Every finding on record at Wayland Nursing and Rehabilitation Center

Based on observation, staff interview, and facility document review, facility staff failed to prepare store and serve food in a sanitary manner in one of one facility kitchens. The findings include: On 04/14/2025 at approximately 11:30 a.m., an observation of the facility's kitchen revealed the following: On 04/14/2025 at approximately 11:25 a.m., an observation of the facility's kitchen revealed a 26-inch fan sitting on a cart blowing into the kitchen and onto a metal shelving unit with four shelves. Observations of the shelves revealed, the top shelf contained 25 clean meal tray covers, the second from the top shelf contained 12 clean tray bottoms, the third from the top shelf contained 30 clean eight-ounce bowls and the bottom shelf contained three racks of clean cups and glasses. Observation of the fan revealed the fan blades, and the front and back fan guards were coated in dust. Observation of the inside of the facility's walk-in refrigerator revealed a ladder rack containing two sheet pans with a combined total of 40, eight-ounce bowls containing mixed fruit. Further observation revealed that the fruit bowls were uncovered. Observation of the top, right hand shelf inside the facility's walk-in refrigerator revealed a Ziploc bag containing three one-half pound stacks of sliced Swiss cheese. Observation of one of the stacks of cheese revealed it was open to the environment. Observation of the Ziploc bag revealed it was open to the environment. Observation of a shelf, second from the top, on the right-hand side inside the facility's walk-in refrigerator revealed a sandwich wrapped in a paper wrap. Further observation failed to evidence a name or date on the sandwich. Observation of the food processor located in the facility's kitchen on a food preparation table was conducted with OSM #1. When asked if the food processor was cleaned and ready for use OSM #1stated, Yes. Observation of the inside of the food processor lid revealed it was wet, standing water inside the bowl and a wet blade. After observing the food processor bowl OSM #1 verbally agreed that the inside of the lid, bowl and blade were wet. On 04/14/2025 at approximately 2:20 p.m., an interview was conducted with OSM (other staff member) #1. When asked about the fruit on the ladder rack in the walk-in refrigerator being uncovered, she stated the bowls should have been covered to keep any debris from falling on them. OSM #1 stated the Swiss cheese in the Ziploc bag should have been closed, the sandwich found on the shelf in the walk-in refrigerator should have been labeled with a resident's name and dated. Regarding the food processor, she stated it should have been air dried to prevent the development of bacteria or mold. After being informed of the observation of the fan blowing on the clean items on metal shelving, OSM #1 observed the fan and verbally agreed the fan blades, and front and rear fan guards were coated in dust. She further stated the fan should not have been blowing into the kitchen and it was blowing dust onto the clean items on the metal shelving. The facility's policy Cleaning Procedures. Warewashing documented in part, Dishes and other reusable components of metal service, pots and pan, will be washed using the proper temperature, correct chemicals, and then air-dried. On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings. No further information was provided prior to exit.

Based on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all residents within the facility for nine of ten quarters reviewed. The findings included: The facility staff failed to evidence QAPI sign-in sheets for meetings held between Q4 of 2022 and Q4 of 2024. On 4/14/25 at 11:28 a.m., during entrance conference a request was made to ASM (administrative staff member) #1, the administrator for QAPI meeting attendance records from 7/28/22 to the present. On 4/16/25 at 12:38 p.m., ASM #1 provided QAPI meeting attendance records and stated that he was not able to find all the sign-in sheets going back to the last survey and what was provided was all that he had. ASM #1 stated that he was not able to identify the dates that the meetings took place, and they did not have dates on the sign-in sheets or any documentation identifying when the meetings took place. Review of the provided QAPI meeting attendance records documented a meeting completed in Q1 of 2025. A QAPI meeting attendance record dated 10/24/24 documented the medical director, administrator and director of nursing attending with no additional staff members. Three undated QAPI meeting attendance records documented three meetings with the required attendees, one meeting with the infection preventionist not attending and one meeting with the director of nursing not attending. On 4/16/25 at 3:49 p.m., an interview was conducted with ASM #1 who stated that since he had been at the facility the QAPI team met monthly with a minimal of a quarterly meeting to discuss subjects that they identified through audits, tracking, morning meetings, the clinical team and resident suggestions. He stated that they worked as a team to determine performance improvement projects, tracked progress of ongoing projects and perform root cause analysis of identified problems. The facility policy, Quality Assurance and Performance Improvement (QAPI) Plan revised 10/15/2022, documented in part, . The QAPI Committee will meet on a regular basis, and at least quarterly . On 04/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4 (administrator colleague from another facility) were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide education and the opportunity to refuse the implementation of psychoactive medications for one of 19 residents in the survey sample, Resident #41. The findings include: For Resident #41 (R41) the facility staff failed to provide education for and the opportunity to refuse the implementation of the use of Risperidone (1) and Sertraline (2). A review of R41's clinical record revealed an order for Risperidone 0.5 mg (milligrams) daily and Sertraline 50 mg daily. A review of R41's MARs (medication administration records) for March and April 2025 revealed these medications were administered as ordered. Further review of the record failed to reveal any evidence that the facility provided the resident (and/or resident representative) education about the risks versus benefits of these medications or offered the opportunity to refuse the administration of these medications. On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated: We are supposed to get consent and provide education. She stated psychoactive medications carry a specialized risk for side effects which can be pretty bad. On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. A review of the facility policy, Psychotropic Drug Therapy, revealed, in part, The resident has the right to accept or decline the initiation or increase of a psychotropic medication. To demonstrate compliance, the resident's medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and was able to choose the option he or she preferred. No additional information was provided prior to exit. References (1) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html. (2) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). This information is taken from the website https://medlineplus.gov/druginfo/meds/a697048.html#:~:text=Sertraline%20is%20in%20a%20class,that%20helps%20maintain%20mental%20balance.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician of a change in condition in a timely manner for 1 of 19 residents, Resident #197. The findings include: For Resident #197 (R197), the facility staff failed to notify the physician of swelling and redness to the residents left knee observed on 3/6/24 in a timely manner. R197 no longer resided at the facility and could not be observed or interviewed. The record was reviewed as a closed record. A facility synopsis of events for R197 dated 3/8/24 documented in part, .Swelling & redness noted to LT (left) knee. MD in to see. X-ray of knee ordered- found acute appearing distal femur fx (fracture) proximal to LT knee replacement. Resident sent to ER. See attached summary . The attached summary documented in part, Resident was noted with redness and swelling to LT knee on 3/6/24. Primary nurse was made aware. Primary nurse assessed resident and found redness and swelling to LT knee and decision was made to notify MD. Resident had no complaints of pain when asked. MD saw resident on 3/7/24 and order given for x-ray. [Name of x-ray service] in on 3/8/25 and performed x-ray. Radiology reading of x-ray states resident had an acute-appearing fracture of the distal femur proximal to her knee replacement. Resident sent to the ER for evaluation. The hospital attributed the fracture to her fall on 2/25/24. Orthopedic surgeon felt that surgical intervention could cause more harm to resident than nonsurgical intervention. States knee was already starting to heal. Knee immobilizer placed in hospital to help with keeping fracture in alignment during healing. Resident has a diagnosis of osteopenia, osteoarthritis, Vitamin B and D deficiencies. The progress notes for R197 documented in part, - 02/25/2024 09:15 (9:15 a.m.) Incident Note. Note Text: CNA (certified nursing assistant) had resident turned on her side to change her sheets and she was scooting to the edge of the bed and was going to fall. CNA stated she was able to catch her but had to ease her to the floor. No injury noted. VS (vital signs) 122/74 (blood pressure)-70 (pulse)-18 (respirations)-98.4 (temperature)-97% (oxygen saturation). - 02/27/2024 13:30 (1:30 p.m.) Note Text: No injury noted from fall on 2/25/24. Voices no complaints of pain or discomfort. - 03/07/2024 13:38 (1:38 p.m.) Note Text: Order for x-ray of residents left knee ordered by [Name of physician]. Call placed to [Name of x-ray service] to alert them of the order. Copy of x-ray order and residents face sheet placed in the front nurses station. - 03/08/2024 11:36 (11:36 a.m.) Note Text: X-ray tech in facility at this time to obtain X-ray. - 03/08/2024 13:45 (1:45 p.m.) Note Text: Received results of Xray. MD notified and gave order to send resident to ER. The physician progress note for R197 dated 3/7/24 documented in part, .Chief complaint/reason for this visit: Left knee pain. HPI (history of present illness) relating to this visit: [age and sex of R197] with history of CAD (coronary artery disease), Dementia, Chronic A. (atrial) fibrillation, CVA (cerebrovascular accident) and OA (osteoarthritis) is seen today for evaluation of pain in her left knee with swelling that she complained about this morning. This knee has had joint replacement in 2011. There were no reports of any trauma. She does complain of pain with moving the knee .Musculoskeletal: Joint Swelling/Inflammation, Mobility, Painful Movement, Left knee tender . Assessment and Plan: 1. left knee pain has had surgery 2021. 1: Obtain x-ray. Tylenol prn (as needed) pain. 2. Dementia: Continue safety precautions. Reorient as necessary . The clinical record failed to evidence documentation regarding the swelling and redness of the left knee first observed on 3/6/24 or notification of the physician. On 4/15/25 at 10:27 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that R197 had been assisted to the floor during care by a former CNA on 2/25/24 and had only complained of some back pain the day after the fall which was addressed by the physician. She stated that the physician assessed R197 on 2/26/24 and started Tylenol for back pain. She stated that when she had investigated the incident, she had found that R197 had only complained of generalized pain when turning and had not knee pain or swelling until 3/6/24 when the CNA observed it and reported it to the LPN (licensed practical nurse). ASM #2 stated that the LPN had assessed R197's knee and notified the physician by placing it in the physician communication book. She stated that the physician saw R197 on 3/7/24 and ordered the x-ray which was obtained on 3/8/24 and the resident was sent out when the results came in. She stated that in hindsight the nurse should have called the physician and documented the assessment and findings in the medical record. On 4/15/25 at 12:42 p.m., an interview was conducted with LPN #1 who stated that the former CNA had called her on 2/25/24 when R197 was on the floor. She stated that the CNA told her that she was changing the resident and R197 had grabbed the rail and rolled over too far, and the CNA was not able to catch her in time to keep her in the bed and had lowered her to the floor. She stated that R197 was a one person assist at that time and would use the rail to hold herself over when they were providing care but had a habit of going over too far. She stated that she had assessed R197 who had no complaints of pain or injuries observed. She stated that she had notified the physician and resident representative at that time. LPN #1 stated that the physician book was used to communicate anything non-urgent that they needed to address when they came in the next day. She stated that the physician came in twice a week and the nurse practitioner came in three days a week and someone was on call on the weekends. LPN #1 stated that observed swelling and redness in the knee should have been documented in the medical record to cover them and show what was going on and should have been called to the physician rather than placed in the book. On 4/15/25 at 1:01 p.m., ASM #3, the facility nurse consultant provided a binder which documented a five-point performance improvement plan for regarding pain management. Review of the plan with an initiation date of 3/9/24, documented the following actions taken: Like Patient or System: - On 3/9/24, the DON initiated a Pain Assessment of all residents not able to report for signs and symptoms of pain. The purpose of the assessments is to identify any resident with new onset of pain or pain not relieved with current interventions and to ensure all residents with s/s pain have been assessed with interventions initiated, MD/RR notified with documentation in the clinical record, and the resident is care planned for pain/pain interventions. All areas of concern will be immediately addressed during the audit. The audit will be completed by 3-10-24. - On 3/15/24 the social worker initiated resident questionnaires with all alert and oriented residents regarding pain. The purpose of the questionnaires is to identify any resident with new onset of pain, worsening pain or pain not relieved with current interventions and to ensure all residents with s/s of pain have been assessed with interventions initiated, MD/RR notified with documentation in the clinical record, and the resident is care planned for pain/pain interventions. All areas of concern will be immediately addressed during the audit. The questionnaires will be completed by 3-15-24. - On 3/9/24, the facility nurse consultant will review the MAR (medication administration record) for all residents receiving pain medication for the past 30 days. The audit ensures the resident's pain medication regimen is effective, including PRN pain medications. The physician will be contacted for any identified areas of concern during the audit. The audit will be completed by 3/10/24. - On 3/21/24 the DON initiated staff questionnaires to ensure there were no residents with unrelieved pain. This was to ensure staff had reported any changes in pain to a nurse and follow-up had occurred. Plan: - On 3/9/24, the DON initiated and in-service with all nursing assistants regarding reporting changes in resident condition including but not limited to pain. - On 3/9/24 the DON initiated an in-service with all nurses regarding assessment of acute changes in condition to include but not limited to pain, notification to the physician and resident representative, initiation of an intervention to address the pain, updates to the resident care plan, and documentation in the clinical record. - The inservices will be completed on 3/15/24. After 3/15/24 all nurses that have not worked and received the inservice will complete upon their next scheduled shift. Monitoring: - The DON/SDC will review residents' progress notes 5x per week x 4 weeks, then monthly x 1 month to identify residents with pain. The purpose of the audit is ensuring the pain was assessed by nursing staff with documentation in the electronic record, new onset of pain, worsening pain, or pain not relieved by current interventions are referred immediately to the physician for further interventions, the RR (Resident Representative) is notified of the pain, and the plan of care reflects pain. The resident will be assessed and/or notification to the provider with documentation in the clinical records, and the nurse will be retrained for all identified areas of concern. - The audit will be discussed during the cardinal IDT (interdisciplinary team) meeting 5x per week x 4 weeks then monthly x 1 month and documented on the pain audit tool. - The administrator or DON will present the findings of the Audit Tools to the QAA committee monthly for 2 months. The QAA committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring. The performance improvement plan documented a compliance date of 3/21/24. Review of the evidence binder documented completed resident pain assessments, resident and staff questionnaires, pain medication audits, progress note audits and education sign-in sheets documenting training on assessing for change in condition, pain, notification of the physician and resident representative, updating the care plan, pain interventions and documentation in the clinical record. The staff sign-in sheets for the inservice training were reviewed and verified by multiple staff interviews. The other points of the plan of correction as described in this writing were verified with resident interviews and observations. No current concerns were identified. On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the concern at past non-compliance. No further information was provided prior to exit. PAST NONCOMPLIANCE

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for 1 of 19 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to maintain the resident's wheelchair cushion in good repair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. On 4/14/25 at 1:24 p.m., an observation was made of R9 in their room eating lunch. R9 was observed sitting in a manual wheelchair. The black cushion underneath R9 was observed to be torn on both corners exposing the yellow foam underneath. On 4/14/25 at 1:34 p.m., an interview was conducted with R9 who stated that he had the wheelchair cushion for a long time and the holes in the cushion had started very small but had gotten larger over time. He stated that the cushion had lost its padding from age, and he needed a new one, but no one had ever offered one. Additional observation of R9's wheelchair cushion with the tears on both sides exposing the yellow foam underneath was made on 4/15/25 at 8:10 a.m. On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that if they saw that a residents wheelchair cushion was torn or damaged, they contacted therapy to replace it. She stated that normally it was a conversation with them to replace the cushion. On 4/15/25 at 12:58 p.m., LPN #1 observed R9's wheelchair cushion with the torn areas on both sides exposing the yellow foam underneath and stated that the cushion should be replaced She stated that she would let R9's nurse know so that therapy could order him a replacement. The facility policy titled, Environment and Property dated 8/2019, documented in part, .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . On 4/15/25 at 3:59 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings. No further information was presented prior to exit.

2. For R1, the facility staff failed to evidence required documentation was provided to the receiving facility for a transfer to the hospital on [DATE] and 04/06/2025. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. The facility's nursing progress noted for R1 dated 02/25/2025 documented, Note Text: Resident complaining that she can't breathe. O2 (oxygen) concentrator, tubing, and all working properly. Nasal spray administered and neb (nebulizer) tx (treatment) given without relief. Md (medical doctor) notified and received order to send to ER (emergency room) for workup. The facility's nursing progress noted for R1 dated 04/06/2025 at 8:00 p.m. documented, Note Text: Writer call to resident room observed resident yelling out, I can`t breathe, Writer observed resident O2 at 4L/M (four liters per minute) intact via (by) nasal canula. Resident observed having difficulty breathing using abdominal muscle. Writer placed POSAT (pulse oximeter) (1) on resident finger an notice her SATS (saturation) was 85 (85 percent). Writer immediately started resident on breathing treatment and notice SATS increase to 90 then went back down to 85. Writer notified (Name of Director of Nursing), DON (director of nursing) as ordered to do so, suggested to writer to contact MD (medical doctor) and see what he advises. The facility's nursing progress noted for R1 dated 04/06/2025 at 8:15 p.m. documented, Note Text: Writer notified (Name of Doctor) and received order to send resident to [NAME] (emergency room department). Writer notified 911 rescue gave report to dispatcher who told me that he has recue in route. Writer notifies (Name of Hospital) [NAME] gave report to (Name of Nurse), RN Registered Nurse). Review of the EHR (electronic health record) failed to evidence documentation of required information provided to the hospital on [DATE] and 04/06/2025 for R1. On 04/15/2025 at approximately 2:55 p.m., an interview was conducted with ASM (administrative staff member) #1, administrator regarding evidence that the required documentation sent to the receiving facility for a resident's transfer. He stated that the nurse's notes document what information is provided to the receiving facility. When asked about the evidence of the documentation that was sent to the hospital on [DATE] and 04/06/2025 for R1's transfer, ASM #1 stated that that there was no evidence of any documentation was sent for the transfers on 02/25/2025 and 04/06/2025 for R1. On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings. No further information was provided prior to exit. Based on clinical record review, facility document review, and staff interview, it was determined the facility staff failed to evidence required documents were sent to the receiving facility at the time of a facility-initiated transfer for two of 19 residents in the survey sample, Residents #38 and #1. The findings include: 1. For Resident #38 (R38), the facility staff failed to evidence that clinical documentation pertaining to the continuity of care was sent to the receiving hospital on 2/2/25 for a facility-initiated transfer. The progress notes for R38 documented in part, - 02/02/2025 14:02 (2:02 p.m.) Note Text: Resident reassessed for temp, increased to 103.7 after Tylenol administered. VS (vital signs) obtained and relayed to MD. Per MD send out to ER for further eval and tx. RR (resident representative), [Name of RR] called and made aware. She agreed to send to ER. - 02/02/2025 14:04 (2:04 p.m.) Note Text: Emergency transport in at this time to transport to [Name of hospital]. - 02/02/2025 18:28 (6:28 p.m.) Note Text: Called ER to check on resident's status. Resident is being admitted with Influenza, UTI (urinary tract infection) and Sepsis. Further review of the clinical record failed to evidence that the resident's representative and physician contact information, advance directive information, instructions for ongoing care, medication list, or care plan goals were sent to the receiving facility. On 4/15/25 at 11:45 a.m., a request was made to ASM (administrative staff member) #1 for evidence of the clinical documentation sent to the receiving hospital on 2/2/25 for R38. On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that when they transferred a resident to the hospital, they sent a copy of the face sheet, the DNR (do not resuscitate) form if applicable, medication list, transfer form and bed hold policy. She stated that they had sent the care plan in the past, but they had stopped because some were over 50 pages, so she did not think they did that anymore. On 4/16/25 at 10:17 a.m., ASM #1 stated that they did not have any evidence to provide of the clinical documentation sent to the receiving hospital on 2/2/25 for R38. A review of the facility policy, Discharge and Transfer dated 8/2012, documented in part, .When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information, as required by the facility receiving the resident, will accompany him/her . On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to develop and/or implement the comprehensive care plan for two of 19 residents in the survey sample, Resident #1 (R1) and R3 The findings include: 1. For R1, the facility staff failed to follow the comprehensive care plan for the administration of oxygen. R1 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1) and respiratory failure (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R1 as receiving oxygen therapy while a resident. On 04/14/25 at approximately 1:15 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. On 04/15/25 at approximately 8:56 a.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. On 04/15/25 at approximately 1:50 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. The physician's order for R1 dated 04/10/2025 documented in part, Oxygen flow is 2 (two) L/min (liters per minute): Type of administration used nasal cannula. The comprehensive care plan dated 12/28/2023 for R1 documented in part, Focus: Potential for or Actual Ineffective Breathing Pattern R/T (related to): COPD and Respiratory failure. Date Initiated: 12/28/2023. Created on: 12/28/2023. Under Interventions it documented in part, Oxygen therapy (specify rate) via (specify device) as ordered. Date Initiated: 02/27/2025. On 04/15/2025 at approximately 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked about the purpose of a resident's care plan she stated that it provides direction for providing care to the resident. When asked if the care plan was followed if the if the oxygen was not set according to the physician's orders, she stated no. The facility's policy Guidelines For Documentation By Interdisciplinary Care Team documented in part, The care team should develop appropriate interventions for the prevention of negative outcomes. Potential negative outcomes may include but not limited to incontinence, skin breakdown, decreased range of motion, decrease ability to ambulate, loss of bone and muscle strength, increase risk of injury, loss of appetite, increased risk of infection, agitation, symptoms of withdrawal, depersonalization, dependency, feelings of entrapment, depression or reduced social contact. The care plan team should design interventions that minimize or eliminate the medical symptom . On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 2. For Resident #3 (R3), the facility staff failed to develop a care plan for the resident's contractures. On the following dates and times, R3 was observed lying supine in bed, with her head elevated. At each observation, both R3's hands and feet were contracted: 4/14/25 at 12:35 p.m. and 3:36 p.m.; 4/15/25 at 7:49 a.m. and 9:52 a.m. At no time was any contracture related device observed. A review of R3's comprehensive care plan failed to reveal information related to prevention of worsening of R3's contractures. On 4/15/25 at 10:21 a.m., RN (registered nurse) #1, the wound nurse, and ASM (administrative staff member) #2, the director of nursing, were interviewed as they completed R3's wound care. RN #1 and ASM #2 identified R3's bilateral feet and hands as being contracted. On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there was nothing required for R3's contractures as far as she knew. On 4/15/25 at 3:09 p.m., RN #2, the MDS (minimum data set) coordinator, was interviewed. She stated R3's most recent comprehensive MDS did not include consideration of R3's contractures as a concern needing interventions or a care plan. She stated ordinarily, a new therapy screening or intervention, or a physician's order for interventions, would trigger an entry on the resident's care plan. She said contractures should definitely be captured in a resident's care plan. On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. No additional information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for 1 of 19 residents in the survey sample, Resident #9. The findings include: For Resident #9 (R9), the facility staff failed to provide routine fingernail care. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R9 being independent for personal hygiene and bathing. On 4/14/25 at 1:34 p.m., an observation was made of R9's fingernails. The fingernails on both hands were observed to be approximately 1/4 inch long. At that time an interview was conducted with R9 who stated that the staff came around at times and would ask them if they needed their nails trimmed but had not been in recently. R9 stated that they had needed their nails trimmed for a while and was not able to do it himself. Additional observation of R9's fingernails was made on 4/15/25 at 8:10 a.m. and 11:57 a.m. The diagnosis information for R9 did not document a diagnosis of diabetes. The comprehensive care plan for R9 documented in part, Activities of Daily Living/ Personal Care related to dementia, OA (osteoarthritis), edema. Date Initiated: 01/10/2020. The goal of the care plan documented, Activities of Daily Living/Personal Care will be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. Date Initiated: 01/10/2020. Created on: 01/10/2020. Revision on: 05/15/2024. Target Date: 06/03/2025. On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that usually the CNA (certified nursing assistant) staff trimmed the residents' fingernails unless the resident was diabetic and then the nurse did it. She stated that the nails were checked every so often and if they noticed that they were long they trimmed them. On 4/15/25 at 12:58 p.m., LPN #1 observed R9's fingernails and stated that they were long and needed to be trimmed. On 4/15/25 at 2:14 p.m., an interview was conducted with CNA #1 who stated that the CNA staff trimmed residents' fingernails unless the resident was diabetic. She stated that the fingernails were assessed every day and especially on shower days when it was the time to give the most attention to the resident for things like shaving and nail care. The facility policy titled, Grooming dated 8/2012, documented in part, Grooming will be performed daily and PRN (as needed) as needed. This includes shampooing, shaving, nail care, and mouth care. On 4/15/25 at 3:59 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions for contractures for one of 19 residents in the survey sample, Resident #3. The findings include: For Resident #3 (R3), the facility staff failed to implement interventions to prevent worsening of contractures. On the following dates and times, R3 was observed lying supine in bed, with her head elevated. At each observation, both R3's hands and feet were contracted: 4/14/25 at 12:35 p.m. and 3:36 p.m.; 4/15/25 at 7:49 a.m. and 9:52 a.m. At no time was any contracture related device observed. On 4/15/25 at 10:21 a.m., RN (registered nurse) #1, the wound nurse, and ASM (administrative staff member) #2, the director of nursing, were interviewed as they completed R3's wound care. RN #1 and ASM #2 identified R3's bilateral feet and hands as being contracted. RN #1 stated, We float her heels, and it brings her feet back. She stated the staff also puts something in both hands, as the resident tolerates. ASM #2 stated if the staff attempted to implement an intervention to prevent contractures and the resident did not tolerate the intervention, there should be a progress note. A review of R3's clinical record, including therapy notes and screenings, failed to reveal evidence that the resident's contractures had been assessed or that interventions to prevent worsening of the contractures had been implemented. On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there was nothing required for R3's contractures as far as she knew. On 4/15/25 at 2:27 p.m., OSM (other staff member) #3, a certified occupational therapy assistant, was interviewed. She stated R3 has bilateral contractures in both hands and both feet, but she could not find any evidence of assessment or treatment for R3's contractures in the therapy records. She stated the facility had undergone several changes of therapy providers, and all previous therapy notes are not available to the current staff. She stated therapy screenings occur approximately every three months, and that the therapy staff should be screening for contractures. She stated the therapy staff will be assessing R3's contractures and making a treatment plan this week. On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. A review of the facility policy, Range of Motion, revealed, in part: Range of motion is performed daily with bath. Because of this daily care, range of motion exercises will not be documented. No additional information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 19 residents in the survey sample, Resident #1 (R1). For R1, the facility staff failed to maintain the oxygen (O2) flow rate at two liters per minute according to the physician's orders. The findings include: R1 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1) and respiratory failure (2). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R1 as receiving oxygen therapy while a resident. On 04/14/25 at approximately 1:15 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. On 04/15/25 at approximately 8:56 a.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. On 04/15/25 at approximately 1:50 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute. The physician's order for R1 dated 04/10/2025 documented in part, Oxygen flow is 2 (two) L/min (liters per minute): Type of administration used nasal cannula. The comprehensive care plan dated 12/28/2023 for R1 documented in part, Focus: Potential for or Actual Ineffective Breathing Pattern R/T (related to): COPD and Respiratory failure. Date Initiated: 12/28/2023. Created on: 12/28/2023. Under Interventions it documented in part, Oxygen therapy (specify rate) via (specify device) as ordered. Date Initiated: 02/27/2025. On 04/15/2025 at approximately 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked to describe how to read the flow meter on the oxygen concentrator she stated the bottom of the float ball inside the flow meter should be on the liter line. The (Name of Manufacturer's) Oxygen Concentrator Instruction Guide documented in part, Check the flow meter to make sure the flow meter ball is centered on the line next to the prescribed number of your flow rate. The facility's policy Oxygen Therapy documented in part, 5. Adjust flow meter to prescribe rate. On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings. No further information was provided prior to exit. References: (1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html. (2) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for two of 19 residents in the survey sample, Residents #35 and #197. The findings include: 1. For Resident #35 (R35), the facility staff failed to document care they provided for the resident's indwelling urinary catheter each shift. On the following dates and times, R35 was observed utilizing an indwelling urinary catheter: 4/14/25 at 12:44 p.m. and 1:14 p.m.; 4/15/25 at 7:51 a.m. and 11:17 a.m. On 4/15/25 at 11:17 a.m., R35 was interviewed about routine care for his indwelling urinary catheter. He stated the staff (especially CNAs [certified nursing assistants]) do a wonderful job of caring for his catheter. He stated they clean the catheter at least every shift. A review of R35's clinical record revealed no orders for catheter care, and no evidence that routine catheter care was being provided to R35. On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she regularly cares for R35, and that she always provides catheter care each morning when she gives the resident a bath. She stated it is important to keep the catheter as clean as possible to prevent a possible urinary tract infection. She stated she is not aware of any place to document the care she gives in the clinical record. On 4/15/25 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. A review of the facility policy, Rules for Medical Records Documentation, revealed, in part: The resident's medical record is used to plan continuous care; coordinate clinical care contributions; communicate ad keep apprised of the resident medical condition; and provide clinical data for continuing education and research. A resident's medical record is legal proof of the quality of care provided .Document any action taken in response to a resident's problem. No additional information was provided prior to exit. 2. For Resident #197 (R197), the facility staff failed to maintain a complete medical record documenting observed swelling and redness to the residents left knee on 3/6/24. R197 no longer resided at the facility and could not be observed or interviewed. The record was reviewed as a closed record. A facility synopsis of events for R197 dated 3/8/24 documented in part, .Swelling & redness noted to LT (left) knee. MD in to see. X-ray of knee ordered- found acute appearing distal femur fx (fracture) proximal to LT knee replacement. Resident sent to ER. See attached summary . The attached summary documented in part, Resident was noted with redness and swelling to LT knee on 3/6/24. Primary nurse was made aware. Primary nurse assessed resident and found redness and swelling to LT knee and decision was made to notify MD. Resident had no complaints of pain when asked. MD saw resident on 3/7/24 and order given for x-ray. [Name of x-ray service] in on 3/8/25 and performed x-ray. Radiology reading of x-ray states resident had an acute-appearing fracture of the distal femur proximal to her knee replacement. Resident sent to the ER for evaluation. The hospital attributed the fracture to her fall on 2/25/24. Orthopedic surgeon felt that surgical intervention could cause more harm to resident than nonsurgical intervention. States knee was already starting to heal. Knee immobilizer placed in hospital to help with keeping fracture in alignment during healing. Resident has a diagnosis of osteopenia, osteoarthritis, Vitamin B and D deficiencies. The physician progress note for R197 dated 3/7/24 documented in part, .Chief complaint/reason for this visit: Left knee pain. HPI (history of present illness) relating to this visit: [age and sex of R197] with history of CAD (coronary artery disease), Dementia, Chronic A. (atrial) fibrillation, CVA (cerebrovascular accident) and OA (osteoarthritis) is seen today for evaluation of pain in her left knee with swelling that she complained about this morning. This knee has had joint replacement in 2011. There were no reports of any trauma. She does complain of pain with moving the knee .Musculoskeletal: Joint Swelling/Inflammation, Mobility, Painful Movement, Left knee tender . Assessment and Plan: 1. left knee pain has had surgery 2021. 1: Obtain x-ray. Tylenol prn (as needed) pain. 2. Dementia: Continue safety precautions. Reorient as necessary . The clinical record failed to evidence documentation regarding the swelling and redness of the left knee first observed on 3/6/24. On 4/15/25 at 10:27 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that R197 had been assisted to the floor during care by a former CNA on 2/25/24 and had only complained of some back pain the day after the fall which was addressed by the physician. She stated that the physician assessed R197 on 2/26/24 and started Tylenol for back pain. She stated that when she had investigated the incident, she had found that R197 had only complained of generalized pain when turning and had not knee pain or swelling until 3/6/24 when the CNA observed it and reported it to the LPN (licensed practical nurse). ASM #2 stated that the LPN had assessed R197's knee and notified the physician by placing it in the physician communication book. She stated that the physician saw R197 on 3/7/24 and ordered the x-ray which was obtained on 3/8/24 and the resident was sent out when the results came in. She stated that in hindsight the nurse should have documented the assessment and findings in the medical record. On 4/15/25 at 12:42 p.m., an interview was conducted with LPN #1 who stated that the physician book was used to communicate anything non-urgent that they needed to address when they came in the next day. She stated that the physician came in twice a week and the nurse practitioner came in three days a week and someone was on call on the weekends. LPN #1 stated that the observed swelling and redness in the knee should have been documented in the medical record of R197 to cover them and show what was going on. On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor residents for the administration of unnecessary psychoactive medications for two of 19 residents in the survey sample, Residents #41 and #17. The findings include: 1. For Resident #41 (R41) the facility staff failed to monitor for side effects for the use of Risperidone (1) and Sertraline (2). A review of R41's clinical record revealed an order for Risperidone 0.5 mg (milligrams) daily and Sertraline 50 mg daily. A review of R41's MARs (medication administration records) for March and April 2025 revealed these medications were administered as ordered. Further review of the record failed to reveal any evidence that the facility was monitoring for the side effects of the medications. On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the facility is responsible for monitoring for side effects of all psychoactive meds. She stated psychoactive medications have the potential for pretty bad side effects for residents, including tardive dyskinesia. She stated the facility's software sometimes automatically triggers for staff to monitor for side effects, but in R41's case, the software had not triggered. On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. A review of the facility policy, Psychotropic Drug Therapy, failed to reveal specific steps to be taken for monitoring for side effects of psychoactive medications. No additional information was provided prior to exit. References (1) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html. (2) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). This information is taken from the website https://medlineplus.gov/druginfo/meds/a697048.html#:~:text=Sertraline%20is%20in%20a%20class,that%20helps%20maintain%20mental%20balance. 2. For Resident #17 (R17), the facility staff failed to for side effects for the use of Seroquel (1) A review of R17's clinical record revealed an order for Seroquel 50 mg (milligrams) nightly. A review of R17's MARs (medication administration records) for March and April 2025 revealed this medication was administered as ordered. Further review of the record failed to reveal any evidence that the facility was monitoring for the side effects of the medications. On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the facility is responsible for monitoring for side effects of all psychoactive meds. She stated psychoactive medications have the potential for pretty bad side effects for residents, including tardive dyskinesia. She stated the facility's software sometimes automatically triggers for staff to monitor for side effects, but in R17's case, the software had not triggered. On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns. No additional information was provided prior to exit. Reference (1) Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder. Quetiapine extended-release tablets are also used along with other medications to treat depression. Quetiapine tablets may be used as part of a treatment program to treat bipolar disorder and schizophrenia in children and teenagers. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a698019.html.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on one of three dates observed and post daily nurse staffing information in a prominent place readily accessible to residents and visitors on three of three dates observed. The findings include: The facility staff failed to post daily nurse staffing information prior to the start of the shift on 4/14/25 and post daily nurse staffing information in a prominent place readily accessible to residents and visitors on 4/14/25, 4/15/25 and 4/16/25. On 4/14/25 at 11:28 a.m., an observation was made of the facility. There was no daily nurse staffing information posted. Observation at 12:50 p.m. revealed a daily nurse staffing posted on the wall inside a plastic page protector. The posting was observed to be hanging on the wall inside the nurses' station on the interior wall not readily accessible to residents or visitors. On 4/15/25 at 8:02 a.m., an observation was made of daily staff posting hanging inside the nurses' station located on the interior wall inside a plastic page protector not readily accessible to residents or visitors. On 4/16/25 at 8:18 a.m., an observation was made of daily staff posting hanging inside the nurses' station located on the interior wall inside a plastic page protector not readily accessible to residents or visitors. On 4/14/25 at 11:44 a.m., an interview was conducted LPN (licensed practical nurse) #2 who stated that the night nurse posted the daily staffing and that it normally hung beside them at the nurses' station. LPN #2 pointed to an empty plastic page protector hanging on the wall on the inside of the nurses' station and stated that she could print one out. On 4/16/25 at 9:53 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing, who stated that the night nurse posted the daily staffing. She stated that they had not posted it on 4/14/25 so she had posted it later that day. ASM #2 stated that residents and visitors did not go in the nurses' station for privacy reasons. She stated that the posting probably could not be seen from a wheelchair or if someone had bad eyesight from where it was hanging on the wall inside the nurses' station. On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings. No further information was provided prior to exit. On 4/16/25 at 5:02 p.m., ASM #1 stated via email that the facility did not have a policy regarding daily staff posting and that they followed the federal regulations.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail inspection for 4 of 29 residents in the survey sample, Residents #43 (R43), #22 (R22), #35 (R35), and #13 (R13). The findings include: 1. (R43) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 2:28 p.m. and on 07/27/22 at 8:45 a.m. (R43) was admitted to the facility with diagnosis that included but was not limited to: a history of falls. (R43's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/27/2022, coded (R43) as scoring a 14 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested. On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment. On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings. No further information was provided prior to exit. 2. (R22) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 2:02 p.m. and on 07/27/22 at 8:50 a.m. (R22) was admitted to the facility with diagnosis that included but was not limited to: a history of falls. (R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/02/2022, coded (R22) as scoring a 13 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested. On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment. On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings. No further information was provided prior to exit. 3. (R35) was observed lying in bed with the right and left upper bed rails raised on 07/27/22 at 8:08 p.m. and at 11:05 a.m. (R35) was admitted to the facility with diagnosis that included but was not limited to: dementia. (R35's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/18/2022, coded (R35) as scoring a 4 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was severely impaired of cognition for making daily decisions. On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested. On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment. On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings. No further information was provided prior to exit. 4. 3. (R13) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 12:31 p.m. (R13) was admitted to the facility with diagnosis that included but was not limited to: thoracic (upper and middle back) vertebrae compression fracture. (R13's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/09/2022, coded (R13) as scoring a 10 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions. On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested. On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment. On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to implement bed rail requirements for 4 of 29 residents in the survey sample, Residents #21, #149, #13 and #22. The findings include: 1. The facility staff failed to attempt alternatives prior to the use of Resident #21's (R21) bed rails, failed to assess R21 for the risk of entrapment from bed rails, failed to educate R21 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/24/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions. On 7/26/22 at 3:58 p.m., R21 was observed lying in bed with bilateral quarter bed rails in the upright position. A review of R21's clinical record revealed a physical device evaluation dated 5/17/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R21 or the RR, and failed to document informed consent was obtained. The evaluation documented n/a (not applicable) for all areas. R21's comprehensive care plan dated 5/18/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Paralysis. On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R21's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation. The facility policy titled, SIDE RAIL GUIDELINES documented, Side rails may be used to enhance resident mobility and transfer to and from the bed .Resident injury or death is more likely to occur when attempts are made to get out of bed with the side rails raised. Injury may occur when a resident attempts to move through, between, or over side rails . No further information was presented prior to exit. 2. The facility staff failed to attempt alternatives prior to the use of Resident #149's (R149) bed rails, failed to assess R149 for the risk of entrapment from bed rails, failed to educate R149 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails. R149's admission minimum data set assessment was not complete. A nursing admission evaluation documented R149 communicates needs and can be understood. On 7/26/22 at 12:39 p.m., R149 was observed in bed with bilateral quarter bed rails in the upright position. On 7/27/22 at 10:54 a.m., an interview was conducted with R149. R149 stated no staff had talked to the resident regarding bed rails or explained the risks and benefits of bed rails. A review of R149's clinical record revealed a physical device evaluation dated 7/20/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R21 or the RR, and failed to document informed consent was obtained. The evaluation was blank. R149's baseline care plan dated 7/26/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness. On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R149's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation. No further information was presented prior to exit. 3. The facility staff failed to attempt alternatives prior to the use of Resident #13's (R13) bed rails, failed to assess R13 for the risk of entrapment from bed rails, failed to educate R13 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails. On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 5/9/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions. On 7/26/22 at 12:31 p.m., R13 was observed in bed with bilateral quarter bed rails in the upright position. A review of R13's clinical record revealed a physical device evaluation dated 5/2/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R13 or the RR (resident representative), and failed to document informed consent was obtained. The evaluation documented none and n/a (not applicable) for these areas. R13's comprehensive care plan dated 5/3/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Safety in transfers. On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R13's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation. No further information was presented prior to exit. 4. The facility staff failed to attempt alternatives prior to the use of Resident #22's (R22) bed rails and failed to assess R22 for the risk of entrapment from bed rails. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/2/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. On 7/26/22 at 2:02 p.m., R22 was observed lying in bed with bilateral quarter bed rails in the upright position. On 7/27/22 at 8:00 a.m., an interview was conducted with R22. R22 stated the resident doesn't use the bed rails unless the resident is about to fall. R22 stated the staff had explained the risks and benefits of bed rails to the resident. A review of R22's clinical record revealed a physical device evaluation dated 5/2/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R13 or the RR (resident representative), and failed to document informed consent was obtained. The evaluation documented none and n/a (not applicable) for these areas. R22's comprehensive care plan dated 12/4/19 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Safety in transfers. On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R22's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment. No further information was presented prior to exit.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide adequate wanderguard monitoring for one of 29 residents, Residents #22; and failed to ensure safety protocols were in place per facility policy for 3 of 3 residents smoking, Residents #36, #38, and #5. The findings include: 1. The facility staff failed to check the placement of (R22's) wanderguard according to the physician's orders (R22) was admitted to the facility with diagnoses that included but were not limited to: dementia (1). (R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/2/2022, coded (R22) as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section P Restraints and Alarms coded (R22) for a wander guard Used daily. The physician's order for (R22) documented in part, WANDERGUARD- Check Location and expiration every shift. Date Order: 07/11/2022. The comprehensive care plan for (R22) dated 12/04/2019 documented. FOCUS: RESIDENT CARE GUIDE Date Initiated: 12/04/2019. Under Interventions it documented in part, WANDERS - wander guard in place Date Initiated: 02/10/2022. The facility's Wandering Risk assessment dated [DATE] for (R22) documented in part, Score: 5.0. I. NOTE: A resident who scores greater than 5 (five) is at risk for wandering. The facility's Transmitter Testing Log dated June 22 (2022) documented, Expiration Date: Oct (October) 23(2023). Under the heading it documented, Day of Month; Transmitter Test OK; Transmitter tested By and Comments. Review of the Transmitter Testing Log failed to document the facility's nursing shifts. Further review revealed missing check marks for transmitter tests on 06/04/2022, 06/11/2022, 06/12/2022, 06/18/2022, 06/19/2022, 06/25/2022 and on 06/26/2022. The facility's Transmitter Testing Log dated July 22 (2022) documented, Expiration Date: Oct (October) 23(2023). Under the heading it documented, Day of Month; Transmitter Test OK; Transmitter tested By and Comments. Review of the Transmitter Testing Log failed to document the facility's nursing shifts. Further review revealed missing check marks for transmitter tests on 07/02/2022, 07/03/2022, 07/10/2022, 06/18/2022, 07/15/2022, 07/16/2022, 07/17/202, 07/23/2022 and on 07/24/2022. On 07/28/22 at approximately 8:04 a.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked to explain Expiration, location and every shift written on the physician's order for the wander guard as stated above ASM # 2 stated that expiration referred to the expiration date of wander guard, location referred to the resident wearing the wander guard and every shift referred to all three nursing shifts, 7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m. and 11:00 p.m. to 7:00 a.m. When asked to interpret the blanks on the testing log as stated above ASM # 2 stated that they indicated it wasn't done. After reviewing the facility's Transmitter Testing Logs ASM # 2 stated that the location of (R22's) wander guard was being checked and not being done every shift. They further stated that the facility's form would need to be revised to reflect the physician's orders. After reviewing the comprehensive car plan for (R22's) wander guard as stated above ASM # 2 stated that the care plan should match the physician order for the wander guard. On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings. No further information was provided prior to exit. 2. The facility staff failed to provide safety equipment specifically a fire extinguisher in the designated smoking area for Resident #36. A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room. Resident #36 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #36 did not exhibit any unsafe smoking behavior. Resident #36 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area. Resident #36 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: [CONDITION(S)], diabetes and [CONDITION(S)]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/20/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being independent for bed, transfer, locomotion, dressing, eating, hygiene and bathing. The MDS annual assessment with ARD of 1/13/22, Section J: coded current tobacco use yes. A review of the comprehensive care plan dated 8/23/20, revealed, FOCUS: Resident is a smoker or user of tobacco products. Resident will continue to smoke safely in designated areas thru next review. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Assist resident in obtaining smoking materials from secured storage area upon request. A review of the smoking evaluation dated 4/25/22 at 11:24 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking. An interview was conducted on 7/26/22 at 12:00 PM with Resident #36. When asked how long he has smoked, while he has been a resident, Resident #36 stated, since I came here. On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them. On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings. According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures. No further information was provided prior to exit. 3. The facility staff failed to provide safety equipment, specifically a fire extinguisher, in the designated smoking area for Resident #38. A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room. Resident #38 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #38 did not exhibit any unsafe smoking behavior. Resident #38 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area. Resident #38 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: [CONDITION(S)], chronic obstructive disease, [CONDITION(S)] cardiovascular disease and tobacco use. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/24/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being independent for bed, transfer, locomotion, walking, dressing, eating, hygiene and bathing. The MDS annual assessment with ARD of 12/15/21, Section J: coded current tobacco use yes. A review of the comprehensive care plan dated 11/19/21, revealed, FOCUS: Resident is a smoker or user of tobacco products. Resident will continue to smoke safely in designated areas thru next review. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Supervised Smoker-unsafe. Assist resident in obtaining smoking materials from secured storage area upon request. A review of the smoking evaluation dated 5/15/22 at 11:36 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking. An interview was conducted on 7/26/22 at 12:15 PM with Resident #38. When asked how long he has smoked, while he has been a resident, Resident #38 stated, for a while. When asked where he smokes, Resident #38 stated, we smoke out under the carport at the front of the building. On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them. On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings. According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures. No further information was provided prior to exit. 4. The facility staff failed to provide safety equipment specifically a fire extinguisher in the designated smoking area for Resident #5. A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room. Resident #5 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #5 did not exhibit any unsafe smoking behavior. Resident #5 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area. Resident #5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/7/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed, transfer, locomotion, walking, dressing, hygiene and bathing; supervision for eating. The MDS annual assessment with ARD of 12/13/21, Section J: coded current tobacco use yes. A review of the comprehensive care plan dated 7/1/20, revealed, FOCUS: Resident is a smoker at the facility and requires assistance to smoke safely. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Assist resident in obtaining smoking materials from secured storage area upon request. A review of the smoking evaluation dated 5/15/22 at 11:33 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking. An interview was conducted on 7/26/22 at 2:15 PM with Resident #5. When asked how long she has smoked, while she has been a resident, Resident #5 stated, since I have been here. When asked how frequent she smokes, Resident #5 stated, two or three times a day. On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them. On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings. According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures. No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that facility staff failed to review or revise the comprehensive care plan for 2 of 29 residents in the survey sample, Residents #22 (R22) and (R29). The findings include: 1. The facility staff failed to update (R22) comprehensive care plan following (R22's) fall on 07/07/2022. (R22) was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/02/2022, coded (R22) as scoring a 13 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. The facility's progress note dated 07/07/2022 documented in part, Called to resident's bathroom @ (at) 1305 (1:35 p.m.). Resident noted to be sitting on bottom on bathroom floor with back against wall. Assessed for injury, none noted. When asked what happened, she stated that she got dizzy and lost her balance. Assisted back into room into bed x2 assist. VS obtained . The facility's fall investigation for (R22) dated 07/707/2022 documented in part, Incident Description. Nursing Description: Called to resident's bathroom @ (at) 1305 (1:35 p.m.). Resident noted to be sitting on bottom on bathroom floor with back against wall. Resident Description: stated that she got dizzy and lost her balance. Type of Injury: No injuries observed at time of incident. The comprehensive care plan for (R22) dated 02/10/2022 documented, Focus: Problematic manner in which resident acts characterized by ineffective coping: Wandering and/or at risk for unsupervised exits from facility related to: cognitive impairment, restlessness Date Initiated: 02/10/2022. Under interventions it documented, At Risk Wandering Protocol Date Initiated: 02/10/2022, Document episodes of wandering per facility protocol Date Initiated: 02/10/2022, Wander guard alarm bracelet Date Initiated: 02/10/2022. Further review of the care plan failed to evidence documentation that that it was reviewed or revised regarding (R22's) fall on 07/07/2022. On 07/28/22 at approximately 8:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing, regarding the revision or review of (R22's) care plan following the fall on 07/07/2022. ASM #2 stated that the care plan was revised yesterday, 07/27/2022. They further stated that (R22's) medications were reviewed at the time of the fall by the physician but they failed to update the care plan at that time. When asked to describe the procedure for revising/ reviewing a resident's care plan ASM #2 stated that the care is reviewed/revised at the time of the new intervention. When asked to describe the purpose of a resident's care plan ASM #2 stated that the care plan makes a continuous continuity of care for the resident. The facility's policy Resident Care Plan documented in part, The resident care plan will be an ongoing process and will include current problems and/or needs identified from a complete assessment including the Minimum Data Set (MDS) and Care Assessments (CAAs) relevant to the resident's response to aging, illness, and his/her general health status. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and bought to the next scheduled care plan meeting to inform the ICP team of its addition. On 07/28/2022 at approximately 11:35 a.m., ASM #1, administrator and ASM #2, were made aware of the findings. No further information was provided prior to exit. 2. The facility failed to revise the comprehensive care plan to include correct fluid restriction for Resident #29. Resident #29 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/8/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the Section G-functional status coded the resident as requiring extensive assistance for transfer, dressing and hygiene; totally dependent for bed mobility, locomotion and bathing; supervision for eating. Section O-special procedures/treatments coded the resident as [CONDITION(S)] yes. A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: [CONDITION(S)]: The resident is at risk for complications due to hemodialysis. INTERVENTIONS: [CONDITION(S)] (Tuesday, Thursday, Saturday). Diet as ordered; 1000ml daily Fluid Restriction. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/27/22 at 12:00 PM, a request was made for evidence of 1200 milliliters daily fluid restriction monitoring for July 2022. A review of the nursing progress note dated 7/27/22 at 7:00 PM, revealed, Physician called to clarify fluid restriction order for the resident. On 7/28/22 at 9:00 AM, ASM (administrative staff member) #2 stated, We do not have any evidence of monitoring the fluid restriction at 1200 milliliters. Normally the order is more specific with dietary and nursing having specific set amounts. When asked if the care plan should have been revised to reflect the new order, ASM #2 stated, It should have been revised. The care plan currently has the 1000 milliliters fluid restriction. On 7/28/22 at 9:30 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated the care plan is the plan of care specific for that resident. When asked if fluid restrictions should be on the care plan, LPN stated yes, it should. When asked if the care plan should be revised if the fluid restriction amount is changed, LPN #1 stated, if there is an amount on the care plan, it should be revised. On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings. A review of the facility's Resident Care Plan policy revised 11/17, reveals, Review and/or modification of the plan will occur after each assessment, including the comprehensive and quarterly review assessments. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and brought to the next scheduled care plan meeting to inform the ICP (interdisciplinary care plan) team of its addition. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 29 residents in the survey sample, Residents #11 (R11). The facility staff failed to keep (R11's) catheter collection bag off the floor. The findings include: (R11) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (R11's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/18/2022, coded (R11) as scoring a 3 (three) on the brief interview for mental status (BIMS) which indicated severely impaired cognition for making daily decisions. Section H Bladder and Bowel coded (R11) as having an indwelling catheter. On 07/26/22 at approximately 12:32 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair. On 07/26/22 at approximately 1:58 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair. On 07/26/22 at approximately 3:50 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .indwelling urinary catheter to gravity drainage . The comprehensive care plan for (R11) dated 03/22/2022 documented in part, Focus: Altered Pattern of Urinary Elimination with Indwelling Catheter . - At Risk for Infection due to urinary retention Date Initiated: 03/22/2022. On 07/27/2022 at approximately 12:53 p.m. an interview was conducted with RN (registered nurse) #1. When asked how the catheter collection bag should be positioned when a resident is in a wheelchair RN #1 stated that the collection bag is hooked up underneath wheelchair and off the floor. When asked why it was important to keep the collection bag off the floor RN #1 stated that is was to prevent the spread of infection and discomfort for the resident. On 07/27/2022 at approximately 4:35 p.m., ASM #1, administrator and ASM #2, were made aware of the findings. No further information was provided prior to exit. References: (1) A problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. This information was obtained from the website: https://medlineplus.gov/ency/article/ 4.htm.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required clinical information was provided to the hospital staff for 2 out of 29 residents in the survey sample that were transferred to the hospital; Residents #29 and Resident #12. The findings include: 1. The facility staff failed to evidence provision of required resident clinical information to a receiving facility at the time of discharge for Resident #29. Resident #29 was transferred to the hospital on 6/21/22. Resident #29 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/8/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the Section G-functional status coded the resident as requiring extensive assistance for transfer, dressing and hygiene; totally dependent for bed mobility, locomotion and bathing; supervision for eating. Section O-special procedures/treatments coded the resident as [CONDITION(S)] yes. A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: [CONDITION(S)]: The resident is at risk for complications due to hemodialysis. INTERVENTIONS: [CONDITION(S)] (Tuesday, Thursday, Saturday). Diet as ordered; 1000ml daily Fluid Restriction. A review of the nursing progress note dated 6/21/22 at 11:55 AM, revealed, Time Resident Returned from [CONDITION(S)]: 11:55. Condition of Shunt Site (dressing intact, bleeding, drainage, etc.): intact. Bruit & Thrill: =/- Site: +. Condition & Mental Status upon return (alert, oriented, confusion, lethargy, other symptoms, etc.): lethargic. Instructions &/or Communication from [CONDITION(S)] Center (pre/post weights, order changes, lab results, etc.): patient complained of upset stomach. Complained of not feeling well. Blood pressure within normal limits. Heart rate [CONDITION(S)]/irregular. Patient coughed and heart rate dropped within normal limits. 20 min later heart rate up to 129. Vital signs 112/82-118-18-98.1. Additional Comments (time dressing removed, MD notification & orders changes/verified, etc.). 12:30 resident complained of chest pain and left arm pain with nausea. Physician in room. Vital signs 159/83-90-16-95.9. O2 saturations at 85%. O2 applied via nasal cannula at 2 liters per minute. Order to send to emergency room . 12:43 911 called. 13:10 county rescue squad arrived. Resident left facility via stretcher and 2 attendants at 13:15. 13:20 report called to emergency room . There is no evidence of transfer documentation in the medical record. A request for clinical documents for the transfer of Resident #29 on 6/21/22 was made on 7/26/22 at 4:40 PM. On 7/27/22 at 7:35 AM, ASM (administrative staff member) #2, the director of nursing stated, there is no evidence of the clinical documentation for this resident for this transfer. An interview was conducted on 7/27/22 at 8:30 AM with LPN (licensed practical nurse) #1. When asked what information is provided to the hospital upon transfer of a resident, LPN #1 stated, there is some paperwork that we send. When asked if there is a checklist, LPN #1 stated, We do not have a checklist. On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings. A review of the facility's Discharge and Transfer policy dated 8/12, reveals, Discharge and/or transfer to other medical facilities will be effected only when medically appropriate as indicated by the attending physician. When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information, as required by the facility receiving the resident, will accompany him/her. No further information was provided prior to exit. 2. The facility staff failed to provide Resident #12's (R12) comprehensive care plan goals to the hospital staff when R12 was transferred to the hospital on 6/20/22. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/9/22, the resident's cognitive skills for daily decision making were coded as severely impaired. A review of R12's clinical record revealed the resident was transferred to the hospital on 6/20/22 for abdominal distention and hypoactive bowel sounds. Further review of R12's clinical record failed to reveal evidence of the clinical documentation provided to hospital staff. On 7/27/22 at 9:14 a.m., an interview was conducted with RN (registered nurse) #1 (the nurse who sent R12 to the hospital). RN #1 stated she provides hospital staff with a copy of residents' face sheets, a copy of monthly orders, a copy of telephone orders that are received after the monthly orders are signed, a copy of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated sometimes she provides a piece of residents' care plans that is related to the problem but she did not provide any portion of the care plan or the comprehensive care plan goals when R12 was transferred to the hospital on 6/20/22. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop a complete baseline care plan for one of 29 residents in the survey sample, Resident #149. The facility staff failed to include Resident #149's (R149) indwelling urinary catheter on the resident's baseline care plan. The findings include: On 7/27/22 at 8:14 a.m., R149 was observed lying in bed with an indwelling urinary catheter. A review of R149's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R149's baseline care plan initiated on 7/20/22 failed to document information regarding an indwelling urinary catheter. On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of a care plan is to drive the resident's plan of care. RN #1 stated she initiates a resident's baseline care plan if she is the admitting nurse and an indwelling urinary catheter should be included on the baseline care plan because a resident receives specialized care related to the catheter. On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, RESIDENT CARE PLAN documented, The initiation of a baseline care plan will begin upon admission by the designated RN. Baseline care plans will include the instructions needed to provide effective and patient-centered care for residents that meet professional standards of quality care. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility failed to protect one of 35 residents in the survey sample from resident-to-resident abuse. On 2/28/21, Resident #37 and Resident #4 argued in their room which escalated to Resident #37 pushing his wheelchair into Resident #4's table causing a laceration to Resident #4's right lower leg that required treatment in a local emergency room and closure with 9 staples, resulting in harm. The findings include: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/1/21 coded Resident #4 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. On 3/9/21 at approximately 3:10 p.m., an interview was conducted with Resident #4. Resident #4 was observed to have a gauze wrap dressing dated 3/9/21 on his right lower leg. When asked about the dressing on his right lower leg, Resident #4 stated that he was assaulted by their previous roommate, Resident #37 and had to go to the emergency room to get staples in his leg to close an injury. Resident #4 stated that Resident #37 was no longer in the facility because they got rid of him after that happened. Resident #4 stated that he had argued with Resident #37 over the television and that Resident #37 pushed his empty wheelchair through the privacy curtain into him causing the over bed table to cut his right lower leg. Resident #4 stated that the nurse had to apply pressure to the area and he had to go to the emergency room to get staples to the area. The progress notes for Resident #4 documented in part the following: - 2/17/2021 10:26 (10:26 a.m.) Note Text: Writer met with resident and advised that he would be getting a roommate today. - 2/28/2021 16:25 (4:25 p.m.) Note Text: resident had been arguing with his roommate over the TV, his room mate was yelling & they were calling each other names, resident states he cannot stand the way his room mate talks to him & the way he (curse) on himself. Writer explained to resident that he can not help being incontinent (without control of) however, he should not yell at his roommate & curse at him. They should try to compromise with what to watch on the TV. - 2/28/2021 16:40 (4:40 p.m.) Note Text: called to room Resident noted to be bleeding from a 8.5 cm (centimeter) laceration on the right lateral lower leg. Resident holding tissues on wound, large puddle of blood noted on the floor & in trash can. Resident had his leg propped on the trash can, blood dripping into it. Resident stated that his roommate pushed the w/c (wheelchair) on the other side of the curtain into his overbed table, which hit his leg. Roommates w/c (wheelchair) removed from the room, pressure applied to wound for several minutes to slow bleeding, wrapped with gauze. Explained to resident that he needed to go to the ER (emergency room ) due to excessive bleeding, & for a tetanus shot. Resident still arguing, cursing & threatening with the room mate intermittently, yelling that he wanted to have the cops called on that piece of (curse) because he assaulted me Administrator made aware & stated that resident needed to go to a room on C-wing upon return from ER & he would straighten it out in the morning with both residents. - 2/28/2021 17:01 (5:01 p.m.) Note Text: resident sustained [REDACTED]. RN (registered nurse) supervisor applied pressure dressing. Received verbal order from (name of nurse practitioner) to send resident to ER. Report called. Bed hold policy sent with resident. Resident is own RR (responsible representative). - 2/28/2021 20:40 (8:40 a.m.) Note Text: Returned to facility after receiving 9 staples and new orders for Keflex (antibiotic) 500 mg (milligrams) q (every) 12 hours x 10 days. Resident is own RR and is aware. - 3/1/2021 13:02 (1:02 p.m.) Note Text: Resident stated that he wanted to file assault charges against roommate for injuring him causing 9 staples in lower leg. This writer notified (County Name) Sheriff Dept. Spoke with investigator several times. Also notified (Name of ombudsman) LTC (long term care) Ombudsman and (Name of staff) with APS (adult protective services). Awaiting return call from investigator with (County Name). - 3/1/2021 17:31 (5:31 p.m.) Note Text: Investigator and deputy in to speak with resident. The ED (emergency department) Note Physician for Resident #4 from (Name of Hospital) dated 2/28/2021, documented in part, .Chief complaint from (Name of facility) - verbal argument with roommate; knocked wheelchairs into each other; laceration to right lower leg; dressing on with controlled bleeding .This is a (age and sex of Resident #4) that presents to the emergency department with a laceration to the right lower extremity. He was cut to the lower leg with a metal part of the wheelchair. The wound was thoroughly irrigated, cleansed with [MEDICATION NAME], and closed with staple gun. Patient will be placed on oral antibiotics. His tetanus shot was updated. Patient will be discharged back to the facility . Resident #37 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/21 coded Resident #37 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section E documented Resident #37 failed to evidence documentation of any behavioral symptoms during the observation period. Resident #37 no longer resided at the facility and could not be observed during the survey dates. The record was reviewed as a closed record. The comprehensive care plan for Resident #37 dated 12/28/2020 documented in part, Problematic manner in which resident acts characterized by ineffective coping; verbal/ physical Aggression or Agitated, Combativeness related to: Anger, cursing, yelling at staff, threatening to hurt staff. Date Initiated: 12/22/2020, Created on: 12/22/2020, Revision on: 03/08/2021. The care plan further documented, Negative feelings regarding self and social relationships characterized by; low self esteem, anxiety, mistrust, conflict/anger, ineffective coping related to: displays of inappropriate social behavior exposing self to staff, inappropriate communication with staff through letters & email. Date Initiated: 01/04/2021, Created on: 01/04/2021, Revision on 03/08/2021. The progress notes for Resident #37 documented in part the following: - 12/20/2020 14:52 (2:52 p.m.) Note Text: CNA (certified nursing assistant) came to writer and stated that resident was cursing her. She stated that she set up a bed bath, she asked (Resident #37) to go ahead and get started washing his face to his waist. She then informed him that she will be right back because she had 2 call lights going off. About 10 mins (minutes) had passed and he put his call light on. When she went in the room and apologized for taking longer to het (sic) back to him he started cursing at her. She said he threatened to Kick my (curse words). Then he stated he hopes that she become paralyzed. He also threatened to call the state and he has done it before. He also stated that he would refuse to feed himself so that CNAs would have to feed him because he pays good money to be here and he want his moneys worth. Housekeeper and another CNA heard him cursing and yelling. - 12/21/2020 08:37 (8:37 a.m.) Note Text: This writer and Clinical Care Coordinator went in to speak with resident. Staff reported that resident this weekend was cursing them, calling staff MF and F you. Also threatening staff. This writer and Clinical Care Coordinator explained to resident this behavior was unacceptable and if continued we would have to discharge. Explained that there are other ways of communicating with staff other than threatening and cursing staff. Resident replied, I will call state and report yall for abuse. I know how it works. Stated I will just walk to the door and fall and sue yall. Resident stated that he would also call the LTC (long-term care) Ombudsman. This writer provided resident with the cell number to (Name of Ombudsman) LTC Ombudsman. Resident got out of bed and pushed bedside table toward door as walking. - 12/21/2020 08:57 (8:57 a.m.) Note Text: After speaking with social worker and clinical care coordinator resident became angry and got up out of the bed pushed his bedside table into the hallway. Very unsteady gate. - 12/23/2020 12:06 (12:06 p.m.) Note Text: This writer and AR in to speak with resident regarding DSS (Department of Social Services) stating that his insurance will not cover his LTC (long term care) stay. Resident stated that he would call his father. Resident's sister called and stated that resident can not return to live with her or the father. Stated that the property manager also stated that he is not allowed on property. Sister stated something to do with indecent exposure. - 12/23/2020 13:21 (1:21 p.m.) Note Text: Was given note from CNA (Name of CNA) that resident gave her. Note entails resident's personal phone number and email note reads I missed you, signed by resident. CNA states resident asked her why she didn't call him, CNA responded to resident stating that would be inappropriate and was illegal. Resident wasn't happy with her comment. No further gestures at this time, CNA was informed that 2 staff members should be present when caring for resident. - 12/23/2020 14:19 (2:19 p.m.) Note Text: Received call from LTC Ombudsman regarding that she received a voicemail from resident stating that he is not allowed to have friends here. Explained to (Name of Ombudsman) (LTC Ombudsman) that resident was sending note to a CNA with his personal information on it such as email address, cell phone number and that CNA advised Clinical Care Coordinator. CNA stated to resident that this action was not acceptable. - 12/30/2020 10:31 (10:31 a.m.) Note Text: Received fax from Harrisonburg DSS (department of social services) for resident to apply for Medicaid. Resident stated that the bank account and vehicle are in both his name and wife's name. This writer called (Name of staff) at Harrisonburg DSS at (Phone number) and left message to inquire how to obtain this information since the wife has a protective order against resident. - 12/30/2020 12:18 (12:18 p.m.) Note Text: CNA asked this writer to speak with resident because resident wanted CNA to wash him. Resident is capable of washing himself. Resident writes notes and texts on his cell phone. CNA stated that resident makes a effort to expose himself to them. Resident also will put his hands behind his head while they are giving care. This writer spoke with resident and advised that he is capable of washing himself. When this writer left room resident was starting to bathe himself. - 12/31/2020 09:54 (9:54 a.m.) Note Text: heard resident yelling at CNA. entered room, resident trying to make CNA leave room before she had finished cleaning him from a BM. he was talking about some shirts that had went to laundry and had not came back yet. told CNA to go buy me some more shirts. explained to resident that we would see about his shirts being found. he went on to say that therapy was not helping him, and that he would find somewhere else to go. this nurse explained that he could do some things for himself, that we were here to help him do what he was unable to do, he stated he was not going to wear a gown, resident has issues with exposing himself and attempting to have staff provide care in genital area when he is capable of doing this himself. When staff is entering room, resident will place both hands behind his head. Resident stated that we get paid to wait on him. Resident stated that he is going to stay naked, that would get somebody's attention. Stating that he has not been able to see his psychiatrist. states he is going to call the advocate. Was very rude and disrespectful with CNA and this nurse. Notified Social Worker of same. - 12/31/2020 10:54 (10:54 a.m.) Note Text: Resident no longer on precautions so will be moved to (Room number on C hall). Resident is aware and is own RR (resident representative). - 1/12/2021 16:50 (4:50 p.m.) Note Text: CNA came to get this writer to listen to resident yell. CNA and this writer were at resident's door. Resident found on floor laying on right side. CNA stated that resident continues to make statements about throwing himself on the floor when he is mad. This writer called (Name of Physician) who gave verbal order to sent to ER (emergency room ) for eval (evaluation) of fall and psych (psychiatric) eval. 911 called. This writer also spoke with LTC Ombudsman regarding resident. LTC Ombudsman stated that resident calls several times on multiple occasion. - 1/13/2021 07:05 (7:05 a.m.) Note Text: resident returned from ER at this time. No new orders received. - 1/13/2021 10:41 (10:41 a.m.) Note Text: Law enforcement officer in to serve protective order on resident from his wife. - 1/13/2021 14:57 (2:57 p.m.) Note Text: This writer and DON (director of nursing) in to talk with resident. This writer advised resident that his behaviors were unacceptable. Explained to resident that as of now he also has no payer source, that his Medicaid has not been approved for LTC (long-term care). Advised that this writer has sent his information to several facilities due to resident wanted to transfer but because of his behavior, the other facilities refused to take resident due to his behaviors. - 1/20/2021 07:55 (7:55 a.m.) Note Text: CNA reported that when she went to pick up resident's dinner tray, he had thrown it in the floor. - 1/23/2021 14:14 (2:14 p.m.) Note Text: resident rang call bell for tray to be picked up. told him that CNA would be picking all trays up in a few minutes. Because she did not go in room right away he got angry and threw tray and urinal full of urine in floor in room. Told resident that was uncalled for. He stated he has a mental problem and he demands service right now. Stated that is what we are getting paid for. Stated he would call social services. Mad because he cannot go to bank and dmv. Explained to him that there was nothing that myself or CNA could do about that but that he did not have to act in the manner that he did. - 1/27/2021 11:05 (11:05 a.m.) Note Text: CNA in to see this writer. Resident throwing tray in floor for CNA to clean up. Resident continues to have behavior issues. This writer received message to call (Name of Deputy) at sheriff's office due to resident needs to be served papers. - 1/27/2021 15:11 (3:11 p.m.) Note Text: LPN (licensed practical nurse) requested this writer to come in to resident room as he had a conversation with him to address appropriate ways to address complaints. per staff on unit resident has been threatening to throw himself on the floor because the staff are not coming in rt (right) when he wants them to. This writer observed meal tray and trash all over the floor as the resident had thrown it. Resident was advised that as we have responsibilities toward him he also has responsibilities as a resident to behave appropriately. resident verbalized understanding. - 1/29/2021 15:30 (3:30 p.m.) Note Text: Resident stated to staff that she did not want to change him. CNA had been in residents room most of day. CNA stated that she has changed him 6 time. Resident had soiled his brief and as soon as he did, he removed brief and threw soiled brief in floor. CNA stated that she was giving care to another resident at the time he soiled brief but resident did not give CNA time to get to his room. CNA on next shift was making rounds with CNA from 1st shift, resident started cursing 2nd shift CNA for no reason as she had just came in room to do reporting rounds. - 2/9/2021 10:14 (10:14 a.m.) Note Text: Resident removed feces from brief and threw in the trash can. Resident made aware that CNA was coming to give care as soon as possible but resident removed feces and threw in trash can. - 2/9/2021 10:14 (10:14 a.m.) Note Text: writer walking down hall heard resident yelling at CNA that he wanted her to give him a bath, writer went into room to inquire on what was going on, resident stated he needed an arbitrator, writer asked again what the problem was, he stated he wanted to file suit to make sure he received proper hygiene every day that the CNA's bathed him. writer informed resident that she would have can set up his bath water, that he was more than capable of bathing himself. He stated I didn't say I couldn't. Then he stated that he needed to be changed, CNA was in room to change him when he started yelling at her about the bath. Resident assured that the CNA would perform incontinent care on him and then set him up for bath. - 2/17/2021 10:25 (10:25 a.m.) Note Text: This writer met with resident to advise would be moving to (Room number) and will have a roommate. Resident not on precautions. - 2/23/2021 13:43 (1:43 p.m.) Note Text: Activity Director reported hearing resident call CNA racial slurs and cursing her. CNA stated that she was going to provide him care as soon as she put the tray on the cart. Resident continued to call CNA racial slur and curse her. This writer spoke with Administrator who went and advised resident that cursing and racial slurs would not be tolerated. Resident stated find me another facility. Administrator explained that we have attempted to but all facilities have declined due to resident's behavior. - 2/23/2021 14:11 (2:11 p.m.) Note Text: Staff stated that resident continues to call CNA racial slurs and curse. Administrator again went to speak with resident and advise that this is not acceptable behavior. - 2/28/2021 16:23 (4:23 p.m.) Note Text: resident arguing with his room mate over TV. Accused his roommate of being spoiled & babied by the staff. Stated he was going to beat his (curse) to his roommate Writer reminded resident that he was not able to ambulate or transfer alone. Writer encouraged resident to try to work toward compromise with the TV & share what programs are watched, perhaps take turns. Also explained to him that the staff provide his room mate with time to smoke because it is the roommates right to smoke. It is also the roommates right to have the staff do shopping for him, resident was encouraged to let the activity department know if he wanted items purchased for him at the store on resident shopping day, explained he needed to have funds in his account & that they could find that out for him on Monday. Writer encouraged resident to try to speak nicely & politely to his room mate & to other resident's & staff. Reminded him that polite people do not throw things & yell at others during conversation. Resident stated that he wanted to leave writer explained that the social service department has been trying to find alternate placement for him however due to his behaviors other facilitates are not agreeing to having him transfer there. - 3/1/2021 10:00 (10:00 a.m.) Note Text: On 2/28/21 at approximately 1640 hours (4:40 p.m.) writer was called to resident's room. Resident's roommate (Resident #4) had sustained a 8.5cm (centimeter) laceration on his right lateral lower leg. The room mate (Resident #4) states that this resident (Resident #37) pushed the w/c (wheelchair) that was next to his bed (observed w/c on the left side of this resident's bed) into the privacy curtain pushing the overbed table into his leg. Roommate (Resident #4) yelling he was going to call the police; this resident (Resident #37) yelling I didn't do anything, I'm calling my dad to pick me up before the cops come. I'm not going to jail. Resident (Resident #37) observed to be rolling onto his side reaching for the w/c again. Writer removed w/c from the room & placed in the hallway & resident bed lowered to the floor for safety. Writer instructed resident to stop trying to roll out of the bed & to lay on his back & be still. No observable injury from altercation. - 3/1/2021 16:20 (4:20 p.m.) Note Text: staff called code green and stated resident was lying on the floor. Upon entering room resident was lying on his back perpendicular to the bed below the foot of the bed. Resident stated THE POLICE DON'T BELIEVE I CAN'T WALK. Resident reports back pain. Resident was log Rolled and assessed. moving all extremities. resident was assisted back into bed by staff. Bed in low position. RN (registered nurse) returned to room with equipment to obtain vitals- resident had his legs thrown over the side of the bed and stated he was leaving. Assisted resident back in to bed. Resident has no where to go and is at risk to harm himself or others. - 3/1/2021 16:20 (4:20 p.m.) Note Text: MD (Name of medical doctor) was notified of incident. Resident to be sent to ER (emergency room ) for evaluation of back pain post fall and for mental health eval as there is concern for his safety. 911 was called for transport to er, report was called to (Name of Staff) at (Name of Hospital) er. Resident expressed to RN he was concerned about missing dinner as that happened the last time he went to the er. Resident then became more agitated and stated he was going to leave AMA (against medical advice) because we want to send him to jail. Resident is unable to get himself to the door and has no place to go. Explained to resident that we are sending him to the ER for concern for his safety. Rescue squad arrived and resident consented to go to the ER . - 3/1/2021 17:31 (5:31 p.m.) Note Text: Investigator and Deputy in to speak with resident (Resident #37) regarding incident of 2/28/21. - 3/2/2021 10:32 (10:32 a.m.) Note Text: Charlotte County Deputy in to serve resident (Resident #37) with assault charges on another resident (Resident #4). Also was served a protective order against him taken out by his wife. Resident (Resident #37) after deputy left threw leg over side of bed. This writer in to speak with resident that stated he did not bother the other resident today. Explained that it was from the other day when he caused the other resident (Resident #4) to have to have 9 staples in leg. - 3/2/2021 11:34 (11:34 a.m.) Note Text: Received report from Housekeeping Supervisor and CNA that resident stated that he wanted to kill himself and get it over with. Writer asked resident if he had a plan. Received no response. Reported incident to ADON (assistant director of nursing). MD (medical doctor) made aware. Resident to be sent to ER. The psychiatric med management note dated 1/8/2021 for Resident #37 documented in part, .Reports that he does get angry and yell at times but has not thrown anything recently. Reports he has in the past thrown things out of frustration .He can also be verbally aggressive. He has thrown his table in the past .Social history: Pt is married with children. Reports they are separated. Reports he does not get a long well with his family. Reports his wife has a restraining order against him because, I have anger issues and it upset her. Reports he did not hit her. Family does not visit . The psychiatric med management note dated 1/22/2021 for Resident #37 documented in part, .Reports he did yell at staff last evening because his urinal was not close enough. He did not throw anything. He denies any recent sexual behaviors . The psychiatric med (medical) management note dated 2/5/2021 for Resident #37 documented in part, .He was seen today for a f/u (follow up) for moderate intermittent depression, anxiety, sexual behaviors, and verbal abuse that have been ongoing since admission .He can also be verbally aggressive. He has thrown his table in the past. Staff report that they have set limits and behaviors have overall improved. per staff, his wife has a restraining order against him for assault. Family will also not take him back due to him exposing himself to family and children in the past .If unable to maintain safety, please send to the ED (emergency department) for evaluation. Discussed behaviors with pt (patient) who agrees there is better ways to handle his frustration and will attempt talking with staff. Maintain sexual precautions . On 3/10/2021 at approximately 2:00 p.m., an interview was conducted with OSM (other staff member) #5, social services. OSM #5 stated that each morning they had a meeting with the administrator and other members of the interdisciplinary team. OSM #5 stated that when a resident needed to be moved to another room they discussed the best placement and potential room mate for the resident in the meetings. OSM #5 stated that they talked about which residents they thought would have common interests and get along when assigning room mates. OSM #5 stated that Resident #37 was admitted to the C hallway in a private room and was on quarantine for the required amount of time. OSM #5 stated that after the quarantine period was over Resident #37 was moved into the room with Resident #4 on the A hallway for long term care where Resident #4 was already residing. OSM #5 stated that Resident #37 started displaying inappropriate behaviors a few days after they were admitted . OSM #5 stated that Resident #37 displayed verbally abusive behaviors to staff and exposed himself to female staff but they did not think that those behaviors would transfer to a resident. OSM #5 stated that they had hoped that Resident #37 and Resident #4 would get along because they were both cognitively intact and may have shared common interests. OSM #5 stated that they had sent out requests to other facilities at Resident #37's request for transfer but none would accept them due to his behaviors. OSM #5 stated that Resident #4 had a history of [REDACTED]. OSM #5 stated that when a resident to resident incident occurred the staff were to immediately intervene and separate the residents. When asked if Resident #37's behaviors were taken in to consideration when placing him in the room with Resident #4, OSM #5 stated that they thought that the residents would get along. OSM #5 stated that there were other empty beds on 2/17/21 and Resident #37 could possibly have been placed in a room by himself. On 3/10/21 at approximately 2:34 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 2/28/21 she was asked to go to Resident #37 and Resident #4's room because a staff member could hear them arguing about the television from the hallway. RN #1 stated that when she entered the room the residents were not talking and the curtain was pulled between them. RN #1 stated that she told the residents that they had been arguing about the television and then they began arguing again. RN #1 stated that they talked about compromise on TV shows and both residents seemed to agree on the idea so she left the room to document the incident. RN #1 stated that she went to the nurses station and started documenting and was called back to the room by another staff member a few minutes later. RN #1 stated that when she entered the room Resident #4 had their leg over the trashcan and was bleeding. RN #1 stated that when she entered the room the second time Resident #37 and Resident #4 were arguing again. RN #1 stated that Resident #37 was lying in bed smiling and watching TV. RN #1 stated that staff had reported to them that both Resident #37 and Resident #4 had been bickering all day but had not shown any physical aggression. RN #1 stated that the incident occurred near the end of the day shift. RN #1 stated that the first thing she did was to maintain safety so she sent Resident #4 to ER and stayed in room until the ambulance arrived. RN #1 stated that if Resident #4 had not been sent to the ER, she would have separated the two residents at that time. When asked about the progress note dated 2/28/2021 at 4:23 p.m. which documented Resident #37 threatening to beat his (Resident #4's) (curse), immediately prior to the physical altercation, RN #1 stated that she had reminded Resident #37 that they could not get out of bed to beat anyone's (curse). RN #1 stated that in hindsight, it was a threat to Resident #4 and she should have separated the residents when they were arguing. RN #1 stated that she did not think Resident #37 was physically capable of moving as well as he did or being able to cause the injury to Resident #4. RN #1 stated that she thought Resident #37 was angry and just talking as he frequently did and was not able to follow through on any physical violence. The facility daily census documented the following: - 43 empty beds in the facility, 13 empty beds on A hall and 20 empty beds on C hall on 2/15/2021. - 42 empty beds in the facility, 12 empty beds on A hall and 20 empty beds on C hall on 2/16/2021. - 41 empty beds in the facility, 9 empty beds on A hall and 24 empty beds on C hall on 2/17/2021. - 42 empty beds in the facility, 9 empty beds on A hall and 24 empty beds on C hall on 2/18/2021. - 40 empty beds in the facility, 8 empty beds on A hall and 24 empty beds on C hall on 2/19/2021. The FRI (facility reported incident) dated 3/1/2021 documented in part, .Resident to resident altercation with injury, physician contact/intervention and/or transfer to hospital. Resident (Name of Resident #37) was involved with resident (Resident #4) regarding TV and Cable channels. (Resident #37) pushed wheelchair against bedside table causing injury to (Resident #4). (Resident #4) was sent to ER where he was treated for [REDACTED]. The five-day follow up report to the FRI dated 3/5/2021 documented in part, . (Resident #4) was sent out to the E.R. for evaluation and treatment. Upon his return, he was placed in a private room away from (Resident #37). The Charlotte County Sheriffs department was notified and a complaint was filed by (Resident #4) against (Resident #37). Papers were served on (Resident #37) for assault on 3/2/21 .See attached POC . The attached plan of correction summary documented a detailed summary of the incident details describing the residents involved, a summary of actions taken by the facility to prevent a recurrence, the facility procedure for monitoring the plan of correction and the person responsible for implementing the plan of correction. The Final Compliance date documented was 3/2/2021. On 3/10/21 at approximately 12:30 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for all documentation and investigation for the resident-to-resident incident on 2/28/21 for Resident #4 and Resident #37. ASM #2 stated that the facility had completed a FRI (facility reported incident) with investigation and had completed a plan of correction including education, interviews with residents, staff abuse testing, audits and the plan to monitor the plan of correction. ASM #2 stated that they would provide the evidence for review. On 3/10/2021 at approximately 1:30 p.m., ASM #2, the director of nursing presented a binder, which documented the following: - Interviews completed by the social worker of all cognitively intact residents in the facility on 3/2/21 regarding abuse. - An audit of any resident-to-resident altercations for the past six months at the facility. No other incidents were identified. - Staff in-service sign in sheets. - Copies of envelopes with in-services on resident-to-resident abuse mailed to staff not currently working at the facility. - Resident to Resident abuse quizzes completed by staff. - Incident reports for each resident dated 2/28/2021. - An investigational summary completed by the Dire (TRUNCATED)

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure residents were free of significant medication errors for four of 19 residents in the survey sample, Residents # 13, # 10, # 17, and # 18. 1. Resident # 13 received an incorrect amount of regular insulin which required hospitalization in the intensive care unit. 2. Resident #10 was not administered sliding scale insulin dosages as prescribed by the physician on 39 separate occasions during the months of February, March and April 2012. 3. Resident # 17 was not administered 4 doses of her regular insulin and sliding scale insulin on 3/3/12 according to the physician orders. 4. Resident # 18 was not administered her sliding scale regular insulin on 3/30/12 according to the physician orders. Insulin is a hormone produced by the beta cells of the pancreas that permits glucose to enter cells and helps the body use glucose for energy. Insulin controls the amount of glucose in the blood. People who are Type 1 diabetic must use manufactured insulin, usually in an injectable form, to replace the natural insulin that is no longer produced by their body. This information was obtained from the website: <http://diabetes.about.com/od/glossaryofterms/g/insulin.htm> "Insulin is available in rapid-, short- intermediate-, and long acting formulations. Regular or [MEDICATION NAME] R insulin is short acting (starts to lower the blood glucose level within 30 minutes of injections with duration of 5 to 8 hours). NPH and Lente and [MEDICATION NAME] N and [MEDICATION NAME] L and [MEDICATION NAME] are types of intermediate-acting insulin (start to lower blood glucose level within 2 hours of injection with a duration of 10 hours for NPH and approximately 18 to 24 hours for Lente) ...Manufacturers also make combination insulins, such as Humalog 75/25 (75% [MEDICATION NAME] and 25% [MEDICATION NAME]). The complexity of insulin therapy has risen sharply in the past decade. Insulin is considered a high -alert medication." Fundamentals of Nursing, 5th edition; Lippincott, Williams & Wilkins, page 582. The findings included: 1. Resident # 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, prior to the transfer to the hospital was an admission assessment, with an ARD (assessment reference date) of 02/21/12. The resident was coded as being able to be understood and to understand others. The resident was coded as not having any concerns with vision or hearing. Resident # 13 was coded as being moderately impaired to make daily cognitive decisions. Resident # 13 was coded as requiring extensive assistance of one staff member for all activities of daily living except eating in which she required supervision and set up help only. The resident was coded as being occasionally incontinent of urine but continent of bowel. In Section I, the resident was coded as having diabetes and a [MEDICAL CONDITION] disorder. Resident # 13 was coded in Section K as being 61 inches in height and weighing 150 pounds. The review of the clinical record revealed physician orders [REDACTED]." Also documented on the orders was the following: "[MEDICATION NAME] R (regular) SQ sliding scale q ac and hs (before each meal and at bedtime); 150 - 199 (FSBS (finger stick blood sugar)) = 2 units; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; > (greater than) 349 = 8 units + (and) notify MD (medical doctor)." Blood glucose values for adults is 60-100 mg/dl; Nurse's Manual of Laboratory and Diagnostic Tests; Bonita Cavanaugh Fourth Edition page 107 The facility drug reference manual was provided to this surveyor. The Geriatric Dosage Handbook; 14th edition, page 845 documented; Regular insulin; [MEDICATION NAME] is used to treat type 1 diabetes and insulin dependent type 2 diabetes and used to improve glycemic control. Warning: [DIAGNOSES REDACTED] is the most common adverse effect of insulin. The timing differs among various insulin formulations. [DIAGNOSES REDACTED] may result from increased work or exercise without eating; use of long acting insulin preparations may delay recovery from [DIAGNOSES REDACTED]. Insulin requirements may be altered during illness, emotional disturbances or other stresses. Use with caution in renal or hepatic impairment ....Pharmacodynamics: Onset of action - 0.5 hours. Duration of action - 6-8 hours (may increase with dose). Pharmokinetics: Time to peak - 2 - 4 hours. [DIAGNOSES REDACTED] is a lower than normal level of glucose in the blood, usually resulting from administration of too much insulin (in diabetes mellitus), excessive insulin secretion from the pancreas, or poor diet. Symptoms include headache, weakness, anxiety, personality changes, and if severe and untreated, coma and death. Treatment is by administration of glucose. Information taken from the Dictionary of Medical Terms for the Non-Medical Reader, 5th edition; Mikel Rothenberg, M.D. and Charles Chapman, page 285. The MAR (medication administration record) for 02/14/12 through 02/29/12 documented, "[MEDICATION NAME] 70/30; give 10 units SQ before dinner." It was documented on 02/28/12 at 4:30 p.m. as having been administered. The MAR for the same date, documented the [MEDICATION NAME] R sliding scale for 02/28/12 at 1630 (4:30 p.m.) as "OOF (out of facility)." No blood sugar was documented in the space, or initials representing that it had been given. The nurse's notes documented on 02/28/12 at 0400 (4:00 a.m.), "Resident in bed with eyes closed. Skin warm/dry. Respirations even/nonlabored. No cough, sputum or dyspnea noted. No C/O (complaints) of pain voiced. Cont (continent) of B + B (bowel and bladder), No S/S (signs and symptoms) of [DIAGNOSES REDACTED]. No abnormal behaviors." The next documented nurse's note was dated, 02/29/12, "(no time documented) (initials of hospital) resident with [DIAGNOSES REDACTED]. BS (blood sugar) stable. Called - 0500 (5:00 a.m.)." The next entry in the nurse's note was dated 02/29/12 at 1700 (5:00 p.m.) documented, "Resident arrived to facility via ambulance. A & O (alert and oriented) X (times) 3. No c/o pain or discomfort. Resp (respirations) are even & non labored. Skin warm & dry. Abd (abdomen) soft & non distended. BS (bowel sounds) active in all quads (quadrants). Lower extremities are [MEDICAL CONDITION] with dry skin intact. C/B (call bell) in easy reach." A "Transfer/Discharge Summary" dated 02/28/12 at 16:05 (4:05 p.m.) documented under "Brief hx (history) essential findings during stay (including treatment relevant to transfer/discharge): Received 70 units of Reg (regular) insulin at 4 p.m. instead of 70 U of 70/30." The rescue squad report sheet, dated 02/28/12 at 1709 (5:09 p.m.) documented, "Pt (patient) was administered 70 units of Regular Insulin instead of 70/30. Physician wanted pt. transported to ED (emergency department). Nursing Home had 22 gauge IV (intravenous) access w/ (with) 5 % [MEDICATION NAME] running. Glucose - 253." The hospital records were reviewed. The emergency record documented, "Chief complaint: Overdose. Patient was given 70 units of regular insulin instead of 70/30 insulin. Treatment prior to arrival; orange juice and peanut butter sandwich. D5W (5% [MEDICATION NAME] and water solution) was hung by EMS (emergency medical services) in route but her sugars were elevated at over 200s and that was stopped. Note: Correction- patient's usual PM dose of 70/30 is 10 units, not 70. Progress notes: Will observe until 10 p.m. May eat and drink. Regular insulin should have peaked at 2 hours, so around 6 pm. Diagnosis- Overdose - insulin. [DIAGNOSES REDACTED]. [MEDICAL CONDITION]." The laboratory test results from the hospital documented the resident's blood sugars as follows: 02/28/12 at 1811 (6:11 p.m.) as 207 (Normal range is 70 - 100 mg/dl (milligrams per deciliter) 02/28/12 at 1927 (7:27 p.m.) as 93. 02/28/12 at 2005 (8:05 p.m.) as 87. The resident was noted at 2040 (8:40 p.m.) to be, "Patient diaphoretic, shaking, unresponsive. Blood sugar checked, 27. (Name of doctor) notified. 1 amp ([MEDICATION NAME]) of D50 given. Patient responsive, talking." The decision was made to transfer resident to the intensive care unit for observation. The laboratory test results from the hospital documented the resident's blood sugars as followed: 02/28/12 at 2158 (9:58 p.m.) as 117. 02/28/12 at 2240 (10:40 p.m.) as 37. Resident received a second [MEDICATION NAME] of D50 IV (intravenous). IV fluids of D5W at 125 ml (milliliters)/hr were started. 02/28/12 at 2313 (11:13 p.m.) as 96. 02/28/12 at 2327 (11:27 p.m.) as 79. 02/28/12 at 0004 (12:04 a.m.) as 102. No further blood sugars less than 90 were reported. The resident remained in intensive care throughout the night. The history and physical dated 02/28/12 documented, "History of Present Illness: The patient is an [AGE] year old female with a history of diabetes. She is on insulin 70/30 twice a day. Apparently, according to the nurse home, she was inadvertently given 70 units of regular insulin at about 4:00 p.m. in the afternoon on the day of admission. She normally takes 70/30, but rather low dosages about 5 or 10 units. On the way to the emergency room she was given D50 ([MEDICATION NAME] 50% solution). Apparently, she was started on D5 ([MEDICATION NAME] 5 % solution) as well but her blood sugars were ion the 200s, so that was stopped. Most of the history is coming from the ER (emergency room ) physicians and talking with the nurse at the nursing home, as patient is a rather poor historian. They were going to just watch her in the emergency room as her blood sugars have been okay, especially since it was regular insulin and was dosed approximately 4 p.m. in the afternoon. There (sic) were going to watch here until 10 p.m. at night and send her back to the nursing home. However, she was seen diaphoretic and shaking and kind of unresponsive. So, they checked her sugar again at about 9:40 p.m. and her blood sugar was 27. She was given another amp of D50 and she perked up right away. She was also given crackers and orange juice, etc. I have been asked to admit as she is still dropping her blood sugars ....Laboratory Data: Glucometers (sic) have been running 207, 93, 87, 105, 26 and that was at 2138 hours. Then came up to 117, then down to 37 again at 2240. She was relatively asymptomatic with that and most recent reading at 2313 is 96 ....Assessment and Plan: 1. [DIAGNOSES REDACTED]. Inadvertently received, apparently, regular insulin. If it is regular insulin, then I would certainly expect the effects to be worn off by now. Nonetheless, we will watch her in the Intensive Care Unit. I was going to put her on the floor, but she dropped again to 37, so I think I will put her in the unit. Do q (every) one hour glucometers (sic) for now. I will put her on D5 half normal saline overnight. Reassess fluid status in the morning." The hospital discharge summary dated, 02/29/12 documented, "Patient was admitted from the (name of nursing home), after yesterday evening when she supposed to receive 10 units of 70/30 insulin and she was inadvertently given 70 units of regular insulin. She was brought emergently to the emergency department, where she was watched for four to five hours. Initially she was not hyperglycemic, but they went ahead and treated her with a [MEDICATION NAME] infusion and [MEDICATION NAME]. She did have low blood sugars around 29 at 10 o ' clock in the evening, with some altered mental status, which improved with just sugar infusion. She was admitted to Intensive Care Unit on D 5 drip. Her sugars have been stable here. She actually has [MEDICAL CONDITION] this morning, requiring a small amount of sliding scale insulin. At this point, the regular insulin should have cleared her system. She is awake, oriented, in no distress. She is eating a good breakfast. I think she can be discharged back to the nursing home at this point and can resume her regular insulin as taken there." The medication pass and pour observation was conducted with LPN (licensed practical nurse) # 3 on 04/17/12 at 4:12 p.m. During the observation, LPN # 3 was asked when she had started her employment at the facility. LPN # 3 stated, "I just started 02/17/12. I just passed my boards on 02/03/12." Upon observation of insulin administration, LPN # 3 stated, "I have to have someone watch me draw up this insulin." When asked why this was done, LPN # 3 stated, "Insulin is a very serious thing and for six months I have to have someone check all my insulin" When asked when this practice was started, LPN # 3 stated, "After I started here." A second interview was conducted with LPN # 3 on 04/19/12 at 11:20 a.m. in the presence of administrative staff member # 2, the corporate nurse consultant. When asked to describe the events that took place on 02/28/12 regarding Resident # 13, LPN # 3 stated, "It was my second day with a nurse on the med (medication) cart. (Name of other nurse (LPN # 6)) went off for an emergency situation with another resident. I checked the resident's blood sugar. I got her insulin out, I pulled regular insulin, and I drew up 70 units of regular. She was supposed to get 10 units of 70/30. No one checked it. I went back after I gave it and checked the order. I immediately went and told (LPN # 6) and we went directly to (name of director of nursing (DON)). We started giving the resident [MEDICATION NAME] and checked her blood sugar frequently. Then (name of doctor) told us to send her to the hospital." LPN # 3 verified her documentation on the MAR indicated [REDACTED]. She stated that she did not document on the MAR under the sliding scale orders for [MEDICATION NAME] R. An interview was conducted on 04/19/12 at 12:07 with LPN # 6. When asked to describe the events that took place on 02/28/12 regarding Resident # 13, LPN # 6 stated, "I was orienting (LPN # 3) on the med cart. I let her have the keys and I watched her. I got called to the front desk. I asked (LPN # 3) if she was okay and she said yes. She had been doing really well. I had watched her do other insulin injections and she was fine. I was still on the phone when she came up in front of me, white as a ghost. She told me she had given 10 units of regular insulin instead of the 70/30 that was ordered. We went right into (name of DON)'s office. I thought she said 10 units of regular instead of the ordered 10 units of 70/30. (Name of DON) called (name of doctor) and we started checking her sugars every few minutes. We gave her peanut butter and jelly sandwich, orange juice and a milkshake. The (name of doctor) told us to start an IV. We couldn't get it started, so (name of doctor) decided to send her out (to the hospital)." An interview was conducted with the administrator on 04/19/12 at 1:15 p.m. When asked what she could recall of 02/28/12 with Resident # 13 and her blood sugars, the administrator stated, "I was in the middle of a conference call that I have every day at 4:00 p.m. I was just told she was sent to the ER (emergency room )." The administrator was notified on 04/19/12 at 1:40 p.m. the concern for harm. At the end of the day meeting on 04/19/12 at 6:52 p.m. with ASM # 1, the administrator, ASM # 2, the corporate nurse and ASM # 5, the director of nursing, were asked to present any documentation regarding the event on 02/28/12 regarding Resident # 13. ASM # 1 and ASM # 5 stated, "We have no documentation." An interview was conducted with the Director of Nursing (DON) on 04/20/12 at 8:25 a.m. The DON was asked to describe the events that took place on 02/28/12 regarding Resident # 13. The DON stated, "I was in my office with the assistant director of nursing when (LPN # 3) and (LPN # 6) came into my office with a 'panicked' look on their faces. (LPN # 3) told me, 'I think I gave the wrong insulin.' She told me she wasn't sure what she gave. She told me the order was for 10 units of 70/30. When I asked her again what she gave, she couldn ' t tell me what she gave. I asked then what the worst case scenario is. She still didn't know. She told me 70 units of regular. I immediately called (name of doctor). We told him she wasn't sure what she gave. We have one amp ([MEDICATION NAME]) of D50 in the house. He told us to establish and IV and start D5W and drip it slowly and to check her blood sugars frequently. He told us to call him back. I sent the two nurses back to the resident's room with orange juice, sugar and the glucometer. I went in the room and informed the son, who was at the bedside throughout all of this, and told him that there was a possibility that his mother received the wrong insulin and wrong dose. I couldn't tell him what or how much because we just didn't know. I got the first IV started and it infiltrated. We were able to get a second one started and ran it at KVO (keep vein open). Her blood sugar at 4:45 p.m. was 270. I called the doctor again and explained that I had the IV running and the resident was asymptomatic and was concerned that I only had one amp of D50 in the house and concerned if her blood sugar dropped and I didn't have the right medicine to treat it. He advised us to send her out to the ER. Her blood sugar was still in the 200s before we transported her to the hospital." The DON stated that she stayed in the facility until after 9:00 p.m. that night and spoke with the ER and was told her blood sugar was still in the 90's. The DON stated, "We just didn't know how much she got, we still don't know for sure what she got that day." During an interview with the administrator on 04/20/12 at approximately 10:00 a.m. the administrator was asked if she felt more oversight or guidance should have been provided to LPN # 3. The administrator stated, "I would have expected (LPN #6) to take (LPN # 3) with her to learn how to handle an emergency. She shouldn't have kept on giving medications without LPN # 6." A policy on diabetic management was requested from the administrator on 04/19/12 at 9:00 a.m. At 10:00 a.m. the administrator informed the surveyor the facility did not have a policy on diabetic management. The facility policy, "Medication Administration" documented, B. One licensed nurse or medication aide at a time will be responsible for preparing, administering, and recording medication doses for a given resident ...N. Any deviation from the following principles shall be considered a medication error: 1. To the right resident. 2. Administration of the right medication. 3. In the right dose. 4. By the right route. 5. By the right method. 6. At the right time." The facility policy, "Administration of Subcutaneous Medication" documented, "2. Compare Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 3. Read the medication label and check expiration date. 4. Check the MAR for the last site of injection and read the medication label a third time ...19. Chart administration on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" "Five Rights" of Medication Administration: Identify the right client using two identifiers (e.g. name, birth date, medical record numbers). Select the right medication. Give the right dose. Give the medication at the right time. Give the medication by the right route. Fundamentals of Nursing, 5th edition; Lippincott, Williams & Wilkins; page 564. COMPLAINT DEFICIENCY 2. Resident # 10 was admitted to the facility on [DATE] with a most recent readmission on 02/21/11 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 03/22/12, coded the resident as being cognitively intact to make daily decisions. The resident was coded as requiring limited assistance of one staff member for most of her activities of daily living. The resident required extensive assistance of one staff member for bathing and only supervision after set up help for eating. Section I 2900 coded the resident as having diabetes. An interview was conducted with Resident # 10 on 04/19/12 at approximately 2:35 p.m. The resident was lying in bed. She informed the surveyor that she was on [MEDICAL TREATMENT] three days a week. She also stated that she is a diabetic and doesn't take the insulin at time because she doesn't want her blood sugar to bottom out in the mornings. Review of the clinical record revealed a physician order [REDACTED]. The POS documented a physician order [REDACTED].= 0 units; 150-199 = 1 units; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; greater than 349 = 5 units." The FSBS (finger stick blood sugar) were scheduled for "6:30 a.m., 11:30 a.m., 4:30 a.m. and 8:00 p.m." A review of Resident # 10's MAR (medication administration record) for February, March and April of 2012 was conducted and revealed: - February 2012 MAR 1. Date: 02/02/12, 4:30 p.m. Reading of FSBS - 199, Amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 2. Date: 02/13/12, 4:30 p.m., Reading of FSBS - 168, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. There were 39 entries that had a circle around the amount of insulin that should have been given. Several of these were explained on the back of the MAR indicated [REDACTED]. The above entries were not circled and there was no documentation on the reverse of the MAR for the entries as having been refused by the resident. -March 2012 MAR 3. Date: 03/01/12, 4:30 p.m.., Reading of FSBS - 224, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 4. Date: 03/05/12, 4:30 p.m., Reading of FSBS - 150, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 5. Date: 03/08/12, 4:30 p.m., Reading of FSBS - 211, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 6. Date: 03/10/12, 8:00 p.m., Reading of FSBS - 209, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 7. Date: 03/11/12, 8:00 p.m., Reading of FSBS - 187, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 8. Date: 03/17/12, 4:30 p.m., Reading of FSBS - 212, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 9. Date: 03/17/12, 8:00 p.m., Reading of FSBS - 331, amount of insulin given - 0. Amount of insulin that should have been given - 4 units. 10. Date: 03/18/12, 4:30 p.m., Reading of FSBS - 172, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 11. Date 03/18/12, 8:00 p.m., Reading of FSBS - 295, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 12. Date: 03/23/12, 8:00 p.m., Reading of FSBS - 241, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 13. Date: 03/24/12, 4:30 p.m., Reading of FSBS - 182, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 14. Date: 03/24/12, 8:00 p.m., Reading of FSBS - 250, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 15. Date: 03/26/12, 8:00 p.m., Reading of FSBS - 192, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 16. Date: 03/27/12, 4:30 p.m., Reading of FSBS - 223, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 17. Date: 03/27/12, 8:00 p.m., Reading of FSBS - 259, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 18. Date: 03/29/12, 8:00 p.m., Reading of FSBS - 238, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 19. Date: 03/31/12, 4:30 p.m., Reading of FSBS - 236, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. There were 27 entries that had a circle around the amount of insulin that should have been given. Several of these were explained on the back of the MAR indicated [REDACTED]. The above entries were not circled and there was no documentation on the reverse of the MAR indicated [REDACTED]. -April 2012 MAR 20. Date: 04/01/12, 4:30 p.m., Reading of FSBS - 171, amount of insulin that should have been given - 0. Amount of insulin that should have been given - 1 unit. 21. Date: 04/01/12, 8:00 p.m., Reading of FSBS - 236, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 22. Date: 04/02/12, 8:00 p.m., Reading of FSBS - 240, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 23. Date: 04/03/12, 4:30 p.m., Reading of FSBS - 205, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 24. Date: 04/03/12, 8:00 p.m., Reading of FSBS - 281, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 25. Date: 04/05/12, 8:00 p.m., Reading of FSBS - 201, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 26. Date: 04/06/12, 8:00 p.m., Reading of FSBS - 236, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 27. Date: 04/07/12, 8:00 p.m., Reading of FSBS - 266, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 28. Date: 04/08/12, 8:00 p.m., Reading of FSBS - 315, amount of insulin given - 0. Amount of insulin that should have been given - 4 units. 29. Date: 04/09/12, 6:30 a.m., Reading of FSBS - 150, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 30. Date: 04/09/12, 8:00 p.m., Reading of FSBS - 214, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 31. Date: 04/12/12, 4:30 p.m., Reading of FSBS - 250, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 32. Date: 04/12/12, 8:00 p.m., Reading of FSBS - 342, amount of insulin given - 0. Amount of insulin that should have been given - 4 units. 33. Date: 04/14/12, 4:30 p.m., Reading of FSBS - 225, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 34. Date: 04/14/12, 8:00 p.m., Reading of FSBS - 354, amount of insulin given - 0. Amount of insulin that should have been given - 5 units. 35. Date: 04/15/12, 8:00 p.m., Reading of FSBS - 356, amount of insulin given - 0. Amount of insulin that should have been given - 5 units. 36. Date: 04/17/12, 4:30 p.m., Reading of FSBS - 208, amount of insulin given - 0. Amount of insulin that should have been given - 2 units. 37. Date: 04/17/12, 8:00 p.m., Reading of FSBS - 252, amount of insulin given - 0. Amount of insulin that should have been given - 3 units. 38. Date: 04/18/12, 6:30 a.m., Reading of FSBS - 189, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. 39. Date: 04/18/12, 8:00 p.m., Reading of FSBS - 189, amount of insulin given - 0. Amount of insulin that should have been given - 1 unit. There were 8 entries that had a circle around the amount of insulin that should have been given. Only three were documented on the back of the MAR indicated [REDACTED]. The above entries were not circled and did not have documentation on the reverse of the MAR indicated [REDACTED]. Review of the nurse's notes for 02/02/12 and 02/13/12 did not reveal any documentation related to the FSBS, the withholding of the insulin or notification to the physician the resident's insulin was withheld and not administered as ordered and or refused. Review of the nurse's notes for March 2012 was conducted. For 03/01/12, 03/08/12, 03/10/12, 03/11/12, 03/18/12, 03/24/12, 03/27/12, 03/29/12 and 03/31/12, there were no nurse's notes documented. The nurse's notes for 03/05/12, 03/17/12, 03/18/12, 03/23/12, and 03/26/12 did not document notification to the physician the resident's insulin was not administered and or refused. Review of the nurse's notes for April 2012 was conducted. For 04/01/12, 04/03/12, 04/05/12, 04/07/12, 04/08/12, 04/14/12, and 04/17/12, there were no nurse's notes documented. The nurse's notes for 04/02/12, 04/06/12, 04/09/12, 04/12/12, and 04/18/12, did not document the FSBS, did not document notification to the physician the resident's insulin was not administered and or refused. The review of the comprehensive care plan dated 01/12/12 documented, "Behavioral: ineffective coping R/T (related to) refusal of care & treatment for [REDACTED]. Monitor & document refusals per facility policy." There was no care plan for diabetes. An updated care plan was received on 04/19/12 at 4:30 p.m. The care plan was initiated on 03/06/12 and did not contain documentation of the resident's behaviors. The care plan documented, "End Stage [MEDICAL CONDITION]: at risk for complications due to [MEDICAL TREATMENT], acute kidney failure." The "Interventions" documented, "Monitor labs (laboratory tests) as ordered and notify physician of results." There was no care plan for diabetes. The most recent physician progress notes [REDACTED].%." An interview was conducted with LPN (licensed practical nurse) # 6 on 04/19/12 at 4:06 p.m. When asked if a resident was to have a FSBS and had physician orders [REDACTED].# 6 stated, "Yes, I would give it." An interview was conducted with LPN # 2 on 04/19/12 at 4:08 p.m. When asked if sliding scale insulin was ordered for a resident, was she to give the insulin per the sliding scale, LPN # 2 stated, "Yes, I would give it unless the blood sugar was less than 70." A second interview was conducted with LPN # 6 on 04/19/12 at 6:08 p.m. When asked what procedure was followed if a resident refuses medication and or medication is not administered as prescribed, LPN # 6 stated, "We circle our initials and then write the reason on the back of the MAR. We notify the physician if it happens for more than two days." When shown the MAR for Resident # 10, LPN # 6 was asked to explain the zeros that she had written on the MAR under the blood sugar readings. LPN # 6 stated, "She (Resident # 10) refuses her insulin every day I'm here." When asked if she was following the facility policy, LPN # 6 stated, "No, I guess I'm not." An interview was conducted with administrative staff member (ASM) # 5, the Director of Nursing, on 04/19/12 at 6:10 p.m. ASM # 5 was asked for the procedure the staff is to follow if a resident's medication is not administered as prescribed and or refused. ASM # 5 stated, "As long as the initials are circled, it indicates the medication was not given. We follow the legend on the MAR. Staff does not have to document on the back of the MAR indicated An interview was conducted with ASM # 2, the corporate nurse consultant on 04/19/12 at 6:35 p.m. When asked what part of the legend on the MAR indicated You need to follow all steps of the legend, not just one part of it." An interview was conducted with ASM # 4, the medical director on 04/19/12 at 6:35 p.m. His progress notes for Resident # 10 were reviewed. ASM # 4 was asked if a resident was