Every finding on record at Vista Post Acute

Based on observation, interviews, and record review, the facility had a medication error rate of 13.79% when four medication errors occurred out of 29 opportunities during the medication administration observation for four out of nine residents (Residents 3, 8, 10, and 37). Resident 37 did not receive one medication as scheduled; Resident 8 received insulin with incorrect priming; and Residents 3 and 10 did not receive one medication as prescribed. The failures resulted in the residents not receiving the medications as prescribed and had the potential for complications of their medical conditions (such as high/low blood sugar or blood pressure). Findings: 1. During the medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse B (LVN B) was observed preparing one medication, doxazosin (a medication to treat high blood pressure) for Resident 37. LVN B stated, I don't have chlorhexidine [an antiseptic mouthwash with broad-spectrum antimicrobial activity against bacteria, viruses, and fungi], will have to order from pharmacy. On 1/27/25 at 10:08 a.m., LVN B was observed going into Resident 37's room and informing the resident she did not have his mouthwash. During an interview on 1/27/25 at 10:59 a.m., LVN B confirmed the chlorhexidine was due this morning, but it was not available for administration. A review of Resident 37's clinical record indicated a physician's order, dated 7/29/2024, for chlorhexidine gluconate mouth/throat solution 0.12%, give 15 ml orally three times a day for oral care. The facility scheduled it to be administered at 9 a.m., 1 p.m., and 9 p.m. On 1/27/25 at 1:49 p.m., a review of Resident 37's January 2025 Medication Administration Record (MAR) indicated a 9 (meaning, Other/See Progress Notes) in the 1/27/25 9 a.m. entry for chlorhexidine administration. A review of the corresponding progress notes, charted by LVN B on 1/27/25 at 10:04 a.m., indicated: pending supply. A review of the facility's 4/2019 policy and procedures (P&P) titled Pharmacy Services Overview indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 2. During a medication administration observation on 1/27/25 at 12:08 p.m., with LVN D, she was observed preparing an insulin (medication to treat high blood sugar) injection for Resident 8. She stated the resident's blood sugar was 255. At the medication cart, LVN D removed Resident 37's Humalog Kwikpen (a pre-filled insulin pen containing a short acting insulin called insulin lispro) from the medication cart, cleaned the rubber seal (area connecting the insulin chamber to the needle), attached a needle on it, inverted the pen, and squeezed out some of the insulin drops. Then she removed the needle, cleaned the the rubber seal again, attached a second needle on the rubber seal, and then turned the dose dial to 8 units. On 1/27/25 at 12:13 p.m. LVN D was observed injecting the Humalog into Resident 8's left lower abdomen. During an interview on 1/27/25 at 12:15 p.m., LVN D stated she primed the insulin pen by placing a new needle, turning the dial to 1 unit, and pressing the pen to make sure it worked. Then she would take off the needle, put a new needle on, and turn the dial to the prescribed dose. She stated that is the way she has always done it, by making sure the pen works. A review of Resident 8's clinical record indicated a physician order, dated 12/11/2024, for insulin lispro solution, to inject per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings), to give 8 units for blood sugar between 251 - 300. During a follow-up interview with LVN D regarding insulin pen priming on 1/27/2025 at 2:21 p.m., she stated she learned only use one needle and to prime it (the needle) with 1 unit first to make sure the pen works before turning to the ordered dose. She verified she did not prime the insulin pen correctly before injecting it to Resident 8. During an interview on 01/28/25 at 11:35 a.m. conducted with the Director of Nursing (DON) regarding the priming of insulin pens, she stated to prime the needle before each medication administration. A review of the drug manufacturer's INSTRUCTIONS FOR USE HUMALOG ([NAME]-ma-log) KwikPen, dated 7/2023, indicated the following instructions for priming the pen: Prime before each injection, priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your Pen, turn the Dose Knob to select 2 units . Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and '0' is seen in the Dose Window . Turn the Dose Knob to select the number of units you need to inject . A review of the facility's P&P titled Administering Medications, dated 4/2019, indicated, insulin pen needles must be changed and primed between administration doses. 3. During the medication administration observation on 1/27/25 at 4:28 p.m., LVN E was observed administering two medications with water to Resident 3, one included metformin (used to treat diabetes) 1,000 milligrams (mg, unit of measurement) tablet. On 1/27/25 at 4:32 p.m., in a concurrent interview with LVN E, and review of Resident 3's metformin medication, LVN E confirmed the prescription label indicated to give with meals. LVN E stated, We give the medication between 4 to 6 p.m., usually give it with snacks. She said the administration time varies each day. A review of Resident 3's clinical record indicated a physician order, dated 8/3/2024, for metformin 1,000 mg, give 1 tablet by mouth two times a day for diabetes administer with meal. On 1/27/25 at 5:01 p.m., a cart of meal trays was observed about 20 feet from Resident 3's room. The staff stated the cart was for downstairs residents as downstairs always get their meal trays first. This indicated, by 5:01 p.m. on that day (or 33 minutes after metformin administration), Resident 3 did not get his dinner yet. An interview and record review regarding the administration of Resident 3's metformin was conducted with the DON on 1/28/25 at 11:35 a.m. She explained medication ordered with meals means it should be given with a meal. She stated metformin is an irritant and can cause nausea so it should be given with a meal. A review of the Package Insert (provides detailed information of the drugs uses, contraindications, dosage ranges, side effects and how to administer the drug) for metformin indicated: Metformin should be given in divided doses with meals to reduce gastrointestinal side effects. A review of the facility's P&P titled Administering Medications, revised April 2019, indicated, Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example before and after meal orders). 4. On 1/28/2025 at 8:28 a.m., while preparing medications for Resident 10, registered nurse (RN) C stated she will hold the resident's amlodipine and lisinopril (medications used to treat high blood pressure or hypertension). She stated resident's blood pressure was 108/80 (the upper number is the systolic blood pressure, also known as SBP; the lower number is the diastolic blood pressure, also known as DBP). A review of Resident 10's clinical record indicated a physician's order, dated 11/6/2024, for amlodipine 10 mg, 1 tablet one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD FOR SBP <100. It was scheduled to be administered daily at 9 a.m. A review of the resident's January 2025 MAR indicated a 4 (4= vitals outside of parameters for administration) in the 1/28/2025 9 a.m. entry for amlodipine administration. On 1/28/25 at 11:25 a.m., during a follow up interview and concurrent record review with RN C, she confirmed holding both amlodipine and lisinopril for Resident 10. RN C confirmed the physician's order indicated to hold the amlodipine for SBP <100 while the resident's SBP was 108. She stated, .in general the hold for blood pressure is 110. An interview was conducted 1/28/2025 at 2:09 p.m. with the DON regarding the amlodipine hold parameters for Resident 10. The DON confirmed the hold parameter for amlodipine is to hold if blood pressure is less than 100. A review of the facility's P&P titled Administering Medications, revised April 2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame, vitals parameters .

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in a clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Kitchen wall had an opening in the wall around the drain; 4. Kitchen backsplash, where dishes were cleaned, had food and black substance buildup; 5. A kitchen cleaning schedule was not maintained according to facility policy; 6. Frozen meat did not have date received, date placed in freezer, use by date, and expiration date; 7. Produce and food were not labeled with use by date and were not rotated with FIFO, First in-First out per facility policy; 8. Food in refrigerator had expired. These failures had the potential to result in contamination of food leading to food borne illness, for 69 residents who resided in the facility. Findings: During an observation on [DATE], at 9:30 a.m., in the kitchen, a drain cover over the floor drain in the middle of the dish room was not secured with tile, and there was black build up around the drain. The wall was exposed to wooden structure, the wall around the perimeter of the drain was open with a large gap, the backsplash behind the sink had buildup of black sludgy material, and the tile and flooring to the wall of the sink had missing grout with noted buildup of black substance and food particles. Tiles around the floor drain were loose and not attached. There were additional tiles around the floor that were broken off, had missing grout, and were collecting pools of water. There was separation from the wall and the floor tile with no grout, with a length of approximately 2 feet. The gap with no grouting had dark residue particles resembling food crumbs, and small pieces of debris collected in the area. There were loose wall tiles along the right and behind the area of the manual dish washing sink, which created a gap between the wall and the tiles. During a concurrent observation and interview on [DATE], at 9:30 a.m., with Certified Dietary Manager (CDM 1), there was exposed wood on the wall as the protective plastic molding against the lower part of the wall was missing. This area had a collection of dirt and debris with openings on the wall. CDM 1 stated a request had been put in to the Maintenance Director (MD) around one month ago to have this repaired, along with the other areas of missing grout and exposed walls. CDM 1 stated loose tiles and pooled water on the floor could harbor bacteria and was a safety hazard. During a concurrent interview and record review on [DATE], at 9:30 a.m., with MD, MD stated there was a maintenance log where staff put in maintenance requests. A review of the log indicated there was no request to repair the kitchen tile, flooring, and walls. During an interview on [DATE], at 10:04 a.m., with MD, MD stated there was no record of when a deep cleaning was last done in the kitchen. During an interview on [DATE], at 11:01 a.m., with the Janitor, CDM 1 and MD, Janitor stated it was difficult to do a deep cleaning when the surfaces were not maintained. The Janitor stated the area with missing grout and tile could collect food and dirt and develop mold if the sealant was not maintained. During an observation on [DATE], at 9:45 a.m., in the kitchen, Refrigerator #1 contained a bag of turkey slices covered in plastic with expiration date [DATE] and a jar of jelly with expiration date of [DATE]. During an observation on [DATE], at 10:15 a.m., in the kitchen, Freezer 1 had five bags of five pounds of ground beef and seven bags of 12 chicken breasts per bag, with no date when the ground beef and chicken breasts were received, no use by dates, and no expiration dates. During an observation on [DATE], at 11 a.m., the facility received a large order of onions. During an observation on [DATE], at 10:15 a.m., in the storage room, onions received on [DATE] were in a box labeled [DATE]. During an interview on [DATE], at 10:31 a.m., with the Dietary Manager (DM 1) and Cook, [NAME] stated that onions were received on [DATE] and were put in the box with the older onions. The box had a date of [DATE]. DM 1 stated the onions should have been placed in a box with the date they were received, and the onions from the previous shipment should have been placed in a box on top of the box of new onions. The [NAME] stated the new onions should have been put in a separate container with the date of delivery posted on the container. During a concurrent observation and interview on [DATE], at 10:30 a.m., in the storage pantry, with CDM 1, clear containers containing large loose black items were on a cupboard shelf with no open, use by or expiration dates on the containers. CDM 1 stated they were unwrapped raisins. DM 1 stated the raisins needed to be disposed of as they may be contaminated. During an interview on [DATE], at 9:46 a.m., with CDM 1, CDM 1 stated not having received and use by dates on food put residents at risk for acquiring a food borne illness. CDM 1 stated exposed openings in the area where dishes were cleaned made the area susceptible to food and mold build up and made it difficult to sanitize and clean the area. During a review of the policy and procedure (P&P) titled, Sanitation and Infection Control subject cleaning schedules, dated 2023, best practice would include a deep cleaning in the kitchen by an outside cleaning agency quarterly. Cleaning schedules should include drains and walls weekly. During a review of the facility's P&P titled, For food purchasing receiving and production, subject receiving food, dated 2023, expiration dates will be checked on predated packages to ensure food and beverages are not expired. Items not predated will be labeled with the date received to ensure FIFO first in and first out. During a review of the facility's P&P titled, Sanitation and infection control, subject, canned and dry food storage, dated 2023, new stock must be placed behind the old stock so that the oldest items will be used first. Product should be dated to assure FIFO - first in and first out. During a review of the P&P titled, Sanitation, and Infection Control, subject for your freezer storage, dated 2023, frozen foods should be labeled with a date it was placed in the freezer. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. In addition, when cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures are to be coved and closed to no larger than 1 mm (millimeter). If water flush cleaning methods are used, wall junctures are to be coved and sealed. According to the 2022 Federal Food Code Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens.

Based on observation, interview, and record review, the facility failed to observe proper infection control practices when: 1. A nursing staff failed to perform hand hygiene after touching potentially contaminated surfaces during the medication administration; 2. A nursing staff touched and opened two medication capsules with bare hands; 3. A nursing staff failed to observe the enhanced barrier precautions (EBP) as per facility policy and procedures (P&P) for two residents (Residents 37 and 61) during the medication administration; These failures had the potential for Residents 37, 54 and 61 to be placed at risk for infections. Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 1/27/25, at 9:29 a.m., RN A was observed preparing two medications, which was put in a small medication cup, for Resident 54. On 1/27/25, at 9:40 a.m., RN A placed the medication cup along with a cup of juice in a medication tray, brought it to Resident 54's bedside, and placed it on the resident's table. Then, with her gloved hands, she moved the resident's wheel chair out of the way. Next, she looked to the bed's remote control cable that was found disconnected and lying on the floor. She connected it to the resident's bed and pressed on the remote to raise the head of the bed while the resident was lying in it. Then, without changing gloves and performing hand hygiene, she picked up the medication cup and handed to the resident to take. She did the same with the juice cup. During an interview on 1/27/25, at 9:48 a.m., RN A confirmed she touched the resident's wheel chair, the bed remote control cable, and the remote control itself with gloved hands, and stated she should have changed her gloves and performed hand hygiene before proceeding with the medication administration. She acknowledged those were potentially contaminated surfaces and had potential for the spreading of infections. 2. During a medication administration observation on 1/27/25, at 10:35 a.m., Licensed Vocational Nurse (LVN) B was observed preparing five medications for Resident 61, who received medications via the gastrostomy tube (also called a G-tube; a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The medications included two capsules of gabapentin (medication to treat nerve pain) 100 milligrams (mg, unit of measurement). Without donning gloves, LVN B was observed picking up each capsule with her bare hands and opening them to pour the powder contents into a medication cup. During an interview on 1/27/25, at 10:55 a.m., when asked about opening the gabapentin capsules with bare hands, LVN B stated, I should have worn gloves. During an interview with the Director of Nursing (DON) on 1/28/25, at 11:35 a.m., she stated nurses should avoid touching medications with their hands; and they are supposed to wear gloves when opening capsules. A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 3. On 1/27/25, at 10:11 a.m., LVN B was observed administering a medication to Resident 37 via the G-tube. On 1/27/25, at 10:35 a.m., LVN B was observed administering five medications to Resident 61 via the G-tube. Resident 37 and Resident 61 were roommates. During the medication administration for both residents, LVN B was observed wearing a facial mask and gloves while administering the medications, but she did not wear a protective gown. A large orange/reddish poster was observed outside the residents' room, which read: STOP. ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS and STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use: central line, urinary catheter, feeding tube . During an interview with LVN B on 1/27/25, at 10:55 a.m., when asked about wearing personal protective equipment (PPE) while administering medications to Residents 37 and 61, LVN B stated she was supposed to gown up during care such as a wound treatment, but for med pass, I am not quite sure on that. During an interview with the DON on 1/28/25, at 11:35 a.m., she stated the nursing staff need to protect the residents from external infections by donning full PPE including a mask, gown, and gloves while providing care such as wound treatment and G-tube administration. 49498 During a review of facility's P&P titled, Enhanced Barrier Precaution, dated 6/18/24, the P&P indicated, EBP involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with chronic wounds or indwelling medical devices) .'High-Contact Resident Care Activities' include . Device care or use .feeding tube . Incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education.

Based on observation, interview, and record review, the facility failed to provide care according to facility policy and procedures (P&P) when the nursing staff did not check the tube placement and/or residual volume before medication administration for three of three residents (Residents 10, 37, and 61) who were receiving medications via the gastrostomy tube (aka G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). The failure had the potential for complications related to enteral feeding such as aspiration (foreign material into the lungs) due to undetected tube displacement, nausea, vomiting, etc. Findings: a. During a medication administration observation on 1/27/25 at 10:02 a.m., Licensed Vocational Nurse (LVN) B was observed preparing a medication, doxazosin (medication to treat high blood pressure), for Resident 37. She crushed and diluted the medication with water. On 1/27/25 at 10:08 a.m., at the resident's bedside, LVN B was observed attaching the 60-milliliter (mL, unit of measurement) syringe to the resident's G-tube and pulling back on the plunger to see the residual volume, then she flushed the tube with about 30 mLs of water. After several minutes of manipulation to get the water to go down into the tube, LVN B poured the diluted medication into the tube. LVN B did not check the tube placement (to confirm the placement of the tube) before the medication administration. b. During a medication administration observation on 1/27/25 at 10:38 a.m., LVN B was observed preparing 5 medications for Resident 61. On 1/27/25 at 10:47 a.m., at Resident 61's bedside, LVN B was observed checking the residual volume but did not check the tube placement before the medication administration. During an interview on 1/27/25 at 10:55 a.m., when asked about the tube placement check before medication administration, LVN B stated, I just check residuals before medication administration. She stated she would not typically check the tube placement before medication administration. c. During a medication administration observation on 1/28/25 at 8:28 a.m. with RN C, she was observed preparing 2 medications for Resident 10. On 1/28/25 at at 8:36 a.m., at the resident's bedside, RN C turned off the resident's feeding pump, attached the syringe to the resident's tube, added about 50 mLs of water into the syringe, then poured each diluted medication into the tube with flushing of water in between the medications. RN C did not check the tube placement and the residual volume before administering the medications. During an interview on 1/28/25 at 8:45 a.m., RN C was asked about checking the tube placement and the residual volume. She stated, We usually do placement check with 30cc of air using the stethoscope, and check the residual first before administration. She stated she got nervous and forgot to do it. During an interview with the Director of Nursing on 1/28/25 at 11:35 a.m., she stated nurses should check the tube placement by injecting air into the stomach and listening for the sound with the stethoscope, and checking the residual volume, before medication administration. A review of the facility's policy and procedures titled Administering Medications through an Enteral Tube, dated 11/2018, indicated the staff verify placement of feeding tube before medication administration.

Based on observation, interview, and record review, the facility failed to ensure discontinued and unused controlled medications (medications that can be easily abused and are under strict government control) for three residents (65, 123, and 174) were promptly removed from one of three inspected medication carts. The failure had the potential for medication errors or loss/abuse of controlled medications. Findings: 1. During an inspection of the Station 1 medication cart with Licensed Vocational Nurse (LVN D) on 1/27/25 at 11:06 a.m., two opened bottles, one 180-milliliters (mL) and one 120-mL, of morphine (a potent narcotic medication for pain) 2 milligrams (mg) per mL for Resident 174 were identified in the locked compartment of the cart. The Controlled Drug Record (CDR or Count Sheet, an inventory sheet documenting the medication, count, date, time, amount given, the amount left, and the signature of the user) for each bottle was wrapped around the bottle with a rubber band. LVN D stated each bottle has zero count left, meaning the count on the CDR had zero (0) amount remaining but in reality there was some left-over amount in the bottle (an over-fill from the manufacturer). She stated the nursing staff did not count them during shift changes because the count on the CDRs was zero. She stated the bottles were supposed to be given to the DON for destruction. A review of two CDRs indicated one was zero'ed out on 1/14/24 (13 days before the survey); and the other reached zero count on 1/20/25 (7 days before the survey). On 1/28/25 at 1:12 p.m., at Station 1 medication cart with Registered Nurse C (RN C), the same two morphine bottles were observed inside the locked compartment of the cart. Further inspection of the bottles with RN C revealed the 180-mL bottle had about 12 mLs remaining; and the 120-mL bottle had about 10 mLs left. RN C verified this finding and stated they are there for the DON to pick up. 2. During the inspection of Station 1 medication cart on 1/28/25 at 1:12 p.m. with RN C also identified two blister cards (card that packages doses of medication within small, clear, or light-resistant amber-colored plastic bubbles or blisters) containing lacosamide (a controlled medication to treat seizures) 100 mg tablets. One had 30 tablets, and the other had 24 tablets. Their CDRs were wrapped around the cards. RN C stated they belonged to Resident 123 who left the facility. A review of Resident 123's clinical record indicated the resident requested to leave AMA [against medical advice] on 1/13/25 (or 15 days prior to the survey). 3. Inspection of the Station 1 medication cart with RN C on 1/28/25 at 1:18 p.m. also identified a bottle containing 8 tablets of lorazepam (a controlled medication to treat anxiety) 0.5 mg for Resident 65. RN C stated the lorazepam was discontinued. A review of Resident 65's clinical record indicated the lorazepam was discontinued on 1/14/25 (14 days before the survey). During an interview with the Director of Nursing on 01/28/25 at 1:57 p.m., she stated the nursing staff should remove the excess morphine liquid for Resident 174 as soon as possible. Regarding those discontinued medications for residents 65 and 123, she stated they should be given to her immediately after discontinued, to prevent loss. A review of the facility's policy and procedures titled Controlled Substances, revised 4/2019, indicated, Empty or discontinued medication containers, must be discarded with two nurses or given to Director of Nursing for proper destruction, and continued in narcotic count until discarded.

Based on interview and record review, the facility failed to ensure one of 20 sampled residents (Resident 47) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 47 received quetiapine (Seroquel, an antipsychotic medication) for delusion (fixed, false beliefs that conflict with reality) without documented evidence of delusional symptoms, and without demonstration how these symptoms caused harm to the resident/others or caused significant distress to the resident. The failure had the potential for the resident to receive the antipsychotic medication unnecessarily, which had the potential for increased risks associated with psychotropic medication use that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss. Findings: A review of Resident 47's clinical record indicated he was admitted to the facility with diagnoses including unspecified dementia (general term that describes a group of symptoms, such as loss of memory, judgment, language, complex motor skills and other intellectual functions due to permanent damage or death of the brain's nerve cells) and unspecified schizophrenia (a chronic, severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Resident 47's Minimum Data Set (MDS, a care area assessment and screening tool), dated 12/9/24, indicated he had a BIMS score of 4 (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15), which indicated his cognitive condition was severely impaired. A review of Resident 47's clinical record indicated a physician's order, dated 10/21/24, for Seroquel 25 mg by mouth at bedtime related to OTHER SCHIZOPHRENIA .m/b [manifested by] Delusion. A review of Resident 47's January 2025 Medication Administration Record (MAR, where nursing staff documented the medication administration and behavioral symptom monitoring) indicated the staff had been monitoring for delusion associated with Seroquel use since 10/20/24. The MAR showed the resident had zero (0) episodes of delusion. A review of Resident 47's Care Plan, revised 11/15/24, indicated the resident was receiving Seroquel for other schizophrenia m/b Delusion. There was no documented evidence in the clinical record what specific behavioral symptoms related to delusion (such as thinking or believing something that is not there) the resident exhibited, or how these symptoms caused harm to the resident/others or caused significant distress to the resident. During an interview with Resident 47 on 1/29/25 at 11:21 a.m., he stated there was a person who has been bothering him and making him upset. He stated he has told about a dozen staff about this already but nothing has been done. He got up from the bed and started walking out of his room to look for that person. About 2 minutes later, he pointed at a resident (Resident 21) and stated she has been going to his room and bothering him. In an interview with Licensed Vocational Nurse (LVN) F, on 1/29/25 at 11:35 a.m., she stated Resident 47 had no behaviors except he gets irritable with noise and whenever Resident 21 comes into his room. She explained Resident 21 has dementia and does not know her surrounding; she often comes into Resident 47's room, thinking he is her son. LVN F stated she has been working in the facility for many months and has not known Resident 47 having any kind of delusion. During an interview with LVN D on 1/29/25 at 11:44 a.m., she stated Resident 47 is real calm, uses call light if he needs to. She explained that he gets angry when Resident 21 comes into his room, which she often does due to her thinking he is her son. When asked about the resident's delusion, LVN D stated, He doesn't have any delusion that I am aware of. He never had a day where he's delusional. During an interview with Certified Nursing Assistant (CNA) G on 1/29/25 at 11:52 a.m., she stated Resident 47 gets angry sometimes and he doesn't like it when [Resident 21] comes into the room. When asked if she has witnessed the resident having delusions, she stated, I don't know. Never seen him with delusions. In an interview with CNA H on 1/29/25 at 12:48 p.m., she stated, Sometimes he gets angry because [Resident 21] comes into room, sometime he wants medications. When asked if she has witnessed the resident having delusions, CNA H shook her head and said, No. During a concurrent interview and review of Resident 47's clinical record with the Director of Nursing (DON) on 1/29/25 at 12:55 p.m., the DON stated Resident 47 received Seroquel for delusion and sometimes he's paranoid. She was asked to provide any documentation showing Resident 47 had delusional symptoms and how they caused harm to him/others or caused significant distress to the resident. After the review, she stated, There's just delusion in the documentation. A review of the Psychiatric Visit Progress Reports, dated 8/12/24, 8/23/24, 10/10/24, and 12/19/24, with the DON indicated, under the Behavioral Observations, the writer of the reports wrote a No for Delusions in all four reports. A review of the facility's policy and procedures titled Antipsychotic Medication Use, revised 12/2016, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . The Attending Physician and other staff will gather and document information to clarify a resident's . behavior . specific symptoms, and risks to the resident and others . Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, the antipsychotic medications will generally be considered if the following conditions are also met . The behavioral symptoms present a danger to the resident or others .

Based on observation, interview and record review, the facility failed to provide meal assistance for one of five sampled residents ' (Resident 1) when staff did not reposition Resident 1 higher in bed and did not assist in setup of meal tray for 30 minutes during dinner. This failure prevented Resident 1 from finishing dinner because Resident 1 was in an uncomfortable position and could not reach or open food items on the meal tray, which had the potential for weight loss and low blood sugar. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of fall, fracture of lumbar vertebra (lower back bone), rib fractures, muscle weakness, and diabetes (long-term disease in which the body cannot regulate the amount of sugar in the blood). During a record review of Resident 1 ' s physician order set titled, Order Summary Report, dated 10/29/24, the order set indicated Resident 1 had an order for [Carbohydrate control] diet .assist with meal, dated 9/7/24. A review of Resident 1 ' s minimum data set (MDS, an assessment tool to guide resident care), dated 9/13/24, indicated Resident 1 had a Brief interview for mental status score of 14 (BIMS, is a scoring system used to determine the resident ' s cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status), was able to make themself understood and was able to feed themself but required setup assistance for meals. During a phone interview on 10/17/24, at 3:40 p.m., with Resident Family (RF), RF stated Resident 1 had been calling RF complaining about lack of staff assistance during meals. RF stated Resident 1 said staff often left Resident 1 flat on the bed with the bed controls and/or bedside table out of reach. During an observation on 10/18/24, at 5:15 p.m., Resident 1 was in his room in bed, lying down with the head of the bed flat. A bedside table with the dinner meal tray was set up parallel to the bed. Resident 1 ' s feet were at the very end of the bed. The food items on the meal tray were covered and were not opened. During a concurrent observation, interview and record review on 10/18/24, at 5:45 p.m., with Resident 1, Resident 1 was in their room, in bed lying flat and Resident 1 ' s meal ticket for dinner, dated 10/18/24, was on the bedside table. The head of the bed was flat, and the bedside table was parallel to the bed. Resident 1 had finished a cup of fruit and dropped the cup while attempting to place it back on the bedside table. Resident 1 then attempted to reach another food item but was unable to reach anything else. Resident 1 was unable to reposition the bedside table and stated staff brought in the meal tray and left the table like this. The surveyor pushed a cup of soup to Resident 1 ' s reach, but Resident 1 was unable to remove the lid. The meal ticket indicated Resident 1 needed ASSIST W MEALS. Resident 1 stated staff always left food unopened and didn ' t assist with repositioning during meals because staff don ' t follow instructions. Resident 1 exclaimed: look at where my feet are and explained they were too low in the bed to be comfortable even if the head of the bed was raised. Resident 1 was not able to pull themself up higher in bed to reach the bed controls. Resident 1 stated they were uncomfortable and couldn ' t eat the rest of dinner. During a concurrent interview and record review on 10/29/24, at 2:10 p.m., with Dietary Manager (DM), Resident 1 ' s food preferences listed on a facility diet management program were reviewed. DM stated she recalled Resident 1 required assistance in opening food items and removing covers on food. DM stated the ASSIST w MEAL instructions printed on the meal ticket indicated staff were expected to assist Resident 1 with meals according to Resident 1 ' s needs. During a concurrent interview and record review on 10/29/24, at 2:22 p.m., with Certified Nursing Assistant 1 (CNA 1), Resident 1 ' s dinner meal ticket, dated 10/18/24, was reviewed. CNA 1 stated Resident 1 ' s meal ticket indicated Resident 1 needed assistance with meals and would need to ask the nurse or resident what assistance was needed when the meal was served. During an interview on 10/29/24, at 2:48 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was admitted for rehabilitative therapy after a fall. LVN 1 stated Resident 1 needed to be positioned into a comfortable position due to back pain. LVN 1 recalled Resident 1 wanted the head of the bed elevated for comfort while eating. LVN 1 stated Resident 1 could use the bed controls but needed staff assistance for large position changes in bed such as sliding up in bed. During an interview on 10/29/24, at 3:50 p.m., with Director of Staff Development (DSD), DSD recalled the care needs for Resident 1. DSD stated Resident 1 required staff assistance with positioning and to have the bedside table comfortably within reach. DSD stated as long as the lids were open, Resident 1 was able to independently feed themself. During a record review of Resident 1 ' s care plan titled, ADL FUNCTIONING WITH SELF-CARE DEFICIT REQUIRES ASSISTANCE WITH ADL ' S, undated, the care plan indicated Resident 1 needs extensive assistance for . setup help for oral hygiene/eating.

Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during the medication administration observation for three of five residents (Residents 11, 20, and 36). Resident 20 received a corticosteroid (aka steroid) oral inhaler without rinsing her mouth with water afterwards; Resident 11 did not receive two medications as scheduled; and Resident 36 did not receive two medications as prescribed. The failures had the potential for the residents not receiving the full therapeutic effect of medications, or adverse affects, compromising their health. Findings: 1. During a medication administration observation on 9/11/23 at 8:05 a.m., Registered Nurse (RN ) 2 was observed preparing 8 medications for Resident 20 including an oral inhaler containing a combination of budesonide and formoterol (budesonide belongs to a class of drugs known as corticosteroids. It works by reducing the irritation and swelling of the airways. Formoterol belongs to the class of drugs known as long-acting beta agonists. It works by relaxing the muscles around the airways so that they open up and you can breathe more easily) 160 micrograms (mcg)/4.5 mcg. On 9/11/23 at 8:16 a.m., at the resident's bedside, RN 2 was observed administering two puffs of the oral inhaler and asking the resident to drink some water after she finished all her medications. RN 2 did not ask the resident to rinse her mouth with water after the inhaler administration. During an interview on 9/11/23 at 8:33 a.m., RN 2 stated she did not ask the resident to rinse her mouth after the oral inhalation because she did not think it was a steroid medication. A review of the pharmacy label on the budesonide-formoterol inhaler with RN 2 indicated, Rinse mouth after use. A review of Resident 20's physician's order indicated to give budesonide-formoterol 160/4.5 mcg/actuation, inhale 2 puffs orally two times a day related to asthma with acute exacerbation, dated 8/8/23. A review of Lexicomp, a nationally recognized drug information resource, indicated the following for the administration of budesonide-formoterol oral inhalation: Rinse mouth with water (spit out without swallowing) after each use to reduce risk of oral candidiasis (oral thrush infection). A review of the facility's policy and procedures (P&P) titled Medication Administration, dated 4/2019, indicated: Oral inhalers are administered per physician orders and manufactures guidelines. 2. On 9/11/23 at 9:06 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed going into Resident 11's room and informing Resident 11 she did not have his eye drops this morning and was waiting for the pharmacy to deliver. In an interview on 9/11/23 at 9:08 a.m., LVN 1 stated the resident had an eye drop medication, brimonidine (medication to treat glaucoma), which was due this morning but they ran out of it since yesterday evening. During a medication administration observation on 9/11/23 at 9:19 a.m., LVN 1 was observed administering 10 medications to Resident 11. The medications did not include brimonidine eye drops. A review of Resident 11's clinical record indicated a physician's order, dated 2/7/23, for brimonidine ophthalmic solution 0.2%, instill 1 drop into left eye two times a day for glaucoma. The facility scheduled it to be administered at 9 a.m. and 6 p.m. daily. A review of Resident 11's clinical record also indicated a physician's order for Miralax powder (a medication to prevent constipation) 17 grams by mouth one time a day for bowel regularity, dated 10/29/22. A review of Resident 11's September 2023 Medication Administration Record (MAR) indicated the facility scheduled Miralax to be administered daily at 9 a.m.; and that LVN 1 documented she administered the Miralax at 9 a.m. on 9/11/23. This was not observed earlier during the administration of 10 medications at 9:19 a.m. During another interview with LVN 1 on 9/11/23 at 1:48 p.m., she stated she did not have the brimonidine eye drop for Resident 11 yet, and confirmed it was not given last night and this morning. Regarding the Miralax, LVN 1 stated she charted the Miralax administration this morning by mistake, and she had not given it yet. She stated, I missed that one. She went to the medication room and momentarily came back with a Miralax bottle, and stated she will give it now. A review of the facility's 4/2019 P&P titled Pharmacy Services Overview indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. 3. On 9/11/23 at 9:28 a.m., RN 1 was observed using the blood pressure (BP) monitor to obtain Resident 36's BP and pulse (heart rate) at his bedside. After finished, she stated the resident's pulse was 54 beats per minute (regular pulse for adults ranges from 60 to 100 beats per minute). During a medication administration observation on 9/11/23 at 9:35 a.m., RN 1 was observed administering 7 medications to Resident 36 including one tablet of Vitamin B Complex (a medication containing a combination of various B vitamins such as B1, B2, B3, B5, B6, B9, and B12) and a tablet carvedilol (medication for high blood pressure) 6.25 mg. A review of Resident 36's clinical records indicated the following physician's orders: - Vitamin B and C Complex (B complex with C), give one tablet by mouth one time a day for supplements, dated 7/22/23; and - Carvedilol 6.25 mg, give 1 tablet by mouth two times a day for hypertension (high BP). Hold for . HR<60, dated 7/20/23. During an interview with RN 1 on 9/11/23 at 1:53 p.m., she showed the Vitamin B Complex bottle and stated that was what she had been administering to the resident. She stated, It's just B-Complex, not B-Complex with C [as ordered]. She acknowledged they were not the same. Regarding the carvedilol administration, RN 1 confirmed twice that she should have held it, as ordered, because the resident's HR was 54. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .

.Based on observation, interview, and record review, the facility failed to provide an orderly and homelike environment for two of 23 sampled residents (Resident 52 and resident 119), when an old, uncovered sign that showed the name of the previous resident (Resident 42) was not removed from the shared room currently occupied by Resident 52 and Resident 119. This failure had the potential to affect Resident 52 and Resident 119's well-being and cause mental confusion in a setting meant to be their home. Findings: During a concurrent observation and interview on 9/11/23, at 8:06 a.m., with Certified Nursing Assistant 2 (CNA 2), an uncovered typewritten sign (stating, Family will do laundry. followed by a handwritten name of Resident 42) was posted on the closet door visible from both Resident 52 and Resident 119's beds. CNA 2 stated Resident 42's family posted the uncovered sign which was not removed when Resident 42 was sent out to the hospital then later discharged from the facility. CNA 2 stated the old sign should have been removed because it didn't belong to the current residents occupying the shared room. CNA 2 stated housekeeping should have removed the old sign. During an interview on 9/11/23, at 8:50 a.m., with the Housekeeping Aide 1 (Hskg. Aide 1), Hskg. Aide 1 stated housekeeping should remove the personal signs on the wall when a resident is discharged from the facility. Hskg. Aide 1 further stated CNAs or any staff who noticed the old sign was still posted, should have removed it. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated old signs posted on the wall showing name of previous resident or anything that pertained or belonged to the old occupant should have been removed by either the housekeeping, CNAs, or Licensed Nurses (LNs) at the time the old resident was discharged or when the bed hold was up for the old occupant. Review of the facility's policy and procedure (P&P) titled, Homelike Environment, revised date February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment .Staff provides person-centered care that emphasizes the resident's comfort, independence, and personal needs and preferences .The facility staff and management minimizes, to the extent possible, the characteristics of the facility and reflect a depersonalized, institutional setting.

Based on observation, interview, and record review, the facility failed to protect the right of privacy for one of 23 sampled residents (Residents 52) when personal care instructions were posted on the walls of the resident's shared room. This failure had the potential to affect Resident 52's sense of self-worth and self-respect due to the public display of personal care information. Findings: During an observation on 9/11/23, at 8:06 a.m., inside Resident 52's shared room, three signs without privacy covers (two signs stated, Please use wipes when cleaning him. Thank you. and one sign stated, Please use the wipes to wipe the Resident instead of the towel. Thank you!), were posted on the walls (by Resident 52's headboard, to the left side of Resident 52's bed, and across the room, taped to the closet of Resident 52). The signs listed were specific personal care instructions for Resident 52. During an interview on 9/12/23, at 11:45 a.m., with the Director of Nursing (DON), the DON stated because it was the family of Resident 52 who posted the signs in the shared room, DON thought it was acceptable to leave openly posted clinical care instructions on the walls. The DON stated for confidentiality purposes, the signs should have privacy covers. Review of the facility's policy and procedure (P&P) titled, Dignity, revised date February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited .

Based on observation, interview, and record review, the facility failed to ensure three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) did not expire; expired insulin (medication to lower blood sugar) prefilled pens were removed from the medication carts for two of two medication carts inspected; and an opened multi-dose vial had an open date in one of two medication refrigerators inspected. The failure resulted in insulin pens given past the expiration date; and the potential for residents to receive expired medications which would result in unsafe and ineffective use. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on 9/11/23 at 9:44 a.m., three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two IV Supply e-kits (kit containing solutions and supplies for intravenous injection) had the expiration date of 7/2023. RN 1 confirmed the findings. 2. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with RN 1 revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin glargine) for Resident 27, which had a open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Lexicomp, a nationally recognized drug information, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 3. On 9/11/23 at 11:15 a.m., during a visit to the Station 1 Medication Room with the Director of Nursing (DON) identified an open aplisol (an agent to aid diagnosis of tuberculosis infection) solution vial without a written open date. A review of the manufacturer's label with the DON indicated to discard 30 days after opening. The DON confirmed it should have been written with an open date. 4. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. A review of the facility's P&P titled, Medication Storage, dated 11/2020, indicated: The nursing staff is responsible for maintaining medication storage . in a .safe . manner . outdated, or deteriorated drugs . are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents (Residents 10 and 27) and a non-sampled resident (Resident 39) were free from a significant medication error when they received insulin (medication to lower blood sugar) past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, which would result in uncontrolled high blood sugar for the residents. Findings: 1. On 9/11/23 at 10:18 a.m., an inspection of Medication Cart #2 with Registered Nurse 1 (RN 1) revealed the following: - A Basaglar Kwikpen (a pre-filled insulin pen containing a long-acting insulin called insulin glargine) for Resident 27, which had a written open date of 8/3/23. - A Lantus SoloStar (a pre-filled insulin pen containing insulin glargine) for Resident 39, which had a written open date of 8/10/23. On 9/11/23 at 10:45 a.m., a review of the pharmacy label on both insulin pens with RN 1 indicated to discard 28 days after opening. RN 1 confirmed the insulin pen for Resident 27 would have expired on 9/1/23 (28 days after opening); and Resident 39's Lantus SoloStar would have expired on 9/8/23. She reviewed Resident 27's current medication administration record (MAR) and stated he had a physician's order to receive 6 units of insulin glargine at each bedtime; and had received 9 doses since 9/1/23. A review of Resident 27's physician's order, dated 7/25/23, indicated to give insulin glargine 100 units/milliliter, inject 6 units subcutaneously (under the skin) at each bedtime for type 2 diabetes (disease that impairs the body's ability to regulate blood sugar). During a concurrent interview and record review with the Director of Nursing (DON) on 9/12/23 at 1:52 p.m., she stated Resident 39's Lantus SoloStar, which was opened on 8/10/23, would have expired on 9/8/23 (28 days after opening). A review of the physician's order with the DON indicated to give Lantus SoloStar, 6 units in the morning and 3 units at bedtime, dated 9/6/23. The DON reviewed the current MAR and stated the resident received a total of 7 doses since the medication expired on 9/8/23. She stated it is important to discard the insulin after 28 days because it may not be as effective anymore. A review of Lexicomp, a nationally recognized drug information resource, indicated to store opened (or in-use) insulin glargine prefilled pens at room temperature and use within 28 days. 2. On 9/12/23 at 11:19 a.m., an inspection of Medication Cart #3 with Licensed Vocational Nurse 1 (LVN 1) identified a Lantus SoloStar pen for Resident 10 with a written open date of 8/12/23. LVN 1 verified the pen would have expired on 9/10/23 (28 days after opening). She reviewed Resident 10's current MAR and stated the resident received a dose of 12 units each day on 9/10 and on 9/11/23. Review of Resident 10's physician order, dated 1/6/23, indicated to give Lantus 12 units subcutaneously at bedtime related to type 2 diabetes. A review of Resident 10's September 2023 MAR indicated he received 12 units at 9 p.m. on 9/10 and 9/11/23. During an interview with the Consultant Pharmacist (CP) on 9/13/23 at 10:45 a.m., he stated giving insulin past its 28-day discard date would not be as effective. A review of an online publication by the Consumermedsafety.org (a nationally recognized medication safety organization), titled Storage of Insulin, it indicated, Never use insulin if expired. The expiration date will be stamped on the vial or pen. Remember if not in the fridge, the date on the vial or pen does not apply. You must throw away after 28 days since outside the fridge. (https://consumermedsafety.org; accessed 9/18/23) During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 1/1/2020, the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering.

Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) inspect the emergency medication kits (e-kits) on a monthly basis in accordance with the facility policy and procedures (P&P). Also, the CP failed to identify and report to the facility medication irregularities during the monthly medication regimen review (MRR) for two of 23 sampled residents (14 and 27). The failures resulted in opened and expired e-kits not being replaced timely for resident use; and undetected medication irregularities had the potential for residents not achieving highest therapeutic outcomes. Findings: 1. During a visit to Station 2 Medication Room with Registered Nurse 1 (RN 1) on [DATE] at 9:44 a.m., three expired e-kits were identified in a locked cabinet. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of ,d+[DATE]. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of ,d+[DATE]. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of ,d+[DATE]. RN 1 confirmed the findings and acknowledged they should have been replaced. During a telephone interview with the CP on [DATE] at 11:30 a.m., he stated he saw those expired e-kits during one of the previous visits and asked a nurse to request for replacement, but did not document that on the report to the facility. During another interview with the CP on [DATE] at 10:30 a.m., when asked whether he inspected the e-kits during the monthly visits to the facility, the CP stated, When I can. He explained that he did so whenever the nurse was available to open the locked cabinet for him to inspect. He added, I try to. The CP was asked to show written reports indicating he inspected the e-kits on a monthly basis, he showed an example of a report indicating random medication room/med cart audit completed. He stated he did not make any written reports specific to the inspection of the e-kits. A review of the facility's P&P titled Emergency Medications, dated ,d+[DATE], indicated: The Consultant Pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. 2a. A review of Resident 27's clinical record indicated he had physician's orders for and had been receiving Oyster Shell (calcium carbonate) 500 milligrams twice daily at 9 a.m. and 5 p.m.; and ferrous sulfate (to prevent or treat low blood iron level) 325 mg twice daily at 9 a.m. and 5 p.m., both dated [DATE]. A review of Lexicomp (www.[NAME].com), a nationally recognized drug information resource, indicated the concurrent use of calcium carbonate and ferrous sulfate would lead to Risk Rating D (meaning significant) drug-drug interaction. Specifically, Lexicomp indicated calcium carbonate may decrease the absorption of Iron Preparations . The absorption of ferrous sulfate has been shown to be reduced by 15% to 24% with calcium carbonate. It further indicated to consider separating the doses of the two medications as much time as possible in patients who require chronic use of both agents and monitor for decreased therapeutic effects of oral iron preparations. During a concurrent interview and record review with the DON on [DATE] at 9:58 a.m., she confirmed Resident 27 had been receiving both medications at the same time each day since [DATE]. She reviewed the drug information online and stated the calcium would decrease the iron absorption if given together at the same time. She also reviewed Resident 27's clinical record and stated the resident has had low hemoglobin (amount of protein in the red cells able to transport oxygen to all cells in the body ) and hematocrit (represents the percent of red cells in the blood) in February 2023, indicating he was anemic (problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). She also stated the resident had a chronic wound which bled often. When asked whether the CP identified as an irregularity and made a recommendation to separate the two medications, the DON reviewed the resident's clinical record and the MRR binder (which contained the CP's recommendations), and stated she could not find any. During an interview with the CP on [DATE] at 10:40 a.m., he stated he typically would make a suggestion to the nurse based on the resident's reference, but did not make a written recommendation for separating the iron and calcium administration for Resident 27. He confirmed that co-administration of the two medications would lead to decreased absorption of iron. He agreed that he should have made the recommendation in order to minimize the effect of the drug interaction so the resident could receive the full therapeutic effect of the iron. 2b. A review of Resident 14's clinical record indicated she had been receiving Risperdal (an antipsychotic medication) 2 mg once daily since [DATE]. However, there was no documented evidence the facility staff monitored for its adverse effects (or side effects). During a concurrent interview and record review with the CP on [DATE] at 10:45 a.m., he stated, for residents receiving psychotropic medications (drugs that affects brain activities associated with mental processes and behavior), he would make sure the the facility staff monitor for their effectiveness and side effects. He reviewed Resident 14's clinical record and confirmed there had been no monitoring of Risperdal's side effects since [DATE] (10 months ago). He stated it was discontinued when the medication was reduced on that day. When asked whether he identified this as an irregularity and made a recommendation to the facility during the monthly MRR for Resident 14, he stated, It's something that I missed. A review of the facility's P&P titled Psychotropic Medication Use, dated ,d+[DATE], indicated, Residents receiving psychotropic medications are monitored for adverse consequences. A review of the facility's P&P titled, Medication Regimen Reviews, dated ,d+[DATE], indicated, The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility . The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems .other irregularities, for example . inadequate monitoring for adverse consequences; potentially significant drug-drug .interactions. A review of the facility's P&P titled, Pharmacy Services- Role of the Consultant Pharmacist, dated ,d+[DATE], indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including . Providing the facility with written and electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse and addiction) and safe use of emergency medications when: 1. Random controlled medication use audit for three of three sampled residents (Residents 53, 59, and 62) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications; and 2. Three of nine emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened or expired. The failure had the potential for not having emergency medications/supply on hand when needed or expired medications given to the residents. Findings: 1. During the survey, CDRs for three random residents (Residents 53, 59, and 62) receiving PRN (as needed for) controlled medications were requested for review. During an interview with the Director of Nursing (DON) on 9/12/23 at 1:57 p.m., she stated any time a resident requested a PRN controlled medication, the nurse removes the medication from the locked compartment in the medication cart, signs it out of the CDR, administers it to the resident, and then documents the administration on the resident's MAR. a. A review of Resident 62's clinical record indicated he had a physician's order, dated 2/27/23, for Norco (hydrocodone-acetaminophen, a controlled medication for pain) 5/325 milligrams (mg, unit of measurement) 1 tablet by mouth every 8 hours as needed for severe chronic pain. A review of her CDR for Norco indicated she infrequently requested for the PRN Norco. During a concurrent interview and record review with the DON on 9/12/23 at 2 p.m., a review of Resident 62's CDR for Norco 5/325 mg and the April and September 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 4/20/23 at 1700 (5 p.m.) and on 9/1/23 at 9 a.m. but did not document the respective administration on the MARs. The DON confirmed two Norco tablets were not documented as given to the residents and unaccounted for. b. A review of Resident 53's clinical record indicated a physician's order for Norco 5/325 mg, give 1 tablet every 4 hours as needed for moderate pain, dated 6/7/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:09 p.m., a review of Resident 53's CDR for Norco 5/325 mg and the July and August 2023 MARs indicated the nursing staff removed and signed out 1 tablet on 7/17/23 at 1800 (6 p.m.) and on 8/10/23 at 7:15 a.m. without documenting the respective administration on the MARs. The DON confirmed this finding. c. A review of Resident 59's clinical record indicated a physician's order for oxycodone (a potent narcotic for pain) 10 mg, 1 tablet every 4 hours PRN moderate pain, and 2 tablets every 4 hours PRN severe pain, dated 8/10/23. During a concurrent interview and record review with the DON on 9/12/23 at 2:13 p.m., a review of Resident 59's CDR for oxycodone 10 mg and the September 2023 MAR indicated the nursing removed and signed out 2 tablets on 9/9/23 at 6:15 p.m. but did not document the administration on the MAR. The DON verified two oxycodone tablets for Resident 59 were unaccounted for. A review of the facility's policy and procedures (P&P) titled Controlled Substances, dated 4/2019, indicated: The facility complies with all laws, regulations, and other requirements related to handling . and documentation of controlled medications . The nurse administering the medication is responsible documenting record of administration of dose. A review of the facility's P&P titled Medication Administration, dated 4/2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . the individual administering the medication records in the resident's medical record . the date and time the medication was administered . 2. On 9/11/23 at 9:44 a.m., a visit to Station 2 Medication Room was conducted with Registered Nurse 1 (RN 1). Three expired e-kits were identified. The CIII-CV E-kit (kit containing Scheduled 3 to Schedule 5 controlled medications) had the expiration date of 4/2023. Two medications, the lorazepam and temazepam (medications to treat agitation and anxiety) tablets, inside the kit had the expiration date of 4/2023. Two large IV Supply e-kits (kit containing solutions and supplies for intravenous injection) were identified with the expiration date of 7/2023. A review of the Emergency Drug Kit Usage Report (log) inside each e-kit indicated one was opened with a content removed on 6/9/23 (3 months ago), and the other was opened on 6/19/23. RN 1 confirmed the findings and acknowledged they should have been replaced. During an interview with the DON on 9/11/23 at 10:04 a.m., she stated, Usually when we use it, we fax to the pharmacy [for replacement] right away. She stated the facility staff requested the replacement shortly after they were opened, but she was not sure what happened and why they were not replaced since June 2023. During a telephone interview with the Consultant Pharmacist (CP) on 9/12/23 at 11:29 a.m., he stated the e-kits should be replaced right away after opening. A review of the facility's P&P titled Emergency Medications, dated 4/2007, indicated: Any time medications and supplies used from the emergency medication kit are used, pharmacy should be contacted immediately for replacement.

Based on observation, interview, and record review, the facility failed to provide pain-relieving medication to one of 23 sampled residents (Resident 120) before a Stage 4 pressure ulcer (severe tissue damage that extends to muscles, bones and/or tendons) wound dressing change was rendered. This failure resulted in Resident 120's avoidable, unnecessary pain and discomfort during Resident 120's wound treatment which affected Resident 120's ability to maintain his highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 120's Admission Record, dated 9/14/23, indicated resident was admitted to the facility on [DATE] with diagnosis of Stage 4 pressure ulcer of sacral region. A review of Resident 120's clinical record titled, Admit/Readmit Assessment, dated 9/12/23, indicated Resident 120 had moderately impaired cognition. Resident 120's Pain Assessment indicated resident verbalized and/or exhibited non-verbal symptoms of pain and had a numeric pain scale (pain rate where 0 is no pain, and 10 is worst pain possible) of 3-4 (mild pain). A review of Resident 120's Physician Order, dated 9/8/23, indicated, Acetaminophen tablet 325 milligrams (mgs) give two (2) tablets via PEG tube (Percutaneous Endoscopic Gastrostomy, a feeding tube) every 4 hours as needed for general discomfort . A review of Resident 120's Care Plan, dated 9/11/23, indicated, Resident 120 had a Stage 4 pressure ulcer on sacrum (present on admission). The Care Plan also indicated, Administer medications as ordered . Further review of the Care Plan, dated 9/11/23, indicated, The resident is at risk for pain related to medical diagnoses .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Monitor/record/report to Nurse any signs/symptoms (s/sx) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing) . During a concurrent observation and interview on 9/13/23, at 11:10 a.m., with the Infection Preventionist (IP) and Licensed Vocational Nurse 2 (LVN 2), Resident 120's wound dressing change was observed. Resident 120 was noted to be stiff and grimacing during the entire time of wound treatment. Resident 120 was also heard saying, Stop, once before the treatment ended. After Resident 120's wound treatment was completed, IP stated she did not assess resident's pain level nor offered the resident pain medication 30 minutes prior to start of the wound dressing change. IP also stated she did not know if the resident took any pain medication from RN 1 in the morning. During an interview on 9/13/23, at 11:50 a.m., with Registered Nurse 1 (RN 1), RN 1 stated she assessed Resident 120 for his pain level during the start of the morning shift but since the resident denied any pain, RN 1 did not offer resident any pain-relieving medication. RN 1 stated IP did not request any pain-relieving medication for Resident 120 prior to rendering wound treatment. A review of the facility's policy and procedure (P&P) titled Wound Treatment, undated, indicated, .Assess resident for pain prior to treatment, if pain indicated, offer pain medication as ordered, administer pain medication as ordered, and wait 30 minutes - 1 hour for medication to be effective prior to rendering treatment. If pain medication is denied, ask resident if agreeable to render treatment. If not agreeable, cease treatment and contact physician .

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 27) when Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using a mechanical lift (a mechanical device used to assist with transfer and movement of residents who required support for mobility beyond the manual support provided by caregivers alone) by himself and without assistance. This failure had the potential to result in serious avoidable resident injury. Findings: A review of Resident 27's Admission Record, dated 9/12/23, indicated Resident 27 was admitted to the facility in 2021 with diagnoses of Parkinson's disease (a chronic disorder that affects movement causing tremors, stiffness, and loss of balance) and other abnormalities of gait and mobility. A review of Resident 27's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/23, indicated resident required extensive assist with 2 or more person-transfer from bed to chair. A review of Resident 27's Care Plan, dated 8/28/23, indicated, Resident requires [mechanical] lift for safe transfer .Interventions/Tasks - 2 person assist at all times when operating mechanical lift . During a concurrent observation and interview on 9/11/23, at 9 a.m., with Registered Nurse 1 (RN 1), outside by Resident 27's room, Certified Nursing Assistant 1 (CNA 1) transferred Resident 27 from bed to shower chair using the mechanical lift by himself and without assistance from another staff. RN 1 stated mechanical lift transfers were usually 2-person assist. RN 1 also stated sometimes CNAs called licensed nurses to assist with transfers when other CNAs were unavailable. During an interview on 9/12/23, at 8:30 a.m., with CNA 1, CNA 1 stated Resident 27 required a mechanical lift during transfer from bed to chair or chair to bed. CNA 1 stated he transferred Resident 27 using the mechanical lift by himself even though he knew the resident was a 2-person assist. CNA 1 stated transfers with mechanical lift required 2-persons for safe resident transfer. During an interview on 9/14/23, at 10:03 a.m., with the Director of Nursing (DON), the DON stated when a resident required extensive assist, it could be because a resident is not able to follow directions and/or he/she needed more assistance during care. DON also stated some residents can be on extensive assist or total assist (when a resident is totally dependent and not able to help at all). DON stated that either way, use of a mechanical lift always required a 2 or more person-assist for safe transfer. A review of the facility's Patient Lift Owner's Manual titled Battery Operated Patient Lift, revised date 8/10/16, indicated, .TRANSFER FROM BED .Roll the patient onto one side with the assistance of another caregiver .The second caregiver can now pull the remainder of the sling (a cloth harness placed under and around patients with mobility issues to assist during safe transfers from a bed to chair and to help in reducing possible injury for both the patient and the caregiver) from the other side of the patient so that the sling lays flat .Lift the patient above the bed using the hand control .

Based on observation, interview and record review, the facility failed to ensure one of 23 sampled residents (14) was referred and was provided podiatry services. This deficient practice resulted in Resident 14 to have pain and at risk of injury because of her long toenails. Findings: A review of Resident 14's face sheet, dated 8/14/23, indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of peripheral vascular disease (narrowing of the tubes that carry blood to the different parts of the body which can cause poor blood flow to the legs). A review of Resident 14's Minimum Data Set (MDS, a comprehensive assessment tool to guide care), dated 7/5/23, indicated Brief Interview for Mental Status (BIMS, a screening tool to identify resident's cognitive status) score of 13, indicating Resident 14 had intact cognitive function. During a concurrent observation and interview on 9/11/23, at 9:50 a.m., with Resident 14, in Resident 14's room, Resident 14 had long toenails. Resident 14 stated all her toenails were long, painful and were rubbing against each other. During a concurrent observation and interview on 9/11/23, at 9:52 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 14's room, Resident 14 had long toenails. LVN 1 described each of Resident 14's toenails as approximately 1/2 inch long. LVN 1 stated long toenails could cause Resident 14 pain. During a concurrent interview and record review on 9/12/23, at 10:51 a.m., with the Social Service Director (SSD), the Podiatry Worksheet, dated 6/21/23, was reviewed. The Podiatry Worksheet indicated, the last time Resident 14 had her toenails trimmed was on 6/21/23. SSD stated she was responsible for making the podiatrist referrals in the facility. SSD stated, Resident 14 requested podiatry services, and SSD made the podiatrist referral, on 8/14/23. SSD further stated Resident 14 had not been seen by the podiatrist yet, and SSD did not follow up with the resident's podiatrist referral since 8/14/23 because the podiatrist only went to the facility every 3 months. During an interview on 8/14/23, at 11:05 a.m., with Director of Nursing (DON), DON stated that facility could refer the residents to podiatrist as needed. DON stated the risks for Resident 14 who had long toenails were pain, discomfort and a wound could be created by the long toenails which could get infected. During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health .Residents will be provided with foot care and treatment in accordance with professional standards of practice. Overall footcare will include the care and treatment of medical conditions associated with foot complications (e.g., . peripheral vascular disease, etc.). Residents will be assisted in making transportation appointments to and from specialists (podiatrist .) as needed .

Based on observation, interview and record review, the facility failed to verify the physician's wound care treatment order for one of 23 sampled residents (Resident 29) prior to rendering wound treatment. This failure had the potential to not promote the healing of Resident 29's wounds. Findings: A review of the face sheet for Resident 29, indicated Resident 29 was admitted to the facility on [DATE]. During a review of Resident 29's Surgical Consult, dated 9/6/23, the Surgical Consult indicated, Resident 29 had left foot wounds caused by venous stasis disease (veins cannot send the blood from the legs back to the heart). During a concurrent observation and interview on 9/12/23, at 1:29 p.m., with Infection Preventionist (IP), in Resident 29's room, IP administered Resident 29's left foot wound care without checking the physician's wound care order. IP stated the risk of doing the wound treatment without checking the physician's order was giving the wrong wound care to Resident 29. During an interview on 9/14/23, at 11:07 a.m., with Director of Nursing (DON), DON stated, IP should have checked the wound treatment order before administering the wound care for Resident 29 to prevent mistakes in giving wound care. During a review of the facility's policy and procedure (P&P) titled, Wound Care, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Wound treatment administered per order of attending physician and/or wound physician .License nurse to verify that there is physician's order for wound care prior to rendering treatment.

Based on interview and record review the facility failed to ensure the facility menu was followed. This failure had the potential to result in residents having unmet nutritional need due to substitution of nonequivalent foods. Findings: During an interview on 3/15/23 at 2:15 p.m. with the Dietary Supervisor (DS), DS was asked about food supplies and menu substitutions. DS stated the facility was having issues with the facility food delivery vendor. DS stated when the vendor did not have the ordered food item, the vendor would substitute another item such as cauliflower when broccoli was ordered, but not available. During an interview on 3/15/23 at 3:06 p.m. with the facility Cook 1, and Cook 2, (translation by Certified Nursing Assistant), Cook 1 stated sometimes the cooks did not have the food items they needed to cook the foods planned on the menu, and would have to substitute items and change the menu. Cook 2 stated the cooks would change the menu when they did not have the necessary ingredients. Cook 2 stated she checked the menu in advance and would tell DS what items were missing, and DS would change the menu using substitute items. During an interview and concurrent record review on 3/21/23 at 11:30 a.m., with DS, the Menu Substitution Log was reviewed. DS stated the Menu Substitution Log indicated the following dated entries: 2/4/23 (dinner): No tater tots, used mashed potatoes. No coleslaw, used Italian vegetables. 2/9/23 (breakfast): No cream of wheat to make hot farina, used oatmeal. 2/10/23 (lunch): Cranberry gelatin salad peach fluff wasn ' t prepared. No peaches. Used apricots, fresh strawberries. 2/11/23 (lunch): No pumpkin cheesecake, used pumpkin pie. 2/14/23 (lunch): No turkey meat to make meat balls for renal, gave ground beef. 2/16/23 (lunch): no berry cheesecake bar, used vanilla pudding. 2/16/23 (dinner): No diced ham, used diced chicken. 2/23/23 ( dinner): No bow tie pasta, used macaroni pasta. No mandarin oranges, used peaches. 2/28/23 (dinner): No soy sauce, used sweet and sour sauce. 3/1/23 (lunch): No cherry and cream squares, used banana pie. Didn ' t have all ingredients needed to make. 3/4/23 (lunch): No Dijon mustard for chicken and no chicken thighs, used chicken breasts with turkey gravy. No chicken gravy. No brussel sprouts, used carrots. 3/5/23 (breakfast): No muffin mix to make apple raisin muffins, used wheat toast and rest of English muffins. 3/6/23 (dinner): No split peas to make soup, used vegetable soup. 3/7/23 (lunch): No peanut butter cookie. Made chocolate chip cookies. 3/7/23 (dinner): No beef broth, used chicken broth. No cornbread, used biscuit mix. Not enough fresh fruit for fruit salad. During an interview on 3/21/23 at 1:00 p.m., with the Administrator (Admin), Admin stated she was aware that food substitutions were an issue.

Based on observation and interview, the facility failed to properly store a medication when Protonix (a medication which works by decreasing the amount of acid the stomach makes) was on top of the medication cart unattended. This failure placed demented residents in the area at risk of ingestion and subjected medication to theft or loss. Findings: During an observation on 3/21/23, at 10:40 a.m., medication Protonix was in a box sitting on top of the unsupervised medication cart. During an interview on 3/21/23, at 10:42 a.m., with Charge Nurse 1 (CN 1), CN 1 stated the medication should have been stored inside the locked medication cart. During an interview on 3/21/23, at 10:50 a.m., with the Director of Nurses (DON), the DON stated the medication should not have been sitting on top of the medication cart unsupervised and should have been securely locked inside the medication cart. During an interview on 3/21/23 at 1 p.m., the Administrator (Admin) stated the expectation is that all medications are locked up inside the medication cart. The facility ' s Medication Storage Policy & Procedure was requested but was not given to this writer.

Based on observation, interview, and record review, the facility failed to: 1. Protect residents by allowing Certified Nursing Assistant 5 (CNA 5) to continue to work as a direct care giver, before completion of an investigation of Resident 12's sexual assault allegation against CNA 5. 2. Thoroughly investigate the sexual abuse allegation of one of three sampled residents (Resident 12). These failures had the potential to result in repeated sexual abuse of Resident 12, or the sexual abuse of one or more of the other 59 residents at the facility. The Administrator (ADM) was verbally notified of an Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more in jeopardy of being significantly harmed up to the point of the potential for death to occur if not immediately corrected) on 6/10/20 at 6:00 p.m., regarding the facility's failure to thoroughly investigate a sexual abuse allegation and protect 60 residents from the potential for further abuse. Through record review and observation, the facility showed they initiated a plan of action and the IJ was lifted on 6/12/20 at 4:45 p.m. Findings: 1. During an observation of Resident 12 from the hallway and concurrent phone interview on 6/9/20 at 11:14 a.m., Resident 12 lay in bed, while talking on the phone. Resident 12 stated on 6/5/20, before dinnertime, CNA 5 touched her vagina with one hand while placing her bedpan underneath her, with his other hand. Resident 12 stated she wanted to yell out and throw up. Resident 12 stated it made her so upset, that she called a family member, and then the police to complain about the incident. During a review of Resident 12's Minimum Data Set (MDS - an assessment tool used to guide care), dated 4/15/20, the MDS indicated Resident 1's thinking and reasoning skills were intact including both short-term and long-term memory. The MDS also indicated Resident 12 required one staff to provide extensive assistance with toileting needs. During a phone interview on 6/10/20 at 1:08 p.m., Licensed Vocational Nurse 2 (LVN 2) confirmed she was the charge nurse on 6/5/20. LVN 2 stated Resident 12 called LVN 2 into her room and said that CNA 5 pinched her vagina. LVN 2 stated she called the Administrator (ADM) to inform him of the allegation and the ADM told her to reassign CNA 5 to another patient care assignment, away from direct care of Resident 12. LVN 2 stated she first documented this incident in Resident 12's clinical record on 6/10/20. During a phone conference on 6/10/20 at 2:30 p.m., with the Director of Nursing (DON) and ADM, the ADM stated on 6/5/20 he had allowed CNA 5 to continue to work with other residents after the sexual assault allegation on 6/5/20. ADM stated CNA 5 denied sexually abusing Resident 12, and that the ADM, did not have any reason to believe Resident 12. During a phone interview on 6/10/20 at 1:56 p.m., CNA 5 stated he finished his shift on 6/5/20, in a patient care assignment that excluded Resident 12. CNA 5 stated he continued to work on patient care assignments that excluded Resident 12 on 6/6/20 and 6/7/20. During a review of the facility's document titled, Nursing staffing assignment and Sign-in sheet, for the dates of 6/5/20, 6/6/20, and 6/7/20; for 6/5/20 the document indicated CNA 5 continued to provide direct care to residents at the facility until 11:30 p.m. (end of the shift). Continued review of the sheets dated for 6/6/20 and 6/7/20 also showed CNA 5 provided direct care to residents at the facility on both days. During a review of CNA 5's, Employee Timecard, dated 6/10/20, the timecard showed CNA 5 was removed from direct care duties on 6/10/20 at 6:15 p.m., after imposition of the Immediate Jeopardy. 2. During a phone interview and with the Director of Staff Development (DSD) and a concurrent review of Resident 12's clinical records on 6/10/20 at 11:00 a.m., the DSD stated Resident 12's clinical record had no documented physical or psychological assessment after the abuse allegation. During a review of the facility's document titled, Abuse Investigation: (Resident 12), dated 6/5/20, the document indicated ADM had completed the investigation as follows: After LVN 2 told ADM of Resident 12's allegation of abuse on 6/5/20, ADM interviewed Resident 12. Resident 12 repeated the allegation and said CNA 5 had touched her in a sexual manner. Resident 12 told ADM she would contact the police, and ADM told her to do so, if she thought it was necessary. ADM then conferred with managerial staff and removed CNA 5 from Resident 12's care. ADM interviewed CNA 5, who denied touching Resident 12 in a sexual manner, and ADM delegated the investigation to the Social Services Director (SSD). Later the same day, the police arrived in response to a sexual abuse allegation call from Resident 12. ADM told the police what he knew about the allegation, escorted the police through the building to facilitate completion of their interviews, and conferred with the police about their findings. The document indicated there were possible inconsistencies in Resident 12's story as discussed with the police officer, but ADM did not think the abuse was substantiated, nor was there a need for any further interventions. During a review of a facility document titled, Investigation, dated 6/5/20, with handwritten notes by the Social Services Director (SSD), the document indicated the SSD's investigation consisted of interviews with Resident 12, CNA 5, and LVN 2. During a review of the facility's policy and procedure (PNP) titled, Abuse Investigations, dated 12/2006, the PNP indicated, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Under Investigation Process, the document indicated, Interview the person(s) reporting the incident; Interview the resident (as medically appropriate); Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; Interview staff members (on all shifts) who have had contact with the resident during the period of alleged incident; Interview the resident's roommate, family members, and visitors; Interview other residents to whom the accused employee provides care or services; and Review all events leading up to the alleged incident. In the section titled, Reassignment/Suspension of Employees, the PNP indicated, Employees of this facility who have been accused of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator.

Based on observation, interview, and record review, the facility failed to follow infection control practices to prevent spread of infection in the facility during a novel Coronavirus Disease (COVID 19, a mild to severe respiratory (lung) illness) outbreak (an occurrence of disease greater than expected at a particular time and place) when: 1. Eight of 13 sampled employees were not screened for all symptoms of COVID-19 prior to entering the facility, as required by facility policy and procedure. 2. Facility staff did not ensure staff followed social distancing (maintaining a distance of at least six feet between personnel) while sharing a common workspace area. 3. Occupational Therapist 1 (OT 1) did not wear a facemask in the COVID positive unit while sharing an office with Physical Therapist (PT 1). 4. Certified Nursing Assistant 4 (CNA 4) did not perform hand hygiene before donning a new pair of gloves during direct care of Resident 34, and OT 1 did not change gloves or perform hand hygiene between direct care of residents (3,27,28,29,30 and 31). 5. There were no dedicated personnel to provide housekeeping services in the units for COVID positive residents or Persons under Investigation. (PUI, people whose COVID infection status is unknown. PUI residents are placed in a designated area/unit commonly known as the yellow zone.) 6. The bedroom doors to COVID positive and PUI residents were kept open to the communal hallways. The exit doors to the units for the COVID positive and PUI residents were kept open. These failures had the potential to result in the spread of COVID-19, and COVID-19 related complications, up to and including death. The Administrator (ADM) was verbally notified of an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident.) on 6/10/20, at 6:00 p.m. for failure to follow infection control practices to prevent the spread of infection. Through observations, interviews with staff members, and record reviews, the facility showed they initiated the plan of action and the IJ was lifted during an onsite visit on 6/24/20, at 11:23 a.m. Findings: 1. During a review of the facility's document titled, Employee Log In - COVID Screening, dated 6/9/20, the document had columns for date, name of person entering, presence of cough, shortness of breath, or temperature, and the name of other work locations. During an interview on 6/9/20 at 11:03 a.m., with the Director of Nursing (DON), the DON stated staff who worked in the COVID positive and PUI units, were screened for COVID-19 at the separate downstairs entrance prior to entering the facility. During observations on 6/9/20, from 11:36 a.m. to 11:42 a.m., the following staff worked in the downstairs COVID-19 positive unit: Licensed Vocational Nurse 2 (LVN 2), Certified Nursing Assistant 2 (CNA 2), OT 1, and PT 1. During a concurrent observation and interview on 6/9/20, at 11:34 a.m., with LVN 1 in the downstairs COVID positive unit, LVN 1 confirmed there was no screening station at the downstairs entrance. LVN 1 stated she was not screened for COVID-19 symptoms prior to starting her work shift on 6/9/20, nor on the shift starting 6/8/20. During an interview on 6/9/20, at 11:36 a.m., with LVN 2, LVN 2 stated she was unable to locate the COVID screening log for staff. LVN 2 stated staff were only screened for elevated temperature. During an interview on 6/9/20, at 11:39 a.m., with Occupational Therapist (OT 1) and Physical Therapist 1 (PT 1), OT 1 stated she had not been screened for COVID symptoms that day. PT 1 stated some nurse checked his temperature that morning but he did not remember who it was. During a review of the facility document, Employee Log In - COVID Screening, dated 6/8/20, and 6/9/20, the log indicated no entries on 6/9/20 for LVN 1, LVN 2, OT 1, PT 1, ADM, or CNA 3. The log also indicated no entry for LVN 1 for 6/8/20. During an interview on 6/9/20, at 12:29 p.m., ADM confirmed the facility had not routinely screened the staff who worked in the COVID positive or PUI units for COVID-19 symptoms. During a concurrent interview and record review on 6/23/20, at 11:38 a.m., the DON stated the document titled, Employee Log in - COVID Screening, was used by the facility to document employee pre-entrance screening for COVID-19 symptoms. The DON stated the document did not include all required elements for COVID-19 screening as listed in the facility document titled, Emergency Preparedness Plan COVID-19 Standard Operating Guideline, dated 3/18/20. The Plan indicated the purpose of the document was, To establish an SOG (Standard Operating Guideline) for a COVID-19 outbreak, and the facility would Regularly monitor COVID-19 CDC (Center for Disease Control, a national government organization whose mission is to protect America from health, safety, and security threats through critical science and provision of health information.), Public Health, and CMS (Centers for Medicare and Medicaid, a federal agency that administers the Medicare program and partners with State governments to administer the Medicaid health insurance program.) The Plan indicated all individuals entering the facility should be screened, and answers documented for the following: international travel within last 14 days to CDC restricted countries; presence/absence of sore throat; and any contact with someone who has or suspected to have COVID-19. The Plan also indicated, All individuals will be required to have their temperature taken upon entering the site. 2. During a concurrent observation and interview on 6/9/20, at 9:45 a.m., accompanied by the DON, of the Office of Medical Records/MDS (Minimum Data Set, a resident assessment tool used to guide care), the Director of Staff Development (DSD) and the MDS Coordinator (MDSC) sat at a shared table, two to three feet apart and used their laptops. When asked about social distancing, DSD moved the laptop in her lap, but did not reply. When asked again, if the facility had other workstation available, MDSC stated DSD could go somewhere else, and DSD left the office. During an interview on 6/23/20, at 10:22 a.m., with MDSC, MDSC stated she had an itchy throat from 6/8/20, through 6/11/20, and had tested positive for COVID-19 on 6/10/20. During a review of the Center for Disease Control (CDC) article titled, Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/2020, the article indicated, Ensure HCP practice source control measures and social distancing in the break room and other common areas (i.e., HCP wear a facemask and sit more than 6 feet apart while on break). 3. During an observation on 6/9/20, at 12:24 p.m., the Business Office was located in the downstairs COVID positive unit. Inside the Business Office, OT 1 was not wearing a face mask while sharing the office space with PT 1. During an interview on 6/9/20 at 12:24 p.m., OT 1 stated, I wear a mask when I go out on the floor. During a review of the CDC article titled, Preparing for COVID-19 in Nursing Homes, dated 4/12/20, the article indicated, HCP (healthcare personnel) should wear a facemask at all times while they are in the healthcare facility, including in break rooms or other spaces where they might encounter co-workers. 4. During a concurrent observation and interview on 6/9/20, at 10:14 a.m., in Resident 34's room, Certified Nursing Assistant 4 (CNA 4) used gloved hands to pick up linen and place it in a barrel located just outside Resident 34's doorway. CNA 4 stated the linen was soiled. CNA 4 re-entered Resident 34's room, removed the used gloves, and without performing hand hygiene, donned a new pair of gloves. CNA 4 directly proceeded to move Resident 34's wheelchair and placed a sling under Resident 34's body in preparation for transferring Resident 34 from the bed to the wheelchair by use of a mechanical lifting device. CNA 4 stated she had not performed hand hygiene after doffing the used gloves because the hand sanitizer was on the wall outside the room. During an observation on 6/9/20, at 11:51 a.m., OT 1 exited a room shared by three COVID-19 positive residents (Resident 3, 27, 28), and without changing gloves, or performing hand hygiene, opened the door and entered another resident room shared by three COVID positive residents (Resident 29, 30, and 31). During a review of the facility's document titled, Emergency Preparedness Plan COVID-19 Standard Operating Guideline, dated 3/18/20, the document indicated, Staff should perform hand hygiene using Alcohol Based Hand Sanitizer (ABHS) before and after patient contact, contact with potentially infectious material, and before putting on and upon removal of Personal Protective Equipment (PPE), including gloves. During a review of the facility policy and procedure (PNP), titled, Handwashing/Hand Hygiene, revised 12/07, indicated hand hygiene should be performed after removing gloves, and before and after direct contact with residents. 5. During an observation of the downstairs COVID positive unit, on 6/9/20, at 11:34 a.m., the unscreened exit door to the unit was open, dirt and dry leaves were on the hallway floors, and flying insects were in the hallways. During an interview on 6/9/20, at 11:51 a.m., CNA 2 stated facility did not have dedicated housekeeping service for the COVID positive unit. During a phone interview on 6/10/20, at 1:08 p.m., LVN 2 confirmed there was no dedicated housekeeping services in the COVID positive units. During a phone conference call on 6/10/20, at 2:30 p.m., with ADM and the DON, ADM stated he was overseeing housekeeping services. ADM confirmed the facility did not have designated housekeeping staff for COVID positive units. ADM stated he believed the nursing staff performed the housekeeping duties in the COVID positive units. ADM was unable to provide documentation of completion of housekeeping duties. During a review of the CDC article titled, Preparing for COVID-19 in Nursing Homes, dated 4/12/20, the article indicated, Assign environmental services (EVS) staff to work only on the unit . Also, assign HCP dedicated to the COVID-19 care unit (e.g., NAs (nurse assistants)) to perform cleaning and disinfection of high-touch surfaces and shared equipment when in the room for resident care activities. 6. During an observation of the upstairs COVID positive/ PUI unit, on 6/9/20, at 11:04 a.m., with LVN 1, the unscreened exit door to the unit was open, and flying insects were in the hallway. The exit was blocked by four wheelchairs, and signage that indicated, Smoking Area. LVN 1 stated the exit door was kept open for fresh air. During a concurrent observation and interview, on 6/9/20, at 11:04 a.m., with LVN 1, LVN 1 confirmed the bedroom doors were fully open to bedrooms of COVID positive residents (Resident 11, 12, 13, 14, 15 and 19), and PUI residents (Resident 6, 8, 9, 10, 17, 18 and 20). LVN 1 stated she was told to leave the doors to the PUI resident rooms open. During a review of the facility's Emergency Preparedness Plan COVID-19 Standard Operating Guideline, Outbreak Response, dated 3/18/20, indicated, Place a facemask on the resident and isolate him/her in a room with the door closed and with a dedicated bathroom. Only essential personnel should enter the room. During a review of the CDC article, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/2020, the article indicated, place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed.

Based on observation, interview and medical record review, the facility failed to ensure that the resident was free from physical restraints not required to treat a resident's medical symptoms for one (1) of one sampled residents. Resident 1, who had episodes of aggressive behavior and needed close supervision by facility staff, was physically restrained with multiple mechanical devices that severely restricted his movement for long periods of the day and night. As a result, Resident 1 was denied freedom of movement so that facility staff were free to carry out other assigned tasks. Findings: During an observation on 9/6/12 at 9:45 a.m., of the lower floor (basement) of the facility, Resident 1 was seated in a geri-chair (an upholstered chair with wheels) that was chained and mounted to the wall in the hallway. A pelvic restraint, worn around Resident A ' s waist and between his legs, had been tied securely to the back of the geri-chair and tied to the lower bar of the chair frame. Attempts to engage Resident 1 in conversation were unsuccessful; he stared straight ahead. In an interview with certified nurse assistant (CNA) 1 on 9/6/12 at 9:55 am, when asked how long Resident A had been physically restrained in the chair that morning, CNA 1 stated he got Resident 1 out of bed at 8:30 a.m., placed him in the chair and reapplied the pelvic restraint that Resident 1 wore to restrain him in bed during the night. In continued interview, CNA 1 stated that he had an assignment of eight residents, one of which included Resident 1. CNA 1 could not provide constant supervision to Resident 1. When asked why Resident 1 had been seated and restrained in the chair, CNA 1 stated, if Resident 1 is not, "tied down," he would hit other residents, and maybe hurt himself. CNA 1 stated that Resident 1 may be released later on that afternoon and taken upstairs and outside of the building for a walk. When asked if Resident 1 would be restrained during the walk, CNA 1 stated that if two staff persons were available to walk with Resident 1, staff would use a transfer (gait) belt around his waist and hold on to the belt so that Resident 1 did not run away. If only one staff person walked with Resident 1, wrist restraints were used to prevent him from running away or hitting other residents. Medical record review on 9/6/12, showed that Resident 1 was a [AGE] year old who had [DIAGNOSES REDACTED]. First admitted on [DATE], Resident 1 had continuously lived in the facility for [AGE] years. According to admission information, Resident 1 had, " aggressiveness, " at the time of admission. More recent records, showing the facility ' s assessment of restraint use showed that on 6/5/09 the facility would use a, " pelvic restraint, " when Resident 1 was in bed and when in a chair. A list of suggested, " alternatives, " to restraining devices did not include increased staff supervision. The most recent documented assessment for " physical restraint reduction, " dated 5/24/11, showed that the facility assessed Resident 1 as a, " good candidate, " for reduction. However, according to additional documentation for the last assessment, no reduction or elimination of restraining devices would be attempted because Resident 1 had behaviors of, " hitting others, tripping others, banging his head, and getting up and going into unsafe areas ... " The facility would continue to use the pelvic restraint in bed and in a chair. There was no mention in the assessment of the chair being secured to a wall. The facility ' s care plan for restraint use, most recently updated on, " 5/11, " listed the indications for restraints as Resident 1 ' s aggressive behavior toward staff and other residents and, " tendency to run and get out of the facility. " According to the care plan, previous attempts to reduce restraints had been, " unsuccessful. " The care plan did not include increased staff supervision to reduce the need for restraining devices. Review of the Interdisciplinary Team (IDT) notes dated 5/27/11, showed a care conference in which Resident 1 ' s Responsible Party (RP) attended by telephone. During this care conference, the facility ' s social worker designee informed the RP of the need to secure Resident 1's chair to the wall by use of chain for the safety of the resident, other residents and staff due to Resident 1's behavior. Resident 1 had tipped the unsecured wheelchair over numerous while restrained. The Minimum Data Set (MDS, a screening tool used for a comprehensive assessment of the resident ' s condition for the development of a nursing care plan) dated, 5/27/12, indicated that Resident 1 was unable to answer verbal inquiries used to evaluate his mental status and the facility assessed Resident A's cognitive skills for daily decision making as severely impaired. Resident 1's behaviors listed in the MDS assessment were: (a) Physical: incidents of hitting, kicking, pushing, scratching, and grabbing having occurred in the last 1-3 days. (b) Verbal: incidents of threatening, screaming, and cursing at others had also been reported in the last 1-3 days of the MDS assessment). The facility ' s assessment of Resident 1's ability to perform activities of daily living (ADL's: eating, grooming, toileting) showed that Resident 1 required total assistance with all ADL's. He could do nothing for himself. The MDS record included the use of a, " trunk restraint, " in bed and in a chair daily. Review of current physician orders, last dated 8/1/12, showed the following instructions: 1. Soft pelvic restraints when in chair ... for behavior of hitting, tripping others, banging head and going to unsafe areas. 2. Soft pelvic restraints when in bed ... for inappropriate behavior of hitting, tripping others, banging head and going to unsafe areas. 3. Chair mounted on wall for safety awareness ...tipping over the chair. In an interview with the facility ' s regional Director of Operations (DO) on 9/6/12 at 10:55 a.m., he stated that Resident 1 had been previously located on the main floor of the facility and his chair was secured by straps near the nurses ' station. This had been done for the safety of Resident 1, other residents and staff. The DO stated that Resident 1 attempted to trip staff and other residents as they passed by him. On 9/6/12 at 1:10 p.m., the surveyor observed Resident A, in the same position, sitting in the geri-chair, chained to the wall with the pelvic restraint in place. CNA 1, when asked if Resident 1 had been released from the restraints, stated that later in the day, Resident 1 would have 10 minutes of exercise provided by the RNA (restorative nursing assistant). CNA 1 stated that during the exercise the pelvic restraint would be released and the RNA would apply a gait belt to assist Resident A while walking. In an interview with the RNA on 9/6/12 at 1:15 pm., when asked about Resident 1 being seated in a chair that was chained to the wall, the RNA stated, "I don't like to see him like that. When we walk outside he is happy." During an interview with both the Director of Nurses (DON) and the administrator on 9/7/12 at 3:40 p.m., both stated that the only way to safely care for Resident 1, was to " secure him with restraints." On 9/17/12 at 9:15 a.m., during an interview with Resident A's primary physician (A), Physician A stated that Resident 1 required the use of physical restraints in order to keep him (Resident A) safe and, for the safety of other residents. On 10/23/12, at 9:20 a.m., during a telephone interview with CNA 2, who routinely provided care to Resident 1 during the night shift, CNA 2 stated that Resident A wore a pelvic restraint that was tied to the bed during the night. CNA 2 stated that if unrestrained, Resident 1, "might run away, get agitated or hit somebody." On September 6, 2012, Resident 1 attempted to run away from the skilled nursing facility while on a walk outside with staff. When staff attempted to take Resident 1 back inside the facility, Resident 1 became combative and the facility called the police. The police arrived and transferred Resident 1 to the local psychiatric hospital for evaluation. The local psychiatric hospital refused to admit and evaluate Resident 1 until he had a physical clearance from an acute care hospital. The acute care hospital performed a physical assessment of Resident A and then transferred Resident 1 back to the psychiatric hospital for evaluation. After evaluation of Resident 1, the psychiatric hospital determined that Resident 1 did not have a psychiatric condition and returned Resident 1 to the acute care hospital where he was admitted for ongoing care. Communication with acute care hospital staff showed the following progression of restraint use for Resident 1. 10/5/12 at 12:16 p.m.: " Physical restraints (at times, 4-point restraints) were initially used while in the (emergency room ) at the height of patient ' s crisis status when behaviors were so volatile that his as well as public safety were in imminent risk. When he was transferred to the floor, 2-point restraints were required intermittently for the first week. Additionally, during the initial weeks, he required 5-staff response to manage his explosive behaviors. Within 3 weeks of admission, the staffing ratio was decreased to 2:1. " " As of today, we will begin another staffing ratio change as follows: 1:1 in-room staff 24/7; Security outside of room from 3p - 7a daily. As always, this will be evaluated and modified as needed to ensure patient safety. On a positive note, a heart-tugging event: on his first out-of-the-building walk, the 1:1 staff reported that the patient took a deep breath, softly said " pretty " and beamed! " 10/29/12 at 3:55 p.m.: Currently, 1:1 staff 24/7 still required as patient ' s safety awareness is non-existent. He is a high risk for wandering. Patient continues to require cuing, verbal & physical re-direction when signs/symptoms of agitation are noted & these have been effective. Per 1:1 staff, patient is more likely to flail his arms or hard taps another person when that person intrudes his space or during care routines. He also would bang on windows, elevator doors especially if he has been standing in front of these for some time. It is the opinion of the 1:1 staff that patient is NOT likely to be aggressive with others unless he feels threatened or asked to do something he does not care to do. Patient reportedly does pull/snatch objects, i.e, plants. Because of his impaired memory, he will require constant verbal re-direction. It is the opinion of the 1:1 staff as well as the entire care team that the patient will require 1:1 support for the foreseeable future especially during awake hours. 11/9/12 at 6:20 a.m. " No restraints have been used for the past 2 months. "