 9/2/21 100% of window screens were audited, ordered approximately window 42 screens - 9/6/21 In-serviced kitchen staff to keep the back door closed at all times and use the TELS system to report observations of flies or pests. HOW CORRECTIVE ACTION WILL BE MONITORED: - 100 % audits of all rooms and common areas will be inspected by the Maintenance staff weekly x 4 weeks then monthly x 2 months for signs of pest. The administrator will review and initial the audit tool weekly x 4 weeks then monthly x 2 months to ensure all areas of concern were addressed. - The treatment nurse will audit all wounds twice weekly x 4 weeks then once weekly ongoing and take findings to QAPI for further recommendations. - The Administrator will forward the results of the audits to the Executive QA Committee monthly x 2 months. The Executive QA committee will meet monthly x 2 months and review the audits to determine trends and/or issues that ay need further interventions put into place and to determine the need for further and/or frequency of monitoring. - Performance Improvement Plan was reviewed with the Interdisciplinary Team on 9/1/21 and they agreed with the plan and monitoring. Resolution date 9/6/21. The facility's corrective actions implemented after the incident to prevent a reoccurrence included the following: All items listed on this self-imposed action plan have been completed and implemented on 9/6/21 with ongoing monitoring to ensure compliance. This concluded the action plan and any potential citations associated with this action plan should be considered past noncompliance as of 9/6/21. The Administrator was responsible for compliance. The date for the decision to QA and monitor was 8/29/21. Resident #1 was transferred to the hospital on 8/30/21 at the request of the POA and did not return to the facility. On 9/20/21 the facility's corrective action plan with a completion date of 9/6/21 was validated by the following: On 9/20/21 at 11:15 AM initial observations revealed no flies were observed in the lobby or the conference room. The doors to the courtyard had weather stripping but no air curtains were in place. There was no fly activity noted in resident rooms or common areas. Interviews with staff and review of the in-service logs revealed they had received education on 9/1/21 about the use of the TELS system to report observations of flies or pests. An observation of the kitchen revealed no flies or other pests. The back door was closed. The air curtain over the kitchen door was on and functioning. An interview was conducted with the Dietary Supervisor, who stated the back door was to remain closed except for deliveries. She stated if she were to see flies or other pest, she would alert the Dietary Manager and he would put a request into Maintenance. Interviews with the kitchen staff and review of the in-service log revealed they received education on keeping the back door to the kitchen closed at all times. Ultraviolet lights were observed in rooms 106B, 305A, 504 and two rooms on Rehab. Review of the audits revealed the treatment nurse audited all resident wounds on 8/30, 8/31, 9/7, 9/10, 9/13 and 9/17/20. Room audits were conducted on 8/30/21 and 9/7/21. An interview with the Maintenance Director revealed the outside doors have been sealed. The air curtains have been ordered for the smoke door and the courtyard doors and the window screens are on back order and will be installed immediately upon delivery. Any window that does not have a screen will get one. An interview with the Administrator revealed the air curtains have been ordered, but they have not been delivered. The kitchen had a working air curtain but it will be replaced. The window screens have been ordered and will be delivered 10/12/21, constructed onsite and installed on that date. The purchase orders for the air curtains and the window screens were reviewed and both were dated 9/3/21. In summary, on 9/20/21 the facility's plan for past noncompliance was validated by the following: 1) Review of the in-service training records revealed all staff were educated on 9/1/21 to report the presence of flies and pests in the TELS system. 2) Review of the in-service training record revealed all kitchen staff were educated on 9/6/21 to assure the back door is kept closed. 3) Interviews were completed with facility including kitchen staff to validate the education had been completed. 4) A review of the facility's audits verified the Treatment Nurse and Maintenance Staff completed audits as specified in their self-imposed action plan. 5) Compliance was achieved on 9/6/21 when all the staff were educated regarding reporting flies and pests in the facility, to keep the back door closed at all times, and the air curtains and window screens were ordered.

Based on observations, record reviews, staff and Medical Doctor (MD) interviews, the facility failed to monitor a severely cognitively impaired resident who wandered into an outdoor courtyard and sat in 90- degree sun without shade or fluids for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 was found slumped over to the side of his chair and not responsive to caregivers. Resident #1 was sent out to the Emergency Department (ED) where he was treated for [REDACTED]. Resident #1 was hospitalized , stabilized and returned to the facility four days later. Immediate jeopardy began on 06/29/19 when the facility failed to maintain a safe environment as evidenced by a severely cognitively impaired resident exiting the dining room door into the courtyard and was discovered approximately 75 feet from the door one and a half hours later in the direct sunlight without supervision. The Immediate Jeopardy was removed on 07/11/19 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His date of birth was 12/20/1952 Resident #1's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed he was severely cognitively impaired for daily decision making, required extensive assistance of 2 with transfers but was able to self-propel once he was in his wheelchair. The resident had no impairment of his upper or lower extremities and received antipsychotics on a routine basis. Review of Resident #1's Medication Administration Record [REDACTED]. Additionally, Resident #1 was diagnosed with [REDACTED]. Resident #1's medical record revealed a note written on 06/29/19 by Nurse #1 which read in part: Resident alert and wheeling self around during the morning. Noted to be outside around 11:00 AM in his wheelchair. At about 12:28 PM the resident was still outside and assisted back in the building by Nurse Aide (NA) #1 and NA #2 due to being less responsive. The resident was dressed in a tee shirt, sweat shirt and sweat pants and his temperature was noted to be increased with a decreased pulse. The resident was assisted to bed and had some clothing removed and cool towels were placed on the resident. The resident was assisted in drinking some sips of water and when assessed remained less responsive, so a telephone order was obtained to send the resident to the hospital for evaluation and treatment. A telephone interview on 07/09/19 at 2:33 PM with Nurse #1 who had taken care of Resident #1 on 06/29/19 revealed she was not sure what time the resident had gone out into the courtyard. She stated she remembered him self-propelling his wheelchair in the hallway that morning but stated she was not aware of what happened after that until she was summoned by NA #1 and NA #2 to assess the resident after being out in the sun. Nurse #1 stated his temperature had been elevated (could not remember what it was) and his pulse had been low (could not remember what it was). Nurse #1 stated she was not aware how long the resident had been out in the courtyard but stated when he came in he was hot to the touch and he was unresponsive except to painful stimuli. She stated they tried to cool him off and get him comfortable and stated he was having some jerking movements but stated she was not sure that it was [MEDICAL CONDITION]. Nurse #1 stated Resident #1 remained unresponsive as he was taken out of the facility by EMS. Nurse #1 stated she had not typically taken care of Resident #1 and was not familiar with him. An interview on 07/09/19 at 2:18 PM with NA #1 who was assigned to Resident #1 on 06/29/19 on first shift (7:00 AM to 3:00 PM) revealed she recalled the day of the incident. NA #1 stated the resident had eaten breakfast in his room and was self-propelling himself in the hallway. She stated she rolled the resident into the Rose Dining Room at 11:00 AM while Bingo was going on. NA #1 stated at approximately 12:28 PM NA #2 discovered Resident #1 out in the courtyard leaning over to the side and came and got her and the two brought him in the facility. NA #1 stated he would not respond to them, so they put him in the bed and summoned the nurse and 2 emergency medical technicians (EMTs) who happened to be in the facility picking up another resident. She stated they put him in the bed with the help of the nurse and the EMTs took his temperature and it was 105.1 degrees F. NA #1 stated Resident #1's skin was hot to touch, and they started taking off some of his clothing and applying cold towels to his body. She said Nurse #1 called the Medical Doctor (MD) and received orders to transport the resident to the ED for evaluation and treatment. NA #1 stated EMS came and transported the resident to the hospital. NA #1 stated Resident #1 had never gone out of the facility into the courtyard on his own when she had taken care of him and stated she was not sure why he had done it on this day. NA #1 stated she was not sure how he had gotten out the door unless he followed a staff member out or opened the door himself. A second interview on 07/10/19 at 11:30 AM with NA #1 revealed the location where the resident was found out in the courtyard. The resident was found in his wheelchair in the direct sun with no shade on the concrete walkway approximately 75 feet from the door of the dining room. An interview on 07/09/19 at 2:45 PM with NA #2 revealed during lunch on 06/29/19 she had noticed Resident #1 in the courtyard slumped to the side and went and got NA #1. She stated the two of them brought him into the facility and put him to bed, so they could take some of his clothing off and cool him down. NA #2 stated he was not verbally responding to them and stated it was hot outside that day and where he was sitting in the courtyard there was no shade. She stated the EMTs and Nurse #1 came into the room and started assessing him and the nurse obtained orders from the MD to send him out to the ED for evaluation and treatment. She stated he had not had any fluids with him when they brought him in from outside and to her knowledge he had not had any fluids since going out in the sun. She stated she had not typically seen him out in the courtyard and was not sure how he had gotten out there that day. NA #2 stated the door was not closing properly that day and that if he could push it open it was possible that he went out on his own or he had followed a staff member out the door. An interview on 07/09/19 at 3:20 PM with NA #3 revealed she had cut through the courtyard and seen Resident #1 sitting in his wheelchair in the sun. She stated she remembered she was going to get him something to drink on her way back across the courtyard but stated by the time she got back NA #1 and NA #2 were getting him in the facility. She stated he had not typically gone out into the courtyard but stated he could go out if he wanted because he was not monitored for wandering. She stated she was not sure how he got out there or how long he had been out there. A review of the Emergency Medical Services (EMS) report revealed they were dispatched to the facility on [DATE] at 12:57 PM and arrived on scene at 1:07 PM. EMS was informed by Nurse #1 the resident was found outside by staff members of the facility in his wheelchair. Resident #1 was found noncommunicative and moved into his room inside the facility. The EMS report documented temperature noted outside at approximately 90 degrees F and sunny. Their assessment revealed Resident #1 was noncommunicative, patent airway but breathing at an elevated rate and shallow depth with mild distress and clear lung sounds with oxygen saturation at 94 percent on room air, skin color normal, skin hot to touch, slow and irregular radial pulses noted, tremors noted, not following commands but is making some purposeful movement to pain stimuli, no noted trauma, pupils equal and remainder of physical exam unremarkable. Temporal temperature (forehead scanner) obtained and shown to be 105.1 degrees F. Nurse #1 arrived in room with resident and stated she believed the resident went outside at approximately 9:00 AM and had been outside since EMS was notified. Resident #1 was placed on cot and secured, ice packs were placed bilaterally to resident's axillary, fluid bolus was infusing, and resident was transferred to the Emergency Department (ED) at the local hospital. A review of the ED notes at the hospital revealed Resident #1 arrived at the ED on 06/29/19 at 1:31 PM via EMS for evaluation of a potential heat stroke. Resident #1 arrived showing signs of altered mental status with a temperature of 105 degrees F. Resident #1's temperature was assessed in the ED as 98.9 degrees F, heart rate 111, respirations 25 and blood pressure 93/74 with oxygen saturation at 100 percent. Resident #1 was responsive to painful stimuli and withdrew to pain and had active [MEDICAL CONDITION] activity. The resident appeared to purposefully withdraw to painful stimulus in his right lower extremity and had a positive Babinski (a reflex action in which the big toe remains extended or extends itself when the sole of the foot is stimulated, abnormal except in young infants) bilaterally. Resident #1's initial [MEDICAL CONDITION] activity appeared to have subsided after multiple rounds of intravenous (IV) [MEDICATION NAME]. Resident #1 continued with myoclonic jerking of bilateral upper and lower extremities and was unclear if this represented ongoing intermittent [MEDICAL CONDITION] activity which prompted a stat neurological consult. At the urging of the Neurologist intravenous [MEDICATION NAME] was given and transfer to a facility that had EEG (a test that detects electrical activity in your brain using small, metal discs ([MEDICATION NAME]) attached to your scalp) capabilities was arranged. Resident #1 received a nasal trumpet to support his breathing and high flow nasal canula was initiated. Resident #1 continued with ongoing bouts of [MEDICAL CONDITION] (low blood pressure- less than 90/60), attempted to minimize amount of IV fluids given, resident was able to make urine and his temperature was greatly improved so ice packs and fans with topical water spray were discontinued. At 2:15 PM reexamination revealed Resident #1's blood pressure dropped and Resident #1 was started on an additional cool normal saline IV. Resident #1's suprapubic catheter was draining urine and the resident's temperature was assessed at 100 degrees F. The resident was discharged to a secondary hospital that supported continuous EEG monitoring at 6:26 PM via EMS. A review of the secondary hospital record dated 06/29/19 for Resident #1 revealed on admission he remained unresponsive and unable to provide any history. He was only grimacing to painful stimuli, remained hypotensive and Resident #1 was admitted to the Intensive Care Unit for monitoring. His temperature went down to 99 degrees after some cooling blankets were applied and his computerized tomography (CT) scan of his head did not show any acute intracranial process. The physician's assessment noted a fever of unclear etiology, likely secondary to heat stroke and the assessment so far did not favor infection. The physician documented the unresponsiveness was likely secondary to heat stroke and the [MEDICAL CONDITION] activity could have caused the unresponsiveness, but unresponsiveness seemed to be very prolonged. The last problem noted by the physician was acute kidney injury. The Plan was for Resident #1 to be admitted to ICU, IV normal saline at 125 milliliters (ml) per hour, continuous EEG monitoring, [MEDICATION NAME] 300 mg daily IV since resident cannot take medications by mouth, Neurology consult and hold antibiotics for now due to no leukocytosis and no clear source of infection. The hospital discharge summary dated 07/03/19 revealed Resident #1 was stabilized over the next 3 days and was discharged back to the facility on [DATE]. His primary [DIAGNOSES REDACTED]. The resident was discharged on [MEDICATION NAME] and was to continue on [MEDICATION NAME] and Topomax as previously ordered. Resident #1 was discharged back to the facility at 6:27 PM on 07/03/19 via EMS. Observation on 07/09/19 at 9:15 AM of Resident #1 revealed him lying in bed resting with his eyes closed. Observation on 07/09/19 at 1:00 PM of Resident #1 revealed him walking with a walker with Physical Therapy Assistant (PTA) with wheelchair being rolled behind him. Observation on 07/09/19 at 3:00 PM of Resident #1 revealed him in the gym with Physical Therapy working on a machine to strengthen his arms. An interview on 07/09/19 at 4:30 PM was attempted with the resident; however, he did not recall anything about the incident. An interview on 07/09/19 at 5:00 PM with the Administrator revealed she was aware of the incident with Resident #1 on 06/29/19 and stated her investigation was unable to determine how Resident #1 got out into the courtyard, but stated she suspected he followed a staff member out the door without the staff member realizing the door had not closed. The Administrator provided copies of her complete investigation. The root cause analysis was determined to be the resident's underlying medical conditions, including a urinary tract infection [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. The Management Team and Quality Assurance/Process Improvement (QAPI) recommended: a proactive in-service be presented to staff, to residents playing Bingo, to resident council, and to families during the next family meeting on hydration to residents and frequent monitoring of residents outside during periods of inclement weather including increased temperatures. A Process Improvement Plan was put into place with updates to be made at upcoming meetings as necessary. An in-service was conducted on 07/01/19 with staff present in the building on hydration to residents and frequent monitoring of residents outside during periods of inclement weather including increased temperatures - 38 of 137 staff members were educated. On 07/02/19 an in-service was conducted on the Rose Dining Room door being kept locked. Staff was instructed not to let any resident out without first checking with their nurse - 38 of 137 staff members were educated. The Administrator stated it was her expectation that staff be aware of any resident out in the courtyard and monitor them and assure they are properly hydrated. A telephone interview on 07/09/19 at 5:26 PM with the MD revealed he was aware of the incident with Resident #1. The MD stated apparently the resident went outside for a period of time and normally this would not have been a problem except no one was aware that he had gone outside. The MD stated any time any of the residents were outside, he would expect the staff to be aware and monitor the time they are outside and make sure they had something to drink. The MD stated Resident #1 had a history of [REDACTED]. The MD stated this particular antibiotic (Cipro) could have lowered Resident #1's threshold for [MEDICAL CONDITION] activity. The MD stated this along with his overall poor health and the heat exposure more than likely contributed to him having [MEDICAL CONDITION] activity. The MD stated it was his understanding the staff at the facility had not witnessed any [MEDICAL CONDITION] activity and this had not occurred until he was in the ED at the first hospital. He stated in his experience, all factors could have contributed to the [MEDICAL CONDITION] activity noted at the first hospital. The MD also stated in his experience a heat stroke takes a longer time to normalize body temperature than had occurred with Resident #1. He stated his body temperature returned to normal much quicker than residents he had seen with heat stroke but stated it was probably the logical answer for his unexplained fever as he had no symptoms of an infection. The MD stated he had examined the resident on 07/08/19 and stated that he was up in the wheelchair, and had the same cognitive deficits, communication skills and looked exactly the same as prior to the incident. He stated Resident #1 had not suffered any new deficits as a result of the incident. A review of the weather conditions per Weather Underground web site revealed the following data for Charlotte, North [NAME]ina (NC) on 06/29/19 at 11:00 AM to 12:30 PM: sunny and 90 degrees Fahrenheit (F) with wind at 6 miles per hour in south southwest direction and no precipitation. The Administrator was informed of Immediate Jeopardy on 07/10/19 at 1:41 PM. On 07/12/19 the facility provided the following Credible Allegation of Compliance: Removal Plan 7/11/19 Supervision to prevent accidents 1. Identify the residents who have suffered, or are likely to suffer, a serious adverse outcome as a result of non-compliance: 6/29/19 at 11am Resident #1 was assisted to Rose dining room by facility staff. 6/29/19 prior to meal trays being delivered in Rose dining room a CNA observed Resident #1 outside in the enclosed courtyard sitting at a table outside of the Rose dining room. 6/29/19 at approximately 12:28pm Resident #1 was observed by additional staff outside in enclosed courtyard outside Rose dining room sitting in wheelchair at a table. Resident #1 was noted by staff member to be leaning more to side. Per staff interviews resident was not verbal but eyes open when observed. Vital signs not obtained by CNA staff while resident was outside. 6/29/19 at approximately 12:30pm two staff nursing assistants assisted Resident #1 in his wheelchair to the resident's room. 6/29/19 at approximately 12:32pm the staff nurse assessed Resident #1, clothing was partially removed by staff and cool compress (towel) applied. Nurse assessment revealed resident was responding and drinking sips of water. Emergency services (medics) were already in the facility for an unrelated issue; and were asked by facility staff to evaluate Resident # 1. Nurse was unable to obtain vital signs before medics arrived in room to evaluate Resident #1. CNA staff were present with medics when nurse exited resident room to notify physician. 6/29/19 at approximately 12:33pm, while medics were present, the nurse contacted Resident #1's physician. The physician gave an order to transfer Resident #1 to the hospital for evaluation. 6/29/19 emergency medical services (EMS) that were dispatched at 12:55pm were in addition to initial emergency services who were already onsite. The additional emergency services team arrived at facility at 1:07pm and departed with Resident #1 at 1:21pm. 6/29/19 per ED documentation Resident #1's initial assessment shows: a tympanic temperature of 98.9 F, heart rate of 111, blood pressure of 93/74 (within normal range for the resident), 100% SpO2, with active [MEDICAL CONDITION] activity at 1:31pm, and pacemaker at end of battery life. The emergency room treatment was initiated based on the EMS report of temporal temperature (skin) of 105 F and the resident presenting symptoms of active [MEDICAL CONDITION] activity ([MEDICATION NAME] less than 9 minutes). Resident #1 was provided with intravenous fluid, and oxygen for respiration drive after provided with [MEDICATION NAME] for [MEDICAL CONDITION]. 6/29/19 6:26pm Resident #1 was subsequently transferred to another acute care hospital for neurology monitoring (EEG) and in-depth evaluation as this was not available at the facility housing the emergency room . All residents that utilize the courtyard (which has the potential to be any resident not in the memory care unit) have the potential to be affected by a heat related stress event during times of elevated environmental temperatures in the outside courtyard area. But on 6/29/19, the day of incident with Resident # 1, no other residents were observed outside in the courtyard at 12:38pm by facility staff. 2. Specify the action taken to alter the process or system failure to prevent a serious adverse event from occurring or reoccurring, and when the action will be complete. On 7/1/19 the director of nursing started a proactive in-service for staff of all departments on hydration (fluids will be present in courtyard) and frequent monitoring of residents outside. C.N.A.s and nurses will check residents on their assignment during each round, including residents who are in the courtyard. An administrative staff member will check the courtyard three time daily. This in-service was started as a proactive reminder to staff to provide hydration to residents outside to encourage hydration status. This in-service was completed on 7/10/19 by in- person in-servicing or by mail. If in-service was mailed the staff member must compete a quiz and return prior to working to validate competency. This in-service was added to the orientation for new staff on 7/10/19 by the administrator. On 7/10/19 the facility implemented hydration station in the courtyard. The dietary manager or dietary aide will provide fresh ice and fluids to the hydration station. The hydration station allows for access to fluid for residents utilizing the courtyard. Fluids will be contained in a cooler. Residents who cannot physically access fluids at the hydration station will be assisted by staff. On 7/11/19 the facility placed four large patio umbrellas in the courtyard and two canopies in the courtyard to provide additional shade for resident safety to decrease the risk of heat related stress by addressing a risk factor in heat related stress. On 7/11/19 the staff facilitator initiated an in-service for staff of all departments on signs and symptoms of heat related stress, preventive actions to prevent heat related stress and actions to take if they note a resident with possible heat related stress change. This in-service was completed on 7/11/19 by in-person in-servicing or by mail on 7/11/19 (2nd mailing). If the in-service was mailed, the staff member must complete the included quiz to prove competence and return the quiz prior to their next scheduled shift. On 7/11/19 the administrator added the in-service to the new staff orientation for staff of all departments. The facility's expectation of staff for a cognitively impaired resident who is taken outside or propels outside to the courtyard is: 1. Follow the residents' plan of care/care guide; 2. Honor resident rights and choices; 3. Offer hydration and shade; 4. Provide supervision to prevent accidents. No staff will be allowed to work after 7/11/19 without in-service completion by phone, in-person, or satisfactory completion of mailed quiz. The quizzes are monitored and graded by the director of nursing, assistant director of nursing and the staff facilitator. Residents will be monitored during routine rounds by facility staff and more frequently based on the resident's current needs and preferences. On 7/11/19 facility staff members educated residents one on one and in small groups on heat stress, heat related stress prevention, and heat related stress risk factors. This education was also provided on 7/11/19 to family members via telephone or in person. On 7/11/19 facility staff members posted educational posters in visible places throughout the facility and courtyard to provide families and residents visual reminders of education they received on heat stress, heat related stress prevention, and heat related stress risk factors. The education will also be presented to the resident council on 7/22/19 and the family council on 7/16/19. A complete mailing of the education material to all resident representatives was completed on 7/11/19. University Place Nursing & Rehab alleges removal of immediate jeopardy as of 7/11/19. The credible allegation was verified on 07/12/19 at 1:45 PM as evidenced by observations and interviews. Observations revealed canopies and patio umbrellas placed in the courtyards. (There were 2 canopies and 4 patio umbrellas in the main courtyard and 1 patio umbrella in the smoker's courtyard). Each courtyard had a cooler with bottled water available. Staff checked on residents and offered them fluids. Signage which listed warnings and interventions to avoid extreme heat were posted on the front doors and courtyard doors. Resident and family member interviews revealed receipt of information regarding heat stress and hydration. Staff interviews revealed receipt of training regarding hydration needs, symptoms of heat stress and implementation of interventions to prevent heat stress. Staff reported residents received regular checks and hydration passes. Review of the training records and copies of mailed information revealed staff members and responsible persons received heat stress information and those mailed were informed they would have to complete education prior to their next scheduled work day.

Based on observations, record reviews, resident, physician and staff interviews the facility failed to notify the physician when during a urinary catheter change the nurse observed a slit in the skin at the catheter insertion site with progression of increased erosion of skin around an indwelling urinary catheter, which resulted in the resident experiencing pain for over a month, for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent 30 day minimum data set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact for daily decision making, required extensive assistance with toileting and hygiene and had an indwelling urinary catheter. A review of an admission nursing assessment dated [DATE] at 3:35 PM indicated Resident #1 was alert and oriented and had an indwelling urinary catheter in place. A section of the assessment labeled skin assessments had no documentation regarding the condition of Resident #1's skin around his urinary catheter. A review of a physician's history and physical dated 11/14/16 indicated Resident #1 had chronic [MEDICAL CONDITION] with a history of [MEDICAL CONDITION] and because of nerve damage was dependent on an indwelling urinary catheter. A review of a nurse's note dated 12/30/16 at 11:50 PM documented by Nurse #4 indicated indwelling urinary catheter was changed and resident tolerated procedure well. The note further indicated there was no assessment regarding the condition of Resident #1's skin around the urinary catheter and no documentation the physician was notified regarding the condition of Resident #1's skin around the urinary catheter. A review of a progress note dated 01/16/17 by the Nurse Practitioner (NP) indicated Resident #1 was seen today because of recurrent UTIs and refer to urology for further work up. A review of a Urology Specialists note dated 01/17/17 by a Physician's Assistant (PA) indicated Resident #1 had been treated for [REDACTED]. A review of a progress note dated 01/18/17 by the Nurse Practitioner (NP) indicated the notes from urology were reviewed and Resident #1 was having issues related to chronic indwelling urinary catheter which included pain and some increase in urethral opening and urology suggested a suprapubic catheter (a tube place through the abdomen into the bladder to drain urine into a bag). A section labeled assessment and plan indicated frequent urinary tract infections and urethra meatus erosion. A review of a facility document titled Physician Communication Record indicated an entry dated 01/22/17 Resident #1 complained of pain to the skin of his penis. During an interview on 01/24/17 at 2:52 PM with Nurse #3 she stated she worked first and second shifts and had provided care to Resident #1. She explained family had approached her recently and were upset and asked her if she had seen Resident #1's private area. She stated she told them she had not looked at his private areas and confirmed she had not received any report from other nurses regarding any problem with the skin in his private areas and had not talked to the physician or NP about it. During an interview on 01/24/17 at 3:28 PM with Nurse #4 who was also the second shift Nursing Supervisor he explained he changed Resident #1's catheter on 12/30/16 because the NP wanted him to change it because she wanted a clean urine specimen for a urinalysis and culture and sensitivity. He stated when he changed Resident #1's catheter he noticed there was a slit in the skin on the underside of his penis. He explained he did not know the length of the split in the skin or how long the slit in the skin had been there. He stated he thought the slit had occurred because of long term use of a urinary catheter but he had not received any reports from staff regarding the condition of Resident #1's skin around his urinary catheter and had not reported the slit in the skin to the physician or NP because he thought it was a chronic condition and they were already aware. During an interview on 01/24/17 at 4:10 PM with the treatment nurse she stated when Resident #1 was admitted she was in his room with another nurse who completed his admission nursing assessment and she had observed Resident #1 had an area that looked like a slit at the catheter insertion site and it appeared to her to be an old scar. She explained she assessed the open skin on Resident #1's penis on 01/19/17 and reported to the Director of Nursing (DON) that Resident #1's skin did not look like that when he was admitted . She stated she also observed 2 small open areas on his scrotum that she thought was excoriation of the skin and she put barrier cream on the areas. She further stated she was not aware of the slit skin because no one had reported it to her so she had not reported it to the physician or NP until today and the NP had just written an order to have the wound Physician to see Resident #1 on 01/25/17. During an observation and interview on 01/24/17 at 4:52 PM Resident #1 was seated in a wheelchair in his room and was shifting from one side to another. He stated he could not sit comfortably in his wheelchair because he had problems related to his urinary catheter. He explained he could not get comfortable when sitting in his wheelchair because it caused pressure and pain to the split skin on his penis and the only time he was comfortable was when he is in bed. He stated he had told staff he was hurting and sore during the last month but nobody took him seriously and felt they had ignored him and the opening of skin had increased during that time. He explained he had told his family he wanted to see his Urologist because he was hurting in his private areas and he saw an Associate who was a Physician's Assistant (PA) in the Urologist office last week and was told the skin on his penis had split from the end of his penis where the catheter went in down to his scrotum and he would have to have a new catheter inserted in his stomach on 01/27/17. He stated the PA asked him how long it had been like that and he told him it had happened over the last month but nobody listened to him when he told them something was wrong. He explained he took routine pain medication for back pain and that helped decrease his pain but the area was uncomfortable and sore especially when he sat in his wheelchair During an interview on 01/25/17 at 1:05 PM with Resident #1's physician who was also the facility Medical Director he explained fissuring occurred at the end of the penis with long term urinary catheter use and even with use of a leg strap it was hard to keep movement from causing some erosion. He stated he had not received calls from nursing staff regarding the erosion of the skin on Resident #1's penis but had heard about it indirectly but could not recall who had reported it. He further stated he expected for staff to keep him or his NP or the on-call physician notified if there was increased erosion or splitting of the skin and there were on call providers available for staff to call and report any changes a resident had. During an interview on 01/25/17 at 2:36 PM with the NP she confirmed she had seen Resident #1 numerous times for chronic UTIs and she had made a referral for him to see his Urologist and had read the notes from his visit on 01/17/17. She stated she had not seen the open skin on Resident #1's penis until 01/24/17 and she had referred him for the wound Physician for evaluation today. She stated she was not sure when the skin had split but she saw a note in the physician's communication book on Monday 01/23/17 when she made rounds in the facility that Resident #1's skin had split on his penis. She stated she relied on staff to inform her when a resident had open areas of their skin or had changes in their condition. She explained there was a physician communication book for nurses to document resident concerns and she expected for staff to write concerns in the book or call the provider on call when a resident had changes in their condition. During a telephone interview on 01/25/17 at 3:11 PM with the PA from Resident #1's Urologist office he confirmed he saw Resident #1 on 01/17/17 and Resident #1 had long term urinary catheter use and was at risk for erosion of skin around the catheter due to chronic rubbing or friction by the catheter in his pants. He explained the erosion of skin around a catheter usually began at the opening where the catheter was inserted and then over time the skin split open. He stated he had looked back in Resident #1's chart to see when the erosion had started but he could not confirm when it had begun. He explained when the catheter was down in Resident #1's pants leg it caused the catheter to move and caused friction and tearing of the skin and if he was moved around by staff it increased the risk of pulling on the catheter which caused erosion and tearing. He confirmed he did not expect to see the extent of tearing of the skin on Resident #1's penis before he examined him but verified the tear extended from the urethra where the catheter was inserted down the underside of his penis to his scrotum. He stated they encouraged staff to let them know if there was a change in the skin around his catheter in order to prevent infection or complications and now since the skin had opened the only option was to insert a suprapubic catheter. He explained the Urologist would be able do a more detailed examination of his skin while Resident #1 was under anesthesia on 01/27/17 and would be able to assess for any skin damage but they could not do that examination now because it would be too painful for him. During an interview on 01/25/17 at 4:51 PM with the Administrator she explained last Thursday afternoon on 01/19/17 after second shift started the Social Worker (SW) was looking for the DON because Resident #1's family had questions. She explained the DON reviewed Resident #1's medical record and then talked to the treatment nurse and they went to Resident #1's room and looked at Resident #1's skin. She stated then they came and reported to her what his skin looked like and that was first she had heard of it. During an interview on 01/26/17 at 12:24 PM with Nurse #5 she explained she worked the day shift and had been assigned to care for Resident #1 in the past. She stated she recalled she had looked at the skin around his catheter about 5 weeks ago with the treatment nurse and there was a small slit at the catheter insertion site that looked like a scar and the treatment nurse told her to keep an eye on it and if it started draining or changed to let her know. She stated no one had reported any open skin around Resident #1's catheter to her and she had not reported any problems with his catheter or his skin to the physician. During a telephone interview on 01/26/17 at 2:01 PM with Nurse #6 she stated she had provided care for Resident #1 and had assessed his catheter and his skin approximately 2 months ago and he had no skin breakdown but Resident #1 had complained his catheter was pulling when he stood up and she had adjusted the leg strap higher up on his thigh and he had no more complaints to her. She stated she had not reported any problems with his skin or catheter to the physician. During an interview on 01/26/17 at 2:28 PM with Nurse #7 he stated he worked second and third shifts and he recalled he had done a skin assessment for Resident #1 over a month ago but he did not see any erosion or open skin at that time. He further stated he had not reported any skin concerns to the physician. During an interview on 01/26/17 at 2:39 PM with Nurse #8 she stated she was assigned to care for Resident #1 last Friday on 01/20/17 on first shift but she did not usually work on the hall where Resident #1 lived and she was unfamiliar with the resident's. She stated she received no report from the night shift nurse about open skin around Resident #1's catheter and she did not look at his skin because she did not have any reason to look at his catheter or his skin during her shift. She stated the Nurse Aides (NAs) did not report to her any problems or concerns with open skin around his catheter and she had not reported any concerns to the physician. During an interview on 01/26/17 at 3:47 PM the DON stated it was her expectation for nursing staff to notify the physician when a resident had a change in condition. She explained the facility utilized a communication book and staff were expected to document any concerns for the NP or physician to review when they made rounds in the facility. She stated she also expected for staff to call the NP or physician or physician on call when a resident had a change in their condition.

Based on observations, record reviews and resident and staff interviews the facility failed to promote a resident's dignity and respect when they failed to pay attention to him after he had told staff he was hurting and sore due to erosion of skin around a urinary catheter during the last month and the opening of skin had increased for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent 30 day minimum data set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact for daily decision making, required extensive assistance with toileting and hygiene and had an indwelling urinary catheter. A review of an admission nursing assessment dated [DATE] at 3:35 PM indicated Resident #1 was alert and oriented and had an indwelling urinary catheter in place. A section of the assessment labeled skin assessments had no documentation regarding the condition of Resident #1's skin around his urinary catheter. A review of a physician's history and physical dated 11/14/16 indicated Resident #1 had chronic [MEDICAL CONDITION] with a history of [MEDICAL CONDITION] and because of nerve damage was dependent on an indwelling urinary catheter. A review of a nurse's note dated 12/30/16 at 11:50 PM documented by Nurse #4 indicated indwelling urinary catheter was changed this morning and resident tolerated procedure well but there was no assessment regarding the condition of Resident #1's skin around the urinary catheter. A review of a progress note dated 01/16/17 by the Nurse Practitioner (NP) indicated Resident #1 was seen today and had recurrent UTIs and refer to urology for further work up. A review of a Urology Specialists note dated 01/17/17 by a Physician's Assistant (PA) indicated Resident #1 had been treated for [REDACTED]. A review of a progress note dated 01/18/17 by the NP indicated the notes from urology were reviewed and Resident #1 was having issues related to chronic indwelling urinary catheter including pain and some increase in urethral opening and urology suggested a suprapubic catheter (a tube place through the abdomen into the bladder to drain urine into a bag). A section labeled assessment and plan indicated frequent urinary tract infections and urethra meatus erosion. During an interview on 01/24/17 at 3:28 PM with Nurse #4 who was also the second shift Nursing Supervisor he explained he changed Resident #1's catheter on 12/30/16. He stated when he changed Resident #1's catheter he noticed there was a slit in the skin on the underside of his penis. He further stated he did not know the length of the split in the skin or how long the slit in the skin had been there but the treatment nurse should know how long the slit had been there and he had not received any reports from staff regarding the condition of Resident #1's skin around his urinary catheter. During an interview on 01/24/17 at 4:00 PM with the treatment nurse she stated when Resident #1 was admitted she was in his room with another nurse who completed his admission nursing assessment and she had observed Resident #1 had an area that looked like a slit at the catheter insertion site and it appeared to her to be an old scar. She explained Resident #1 went for a visit to a Urologist office on 01/17/17 and she was called to Resident #1's room on 01/19/17 by the Director of Nursing (DON) and she assessed the open skin on Resident #1's penis and reported to the DON that Resident #1's skin did not look like that when he was admitted . She stated she did not know how the skin had split but thought the catheter could have caused the split in the skin especially when he pulled up his pants or if there was movement of the catheter. During an observation and interview on 01/24/17 at 4:52 PM Resident #1 was seated in a wheelchair in his room and was shifting from one side to another. He stated he could not sit comfortably in his wheelchair because he had problems related to his urinary catheter. He explained he could not get comfortable when sitting in his wheelchair because it caused pressure and pain to the split skin on his penis and the only time he was comfortable was when he is in bed. He stated he had told nurses he was hurting and sore during the last month but nobody took him seriously and felt they had ignored him and the opening of skin had increased during that time. He further stated he could not recall the names of the nurses but they were the nurses who had taken care of him. He explained he had told his family he wanted to see his Urologist because he was hurting in his private areas and he saw an Associate who was a PA in the Urologist office last week and was told the skin on his penis had split from the end of his penis where the catheter went in all the way down to his scrotum and he would have to have a new catheter inserted in his stomach on 01/27/17. He stated the PA asked him how long it had been like that and he told him it had happened over the last month but nobody listened to him when he told them something was wrong. He explained he took routine pain medication for back pain and that helped decrease his pain but the area was uncomfortable and sore especially when he sat in his wheelchair. During an interview on 01/25/17 at 3:23 PM with the Social Worker (SW) he explained Resident #1's family came to his office on 01/19/17 and told him Resident #1 was having pain, discomfort and issues with his catheter and he reported the conversation to the treatment nurse and to the DON. He stated no one had told him anything about concerns prior to his family mentioning it. During an interview on 01/25/17 at 4:51 PM with the Administrator she explained on 01/19/17 after second shift started the SW was looking for the DON because Resident #1's family had questions. She explained the DON reviewed Resident #1's medical record and then talked to the treatment nurse and they went to Resident #1's room and looked at Resident #1's skin and they came and reported to her what his skin looked like and that was first she had heard of it. During a follow up interview on 01/26/17 at 9:00 AM with Resident #1 he stated he was upset about the condition of his skin on his penis. He explained he could not get comfortable when he was sitting in his wheelchair and that upset him and he was upset because this problem had been going on for a month. He then started crying and with tears flowing down his cheeks and his voice cracking he stated he was so upset because staff let it go for so long and he felt like they didn't believe him and it shouldn't have happened and he didn't want anyone else to go through what he had gone through. During an interview on 01/26/17 at 9:24 AM with the DON she stated she expected for nursing staff to treat all residents' with dignity and respect. She also stated it was her expectation for staff to assess residents when they complained of skin concerns and she was not made unaware of the split skin on his penis until 01/19/17 when she was informed family had concerns.

Based on observations, record reviews, resident, physician and staff interviews the facility failed to assess the progression of erosion of skin around an indwelling urinary catheter, which resulted in the resident experiencing pain and discomfort for over a month and was subsequently scheduled for a surgical procedure for insertion of a suprapubic catheter (a tube place through the abdomen into the bladder to drain urine into a bag), for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent 30 day minimum data set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact for daily decision making, required extensive assistance with toileting and hygiene and had an indwelling urinary catheter. A review of an admission nursing assessment dated [DATE] at 3:35 PM indicated Resident #1 was alert and oriented and had an indwelling urinary catheter in place. A section of the assessment labeled skin assessments had no documentation regarding the condition of Resident #1's skin around his urinary catheter. A review of a physician's history and physical dated 11/14/16 indicated Resident #1 had chronic [MEDICAL CONDITION] with a history of [MEDICAL CONDITION] and because of nerve damage was dependent on an indwelling urinary catheter. A review of a care plan dated 11/28/16 with a problem statement for altered pattern of urinary elimination with indwelling urinary catheter indicated Resident #1 was at risk for infection and had a history of [REDACTED]. The goals revealed Resident #1 would be free from urinary tract infections and would be clean, dry and free from skin breakdown. The interventions indicated in part to change indwelling urinary catheter per physician's orders [REDACTED]. The interventions also indicated to monitor for signs or symptoms of urinary tract infections and notify the physician as indicated. A review of a facility document labeled resident care guide included in part Resident #1 had an indwelling urinary catheter and ensure drainage tubing was secured with anchoring device such as a leg strap to prevent tension or accidental removal. A review of a nurse's note dated 12/30/16 at 11:50 PM documented by Nurse #4 indicated indwelling urinary catheter was changed and resident tolerated procedure well but there was no assessment documented regarding the condition of Resident #1's skin around the urinary catheter. A review of a progress note dated 01/16/17 by the Nurse Practitioner (NP) indicated Resident #1 was seen today and had recurrent UTIs and refer to urology for further work up. A review of a nurse's note dated 01/16/17 at 11:33 PM indicated a urine culture showed bacterial growth and the NP was notified and new orders were received for Bactrim DS (oral antibiotic) and a urology consult. A review of a Urology Specialists note dated 01/17/17 by a Physician's Assistant (PA) indicated Resident #1 had been treated for [REDACTED]. A review of a progress note dated 01/18/17 by the NP indicated the notes from urology were reviewed and Resident #1 was having issues related to chronic indwelling urinary catheter including pain and some increase in urethral opening and urology suggested a suprapubic catheter. A section labeled assessment and plan indicated frequent urinary tract infections and urethra meatus erosion. A review of a therapy note dated 01/19/17 by Speech Therapist (ST) #1 indicated Resident #1 stated he was in too much pain to do anything today because his penis was split down the middle from his catheter and treatments would resume the following day. During an interview on 01/24/17 at 2:52 PM with Nurse #3 she stated she worked first and second shifts and had provided care to Resident #1. She explained family had approached her recently and were upset and asked her if she had seen Resident #1's private area and she stated she told them she had not and had not received any report from other nurses regarding any problem with the skin in his private areas. During an interview on 01/24/17 at 3:28 PM with Nurse #4 who was also the second shift Nursing Supervisor he explained he changed Resident #1's catheter on 12/30/16 because the NP wanted him to change it because she wanted a clean urine specimen for a urinalysis and culture and sensitivity. He stated when he changed Resident #1's catheter he noticed there was a slit in the skin on the underside of his penis. He further stated he did not know the length of the split in the skin or how long the slit in the skin had been there but the treatment nurse should know how long the slit had been there. He also stated he had not reported it to anyone because he thought the slit had occurred because of long term use of a urinary catheter. He further stated he had not received any reports from staff regarding the condition of Resident #1's skin around his urinary catheter. During an interview on 01/24/17 at 3:55 PM with Nurse Aide (NA) #1 she stated she had been assigned to care for Resident #1 and Nurse #4 had asked her to assist him when he changed Resident #1's catheter on 12/30/16. She stated she didn't notice the slit on Resident #1's penis but Nurse #4 mentioned it when he changed the catheter. She further stated she didn't think any more about it and did not report anything to anyone since Nurse #4 was already aware. During an interview on 01/24/17 at 4:00 PM with the treatment nurse she stated when Resident #1 was admitted she was in his room with another nurse who completed his admission nursing assessment and she had observed Resident #1 had an area that looked like a slit at the catheter insertion site and it appeared to her to be an old scar. She explained Resident #1's family went with him for a visit to a Urologist office prior to 01/18/17 and they saw the open skin on his penis during that visit. She stated when he came back to the facility Resident #1's family wanted to know what had happened and she was called to Resident #1's room on 01/19/17 by the Director of Nursing (DON) because family wanted to know why the skin on his penis had split and had progressed. She further stated she assessed the open skin on Resident #1's penis and reported to the DON that Resident #1's skin did not look like that when he was admitted . She stated she also observed 2 small open areas on his scrotum that she thought was excoriation of the skin. She explained she put barrier cream on the areas but was not aware of the split skin because no one had reported it to her. She stated she did not know how the skin had split but thought the catheter could have caused the split in the skin especially when he pulled up his pants or if there was movement of the catheter. She further stated the NP had just written an order to have the wound Physician to see Resident #1 on 01/25/17. During an observation and interview on 01/24/17 at 4:52 PM Resident #1 was seated in a wheelchair in his room and was shifting from one side to another. He stated he could not sit comfortably in his wheelchair because he had problems related to his urinary catheter. He explained he could not get comfortable when sitting in his wheelchair because it caused pressure and pain to the split skin on his penis and the only time he was comfortable was when he is in bed. He stated he had told staff he was hurting and sore during the last month but nobody took him seriously and he felt they had ignored him and the opening of skin had increased during that time. He explained he had told his family he wanted to see his Urologist because he was hurting in his private areas and he saw an Associate who was a PA in the Urologist office last week and was told the skin on his penis had split from the end of his penis where the catheter went in down to his scrotum and he would have to have a new catheter inserted in his stomach on 01/27/17. He stated the PA asked him how long it had been like that and he told him it had happened over the last month but nobody listened to him when he told them something was wrong. He explained he took routine pain medication for back pain and that helped decrease his pain but the area was uncomfortable and sore especially when he sat in his wheelchair. During a telephone interview on 01/25/17 at 10:21 AM with Nurse #1 she stated she usually worked on weekends from 7:00 PM until 7:00 AM and had only been assigned to care for Resident #1 once or twice. She stated she thought she was assigned to care for him the last time about a month ago. She explained she recalled she checked to make sure the leg strap was in place to secure Resident #1's urinary catheter but she had not assessed his skin around his catheter or on his penis and no one had reported any open skin to her. On 01/25/17 at 10:42 AM an attempt was made to call NA #2 who had been assigned to care for Resident #1 but there was no answer or option to leave a message. During an observation and interview on 01/25/17 at 11:00 AM a wound Physician and the treatment nurse were in Resident #1's room. Resident #1 was lying in bed and the skin on the underside of his penis was split open from the top of the penis where the urinary catheter was inserted down to his scrotum. The wound Physician stated he felt the urinary catheter had caused the skin to split and Resident #1 was scheduled to have a suprapubic catheter placed through his abdomen into his bladder on 01/27/17. A review of a wound care specialist evaluation dated 01/25/17 indicated Resident #1 was seen and evaluated today for a wound of the inferior (underside) split of his penis of greater than 10 days duration due to an indwelling catheter and the wound size was 4 centimeters (cm) x 1.5 cm width and depth was not measurable. The notes further indicated Resident #1 was scheduled for a surgical procedure to have a suprapubic catheter placed on Friday 01/27/17. The notes also indicated to apply a dry protective dressing daily and as needed. During an interview on 01/25/17 at 1:05 PM with Resident #1's physician who was also the facility Medical Director he explained fissuring occurred at the end of the penis with long term urinary catheter use and even with use of a leg strap it was hard to keep movement from causing some erosion. He stated he had not received calls from nursing staff regarding the erosion of the skin on Resident #1's penis but had heard about it indirectly but could not recall who had reported it. He further stated he expected for staff to keep him or his NP or the on-call physician notified if there was increased erosion or splitting of the skin and there were on call providers available for staff to call and report any changes a resident had in their condition. During an interview on 01/25/17 at 2:36 PM with the NP she confirmed she had seen Resident #1 numerous times for chronic UTIs and she had made a referral for him to see his Urologist and had read the notes from his visit on 01/17/17. She stated she had not seen the open skin on Resident #1's penis until 01/24/17 and she had referred him for the wound Physician for evaluation today. She stated she was not sure when the skin had split but she saw a note in the physician's communication book on Monday 01/23/17 when she made rounds in the facility that Resident #1's skin had split on his penis. She stated she only looked at his catheter if there was problem and she relied on staff to inform her when a resident had open areas of their skin. She further stated she expected for staff to write in the communication book or call her or the on call physician if a resident had a change in condition or if they had concerns about skin issues. During a telephone interview on 01/25/17 at 3:11 PM with the PA from Resident #1's Urologist office he confirmed he saw Resident #1 on 01/17/17 and Resident #1 had long term urinary catheter use and was at risk for erosion of skin around the catheter due to chronic rubbing or friction by the catheter in his pants. He explained the erosion of skin around a catheter usually began at the opening where the catheter was inserted and then over time the skin split open. He stated he had looked back in Resident #1's chart to see when the erosion had started but he could not confirm when it had begun. He explained when the catheter was down in Resident #1's pants leg it caused the catheter to move and caused friction and tearing of the skin and if he was moved around by staff it increased the risk of pulling on the catheter which caused erosion and tearing. He stated he did not expect to see the extent of tearing on Resident #1's penis before he examined him but during the exam he observed the tear extended from the urethra where the catheter was inserted down the underside of his penis to his scrotum. He stated they encouraged staff to let them know if there was a change in the skin around his catheter in order to prevent infection or complications and now since the skin had opened the only option was to insert a suprapubic catheter. He explained the Urologist would be able do a more detailed examination of his skin while Resident #1 was under anesthesia during the procedure for suprapubic catheter insertion on 01/27/17 to assess for any skin damage but they could not do that examination now because it would be too painful for him. During an interview on 01/25/17 at 3:23 PM with the Social Worker (SW) he explained Resident #1's family came to his office on 01/19/17 and told him Resident #1 was having pain, discomfort and issues with his catheter and he reported the conversation to the treatment nurse and to the DON. He stated no one had told him anything about concerns prior to his family mentioning it. He confirmed family had gone with Resident #1 to an Urologist appointment and saw the open skin during the appointment and they seemed to be very surprised by what it looked like. On 01/25/17 at 4:00 PM an attempt was made to call NA #3 who had been assigned to care for Resident #1 but there was no answer. During an interview on 01/25/17 at 4:51 PM with the Administrator she explained last Thursday afternoon on 01/19/17 after second shift started the SW was looking for the DON because Resident #1's family had questions. She explained the DON reviewed Resident #1's medical record and then talked to the treatment nurse and they went to Resident #1's room. She stated they talked to Resident #1's family and looked at Resident #1's skin and then they came and reported to her what his skin looked like and that was first she had heard of it. During an interview on 01/26/17 at 8:30 AM with ST #1 he confirmed he had routinely provide speech therapy to Resident #1 but on 01/19/17 Resident #1 said he was in too much pain because the skin was split on his penis. He further explained he asked one of the nurses about it and she said he was in a lot of pain but did not explain why he was in pain and he could not remember the name of the nurse. During an interview on 01/26/17 at 12:24 PM with Nurse #5 she explained she worked the day shift and had been assigned to care for Resident #1 in the past. She stated she recalled she had looked at the skin around his catheter about 5 weeks ago with the treatment nurse and there was a small slit at the catheter insertion site that looked like a scar and the treatment nurse told her to keep an eye on it and if it started draining or changed to let her know. She stated since then no one had reported any open skin around Resident #1's catheter to her. On 01/26/17 at 1:52 PM an attempt was made to call NA #4 who had been assigned to care for Resident #1 but there was no answer or option to leave a message. On 01/26/17 at 1:59 PM an attempt was made to call NA #5 who had been assigned to care for Resident #1 but there was no answer. During a telephone interview on 01/26/17 at 2:01 PM with Nurse #6 she stated she had provided care for Resident #1 and had assessed his catheter and his skin approximately 2 months ago and he had no skin breakdown. She explained Resident #1 had complained his catheter was pulling when he stood up and she had adjusted the leg strap higher up on his thigh and he had no more complaints to her. During an interview on 01/26/17 at 2:28 PM with Nurse #7 he stated he worked second and third shifts and he recalled he had done a skin assessment for Resident #1 over a month ago but he did not see any erosion or open skin at that time. During an interview on 01/26/17 at 2:39 PM with Nurse #8 she stated she was assigned to care for Resident #1 last Friday on 01/20/17 on first shift but she did not usually work on the hall where Resident #1 lived and was unfamiliar with the resident's. She stated she received no report from the night shift nurse about open skin around Resident #1's catheter and she did not look at his skin because she did not have any reason to look at his catheter or his skin during her shift. She stated the Nurse Aides (NAs) did not report to her any problems or concerns with open skin around his catheter. During a follow up interview on 01/26/17 at 2:55 PM with Nurse #4 he confirmed when he changed Resident #1's catheter on 12/30/16 the skin was split under the catheter insertion site on the underside of his penis. He stated he did not recall the exact length of the split because he did not measure it at the time but then held up his thumb and forefinger to indicate the slit was approximately one and a half to two inches in length. He explained he had reminded the NAs to not fasten Resident #1's brief because he felt when the brief was fastened it caused the catheter to pull against his skin and could cause the skin to tear. He stated he thought Resident #1 had a chronic skin issue at his catheter site but he thought almost everyone knew the skin was open at Resident #1's catheter site. He stated Resident #1 was alert and oriented but hardly ever complained but if he was asked if he had pain or discomfort Resident #1 would state yes or no. During a follow up interview on 01/26/17 at 3:12 PM with Nurse #3 she stated she had not changed Resident #1's catheter and had not assessed the skin around his catheter when she was assigned to care for him. She further stated the NAs had not reported any open areas of skin but she had told them to make sure the leg strap was in place. She explained if the NA had reported any skin concerns to her she would have looked at his skin to evaluate it. During an interview on 01/26/17 at 3:41 PM with Nurse #9 she stated she had been assigned to care for Resident #1 in the past on second shift and had received no reports of open skin or problems related to his urinary catheter. She stated the NAs had not reported any problems with Resident #1 's skin around the catheter so she had not assessed it. During an interview on 01/26/17 at 3:47 PM the DON stated the assessment of Resident #1's skin around his urinary catheter should have been assessed on admission as a baseline. She confirmed she could find no nursing assessments regarding the open skin at Resident #1's catheter insertion site until it was brought to their attention when Resident went for a urology visit on 01/17/17. She stated it was her expectation for NAs to report any skin issues to the nurse and the nurse was expected to go and assess the resident. She explained she would have expected to see nursing assessments even if the open skin was a change with a chronic condition. She stated it was her expectation for nurses to assess a resident anytime something was reported to them.

Based on observations, record review and staff interviews the facility's administration failed to provide oversight of care for a resident when facility staff failed to do ongoing assessments of the progression of erosion of skin around an indwelling urinary catheter, which resulted in the resident experiencing pain and discomfort for over a month and was subsequently scheduled for a surgical procedure for insertion of a suprapubic catheter (a tube placed through the abdomen into the bladder to drain urine into a bag), for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). The facility also failed to utilize its resources effectively to implement and sustain plans of correction which resulted in observations of expired medications in medication carts during 4 federal surveys of record for a repeat deficiency in the area of medication storage. Findings included: Cross refer to F 315: Based on observations, record reviews, resident, physician and staff interviews the facility failed to assess the progression of erosion of skin around an indwelling urinary catheter, which resulted in the resident experiencing pain and discomfort for over a month and was subsequently scheduled for a surgical procedure for insertion of a suprapubic catheter (a tube placed through the abdomen into the bladder to drain urine into a bag), for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). Cross refer to F 431: Based on observations, record review and staff interviews the facility failed to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline in 2 of 7 medication carts (100 hall medication cart and a cart which was used for 300, 500 and 700 halls). The facility was recited for F 431 for failure to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME][MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline in 2 of 7 medication carts. F 431 was originally cited on the annual recertification survey on 02/04/16 for failure to discard an expired vial of Humalog (insulin) and failed to ensure 2 bottles of [MEDICATION NAME] (blood thinner) were dated when opened. F 431 was cited again during the annual recertification survey conducted on 11/03/16 for failure to remove expired pain medication and was recited on a Revisit/Follow up survey on 12/29/16 for failure to remove expired medications from use. F 431 was subsequently recited again on the current Revisit/Follow up survey of 02/09/17 for failure to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME][MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline.

Based on observations, record reviews and staff interviews the facilities Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in December of 2016. This was for 2 recited deficiencies which were originally cited in February of 2016 on a Recertification survey and was recited again in November of 2016 on a Recertification survey. The facility was subsequently cited on the Revisit/Follow up survey on 12/29/16 and again on the current Revisit/Follow up survey. The deficiencies were in the areas of effective Administration and drug storage. The continued failure of the facility during 4 federal surveys of record show a pattern of the facilities inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referred to: 1. a. F 490 Administration: Based on observations, record review and staff interviews the facility's administration failed to provide oversight of care for a resident when facility staff failed to do ongoing assessments of the progression of erosion of skin around an indwelling urinary catheter, which resulted in the resident experiencing pain and discomfort for over a month and was subsequently scheduled for a surgical procedure for insertion of a suprapubic catheter (a tube placed through the abdomen into the bladder to drain urine into a bag), for 1 of 3 residents sampled with indwelling urinary catheters (Resident #1). The facility administration also failed to utilize its resources effectively to implement and sustain plans of correction which resulted in observations of expired medications in medication carts during 4 federal surveys of record for a repeat deficiency in the area of medication storage. During the recertification survey of February 2016 the facility was cited for failure to discard an expired vial of Humalog (insulin) and failed to ensure 2 bottles of [MEDICATION NAME] (blood thinner) was dated when opened. On the annual recertification survey November 2016 the facility was again cited for failure to remove expired medications from use on medication carts and in medication storage rooms. On the Revisit/Follow survey of December 2016 the facility was cited again for failure to remove expired pain medication from medications carts and on the current Revisit/Follow up survey the facility was cited again for failure to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME] Flex pen and discard an opened, undated multi-dose vial of normal saline in medication carts. b. F 431 Drug storage: Based on observations, record review and staff interviews the facility failed to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline in 2 of 7 medication carts (100 hall medication cart and a cart which was used for 300, 500 and 700 halls). The facility was recited for F 431 for failure to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME][MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline in 2 of 7 medication carts. F 431 was originally cited on the annual recertification survey on 02/04/16 for failure to discard an expired vial of Humalog (insulin) and failed to ensure 2 bottles of [MEDICATION NAME] (blood thinner) was dated when opened. F 431 was cited again during the annual recertification survey conducted on 11/03/16 for failure to remove expired pain medication and F 431 was recited on a Revisit/Follow up survey on 12/29/16 for failure to remove expired medications from use. F 431 was subsequently recited again on the current Revisit/Follow up survey of 02/09/17 for failure to discard 2 medications in unlabeled cups prepared for administration, remove an expired [MEDICATION NAME][MEDICATION NAME] and discard an opened, undated multi-dose vial of normal saline. During an interview on 01/25/17 at 4:51 PM with the Administrator she explained she was unaware of the split skin on Resident #1's penis until the Director of Nursing (DON) and treatment nurse went to Resident's #1's room on 01/19/17 and assessed his skin and then they came and reported to her what his skin looked like and that was first she had heard of it. She further stated it was her expectation for nurses to do a skin referral to the treatment nurse when a resident had a change in their skin condition and she expected for the treatment nurse to assess the resident's skin. She explained the Quality Assurance and Assessment Committee met on a monthly basis and the Pharmacist attended the meetings on a quarterly basis. She stated the committee had developed the plans of correction for drug storage and they had last met in January 2017. She explained they had in-serviced nursing staff again after the last Revisit/Follow up survey to check medication carts and discard all expired medications and nurses who were assigned to a medication cart were expected to check the carts for expired medications. She further explained Administrative nurses which included the DON, Assistant Director of Nursing and Nursing Supervisors were expected to monitor medication carts and medications storage rooms for expired medications. She stated she had also checked for expired medications and the Pharmacist had audited for expired medications. She further stated she did not know why the plans had failed because everything had looked good to her and she thought with multiple layers of observations there would be no expired medications in medication carts. She explained they would have to develop another plan to ensure expired medications were not left on medication carts or in medication storage rooms and in-servicing of nursing staff would have to be done again.

Based on observations, record review and staff interviews, the facility failed to supervise one (1) of eighteen (18) sampled cognitively impaired residents at risk for wandering who exited the building unattended by staff. (Resident #1). Immediate Jeopardy began on 12/20/10 when Resident #1 exited the building for an undetermined amount of time resulting in her having to be hospitalized for [REDACTED]. The facility remains out of compliance at a lower severity level of D (an isolated deficiency, no actual arm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitor of systems put in place. The findings are: 1. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The current care plan, last reviewed 7/27/10, for the potential for wandering had a goal that the resident's whereabouts will be known to staff as demonstrated by no events of leaving facility unsupervised as evidenced by no unsupervised exits through next review. The following interventions were dated as being in place since 8/12/09: check for whereabouts frequently, insure that alarmed exits are functional, orient to surroundings and room number as frequently as needed, insure picture and name are present on wandering resident board, and monitor wanderguard. On a Wandering Risk assessment dated [DATE], Resident #1 scored a "15" with a score of greater than "5" indicating the resident was at risk for wandering and that follow up was required. This assessment did not include any comments or actions taken in the narrative section. The most recent quarterly MDS dated [DATE] coded Resident #1 with short term memory impairment and moderately impaired decision making skills. She required limited assistance for transfers, dressing, walking in her room, toileting, hygiene, and supervision and set up for locomotion on and off the unit. She was assessed with [REDACTED]. Her primary mode of transportation was coded as self propelling a wheelchair. An incident report for Resident #1 dated 12/20/10 stated the time of the incident as "unsure of time of incident - found @ 0330 (3:30 AM)." Per this incident report, Resident #1 had an unsupervised exit while in her wheelchair and received abrasions to her right elbow and right lower leg. The report noted that she was located outdoors by an entrance/exit door and subsequently went to the emergency room . There was no indication as to who completed this incident report. The nursing note written by Licensed Nurse #4 on 12/20/10 at 5:02 AM stated a nurse aide returned the resident to the resident's area of the facility. The resident was observed to have a reddened area to her right elbow, a small abrasion on the elbow and two more reddened areas and abrasion on her right lower outer leg. Her rectal temperature was 90.5 degrees Fahrenheit. Warm blankets were placed over the resident, the on call physician's nurse was called and the resident was sent to the emergency room for evaluation. The note indicated the resident left for the hospital by 4:40 AM. Per the Weather Channel Internet service, the low temperature on 12/20/10 was 21 degrees Fahrenheit. Review of the EMS report, dated 12/20/10 at 3:26 AM, revealed upon EMS assessment, Resident #1 was "red and cold to touch all over body" and "shivering". The Emergency Department Documentation dated 12/20/10 noted her temperature in the ED was 91 degrees Fahrenheit and she was placed in a Bear hugger with warmed IV fluids and covered with warm blankets. She was admitted to the hospital for further observations when after three hours her temperature was still 95 degrees Fahrenheit. This report listed her [DIAGNOSES REDACTED]." Review of the facility's posted floor plan revealed six (6) outside courtyards. One was a fire door off the secured memory impaired unit which required a key code to exit. Observations of the remaining five (5) courtyards, all surrounded by the facility building, revealed there were a total of twelve (12) doors leading outside into a courtyard. None of these doors were equipped with a wanderguard system or a fire alarm system (which opened and alarmed after pushing for fifteen seconds). Observations on 12/22/10 beginning at 9:22 AM of these twelve (12) courtyard doors revealed: * five (5) doors had an alarm box located in the upper corner which sounded when the door opened and immediately quit sounding when the door closed (Resident #1 was suspected of exiting one of these doors, per the Administrator, which self closed); *three (3) doors had an alarm box located in the upper corner which were turned off (if turned on they would immediately quit sounding when closed); *three (3) doors had no alarm at all on the door and were not locked (one was off the therapy room which had staff present at all times when the door to therapy was open); *one (1) door was off the staff breakroom which required a key code to enter. The wanderguard system was only located on some of the doors exiting the building into the parking area, not the courtyards. The doors exiting to the parking areas which were not alarmed with the wanderguard system were fire doors which would alarm and open after pushing for fifteen seconds. Interview with the Director of Nursing (DON) on 12/22/10 at 10:55 AM revealed that a form was developed to document hourly monitoring of exit/patio doors, however, it had not been implemented at this time. When asked when this system would begin, the DON stated "today." Per the DON, this was to be included in the inservicing of staff and expected all inservicing to be completed by tomorrow, as they were inservicing staff as they came to work. Interview with maintenance staff on 12/22/10 at 11:16 AM revealed he checked all of the alarms on Friday 12/17/10 and found them to be operational. He reported that he regularly checked the alarms once or twice a week but did not document these checks. He stated he would often find the alarm on the door to the courtyard by room 900 (not the door Resident #1 exited but closest to her room) either turned off or broken. This alarm was turned off during the above observation. He was not sure if staff or residents were turning the alarms off or breaking them. He stated he reported this to the DON "a week or so ago" and was instructed to keep a list of what he discovered. He stated he had not done this yet. He further reported that he had not received any direction specific to alarms since Resident #1's exit from the facility until this date. Further interview with maintenance staff revealed that only three doors leading to the courtyards were locked at night. One was the exit through the therapy room, one was through the staff breakroom, and the other was through the restorative dining room across from the therapy room (which had an alarm which sounded when the door opened and quit sounding when the door closed). On 12/22/10 at 11:06 AM, Licensed Nurse (LN) #5 stated she was very familiar with Resident #1 and said that Resident #1 sometimes slept through the night and sometimes did not. When she wouldn't sleep, Resident #1 roamed around the halls in her wheelchair. LN #5 stated the resident had been in and out of bed several times the night of 12/20/10. When she started her rounds at 3:20 AM, LN #5 started at Resident #1's room. She noticed the resident was not in bed or in the bathroom and told staff to look for her. LN went down 1000 hall as the resident usually went down 1000 hall per her usual pattern of wandering at night. Once in the service area she found NA #5 bringing Resident #1 down the hall, saying he found her outside. LN #5 stated Resident #1 was only wearing a hospital gown, nothing on her feet, she was shivering and her skin felt cold. She had abrasions on her side. LN #4 proceeded to care for her and changed her wet incontinent brief, while LN #5 called the physician and prepared for transfer to the hospital. LN #5 stated Resident #1 did not receive any medications after 9:00 PM. LN #5 could not recall when she had last seen Resident #1 prior to her 3:20 AM rounds. LN #5 further stated that she recalled Resident #1 getting out into the courtyard once before on the 7p - 7a shift. She could not give any details. LN #5 stated that all staff were aware that Resident #1 wandered at night. She stated staff were expected to look in on her when they passed her bedroom door and check the door alarms whenever they sounded. Interview with NA #7 on 12/22/10 at 2:45 PM revealed she was assigned to Resident #1 the night of 12/20/10. She stated that during her rounds at about 1:30 AM, Resident #1 was in bed. She did not see Resident #1 again until she was informed that the resident was missing. She stated that Resident #1 often wandered around the facility and everyone was supposed to watch out for her. She further stated she did not hear any alarms go off that night. Interview with NA #8 on 12/22/10 at 3:25 PM revealed the NA had last seen Resident #1 around 1:30 AM. She reported she had seen the resident "go around the corner toward the laundry room." She further explained that this was Resident #1's usual routine during the night shift. NA #8 stated that the staff were expected to check on her every two hours and watch for her when she was moving around in her wheelchair. Interview with LN #6 on 12/23/10 at 11:00 AM revealed that she saw Resident #1 go through the fire doors into the service hallway around 1:00 AM on 12/20/10. She returned Resident #1 to her unit and asked LN #5 about the resident being in the service hall. LN #6 stated she was told that the resident should not be in the service hall but that you "can't stop her". LN #6 reported that she did not see Resident #1 again that night. On 12/23/10 at 11:22 AM, LN #4 who assessed Resident #1 following the incident was interviewed. LN #4 stated Resident #1 wheeled all around the facility during night shift. LN #4 stated that she thought she had seen her thirty minutes before she was found outside but couldn't be sure. She stated that she was called to the resident's room and noted abrasions and stated she suspected Resident #1 had fallen out of her wheelchair. She stated Resident #1 was very cold to the touch. She further stated that the facility had multiple courtyards which were not secured. Interview with NA #5 on 12/23/10 at 12:05 PM revealed he was not assigned to Resident #1 on 12/20/10, but was familiar with her. He described her usual behavior at night was propelling herself in her wheelchair around the building. He stated she had a certain path she liked to follow which included going down the 1000 hall through the fire doors into the service hall, and around the corner, back out another set of fire doors making a circle. NA #5 could not say when he had last seen Resident #1 prior to the incident. NA #5 stated on 12/20/10 he went to the staff breakroom in the service hall. Once in the room, he heard a "noisy voice", which he described as a low faint voice. NA #5 stated he walked around the staff breakroom trying to track the source of the noise. Finding the noise louder at one end of the room, he left the staff breakroom and followed the direction from which he suspected the noise was coming. NA #5 stated he followed the noise around the corner, along the kitchen wall and out the door which lead to a courtyard. Although the courtyard was dark, he saw Resident #1 sitting in the wheelchair several feet from the door and brought her back inside. He stated it was very cold outside. Interview with NA #6 on 12/23/10 at 2:47 AM revealed he had seen Resident #1 by the nursing station just sitting in her wheelchair around midnight on 12/20/10. He was not assigned to Resident #1. He further stated that Resident #1 usually wheeled herself in a circular path down 1000 hall through the doors into the service hall and back out another door. He stated she was very capable of opening the doors and going through them without difficulty. The administrator was notified of the immediate jeopardy on 12/22/10 at 2:40 PM. The facility presented a credible allegation of compliance on 12/23/10 at 1:00 PM which included: CREDIBLE ALLEGATION OF COMPLIANCE How corrective action will be accomplished for each resident found to be affected by the deficient practice The facility nurse supervisor assessed resident # 1 on 12-20-2010. The resident was sent to the hospital on 12-20-2010 at 4:40 am for evaluation and treatment of [REDACTED]. Address how corrective action will be accomplished for those residents having a potential to be affected by the same deficient practice A 100 percent audit was completed on 12-20-2010 to assure all residents whereabouts were known by the floor nurse utilizing a census form. On 12-20-2010 direct care staff to include nurses and nursing assistants were inserviced by the Staff Development Coordinator to assure they know the whereabouts of residents on their assignment who wander, when making routine rounds. Certified Nursing Assistants and Nurses should check courtyards, service halls, and exit doors during routine rounds to assure no residents who wander are inappropriately out in the courtyard. Nurses and nursing assistants can identify who wandering residents are by looking at the Happy Feet wanderer notebook (Happy Feet is the name of the wandering resident picture book that is kept at the two main nurses stations that direct care staff have access to view pictures). The Staff Development Coordinator will continue to inservice until all staff is complete. No staff will be allowed to work without this inservice. In addition to routine rounds, all identified wandering residents whereabouts will have documented check two times per shift daily ongoing by the Administrative staff and/or the Administrative Nurses. The facility already has existing door alarms on all exterior exit doors that alarm when residents wearing a wandering bracelet attempt to go through the door. In addition, door alarms were installed by the Maintenance Director and Maintenance Assistant on 12-22-2010 on all interior enclosed courtyard doors. The facility determined on 12-22-2010 that the first type of door alarms installed on the courtyard interior doors needed a mechanism to assure alarm did not stop sounding until a staff member arrives to check situation. Facility Maintenance staff have purchased and have installed door alarms on 12-22-2010 to courtyard interior doors that will not stop alarming until a staff member places a key in the alarm to stop the alarm. All nurse key rings have a key to the alarm and all nursing staff have been inserviced on the key alarm mechanisms to the courtyards starting 12-22-2010. No staff will be allowed to work without this inservicing. On 12-22-2010 the staff were additionally inserviced by the Staff Development Coordinator and Admissions Coordinator on the courtyard alarms and that the courtyards that are not routinely used by residents will be alarmed at all times. The courtyards that are routinely used by residents will be alarmed from 6:00 pm until 7:30 am daily. No staff will be allowed to work without this inservice. On 12-22-2010 the Administrative Nurses completed wandering risk assessments on all residents to determine that residents are identified with the potential for elopement. Residents who are identified as wanderers will have a wandering bracelet that alarms exterior exit doors, have a wandering care plan, a picture in the facility " Happy Feet " wanderer notebook (Happy Feet is the name of the wandering resident picture book that is kept at the two main nurses stations that direct care staff have access to view pictures), and a transmitter test log sheet that will be used to test the wandering bracelet daily to assure it is working. Administrative Nurses and rotating Administrative Department Managers will check the whereabouts of all identified wanderers twice per shift daily ongoing using the wandering resident list. What measures will be put in place or systemic changes made to assure the deficient practice will not reoccur. Door alarms were installed on 12-22-2010 by the facility maintenance staff on all doors exiting into enclosed courtyards that alarm when door is opened and will not stop alarming until a staff member comes to door and uses key. These alarms will be audited daily to include weekends by facility maintenance and weekend administrative staff to assure they are working utilizing a QI audit tool. Administrative staff who will be performing these door alarm checks will be educated on the procedure to follow when a door is found non functioning by the Administrator. On 12-22-2010 the staff were additionally inserviced by the Staff Development Coordinator and Admissions Coordinator on the courtyard alarms and that the courtyards that are not routinely used by residents will be alarmed at all times. The courtyards that are routinely used by residents will be alarmed from 6:00 pm until 7:30 am daily. No staff will be allowed to work without this inservice. Staff members who are responsible for cutting on and off door alarms will use a log to verify this task was completed. On 12-22-2010 the Administrative Nurses completed wandering risk assessments on all residents to determine that residents are identified with the potential for elopement. Residents who are identified as wanderers will have a wandering bracelet that alarms exterior exit doors, have a wandering care plan, a picture in the facility " Happy Feet " wanderer notebook, and a transmitter test log sheet that will be used to test the wandering bracelet daily to assure it is working. Nursing and Administrative staff will check the whereabouts of all identified wanderers twice per shift daily using the wandering resident list. All new admissions will have a wandering risk assessment completed to determine the potential for wandering. How the facility will monitor the measures to assure solutions are sustained. The Administrator will review the QI audit tool log where wandering residents whereabouts are checked and the log where alarms were cut on and off to courtyards 3 times weekly ongoing and sign verifying review. Both logs will be reviewed monthly by the Quality Improvement Committee for continued monitoring in this area. Any areas identified as a concern will be followed up on by the Maintenance Director and Administrator to assure intervention is in place as appropriate for situation and documentation of the intervention will be on the QI audit tool log. Allegation of Compliance Date 12-23-2010 Immediate jeopardy was removed on 12/23/10 at 4:25 PM. Resident #1 was observed residing on the secured Alzheimer's unit and wearing a wanderguard bracelet. A review of wandering elopement risks assessments were verified as completed per record review. The books containing information identifying the residents who were at risk for wandering was reviewed and found to be complete and accurate and available to all staff. Interviews with direct care staff and licensed nursing staff confirmed that they had received inservicing on monitoring of residents identified with wandering behaviors, the new alarm systems placed on each courtyard door and on which doors would be unalarmed during the day and alarmed at night. Documentation was provided showing evidence doors were opened, locked/alarmed and checked per schedule. Observations of the new alarm systems being in place and working were made by the surveyors. Observations confirmed that staff responded to alarms immediately.