Every finding on record at West Volusia Healthcare and Rehabilitation Center

Based on observations and staff interviews, the facility failed to follow proper sanitation and food handling practices to prevent foodborne illness by failing to ensure: (1) Opened refrigerated foods were labeled and dated; (2) Canned goods received from the vendor and intended for resident consumption were within the manufacturer's expiration date; and (3) Food was prepared and served from a clean, sanitary kitchen. Unsafe food handling and sanitation practices present a potential source of pathogen exposure which could result in foodborne illness. This had the potential to affect all residents who consumed foods from the facility's kitchen. The findings include: During an initial kitchen tour with the Certified Dietary Manager (CDM) on [DATE] at 10:28 AM, the walk-in refrigerator was observed with a large, clear plastic bin containing shredded iceberg lettuce. There was no label or date on the bin. A small cellophane-covered bowl held one half of a cut onion, and a Ziploc baggie contained fresh herbs; however, neither item was labeled or dated. The bread rack in the dry storage room held several loaves of bread that had a manufacturer's date stamp of [DATE]. The hot dog buns manufacturer's date stamp was [DATE]. There was no label to reflect when the baked goods were received by the facility. Inspection of the canned good rack revealed six cans of pineapple tidbits with handwritten dates on each can of [DATE]; however, the manufacturer's expiration date on the cans was [DATE]. (Photographic evidence obtained) The horizontal surface of the table under the food steamer was soiled with debris resembling flour and food crumbs, and the legs of the steamer had build-up resembling lime/scale or rust. Some of the buildup had come off and pooled around the base of the legs. The inside of the drain underneath was coated with wet, black mildew-like matter. The floor tiles in the corner of the kitchen near the walk-in refrigerator were coated with a buildup of a black grimy substance. The drain under the pipes in the corner was surrounded by a wet, black substance that was also built up in large patches on the surface of the drain cover. Similar buildup was seen in the drain under the two-compartment sink. Splatters of dried food and hard water marks were seen on the vertical surfaces of the serving side of the tray-line steam table. The metal cart that housed the juice machine was rusted and soiled. The CDM acknowledged the unlabeled lettuce, onion and herbs in the refrigerator, confirming that each should be dated. She explained that the baked goods were all delivered frozen. She thawed them upon receipt and placed them on the racks for use. She acknowledged that there was no date on the bread or the rack reflecting when the items were received and thawed. The CDM produced an invoice for the last bread delivery, which revealed a delivery date of [DATE], one month ago. The CDM could not locate a delivery slip for the hot dog buns and confirmed that the handwritten date on the pineapple chunks reflected the date they were received and stocked. The CDM also confirmed the manufacturer's date revealed they were all expired upon receipt. She said no one had recognized the products were expired, and had no explanation as to how it was missed. A final walk-through of the kitchen was conducted on [DATE] at 9:40 AM with the CDM. The buildup of drips, debris and crumbs were still evident on the metal table under the food steamer. The floor drain under the steamer was still soiled, and closer inspection revealed the tiles around the drain were loose. Water condensing from the drain was dripping down and pooling under the floor tiles. The exposed side of the ice machine had scale-like drip marks on it, and the juice machine rack was still rusted and soiled. The floor tiles in the corner near the walk-in refrigerator held the same black slimy substance as previously observed. Close inspection of the drain under the 2-compartment sink revealed the same black wet buildup as before. [NAME] sewer flies surrounded and flew in and out of the drain. Drips of dried-on food soiled the vertical surface of the serving side of the tray-line steam table. Food had dripped, pooled and dried on the bottom of the table at the shelf level. The face of the electrical outlet protruding from the floor in front of the the steam table was broken and the housing was coated with a buildup of unknown substance. There was a large piece of white PVC (polyvinyl chloride) pipe next to the outlet that was soiled with brown debris. The CDM explained this pipe was intended to be placed over and cover the floor outlet. (Photographic evidence obtained) The CDM confirmed each of the above findings throughout the tour. She stated housekeeping was responsible for deep-cleaning by pressure washing the kitchen. She had seen this done twice in the last year.

Based on facility record review, staff interview, and facility policy and procedure review, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. The program must include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. The findings include: A review of the facility's water management program revealed a copy of the Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, A Practical Guide to Implementing Industry Standards by the U.S. Department of Health and Human Services Centers for Disease Control (CDC) and Prevention, dated 06/05/2017. Page two contained a guide form to Identify Buildings at Increased Risk. This form was left blank. A review of the CDC tool kit, on pages 3 and 23 revealed, Identified control measures: Things you do in your building water systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning. Control limits: The maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread. Control points: Locations in the water systems where a control measure can be applied. Disinfectant: Chemical or physical treatment used to kill germs, such as chlorine, monochloramine, chlorine dioxide, copper-silver ionization, ultraviolet light, or ozone (Photographic evidence obtained) The water management program contained drawings showing water flow throughout the facility, resident room water temperature checks, flushing dates for the water pipes, and pressure relief valve checks. The program did not include control measures for preventing Legionella growth. It did not include points in the system where critical limits of the antigen could be monitored or where control could be applied. There were no physical controls or protocols, such as testing of the water's disinfectant levels and pH, performing visual inspections, or environmental testing for pathogens. There were no acceptable ranges or control measures within the water management plan. The Regional Maintenance Director was interviewed on 01/28/25 at 11:00 AM. He stated they did not do any water or Legionella testing in the facility, as it was not required by the Centers for Disease Control. He then produced a diagram of the water lines for both hot and cold water. The diagram did not identify the areas where Legionella could potentially grow and spread. (Photographic evidence obtained) During an interview with the Director of Maintenance on 01/30/25 at 02:30 PM, he confirmed that he had received no training on the water management program, and confirmed that water testing had not been done since he was hired in March 2024. He stated he had no testing kit for the disinfectant levels in the water. A review of the facility's policy and procedure titled Infection Control Prevention and Control Program, section 13, Water Management (effective 02/21/23) revealed: A water management program has been established as part of the overall infection prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. The Maintenance Director serves as the leader of the water management program. (Photographic evidence obtained) There were no guidelines within the policy for identifying or testing for Legionella.

Based on a review of resident records, resident and resident room observations, and resident and staff interviews, the facility failed to maintain accurate resident records reflective of the care provided for one (Resident #17) of two residents reviewed for wounds, from a total of 34 sampled residents whose records were reviewed. The findings include: A record review for Resident #17 revealed she was admitted to the facility on [DATE]. She had diagnoses including, but not limited to, diabetes mellitus and left foot diabetic ulcer. A Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #17 had a brief interview for mental status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. She was dependent on staff for toileting, dressing and transfers. Resident #17 was care planned on 9/13/24 for compromised skin integrity with an ulcer of the left planter foot. The care plan revealed that she was readmitted status-post graft to the left foot/osteomyelitis (infection of the bone) on 10/25/24. A weekly nursing skin observation, dated 1/25/25 at 2:08 revealed, Sacrum Wound. Left plantar wound, under treatment. Resident #17 had a physician's order dated 12/6/24 for a Multi podus boot (a medical device that suspends or floats the heel and removes pressure from the back of the heel to help heal and prevent ulcers) to left foot when out of bed. She also had an order dated 1/16/25 for wound care to the left planter foot ulcer. Instructions were to clean with normal saline, pat dry, apply collagen sheet to ulcer and cover with a dry dressing. A review of the Treatment Administration Record (TAR) found the multi podus boot for the left foot when out of bed was signed off as having been worn daily on every shift up to 1/28/25. (Photographic evidence obtained) A review of the certified nursing assistant (CNA) task records also reflected that the boot was worn every day. (Photographic evidence obtained) An interview was conducted with Resident #17 on 1/27/25 at 2:19 PM. She stated her heel had been hurting and she had a history of facility-acquired pressure ulcers, but they had resolved. With consent from Resident #17, the affected left heel was observed by the Registered Nurse Specialist surveyor. Resident #17 had a sock on that foot, which was pulled back to reveal an unbandaged wound on the bottom center of her left heel. The wound was approximately quarter-sized in diameter with a deep red wound bed and raised white border. The left foot was swollen. (Photographic evidence obtained) Resident #17 explained that she required assistance with putting her sock on that foot. There was no multi podus boot on her left foot. Resident #17 was observed daily in the west and front hall throughout the survey between 1/27/25 and 1/30/25. At at no time did she have a multi podus boot on her left foot; she only wore socks. An interview was conducted with CNA A on 1/29/25 at 3:42 PM in Resident #17's room. She was asked where Resident #17's multi podus boot was. CNA A said there was no boot, only a padded footrest. She said she often put a pillow under Resident #17's left foot. Resident #17, also in the room, confirmed there was no multi podus boot. She said there used to be one, but not any more. She did not have one. With consent from Resident #17, a search of the room, including the closet and drawers, revealed no multi podus boot. The wound care doctor (WCD) was interviewed on 1/30/25 at 4:01 PM. He stated Resident #17 had a partial calconectomy (a surgical procedure that removes infected or non-viable tissue from the heel bone) before he took over management of her heel wound. He was not sure if he was the ordering physician for the multi podus boot. When asked if she wore the boot, he stated, in a perfect world, but she has rights. He stated Resident #17 worse than refuses to wear the boot. The WCD stated Resident #17 had hydrocephalus (a build-up of fluid in the cavities deep within the brain) and a decline in executive function. She still, however, made her own decisions. The WCD was advised that CNAs and nurses were documenting that the boot was in place daily; however, she had not been observed wearing the boot during the four-day survey. The WCD replied that Resident #17 was resistant to most offloading interventions; We just cant do the things we used to be able to do twenty years ago. The wound care nurse/licensed practical nurse was interviewed on 1/30/25 at 4:10 PM. He stated he had not seen Resident #17 wearing the multi podus boot; she refused. He had no comment about staff signing that the boot was being worn daily.

Based on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse for two (Residents #2 and #4) of four residents reviewed for abuse, out of a total sample of 7 residents. Resident #2 was physically hit by a staff member after the staff member reacted to being hit by the resident in the shower. Resident #4 was verbally abused by a staff member while the resident was in the process of taking a shower. The findings include: 1. Review of the medical record for Resident #2 revealed an admitted [DATE]. His diagnoses included type 2 diabetes mellitus (DM) with diabetic neuropathy, hyperlipidemia, high blood pressure (HTN), anxiety disorder, depression and low back pain. Review of the Admission Medicare 5-day minimum data set (MDS) still in progress with an assessment reference date (ARD) of 1/14/25, revealed Resident #2 had a brief interview for mental status (BIMS) score of 1 out of a possible 15 points, indicating severe cognitive impairment. Rejection of care or wandering behaviors were not exhibited. On 1/23/25 at 10:50 am, Resident #2 was observed in his room, dressed and lying in bed. A bruise and dry scab was observed on his right elbow. He appeared confused and mumbled when asked about his bruised elbow. Review of physician orders for Resident #2 dated 1/7/25 revealed Buspirone 5 milligrams (mg) three times (TID) a day for anxiety, Trileptal 150 mg three times a day for mood, Trazadone 50 mg at bedtime for depression, Melatonin 5 mg -2 tablets at bedtime for insomnia, Gabapentin 800 mg two times a day (BID) for neuropathic pain and amlodipine 10 mg daily (QD) for HTN. Review of the nursing progress notes for Resident #2 dated 1/10/25, noted that Certified Nursing Assistant (CNA) called the nurse into the shower room to report resident had slid out of the shower chair onto the floor. Resident had become combative and resistive to care and slid down. Resident transferred via mechanical lift to wheelchair, skin assessed, redness to his back, no open areas, physician and family notified. Review of a social service note for Resident #2 dated 1/10/25, indicated that the abuse coordinator was notified that the resident became combative during care. He struck CNA in the stomach/face. CNA in reflex grabbed hand of resident and grazed the left side of his face/ear with the other hand. No visible injuries noted. Review of a behavior note for Resident #2 dated 1/10/25, indicated that he remained in a wheelchair all night long. He was encouraged to go to bed but would not. Behavior notes from 1/12/25- 1/22/25 noted residents behaviors of resisting care and hitting staff during care. Review of a social service note for Resident #2 dated 1/15/25, noted that he had multiple episodes of resisting care. Review of the care plan for Resident #2 initiated on 1/8/25 revealed resident is resistive to care related to adjustment to nursing home. Dementia does not allow staff to change him, hits and kicks and punches at staff - holds on to other residents wheelchair and does not understand interactions. Resident #2 was also care planned for potential to be physically aggressive related to anger and poor impulse control. On 1/23/25 at 1:45 pm, an interview was conducted with CNA F who was familiar with Resident #2. She stated that she had assisted other staff caring for Resident #2. She explained that he was combative, and required total care for activities of daily living, but can feed himself with supervision. She added resident is confused and cannot make needs know. She mentioned that when she was assisting Resident #2 yesterday, he held her hand and would not let go. She calmly got the resident to release her hand without incident. She stated the resident needs redirection and reapproaching to get care done and at times it takes several attempts. She added that staff should not force him to get the care. When asked if she had received training on dealing with combative residents. She said, I have been her for [AGE] years and I have received a lot of education, but I cannot remember specific training. During an interview with Licensed Practical Nurse (LPN B) on 1/23/25 at 2:15 pm, she stated that on 1/10/25, she heard yelling from the shower room. Shortly thereafter, Patient Care Attendant (PCA C) came to the nursing station and asked if she was the assigned nurse to Resident #2 because the resident was on the floor in the shower room. Upon entering the shower room, the resident was seated on the floor next to the shower chair. Some bruises were noted on the assessment. Resident #2 could not explain what happen and was still anxious and agitated. She asked CNA A (Assigned CNA) to get a Hoyer lift to assist getting the resident back on the chair. During this time, she asked PCA C what happened. The CNA told her that the resident became combative and punched CNA A in the stomach. PCA C reported that she witnessed CNA, A react and made contact with Resident #2 with an open hand on the ear. PCA C stated that she had asked CNA A to stop giving him a shower as the resident was combative, but she did not listen. When CNA A returned and asked what happened, she stated the resident was combative, but she wanted to clean him up because he was soiled. She added that as she was bending down to clean the resident, he punched her in the stomach and out of reflect, she hit him on the side of his ear. She reported the incident to the abuse coordinator. 2. Review of the medical record for Resident #4 revealed an admitted [DATE]. His diagnoses included metabolic encephalopathy, muscle wasting and atrophy, depression, gout, need for assistance with personal care, gastroparesis, type II diabetes mellitus, diverticulosis of large intestine and inflammatory liver disease. Review of the quarterly MDS with ARD of 12/20/24, revealed Resident #4 had a BIMS score of 15, indicating cognitively intact, with no behaviors noted. He required partial/moderate assistance with showering and personal hygiene and was totally dependent with toileting and transfer. The assessment indicated that he was frequently incontinent of urine and bowel. On 1/23/25 at 2:45 pm, an interview was conducted with Resident #4. When he was asked about the incident that happened in the shower room. He explained that the CNA E had an attitude from the time she was beginning his shower. He said that it was around 11:00 am and lunch time is around 11:30 am (his shower takes 30-45 minutes). CNA E came to get him to the shower and she said, it's almost time for lunch and I won't be dealing with you stupid cracker shitting in here because I'm not going to be cleaning it up. CNA E walked out of the shower obtained a plastic bag and placed it under the shower chair. CNA E then told him that she was an agency staff and there was nothing he could do as she would find a job somewhere else. Resident #4 stated that he felt bad and defeated and did not tell anyone at the time. The next day when he saw a familiar face (did not recall who) he told her what happened and she asked him to report it, and that's when he went to front office to report it. He continued to state that the agency staff did not seem to care and were always in hurry while providing care Review of the physician orders for Resident #4 dated 9/18/24 revealed furosemide (Lasix) 40 mg daily for fluid retention, duloxetine 60 mg daily for depression, and trazadone 50 mg at bedtime for depression. On 1/23/25 at 2:56 pm, an interview was conducted with the Social Services Assistant (SSA). She stated that on 1/21/25, Resident #4 came to the front office and stated that the CNA who was assigned to him the previous day was rude. He told her that the CNA said , You cannot Shit here cracker. She stated she helped the resident write the report and handed it to the Social Service Director (SSD). She confirmed that Resident #4 was alert and oriented x4 and was able to make needs know. On 1/23/25 at 3:00 pm, an interview was conducted with the Administrator. She explained that she was new to the facility and the investigation for Resident #2 was ongoing at the time of her hire. She went on to say the resident was combative during care. However, CNA A who was assigned to Resident #2 confirmed that she forced resident to the shower to clean him up as he was soiled. In the shower Resident #2 hit the CNA on the stomach and out of reflex the CNA grazed Resident #2 on the side of the face near his ear. She stated that the CNA was suspended after the allegation and abuse training initiated related to resident rights - Right to refuse care. The allegation of abuse was substantiated. When asked about Resident #4's abuse concerns. The administrator explained that CNA E was providing a shower. When the resident was in the shower, he had a tendency of having the bowel movement during shower. CNA E told him that he was not going to shit there and called him a cracker. She continued to state that the CNA was an agency CNA and would not be returning to the facility. When asked for the agency staff training and competency, she confirmed that the training could not be obtained. When asked about the training for Dementia and Alzheimer's training/behavior management training for CNA A prior to the incident. She confirmed that the training could not be found. She also confirmed that the facility had not conducted any training or in-service on Dementia and Alzheimer's training/behavior management after the incident with Resident #2. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury Of Unknown Source And Investigations, effective 04/01/2022 and no revision date revealed the following: PURPOSE: It will be the policy of this facility honor residents' rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds, or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. DEFINITIONS: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology (mental abuse including, but not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident). Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. TRAINING: a. Training of employees will be through the following: i. Orientation program ii. Ongoing in-service training iii. Annually and more often if needed iv. One-to-one counseling when identified v. Indicators to identify staff burnout b. Training will focus on the following topics: i. Recognizing abuse, neglect, and misappropriation of resident property ii. Steps on how to report including to whom and when. iii. How to protect residents, staff, and others from immediate danger iv. Signs of and intervention techniques to be used with residents having aggressive behavior or catastrophic reaction. v. How to recognize the signs of burnout, frustration, and stress in self and co-workers. vi. Employees' responsibility upon witnessing neglect, or misappropriation of property. vii. Federal standards on resident protection, reporting, and investigation of ANEMMI.

Based on observations, interviews, medical record review, and facility policy review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #3, #2, and #4) of 5 residents on various precautions, from a total sample of 9 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: During a tour on 2/14/24 at 10:15 AM, three resident rooms (Residents #2, #3, and #4) were observed with personal protective equipment (PPE) hangers on their door. None of the doors had a sign identifying why the PPE was needed to be used in the room. On 2/14/24 at 10:36 AM, Employee B, Certified Nursing Assistant (CNA) was observed to don PPE outside the door of Resident #2. When Employee B was asked if she knew what the precaution was for this resident. The CNA stated, I think it's Covid. She and (Resident #4) have Covid, I think. On 2/14/24 at 12:00 PM, the Infection Preventionist was asked to conduct a tour of the current residents who were on any type of precaution. 1. The Infection Preventionist identified Resident #3 as having a urine infection. The PPE hanger was observed on the door, stocked with gloves, gowns, face masks and face shields. There was no signage on the door. When she was asked if there should be signage on the door to alert staff as to the type of precaution and PPE required for entry to room. She stated, Yes, there should be a sign, there was a sign, it must have fallen down. No sign was observed on the floor or within sight of the door and PPE hanger. A review of Resident #3's medical record indicated she was admitted to the facility on [DATE] with a diagnosis that included spinal stenosis. The resident's physician's order, dated 2/8/24, revealed she was to be on Isolation Precaution for Extended Spectrum Beta Lactamase (ESBL) + urine: contact isolation- provide isolation set up with cart, barrels, red bags, stop sign and PPE. Every shift for ESBL +. (Photographic evidence obtained) 2. The Infection Preventionist identified Resident #2 as being admitted to the facility yesterday with a + Covid diagnosis. A PPE hanger was observed stocked with gloves, gowns, face masks, and face shields. No sign was observed on the door. When she was asked if there should be a sign on the door identifying the precaution type and PPE required to enter the room. She stated, Yes, I don't know where the sign is. She is droplet precautions for Covid. A review of Resident #2's medical record indicated the resident was admitted to the facility on [DATE] with a primary diagnosis of Covid 19. The resident's physician's order, dated 2/8/24, revealed the resident was to be on contact/droplet isolation. (Photographic evidence obtained) 3. The Infection Preventionist identified Resident #4 as being on contact precautions for herpes zoster. A PPE hanger was observed stocked with gloves, gowns, face masks, and face shields. There was no sign observed on the door. She was asked if there should be a sign on the door identifying the precaution type and PPE required to enter the room. She stated, Yes, there should be a sign for contact precautions. A review of Resident #4's medical record indicated she was admitted to the facility on [DATE] with diagnoses that included weakness and Covid 19 (2/5/24 per hospital record review). The resident's physician order, dated 2/13/24, revealed Covid 19/UR (Upper Respiratory) Symptom Monitoring: Monitor for Covid 19 and UR symptoms every shift. Her physician's order, dated 2/14/24, revealed she was to be on Isolation Precautions: Contact Isolation- provide isolation set up with cart, barrels, red bags, stop sign and PPE. (Photographic evidence obtained) During a second tour of the facility on 2/14/24 at 1:50 PM, Employee A, CNA was observed entering Resident #3's room, without donning any PPE. Employee A was observed exiting the same room without any PPE on or doffing PPE. When Employee A was asked if she had entered Resident #2's room without donning PPE. She stated, Yes. When asked if she was trained to don PPE, per the contact precaution sign posted on the door of the room, prior to entering the room. She stated, Yes, if I am going to care for the resident in the B bed, because he has a urine infection. But if I am only caring for the resident in the A bed, then no, I don't need to use the PPE. She was asked if she knew which resident was ringing the call bell before she entered the room. She stated, The B bed rang the light for the A bed, because the A bed can't ring the light because he is confused, and the B bed thought that the A bed needed some help to get out of bed. A second interview was conducted with the Infection Preventionist on 2/14/24 at 2:50 PM. She was asked to review what Resident #4 was on precautions for, and what type of precautions she is on. She stated, She just got here last night, she has herpes in her oral cavity and is on Acyclovir. She was then asked to review her chart to determine if the resident's precautions were also related to Covid 19. After reviewing the chart, the Infection Preventionist stated, Yes, she is Covid; you are correct, she is both. When asked if Resident #3 should be on both droplet and contact precautions. She stated, Yes, she should be on both precautions. When asked if the staff were trained to don required PPE for precaution every time they enter the room? She replied, Absolutely. When she was asked if staff should don the required PPE per signage on the door regardless of which resident they think they are going to provide care to once they enter the room. She stated, The staff is aware of which resident in the room is on precautions. I would expect them to always don and doff the PPE when they enter the room. My rationale is they may have to do something for either resident while they are in the room. A review of the facility's policy titled Infection Control Program Overview (Published 12/4/23) revealed the following: Purpose: The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Scope of the Infection Control Program: The infection Control Program is comprehensive in that it addresses detection, prevention, and control of infections among residents, staff, volunteers, visitors, and others. Staff and resident education are done to focus on risk infection and practices to decrease risk. Policies, procedures, and aseptic practices are followed by personnel in performing procedures. (Photographic evidence obtained)

Based on observations, interviews, and record review, the facility failed to ensure residents had a comfortable and homelike environment, by failing to utilize maintenance services to maintain baseboards, bedframes, ceiling tile framework, toilets, paint, walls, and tile, affecting rooms 110, 115, 200, 201, 203, 204, 206, 208, 210, 211, 218, 224, 301 and 304, fourteen of 68 rooms in the facility. A failure to maintain the facility's interior can result in water damage, mold, accidents, pests, and other environmental hazards which could place residents, staff, and visitors at risk. The findings include: On 08/09/2023, the facility, including all 68 resident rooms, was toured beginning at 9:55 AM. The building integrity appeared intact without any observations of pests. The lobby was clean and free of debris with adequate lighting, a comfortable temperature, and no malodor. Hallways appeared clean and were free of debris/tripping hazards. The ceiling tiles, baseboards and floors were worn. The facility is [AGE] years old. Housekeeping staff were observed cleaning resident rooms and common areas. No malodor was noted in the facility or on residents' persons during the survey. Staff/resident interactions were friendly, courteous, and professional. On the facility's central hall, the baseboard located between the Employee Lounge and the 200 hall was damaged and pulled away from the wall, leaving enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed, even when the baseboard was disturbed. The Janitor's Room located on the same hall and adjacent to the Employee Lounge had broken tile at the corner of the doorway. (Photographic evidence obtained) On 08/09/2023, beginning at 10:00 AM, observations of multiple resident rooms revealed damaged baseboards with enough space between the baseboards and walls to harbor pests, soil/debris and/or mold. Flaking paint and plaster were observed, however, no mold or pests were observed during the survey. The rooms observed with baseboard damage were rooms 200, 201, 203, 204, 206, 208, 210, 211, 218, 301, and 304. (Photographic evidence obtained) room [ROOM NUMBER], Bed A, was observed with surface rust on the front, right leg of the bed, however, the bed was secure and functional. No other beds in the facility were observed with rust damage. room [ROOM NUMBER] was observed with surface rust on the metal ceiling tile frames and air vents. No water damage was observed. Ceiling tiles were not discolored. room [ROOM NUMBER] was observed with a slightly warped wall/sheet panel. room [ROOM NUMBER] was observed with a cracked windowsill. room [ROOM NUMBER]'s toilet was off-center and had a broken caulk seal at its base, however, the toilet was secured to the floor and did not move when pressure was applied. There was no leakage at the base of the toilet; the floor was dry, and the toilet was functional. There was some surface rust on the metal fixtures securing the toilet to the floor and at the water inlet valve. (Photographic evidence obtained) room [ROOM NUMBER]'s wall, adjacent to the window, was observed with a dried, splash of liquid resembling a dark-colored beverage. No other walls in the facility were observed with spilled/smeared substances during the survey. No privacy curtains were observed to have been soiled. (Photographic evidence obtained) On 08/09/2023 at 10:03 AM, an interview was conducted with Resident #5 (room [ROOM NUMBER], Bed B) regarding his baseboards. He stated the baseboard in his room had been damaged since his admission and no one had been in to repair it. He added that he had not complained about it, because it did not bother him. (Photographic evidence obtained) Aside from this, the resident reported no concerns and stated he was happy with the care he was receiving. When asked if he knew how to file a grievance should he have one, he replied yes. On 08/09/2023 at 10:30 AM, and interview was conducted with Resident #3. She was sitting in her motorized wheelchair, dressed appropriately, and well-kempt. Numerous boxes and bags of personal belongings were observed in her room and bathroom. When she was asked about her personal items, she became agitated and stated, I don't want anybody touching my stuff! I'll [expletive] kill them! She stated the facility staff were afraid of her because she would not take any [expletive]. She further stated they took her taser away from her. On 08/09/2023 at 10:35 AM, the area Ombudsman stated their office had not received any recent complaints for this facility and that during their last visit in late June 2023, they had no concerns. On 08/09/2023 at 11:05 AM, Resident #7 (room [ROOM NUMBER], Bed A) was interviewed. He was clean and well-kempt, and his linens were clean. He stated he was able to take himself to the bathroom and felt safe in doing so. An empty urinal was observed on his nightstand. He stated the Certified Nursing Assistants (CNAs) were pretty good. They emptied his urinal when they made rounds or when he called them for assistance. He was receiving physical therapy and got his medications on time. When asked, he stated his bed controls worked and he demonstrated that. He said they had always worked. When asked how he got along with his roommate, he replied, He's something else. When asked whether he had any complaints, he stated he would prefer a higher toilet seat, but he had not mentioned that to staff. On 08/09/2023 at 11:20 AM, an interview was conducted with Certified Nursing Assistant (CNA) D regarding the facility expectation for emptying urinals. She stated she was expected to round every two or so hours to check on the residents and provide care as needed. When asked whether she was familiar with Resident #2 in room [ROOM NUMBER], Bed B, she replied that she was familiar with him. She further stated Resident #2 was always telling us he's going to sue us. When we go in to do AM care, he tells us to go away, then turns around and says we aren't taking care of him. When she was asked whether there had been any concerns with the mechanical lifts not functioning, she replied that she was not aware of any concerns. When she was asked what the protocol was for when a remote control or bed controls were not working properly, she stated she made the unit manager or maintenance department aware so the item could be repaired/replaced. On 08/09/2023 at 11:35 AM, an interview was conducted with Resident #6 (room [ROOM NUMBER], Bed B) regarding the condition of her baseboard and wall. She stated the maintenance department had pulled the baseboard away from the wall and tried to repair it about a month ago, but no one had returned since then to finish the job. She stated she had no other concerns and was happy with the care she was receiving. She further stated all the equipment in her room was functional and she had not had any trouble with her toilet or sink. Despite the damaged baseboard, she stated the facility was kept clean. She denied having seen any pests. (Photographic evidence obtained) On 08/09/2023 at 12:13 PM, Resident #7 (room [ROOM NUMBER], Bed A), admitted on [DATE], was interviewed again. He stated his television worked and he demonstrated that. He further stated it had always worked. He had no complaints about the bathroom or toilet, and stated the bathroom walls were always clean. The bathroom toilet did not smell or leak. He had no concerns about furnishings, equipment or services received. He did mention that his roommate complained about anything and everything ever since his admission. He was aware that his bed frame had some surface rust but stated it was stable. On 08/09/2023 at 4:09 PM, the Maintenance Director was interviewed about his process for maintaining a safe and homelike environment for the residents. He stated he received workorders either verbally from residents or staff, or through the facility's life safety computer software program work orders, which informed him of what needed to be repaired/addressed. When asked if he conducted walking rounds to see whether anything required his attention, he replied yes, he conducted rounds every two weeks, and every three weeks he would touch up the rooms by conducting patchwork and/or applying paint to the walls. When asked whether his observations included observing walls, baseboards, and toilets, he replied, yes, the baseboards were observed when he or his team were painting or patching the walls. When asked if he checked bathroom fixtures such as toilets, he asked, Why do I need to look at the toilets? No, he continued, explaining that he did not check toilets if nothing was specifically mentioned to him. When asked what he did when he noticed that the walls may require his attention, he replied, If baseboards are ripped or off the wall, this would constitute a replacement. Why, what's wrong? He was shown photographs taken this day of resident room and hallway walls/baseboards, windowsills, broken floor tiles, a rusty bed frame, and an off-center toilet. He was asked whether those items required repair? He reviewed the photographs that were marked with respective resident room numbers, and replied, Yes, those need repairs. On 08/09/2023 at 4:26 PM, the Environmental Director was interviewed. She stated the facility employed seven housekeepers. The facility's daily cleaning process included sweeping, mopping, dusting, emptying trash, cleaning everything in the bathrooms, and ensuring toiletry items were supplied. The facility also had a deep-cleaning process during which bed frames and furnishings were moved. She stated cleaning residents' rooms could be challenging, because they had many personal items and did not want them touched/moved. Some residents also tended to be impatient during room cleaning, wanting the staff to finish quickly. On 08/09/2023 at 5:17 PM, an interview was attempted with Resident #2 (room [ROOM NUMBER], Bed B), who had been out of the facility all day. After a brief introduction, and while on his way out again, the resident stated he wanted the facility shut down. The interview ended at that time. On 08/09/2023, a review of the facility's life safety computer software program repair logs from 06/01/2023 through 08/09/2023, revealed no evidence of repairs having been made to the aforementioned resident room and hallway walls/baseboards, windowsills, broken floor tiles, rusty bed frame, rusty ceiling tile framework, or off-center toilet. .

Based on interviews, medical record review, and facility policy and procedure review, the facility failed to ensure residents were free from any significant medication errors, by failing to administer medications within the specified timeframe based on physicians' scheduling orders for three (Residents #2, #3, and #4) of seven sampled residents, from a total census of 104. Failure to administer medications in a timely manner can result in a resident's inability to maintain the proper level of medication in the bloodstream to be effective; reduced functional ability; lower quality of life; hospitalization , disease progression, and/or death. Resident #2 received routine and sliding scale insulin more than one hour late 24 times over 10 days between July 1, 2023 and July 14, 2023. Resident #4 received insulin at least one hour late once daily over 12 of 14 days reviewed and twice daily over four of 14 days reviewed. Repeated medication administration errors (timeliness of administration) were identified for Residents #2, #3, and #4. The findings include: 1. A review of Resident #2's medical record revealed an admitted [DATE] and diagnoses including diabetes mellitus, hypertension (high blood pressure), and peripheral vascular disease (poor circulation). The resident was admitted with wounds. A review of Resident #2's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 10 of 14 days as follows: On July 3rd, the following medication was ordered for 8:00 AM and was administered at 11:11 AM: Lispro sliding scale insulin for diabetes mellitus. On July 3rd, the following medications were ordered for 9:00 AM and were administered at 11:11 or 11:12 AM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 3rd, the following medication was ordered for 4:30 PM and was administered at 6:30 PM: Lispro sliding scale insulin for diabetes mellitus. On July 3rd, the following medication was ordered for 5:00 PM and was administered at 6:30 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 3rd, the following medication was ordered for 9:00 PM and was administered on July 4th at 1:29 AM: Carvedilol (Congestive Heart Failure (CHF) On July 4th, the following medication was ordered for 8:00 AM and was administered at 9:12 AM: Lispro sliding scale insulin for diabetes mellitus. On July 4th, the following medication was ordered for 11:30 AM and was administered at 1:37 PM: Lispro sliding scale insulin for diabetes mellitus. On July 4th, the following medication was ordered for 12:00 PM and was administered at 1:35 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 5th, the following medication was ordered for 8:00 AM and was administered at 9:14 AM: Lispro sliding scale insulin for diabetes mellitus. On July 5th, the following medication was ordered for 9:00 PM and was administered on July 6th at 2:01 AM: Lispro sliding scale insulin for diabetes mellitus. On July 5th, the following medications were ordered for 9:00 PM and were administered on July 6th between 1:29 AM and 2:00 AM: Carvedilol (Congestive Heart Failure (CHF) Hydralazine HCL (HTN) Atorvastatin Calcium (Hyperlipidemia) On July 6th, the following medication was ordered for 9:00 PM and was administered on July 7th at 12:25 AM: Lispro sliding scale insulin for diabetes mellitus. On July 6th, the following medication was ordered for 9:00 PM and was administered on July 7th at 12:25 AM: Lantus Insulin for diabetes mellitus. On July 8th, the following medication was ordered for 8:00 AM and was administered at 3:46 PM: Lispro sliding scale insulin for diabetes mellitus. On July 8th, the following medications were ordered for 9:00 AM and were administered between 3:34 PM and 3:48 PM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 8th, the following medication was ordered for 12:00 PM and was administered at 3:41 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 8th, the following medication was ordered for 4:30 PM and was administered at 6:32 PM: Lispro sliding scale insulin for diabetes mellitus. On July 8th, the following medication was ordered for 5:00 PM and was administered at 6:33 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 9th, the following medication was ordered for 8:00 AM and was administered at 11:49 AM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medications were ordered for 9:00 AM and were administered between 11:36 AM and 11:50 AM: Empagliflozin (Diabetes Mellitus (DM) Losartan (High Blood Pressure (HTN) Carvedilol (Congestive Heart Failure (CHF) Lantus Insulin (DM) Sevelamer Carbonate (Chronic Kidney Disease) Aspirin (CHF) Allopurinol (Gout) Bumetanide (CHF) Plavix (Coronary Artery Disease) Hydralazine HCL (HTN) On July 9th, the following medication was ordered for 4:30 PM and was administered at 6:02 PM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medication was ordered for 5:00 PM and was administered at 6:02 PM: Sevelamer Carbonate (Chronic Kidney Disease) On July 9th, the following medication was ordered for 9:00 PM and was administered on July 10th at 3:18 AM: Lispro sliding scale insulin for diabetes mellitus. On July 9th, the following medication was ordered for 9:00 PM and was administered on July 10th at 3:20 AM: Lantus Insulin for diabetes mellitus. On July 10th, the following medication was ordered for 8:00 AM and was administered at 9:24 AM: Lispro sliding scale insulin for diabetes mellitus. On July 10th, the following medications were ordered for 9:00 PM and were administered on July 11th between 1:08 AM and 2:09 AM: Carvedilol (Congestive Heart Failure (CHF) Lispro sliding scale insulin for diabetes mellitus. Lantus Insulin for diabetes mellitus. Atorvastatin Calcium (Hyperlipidemia) Hydralazine HCL (HTN) On July 11th, the following medication was ordered for 6:00 AM and was administered at 2:09 AM: Pantoprazole sodium (Gastroesophageal reflux disease (GERD) On July 11th, the following medication was ordered for 11:30 AM and was administered at 12:39 PM: Lispro sliding scale insulin for diabetes mellitus. On July 12th, the following medication was ordered for 11:30 AM and was administered at 12:56 PM: Lispro sliding scale insulin for diabetes mellitus. On July 13th, the following medications were ordered for 9:00 PM and were administered at 10:20 PM: Carvedilol (Congestive Heart Failure (CHF) Lispro sliding scale insulin for diabetes mellitus Lantus Insulin for diabetes mellitus. Atorvastatin Calcium (Hyperlipidemia) Hydralazine HCL (HTN) (Copy obtained) 2. A review of Resident #3's medical record revealed an admitted [DATE] and diagnoses including multiple sclerosis, hypertension (high blood pressure), depression, and peripheral neuropathy (nerve damage). A review of Resident #3's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 14 of 14 days as follows: Nystatin fungal cream (breast redness) was administered outside of the two-hour window every day. Prostat (supplement) was administered outside of the two-hour window on four of 14 days. Senna S (constipation) was administered outside of the two-hour window on three of 14 days. Miralax (constipation) was administered outside of the two-hour window on three of 14 days. Mirabegron (urinary retention) was administered outside of the two-hour window on three of 14 days. Omeprazole (gastroesophageal reflux) was administered outside of the two-hour window on two of 14 days. Neurontin (peripheral neuropathy) was administered outside of the two-hour window on three of 14 days. Hydrocodone-Acetaminophen (pain) was administered outside of the two-hour window on four of 14 days. Lidocaine patch (pain) was administered outside of the two-hour window on two of 14 days. Magnesium Citrate (constipation) was administered outside of the two-hour window on two of 14 days. Amlodipine Besylate-Benazepril (HTN) was administered outside of the two-hour window on two of 14 days. Metformin (Diabetes mellitus) was administered outside of the two-hour window on two of 14 days. (Copy obtained) 3. A review of Resident #4's medical record revealed an admitted [DATE] and diagnoses including diabetes mellitus and depression. The resident was being treated for wounds. A review of Resident #4's Medication Administration Audit Report for 07/01/2023 through 07/14/2023, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 12 of 14 days as follows: Lispro sliding scale insulin (diabetes mellitus) was administered outside of the two-hour window once a day for 12 of 14 days reviewed and twice a day for four of 14 days reviewed. Zinc sulfate (wound healing) was administered outside of the two-hour window on five of 14 days. Paroxetine Hydrochloride (HCL) (Depression) was administered outside of the two-hour window on five of 14 days. Vitamin C (wound healing) was administered outside of the two-hour window on five of 14 days. Eliquis (blood thinner) was administered outside of the two-hour window once a day on five of 14 days reviewed and twice a day on one of 14 days reviewed. (Copy obtained) On 08/09/2023 at 11:55 AM, Licensed Practical Nurse (LPN) A was interviewed. When asked to describe the allowable administration window for resident medications, she replied, an hour before to an hour after the scheduled time. When she was asked what happened if medications were late, she stated the nurse was expected to call and notify the physician. When she was asked whether she had done that, she replied, Recently I was asked to come in because a nurse had called out. By the time I came in all the AM meds were really late. I think I documented on everyone about being late but I'm not 100% sure. When she was asked if she informed the resident's physician, she stated, When that happens, I usually just tell the doctor when he's doing rounds. When asked if she documented notification of the physician, she said no. On 08/09/2023 at 2:05 PM, an interview was conducted with the Interim Director of Nursing (IDON), a registered nurse (RN) who had initially been hired as the Assistant Director of Nursing (ADON) in June 2023, but had been the IDON for eight days. When she was asked if there was a policy regarding the timeframe for administration of medications, she replied, Nurses have an hour before and after the scheduled time to administer medications, and they are supposed to notify the doctor and document. When she was asked to run a Medication Audit Report using the facility's electronic medical record software, she stated she was not familiar with the report but she would look into it. On 08/09/2023 at 4:00 PM, a joint interview was conducted with the Administrator and the IDON. After a preliminary review of the Medication Administration Audit Report, there were indications of several occurrences of medications having been administered beyond the allowable administration time according to the facility's policy. When they were asked if they were aware that medications for some residents were not being administered in a timely manner, they acknowledged the results of the report and added that while they were aware that they were ultimately responsible, neither of them had been in their positions long enough to have discovered the issue. On the day of the survey, the Administrator had been employed by the facility for three days and the IDON was on her eighth day in her new position. On 08/09/2023 at 7:55 PM, a joint interview was conducted with the IDON and Licensed Practical Nurse (LPN) B/Evening Supervisor. When they were asked why medication administration was late, LPN B stated, On weekdays the expectation is for a manager to cover the cart (medication cart) until another staff member can be brought in if there is a call out. On a Saturday or Sunday, leadership is not in the building. The IDON stated that there had been several call outs on the weekends. When that happened the night shift nurses were asked to remain until they could arrange for nursing staff to come in. The night shift nurses stayed, however, they did not pass any medications. When the replacement nurses finally arrived, the medications were already late. A review of the facility's policy and procedure for Administering Medications (Revised April 2019) page 1, item 4: Medications are administered in accordance with prescriber orders, included any required time frame. Item 7: Medications are administered within (1) one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observations and interviews, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and clean environment for two (rooms [ROOM NUMBERS]) out of 10 rooms observed. The findings include: On 2/28/2023 at 12:23 PM, room [ROOM NUMBER] was observed to have a covered linen cart, a soiled towel, and a clear bag containing soiled linens next to the empty A-bed. (Photographic evidence obtained) An interview was attempted with the resident in B-bed; however, she was determined not to be interviewable. On 2/28/2023 at 12:30 PM, room [ROOM NUMBER] was observed to have a large round stain coming from under A-bed. The stain appeared to be a dried liquid, dark gold in color. Further observation revealed the stain extended under the B-bed to the other side of the bed leading to the middle of the room between A and B beds. Bed A had a catheter bag attached to lower side of the bed. The catheter bag hung above an area where more stains, dark goldish brown in color where observed. (Photographic evidence obtained) On 3/1/2023 at 10:12 AM, a second observation of room [ROOM NUMBER] was conducted. A clear bag containing soiled items was left next to A-bed. There was also a stain dark black in color with the appearance of a [NAME] texture observed extending from the inner side between A and B beds to the center of the room. Stains were observed on the privacy curtain between A and B beds. (Photographic evidence obtained) On 3/1/2023 at 10:17 AM, an interview was conducted with Employee C, Certified Nursing Assistant (CNA) who was assigned to room [ROOM NUMBER]. When she was asked about the bag of soiled items in the room, she acknowledged, she was responsible for leaving the bag in the room. She stated she had been in the room earlier and intended to come back later to get it. She was shown the stains on the curtain and the floor. She stated housekeeping is responsible for cleaning them. She stated there is no reporting log and that the CNAs verbally tell housekeeping when they see anything that needs to be cleaned. When asked if she had reported the dirty curtain or floor stain, she stated she had not. When asked what should be done with large items that don't fit in the small trash cans in the room, she stated they are to be taken to the soiled utility room. During an interview with Employee D, Housekeeper on 3/1/2023 at 10:31 AM, she stated, she did the daily cleaning on the 100 and 300 halls. She was responsible for emptying the trash, cleaning the bathroom, sweeping, mopping, dusting, and wiping down the bars in the room. She confirmed the housekeepers were responsible for sweeping and mopping under the beds. On 3/1/2023 at 1:31 PM, room [ROOM NUMBER] was observed for a second time. The dried liquid, golden in color remained visible under A-bed. At this time Employee E, Account Manager/Housekeeping Supervisor was observed walking on the hallway. When Employee E, was asked about the process for reporting housekeeping concerns to his department, he stated any facility staff member can submit them via TELS (electronic reporting system) or verbally to him. Employee E was shown the dried substance in room [ROOM NUMBER] under A-bed. After seeing it, he replied, Oh no, I'll get that taken care. He then exited the room without continuing the interview. During an interview with Employee E on 3/1/2023 at 2:47 PM, he stated the housekeepers had a routine cleaning list to follow. He confirmed, the housekeepers should mop the entire floor including under the beds, take out the trash every morning, and take soiled items to the soiled utility room.

Based on observations and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 2 of 2 days observed. The findings include: On 2/20/2023 at 10:10 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 8:45 AM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) On 2/21/2023 at 1:24 PM, the daily nurse staffing data had not been updated for the current date. The data posted reflected the census and nurse staffing data for 2/16/2023. (Photographic evidence obtained) During an interview with the Administrator on 2/21/2023 at 4:54 PM, she was asked about the nurse staffing information posted at the entrance of the facility. Upon seeing the information posted dated 2/16/2023, she stated, Oh that's not correct. That needs to be changed. She acknowledged the nurse staffing information posted had not been updated and was out of date.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the refrigerator and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on 2/19/2023 at 11:45 AM. During the tour, no date markings were observed on and open container of mayonnaise, an open box filled with tomatoes, an open bag of cabbage, another open box filled with lettuce, a bag of cream wrapped in plastic, and another open bag of shredded cheese on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) Another tour of the kitchen was conducted on 2/20/2023 at 9:45 AM. No date markings were observed on an open box filled with tomatoes, an open bag of cabbage, an open box filled with lettuce, and another open bag of shredded cheese on the shelf in the walk-in refrigerator on the shelf in the walk-in refrigerator. There was no date marking observed on one open package of buns sitting on a shelf in the walk-in freezer. (Photographic evidence obtained) An interview was conducted with Dietary Aide H on 2/23/2023 10:44 AM, who confirmed that the facility's policy for date marking was to ensure open food was covered, labeled, and dated. An interview was conducted with the Certified Dietary Manager (CDM) on 2/23/2023 at 10:53 AM. The CDM stated it was a collective responsibility of all staff to maintain food storage standards. She confirmed that the facility policy for food storage and date marking was that opened foods should be zipped locked or saran wrapped, labeled, and dated. A review of the facility's policy and procedure entitled Food Storage: Cold Foods (dated 9/2017), revealed: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures: #5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. (Copy obtained) Reference: FDA Food Code 2022 Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on 1/23/2023): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observations, interviews, and record review, the facility failed to provide adequate staffing to respond timely to call lights for 2 (Residents #103 and #262) of 2 residents requiring assistance with activities of daily living. The facility also failed to ensure sufficient nursing staff to provide a timely medication pass for 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication. The findings include: Cross reference F759 and F760 Upon entrance to the facility on [DATE] at 11:00 AM, the Director of Nursing (DON) was observed passing medication on the East wing. During an interview with the DON on 2/19/2023 at 11:05 AM, she confirmed, she was the assigned nurse for that section. She added that her shift was 7 AM - 7 PM. On 2/19/2023 at 12:35 PM, Resident #103 was interviewed. He stated that the care was terrible. He added, Sometimes I have to wait an hour for staff to answer my call light and sometimes an aide will come in, turn off the call light and say they will return, and never come back. Not to mention the weekends are the worst. He went onto say, The DON is on a med cart even today, and sometimes they have one nurse on two med carts. On 2/20/2023 at 9:30 AM, the call light for Resident #262 was observed to be on. During this time, staff were walking past the light, but no one answered it. At 10:30 AM, the call light was still on and staff were observed walking right past the light. On 2/2/2023 at 10:30 AM, Resident #262 was interviewed. He stated that he had the call light on because he needed to be changed. He added that the certified nursing assistant (CNA) assigned to him came in and stated she would be back, but it had been almost an hour and she never came back. In an interview with Employee C, LPN/Unit Manager on 2/20/2023 at 9:45 AM, she stated, all staff have the responsibility to answer the call lights. When asked who was assigned to Resident #262, she was not sure as she was working on a different unit. When she asked the other staff members, she was told the assigned CNA was providing a shower to another resident. She then asked another staff member to attend to the resident's light. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the West Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents (Residents #102, #215, #214, and #71) to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. In an interview with the DON on 2/20/23 at 02:49 PM, she confirmed that medications were administered late. She mentioned that there was a hick up with staffing and hence the late medication administration. During an interview with the Administrator and the DON on 2/23/2023 at 4:54 PM, they both confirmed that staffing has been a challenge, but they always try to get agency staff to cover. The DON confirmed that she worked on the cart on a rotating basis with other supervisors.

Based on observations, record reviews, staff interviews, and facility policy and procedure review, the facility failed to ensure a medication error rate of less than 5%, based on 14 errors with 33 opportunities for errors, resulting in an error rate of 42.42%. The findings include: Cross reference F760. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the West Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). During a medication administration observation on 2/20/2023 at 11:23 AM, Employee P Registered Nurse (RN) was observed preparing to obtain blood sugar for Resident #262. After gathering all the supplies, nurse donned gloves and walked into the resident room. He cleaned the resident's middle finger of the left hand and obtained a drop of blood to the testing strip. He stated that the blood sugar was 327. He walked out of the resident room, discarded the lancet in the sharps container. In the same gloves he obtained a sani wipe for cleaning the glucometer. After scrubbing the glucometer for about 30 seconds, he wrapped it in a clean sani wipe and left it on a barrier placed on the cart. He doffed gloves, (no hand hygiene was performed); obtained a Humalog insulin pen, reviewed the orders and stated that resident required 16 units of insulin. He went to the resident room, donned gloves and injected 16 units to the left upper arm. He walked out of the resident room, doffed gloves (no hand hygiene was performed) and checked the electronic medication record as administered. He then took the glucometer and placed in the cart and walked way to pick up a phone call form the facility phone. On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. While preparing the medications, Resident #31 walked up to her and stated she had a headache. She described the pain level at level 8 out 10 (10 being most severe) and requested that Employee B give her Tylenol. The nurse obtained all other mediation, but did not get the Tylenol. she stated that she did not have the 500 milligrams (mg) per orders and she would have to call the physician to request another medication or a different dosage. She explained the same to the resident. Resident #31 expressed disappointment for the medication being so late. She added, I have severe acid reflux and it bothers me if I don't get my medications on time. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that three residents (Residents #31, #14, and #212) had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. On 2/20/2023 at 2:51 PM, Resident #31 stated she still had headache and was not sure if Employee B had given her the Tylenol medication. She added that the ice pack helps and she would ask the staff to give it to her. On 2/20/2023 at 3:20 PM, Employee B confirmed that she had not administered the Tylenol to Resident #31 and had not provided any non-pharmacological interventions. When asked if she had notified the physician that the dosage require was not available, she said, No , I did not call the physician because the central supplies stated that they would get the medication and I forgot to follow up to get the medication. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that hand hygiene should be performed before donning gloves and after doffing off gloves including while administering medication. She added that if medication is not available in the cart, the nurse should try and check if its available in the pyxis system, if it's still not available the physician should be notified to see if the dose or a different medication should be given. When asked about obtaining blood pressure medication for medications with parameters, she stated that the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with the prescribers orders, including any required time frames. 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to 1) ensure that 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication administration, remained free of significant medications errors, by failing to administer their 9:00 am medications within one (1) hour of prescribed time and failing to notify the physician of the medication errors, and 2) failed to administer blood pressure medication as ordered, following parameters set by the physician for 1 (Resident #41) of 12 residents reviewed for medication administration, by failing to obtain blood pressure readings prior to giving the medication. The findings include: 1. On 2/20/2023 at 11:24 AM, Employee A, Licensed Practical Nurse (LPN) was observed passing medication on the West Wing front hall. The nurse was asked if she had any residents that were due for blood sugar checks, she said, I don't know yet because I'm still not done with the 9:00 o'clock medications, I still have 4 more residents to give medications to. When asked what the time frame was for administering medications, she stated that she had one hour before and one hour after the scheduled time. She confirmed that the medications were late. When asked what the facility protocol was if medications are administered late, she said, I need to contact the Director of Nursing (DON) to come and help. Employee A confirmed she had not notified anyone that she was running behind schedule and walked away from the cart to the DON's office. During an interview with the DON on 2/20/2023 at 11:30 AM, she confirmed that the medications were late for 4 residents (Residents #102, #215, #214, and #71). She added that late medications are considered as med errors and the physician should be notified of the medication errors. (Copies of the physician orders obtained for the four residents). A review of the current physician's orders for the four residents revealed the following orders for critical medications: Resident #102 had orders for Baclofen 20 mg every 6 hours for muscle spasms, Gabapentin 600 mg three times a day for polyneuropathy, Levetiracetam (Keppra) 750 mg 2 times a day for convulsions, Oxycontin 10 mg every 12 hours for pain and Oxcarbazepine 150 mg (give 450 mg) two times a day for spasms and neuropathy. (Photographic evidence obtained) Resident #215 had orders for Apixaban (Eliquis) 5 mg every morning and at bedtime. Insulin lispro sliding scale before meals, midodrine 5mg give three tablets three times a day for hypotension. (Photographic evidence obtained) Resident #214 had orders for Apixaban (Eliquis) 5 mg in the morning and at bedtime. Metoprolol 25 mg every morning and at bedtime. Levemir insulin 25 units one time a day for diabetes. (Photographic evidence obtained) Resident #71 had orders for Quetiapine (Seroquel) 25 mg and 50 mg two times a day for anxiety. (Photographic evidence obtained) On 2/20/2023 at 12:15 PM, Employee B, LPN was observed preparing medication for Resident #31. During an interview with Employee B on 2/20/2023 at 12:30 PM, she confirmed that Resident #31's medications were due at 9:00 AM. When asked if there were any other residents that had not received medications, she reviewed the electronic medication administration record (eMAR) and stated that two more residents (Residents #14 and #212) other than Resident #31 had not received their 9:00 AM medications. She added that she started the medication administration late because there was a staffing issue, and she started her med pass at 10:00 AM. A review of the current physician's order for Resident #31 and other two residents revealed all three had orders for critical medications: (Photographic evidence obtained) Resident #31 had orders for Clonidine HCI 0.1 mg two times a day for hypertension and Gabapentin 300 mg two times a day for pain. Resident #14 had orders for Apixaban (Eliquis) 5 mg two times a day of thrombosis, insulin apart per sliding scale before meals and at bedtime. (Photographic evidence obtained) Resident #212 had orders for Apixaban 5 mg two times a day for blood thinner. Humalog 5 units before meals for diabetes, Lantus 10 units two times a day for diabetes. (Photographic evidence obtained) During a follow up interview with the DON on 2/20/2023 at 2:49 PM, she confirmed that the medications were administered late. She added that the nurse should have called the physician to see if the dose or the time could be adjusted. She mentioned that there was a hick up with staffing and hence the late medication administration. 2. On 2/22/2023 at 9:43 PM, an observation of medication administration was conducted for Resident #41 with Employee C, LPN (Agency). The nurse obtained one tablet for Entresto 24 mg- 26 mg, and metoprolol 25 mg one-half tablet. He then went to the resident's room and gave the medication to the resident. A review of the medication orders for Resident #41 revealed Entresto 24 mg- 26 give one tablet two times a day hold for Blood pressure (BP) less than 110/60 and Metoprolol 25 mg give 1 tablet daily and hold for BP less than 110/60. (Photographic evidence obtained) On 2/22/2023 at 9:45 PM, Employee C was asked what the blood pressure was for Resident #41. He confirmed that he did not obtain it. He added that the nursing assistants were supposed to obtain the blood pressure and he was not sure what the readings were. During an interview with the DON on 2/23/2023 at 12:07 PM, she stated that while administering blood pressure medications with parameters, the blood pressure should be obtained by the nurse before giving the medication. A review of the facility's policy and procedure titled: Administering Medication (revised April 2019) read: Medications are administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation revealed the following: 2. The Director of Nursing Services supervises and directs all personnel who administer medication and have related functions. 3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with the prescribers orders, including any required time frames. 5. Medications administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication b. Preventing potential medication of food interactions; and c. Honoring resident choices and preferences, consistent with his or her plan of care. 6. Medication errors are documented, reported and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time unless otherwise specified (for example before and after meal orders). 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage right time and right method (route) of administration before giving the medication. 11. The following information is checked/ verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precautions, etc.) for administration of medication, as applicable. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to revise the comprehensive care plan to reflect the current level of care for one (Resident #42) of 3 residents sampled for falls, and failed to include one (Resident #54) of 2 residents sampled for care planning, out of a total of 63 sampled residents, the opportunity to participate in the development of the care plan. Failure to update the care plan puts the resident at risk of not receiving appropriate care interventions. Failure to include the resident or their representative in care planning ensures the resident lacks information that will assist the resident in making informed decisions about her health care. The findings include: 1. During an interview on 2/21/2023 at 9:32 AM with the contracted Nurse Practitioner for the facility, she stated that Resident #42 fell out of his wheelchair while his wife was pushing it and he was sent to the hospital. She could not remember the exact date. It was around Christmas time. He sustained a deep laceration to his head and needed 11 staples to close it. A review of Resident #42's medical record revealed he was admitted on [DATE]. Diagnoses included cancer, hypertension, diabetes mellitus, hyperlipidemia, Alzheimer's disease, malnutrition, anxiety disorder, depression, schizophrenia, dysphagia, muscle wasting, muscle weakness, sleep apnea, lymphedema, gastro-esophageal reflux disease without esophagitis, amnesia, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic pain syndrome. The resident had one fall with major injury since the last assessment or since admission. (Copy obtained) A review of the electronic clinical record nursing notes for dated 10/13/2022 at 22:58 hours read: Patient was sent out post fall for a closed head injury. Contusion of the forehead. When he had fallen from his wheelchair. (Photographic evidence obtained) A review of the Situation, Background, Assessment and Recommendation (SBAR) form and witness statements from staff dated 12/23/2022 read that Resident #42 had a fall that occurred on 12/23/2023, resulted in a major injury and required the use of staples to close the laceration to the top of the resident's head. The fall occurred while the resident's wife was pushing him in his wheelchair to his room. As she pushed him around the corner, she was heard to be saying very loudly to her husband to pick up his feet. The nurse (Employee J) observed the resident's feet on the floor. (Copy obtained) On 2/21/2023 at 11:09 AM, a review of the resident's electronic care plan dated 5/08/2022 revealed the resident was care planned for being at risk for falls related to deconditioning, gait/balance problems, incontinence, psychoactive drug use and fall. The goal was to minimize the risk for minor injury through the next review date. The care plan included the following interventions: Anticipate the needs of the resident; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; bed in low position; educate the resident/resident's representative/caregivers about safety reminders and what to do if a fall occurs; ensure that the resident is wearing appropriate footwear/non-skid socks when ambulating or mobilizing in wheelchair; patient evaluate and treat as ordered or as needed. Further review of the care plan revealed that there was no evidence that the care plan was revised or reviewed by the interdisciplinary team after the resident fell on [DATE] or on 12/23/2022. (Photographic evidence obtained) During an interview with Employee K, Licensed Practical Nurse (LPN) on 2/23/2023 at 4:43 PM, she stated that she was the nurse that responded to Resident #42's fall on 12/23/2022. She stated, she saw it happen. She was approximately 20 feet away and could not get to him fast enough to prevent him from hitting his head. He fell forward out of the front of the wheelchair and hit his head on the double panic bolt bar on the fire door. She stated, Oh I remember it like it just happened. It was like a dolphin dive! She stated that he had fallen before. An interview was conducted with the Director of Nursing (DON) on 2/23/2023 at 5:27 PM about the falls. The DON confirmed that the care plan was not updated to reflect the falls on 10/13/2022 and 12/23/2022 and did not contain any updated interventions to prevent future falls or protections from injury. A review of the facility's policy and procedure entitled, Fall Management (effective date 11/30/2014, revised 7/29/2019) read: Residents are evaluated for fall risk. Patient centered interventions are initiated, based on resident risk. Purpose: Is to identify residents at risk for falls and establish/modify interventions to decrease the risk of further fall(s) and minimize the potential for a resulting injury. B. Fall Mitigation Strategies: 1. Develop resident centered interventions based on resident risk factors. 2. Update the resident's care plan and the Nurse Aide Kardex with interventions. C. Post Fall Strategies: 5. Update care plan and Nurse Aide Kardex with interventions. 8. Update plan of care with new interventions as appropriate. (Photographic evidence obtained) 42442 2. On 2/21/2023 at 11:29 AM, Resident #54 stated that she wished to go home, and no one was assisting her with discharge. She added that she was capable of taking care of herself and would get home health services if needed. The resident added that she does not know who made the decision for her to stay at the facility because she had her own home. She said, Institutional living is not for me. Resident could not recall attending any care plan meeting. A review of Resident #54's medical record revealed she was admitted to the facility on [DATE] with a re-entry on 6/19/2022 with admitting diagnoses of muscle wasting and atrophy, cognitive deficit, and need for assistance with personal care. A review of the quarterly minimum data set assessment dated [DATE] indicated Resident #54 had a brief interview for mental status (BIMS) score of 9 out of 15 possible points, indicating moderate cognitive impairment. She required extensive assistance for bed mobility, transfer, and toilet use. She was independent with eating. According to the assessment, Resident's return to the community was uncertain. Resident #54's care plan dated 2/3/2022 indicated she wished to be discharged home. The care plan was updated on 3/10/22 and indicated the resident wished to remain in the facility for long term care. Interventions included to encourage the resident to discuss concerns. The care plan also indicated that resident is an elopement risk/wanderer related history of attempts to leave facility unattended. In an interview with the Social Services Director (SSD) on 2/22/2023 at 2:57 PM, she stated that the discharge plan is initiated upon admission. She added that she also visited the resident if there covered days were almost expiring before initiating a notice of medicate non coverage (NOMNC) to review their discharge plan. When asked about residents that were long term at the facility, but would wish to return to the community, she said, Residents who are long term can request discharge and time. The interdisciplinary team (IDT) also discuss discharge plan during care plan meeting, but I have to make sure that residents who wish to discharge have a plan on discharge location. She added that she had received requests for discharge from three long term care residents and Resident #54 was not among them. When asked if Resident #54 attended her care plan meetings, she stated that the MDS department would have a list of the attendees for each care plan. In an interview on 2/23/2023 at 12:52 PM, Employee D, Licensed Practical Nurse (LPN MDS) stated that when residents are admitted the care plan is done based on the hospital documentation and resident/ family interview. She added the care plan was updated quarterly. When asked about the process of care planning, she said, Resident family/representative are sent a letter a week prior to invite them to the care plan meeting. During the care planning meeting the staff and the families who are present sign the Care conference Card. She added that the resident should always be present and if resident does not participate in the care plan, a documentation should be included that attempts were made along with resident response. When asked if Resident #54 participates in her care plan, she stated that she would obtain the care conference cards to verify. After she obtained the care conference cards for 2022, she confirmed that Resident #54 did not attend in any of the meetings in 2022. There was no documentation proving any attempts were made to have resident attend the meeting. Review of the care conference dated 3/10/2022, 6/7/2022 and 11/29/2022 revealed that Resident #54 did not attend any of the care plan meetings. (Copies obtained) A review of facility's policy and procedures title, Care Plan Invitation (revised on 09/25/2017) read: The resident and/or the resident representatives shall be invited to attend each of the interdisciplinary care planning conference for the specific resident. The procedure included: -Deliver care plan invitation to the resident 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record. - If the resident has capacity, ask if they wish to have the resident representative at the care conference. Per resident choice or determination of capacity, mail care planning invitation to the resident representative 7-14 days prior to the date of the conference. Place a copy of the invitation in the medical record - Have all attendees to the Care Planning Conference, including resident and resident representatives sign the Care Plan Conference Record to verify their attendance. (Copy obtained) A review of the facility's policy and procedure titled, Plans of Care (revised on 09/25/2017) read: An individualized person- centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with the state and federal regulatory requirements. The procedure read, Develop and implement and individualized person- centered comprehensive plan of care by the interdisciplinary Team that include but not limited to the attending physician, a registered nurse with registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition service staff, and other appropriate staff of professionals in the disciplines as determined by the resident's needs or as requested by the resident, and to the extent practicable the participation of the resident and the resident's representative(s). (Copy obtained)

Based on observation, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) out of 63 sampled residents. The findings include: On 2/20/2023, Resident #6 was observed lying in bed under the covers. There were no physical signs of abuse or neglect. When an interview was attempted, the resident responded nonsensically to many of the questions that were asked. The resident appeared to be pleasantly confused, and the interview was ended. A record review for Resident #6 revealed she was admitted on [DATE] and was readmitted on [DATE], after being transferred out for acute care. Diagnoses included urinary tract infection (UTI); muscle weakness; unspecified atrial fibrillation; dysphagia; muscle wasting & atrophy; acute embolism and thrombosis of deep veins; long term use of anticoagulant and essential hypertension. A review of Resident #6's admissions minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 14 out of 15, indicating cognitively intact. Resident required extensive assistance with all activities of daily living. Pain assessment was completed. There was no pain or falls reported during the look back period. A review of the current physician's orders for Resident #6 revealed Eliquis 5mg by mouth twice a day; monitoring for anticoagulant usage each shift; pain monitoring each shift; complete blood count (CBC) and basic metabolic panel (BMP) each Friday; vital signs each shift; regular no added sodium (NAS) diet, dysphagia puree texture and regular thin liquids consistency A review of nursing progress note dated 1/23/2023, read: Resident found on floor next to bed 1cm X 1cm abrasion on left side forehead appeared resident hit head on bedside table. Further record review revealed Resident #6 was enrolled in hospice services on 1/27/2023. A review of the resident's most recent care plan addressed falls as: Focus: the resident is at risk for falls related to gait/balance problems, incontinence, history of fall date initiate 11/30/2022; Goal: Minimize the risk of falls through next review date Target date 4/10/2023; Interventions: Frequent toileting, anticipate and meet the resident's needs; be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; ensure the resident is wearing appropriate footwear/non-skid socks when mobilizing in wheelchair; physical therapy evaluate and treat as ordered or as needed dated initiated 11/30/2023. During an interview on 2/22/2023 at 12:59 PM with Employee E, Advance Registered Nurse Practitioner (ARNP), she acknowledged she was familiar with Resident #6. She confirmed the resident is currently receiving Hospice services. She was not sure how often these services were provided in the facility. She stated the facility nurse coordinates with hospice. She confirmed the resident sustained a fall with injury in the facility on 1/23/2023. She stated, she sees the resident every 30 days and/or in the event of an acute situation. When asked, she stated the fall would have been considered an acute situation, however, she did not see the resident until 1/25/2023, two days after the fall with injury, then again on 1/26/2023 and 1/30/2023. On 2/2/2023, she documented the bruise the resident sustained during the fall as it was more prominent at that time. She stated there was no x-ray nor was Resident #6 sent out for evaluation and/or treatment. During an interview with the Director of Nursing (DON) on 2/22/23 at 4:17 PM, she reviewed the details of Resident #6's fall on 1/23/2023. She confirmed the date of the fall and stated it occurred at 1:15 AM. The resident was observed next to her bed and sustained a laceration to the forehead 1 cm x 1 cm in size. The laceration was treated in house by the facility staff and the resident's physician was notified. When asked about post fall interventions, she stated the resident was re-educated to ask for assistance when getting out of bed. The DON was asked about the facility's fall process. She stated a facility wide code green is called when there is a fall. Nursing does the assessment and the doctor is called. She stated there is no physical documentation. She stated if a fall is unwitnessed neurochecks are performed. She confirmed the fall sustained by Resident #6 was unwitnessed and the resident would have needed neurochecks. She stated some of the neurochecks are done on paper as well as electronically. She stated the neurochecks are done within the first 15 minutes then every hour then every four hours after a resident sustains a fall. She was asked to provide the neurochecks done for Resident #6. She stated, they should be located in the resident's electronic chart. At this time, she was also asked to confirm the order for hospice services. She stated the facility was still verifying the order for hospice. She stated the order was put in by an agency nurse and was being investigated by the facility. She stated the facility needed to determine if the family or the doctor requested hospice services. During an interview with the DON on 2/22/2023 at 4:47 PM, she was advised the neurochecks for Resident #6 were not found in the electronic chart. She was given the physical chart retrieved from the nurses' station on the East Wing of the facility. In the presence of Administrator, the DON sorted through the resident's physical chart looking for the neurochecks that should have been done after resident sustained the fall on 1/23/2023. After several minutes, the DON confirmed there were no neurochecks in the resident's physical chart. During an interview with Employee E, the ARNP on 2/23/2023 at 11:52 AM, she confirmed she put in the consult for hospice service. She stated the diagnosis was failure to thrive. She stated the Power of Attorney for Resident #6 spoke to Hospice and the services were optional. She again stated the reason for her consult was the resident's failure to thrive. She was provided a copy of the hospice documentation showing atherosclerotic heart disease listed as admitting diagnosis. The ARNP was asked if this information was accurate. She stated, she can't prove a resident's primary diagnosis. She stated she puts in the consult, but she can't pick the resident's diagnosis. When asked about collaboration between herself, hospice, and the physician, she stated they meet in the facility. She stated the on-call team was notified after Resident #6 sustained the fall on 1/23/2023. She confirmed the resident sustained an injury as a result of the fall but stated she was fine and confirmed there were no post fall interventions put in place. She was asked in her professional opinion about residents who take anticoagulants who had falls and sustained a head injury with bleeding. She stated she would probably send the resident out, but Hospice would have to be called since this resident is on Hospice. During a phone interview with the Medical Director on 2/23/2023 at 12:01PM, he acknowledged being the Medical Director for the facility and member of the facility's Quality Assurance and Performance Improvement (QAPI) team. He stated he was aware of the fall Resident #6 sustained on 1/23/2023. He stated his on-call service took the report for the fall. He stated the specific person who took the report was currently out of the country and unavailable for interview. He stated the facility advised there was head injury and provided the resident's vitals. He stated the facility was advised to perform neurochecks for Resident #6 after the fall. He stated, When a resident is on a anticoagulant there is a low threshold there so we send them out to the hospital to make sure there is no cranial bleeding. When asked about the order for Hospice, he stated the ARNP spoke with the resident's Power of Attorney (POA). He stated there was a phone call with the POA for Resident #6 to discuss Hospice as an option. When asked how he collaborates with Hospice, he specifically replied, That's a great question. I've been trying to open the lines of communication. I've asked that we be involved when residents and their families make that decision. It's getting better. A review of the facility's policy and procedure titled, Fall Management (Effective Date: 11/30/2014 Revision Date 7/29/2019) read: C. Post Fall Strategies 2. Initiate Neurological checks as per policy or directed by physician order 6. Initiate post fall documentation every shift for 72 hours 9. Review resident weekly x 4. (Photographic evidence obtained)

Based on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #21) of 10 residents receiving respiratory care, received oxygen as ordered, from a total sample of 63 residents. The findings include: On 2/20/2023 at 10:57 AM, Resident #21 was observed lying in bed wearing a nasal cannula. The oxygen concentrator located at bedside revealed an oxygen flow of 1.5 Liters per minute (L/min). A bag attached to the oxygen concentrator was dated 2/7/2023. (Photographic evidence obtained) A record review of Resident #21's physician's order revealed no current oxygen order. Respiratory oxygen at 2 L/min via nasal cannula as needed for shortness of breath was discontinued 8/22/2021 at 4:15 PM. (Photographic evidence obtained) On 2/21/2023 at 10:15 AM, a second observation of Resident #21 was conducted with Employee B, Unit Manager. The resident's oxygen concentrator was set at 1.5 L/min with a bag attached to the oxygen concentrator dated 2/7/2023. (Photographic evidence obtained) Employee B confirmed Resident #21's oxygen order was discontinued on 8/22/2021. A record review for Resident #21 revealed an initial admitted [DATE] and readmitted [DATE]. Diagnoses included hemiplegia unspecified affecting left nondominant, weakness; unspecified lack of coordination; cognitive communication deficit; anxiety disorder, unspecified; other schizoaffective disorders; major depressive disorder, recurrent, unspecified; long term (current) use of anticoagulants; and muscle weakness. A review of the quarterly minimum data set (MDS) assessment, dated 1/16/2023, revealed Resident #21 had no interview for mental status, resident was rarely/never understood. The assessment also documented she was receiving oxygen therapy. A review of the January 2022 Medication Administration Record (MAR) for Resident #21 identified no monitoring of oxygen therapy. A review of Resident #21 care plan dated 12/1/2022 revealed she had oxygen therapy as needed via nasal prongs as ordered. Progress notes dated 2/6, 2/7, 2/10, 2/11, 2/12, and 2/13 revealed oxygen administered at 2 L/min via nasal cannula. During an interview with the Director of Nursing (DON) 2/22/2023 at 3:25 PM, the DON confirmed that nursing was responsible for providing ongoing monitoring of oxygen therapy and tube changes. She stated, the physician provides orders, and nursing follow the physician orders. Each nurse had access to the electronic medical record to identify oxygen settings. A review of the facility's policy and procedure titled, Oxygen Therapy (revision date 8/28/2017) read: Physician's order for oxygen therapy shall include Administration modality, FiO2 or liter flow, Continuous or (as needed) PRN, PRN orders must include specific guidelines as to when the resident is to use oxygen. (Photographic evidence obtained)

Based on record review, interviews, and facility policy and procedure review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of four residents reviewed for elopement, from a total of 12 residents in the sample. The findings include: A record review for Resident #1 revealed he was admitted on [DATE] and discharged on [DATE], with diagnoses including fractures and other multiple trauma, difficulty walking and muscle weakness. Resident #1 was his own decision maker and had a family member listed as an emergency contact. A review of Resident #1's 5-day minimum data set (MDS) assessment dated [DATE] revealed he was admitted from an acute hospital. Resident #1 had a brief interview for mental status (BIMS) score of 12, indicating moderate cognitive impairment. He was assessed with no wandering behavior. An Elopement Risk Evaluation dated 12/7/22 revealed he was independently mobile but was not at risk for elopement (leaving facility without supervision and permission). A review of nursing progress notes indicated Resident #1 was oriented to person, place, and time. A facsimile transmission dated 1/6/23 included a Notice of Medicare Non-Coverage (NOMNC) notifying Resident #1, his insurance would stop paying for his skilled therapy services as of 1/9/23. The form was signed in acknowledgement by Resident #1 on 1/9/23. A corresponding Social Services Progress Note dated 1/9/23 revealed Resident #1 received his NOMNC Friday. The Social Services Assistant reviewed the notice with the resident, who signed the form. Resident is VA (Veterans Administration) and has been approved with HUD-Cash program; however, it will take time to secure housing. Resident #1's plan is to remain in the facility until housing is available. A review of the resident sign-in and sign-out book found Resident #1 signed himself out and back into the facility 25 times during his stay. A review of Resident #1's physician's order dated 12/7/22 revealed he could go on leave of absence (LOA). A nursing progress note dated 1/30/23 at 12:32 reported Resident #1 called the facility to state he left the facility against medical advice (AMA). The note was authored by Licensed Practical Nurse (LPN) A. There was no other progress note or entry explaining further. An interview was conducted with LPN A on 2/2/23 at 2:20 pm. She said some residents were permitted to go out on leave. She remembered Resident #1, he was always coming and going from the facility. He was very independent, very alert, and oriented. She does not know any circumstances about his departure but recalled being told that day Resident #1 called and said he wasn't coming back. She was asked to chart it. LPN A recalled seeing him for lunch medications and saw him leave his room at one point. Then, Resident #1's roommate told her about 5:00 pm or 5:30ish that Resident #1 said he was leaving. Resident #1 was telling people he was leaving. Residents sign in and out, or are supposed to, when they leave. An interview was conducted with the Administrator on 2/2/23 at 2:50 pm. She recalled Resident #1 was admitted for short term rehabilitation services, then he was supposed to return to the community. His insurance covered up to 20 days at 100%. The Business Office Manager had a conversation with him about his co-pay of 20% to remain in the facility. Resident #1 was not happy and said he wasn't paying to stay and would just go back to where he previously was. On Sunday, he was telling everyone he was going to leave and was packing up his stuff. Someone came to the facility, picked him up, and brought him back. Then he told a staff person he was leaving again. He took his stuff, and he did. He also told a CNA he was leaving. LPN A called the Administrator and told her Resident #1 said he was leaving, that he wasn't staying here. The Administrator spoke to Resident #1 on the telephone, and he said he was leaving for good, that they were not taking his money. The Administrator started calling the emergency contact but didn't talk to her until 5:00 am the next day. She did not notify the resident's doctor but did notify the medical director. The Administrator admitted she did not document the conversations. She also confirmed Resident #1 did not sign an AMA form. When she told him, he should have signed the form, Resident #1 told her he wasn't signing nothing. A review of the facility's policy titled Leaving Against Medical Advice (AMA), policy #N-762 effective 11/30/14 revised 10/24/22 revealed, The nurse will ensure the resident has the authority or capacity to make the decision to leave. 1. Discuss/attempt to resolve concerns contributing to desire to leave AMA. 2. Inform the resident of the risk/benefits. Document in the medical record. 4. Notify the physician and document in the medical record. 5. Contact the resident representative and document in medical record. 7. Complete the AMA form and ask the resident to sign. If the resident refuses to sign, document in the medical record. (Photocopy was obtained) A follow up interview was conducted with the Administrator on 2/3/23 at 12:30 pm concerning the facility's AMA policy. She was asked about the lack of documentation in the clinical record regarding the physician and family being notified of Resident #1's departure, and lack of documentation showing that Resident #1 refused to sign the AMA form. The Administrator stated, she did speak with the emergency contact and asked if it was too late for her to write a note? She said, she did talk to the Medical Director and would call him to ask for a note. She acknowledged the lack of documentation per the AMA policy.

Based on interview, document review, and review of facility policy, the facility failed to meet the requirement for 100% compliance, which requires that all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose COVID-19 vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the Centers for Disease Control Prevention (CDC). Ninety-two out of 93 current staff were either fully vaccinated against COVID-19 vaccination or were granted an exemption or delay in accordance with CDC guidelines, for a compliance rate of 98.9%. One staff member, Registered Nurse (R)1, was not fully vaccinated, had not been granted a qualifying exemption, and was not identified as having a temporary delay as recommended by the CDC. Findings include: Review of the facility policy titled, Employee COVID-19 Vaccination, revised 05/03/22, revealed, Individuals who decline vaccination because of medical contraindication or religious beliefs must complete the applicable Company form and submit for review by the applicable regulatory deadline .Exempt: An individual whose request for a religious or medical exemption has been approved .Exempted Employees and Reasonable Accommodation: .4.a. Individuals who request and are granted a medical or religious exemption through the company's exemption review process. Review of a COVID-19 Staff Vaccination Status for Providers document, provided and completed by the facility on 05/17/22, and referencing a facility spreadsheet, revealed that the facility had a total of 93 staff. Of these 93, 74 staff were completely vaccinated, 14 staff had been granted a non-medical exemption, and four staff had a temporary delay in being fully vaccinated, per CDC guidelines. Per this document, one staff, RN1, was not vaccinated against COVID-19, and had not been granted an exemption or a temporary delay. Based on the one unvaccinated/non-exempt staff, the facility did not attain the required compliance rate of 100%. The spreadsheet revealed that RN1 was listed as not vaccinated, was not granted an exemption, or did not have a vaccination delayed per CDC guidelines. Interview with the Administrator on 05/17/22 at 2:15PM confirmed RN1 was not vaccinated against COVID-19, was not granted an exemption, and was not on a temporary delay per CDC guidelines. The Administrator stated that RN1 completed a Request for Medical Accommodation: COVID-19 Vaccine form on 12/03/21 for a medical exemption; however, the form was not reviewed or approved. The Administrator stated that after the form was completed, the facility went through a change of management company in December 2021, and he was appointed the new Administrator in January 2022. The Administrator confirmed that RN1's medical exemption request was not reviewed, approved or not approved and that he only recently submitted RN1's request for exemption for review. The Administrator further confirmed that RN1 is a current employee of the facility.

Based on observation, interviews and record review, the facility failed to adequately manage pain for one (Resident #2) of three residents reviewed for pain management. Lack of treatment can cause worsening of condition, health complications, and inhibits the resident from reaching his/her highest practicable level of wellbeing. The findings include: A review of Resident #2's medical record revealed he was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent quarterly minimum data set (MDS) assessment, dated 8/12/21, indicated the resident had a brief interview for mental status score of 15, indicating cognitively intact. He required extensive to total assistance with activities of daily living. During an interview with Resident #2 on 11/16/21 at 2:35 PM, he stated that he had not received his Biofreeze in the past few days for pain. He went on to say that he did not want to take his oral pain medications because they caused him to be constipated. He confirmed that he did not refuse his Biofreeze medication today and repeated that he had not received it in the past few days. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) On 11/16/21 at 2:37 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She confirmed that she was assigned to Resident #2 and that he refused all his medications today. Employee A, LPN was asked to locate the Biofreeze medication for Resident #2. Employee A, LPN looked through the treatment cart, but could not locate the Biofreeze. She stated, It should be here, maybe we need to order more. A review of Resident #2's care plan indicated he had chronic shoulder, neck, knees, ankles and feet pain. With a goal to have minimal interruption in normal activities due to pain through the review date. Interventions included, administer [MEDICATION(S)] medication as per orders. (Copy obtained) On 11/16/21 at 2:47 PM, an interview was conducted with Resident #2 and the Director of Nursing (DON). Resident #2 explained that he did not refuse his Biofreeze today and that he had not had the Biofreeze applied in a few days. He also stated that he preferred the Biofreeze treatment over his oral medications because the oral medications caused him to have constipation. A review of the November 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) On 11/12/21 for 9:00 AM and 2:00 PM, there was no documentation that the topical medication was given. On 11/13/21 and 11/14/21, topical medication was documented as administered. On 11/15/21 for 9:00 AM and 2:00 PM, there was no documentation that the topical medication was given. On 11/15/21 at 9:00 PM, topical medication was documented as administered. On 11/16/21 at 9:00 AM, topical medication was documented as drug refused. On 11/16/21 at 2:00 PM, topical medication was documented as administered. A review of the MAR for Resident #2 was conducted with the DON on 11/16/2021 at 2:50 PM. The DON confirmed that the Biofreeze treatment had omissions in the MAR. She acknowledged that Employee A, LPN had documented that the Biofreeze was administered on 11/16/2021 at 2:00 PM, however, Resident #2, who was alert and oriented denied the treatment was ever provided at that time. On 11/16/21 at 3:03 PM, an interview was conducted with Employee B, Certified Nursing Assistant (CNA). He confirmed that Resident #2 requested Biofreeze earlier in the day (around 1:00 PM) when he went to put the resident back to bed. Employee B, CNA confirmed that Resident #2 told him that he had not had Biofreeze applied for a couple of days. He stated that Resident #2 does not usually refuse the Biofreeze, and they did not have the Biofreeze available for at least the last couple of days. A review of the facility's policy titled, Physician Orders, with revision date of 3/3/21 indicated, The center will ensure that Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained)

Based on medical record reviews, staff interviews and a review of the facility's Abuse and Neglect Policy and Procedure, the facility failed to provide vulnerable residents protection from sexual abuse for one (Resident #1) of five vulnerable residents reviewed. The facility failed to implement adequate interventions for one (Resident #1) of five residents reviewed with known wandering behaviors and a potential to suffer physical and/or sexual abuse. On [DATE] at 4:30 p.m., Resident #1, who was severely cognitively impaired, was found in Resident #2's room, sitting on his bed with her head in his lap, performing oral sex. Resident #2 was holding his underwear. Resident #1 was not able to consent to sexual activity due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was not cognitively impaired and could consent. Five residents living in the facility who wander, and are not able to consent to sexual actitivity, have the potential to be affected by the deficient practice and potentially suffer serious psychosocial harm, not yet realized, because of their inability to consent to sexual activity, which diminishes self-worth and self-respect. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 4:32 p.m. on [DATE]. On [DATE] at 4:30 p.m., the Immediate Jeopardy (IJ) began. On [DATE] at 5:15 p.m., the Administrator was notified of the IJ determination, and immediate jeopardy was removed upon survey exit on [DATE], effective [DATE]. The facility remained out of compliance, and the scope and severity were reduced to D. The findings include: An interview was conducted with Licensed Practical Nurse (LPN) A at 1:49 p.m. on [DATE]. She reported working a 12-hour shift and starting to check blood glucose levels on her hallway at approximately 4:00 p.m. on [DATE]. LPN A reported knocking on Resident #2's door, opening it, and seeing Resident #1 sitting on the bed. Resident #2 had his underwear in his hand. Resident #1 was fully dressed. She had been wearing two shirts, but one had been removed. Resident #2 was not touching her. Resident #1 was performing oral sex on him. LPN A called Resident #1's name, and Resident #1 stopped. LPN A took the resident by her hands and asked, What are you doing?, and took her off the bed and out of Resident #2's room. She stated she spoke to the Unit Manager, Administrator, and the Assistant Director of Nursing (ADON) immediately. Resident #2 said nothing, he just looked around. Both residents were started on 1:1 (one to one) supervision immediately. The police came out and I reported what I saw, and answered questions about what happened. LPN A stated Resident #1 would wander, walk around in halls, and spoke both English and Spanish. She reported having seen Resident #1 around 3:00 p.m. Resident #2's roommate was in the room but the curtain was closed. He was sleeping and did not know what was going on during the incident. Resident #2 has been moved and is staying in his room with a 1:1. She reported Resident #2 exhibited no sexual behaviors toward her. An interview was conducted with Certified Nursing Assistant (CNA) B at 9:45 a.m. on [DATE]. He reported working having been employed by the facility for six months. He stated Resident #1 used to walk in the hallways and would talk to people. CNA B stated, [Resident #1] will do whatever you tell her. An interview was conducted with Resident #1 at 10:50 a.m. on [DATE]. When asked if she knew what oral sex was, she replied Oral sex is for young people. She was asked if she had oral sex with Resident #2, and she replied, No, hesitated, then said not that I remember. Resident #1 also reported the caregiver in her room was her sister. The care giver in her room was a facility staff member. An interview was conducted with the Advanced Practice Registered Nurse (APRN) at 9:40 a.m. on [DATE] concerning the resident-to-resident abuse incident that occurred on [DATE]. The APRN stated Resident #1 had zero recollection of the event, and her power of attorney made all of her decisions for her. She stated the resident did not understand or have the capacity to make decisions, and did not know what was going on. Both residents were examined. Resident #1's husband died , and she was living with her daughter prior to her nursing home admission. The APRN stated Resident #2 denied the whole thing. She stated Resident #1 did not know it was wrong, she was compliant, and would do whatever you asked. [Resident #2] knows right from wrong and made-up a story about her inviting him to dinner. [Resident #1] does not know right from wrong. An interview was conducted with LPN C at 3:38 p.m. on [DATE]. She stated she wrote in a nurse's note about a housekeeper being uncomfortable cleaning Resident #2's room. She stated Resident #2 was making the housekeeper uncomfortable, so she told the housekeeper to stay out of his room. She did not know what statements Resident #2 made to the housekeeper. LPN C stated, He would stare at your butt and make comments like, I like your butt in those peach scrubs. I quit wearing them. He would do this to staff not residents. I don't know what statements he was making to the housekeeper. Staff would walk away if he made comments. He never touched me, I just heard staff say he made them uncomfortable. It was how he would say things and stare at you at the same time that made you uncomfortable. An interview was conducted with Social Services Assistant (SSA) D on [DATE] at 4:26 p.m. via telephone. She was asked about her progress note documenting that Resident #2 caressed her arm on [DATE]. She stated, It happened exactly how I wrote it. He was flirtatious with staff members. I wanted to document it because it made me a little uncomfortable. [Resident #2] was younger than the other residents, and it did not feel right. He reached out his arm when I gave him the paper. I just documented it. He was flirtatious with staff members, stating things like I like your shirt. Caressing my arm was different. This was the first time it happened. I had never heard of it happening before. She stated there were no other encounters between her and Resident #2. An interview was conducted with Registered Nurse (RN) E at 5:00 p.m. on [DATE]. He reported Resident #1 wandered or walked in the hallways, and would go into resident rooms, but she was redirectable. An interview was conducted with LPN/Minimum Data Set (MDS) Coordinator F at 8:55 a.m. on [DATE]. She stated the wandering care plan was initiated for Resident #1 on [DATE]. Resident #2 was care planned for behaviors on [DATE] for flirting with staff. He was very complimentary. He was never inappropriate, just flirting. On [DATE], [SSA D] came and told me he caressed her arm, so I told her to document it. The care plan was updated, adding on [DATE] that [Resident #2] was sexually inappropriate with staff. An interview was conducted with Resident #5 in the private dining room at 9:05 a.m. on [DATE]. She stated there was a small crack in the door to her room. Her door wasn't entirely closed. She heard the door open, she finished getting dressed, and she went to the door to find it had been opened, and Resident #2 was looking into her room. She said she told him, If I catch you outside my door again, I will use the dullest knife to stab you multiple times. She reported that this was the first time she was aware that he had done this. Resident #5 stated, He (Resident #2) would tell me I have a nice ass. The door was open so he could see me. He was moved to 200 hall after that. She confirmed she never wrote anything down or filed a grievance about it, but she stated, I think he was a predator. An interview was conducted with Activities Assistant I on [DATE] at 12:10 p.m. She reviewed attendance and documentation of activities on the computer. She reported Resident #1 was not documented as having participated in any activities between [DATE] and [DATE]. She had been on 1:1 supervision since the abuse incident on [DATE]. An interview was conducted with Resident #3 in her room on [DATE] at 9:43 a.m. She was asked about the incident involving Residents #1 and #2, which she reported in a complaint. Resident #3 stated, [Resident #1] used to visit me in my room and talk. [Resident #2] made comments such as, Hi pretty lady, you want to have fun? Resident #3 stated she told him to step back and get away from her. She said Resident #2 would just look at people especially women. He would sit in the hallway and watch the staff. An interview was conducted with RN/MDS Coordinator G at 11:48 a.m. on [DATE]. RN G stated the care plan meeting for Resident #1 was conducted on [DATE]. The resident's daughter was called, but she did not answer. The Activities Director, a CNA, the Social Services Assistant and Employee G were present. The plan of care was discussed, which included behaviors such as wandering aimlessly and sometimes going into residents' rooms. Resident #1 needed assistance with daily living needs. RN G stated a baseline care plan was in the computer for wandering, but there was no comprehensive care plan for wandering until [DATE]. An interview was conducted with Resident #6 in her room at 12:05 p.m. on [DATE]. She reported being afraid of Resident #2 and said she was glad he left. She stated he used to sit in his doorway and watch people. She stated she never had an encounter with him, but he made her uncomfortable. An interview was conducted with LPN H at 12:20 p.m. on [DATE]. She stated Resident #1 liked to walk in the hallways and would go into people's rooms. I would redirect her, take her with me and talk to her. An interview was conducted with Resident #4 in room [ROOM NUMBER] at 9:23 a.m. on [DATE]. She stated Resident #2 came into her room and invited her to come to his room. She said she told him to get the hell out. She was asked if she knew why he invited her to his room and she replied, I don't know why he invited me. She reported that he would sit in front of her door, and she would ask him to move. Her roommate saw him in front of door and told him not to come back. 1. A review of Resident #1's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Wandering was not checked. A baseline care plan, dated [DATE], noted a care area under Falls/Safety/Elopement with a goal not to exit the facility unassisted with the following interventions: maintain safe environment, wander risk assessment, Wanderguard (elopement bracelet) to ankle, medication change, brought to nurses station for closer monitoring, provide busy activities, and psychiatric evaluation on [DATE]. No specific amount of supervision was documented. A comprehensive care plan for Elopement Risk/Wandering was initiated on [DATE] (a day after the incident). The care plan included: resident is an elopement risk/wanderer r/t dementia. Disoriented to place, impaired safety awareness. Resident wanders aimlessly. Significantly intrudes on the privacy or activities. Interventions included: assess for elopement risk, distract resident from wandering by offering pleasant diversions, structured activities, food conversation, television, book, electronic monitoring device, provide structured activities, toileting,walking inside and outside, reorientation strategies, including signs picture and memory boxes. The Psychosocial Evaluation completed on [DATE] noted the resident was widowed, Catholic, had cognitive impairment and staff would visit her daily to invite and assist her to social distance activities. On [DATE], the nursing Quarterly Data Collection form indicated: alert to person, memory problem, pleasant mood, wanders, severe cognitive impairment (under safety portion), elopement risk, cognitively impaired, independently mobile, poor decision making skills, and at risk for elopement. Nursing notes were reviewed, which noted: On [DATE], a note documented notifying power of attorney about incident with another resident involving her son receiving oral sex from said resident in his room. Care conference scheduled with Administrator for tomorrow. On [DATE] at 7:52 p.m.: Continues to wander facility, in and out of patient rooms, exit seeking, anxious. On [DATE], a Community Life note revealed Resident #1 will wander in other residents' rooms and chit chat with them. On [DATE], a nursing note reported the resident as very confused, she is wandering saying her mom is in her bed. On ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE], nurses' notes documented behavioral problems as wandering. On [DATE], a Community Life note documented that Resident #1 likes to walk around the facility aimlessly. She will wander in other resident rooms and chit chat with them. On [DATE], a note entered by the Unit Manager reported behavioral problems as wandering. Patient wanders through halls. A change in condition, documented on [DATE] at 4:30 p.m., noted [Resident #1] was in a male room (Resident #2) providing oral sex. Resident was immediately redirected out of room and placed 1:1 (one to one supervision). The Advance Practitioner Registered Nurse (ARNP) and family were notified. A progress note for the Advanced Registered Nurse Practitioner (ARNP), dated [DATE], revealed: Patient is seen for follow-up visit concerning patient found in an inappropriate sexual position with another resident. History was reviewed with medications. Resident is alert, not oriented, confused, poor choices, and slightly anxious. Adult sexual abuse, suspected initial encounter. Patient was found providing sexual gratification to another resident in the facility. Patient lacks capacity to consent to sexual activity. Patient does not remember anything that occurred yesterday and is now 1:1. A Behavioral progress note, dated [DATE], was reviewed for Resident #1. The consultation was to evaluate the resident's psychological well-being. The note read: On [DATE], there was an incident where she was in anothers resident's room giving oral sex. Police were notified and a possible abuse allegation is being investigated. Cognitive screen score 3. The resident was noted with severe cognitive impairment, judgement test less than 10 % and impaired. [Resident #1] engages in impulsive behavior, and will just agree with others in interactions. She does not recall the incident from [DATE]. Mild anxiety with a score of 6. 2. A review of Resident #2's medical record noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], noted a BIMS score of 15 out of a possible 15 points, indicating intact cognition. The resident required assistance with bed mobility, while transfers and toileting required supervision. The care plan focus for behaviors related to flirting with staff was initiated on [DATE]. The care plan was updated on [DATE] to include sexually inappropriate behaviors with staff, sexually inappropriate behavior with another resident, manipulative talking to confused resident to perform oral sex, and confabulation on [DATE]. Interventions included: If reasonable, discuss the resident's behavior. Explain/reinforce why behaviors are inappropriate and or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. On [DATE], Monitor behavior episodes and attempt to determine underlying cause was added. Consider location, time of day, persons involved and situations. Document behavior and potential causes. On [DATE], the intervention for Resident #2 to remain 1:1 was added. A progress note, dated [DATE] from Social Services Assistant D read, Went to resident's room to get a disenrollment paper signed, he continuously asked me to come closer. I stayed my distance but when I went to give the paper, he caressed my arm, let go and then grabbed the paper. A Behavioral note documented on [DATE] read, On [DATE], he received oral sex in his room from another resident (reported by nurse). He denies any touching occurred, says she walked in his room, sat on his bed and invited him to dinner with her mother and father. Other resident does not have decisional capacity (reported as a potential abuse case). He has also been verbally aggressive with staff. His BIMS was 12. The facility policy MN-1265, Abuse, Neglect Exploitation and Misappropriation (revised [DATE]) specified, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment and exploitation. Abuse is the willful infliction of injury with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through [sic] the use of technology. Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: unwanted intimate touching of any kind especially the breast or perineal area, all types of sexual assault or battery, such as rape, sodomy, and coerced nudity. Forced observation of masturbation and/or pornography; and taking sexually explicit photographs and/or audio/video of recordings of a resident(s) and maintaining and/or distributing them (i.e., posting on social media)this would include, but is not limited to, nudity,fondling, and/or intercourse involving a resident. The facility provided their immediate jeopardy removal plan, and these immediate actions were verified as having been completed by the surveyor as follows: On [DATE], the responsible party was notified for Resident #1 (daughter). On [DATE], the responsible party was notified for Resident #2 (mother). On [DATE], the physician was notified for both residents with orders written for 1:1 supervision. On [DATE], staff and resident interviews were conducted related to whether staff had seen any type of misconduct/abuse from resident to resident or staff to resident. They were asked whether comments were made either to staff or residents that made them feel uncomfortable, including from Resident #2. Had they seen any inappropriate touching from resident to resident or resident to staff to include Resident #2. On [DATE], an interview was attempted with Resident #1 by the Administrator, but she received no response to her questions. On [DATE], the Administrator attempted to interview Resident #2. The resident was belligerent and would not answer any questions. On [DATE], Other residents on the 200 and 300 hallways were interviewed by the Social Services Director (SSD) regarding possible concerns of mistreatment or abuse by a resident or staff member and no concerns were voiced. On [DATE] at 2:00 p.m., a care conference meeting was held for Resident #2. The notes read: Care conference with resident face to face and family member via telephone as well as Regional Vice President of Operations, Regional Clinical Director of Services, Administrator, and SSD. The purpose of this call was to discuss [Resident #2's] overall medical condition and ability to thrive externally in move-in community. On [DATE], Resident #2's care plan was reviewed and updated by the IDT (Interdisciplinary Team) members. On [DATE] at 11:45 a.m., the Physician's Assistant examined Resident #2: Goal of Physiatrist oversight is to maintain a safe and timely discharge. On [DATE] at 5:14 p.m., a head to toe skin evaluation was completed for Resident #1. No skin issues were identified. The resident denied pain or discomfort. On [DATE], the Psychiatric ARNP was on site and evaluated Resident #1. Findings included that the resident had no recall of the event. Resident #2 was discharged on [DATE] at 11:00 a.m. to an Assisted Living Facility. Resident #1 remains at the facility and is on 1:1 supervision. Resident #1 was placed on 1:1 direct supervision on [DATE]. Resident #2 was placed on 1:1 direct supervision on [DATE] until the date of his discharge. The Administrator and Director of Nursing (DON) received education from the Regional Director of Clinical Services (RDCS) on [DATE], related to federal regulation F600 (Free from Abuse and Neglect) and facility policy N-1265 Abuse Neglect Exploitation and Misappropriation, with emphasis on the definition of sexual abuse, varying types of sexual abuse, recognition that when comments are made to either staff or residents making them feel uncomfortable, immediate steps are taken to remove the potential for any nonconsensual contact of any type with a resident. A quality review of current residents who wander was completed by the DON on [DATE]. As of [DATE], the Administrator and DON conducted interviews with the current staff related to the components of F600 with emphasis on sexual abuse and/or any statement made by another resident which made them feel uncomfortable. The Administrator and DON conducted interviews with current residents able to be interviewed related to the components of F600 with an emphasis on sexual abuse and/or any statement made by another resident which made them feel uncomfortable. On [DATE], a Performance Improvement Plan was developed and initiated based upon root cause analysis by the following interdisciplinary team members (IDT): Vice President of Clinical Services, Administrator, DON, and Regional Vice President of Operations, to ensure facility staff including contracted staff verbalized an understanding and maintained compliance with the components of F600 and the facility's Abuse Policy. Staff were educated by the Administration on [DATE] regarding the components of F600, immediate steps were taken to remove the potential for any nonconsensual contact of any type with a resident, thus removing the ability of such acts to occur by immediately placing the resident making such statements on 1:1 supervision and contacting the Abuse Coordinator and DON. Any staff member including contracted staff that did not receive education related to the above mentioned, were notified by the Administrator verbally via telephone indicating they may not return to work until education is received. Education to be provided by: Administrator, DON or Human Resources. The facility listed the number of staff and until 100% compliance was reached as of [DATE], the staff who had not received the education would be removed from the schedule until education had been provided. Staff who require education will be contacted daily by the Administrator, and on shift messaging by Human Resources to alert them that they are no longer on the schedule, and will need to receive education related to F600 and the facility's Abuse Policy and Procedure. Staff who require education are to contact the DON, Administrator or Human Resources to communicate a date and time they will be at the facility to receive education. At that time the staff member will be added back to the schedule. Newly hired staff will receive education during orientation. Actions to prevent further deficient practice include: Education received by staff included recognition that when comments are made to either staff or residents making them feel uncomfortable, immediate steps are taken to remove the potential for any nonconsensual contact of any type with a resident, thus removing the ability of such acts to occur by immediately placing the resident making such statements on 1:1 supervision and contacting the Abuse Coordinator and DON. On [DATE], a review of current residents who wander and who do not have the cognitive ability to consent to sexual activity was completed by the DON, and staff were educated to report any signs of inappropriate physical/verbal interactions between residents to the Administrator and DON immediately. Residents with impaired cognition are visualized frequently by facility staff throughout the day. Residents with a tendency to wander will be redirected and placed on increased supervision of 15-minute checks and/or 1:1 as appropriate. The need for alternate placement to be reviewed by the physician/psychiatric services to allow residents to wander safely without risk of an altercation and/or harm by another resident. Staff re-direct residents who wander when necessary. The DON reviews and discuss residents who wander when witnessed and communicated by staff in the Daily Clinical Meeting with the IDT team. Follow up is initiated. The medical record and care plan are updated as indicated. On [DATE], staff and residents were interviewed again by the Administrator and DON. At this time they were also informed that if they should witness any type of abuse, they should report it to the Abuse Coordinator immediately, which is the Administrator. An AD HOC Quality Improvement Performance Committee meeting was held on [DATE] to review the results of the facility-wide quality reviews that had been completed. The team members included: Medical Director via phone, Administrator, Assistant Business Office Manager, Director of Maintenance, Business Development Coordinator, Dietary Manager, Social Services Director, Community Life, Human Resources, Business Office, Therapy, MDS, Admissions and Medical Records. The AD HOC Quality Committee approved the recommendations on [DATE]. Weekly meetings will continue to be held to review and discuss the results of the ongoing quality monitoring along with staff and resident interviews. The findings of these quality reviews to be reported to to QAPI committee weekly.

Based on observations, record reviews and interviews, the facility failed to provide care and treatment in accordance with professional standards of practice, by delaying hospitalization for one (Resident #56) of two residents reviewed for falls with major injuries, from a total of 41 residents sampled. Resident #56, who had severe cognitive impairment, was discovered on 5/4/19 at 7:45 AM with [MEDICAL CONDITION], bruising and pain with movement of the left lower extremity. The pain was such that she had to remain in bed. She would not cooperate when staff tried to get her out of bed for the day. At 1:40 PM, x-rays were ordered. They were not ordered STAT (immediately). The x-ray results arrived on 5/4/19 at 6:07 PM, revealing a fracture. At 7:48 PM, an order was written to send the resident to the emergency room . From 7:45 AM through 7:48 PM, the resident remained in bed due to pain with mobility, bruising and [MEDICAL CONDITION] before she was sent to the emergency room for treatment. The findings include: 1. On 10/22/19 at 9:15 AM, Resident #56 was observed in her wheelchair sitting in the hallway adjacent to the nurses' station. She did not respond when spoken to, but made eye contact. At 9:23 AM, staff could be overheard asking her whether she'd like to go outside to the courtyard. There was no intelligible answer. Staff asked her again whether she'd like to go out to the courtyard, then proceeded to wheel her down the hall in that direction. Again, she was not heard speaking with the staff member. A review of her clinical record revealed she was admitted to the facility on [DATE]. She had an unplanned discharge to the hospital on [DATE] and was readmitted on [DATE] following treatment for [REDACTED]. Other [DIAGNOSES REDACTED]. A review of the hospital History and Physical, dated 5/5/19, revealed the following: admitted ,[DATE] for left tib/fib fx (tibia/fibula fracture). Ongoing senile dementia. Advanced dementia. All of the following (information) obtained from ED (emergency department) staff, as resident is unable to answer questions appropriately. She fell at her facility on Thursday (5/2). They did hip x-rays at the time which were negative, however, they noted that she was having difficulty with ambulation and did an x-ray of the tib/fib today revealing a fracture. The resident is unable to tell me how or why she fell . Resident is HOH (hard of hearing), awake, alert, conversant but not oriented. During an interview with the resident's assigned nurse (Employee F, Registered Nurse (RN), on 10/24/19 at 10:15 AM, she stated, (Resident #56) talks but not to you. She just talks, maybe to herself. When you ask her a question, she will respond but not correctly. We know her well, so we can usually tell what she needs. She is total care. We try to keep her in activities all the time to keep her busy. She has been deteriorating over the last year. When asked whether she could express her pain level on a pain scale, Employee F replied, no and said the nurse would have to check for physical signs of pain such as facial grimacing. During an interview with the resident's assigned certified nursing assistant (CNA), Employee G, on 10/24/19 at 10:28 AM, she stated, She (Resident #56) can say she has pain, but she cannot tell you how much. She cannot carry on a conversation. She is total care for everything. On 10/24/19 at 12:49 PM, an interview was conducted with Employee L, RN. When asked for the facility's protocol following a resident fall, she stated, We assess the resident for injury, take vitals, and if there is no injury, we transfer them to bed. We assess for skin tears and notify the resident's physician and family. If the fall is witnessed, we do vitals once and monitor. If it is not witnessed, we complete a 24-hour report sheet including vital signs, neuro checks, and we assess for pain. We do a fall assessment, a pain assessment and an Interact form. We also do an incident report. We notify the supervisor or whoever is on call. If an injury appears severe, like pain in a body part, the resident hit their head, got a cut or lump or bruise, we notify the physician and family, and tell the physician we would like to send the resident to the hospital. If we think the resident is injured, but we're not sure, we call the physician, maybe get x-rays, and then call the physician back. It depends on the assessment of the resident. On 10/24/19 at 1:05 PM, the Director of Nursing (DON), Administrator and Regional Clinical Nurse stated the facility had no specific policy for when to send a resident to the hospital. If the resident was alert and oriented and requested to go, the facility would honor their wishes. Otherwise, it depended on the situation. On 10/24/19 at 1:18 PM, during an interview with Employee F, RN, she stated that on 5/4/19 after assessing Resident #56, she spoke with the ARNP who told her not to send the resident to the hospital until the x-ray results were received. When asked where that was documented, she was unable to provide an answer. She stated she told the CNA assigned to Resident #56 to be very careful and not to move the resident too much due to the resident's pain and suspected fracture. She said she left at 3:00 PM that day and further stated, I can't really remember that incident, but most of the time when I push to send the residents out, the doctor or the ARNP tells me to wait for the x-rays. Its too far back, though. I really can't remember what happened. On 10/24/19 at 1:45 PM, Employee E, Licensed Practical Nurse (LPN)/Unit Manager, stated that the 5/4/19 x-ray was ordered STAT, and beyond that the facility could not control when the mobile x-ray service arrived. When asked how long the service had to complete a STAT order, she said she thought it was four hours. She was asked to produce documentation confirming the 4-hour window, but no documentation was produced during the time of the survey. When asked whether the nursing staff should be monitoring and following up with the x-ray service/physician when a resident was assessed with [REDACTED]. She further stated that when she was on duty, she had more time to follow up on things like this as the charge nurse, whereas the nurses working the medication carts with assignments were busier than she was, passing medications, etc. She stated she called the nurse practitioner today (10/24/19), after the concern was brought to her attention, to discuss the x-rays and then remembered that the ARNP wanted the x-rays done in-house, on the Saturday this occurred, when she was not on duty. This was the reason for not sending the resident out to the hospital sooner. A review of the telephone order for the 5/4/19 x-rays revealed the order was not a STAT order, and it came from the resident's physician, not the ARNP. There was no documentation in the chart or on the order indicating where x-rays should be obtained. Employee [NAME] acknowledged the more than 11-hour gap in time between the identification of the problem and the resident having been sent to the ER. She confirmed that the x-ray orders for this resident were not STAT orders. A review of the Pain Evaluation, dated 5/2/19, revealed: Hurts a little at upper left thigh/hip following the fall. A review of the Change in Condition form, dated 5/2/19 at 5:00 AM, revealed: Situation - Fall on the morning of 5/2/19 Background - LTC (long-term care), [MEDICAL CONDITION], muscle weakness, difficulty walking, left knee pain, cognitive/communication deficit, abnormal posture, dementia, no change in cognitive, behavioral or functional status, pain present, can rate pain on a scale, rated pain at 4/10 (4 on a scale of 0-10 with 10 representing the most acute pain), acute pain at left hip. Reported to ARNP (advanced registered nurse practitioner) at 5:00 AM. View x-ray of resident's left hip due to pain. Family notified at 5:05 AM. A review of the physicians' orders revealed: 5/2/19 at 5:26 AM - x-ray of left hip resident is unable to leave facility for x-ray due to weakness (This was not a STAT (immediate) order.) 5/2/19 at 2:57 PM - Tylenol 325 mg (milligrams), 2 tablets PO TID (by mouth three times daily) related to pain in unspecified joint for two weeks 5/4/19 at 1:40 PM - x-ray left knee, tib/fib, fistula, ankle and toes (2 views) - for pain/[MEDICAL CONDITION] left leg (This was not a STAT order.) 5/4/19 at 7:48 PM - Send to hospital ER (emergency room ) due to distal tib/fib fx ([MEDICAL CONDITION] between the knee and ankle, closer to the ankle than to the knee) A review of the Transfer to Hospital form, dated 5/4/19 at 8:07 PM, revealed: Sent to (hospital name) on 5/4/19 at 8:00 PM, planned discharge, LTC resident, will accept readmission if hospital feels resident can be treated in the NH, diagnosed with [REDACTED]. (anterior left lower leg) Alert and disoriented, but can follow simple instructions, non-ambulatory. Fall risk. Cognitive, hearing and vision impairment. A review of the Readmission Data Collection form, dated 5/6/19 at 1:10 PM, revealed: AAOx1 (alert and oriented to self), memory problem, vision adequate, speech clear, surgical incision left knee with 11 staples, below knee incisions with 5 staples in each, cast lower knee to ankle. A review of the Progress Notes from 5/2/19 through 5/6/19 revealed: 5/2/19 at 5:24 AM - Resident found on floor mat on the left side of her bed. Complained of left hip pain nurse practitioner on call for physician. Notified order received for two view x-ray of left hip. 5/2/19 at 9:49 AM - Tylenol 325 mg, give two tablets by mouth every 6 hours as needed for right hip pain related to age-related [MEDICAL CONDITION] with current pathologic fracture, right femur, initial encounter for fracture alternating with [MEDICATION NAME] 600 mg by mouth every 6 hours prn (as needed). Complained of pain on a scale of 5 to left hip after post fall this morning. 5/2/19 at 12:35 PM - Tylenol 325 mg, give two tablets by mouth every 6 hours as needed for right hip pain. PRN administration was effective, follow up pain scale was a 1/10. 5/2/19 at 4:32 PM - X-ray to left hip and pelvis done today after post fall. ARNP made aware of x-ray WNL (within normal limits) without fracture. 5/3/19 - No notes were entered which addressed the resident's fall or subsequent condition. 5/4/19 at 7:45 AM - Resident in bed and not cooperating to get up. Resident assessed and noted with [MEDICAL CONDITION], bruising and pain with movement of the left leg. Physician notified and requested x-ray. Resident bed bound r/t (related to ) pain. 5/4/19 at 8:00 PM - X-ray results positive for fracture of left tibia. Physician notified and ordered resident transfer to hospital. Sister notified of change in condition. Gave report to ER nurse. 5/6/19 at 11:10 PM - [MEDICATION NAME] tablet 50 mg , give 1 tablet by mouth every 6 hours for pain in unspecified joint for two days. Medication authorization not available. Physician notified. A Significant Change Minimum Data Set (MDS) assessment, dated 5/23/19, was completed after the resident's readmission on 5/6/19, which revealed a Brief Interview for Mental Status (BIMS) score of 4 out of a possible 15 points, indicating severe cognitive impairment. She was also documented as follows: sometimes understands, sometimes understood, no acute mental status change, no behaviors, extensive assistance of two staff members for bed mobility and transfers, nonambulatory, extensive assistance to total dependence on one staff member for mobility on and off the nursing unit, unsteady on her feet and used a wheelchair for mobility. She was coded with mild, occasional pain and had as needed pain medications. She had a surgical wound and no personal alarms in place. A Quarterly MDS assessment, dated 2/25/19, prior to the fall, revealed a BIMS score of 6 out of a possible 15 points, indicating severe cognitive impairment. She was coded as sometimes understands, sometimes understood, hallucinations, no behaviors, extensive assistance from one staff member for bed mobility and ambulation with supervision for locomotion on and off the nursing unit. She required limited assistance from one staff member for transfers, she was unsteady on her feet and used a wheelchair for mobility. She was incontinent of bowel and bladder, had no pain and had one fall without injury since her last assessment. She was also coded as having used a bed/chair alarm daily. A review of the resident's radiology reports revealed two sets of x-rays were obtained between 5/2 and 5/4/19: 5/2/19 at 10:05 AM (Signed by radiologist) (Faxed at 10:07 AM)- hip/pelvis unremarkable. 5/4/19 at 6:07 PM (Signed by radiologist) (Fax time not legible) - Ankle AP & Lat 2V Left. Severely comminuted [MEDICAL CONDITION] metaphysis distally. A [MEDICAL CONDITION] fibula is also identified.

Based on observations, record reviews and interviews, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for diabetic residents' needs, by failing to ensure consistent nursing practice and provision of education/training as it related to blood glucose monitoring (BGM). During observations of BGM, one (Employee E) of one licensed practical nurses (LPNs) observed, failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) after obtaining the blood glucose level for Resident #6, and prior to attempting to obtain the blood glucose levels for two (Residents #7 and #8) of three additional residents observed, out of a total of 27 residents who required blood glucose monitoring. Following re-education of the nursing staff on 8/13/19, Employee B, RN, remained unable to appropriately clean/disinfect/store the glucometer. This placed three residents observed (#6, #7 and #8), as well as 24 remaining residents who required blood glucose monitoring, at risk for transmission of potentially infectious bloodborne pathogens including [MEDICAL CONDITIONS] and human immunodeficiency virus ,[MEDICAL CONDITION]. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:07 a.m. on 8/13/19, which is ongoing. On 8/14/19 at 4:45 PM, the Administrator and Director of Nursing were notified of the IJ determination. The findings include: On 8/13/19 at 11:07 AM, Resident #6's blood glucose level was checked by Employee E, Licensed Practical Nurse (LPN). After doing so, Employee [NAME] cleansed the glucometer (front only) with an alcohol wipe, while still wearing the same now soiled gloves. She then took the same device into Resident #7's room to check his blood glucose level. She was stopped from using the device, which was improperly cleaned and not disinfected. She then took the same device (without appropriately cleaning it and without disinfecting it) across the hall to Resident #8's room, and attempted to use it to obtain this resident's blood glucose level. She was stopped again from using the soiled glucometer. On 8/13/19 at 11:31 AM, Employee [NAME] was asked why she continued to attempt to use the soiled glucometer. She disagreed that the glucometer was soiled, stating she had cleaned it with an alcohol wipe. On 8/13/19 between 11:15 AM and 11:35 AM, interviews were conducted with all four nurses currently working the medication carts. A second nurse (Employee D, Registered Nurse (RN) stated that it was acceptable to clean and disinfect the devices with alcohol wipes between residents. She further stated that she had performed blood glucose monitoring for five residents during her shift today, and had only cleansed/disinfected the device with the small square alcohol wipe between each of the residents. On 8/14/19 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). When asked whether audits were conducted to ensure nursing staff was handling/utilizing and cleaning/disinfecting the glucometers appropriately, the DON stated that medication pass audits were conducted, but they did not necessarily include a diabetic resident who required blood glucose monitoring. When asked for the frequency of the cart audits, the DON stated that there were no specific audit times. On 8/14/19 at 10:19 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked for the last time she conducted an audit for the glucometers, she could not recall, but stated it was probably May. She could not recall whether the audit involved a resident's individual glucometer or a shared glucometer stored on the medication cart. When asked how the nursing management ensured the nursing staff used the resident-specific glucometers, she was unable to answer the question. On 8/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucose meters. Based on a review of the records provided, 13 licensed nurses were assessed for competency from a total pool of 33 nurses employed by the facility. Employee B, Registered Nurse (RN), was listed as one of the nurses that was provided with re-training. On 8/14/19 at 10:45 AM, an observation of blood glucose monitoring was made with Employee B, RN, for Resident #3. She removed one red tray from the cart, placed two alcohol wipes and two medicine cups on the tray, placed one lancet and one test strip in the medicine cup, removed a glucometer from the bottom drawer that was labeled with the resident's name, placed it on the tray, donned gloves, removed two bleach wipes and placed them in a small water cup. She removed her gloves, retrieved two more gloves and placed them on the red tray. She knocked and entered the resident's room, placed the red tray on the bedside table, washed her hands, donned gloves, inserted a test strip into the glucometer, opened an alcohol wipe, and cleansed the first finger on the resident's left hand. She pricked the resident's finger with a lancet and obtained a blood sample. The blood glucose result was 146 mg/dl (milligrams per deciliter). The nurse then removed the test strip from the device and wrapped it in her glove. She threw the glove in the resident's garbage can. She washed her hands and donned new gloves. She picked up one disinfectant wipe and cleansed the device for 30 seconds. She then picked up the second wipe and cleansed the device for another 20 seconds. The glucometer was visible wet. The nurse placed it back down on the same red tray. She removed her gloves and washed her hands. She then picked up the red tray and returned to the cart, placing the tray on top of her cart. She retrieved the plastic bag with the resident's name and placed the glucometer back in the bag, then in the bottom drawer of the medication cart. On 8/14/19 at 10:51 AM, an interview was conducted with Employee B. She confirmed that she had set the disinfected device on the same red tray. She stated, They (glucometers) are resident specific, so now we just have to make sure we clean them between uses for the resident. A review of nursing competencies for all facility nurses revealed that 31 of a total of 33 nurses had documentation of completion of successful use of blood glucose monitors. Employee's D and [NAME] were included in these competencies, which were dated 5/8/19. Employee's K and L did not have a competency on file prior to 8/13/19. The facility used the form labeled Glucometer Competency Skills Checklist. The criteria for demonstration included: Glucometer Competency Skills Checklist Competency: ____ Annual ____ New Hire _____ Other: __________________ Instructions: 1) Complete with each Nurse 2) Complete upon Hire/Annually/& or as indicated. 3) Complete all sections 4) Record any additional comments as indicated 5) Employee to sign and date 6) Facilitator to sign and date 7) DON (Director of Nursing) to sign and date Competency Criteria 1. Check MAR (Medication Administration Record) to verify glucose monitoring orders 2. Gather supplies: Alcohol pads, gauze, single use lancet, gloves, blood glucose meter (resident specific) blood glucose reagent strip, disinfecting wipes 3. Knock on resident's door for permission to enter and introduce yourself 4. Verify resident identity via arm band/resident photo (Medication Administration Record [REDACTED] 5. Explain procedure to the resident 6. Inspect resident specific glucometer if visibly soiled or dropped clean glucometer utilizing a disinfectant wipe per manufacturer's recommended wet time 7. Wipe resident fingertip with alcohol and allow to air dry 8. Insert test strip, obtain blood specimen using lancet. Allow blood drop to form, apply to test strip. 9. Wait until the meter displays the results. Educate resident with results 10. {Line omitted from document reviewed} 11. Apply gentle pressure to fingertip until bleeding stops 12. Remove the test strip, discard, remove gloves, perform hand hygiene (soap and water or hand sanitizer) 13. Inspect glucometer (resident specific glucometer) if visibly soiled or dropped, apply gloves, clean glucometer with disinfectant wipe per manufacturer's recommended wet time 14. Dispose of all items 15. Remove gloves. Perform hand hygiene (soap and water or hand hygiene) 16. Return glucometer to resident's individual storage bag 17. Ensure resident comfort 18. Document results in the medical record Employee: I acknowledge my competencies in the areas as documented above. I understand it is my responsibility to sustain competencies in these and any other procedures/responsibilities that may not be represented here. Employee Completing Competency Signature Date Completed Facilitator: I acknowledge the above documented competencies have been reviewed. Representative Facilitating Competency Date Completed Note: There was no signature line for the DON to sign and date as indicated in the instructions as listed above. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. A review of the facility's policy and procedure revealed the following: Subject: Blood Glucose Monitoring and Disinfecting Document Name: N-700 Effective Date: 11/30/2014 Revision Date: 9/28/17 Procedure: - Verify Physician order - Identify resident - Explain procedure - Assemble the following equipment - Alcohol swab - Gauze - Single use lancet - Gloves - Blood glucose meter (Resident specific) - Blood glucose reagent strip - Disinfecting wipes - Perform hand hygiene - Apply gloves - Assure calibration of the meter per vial of reagent strips per manufactures guidelines - Prepare glucose meter for testing - Wipe tip of finger with alcohol swab and allow to dry - Pierce the site with lancet - Transfer drop of blood to reagent strip - Apply pressure to puncture site with gauze pad - Test blood specimen per manufactures guidelines - Read Results - Discard test strip and other materials - Discard lancet in sharps container - Remove gloves - Perform hand hygiene - Place meter in resident specific storage container - Meter to be cleansed utilizing a disinfectant wipe (according to manufacture's guidelines for wet time) if the meter is visibly soiled or dropped. - Document result in medical record The facility was utilizing the EVENCARE G3 Blood Glucose Monitoring System throughout the entire facility. The instruction booklet was reviewed and revealed the following: Cleaning and Disinfecting Procedures for the Meter: The Evencare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the Evencare G3 Meter: Medline Micro-Kill + Disinfecting, Deodorizing, Cleaning Wipes with Alcohol. (EPA Registration Number: -10) NOTE: These disinfectants were validated separately; therefore, only one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeable has not been evaluated. Materials Needed: Evencare G3 Meter Gloves A validated disinfecting wipe Step 1. Wash hands with soap and water Step 2. Put on a single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the Evencare G3 system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry. Step 6. Remove gloves. Note: Glucose meters used in the clinical setting for testing multiple persons must be cleaned and disinfected between patients.

Based on observations, record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident, by failing to ensure consistent nursing practice and provision of education/training as it related to blood glucose monitoring (BGM). During observations of BGM, one (Employee E) of one licensed practical nurses (LPNs) observed, failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) after obtaining the blood glucose level results for Resident #6, and prior to attempting to obtain the blood glucose levels for two (Residents #7 and #8) of three additional residents observed, out of a total of 27 residents who required blood glucose monitoring. The facility's clinical management was not conducting audits to ensure nursing staff were appropriately handling, cleansing and disinfecting blood glucose meters (glucometers), or following the facility's policy and procedure specifying that each resident have their own individual glucometer. This placed three residents observed (#6, #7 and #8), as well as 24 remaining residents who required blood glucose monitoring, at risk for transmission of potentially infectious bloodborne pathogens including [MEDICAL CONDITIONS] and human immunodeficiency virus ,[MEDICAL CONDITION]. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:07 a.m. on 8/13/19, which is ongoing. On 8/14/19 at 4:45 PM, the Administrator and Director of Nursing were notified of the IJ determination. The findings include: On 8/13/19 at 11:07 AM, Resident #6's blood glucose level was checked by Employee E, Licensed Practical Nurse (LPN). After doing so, Employee [NAME] cleansed the glucometer (front only) with an alcohol wipe, while still wearing the same now soiled gloves. She then took the same device into Resident #7's room to check his blood glucose level. She was stopped from using the device, which was improperly cleaned and not disinfected. She then took the same device (without appropriately cleaning it and without disinfecting it) across the hall to Resident #8's room, and attempted to use it to obtain this resident's blood glucose level. She was stopped again from using the soiled glucometer. On 8/13/19 at 11:31 AM, Employee [NAME] was asked why she continued to attempt to use the soiled glucometer. She disagreed that the glucometer was soiled, stating she had cleaned it with an alcohol wipe. On 8/13/19 between 11:15 AM and 11:35 AM, interviews were conducted with all four nurses currently working the medication carts. A second nurse (Employee D, Registered Nurse (RN) stated that it was acceptable to clean and disinfect the devices with alcohol wipes between residents. She further stated that she had performed blood glucose monitoring for five residents during her shift today, and had only cleansed/disinfected the device with the small square alcohol wipe between each of the residents. On 8/13/19 at 12:55 PM, an interview was conducted with the Regional Nurse Consultant (RNC) and the Director of Nursing DON). They entered the conference room and stated they were currently working to ensure that each resident had their own glucometer in their room. They stated that for at least the last five years, it had been the facility's policy to use individual glucometers for each resident. They were unable to explain why the nursing staff was using shared glucometers when each resident requiring a glucometer was to have their own individual device, but said they intended to educate the nursing staff. On 8/13/19 at 3:23 PM, Employee D, RN (hired on 2/26/19), stated the glucometers had been stored in the medication carts since she was hired. On 8/13/19 at 3:27 PM, Employee I, LPN, stated she had worked in the facility for approximately eight years and the facility had always had problems with the glucometers. They had been in the resident rooms, on the carts and back in the resident rooms again. She further stated that the glucometers had been on the carts and had been shared between residents for at least the last three months. On 8/13 19 at 3:29 PM, Employee H, LPN, stated the glucometers had been on and off the medication carts at different times. She further stated that the glucometers had been shared between residents for at least six months. On 8/14/19 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). When asked whether audits were conducted to ensure nursing staff was handling/utilizing and cleaning/disinfecting the glucometers appropriately, the DON stated that medication pass audits were conducted, but they did not necessarily include a diabetic resident who required blood glucose monitoring. When asked for the frequency of the cart audits, the DON stated that there were no specific audit times. On 8/14/19 at 10:19 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked for the last time she conducted an audit for the glucometers, she could not recall, but stated it was probably May. She could not recall whether the audit involved a resident's individual glucometer or a shared glucometer stored on the medication cart. When asked how the nursing management ensured the nursing staff used the resident-specific glucometers, she was unable to answer the question. She stated she did not conduct audits specific to that concern but went on to say that the facility kept glucometers on the medication carts for emergencies. When asked what she would do if a resident's individual glucometer was not available or was not working, she stated she would obtain a new device from central supply. On 8/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucose meters. Based on a review of the records provided, 13 licensed nurses were assessed for competency from a total pool of 33 nurses employed by the facility. Employee B, Registered Nurse (RN), was listed as one of the nurses that was provided with re-training. On 8/14/19 at 10:45 AM, an observation of blood glucose monitoring was made with Employee B, RN, for Resident #3. She removed one red tray from the cart, placed two alcohol wipes and two medicine cups on the tray, placed one lancet and one test strip in the medicine cup, removed a glucometer from the bottom drawer that was labeled with the resident's name, placed it on the tray, donned gloves, removed two bleach wipes and placed them in a small water cup. She removed her gloves, retrieved two more gloves and placed them on the red tray. She knocked and entered the resident's room, placed the red tray on the bedside table, washed her hands, donned gloves, inserted a test strip into the glucometer, opened an alcohol wipe, and cleansed the first finger on the resident's left hand. She pricked the resident's finger with a lancet and obtained a blood sample. The blood glucose result was 146 mg/dl (milligrams per deciliter). The nurse then removed the test strip from the device and wrapped it in her glove. She threw the glove in the resident's garbage can. She washed her hands and donned new gloves. She picked up one disinfectant wipe and cleansed the device for 30 seconds. She then picked up the second wipe and cleansed the device for another 20 seconds. The glucometer was visible wet. The nurse placed it back down on the same red tray. She removed her gloves and washed her hands. She then picked up the red tray and returned to the cart, placing the tray on top of her cart. She retrieved the plastic bag with the resident's name and placed the glucometer back in the bag, then in the bottom drawer of the medication cart. On 8/14/19 at 10:51 AM, an interview was conducted with Employee B. She confirmed that she had set the disinfected device on the same red tray. She stated, They (glucometers) are resident specific, so now we just have to make sure we clean them between uses for the resident. A review of nursing competencies for all facility nurses revealed that 31 of a total of 33 nurses had documentation of completion of successful use of blood glucose monitors. Employee's D and [NAME] were included in these competencies, which were dated 5/8/19. Employee's K and L did not have a competency on file prior to 8/13/19. The facility used the form labeled Glucometer Competency Skills Checklist. The criteria for demonstration included: Glucometer Competency Skills Checklist Competency: ____ Annual ____ New Hire _____ Other: __________________ Instructions: 1) Complete with each Nurse 2) Complete upon Hire/Annually/& or as indicated. 3) Complete all sections 4) Record any additional comments as indicated 5) Employee to sign and date 6) Facilitator to sign and date 7) DON (Director of Nursing) to sign and date Competency Criteria 1. Check MAR (Medication Administration Record) to verify glucose monitoring orders 2. Gather supplies: Alcohol pads, gauze, single use lancet, gloves, blood glucose meter (resident specific) blood glucose reagent strip, disinfecting wipes 3. Knock on residents door for permission to enter and introduce yourself 4. Verify resident identity via arm band/resident photo (MAR) or calling resident name 5. Explain procedure to the resident 6. Inspect resident specific glucometer if visibly soiled or dropped clean glucometer utilizing a disinfectant wipe per manufactures recommended wet time 7. Wipe resident fingertip with alcohol and allow to air dry 8. Insert test strip, obtain blood specimen using lancet. Allow blood drop to form, apply to test strip. 9. Wait until the meter displays the results. Educate resident with results 10. {Line omitted from document reviewed} 11. Apply gentle pressure to fingertip until bleeding stops 12. Remove the test strip, discard, remove gloves, perform hand hygiene (soap and water or hand sanitizer) 13. Inspect glucometer resident specific glucometer if visibly soiled or dropped apply gloves, clean glucometer with disinfectant wipe per manufactures recommend wet time 14. Dispose of all items 15. Remove gloves. Perform hand hygiene (soap and water or hand hygiene) 16. Return glucometer to residents individual storage bag 17. Ensure resident comfort 18. Document results in the medical record Employee: I acknowledge my competencies in the areas as documented above. I understand it is my responsibility to sustain competencies in these and any other procedures/responsibilities that may not be represented here. Employee Completing Competency Signature Date Completed Facilitator: I acknowledge the above documented competencies have been reviewed. Representative Facilitating Competency Date Completed Note: There is no signature line for DON to sign and date as indicated in instructions as listed above. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. A review of the facilities policy and procedure was reviewed and revealed the following: Subject: Blood Glucose Monitoring & Disinfecting Document Name: N-700 Effective Date: 11/30/2014 Revision Date: 9/28/17 Procedure: - Verify Physician order - Identify resident - Explain procedure - Assemble the following equipment - Alcohol swab - Gauze - Single use lancet - Gloves - Blood glucose meter (Resident specific) - Blood glucose reagent strip - Disinfecting wipes - Perform hand hygiene - Apply gloves - Assure calibration of the meter per vial of reagent strips per manufactures guidelines - Prepare glucose meter for testing - Wipe tip of finger with alcohol swab and allow to dry - Pierce the site with lancet - Transfer drop of blood to reagent strip - Apply pressure to puncture site with gauze pad - Test blood specimen per manufactures guidelines - Read Results - Discard test strip and other materials - Discard lancet in sharps container - Remove gloves - Perform hand hygiene - Place meter in resident specific storage container - Meter to be cleansed utilizing a disinfectant wipe (according to manufacture's guidelines for wet time) if the meter is visibly soiled or dropped. - Document result in medical record The facility was utilizing the EVENCARE G3 Blood Glucose Monitoring System throughout the entire facility. The instruction booklet was reviewed and revealed the following: Cleaning and Disinfecting Procedures for the Meter The Evencare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the Evencare G3 Meter: Medline Micro-Kill + Disinfecting, Deodorizing, Cleaning Wipes with Alcohol. (EPA Registration Number: -10) NOTE: These disinfectants were validated separately; therefore, only one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeable has not been evaluated. Materials Needed: Evencare G3 Meter Gloves A validated disinfecting wipe Step 1. Wash hands with soap and water Step 2. Put on a single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the Evencare G3 system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry. Step 6. Remove gloves. Note: Glucose meters used in clinical setting for testing multiple persons must be cleaned and disinfected between patients.

Based on observations, record reviews, interviews and the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to ensure quality assurance monitoring of facility processes related to resident protection from communicable and infectious diseases, and to ensure identification of potential problems related to blood glucose monitoring. This placed three residents observed (#6, #7 and #8), out of a total of 27 residents who required blood glucose monitoring, at risk for transmission of potentially infectious bloodborne pathogens including [MEDICAL CONDITIONS] and human immunodeficiency virus ,[MEDICAL CONDITION]. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:07 a.m. on 8/13/19 at F726, F835, F867 and F880. On 8/14/19 at 4:45 PM, the Administrator and Director of Nursing was notified of the IJ determination. The findings include: On 8/13/19 at 11:07 AM, Resident #6's blood glucose level was checked by Employee E, Licensed Practical Nurse (LPN). After doing so, Employee [NAME] cleansed the glucometer (front only) with an alcohol wipe, while still wearing the same now soiled gloves. She then took the same device into Resident #7's room to check his blood glucose level. She was stopped from using the device, which was improperly cleaned and not disinfected. She then took the same device (without appropriately cleaning it and without disinfecting it) across the hall to Resident #8's room, and attempted to use it to obtain this resident's blood glucose level. She was stopped again from using the soiled glucometer. On 8/13/19 at 11:31 AM, Employee [NAME] was asked why she continued to attempt to use the soiled glucometer. She disagreed that the glucometer was soiled, stating she had cleaned it with an alcohol wipe. On 8/13/19 between 11:15 AM and 11:35 AM, interviews were conducted with all four nurses currently working the medication carts. A second nurse (Employee D, Registered Nurse (RN) stated that it was acceptable to clean and disinfect the devices with alcohol wipes between residents. She further stated that she had performed blood glucose monitoring for five residents during her shift today, and had only cleansed/disinfected the device with the small square alcohol wipe between each of the residents. On 8/14/19 at 10:01 AM, an interview was conducted with the Director of Nursing (DON). When asked whether audits were conducted to ensure nursing staff was handling/utilizing and cleaning/disinfecting the glucometers appropriately, the DON stated that medication pass audits were conducted, but they did not necessarily include a diabetic resident who required blood glucose monitoring. When asked for the frequency of the cart audits, the DON stated that there were no specific audit times. On 8/14/19 at 10:19 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When asked for the last time she conducted an audit for the glucometers, she could not recall, but stated it was probably May. She could not recall whether the audit involved a resident's individual glucometer or a shared glucometer stored on the medication cart. When asked how the nursing management ensured the nursing staff used the resident-specific glucometers, she was unable to answer the question. On 8/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucose meters. Based on a review of the records provided, 13 licensed nurses were assessed for competency from a total pool of 33 nurses employed by the facility. Employee B, Registered Nurse (RN), was listed as one of the nurses that was provided with re-training. On 8/14/19 at 10:45 AM, an observation of blood glucose monitoring was made with Employee B, RN, for Resident #3. She removed one red tray from the cart, placed two alcohol wipes and two medicine cups on the tray, placed one lancet and one test strip in the medicine cup, removed a glucometer from the bottom drawer that was labeled with the resident's name, placed it on the tray, donned gloves, removed two bleach wipes and placed them in a small water cup. She removed her gloves, retrieved two more gloves and placed them on the red tray. She knocked and entered the resident's room, placed the red tray on the bedside table, washed her hands, donned gloves, inserted a test strip into the glucometer, opened an alcohol wipe, and cleansed the first finger on the resident's left hand. She pricked the resident's finger with a lancet and obtained a blood sample. The blood glucose result was 146 mg/dl (milligrams per deciliter). The nurse then removed the test strip from the device and wrapped it in her glove. She threw the glove in the resident's garbage can. She washed her hands and donned new gloves. She picked up one disinfectant wipe and cleansed the device for 30 seconds. She then picked up the second wipe and cleansed the device for another 20 seconds. The glucometer was visible wet. The nurse placed it back down on the same red tray. She removed her gloves and washed her hands. She then picked up the red tray and returned to the cart, placing the tray on top of her cart. She retrieved the plastic bag with the resident's name and placed the glucometer back in the bag, then in the bottom drawer of the medication cart. On 8/14/19 at 10:51 AM, an interview was conducted with Employee B. She confirmed that she had set the disinfected device on the same red tray. She stated, They (glucometers) are resident specific, so now we just have to make sure we clean them between uses for the resident. A review of nursing competencies for all facility nurses revealed that 31 of a total of 33 nurses had documentation of completion of successful use of blood glucose monitors. Employee's D and [NAME] were included in these competencies, which were dated 5/8/19. Employee's K and L did not have a competency on file prior to 8/13/19. A review of the facility 's QAPI plan from 4/11/19 through 4/30/19 for infection control related to glucometer use, cleaning and disinfection with germicidal wipes, failed to monitor and document ongoing activity to ensure continued compliance. At the time of the survey, the facility had no consistent monitoring/audit process for ensuring nursing staff was appropriately handling, cleaning and disinfecting glucometers, and did not identify the concern. A review of the facility's Quality Assurance Performance Improvement (QAPI) policy with established date of 11/10/17 was conducted. In the Performance Improvement Projects (PIPs) section it stated,The QAPI team will review data and benchmarks and determine if gaps or patterns exist in our system that could result in quality problems or if there are any opportunities to make improvements.

Based on observations, interviews, record reviews, a review of the EVENCARE G3 Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected between residents to prevent the spread of bloodborne pathogens. During observations of Blood Glucose Monitoring (BGM), one (Employee E) of one licensed practical nurses (LPNs) observed, failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) after obtaining the blood glucose level for Resident #6, and prior to attempting to obtain the blood glucose levels for two (Residents #7 and #8) of three additional residents observed, out of a total of 27 residents who required blood glucose monitoring. Following re-education of the nursing staff on 8/13/19, Employee B, RN, remained unable to appropriately clean/disinfect/store the glucometer. This placed three residents observed (#6, #7 and #8), as well as 24 remaining residents who required blood glucose monitoring, at risk for transmission of potentially infectious bloodborne pathogens including [MEDICAL CONDITIONS] and human immunodeficiency virus ,[MEDICAL CONDITION]. Immediate Jeopardy (IJ) at a scope of J (isolated) was identified at 11:07 a.m. on 8/13/19, which is ongoing. On 8/14/19 at 4:45 PM, the Administrator and Director of Nursing were notified of the IJ determination. The facility also failed to perform a wound dressing change, adhering to principles of infection control and facility policy and procedure for keeping the wound bed clean when applying a new dressing for one (Resident #3) of one resident's wound dressing change observed from a total sample of 11 residents. The findings include: On 8/13/19 at 11:07 AM, Resident #6's blood glucose level was checked by Employee E, Licensed Practical Nurse (LPN). After doing so, Employee [NAME] cleansed the glucometer (front only) with an alcohol wipe, while still wearing the same now soiled gloves. She then took the same device into Resident #7's room to check his blood glucose level. She was stopped from using the device, which was improperly cleaned and not disinfected. She then took the same device (without appropriately cleaning it and without disinfecting it) across the hall to Resident #8's room, and attempted to use it to obtain this resident's blood glucose level. She was stopped again from using the soiled glucometer. On 8/13/19 at 11:31 AM, Employee [NAME] was asked why she continued to attempt to use the soiled glucometer. She disagreed that the glucometer was soiled, stating she had cleaned it with an alcohol wipe. On 8/13/19 between 11:15 AM and 11:35 AM, interviews were conducted with all four nurses currently working the medication carts. A second nurse (Employee D, Registered Nurse (RN) stated that it was acceptable to clean and disinfect the devices with alcohol wipes between residents. She further stated that she had performed blood glucose monitoring for five residents during her shift today, and had only cleansed/disinfected the device with the small square alcohol wipe between each of the residents. On 8/13/19 the facility began retraining and measuring licensed nurse competencies for the proper use of the blood glucose meters. Based on a review of the records provided, 13 licensed nurses were assessed for competency from a total pool of 33 nurses employed by the facility. Employee B, Registered Nurse (RN), was listed as one of the nurses that was provided with re-training. On 8/14/19 at 10:45 AM, an observation of blood glucose monitoring was made with Employee B, RN, for Resident #3. She removed one red tray from the cart, placed two alcohol wipes and two medicine cups on the tray, placed one lancet and one test strip in the medicine cup, removed a glucometer from the bottom drawer that was labeled with the resident's name, placed it on the tray, donned gloves, removed two bleach wipes and placed them in a small water cup. She removed her gloves, retrieved two more gloves and placed them on the red tray. She knocked and entered the resident's room, placed the red tray on the bedside table, washed her hands, donned gloves, inserted a test strip into the glucometer, opened an alcohol wipe, and cleansed the first finger on the resident's left hand. She pricked the resident's finger with a lancet and obtained a blood sample. The blood glucose result was 146 mg/dl (milligrams per deciliter). The nurse then removed the test strip from the device and wrapped it in her glove. She threw the glove in the resident's garbage can. She washed her hands and donned new gloves. She picked up one disinfectant wipe and cleansed the device for 30 seconds. She then picked up the second wipe and cleansed the device for another 20 seconds. The glucometer was visible wet. The nurse placed it back down on the same red tray. She removed her gloves and washed her hands. She then picked up the red tray and returned to the cart, placing the tray on top of her cart. She retrieved the plastic bag with the resident's name and placed the glucometer back in the bag, then in the bottom drawer of the medication cart. On 8/14/19 at 10:51 AM, an interview was conducted with Employee B. She confirmed that she had set the disinfected device on the same red tray. She stated, They (glucometers) are resident specific, so now we just have to make sure we clean them between uses for the resident. A review of nursing competencies for all facility nurses revealed that 31 of a total of 33 nurses had documentation of completion of successful use of blood glucose monitors. Employee's D and [NAME] were included in these competencies, which were dated 5/8/19. Employee's K and L did not have a competency on file prior to 8/13/19. The facility used the form labeled Glucometer Competency Skills Checklist. The criteria for demonstration included: Glucometer Competency Skills Checklist Competency: ____ Annual ____ New Hire _____ Other: __________________ Instructions: 1) Complete with each Nurse 2) Complete upon Hire/Annually/& or as indicated. 3) Complete all sections 4) Record any additional comments as indicated 5) Employee to sign and date 6) Facilitator to sign and date 7) DON (Director of Nursing) to sign and date Competency Criteria 1. Check MAR (Medication Administration Record) to verify glucose monitoring orders 2. Gather supplies: Alcohol pads, gauze, single use lancet, gloves, blood glucose meter (resident specific) blood glucose reagent strip, disinfecting wipes 3. Knock on residents door for permission to enter and introduce yourself 4. Verify resident identity via arm band/resident photo (MAR) or calling resident name 5. Explain procedure to the resident 6. Inspect resident specific glucometer if visibly soiled or dropped clean glucometer utilizing a disinfectant wipe per manufactures recommended wet time 7. Wipe resident fingertip with alcohol and allow to air dry 8. Insert test strip, obtain blood specimen using lancet. Allow blood drop to form, apply to test strip. 9. Wait until the meter displays the results. Educate resident with results 10. {Line omitted from document reviewed} 11. Apply gentle pressure to fingertip until bleeding stops 12. Remove the test strip, discard, remove gloves, perform hand hygiene (soap and water or hand sanitizer) 13. Inspect glucometer resident specific glucometer if visibly soiled or dropped apply gloves, clean glucometer with disinfectant wipe per manufactures recommend wet time 14. Dispose of all items 15. Remove gloves. Perform hand hygiene (soap and water or hand hygiene) 16. Return glucometer to residents individual storage bag 17. Ensure resident comfort 18. Document results in the medical record Employee: I acknowledge my competencies in the areas as documented above. I understand it is my responsibility to sustain competencies in these and any other procedures/responsibilities that may not be represented here. Employee Completing Competency Signature Date Completed Facilitator: I acknowledge the above documented competencies have been reviewed. Representative Facilitating Competency Date Completed Note: There is no signature line for DON to sign and date as indicated in instructions as listed above. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. A review of the facilities policy and procedure was reviewed and revealed the following: Subject: Blood Glucose Monitoring & Disinfecting Document Name: N-700 Effective Date: 11/30/2014 Revision Date: 9/28/17 Procedure: - Verify Physician order - Identify resident - Explain procedure - Assemble the following equipment - Alcohol swab - Gauze - Single use lancet - Gloves - Blood glucose meter (Resident specific) - Blood glucose reagent strip - Disinfecting wipes - Perform hand hygiene - Apply gloves - Assure calibration of the meter per vial of reagent strips per manufactures guidelines - Prepare glucose meter for testing - Wipe tip of finger with alcohol swab and allow to dry - Pierce the site with lancet - Transfer drop of blood to reagent strip - Apply pressure to puncture site with gauze pad - Test blood specimen per manufactures guidelines - Read Results - Discard test strip and other materials - Discard lancet in sharps container - Remove gloves - Perform hand hygiene - Place meter in resident specific storage container - Meter to be cleansed utilizing a disinfectant wipe (according to manufacture's guidelines for wet time) if the meter is visibly soiled or dropped. - Document result in medical record The facility was utilizing the EVENCARE G3 Blood Glucose Monitoring System throughout the entire facility. The instruction booklet was reviewed and revealed the following: Cleaning and Disinfecting Procedures for the Meter The Evencare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the Evencare G3 Meter: Medline Micro-Kill + Disinfecting, Deodorizing, Cleaning Wipes with Alcohol. (EPA Registration Number: -10) NOTE: These disinfectants were validated separately; therefore, only one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeable has not been evaluated. Materials Needed: Evencare G3 Meter Gloves A validated disinfecting wipe Step 1. Wash hands with soap and water Step 2. Put on a single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Other EPA registered wipes may be used for disinfecting the Evencare G3 system, however, these wipes have not been validated and could affect the performance of the meter. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Avoid wetting the meter test strip port. Wipe meter dry, or allow to air dry. Step 6. Remove gloves. Note: Glucose meters used in clinical setting for testing multiple persons must be cleaned and disinfected between patients. 2. An observation of a wound dressing change was conducted on 08/13/2019 at 2:46 p.m. for Resident #3 with Employee C, Registered Nurse (RN). Employee C allowed Resident #3's skin folds to fall back over the newly cleansed, open wound bed. Bare, uncleansed skin was resting in the open wound as Employee C went to the bathroom to wash her hands and don a new pair of gloves. Employee C returned to Resident #3 and lifted the skin folds up from the open wound, then applied the ointment and abdominal (ABD) dressing to the wound. No additional cleansing of the wound was performed. An interview was conducted with Employee C on 08/13/2019 at 2:59 p.m. regarding Resident #3's wound treatment. The nurse confirmed she allowed Resident #3's uncleansed skin folds to rest in the open wound bed after she cleansed the wound. She confirmed that she returned to the wound, applied ointment and a dressing directly to the wound without cleansing it again. She acknowledged that this was inappropriate wound care and could result in subsequent infection of the wound. An interview was conducted with the Director of Nursing (DON) on 08/13/2019 at 3:25 p.m. She stated Employee C should not have allowed Resident #3's uncleansed skin folds to contact the wound bed. This did not aid in the prevention of cross contamination and infections, and it was not the appropriate way to perform the dressing change for Resident #3. A review of Resident #3's 07/22/2019 (11:57 a.m.) wound order revealed: Right abdominal fold: Cleans with NS (normal saline), pat dry. Apply Zinc barrier cream to large ABD pad and place in fold at affected area. A review of the most recent Non-Pressure Skin Condition documentation for Resident #3 revealed: Right flank/abd (abdominal) fold: measuring (2 areas) 1.5 cm (centimeters) X 8.3 cm X 0.3 cm, no undermining or tunneling. Beveled wound edges [DIAGNOSES REDACTED] peri-wound with light serous exudate. 25% granulation and 75% epithelium wound bed. Treatment initiated. Resident instructed to leave brief open as not to cut into that area secondary to resident obesity. A review of the facility's policy and procedure for Dressing Change was conducted and revealed: A clean dressing will be applied by a nurse to a wound as ordered to promote healing. An interview was conducted with the Medical Director on 08/14/2019 at 12:15 p.m. She confirmed that there should have been help to conduct the wound dressing change to keep the skin from falling into the wound. She knew Resident #3 well and the wound care nurse would have needed help.

Based on staff interviews and clinical record review the facility failed to provide needed services, care and protection to prevent injuries for 4 of 11 sampled residents (#2, #3, #10 and #11). Residents #2 and #11 had injuries of unknown origin including bruises and fractures. Residents #2, #3, & #10 experienced delays in medical treatment when exhibiting signs and symptoms of acute change in condition. The facility's failure to provide timely medical treatment, prevent injuries and provide adequate supervision resulted in placing other residents at risk for future occurrences of physical harm and created a situation that is likely to result in serious harm to residents and requires immediate corrective action on the part of the facility. The immediate jeopardy occurred on July 20, 2010 and is ongoing. The findings include: 1. A review of the clinical record for Resident #2 revealed a nurse's note, dated 7/20/10 at 3:00 a.m., that Resident #2 was noted with pain and bruising to the right hip and leg, the physician was notified and orders obtained to transfer the resident to the hospital. On 7/20/10 at 7:35 a.m., a late entry was made for 7/18/10 by a day shift nurse and revealed that Resident #2 had no signs and symptoms of discomfort, a body alarm in place and all needs were met by the staff. On 7/20/10, another late entry for 7/18/10 was made by the 11p-7a nurse that had sent Resident #2 to the hospital. The note read that he (the nurse) had been notified by a certified nursing assistant (CNA) that Resident #2 may be in pain. The nurse documented that he and another nurse examined the right hip and checked it against the other hip and that they were equal. The nurse further documented that Resident #2 was able to turn self in bed without evidence of pain, that skin was warm and dry and there was no bruising to the entire leg. Resident #2 was admitted to the hospital on [DATE] with a fractured right hip. Review of the emergency room (ER) records of 7/20/10 revealed that Resident #2 had a [MEDICAL CONDITION] hip, angulated and comminuted. Documentation by the emergency room physician noted that "the right hip was severely swollen; the right knee was grossly ecchymotic with blue-brown and yellow patches and was clearly an old contusion, best guess at least a week based on the age of the bruise and it is probably even longer". "The right hip was inwardly rotated and shortened approximately 4 inches. There was ecchymosis surrounding the entire right hip into the pelvis and down to the tibial plateau". The ER physician suspected that with the angulated fracture, the resident "was probably in an extreme amount of pain". Review of the medical record revealed Resident #2 was admitted to the facility in March 2010 with arthropathy, difficulty walking, and uncoordination. There was no care plan found to address the resident was at risk for falls. An interview was conducted on 1/4/11 at 2:05 pm with the Director of Nursing (DON) regarding the incident that occurred with Resident #2 on 7/20/10. He stated he was made aware of the incident after Resident #2 was transferred to the hospital on [DATE]. When asked how or when the incident occurred, he indicated an investigation was conducted; however, how or when the injury occurred was not determined. He also revealed that during the facility investigation the following information was obtained on 7/18/10; a 7a-3p shift CNA was aware that Resident #2 was in pain upon movement but did not report it to anyone. An 11p-7a CNA reported to the nurse on 7/18/10 that he thought Resident #2 was in pain. The 11p-7a nurse told the DON that he had examined Resident #2 on 7/18/10 and did not see bruising or indications of pain. The nurse did not document the assessment until two days later, after Resident #2 was sent to the hospital. Continuing with the DON interview, it was revealed on 7/19/10 the 7a-3p shift nurse was informed by a CNA that Resident #2 had bruising to the right hip and thigh and was complaining of pain. When the DON asked the nurse if he was aware of the bruising and complaint of pain, the nurse did not tell the DON he had seen Resident #2 and was aware of the bruising, however did not document the findings nor did he call the physician and family. The nurse also did not pass the information along at report for follow up by the next shift. The DON stated that because the nurse failed to follow facility policy regarding reporting incidents he was terminated. On 1/5/11 at 10 a.m. an interview was conducted with the administrator regarding the incident involving Resident #2. When asked if he knew how the incident occurred on 7/20/10, he stated the facility performed an investigation, but was unable to determine how the incident happened. He revealed after the investigation that a nurse and 2 CNAs were terminated for failing to report in a timely manner. When asked if he was aware that Resident #2 was admitted to the hospital on [DATE] with a [MEDICAL CONDITION], he stated the hospital had notified the facility. When asked if he was aware of the findings of the ER physician on 7/20/10 that the fractured right hip and extensive bruising of the right leg were determined to be at least a week old, he stated he did not know. On 1/6/11 at 2:10 pm an interview was conducted with the licensed practical nurse (LPN) (N6) who was the nurse on duty when Resident #2 was transferred to the hospital. When asked if he recalled the incident regarding Resident #2 on 7/20/10, he stated he was the nurse who sent her to the hospital. He revealed he had been notified by a CNA during his shift on 7/20/10 that Resident #2 had bruises to her hip and leg. He then went to examine Resident #2 and found she had bruises to the leg, but did not recall which one. He then called the physician and sent her to the hospital. When asked if he knew how the injury occurred, he did not know. When asked why he made a late entry in the nursing notes on 7/20/10 for 7/18/10, he stated he did not see any bruising or evidence of pain so did not document his assessment; however, after he observed the bruising on 7/20/10, he felt it then necessary to document his findings from 7/18/10. The nurse was also asked if he had any recollection of skin breakdown to the sacral area. He stated not that he was aware. He also indicated that Resident #2 was incontinent of bowel and bladder and required total assistance with all activities of daily living. When asked about Resident #2's cognition, he stated she was confused and disoriented, but was calm and cooperative. 2. On 1/6/11 at 12:05 pm during observation in the west wing day room, Resident #11 was observed with a cast to her lower right leg. During an interview with the UM-1 (unit manager) at 12:10 pm on 1/6/11, when asked why Resident #11 had a cast on her leg, she stated that a CNA had reported on 12/20/10 at 10:30 a.m. that something was wrong with Resident #11's leg. The nurse documented that the right leg mid shaft area was bruised with a raised area and felt the bones were rubbing together. The advance registered nurse practitioner (ARNP) was notified and ordered an x-ray of the lower right leg and pain medication every 6 hours prn (as needed). Portable x-rays were taken and results were called to the facility at 3:00 pm. The x-rays showed a proximal fibular fracture and mid tibia spiral fracture with anterior angulation and slight shortening. When asked if the injury resulted from a fall, UM1 stated none had been reported. She also stated that Resident #11 had osteopenia and the fracture was probably related to the disease. Review of the minimum data set ((MDS) dated [DATE] for Resident #11 revealed the resident was severely cognitively impaired, required total assist with all activities of daily living (ADLs), and had no falls in the previous 180 days. Review of the orthopedic surgeon's consultation notes of 12/22/10 and 1/5/11 did not indicate the fractures were related to osteopenia. The surgeon's report of 1/5/11 referred to x-rays taken that date and showed satisfactory healing. A care plan was initiated for Resident #11 related to the fracture on 12/21/10 after she returned from the ER with a temporary soft splint. On 12/22/10 Resident #11 was seen by the orthopedic surgeon and was placed in a hard plaster type cast. The care plan was not updated to include the placement of the new cast and need for frequent assessment of the foot for complications. Review of the nursing notes revealed there were no entries made from 12/21/10 until 1/5/11. There was no documentation found in the medical record that Resident #11 had been monitored and assessed for circulatory problems following placement of the cast for a new fracture. 3. A nursing note dated 11/3/10 at 7:00 a.m. revealed Resident #3 was found on the floor calling out for help. The LPN (N1) documented the following observation: "the resident was lying on her back on the floor, she was alert with confusion. The left leg was externally rotated and shorter than the right leg. A prominent bulge was observed at the left hip and had pain when palpated". Her note at 7:25 a.m. reported that the resident was medicated with [MEDICATION NAME] N-100 for pain. The note further read that the leg was "stabilized and a body alarm was placed on the resident to promote safety" while they awaited mobile imaging to come and perform a portable x-ray. The next nurse's note was timed at 9:00 a.m. and indicated that [MEDICATION NAME] Mobile Imaging came into the facility to perform an x-ray of the left hip. Then an entry was timed at 11:15 a.m. which indicated the results of the x-ray "Intertrochanteric fracture with shortening." and that the physician's office was called to report the results. The note further indicated that the daughter was notified of the x-ray results, and that the daughter stated "will meet resident @ hospital." At 11:35 a.m. the resident received another pain pill, [MEDICATION NAME] N-100. At 11:45 a.m. the physician's office called back and an order was received to send the resident to the hospital. Non-emergency transport was contacted according to the 12:00 pm nurse's note entry to transport the resident but then the nurse's note at 12:15 p.m. indicated EVAC was contacted and transported the resident from the facility. Per the nursing notes, when found, the resident stated she was trying to get out of the basement. An interview was conducted on 1/15/11 at 1:45 p.m. with Resident #3. The resident was aware of her name, not the date, month or the current year. She was able to identify the nurse caring for her today. When asked if she could tell how she received her hip injury, she reported she didn't recall when she hurt her hip. She did recall that she thought she could walk and went on to say, "but I couldn't and I fell ". She recalled she was on the floor at the end of the bed calling out for help. She remembered that she was lying there on the floor "for a long time and someone was lying next to me on the floor to keep me quiet". She recalled being placed on a stretcher to go out of the building and she remembered that she went to the hospital, but again, she was unable to determine when she was transported out to the hospital or exactly how long she was on the floor before she was moved. She recalled the person with her lying on the floor saying "Don't move" and that it was very painful. Resident #3 had current [DIAGNOSES REDACTED]. There was a care plan for fall risk implemented on 9/20/10 which indicated that the resident was consistently oriented to own limitations and had the following - altered elimination status, diuretics or medications with sedative effects, required assistance with transferring/ambulating. Further review of both the current and closed record for care plans revealed that the closed chart care plan for Fall Risk was reviewed by the interdisciplinary team and it identified that the resident had four occurrences of falls which were reviewed between September 2009 and September 2010. A New Fall Risk Care Plan was initiated in September 20, 2010 which was the active plan at the time of this occurrence. The care plan noted assist with 1, medication side effects: observe for sedation, confusion, drowsiness, ataxia, weakness, or dizziness; provide appropriate safety and enabler devices (1/2 side rails), non-skid socks. Continued review of the Record for Resident #3 revealed that in June of 2009 this resident had a fall that lead to her being taken to the hospital to rule-out possible fracture. At that time, x-rays and computerized tomography (CT) scans of the pelvis, leg and ankle were performed and indicated that this resident had a previous right [MEDICAL CONDITION] but was free from injury related to this fall. Documentation of changes to the Fall Risk Care Plan following this occurrence were not located. An interview with N1 was conducted on 1/6/11 at 2:15 pm. which revealed that N1 stated that she was covering for the RN unit manager the morning that Resident #3 fell in her room. She indicated she had just arrived on duty when she was alerted that the resident was on the floor. She stated she assessed Resident #3, and one leg was shorter than the other with external rotation. She recalled that she called the physician and believed that the resident should be sent out to the hospital. N1 stated that 5-6 staff members performed a fireman's lift and put her (Resident #3) into bed. An interview was conducted with the DON on 1/6/11 at 1:00 pm. When asked if he was present at the time of Resident #3's fall on 11/3/10 he stated he was and he had responded to "code green". He indicated that Code Green is called to bring assistance when a resident is on the floor. The DON also stated that when he arrived there were a number of staff present and he did not stay in the room. When asked if he had participated in the initial assessment of Resident #3 after the fall he stated "no". The DON was asked why, if he was present, that the LPN supervisor was allowed to make the decision not to send the resident to the hospital via 9-1-1. He stated he was not aware of the nature of the injury at the time. The DON was asked what was the policy regarding moving residents with obvious injuries, and he indicated it depended on the situation. A copy of the facility's Response to Emergency policy was requested, however it was not made available during the survey. An interview conducted with an LPN (N2) on 1/5/11 at 2:15 pm revealed that N2 was the nurse assigned to Resident #3 on 11/3/10 at the time of the fall. When asked about the protocol for moving a resident after a fall she responded, "the nurse was to assess the resident prior to moving them". She also stated that the resident was left in the position that they were found if an injury was suspected. 4. Review of the nurse's notes dated 11/12/10, beginning at 6:45 pm revealed Resident #10 was found on the floor. The nurse documented that Resident #10 complained of pain to the left hip. The supervisor was notified and made the decision not to immediately transfer to the ER. Resident #10 was assisted back into bed. The supervisor called the physician and obtained orders for a portable x-ray. The x-ray results were called to the facility around 7:15 pm and showed an intertrochanter [MEDICAL CONDITION] hip. The physician was not immediately notified of the results as the RN supervisor chose to wait until she received a faxed copy from the provider. The faxed copy was not received until 10:00 pm. The physician was notified and the nurse obtained orders to transfer to the ER. Review of the medication records indicated that Resident #10 had no pain medications administered and no pain assessments were recorded. Resident #10 left the facility via ambulance at 10:30 pm on 11/12/10. Review of Resident #10's care plan dated 11/9/10 revealed that she required assist of one for transfers, monitoring for side effects of medications, and provide half side rails and a walker. Resident #10's [DIAGNOSES REDACTED]. Resident #10 was at high risk for excessive bleeding due to the use of [MEDICATION NAME] (an anticoagulant/blood thinner) and there was no documentation that the nurses assessed or monitored for bruising after the fall with a suspected fracture. The fall risk identification tool dated 11/9/10 did not indicate that Resident #10 was at high risk for falls. 5. An interview was conducted on 1/5/11 at 12:50 p.m. with the medical director (MD). The MD was asked if a resident fell and a nurse documented signs and symptoms of a [MEDICAL CONDITION] would he expect that the nurse immediately transfer the resident to the hospital. He indicated it depended on the symptoms. After reading the nursing note of 11/3/10 for Resident #3, the MD he stated under the circumstances he would have expected the nurses to send the resident via 9-1-1 to the hospital. When asked if there was a facility policy regarding emergency transfers with suspected injuries, he stated he would establish guidelines for the nursing staff for residents with suspected injuries or fractures at the next quality improvement (QI) meeting. 6. On 1/6/11 at 10:30 a.m. an interview was held with the nurse consultant (NC). When asked about the facility policy regarding moving residents with was suspected injuries or fractures, he indicated the facility did not have a policy specific to suspected injuries. A copy of the facility's policy regarding emergency transfers was requested, however it was not provided. The NC presented the surveyors with an Internet article regarding nursing assistant roles in the transfer of residents that could be safely moved even with suspected fractures. When asked if that was the facility policy he stated "no, they did not have one".

Based on review of medical records, resident care plans and staff interview, the facility failed to ensure that 4 of 11 residents at risk for falls and weight loss (#2, #7, #10, and #11) had a current care plan in place that addressed approaches for prevention of falls and weight loss, and were revised as necessary. The lack of revisions does not allow for staff to be able to assist residents appropriately to prevent actual harm. The facility's failure to develop and revise care plans resulted in placing other residents at risk for future occurrences of injuries and weight loss, and created a situation that is likely to result in serious harm to residents and requires immediate corrective action on the part of the facility. The immediate jeopardy occurred on July 20, 2011 and is ongoing. The findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility in March of 2010 with [DIAGNOSES REDACTED]. Resident #2 was transferred to the hospital and found to have a [MEDICAL CONDITION] on 7/20/10. There was no care plan found to address that Resident #2 was at risk for falls. Review of Resident #2's weight records for April-July 2010 revealed the following: 3/31/10 136.6 pounds (admission weight) 4/2/10 136.6 pounds 5/5/10 129.8 pounds 6/1/10 125.0 pounds 7/5/10 118.2 pounds 7/14/10 117.0 pounds The weight record percentage log provided by the dietary manager (DM) revealed that Resident #2 had experienced a 13.47% weight loss in 3 months, between April and July 2010. The MDS dated [DATE] revealed the following: height 62 inches weight 136.6 no nutritional problems identified; mechanical soft diet; had some broken teeth; required total assistance with eating. A review of Resident #2's medical record revealed a care plan dated 4/9/10 regarding nutrition with the goal "to minimize risk for weight loss". The interventions included weigh weekly, weigh per facility protocol, provide snacks prn (as needed), allow time to eat, RD consult as needed. On 5/25/10 Resident #2 was evaluated by speech therapy (ST) related to swallowing difficulty, and was ordered speech therapy 5 times a week for 4 weeks to evaluate and identify swallowing issues, to provide safety when eating and improve oral intake. Goals for Resident #2 included to safely swallow puree food, to tolerate the least restrictive diet with no overt signs and symptoms of aspiration and increase oral intake. The speech therapist provided dysphasia treatment in the dining room for one meal per day. ST notes revealed Resident #2 was usually seen at the lunch meal and ate 100% of her meal. ST determined that Resident #2 required cold nectar thick liquids to promote safe swallowing; however, there was no documentation to reflect this intervention was incorporated into the care plan. The care plan for Resident #2 did not include strategies necessary to promote increased intake, safe swallowing and the prevention of aspiration. On 6/17/10 in response to continued weight loss, the dietitian recommended the addition of fortified foods and Med Pass, a dietary supplement, twice daily. Review of Resident #2's medical record revealed that there was no meal percentages recorded or amounts consumed for the Med Pass supplement. An interview was conducted with the DON on 1/5/11 at 11:15 a.m. When asked where the facility documented meal percentage consumed, he indicated it was not the facility's policy to record meal percentages. When asked how the staff monitored resident intake, he stated he monitored the dining room at the noon meal and the nurses monitor the other dining areas. He was asked what the procedure was if a resident was not eating, and he replied that the resident is referred to the dietitian. When asked what tools the dietitian has to use in evaluating what or how much a resident eats, he stated the nurses and CNAs would be able to tell the dietitian. An interview was conducted with the diet technician (DTR) on 1/5/11 at 4:50 p.m. When asked how she determined how much a resident was eating to assess for weight changes she stated she asked the nurses and CNAs. She revealed that she was in the facility every Wednesday and observed the residents eating in all the dining areas. When asked if the facility documented meal percentages or fluids consumed she indicated they did not. 2. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11 sustained a fracture to the right lower leg on 12/21/10. There was no care plan found to address that Resident #11 was at risk for falls. A care plan was initiated for Resident #11 related to the fracture on 12/21/10 after she returned from the ER with a temporary soft splint. On 12/22/10 Resident #11 was seen by the orthopedic surgeon and the right lower leg was placed in a hard plaster type cast. The care plan was not updated to include placement of the new cast and the need for frequent assessment of the foot and toes for complications related to the fracture and cast until 12/23/10. 3. Record review revealed that Resident #10 had [DIAGNOSES REDACTED]. Review of Resident #10's care plan dated 11/9/10 revealed that she required assist of one for transfers, monitor for side effects of medications, and provide half side rails and a walker. Review of the nurse's notes dated 11/12/10, beginning at 6:45 p.m. revealed Resident #10 was found on the floor. The x-ray results revealed the resident sustained [REDACTED]. Resident #10 was also at high risk for excessive bleeding due to the use of [MEDICATION NAME] (an anticoagulant/blood thinner) and there was no documentation that the nurses assessed or monitored Resident #10 for bruising after the fall on 11/12/10 which resulted in a fracture. The fall risk identification tool dated 11/9/10 did not indicate that Resident #10 was at high risk for falls and the interventions did not include initiation of the facility's fall prevention protocol, Falling Star. 4. A review of Resident #7's medical record revealed a care plan dated 10/5/10, the following related to nutrition: Goal, Resident will improve nutrition status related to depleted visceral protein. Interventions: weigh weekly for 4 weeks then monthly, liberal diet, provide snacks at bedtime, RD consult as needed. Despite the following notes of weight loss, there had been no updates to the resident's care plan. Review of Resident #7's weights were as follows: 10/4/10 208 pounds (admission weight) 11/3/10 197.8 pounds 12/2/10 198.6 pounds 1/3/11 173.4 pounds Resident #7 had a 12.69% weight loss in 30 days and a 16.63% weight loss in 90 days. An interview with the DM on 1/4/11 at 11:00 a.m. revealed that she was unaware of any changes in the condition of Resident #7 that could be attributed to a 25 pound weight loss in 30 days. When asked if this was a planned weight loss she stated, "no". The DM stated when she reviewed the weights she would request a re-weigh when she questioned the amount of weight loss in one month. The re-weigh was done on 1/5/11 and showed the weight to be 172.8 pounds. Review of the nursing notes for Resident #7 revealed no documentation regarding a change in condition or reasons for a significant weight loss. An interview with the DTR was conducted on 1/5/11 at 4:30 p.m. When asked if she was aware of Resident #7's 25 pound weight loss, she revealed she had just received the newest weights and had not had a chance to review the report. When asked if anyone had reported to her a change in condition for Resident #7 she stated, "no". When asked if she had observed any changes in the resident's appetite she stated, "no". An interview with the DON on 1/5/11 at 11:15 a.m. revealed he was unaware of the significant weight loss; however, he did indicated that Resident #7 would be re-weighed today.

Based on staff and resident interviews, and clinical record reviews the facility failed to provide needed services, care and protection to prevent accident and injuries for 4 of 11 sampled residents. Residents #2 and #11 had injuries of unknown origin including bruising and fractures, and Residents #3 and #10 also had falls which resulted in fractures. The facility's failure to prevent accidental and injuries, and provide adequate supervision resulted in placing other residents at risk for future occurrences of physical harm and created a situation that is likely to result in serious harm to residents and requires immediate corrective action on the part of the facility. The immediate jeopardy occurred on July 20, 2011 and is ongoing. The findings include: 1. Review of the clinical record of Resident #2 revealed a nurse's note dated on 7/20/10 at 3:00 a.m., that Resident #2 was "noted with pain and bruising to the right hip and leg, the physician was notified and orders obtained to transfer the resident to the hospital". On 7/20/10 at 7:35 a.m., a late entry was made for 7/18/10 by a day shift nurse and revealed that Resident #2 had "no signs and symptoms of discomfort, a body alarm in place and all needs were met by the staff". On 7/20/10, another late entry for 7/18/10 was made by the 11p-7a nurse regarding Resident #2. The note stated that he (the nurse) had been "notified by a CNA" that Resident #2 may be in pain. The nurse documented that he and another nurse "examined the right hip and checked it against the other hip" and that they were equal. The nurse further documented that Resident #2 "was able to turn self in bed without evidence of pain, that skin was warm and dry and there was no bruising to the entire leg". Resident #2 was admitted to the hospital on [DATE] with a fractured right hip. Review of the ER (emergency room ) records of 7/20/10 revealed that Resident #2 had a fracture of the right hip, angulated and comminuted. Documentation by the emergency room physician noted that "the right hip was severely swollen; the right knee was grossly ecchymotic with blue-brown and yellow patches" and was "clearly an old contusion, best guess at least a week based on the age of the bruise and it is probably even longer. The right hip was inwardly rotated and shortened approximately 4 inches. There was ecchymosis surrounding the entire right hip into the pelvis and down to the tibial plateau". The ER physician suspected "that with the angulated fracture, the resident was probably in an extreme amount of pain". Review of the medical record revealed Resident #2 was admitted to the facility in March 2010 with [DIAGNOSES REDACTED]. There was no care plan found to address the resident was at risk for falls. An interview was conducted on 1/4/11 at 2:05 p.m. with the Director of Nursing (DON) regarding the incident that occurred with Resident #2 on 7/20/10. He indicated he was made aware of the incident after Resident #2 was transferred to the hospital on [DATE]. When asked how or when the incident occurred, he revealed an investigation was conducted; however, how or when the injury occurred was not determined. He also stated that during the facility investigation the following information was obtained on 7/18/10; a 7a-3p shift CNA was aware that Resident #2 was in pain upon movement, but did not report it to anyone. An 11p-7a CNA reported to the nurse on 7/18/10 that he thought Resident #2 was in pain. The 11p-7a nurse told the DON that he had examined Resident #2 on 7/18/10 and did not see bruising or indications of pain. The nurse did not document the assessment until two days later, after Resident #2 was sent to the hospital. On 7/19/10 the 7a-3p shift nurse was informed by a CNA that Resident #2 had bruising to the right hip and thigh, and was complaining of pain. When the DON asked the nurse if he was aware of the bruising and complaint of pain, the nurse told the DON he had seen Resident #2 and was aware of the bruising; however, he did not document the findings nor did he call the physician and family. The nurse also did not pass the information along at report for follow up by the next shift. The DON confirmed that the nurse failed to follow facility policy regarding reporting incidents. On 1/5/11 at 10:00 a.m. an interview was conducted with the Administrator regarding the incident involving Resident #2. When asked if he knew how the incident on 7/20/10 occurred, he advised that the facility completed an investigation, but was unable to determine how the incident happened. The Administrator revealed as a result of the investigation a nurse and 2 CNA's had been terminated for failing to report an incident in a timely manner. The Administrator revealed the hospital had notified the facility that Resident #2 was admitted to the hospital on [DATE] with a fractured hip. When asked if he was aware of the findings of the ER physician on 7/20/10 that the fractured right hip and extensive bruising of the right leg were determined to be at least a week old, he stated he "did not know". On 1/6/11 at 2:10 p.m. an interview was conducted with the LPN (N6) who was the nurse on duty when Resident #2 was transferred to the hospital. When asked if he recalled the incident regarding Resident #2 on 7/20/10, he revealed he was the nurse who sent her to the hospital. He indicated he had been notified by a CNA during his shift on 7/20/10 that Resident #2 had bruises to her hip and leg. He then went to examine Resident #2 and found she had bruises to the leg, but did not recall which one. He then called the physician and sent her to the hospital. When asked if he knew how the injury occurred, he did not know. When asked why he made a late entry in the nursing notes on 7/20/10 for 7/18/10, he stated he did not see any bruising or evidence of pain so did not document his assessment; however, after he observed the bruising on 7/20/10, he felt it then necessary to document his findings from 7/18/10. The nurse stated that the resident required total assistance with all activities of daily living. When asked about Resident #2's cognition, he indicated she was confused and disoriented, but was calm and cooperative. 2. On 1/6/11 at 12:05 p.m. during observation in the west wing day room, Resident #11 was observed with a cast to her lower right leg. During an interview with the UM-1 (unit manager) at 12:10 p.m. on 1/6/11, when asked why Resident #11 had a cast on her leg, she stated that a CNA had reported on 12/20/10 at 10:30 a.m. that something was wrong with Resident #11's leg. The nurse documented that "the right leg mid shaft area was bruised with a raised area and felt the bones were rubbing together". The ARNP was notified and ordered an x-ray of the lower right leg and pain medication every 6 hours prn. Portable x-rays were taken and the results were called to the facility at 3:00 p.m. The x-rays showed a proximal fibular fracture and mid tibia spiral fracture with anterior angulation and slight shortening. When asked if the injury resulted from a fall, UM1 stated "none had been reported". She also stated that Resident #11 had osteopenia and the fracture was probably related to the disease. Review of the MDS dated [DATE] for Resident #11 revealed the resident was severely cognitively impaired, required total assist with all ADLs, and had no falls in the previous 180 days. Review of the orthopedic surgeon's consultation notes of 12/22/10 and 1/5/11 did not indicate the fractures were related to osteopenia. The surgeon's report of 1/5/11 referred to x-rays taken that date and showed satisfactory healing. A care plan was initiated for Resident #11 related to the fracture on 12/21/10 after she returned from the ER with a temporary soft splint. On 12/22/10 Resident #11 was seen by the orthopedic surgeon and was placed in a hard plaster type cast. The care plan was not updated to include the placement of the new cast and need for frequent assessment of the foot for complications. Review of the nursing notes revealed there were no entries made from 12/21/10 until 1/5/11. There was no documentation found in the medical record that Resident #11 had been monitored and assessed for circulatory problems following the placement of the cast for a new fracture. 2. A nursing note dated 11/3/10 at 7:00 a.m. revealed Resident #3 was found on the floor calling out for help. The LPN (N1) documented the following observation, "the resident was lying on her back on the floor, she was alert with confusion. The left leg was externally rotated and shorter than the right leg. A prominent bulge was observed at the left hip and had pain when palpated". Her note at 7:25 a.m. reports that the resident was medicated with Darvocet N-100 for pain. The note further stated that the leg was "stabilized and a body alarm was placed on the resident to promote safety" while they awaited mobile imaging to come and perform a portable x-ray. The next nurse's note is timed at 9:00 a.m. and indicates that Atlantic Mobile Imaging came into the facility to perform an x-ray of the left hip. Then an entry is timed at 11:15 a.m. indicating the results of the x-ray "Intertrochanteric fracture with shortening." and that the physician's office was called to report the results. The note further indicates that the daughter was notified of the x-ray results, and that the daughter stated "will meet resident @ hospital." At 11:35 a.m. Resident #3 received another pain pill, Darvocet N-100. At 11:45 a.m. the physician's office called back and an order was received to send the resident to the hospital. Non-emergency transport was contacted according to the 12:00 p.m. nurse's note entry to transport the resident. However, another the nurse's note at 12:15 p.m. indicated EVAC was contacted and transported the resident from the facility. Per the nursing notes, when Resident #3 was found on the floor, she stated she was "trying to get out of the basement". An interview was conducted on 1/5/11 at 1:45 p.m. with Resident #3. The resident was aware of her name, but not the date, month or the current year. She was able to identify the nurse caring for her today. When asked if she could tell me how she received her hip injury, she reported she didn't recall when she hurt her hip. She recalled that she thought she could walk and went on to say, "but I couldn't and I fell ". She recalled she was on the floor at the end of the bed calling out for help. She remembered that she was lying on the floor "for a long time and someone was lying next to me on the floor to keep me quiet". She recalled being placed on a stretcher to go out of the building and she remembered that she went to the hospital, but again, she was unable to determine when she was transported out to the hospital or exactly how long she was on the floor before she was moved. She recalled the person with her on the floor saying "Don't move" and that "it was very painful". Resident #3 had [DIAGNOSES REDACTED]. There was a care plan done for fall risk implemented on 9/20/10 which indicated that the resident was consistently oriented to own limitations and had the following: altered elimination status, diuretics or medications with sedative effects, requires assistance with transferring/ambulating. Further review of the current and closed records for care plans found that the closed chart care plan for Fall Risk was reviewed by the interdisciplinary team and it identified that Resident #3 had four occurrences of falls which were reviewed between September 2009 and September 2010. A New Fall Risk Care Plan was initiated in September 20, 2010 which was the active plan at the time of the fall on 11/3/10. The care plan notes assist with one, medication side effects: observe for sedation, confusion, drowsiness, ataxia, weakness, or dizziness; provide appropriate safety and enabler devices (1/2 side rails), and non-skid socks. In June of 2009 this resident had a fall that lead to her being taken to the hospital to rule-out possible fracture. At that time, X-rays and CT scans of the Pelvis, leg and ankle were performed and indicated that this resident had a previous right hip fracture, but was free from injury related to this fall. Documentation of changes to the Fall Risk Care Plan following this occurrence could not be located. An interview with N1 was conducted on 1/6/11 at 2:15 p.m. N1 stated that she was covering for the RN unit manager the morning that Resident #3 fell in her room. She stated she had just arrived on duty when she was alerted that the resident was on the floor. She stated she assessed Resident #3 and one leg was shorter than the other with external rotation. She recalled that she called the physician and believed that the resident should be sent out to the hospital. N1 stated that 5-6 staff members performed a fireman's lift and put her (Resident #3) into bed. An interview was conducted with the DON on 1/6/11 at 1:00 p.m. When asked if he was present at the time of Resident #3's fall on 11/3/10 he stated was and that he had responded to "code green". He stated Code Green is called to bring assistance when a resident is on the floor. The DON also stated that when he arrived there were a number of staff present and he did not stay in the room. When asked if he had participated in the initial assessment of Resident #3 after the fall he stated "no". The DON was asked why if he was present, that the LPN supervisor was allowed to make the decision not to send the resident to the hospital via 9-1-1. He stated he was not aware of the nature of the injury at the time. The DON was asked what the policy was regarding moving residents with obvious injuries, and he stated it depended on the situation. A copy of the facility's Response to Emergency policy was requested: however, was not made available during the survey. An interview was conducted with an LPN (N2) on 1/5/11 at 2:15 p.m. N2 was the nurse assigned to Resident #3 on 11/3/10 at the time of the fall. When asked about the protocol for moving a resident after a fall, she responded the nurse is to assess the resident prior to moving them. She also stated that the resident is left in the position that they were found if an injury is suspected. 3. Review of the nurses notes dated 11/12/10 beginning at 6:45 pm revealed Resident #10 was found on the floor. The nurse documented that Resident #10 complained of pain to the left hip. The supervisor was notified and made the decision not to immediately transfer to the ER. Resident #10 was assisted back into bed. The supervisor called the physician and obtained orders for portable x-ray. The x-ray results were called to the facility around 7:15 pm and showed an intertrochanter fracture of the left hip. The physician was not immediately notified of the results as the RN supervisor chose to wait until she received a faxed copy from the provider. The faxed copy was not received until 10:00 pm. The physician was notified and obtained orders to transfer to the ER. Review of the medication records indicate that no pain medications were administered and no pain assessments recorded. Resident #10 left the facility via ambulance at 10:30 pm. on 11/12/10. Review of Resident #10's care plan dated 11/9/10 revealed that she required assist of one for transfers, monitoring for side effects of medications, and provide half side rails and a walker. Resident #10's [DIAGNOSES REDACTED]. Resident #10 was at high risk for excessive bleeding due to the use of Coumadin (an anticoagulant/blood thinner) and there was no documentation to indicate Resident #10 was assessed or monitored for bruising after the fall on 11/12/10. The fall risk identification tool dated 11/9/10 did not indicate that Resident #10 was at high risk for falls. 4. An interview was conducted on 1/5/11 at 12:50 pm with the medical director (MD). The MD was asked if a resident fell and a nurse documented signs and symptoms of a hip fracture would he expect that the nurse immediately transfer the resident to the hospital. He responded that it depended on the symptoms. After reading the nursing note of 11/3/10 for Resident #3 to the MD, he stated under the circumstances he would have expected the nurses to send the resident via 9-1-1 to the hospital. When asked if there was a facility policy regarding emergency transfers with suspected injuries, he indicated he would establish guidelines for the nursing staff for residents with suspected injuries or fractures at the next QI meeting. 5. On 1/6/11 at 10:30 a.m. an interview was held with the nurse consultant (NC). When asked about the facility policy regarding moving residents with suspected injuries or fractures, he responded the facility did not have a policy specific to suspected injuries. A copy of the facility's policy regarding emergency transfers was requested; however, it was not provided during the survey. The NC presented the surveyors with an Internet article regarding nursing assistant roles in the transfer of residents that could be safely moved even with suspected fractures. When asked if that was the facility policy he stated "no, they did not have one".

Based on staff and resident interviews, clinical record reviews and facility provided documents pertaining to the nutrition program, weight records, the facility failed to prevent significant weight loss for 3 of 11 sampled residents (#2, #6, #7). The facility's failure to provide prevent significant weight loss resulted in placing other residents at risk for future occurrences of physical harm and created a situation that is likely to result in serious harm to residents and requires immediate corrective action on the part of the facility. The immediate jeopardy occurred on July 20, 2010 and is ongoing. The findings include: 1. Review of Resident #2's weight records for April-July 2010 revealed the admission weight on 3/31/10 was 136.6 pounds. Subsequent weights were: 4/2/10 136.6 pounds 5/5/10 129.8 pounds 6/1/10 125.0 pounds 7/5/10 118.2 pounds 7/14/10 117.0 pounds The weight record percentage log provided by the dietary manager (DM) revealed that Resident #2 had experienced a 13.47% weight loss in 3 months, between April and July 2010. The MDS completed for Resident #2 on 4/7/10 revealed the following: Height 62 inches; Weight 136.6; No nutritional problems identified; was on a mechanical soft diet; had some broken teeth and required total assistance with eating. A review of Resident #2's medical record revealed a care plan dated 4/9/10 for nutrition with a goal "to minimize risk for weight loss". The care plan interventions included weigh weekly, weigh per facility protocol, provide snacks prn (as needed), allow time to eat, RD consult as needed. On 5/25/10 Resident #2 was evaluated by speech therapy (ST) related to having difficulty swallowing, and ordered speech therapy for 5 times a week for 4 weeks to evaluate and identify swallowing issues to provide safety when eating and improve oral intake. Goals for Resident #2 included to safely swallow puree food, to tolerate the least restrictive diet with no overt signs and symptoms of aspiration and increase oral intake. The speech therapist provided dysphasia treatment in the dining room for one meal per day. ST notes revealed Resident #2 was usually seen at the lunch meal and ate 100%. ST determined that Resident #2 required cold nectar thick liquids to promote safe swallowing; however this intervention was not incorporated into the care plan. The care plan for Resident #2 did not include strategies necessary to promote increased intake, safe swallowing and prevention aspiration. On 6/17/10 in response to continued weight loss, the dietician recommended the addition of fortified foods and Med Pass, a dietary supplement, twice daily. Review of Resident #2's medical record revealed that there was no meal percentages recorded or amounts consumed for the Med Pass supplement. An interview was conducted with the DON on 1/5/11 at 11:15 am. When asked where the facility documented meal percentage consumed, he stated it is not the facility policy to record meal percentages. When asked how the staff monitors resident intake, he responded that he monitors the dining room at the noon meal and the nurses monitor the other dining areas. He was asked what the procedure was if a resident was not eating, and he indicated the resident is referred to the dietician. When asked what tools the dietician used to reference regarding what or how much a resident had been eating, he stated the nurses and CNAs would be able to tell the dietitian. An interview was conducted with the diet technician (DTR) on 1/5/11 at 4:50 pm. When asked how she determined how much a resident was eating to assess for weight changes she stated she asked the nurses and CNAs. She revealed that she was in the facility every Wednesday and observed the residents eating in all the dining areas. When asked if the facility documented meal percentages or fluids consumed she stated no. The DTR was shown the weight log that the dietary manager had provided to the surveyors on 1/4/11. She was asked if she was aware that there were residents with significant weight loss. She stated the weights had just been done and she had not had a chance to review them yet. An interview was conducted with the dietary manager (DM) on 1/4/11 at 11:00 am. and the weight log was requested. The DM provided the monthly weights which were done on 1/3/11. When asked who performed the weights she stated the restorative aides and indicated that the restorative aides were responsible for weekly and monthly weights. The residents were weighed usually on the 3rd of the month and always with the same scale, and if there is a discrepancy, the resident was re-weighed. When asked how often the weights are reviewed she stated weekly at the care meetings. When asked who attended those meetings the DM responded the DON, diet tech or dietitian, MDS nurse, unit manager and herself. The DM also revealed that when changes are recommended or new orders are obtained the person who was responsible for entering the information on the care plans was usually the person taking the order. During the interview the DM was asked how the facility documented what the residents were eating. She advised she was not sure, but if she had any questions she would ask the nurses. When asked what the facility policy for recording meal percentages was, she stated "there wasn't one". 2. A review of Resident #6's medical record revealed a care plan dated 12/2/10 for nutrition with the following goal, "Resident will not have any significant weight changes". Interventions included weigh weekly for 1 month then monthly, provide snacks per facility policy, provide dietary supplement, Med Pass 3 times a day, allow time to eat, labs and RD consult as needed, offer food preferences as available. Resident #6's weights included: 11/22/10 108 pounds - Admission Weight 12/2/10 108 pounds 1/3/11 89.6 pounds This was a 17.19% weight loss in one month. Resident #6 was admitted with status [REDACTED]. She was alert with confusion at times and could make her needs known. She was able to feed herself. A dietary note dated 12/2/10 revealed that Resident #6's intake was usually good, her [MEDICATION NAME] level was 2.8 (mildly depleted), but acceptable for advanced age, doesn't think she wants supplements, and will order Med Pass 90cc 3 times a day. On 1/4/11 at 11:00 am during an interview with the DM she was asked if she was aware of any changes in the last 30 days for Resident #6, she stated the resident had a stomach flu for 2 days in December, but other than that she was unaware of any changes. When asked if she was aware of Resident #6 experiencing an 18 pound weight loss since 12/2/10 she indicated she would have Resident #6 re-weighed the next day to ensure accuracy of the weight. On 1/5/11 at 4:30 pm, the DTR reported that several of the residents had been re-weighed. She provided an updated weight log. Resident #6's weight was reported as 90.3 pounds, still indicating a 17.7 pound weight loss since admission. When asked if she had been made aware of any changes in Resident #6's condition prior to the significant weight loss reported yesterday she stated, "no".When asked if Resident #6 was consuming the Med Pass supplement that was ordered 3 times a day she responded that she would have to check with the nurse. A review of all the nursing notes in the medical record for Resident #6 did not reveal any changes in condition or documentation regarding condition related to weight loss. An interview was conducted with Resident #6 on 1/6/11 at 11:00 am. During the interview Resident #6 was asked about her appetite. She advised she was eating OK, but did not have a big appetite. She was asked if she was drinking her supplement that was ordered 3 times a day, and she stated "not always". When asked if she felt she had a loss any weight recently, she revealed she was not sure. 3. Review of Resident #7's medical record revealed a nutrition/hydration management care plan with the initial date of 10/5/10. The goals established for the care plan were to improve the nutritional status related to depleted visceral protein and that the resident will not have any significant weight changes through the next review. The interventions established to reach the 10/5/10 goals of the care plan were to weigh the resident weekly for 4 weeks and then weigh monthly, liberalize the diet as necessary, provide snacks at bedtime per the diabetic diet, perform labs as ordered, consult the RD as necessary, and monitor for changes. Review of Resident #7's weight at admission on 10/4/10 was 208 pounds. Subsequent weights were: 11/3/10 197.8 pounds 12/2/10 198.6 pounds 1/3/11 173.4 pounds 1/5/11 172.8 pounds The weight loss for Resident #7 reflected a 12.69% loss in 30 days and a 16.63% weight loss in 90 days. An interview with the DM on 1/4/11 at 11 am revealed that she was unaware of any changes in the condition of Resident #7 that could be attributed to a 25 pound weight loss in 30 days. When asked if this was a planned weight loss she indicated it was not. The DM revealed when she reviewed the weights she would request a re-weigh if she questioned the documented weight loss. Review of all nursing notes since admission revealed no documentation regarding a change in condition or reasons for a significant weight loss for Resident #7. An interview with the DTR was conducted on 1/5/11 at 4:30 p.m.. When asked if she was aware of Resident #7's 25 pound weight loss, she revealed she had just received the newest weights and had not had a chance to review them. The DTR confirmed she had not received any reports regarding a change in condition for Resident #7. The DTR also denied observing any changes in Resident #7's appetite. An interview with the DON on 1/5/11 at 11:15 a.m. revealed he was unaware of the significant weight loss, however he did indicate that Resident #7 would be re-weighed today. When asked if he could explain the weight loss he revealed a number of the residents had recently experienced a bout of gastrointestinal influenza (GI flu. Resident #7 was amongst them. When asked how long did the residents present with diarrhea and vomiting he advised 24-48 hours. He also indicated the symptoms for the GI flu began around 12/22/10 and the last reported case was 1/3/11. Review of Resident #7's dietary progress note dated 1/6/11 revealed it was a quarterly assessment. Resident #7 was admitted on [DATE] and there were no previous dietary notes or nutritional assessments before 1/6/11 in the medical record. 4. On 1/4/11 at 9:40 a.m. the DON provided a document that indicated there was no unplanned weight loss in the facility within the past 90 days. At 10:30 a.m. the DM was interviewed about weight loss and provided a current weight log with percentages of weight loss within the last 30, 60 and 90 days. The weight log revealed 10 residents with weight loss of 5% or more in 30 days. In addition, the DM revealed she was waiting re-weights that performed that day and that some weight loss may be due to the recent outbreak of gastro-intestinal flu. On 1/4/11 at 11:20 a.m. the DON was interviewed regarding the discrepancy in the information provided for resident weights. The DON revealed the restorative aides weigh the residents weekly and monthly using the same scale. The DON revealed the policy for reporting weight loss was the restorative aide would notify the nurse and the nurse would report the weight loss to the physician. On 1/6/11 at 12:50 p.m. an interview was conducted with the Medical Director (MD). The MD revealed the nurses keep him informed when there is weight loss. The MD also revealed that the residents are evaluated by the dietitian and orders are given for supplements as needed. The MD advised the QI committee reviewed weight loss every month and looked for trends. The MD revealed the DON provided the information regarding weight loss at the meetings. The MD advised that there was a diet tech and dietitian that visit the facility weekly. The MD revealed he was not aware of how the facility recorded daily food intake. The MD revealed he would refer to staff about meal consumption if a resident was experiencing weight loss. The MD revealed that recording the amount of intake would be beneficial and that it would be discussed at the next QI meeting.

Based on record review, staff interview and review of facility policy and procedures the facility had failed to provide services, care and protection to prevent accidents, prevent significant weight loss, and assess, develop and revise care plans with appropriate interventions for 5 of 11 sampled residents, (#2, #6, #7, #10, and #11). The Quality Assurance and Assessment Committee (QAA) failed to identify or recognize quality of life and quality of care deficient practices by the facility and failed to develop and implement plans of action to correct the deficient practices; therefore, all residents were placed at risk for future occurrences of significant weight loss, physical or mental injury, impairment or death and requires immediate corrective action on the part of the facility. Immediate jeopardy occurred on [DATE] and is ongoing. The findings include: 1. Review of the medical record revealed Resident #2 was admitted to the facility in [DATE] with arthropathy, difficulty walking, and uncoordination. There was no care plan found to address the resident was at risk for falls. Continued review of the clinical record for Resident #2 revealed she was found with bruising of the right hip, thigh and knee on [DATE]. Resident #2 was transferred to the hospital on [DATE] and was diagnosed with [REDACTED]. The ER records described the bruising as extensive, covering the entire hip, groin, and thigh to below the knee. The ER physician documented that neither the bruises nor the [MEDICAL CONDITION] were new and were thought to be at least a week old. The fracture was described as angulated and the physician documented that a fracture of that nature would be extremely painful. It was determined that surgery would not be Resident #2's best interest and ordered a Hospice consult. Resident #2 was admitted to Hospice services on [DATE] and expired on [DATE]. An interview was conducted on [DATE] at 2:05 pm with the Director of Nursing (DON) regarding the incident that occurred with Resident #2 on [DATE]. He stated he was made aware of the incident after Resident #2 was transferred to the hospital on [DATE]. When asked how or when the incident occurred, he indicated an investigation was conducted; however, how or when the injury occurred was not determined. He also revealed that during the facility investigation the following information was obtained on [DATE]; a 7a-3p shift CNA was aware that Resident #2 was in pain upon movement but did not report it to anyone. An 11p-7a CNA reported to the nurse on [DATE] that he thought Resident #2 was in pain. The 11p-7a nurse told the DON that he had examined Resident #2 on [DATE] and did not see bruising or indications of pain. The nurse did not document the assessment until two days later, after Resident #2 was sent to the hospital. On [DATE] at 10 a.m. an interview was conducted with the administrator regarding the incident involving Resident #2. When asked if he knew how the incident occurred on [DATE], he stated the facility performed an investigation, but was unable to determine how the incident happened. He revealed after the investigation that a nurse and 2 CNAs were terminated for failing to report in a timely manner. When asked if he was aware that Resident #2 was admitted to the hospital on [DATE] with a [MEDICAL CONDITION], he stated the hospital had notified the facility. When asked if he was aware of the findings of the ER physician on [DATE] that the fractured right hip and extensive bruising of the right leg were determined to be at least a week old, he stated he did not know. On [DATE] at 2:10 pm an interview was conducted with the licensed practical nurse (LPN) (N6) who was the nurse on duty when Resident #2 was transferred to the hospital. When asked if he recalled the incident regarding Resident #2 on [DATE], he stated he was the nurse who sent her to the hospital. He revealed he had been notified by a CNA during his shift on [DATE] that Resident #2 had bruises to her hip and leg. He then went to examine Resident #2 and found she had bruises to the leg, but did not recall which one. He then called the physician and sent her to the hospital. When asked if he knew how the injury occurred, he did not know. When asked why he made a late entry in the nursing notes on [DATE] for [DATE], he stated he did not see any bruising or evidence of pain so did not document his assessment; however, after he observed the bruising on [DATE], he felt it then necessary to document his findings from [DATE]. The LPN (N6) also indicated that Resident #2 required total assistance with all activities of daily living and the resident was confused and disoriented, but was calm and cooperative. Review of Resident #2's weight records for April-[DATE] revealed the following: [DATE] 136.6 pounds (admission weight) [DATE] 136.6 pounds [DATE] 129.8 pounds [DATE] 125.0 pounds [DATE] 118.2 pounds [DATE] 117.0 pounds The weight record percentage log provided by the dietary manager (DM) revealed that Resident #2 had experienced a 13.47% weight loss in 3 months, between April and [DATE]. 2. Resident #10's [DIAGNOSES REDACTED]. Review of Resident #10's care plan dated [DATE] revealed that she required assist of one for transfers, be monitored for side effects of medications, and required half side rails and a walker. Review of Resident #10's care plan dated [DATE] revealed that she required assist of one for transfers, monitor for side effects of medications, and provide half side rails and walker. Review of the nurse's notes dated [DATE], beginning at 6:45 p.m. revealed Resident #10 was found on the floor. The x-ray results revealed the resident sustained [REDACTED]. The resident was transferred to the ER at 10:30 p.m.. Resident #10 was also at high risk for excessive bleeding due to the use of [MEDICATION NAME] (a blood thinner) and no documentation reflected that the nurses had assessed or monitored the resident for bruising after a fall with a suspected fracture. The [DATE] Fall Risk Identification tool did not indicate that Resident #10 was at high risk for falls nor was there interventions to include initiation of the facility's fall prevention protocol, Falling Star. 3. A review of Resident #6's record revealed a Nutrition care plan dated [DATE] a goal the the resident would not have any significant weight changes. Interventions established to prevent significant weight changes were to weigh the resident weekly for 1 month then monthly thereafter; provide snacks per facility policy; provide a dietary supplement, Med Pass 3 times a day; allow time to eat; labs and RD consult as needed; and to offer food preferences as available. Resident #6's weights included: [DATE] 108 pounds (admission weight) [DATE] 108 pounds [DATE] 89.6 pounds Resident #6 experience a 17.19% weight loss in one month. 4. A review of Resident #7's record revealed a Nutrition care plan dated [DATE]. The goal established was that Resident #7 would improve nutrition status related to depleted visceral protein. The facility established written interventions to improve the nutrition status by weighing the resident weekly for 4 weeks then monthly thereafter; provide a liberal diet; provide snacks at bedtime; and provide a RD consult as needed. Review of Resident #7's weights was as follows: [DATE] 208 pounds (admission weight) [DATE] 197.8 pounds [DATE] 198.6 [DATE] 173.4 Resident #7 experienced a 12.69% weight loss in 30 days and a 16.63% weight loss in 90 days. 5. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11 sustained a fracture to the right lower leg on [DATE]. There was no care plan found to address that Resident #11 was at risk for falls until the resident returned from the ER with a temporary soft splint on [DATE]. On [DATE] Resident #11 was seen by the orthopedic surgeon and was placed in a hard plaster type cast. The care plan was not updated to include the placement of the new cast and need for frequent assessment of the foot for complications until [DATE]. 6. On [DATE] at 9:20 a.m. the DON was requested to provide a list of residents with any unplanned weight loss over the past 90 days. The DON returned at 9:40 a.m. and provided a typed sheet of paper that stated there was no unplanned weight loss in the facility over the past 90 days. An interview with the DON on [DATE] at 11:15 a.m. revealed it was not the facility's policy to record meal percentages. The DON advised he monitored resident intake in the in the dining room at the noon meal and the nurses monitor the other dining areas. The DON indicated in the interview that if a resident was not eating, then the resident is referred to the dietitian. The DON revealed the dietitian relied on the nurses and CNAs to evaluate what and how much a resident eats. 7. An interview was conducted with the diet technician (DTR) on [DATE] at 4:50 p.m. When asked how she determined how much a resident was eating to assess for weight changes she stated she asked the nurses and CNAs. She revealed that she was in the facility every Wednesday and observed the residents eating in all the dining areas. When asked if the facility documented meal percentages or fluids consumed she indicated no. 8. On [DATE] at 10:15 a.m. the Dietary Manager (DM) was interviewed about weight loss and was requested to provide an updated list of resident weights. The DM returned at 10:30 a.m. with the current weight log including percentages of weight loss within the last 30, 60 and 90 days. The weight log revealed 10 residents with weight loss of 5% or more in 30 days. In addition, the DM advised she was waiting for re-weights that were to be completed that day and indicated that some weight loss may be due to the recent outbreak of a gastrointestinal flu. The DM advised weights are reviewed weekly at the Care meetings attended by the DON, diet tech or dietitian, MDS nurse, unit manager and herself. 9. A telephone interview was conducted on [DATE] at 12:50 p.m. with the medical director (MD) who revealed he visited the facility every week and attended the QA meeting monthly. The MD advised that nurses should call [DATE] for residents with suspected [MEDICAL CONDITION] in in order to be evaluated in the ER. The MD also revealed the QA committee reviewed weight loss every month and looked for trends. When asked who provided the information regarding weight loss at the meetings he stated "the DON".