Every finding on record at Wilkes Regional Medical CTR SN

Based on observations, resident and staff interviews, the facility failed to maintain a resident's privacy by not placing a cover over his urine collection bag exposing his urine which was visible to other residents, staff and visitors. This occurred for 1 of 1 resident reviewed for privacy (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses that included retention of urine and benign prostatic hyperplasia (an increased number of cells in a tissue or organ, causing it to become enlarged) of the lower urinary tract. Resident #6's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact and coded as having an indwelling urinary catheter. Observations were completed on 07/14/26 at 11:03 AM and again at 12:05 PM of Resident #6 sitting in his bedside chair inside of his room. Resident #6's urine collection bag containing yellow fluid was hanging on the right side of his chair visible from the hallway. The urine collection bag was observed without a cover with transparent side facing the doorway. Nurse Aide (NA) #1 and Nurse #1 were observed entering and exiting Resident #6's room during this observation. From the hallway, Resident #6's urine collection bag was observed to have been approximately one quarter full of yellow fluid. Visitors, nursing staff (nurse and NA), and other staff (housekeeping, physical therapy) were observed passing Resident #6's room.On 07/15/26 at 8:35 AM an observation of Resident #6 was completed from the hallway. Resident #6 was observed reading while sitting in the bedside chair inside of his room. His urine collection bag was hanging on the right side of the chair with the transparent side facing outward exposing yellow fluid that was observed from the hallway. Visitors were observed passing Resident #6's room. An interview with Resident #6 was conducted on 07/15/26 at 8:54 AM. Resident #6 specified he would prefer his urine collection bag not to be visible to anyone who passed by his room. Resident #6 stated he had often noted the urine collection bag had been hung on the right side of his chair in view of hallway traffic. At 8:57 AM on 07/15/26 an interview was conducted with NA #2. NA #2 revealed she was aware the urine collection bag should have been covered and not visible to the hallway traffic. NA #2 reported she typically covered the urine collection bag with a pillowcase. NA #2 acknowledged she had been trained to cover the urine collection bag during orientation training. NA #2 stated the system breakdown may have occurred during Resident #6's morning therapy session with Occupational Therapy. An interview was conducted with the Occupational Therapist (OT) on 07/15/26 at 9:30 AM. The OT confirmed she provided services for Resident #6 that morning at 7:01 AM. She acknowledged she was not aware the urine collection bag should have been out of view from hallway traffic. The OT was unable to recall the location of Resident #6's urine collection bag. She stated that one of the students working with her may have placed the bag in hallway view. On 07/15/26 at 9:09 AM an interview was completed with Nurse #1. She stated she knew the urine collection bag should have been covered when Resident #6 was in the hallway, but she did not consider the urine collected in the urine collection bag needed to be concealed from hallway traffic. She confirmed this had exposed the resident's urine to staff, visitors, family and all hallway traffic as they passed the open doorway of Resident #6's room. An interview with the Nurse Manager was conducted on 07/15/26 at 9:34 AM. She confirmed Resident #6's body fluids should not have been visible from the hallway. She stated verbal training was given to staff to ensure the opaque, white side of the urine collection bag was faced outward to ensure urine was not visible to public view. The Nurse Manager shared she had not conducted formal training regarding concealment or covering urine collection bags for residents with urinary catheters. She reiterated that verbal training had been shared with nursing staff to conceal collected body fluids by turning the opaque white side of the urinary collection bag outward to conceal body fluid. She revealed the breakdown in the system was likely due to staff not consistently visualizing placement of the urine collection bag and positioning the bag with the opaque white side facing outward ensuring urine would not be exposed. The Nurse Manager reported she was unaware of staff using a pillowcase to cover Resident #6's urine collection bag. She stated the facility ordered urine collection bags with the opaque white side so the bag could be flipped over concealing the body fluid. An interview was completed with Nurse #2 on 07/15/26 at 2:30 PM. Nurse #2 reported she worked in this area covering the nurse's lunch break. She stated she was not aware that urine collected into residents' urine collection bags needed to be out of public view. A telephone interview with the Administrator was conducted on 07/16/26 at 9:15 AM. The Administrator stated the facility staff were to conceal urine collected in resident's urine collection bags when a resident was in public areas, in public view to include visibility from the hallway. He stated the facility culture was to promote resident dignity. The Administrator indicated the staff were trained and educated to promote residents' dignity. The Administrator noted he would have wanted the urine collection bag covered if he had been Resident #6. The Administrator was uncertain as to why Resident #6's urine collection bag with transparent side outward was visible from the hallway.

Based on observations and staff interviews, the facility failed to: (1) remove expired items from 1 of 1 reach in cooler; (2) provide an open/ use by date for food available for use in 1 of 1 walk in refrigerators and 2 of 2 walk in freezers; (3) maintain dishware that was stacked wet and available for use; and (4) keep dishes free from dried debris available for use. This deficient practice had the potential to affect eight (8) of eight (8) residents. The findings included: a. On [DATE] at 11:45 AM with the Kitchen Supervisor, one half gallon of whole milk was observed with an expiration date of [DATE] and was available for use in the reach in cooler. b. Observation of the kitchen occurred on [DATE] at 11:45 AM with the Kitchen Supervisor. The reach in cooler had food open to air and no use by date which included broccoli, shredded chicken and sausage and gravy. The walk-in refrigerator had the following food with no open or use-by date: one package of American cheese, one package of pepper jack cheese, half of a 5-pound (lb.) bag of carrots, and one 5 lb. container of pimento spread. The walk-in freezer #1 and walk-in freezer #2 had food with no open or use-by date which included one package of cheddar cheese wrapped in plastic clear cling wrap, one bag of uncooked potato wedges, and one bag of uncooked omelets. c. Observation of the kitchen occurred on [DATE] at 11:45 AM with the Kitchen Supervisor. Ready-for-use dishware was put away and stacked wet. At the meal preparation station, 4 out of 8 plastic dome lids were stacked wet and available for use, 8 out of 15 trays were stacked wet, and 4 out of 8 bowls were stacked wet. d. Observation of the kitchen occurred on [DATE] at 11:45 AM with the Kitchen Supervisor. Ready-for-use dishware in the meal preparation area and in the plate warmer contained dried food debris. 2 out of 6 plates with dry debris were available for use on the meal preparation station and 8 out of 15 plates with dry debris were available for use on the plate warmer. An interview with the Kitchen Supervisor on [DATE] at 11:45 AM revealed staff should remove dirty plates prior to use. The Kitchen Supervisor explained dishware should be thoroughly dried prior to use. Staff should not stack or use wet dishware. The Kitchen Supervisor continued to explain that all staff were responsible for properly storing, labeling, dating, and disposing of expired items in the kitchen area.

Based on observation and staff interviews, the facility failed to keep the area around the garbage compactor free of accumulated trash and debris for 1 of 1 garbage compactor observed. The findings included: An observation was completed on of the garbage compactor area on 4/21/2025 at 12:40 PM. The observation revealed the following items outside of the garbage compactor: 1 medium black plastic bag of trash, multiple blue latex gloves, 1 tin can, 2 dented hazard cones, 1 empty syringe, 1 small container of unidentified food. A large gray bag of trash and large brown box was sitting on the loading dock where the garbage compactor was located. An interview with the Kitchen Supervisor on 4/21/2025 at 1:00 PM revealed the garbage compactor was used by the whole hospital. The Kitchen Supervisor was not aware that the garbage area was the responsibility of Kitchen Services. An interview with the Nutritional Service Manager on 4/22/2025 at 11:40 AM revealed she was unaware that the garbage area was the responsibility of Kitchen Services. An interview with the Nurse Manager was completed on 4/23/2025 at 3:00 PM revealed she was unaware that the garbage area was the responsibility of Kitchen Services.

Based on record review and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 8 of 8 residents in the facility. Findings included: The facility's Infection Prevention and Control Surveillance policy dated 2/1/25 documented the Infection Preventionist (IP) conducts surveillance of all infections among residents and partners including tracking and analysis of outbreaks of infections. Record review indicated Resident #2 receiving antibiotics for osteomyelitis and Resident #4 receiving antibiotics for a wound infection. The Infection Preventionist (IP) nurse was interviewed on 4/23/25 at 9:15 AM. The IP nurse discussed tracking and analyzing infections in the skilled nursing unit by using an approved tracking form. She explained the form was computerized, so she did not have a paper copy for review. IP provided computerized information for five infections that were regularly tracked, Central Line associated bloodstream infection, catheter associated urinary tract infections, methicillin-resistant staphylococcus, Clostridium difficile(C-Diff), Surgical Site Infection. This data showed only one infection on the unit in the last year. She reported that the system does not track flu, pneumonia, covid-19 or non-catheter associated infections. This system tracked both hospital and nursing home infections, however, IP was able to pull only information for the nursing home. The Unit Nurse Manager was interviewed on 4/23/25 at 10:30 AM. The Unit Nurse Manager explained the IP nurse was responsible for infection surveillance/tracking and she knew there had been at least one case of covid-19, 2 weeks ago, as well as other infections on the unit. She reported covid-19 was not treated on the unit and was transferred out to the hospital. She stated she expected the IP nurse to perform infection surveillance/tracking on all the residents who were present with an infection.

Based on record review and staff interviews, the facility failed to document education was provided in the medical record regarding the benefits and potential side effects of the influenza and pneumonia vaccines. This occurred for 3 of 5 residents (Resident #210, Resident #110, and Resident #159) reviewed for vaccines. The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The resident's immunization record was reviewed and revealed that flu vaccine was current, but the resident was due the pneumonia vaccine and Resident #210 had declined the pneumonia vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record. Interview with Resident #210 on 4/22/25 at 2:45 PM revealed she declined any additional pneumonia vaccine, and she reported her flu vaccine was up to date. She reported she did not remember being educated on the risk of her not receiving them. b. Resident #110 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact The resident's immunization record was reviewed and revealed the resident refused the pneumonia and flu vaccine. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record. Resident #110 declined to be interviewed on 4/21/25 at 11:00 AM. c. Resident #159 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be moderately cognitively impaired. The resident's immunization record was reviewed and revealed he had refused flu and pneumonia vaccine. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record. Interview with Resident #159 on 4/22/25 at 3:00 PM revealed he refused the flu and pneumonia vaccine. He reported he also did not remember getting any education regarding the vaccines An interview with the Infection Preventionist (IP) on 4/23/25 at 10:40 AM revealed that the floor nurse would administer the vaccines per the Medication Administration Record (MAR). She stated there should be education provided prior to administration of the vaccine by the nurse administering the vaccine and documented in the education section of the resident's chart. If the resident declined education should be provided as to the risk of not being vaccinated. IP reports she did not know why this had not been done. An interview with the Unit Nurse Manager on 4/23/25 at 12:30 PM revealed that education should be provided to the residents or the resident's representative prior to the vaccine being administered. She stated the expectation was for the nurse that provided the education to document in the medical record that education had been provided on the immunization record. If the resident declined the vaccine, it should be noted in their chart along with education for risk of not being vaccinated. Unit Nurse Manager reports she did not know why this had not been done. An interview with Nurse Navigator on 4/22/25 at 2:00 PM indicated that immunizations were entered by a data entry person. Vaccines were offered to the resident and if the resident agrees to have the vaccine an order was created and sent to the Medication Administration Record. If the resident declines the vaccines the process stopped with the declination.

Based on record review, resident, and staff interviews, the facility failed to document that education was provided in the medical record regarding the benefits and potential side effects of the COVID-19 vaccines. This occurred for 4 of 5 residents reviewed for immunizations (Resident #210, Resident #110, Resident #159, Resident #4). The findings included: a. Resident #210 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact. The Resident's immunization record was reviewed and revealed that the resident had declined the covid vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this vaccine. An interview with Resident #210 was conducted on 4/22/25 at 2:45 PM and revealed she declined any additional covid vaccines and she did not remember being educated on the risk of her not receiving them. b. Resident #110 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively intact The resident's immunization record was reviewed and revealed that the resident declined the covid vaccine. The immunization record review also revealed that nothing was documented under the education notes section on the immunization record for this vaccine. Resident #110 declined an interview on 4/21/25 at 11:00 AM. c. Resident #159 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be moderately cognitively impaired. The resident's immunization record was reviewed and revealed the resident agreed to the covid vaccine. Review of the immunization record revealed nothing was documented under the education note section on the immunization record for this vaccine. An interview with Resident #159 conducted on 4/22/25 at 3:00 PM revealed he agreed to have the covid vaccine. He reported he did not remember getting any education regarding the vaccine. d. Resident #4 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment dated [DATE] showed the resident to be cognitively impaired. The resident's immunization record was reviewed and revealed the resident refused the covid vaccine. Review of the immunization record also revealed nothing was documented under the education notes section on the immunization record for this vaccine. An interview with Resident #4 was conducted on 4/22/25 at 3:15 PM and indicated he declined any further covid vaccinations and he did not remember getting any education regarding the vaccination. An interview with the Infection Preventionist (IP) on 4/23/25 at 10:40 AM revealed the floor nurse would administer the vaccines per the Medication Administration Record (MAR). She stated there should be education provided prior to administration of the vaccine by the nurse administering the vaccine and documented in the education section of the resident's chart. If the resident declined the vaccine, education should be provided as to the risk of not being vaccinated. She reports she is unsure why education was not documented. An interview with Nurse Navigator on 4/22/25 at 2:00 PM indicated that immunizations were entered by a data entry person. Vaccines were offered to the resident and if the resident agreed to have the vaccine an order was created and sent to the Medication Administration Record. If the resident declined the vaccines the process stopped with the declination. An interview with the Unit Nurse Manager on 4/23/25 at 12:30 PM revealed that education should be provided to the residents or the resident's representative prior to the vaccine being administered. She stated the expectation was for the nurse that provided the education to document in the medical record that education had been provided on the immunization record. If the resident declined the vaccine, it should be noted in their chart along with education for risk of not being vaccinated. She reported she was unsure why education was not documented.

Based on record reviews and staff interviews, the facility failed to develop a baseline care plan that addressed a resident's oxygen and respiratory care for 2 of 3 residents reviewed for baseline care plans (Resident #109 and Resident #110). The findings included: 1. Resident #109 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS also indicated diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was not coded for oxygen. A review of Resident #109's active care plan dated 4/8/2025 revealed there were no goals or interventions regarding oxygen or respiratory care included in the baseline care plan. An interview with Nurse #1 on 04/22/25 at 01:22 PM stated orders and care plans were reviewed by the nurse each shift. Nurse #1 confirmed Resident #109 was receiving oxygen and respiratory status was assessed. Nurse #1 stated that respiratory care was not added to the care plan when Resident #109 was readmitted to the unit. Nurse #1 reported oxygen and oxygen monitoring was ordered on readmission. A review of Resident #109's orders revealed oxygen care orders: - (4/8/25) Nasal Cannula 1 liter per minute, keep oxygen saturation greater than 92% - (4/8/25) Pulse oximetry, continuous, maintain oxygen saturations greater than 94% An interview with the MDS Coordinator on 4/23/25 at 10:43 AM revealed respiratory orders should be added to the care plan and resolved on discharged . The MDS Coordinator reported the nurse should address respiratory care in the care plan on admission and any time after if not addressed on admission. An interview with the Nurse Manager on 4/23/25 at 1:47 PM revealed that each nurse was expected to review orders and the care plan for oxygen needs and to communicate any changes during the shift change report. The Nurse Manager stated that nurses should add respiratory care to the care plan upon admission. She also stated that nurses should have addressed respiratory care in the care plan for Resident #109 when reviewing the care plan during the shift. 2. Resident #110 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included respiratory failure. A review of Resident #110's quarterly Minimum Data Set (MDS) dated [DATE] indicated diagnosis of chronic respiratory failure with hypoxia and was coded for oxygen use. The MDS also revealed Resident #110 was cognitively intact. A review of Resident #110's active care plan dated 4/8/2025 revealed there were no goals or interventions regarding oxygen or respiratory care included in the baseline care plan. An interview with Nurse #1 on /22/25 at 01:22 PM stated orders and care plans were reviewed by the nurse each shift. Nurse #1 confirmed Resident #110 was receiving oxygen and respiratory status was assessed. Nurse #1 stated that respiratory care was not added to the care plan when Resident #110 was readmitted to the unit. Nurse #1 reported oxygen and oxygen monitoring was ordered on readmission. A review of Resident #110's oxygen care orders revealed: -(4/14/25) Oxygen Therapy nasal cannula, rate 3 liters per minute, keep oxygen saturation level greater than 90%. -(4/14/25) Initiate Adult Respiratory Chronic-Stable Bilevel Positive Airway Pressure/ Continuous Positive Airway Pressure (BIPAP/CPAP) Protocol (Adult Non-invasive Ventilation) continuously. An interview with the MDS Coordinator on 4/23/25 at 10:43 AM revealed respiratory orders should be added to the care plan and resolved on discharged . The MDS Coordinator reported the nurse should address respiratory care in the care plan on admission and any time after if not addressed on admission. An interview with the Nurse Manager on 04/23/25 at 1:47 PM revealed that each nurse was expected to review orders and the care plan for oxygen needs and to communicate any changes during the shift change report. The Nurse Manager stated that nurses should add respiratory care to the care plan upon admission. She also stated that nurses should have addressed respiratory care in the care plan for Resident #110 when reviewing the care plan during the shift.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for the use of oxygen for 1 of 8 residents (Resident #109) whose MDS assessments were reviewed. The findings included: Resident #109 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS indicated diagnosis of COPD and was not coded for oxygen use. A review of Resident #109's orders revealed oxygen care orders: - (4/8/25) Nasal Cannula 1 liter per minute, keep oxygen saturation greater than 92% - (4/8/25) Pulse oximetry, continuous, maintain oxygen saturations greater than 94% An interview with the MDS Coordinator on 4/23/25 at 10:43 AM revealed respiratory orders should be addressed on admission by including them in assessments and care plans. MDS Coordinator did not say why the oxygen was not coded.

Based on record reviews, staff, Consultant Pharmacist, and Nurse Practitioner interviews, the facility failed to correctly enter an as needed psychotropic (drug that affects the mental state) medication order to include the 14 day stop date for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. The physician order dated 12/11/24 reviewed for Resident #2 revealed an order for Ativan (antianxiety) 0.5 milligrams (mg) by mouth twice daily as needed for anxiety with a start date of 12/12/2024 for a duration of 14 days (12/26/24). Review of the December 2024 Medication Administration Record (MAR) revealed Resident #2 received Ativan 0.5 mg by mouth each night from 12/11/24 through 12/27/24. He did not receive it on 12/29/24. He did receive it on 12/30/24 and 12/31/24. Review of January 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 01/01/25 through 01/31/25. Review of February 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 2/1/25 through 2/28/25. Review of March 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 3/1/25 through 3/31/25. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. The MDS documented Resident #2 received antianxiety medication 7 out of 7 days during the assessment period. Review of April 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 4/1/25 through 4/23/25. During an interview with Nurse #4 on 4/23/25 at 1:10 PM, she stated that when orders were put into their system, active orders would transfer over, and she believed those orders to be correct and what the provider wanted the resident to receive. Nurse #4 verbalized she could view for 14 days on the order and reported she thought it was a continuous order. An interview with the Unit Nurse Manager on 4/23/25 at 1:20 PM revealed that the order for Ativan should have had a stop date. She reported that she felt the order was entered incorrectly by the hospitalist on admission with no stop date. She reported the for 14 days with a start date of 12/12/24 should have been noticed and questioned. During an interview with the Nurse Practitioner on 4/23/25 at 1:45 PM, she stated the order for Ativan 0.5 mg twice daily as needed for anxiety for 14 days had been entered by one of the hospitalist. The hospitalist had entered the for 14 days in the comment section and had not included the end date. The Nurse Practitioner explained by notating the 14 days in the comment section this caused none of the safeguards or alerts in the system to activate and no one paid attention to the duration of the Ativan. She reported it just slipped through the cracks. The Hospitalist that entered the Ativan order on 12/11/24 was not available for interview on 4/23/25 at 1:15 PM During an interview with the Pharmacy Consultant on 4/23/25 at 2:00 PM, she stated that as needed psychotropics should have a stop date. The Pharmacy Consultant reported she reviewed Resident #2's chart and realized the original order had been entered incorrectly which would not have triggered the safeguards. She reported that she was aware that all as needed psychotropics should have a stop date and be reviewed every 14-21 days.

Based on record reviews and Consultant Pharmacist interviews, the Consultant Pharmacist failed to communicate to the facility the need to limit the use of a psychotropic drug (drug that affects the mental state) ordered as needed to 14 days for 1 of 5 residents reviewed for unnecessary medications (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. The physician order dated 12/11/24 read, Ativan (antianxiety) 0.5 milligrams (mg) by mouth twice daily as needed for anxiety with a start date of 12/12/2024 for a duration of 14 days (12/26/24). Review of January 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 01/01/25 through 01/31/25. The Pharmacy Consultant's drug regimen review dated 1/13/25 included no recommendations for a stop date for Ativan 0.5 mg and there was no clinically significant medication issues identified. Review of February 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 2/1/25 through 2/28/25. The Pharmacy Consultant's drug regimen review dated 2/14/25 included no recommendations for a stop date for Ativan 0.5 mg and there was no clinically significant medication issues identified. Review of March 2025 MAR revealed Resident #2 received Ativan 0.5 mg by mouth each night from 3/1/25 through 3/31/25. The Pharmacy Consultant's drug regimen review dated 3/12/25 included no recommendations for a stop date for Ativan 0.5 mg and there was no clinically significant medication issues identified. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 was cognitively intact. The MDS documented Resident #2 received antianxiety medication 7 out of 7 days during the assessment period. During an interview with the Pharmacy Consultant on 4/23/25 at 2:00 PM, she stated that as needed psychotropics should have a stop date. The Pharmacy Consultant reported she reviewed Resident #2's chart and realized the original order had been entered incorrectly which would not have triggered the safeguards. She reports this was not realized until it was called to her attention during this survey. She reported that she was aware that all as needed psychotropics should have a stop date and be reviewed every 14-21 days. She stated this particular order stop date was missed because the for 14 days was entered in a comment section that was not part of the actual order and was not caught during the January 2025, February 2025, and March 2025 monthly pharmacy reviews. Therefore, when the order flowed over to the MAR it showed as an order without a stop date.

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside resident rooms that indicated the use of oxygen and failed to follow Physicians orders related to oxygen use for 2 of 2 residents reviewed for respiratory care (Resident #109, and Resident #110). The findings included: A. Resident #109 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD). A review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #109 was cognitively intact. The MDS indicated diagnosis of COPD and was not coded for oxygen use. A review of Resident #109's active care plan dated 4/8/2025 revealed there were no goals or interventions regarding oxygen or respiratory care included in the baseline care plan. Resident #109's April 2025 oxygen assessment flowsheet for nursing revealed all nursing staff documented oxygen flow rate was 2 liters per minute and completed a spot check for oxygen level. A review of Resident #109's orders revealed oxygen care orders: - (4/8/25) Nasal Cannula 1 liter per minute, keep oxygen saturation greater than 92% - (4/8/25) Pulse oximetry, continuous, maintain oxygen saturations greater than 94% An observation on 04/21/25 at 11:01 AM revealed Resident #109 sitting in his wheelchair with oxygen being administered via nasal cannula via wall oxygen concentrator at 2 liters. There was no caution or safety signage posted outside of Resident #109's room indicating supplemental oxygen was in use. An observation on 04/22/25 at 9:25 AM revealed Resident #109 sleeping in bed with oxygen being administered via nasal cannula via wall oxygen concentrator 2 liters. There was no caution or safety signage posted outside of Resident #109's room indicating supplemental oxygen was in use. B. Resident #110 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included respiratory failure. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated diagnosis of chronic respiratory failure with hypoxia and was coded for oxygen use. A review of Resident #110's oxygen care orders revealed: -(4/14/25) Oxygen Therapy nasal cannula, rate 3 liters per minute, keep oxygen saturation level greater than 90%. -(4/14/25) Initiate Adult Respiratory Chronic-Stable Bilevel Positive Airway Pressure/ Continuous Positive Airway Pressure (BIPAP/CPAP) Protocol (Adult Non-invasive Ventilation) continuously. An observation on 4/21/25 at 12:39 PM revealed Resident #110 awake with head of bed elevated with oxygen being administered via nasal cannula via wall oxygen concentrator. There was no caution or safety signage posted outside of Resident #110's room indicating supplemental oxygen in use. Resident did not allow a close enough observation to view liters of oxygen An observation on 4/23/25 at 2:51 PM revealed Resident #110 asleep with oxygen being administered via BIPAP via wall oxygen concentrator. There was no caution or safety signage posted outside of Resident #109's room indicating supplemental oxygen was in use. An observation of signs above double doors to the entrance of the skilled nursing unit on 4/21/25 at 11:00 AM and 4/23/25 at 8:30 AM, stated No Smoking Oxygen in Use. An interview with Nurse #1 on 4/22/25 at 01:22 PM stated she did not know if oxygen caution signs were on the resident's door, and was not aware oxygen caution sign should be posted on resident doors. Nurse #1 reported oxygen use was communicated verbally to other staff if residents had oxygen, and orders were reviewed by the nurse each shift. Nurse #1 also stated a respiratory assessment was completed by each nurse for each shift. An interview with Nurse #2 on 4/22/25 at 1:30 PM stated there was an oxygen cautionary sign over the entrance doors to the unit that stated, No Smoking Oxygen in Use. Nurse #2 reported that she had worked for the facility for seven years and used to place oxygen caution signs on resident doors. Nurse #2 stated, Lately staff have not placed signs on resident doors. Nurse #2 stated oxygen orders were communicated in staff-to-staff reports during each shift change. Nurse #2 stated that oxygen levels and care were communicated during nurse-to-nurse shift report. An interview with the Nurse Manager on 4/23/25 at 1:47 PM reported oxygen caution signs were located above the double doors to the entrance of the unit and on residents' doors. Nurse Manager stated that oxygen signs should be placed when an order was implemented. Nurse Manager revealed a respiratory assessment was completed and charted in the electronic health record. The assessment included an assessment of oxygen administration level. She reported that each nurse would review orders and a care plan for oxygen needs and communicate any changes during shift change report. If there was a discrepancy in what the nurse assessed and the actual order, the nurse would call the provider or send a secure chat to clarify an order. The Nurse Manger reported the nurses missed clarifying the order for Resident #109.

Based on observations, record review and staff interviews, the facility failed to follow physician orders for 1 of 1 resident (Resident #209) reviewed for professional standards of practice. The findings included: Resident #209 was admitted to the facility on [DATE] with a diagnosis that included Diabetes, and bilateral leg swelling. A review of the Admission Statement submitted by Nurse #1 on 4/18/2025 revealed Resident #209 was alert, disoriented to place, time, person, and event, speech was clear, and cognition level was appropriate for attention/concentration. At the time of review no behaviors had been identified. A review of the physician orders dated 4/18/25 revealed a treatment for no-sting barrier film to the right heel, heel floating boot placed on resident, and float heels always. A review of the Baseline Care Plan dated 04/18/2025 revealed a problem as skin integrity. The goal listed was that skin integrity would improve with the interventions of providing skin care and provide pressure relieving interventions. An observation and interview on 4/21/2025 at 1:11 PM revealed Resident #209 was up in a recliner with both feet elevated with no heel floating boot and Resident #209's heels were not floating. Resident #209 stated he was admitted because his legs were swollen. He stated he was doing exercises with Physical Therapy/Occupational Therapy (PT/OT) to get rid of the fluid in his legs. Observation at 4/21/25 at 3:15 PM revealed Resident #209 was in bed with a heel floating boot on his right foot. There was no heal floating boot under the sink at the time of the observation. Resident #209 stated he had a heel floating boot that morning while in bed. Resident #209 stated when he got up in the chair staff removed his heel floating boot so he could get some traction. Resident #209 stated they leave the heal floating boot off while he was in the chair. An observation and interview with the Occupational Therapist on 4/22/2025 at 10:41AM revealed Resident #209 lying in the bed with both legs laying flat on the bed without a heel floating boot on the right foot. Two pillows were observed to the right of Resident #209's legs. A dark purple circular area was observed on the resident's right heal. At the end of therapy Resident #209 was assisted into the recliner by the therapist with the stand to lift chair. She was observed floating the residents heals with two pillows under his legs but did not place the heel floating boot on Resident #209's right heel. The therapist stated she assisted him in the chair for the first time on 4/21/2025. An interview and observation with Nurse #1 on 4/22/2025 at 12:21 PM revealed she was the nurse that admitted Resident #209 on the 4/18/2025. She stated he had dry areas to his right leg that looked like scratches and abrasions and a light gray area on his right heel. Nurse #1 read the treatment orders out loud during the interview. Orders for no sting barrier film to the right heel daily, heal floating boot placed on patient, and float heals at all times. She stated she received a new heal floating boot for him this morning around 10:30am because the other one was dirty, but she did not have time to apply it yet. Nurse #1 and the surveyor walked to Resident #209's room. The resident was sitting in the recliner with both heels resting on the leg rest without his heels being floated. Nurse #1 placed the heel floating boot on the right foot. Nurse #1 was observed not to float Resident #209's heels. An interview with the Minimum Data Set Nurse (MDS)/Nurse Supervisor on 4/22/25 at 12:33pm revealed that a new heel floating boot had come in for him today because the old one was soiled. The MDS/Nurse Supervisor was made aware that Resident #209 had been observed without the heel floating boot or feet being floated on pillows. The MDS/Nurse Spervisor stated if a heel floating boot was not available, she would expect the heels to be floated. An interview with Nurse #6 on 4/22/2025 at 1:03 PM revealed she had removed the pillows under Resident #209's legs during lunch. She stated she removed pillows so she could place his lunch tray on the overbed table over the resident's lap. She stated she thought she had put the pillows back under Resident #209's legs but must have forgotten. Nurse #6 stated if the heel floating boot was not available for the resident she would float his heels with pillows. An interview with the Physician's Assistant (PA) at 04/22/25 at 2:03 PM revealed he had not assessed Resident #209 this morning. The PA was notified that Resident #209 was observed without a heel floating boot on his right foot and without his heels being floated. He stated he would expect staff to follow the orders for the heel floating boot and heels to be floated.

Based on observations, record reviews, resident, staff, and Nurse Practitioner interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey conducted on [DATE]. This failure was for one deficiency that was originally cited in the area of Resident Rights (F578) that was subsequently recited on the current recertification survey of [DATE]. The repeat deficiency during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F578: Based on observations, record review, staff, and Nurse Practitioner interviews the facility failed to complete an advance directive when the resident elected Do Not Attempt Resuscitate (DNAR) status with limited scope of treatment (Resident #11) for 1 of 8 residents reviewed for advance directives. During the recertification of [DATE] the facility failed to follow a resident's wishes for Do Not Resuscitate (DNR) status as specified in their advance directives when the resident went into cardiac arrest (heart stopped) and the facility began Cardiopulmonary Resuscitation (CPR). The Nurse Manager was interviewed on [DATE] at 12:02 PM. The Nurse Manager stated that the facility's Quality Assurance (QA) committee consisted of all the managers on the unit, including both Minimum Data Set (MDS) Nurses, direct care staff, and others and they met quarterly. The Nurse Manager also stated that the facility was also a part of the hospital (the facility is attached to) QA meeting that included the pharmacy consultant and medical director. She explained that the facility had an issue with code status several years ago and they had corrected that and they would look at the advance directive information and make any needed adjustments to the their practice.

Based on observations, record review and staff, and Nurse Practitioner interviews the facility failed to complete an advance directive when the resident elected Do Not Attempt Resuscitate (DNAR) status with limited scope of treatment for 1 of 8 residents reviewed for advance directives (Resident #11). The findings included: Resident #11 was admitted to the facility on [DATE]. No Minimum Data Set (MDS) information was available. Review of a physician order dated 03/29/24 read: DNAR with limited scope of treatment. If the patient has no pulse and is not breathing: Do Not Attempt Resuscitation. If patient has pulse and/or is breathing but condition is deteriorating, limited scope of treatment. Do use medical treatment determined by the treatment team to be appropriate. These treatments may include vasopressors and other medications, intravenous (IV) fluids medications, cardiac monitoring, and synchronized cardioversion. Do consider use of less invasive airway support such as bilevel positive airway pressure (bipap) or continuous positive airway pressure (cpap). Do minimize suffering with medication and wound care. Do provide oral and body hygiene; keep warm and dry. Do consider palliative care consultation. Do not initiate endotracheal intubation or mechanical ventilation. Do not initiate unsynchronized cardioversion (defibrillation). The order indicated that the patient agreed with the order and the resident had current decision-making capacity. Review of Resident #11's electronic health record on 04/09/24 revealed no advance directive information (DNAR or Medical Orders for Scope of Treatment (MOST) forms) indicating that Resident #11 had chosen to be a DNAR with limited scope of treatment. Review of Resident #11's folder at the nursing station on 04/09/24 revealed no advance directive information (DNAR or MOST form) indicating that Resident #11 had chosen to be a DNAR with limited scope of treatment. An observation of Resident #11 was made on 04/09/24 at 10:37 AM. Resident #11 had just ambulated to his room with the assistance from the physical therapist and was sitting on the side of his bed. Nurse #1 was outside of his door preparing his morning medication. Nurse #1 was observed to prepare Resident #11's medication and then entered his room to scan his white identification bracelet that was on his left wrist. No other wrist band was noted on his right or left wrist at this time. MDS Nurse #1 was interviewed on 04/09/24 at 3:04 PM. She stated that the facility had recently switched to a new electronic health record and when they did that, they did away with the resident's hard chart and only used folders. Any advance directive information like a DNAR form or MOST forms would be in the folder at the nursing station. MDS Nurse #1 stated that she was not sure if any of the current residents had a DNAR or MOST from but if they did it would be in the folder at the nurse's station. A follow up interview was conducted with MDS Nurse #1 on 04/10/24 at 10:20 AM. MDS Nurse #1 stated that she had looked yesterday and could not locate any DNAR or MOST from for Resident #11. She stated that the facility utilized both the DNAR and Most forms and usually the Nurse Practitioner (NP) would get them completed at some point during their stay. She added that if there was a question about a resident's code status or advance directive information, the staff would look at the computer and any resident who had a DNAR would have a purple armband in place. The NP was interviewed on 04/10/24 at 10:59 AM. The NP stated that most of the residents in the facility came from the acute care hospital attached to the facility and when they admitted to the unit, she verified that the resident had a code status in place. The NP explained that she typically consulted the MOST form if the resident came in as a full code, but if the resident came in as a DNAR it was not customary to complete the DNAR or MOST form. She stated she had never been told that they have to complete the DNAR or MOST form. She explained that they had different tiers of DNAR and those residents would have a purple wristband in place and the staff would look at the computer to find out the residents code status or advance directive information. An observation of Resident #11 was made on 04/10/24 at 12:45 PM. Resident #11 was sitting on the side of his bed eating lunch. He was observed to have a purple wristband in place. The Nurse Manager was interviewed on 04/10/24 at 1:11 PM. The Nurse Manager stated that code status information was written as an order by the provider. She explained that the facility had different levels of code status and scope of treatment. The electronic health system puts that information on a banner in the system and the staff recognized the protocol. If a resident was transported outside of the facility and they wished to have their DNAR or MOST from go with them then the facility would complete them. The Nurse Manager explained that each scope of treatment was different for each resident and was documented in the physician order. MOST forms are a portable form used and are not automatically completed. Finally, the Nurse Manager explained that if the computers were down, they had a down time computer which was kept off site and in the event it was needed a manager would have to obtain the down time computer which housed all the resident information. She added that if a resident was a DNAR they would also have a purple wristband in place.

Based on observations, record review and staff and resident interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen for 1 of 1 resident reviewed for respiratory care (Resident #14). The findings included: Resident #14 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. A review of Resident #14's admission Minimum Data Set assessment was unable to be completed due to Resident #14's recent admission to the facility. Review of Resident #14's physician orders revealed an order for oxygen delivered via nasal cannula at 5 liters per minute (lpm) continuously. An observation of Resident #14 on 04/09/24 at 11:33 AM revealed he was in his room, sitting in his wheelchair, watching television. Resident #14 was observed with a nasal cannula with oxygen being delivered at 5 lpm. There was no cautionary or safety signs noted in Resident #14's room, his door, or anywhere in his environment. An interview with Resident #14 on 04/09/24 at 11:34 AM revealed he received oxygen continuously through his nasal cannula and he believed that it was set at 5 lpm. Another observation of Resident #14 was completed on 04/10/24 at 9:48 AM. Resident #14 was in his bed, resting with his eyes closed. Resident #14 was observed wearing his nasal cannula with oxygen being delivered at 5 lpm. There was no cautionary or safety signs noted in Resident #14's room, his door, or anywhere in his environment. An interview with Nurse #1 on 04/10/24 at 12:50 PM revealed Resident #14 admitted from the hospital receiving oxygen continuously at 5 lpm. She reported the facility did not utilize oxygen signage. She reported the hospital where the facility was located was non-smoking and that she did not feel it was necessary to have cautionary or safety signage posted for residents who utilized oxygen. An interview with Nurse Manager on 04/10/24 at 1:13 PM, she reported the facility did not utilize oxygen cautionary and safety signs since the facility was located in a hospital and the hospital was a non-smoking facility. She reported that the facility would obtain safety and cautionary signs and ensure that they were posted.

Based on observation, record review, resident and staff interviews the facility failed to develop a baseline care plan for a resident on fluid restrictions (Resident #55) and for a resident that was receiving an anticoagulant (Resident #156) for 2 of 6 residents reviewed for care plans. The findings included: 1. Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan titled Fluid volume created on 07/02/21 read; fluid volume will improve, and fluid intake will improve. No Minimum Data Set (MDS) information was available. An observation and interview were conducted with Resident #55 on 07/06/21 at 10:13 AM. Resident #55 was sitting up in her chair and had her feet elevated. There was a sign above her bed that read; fluid restriction 6:00 AM to 6:00 PM= 1000 ml and from 6:00 PM to 6:00 AM=500 ml. Resident #55 stated that she had a chronically low sodium level and stated if she drank too much water it would bring her sodium level down even lower. Resident #55 stated that at home she drank electrolyte replacement which helped bring her sodium up a little bit. She confirmed that she remained on a fluid restriction to help keep her sodium level up. An interview with Nurse #2 on 07/07/21 at 2:42 PM revealed she was familiar with Resident #55 and was aware Resident #55 was on fluid restrictions. She was unaware if the facility had a specific care plan for fluid restrictions but stated the Charge Nurse (CN) would know. She added that Resident #55 had a fluid volume care plan in place but did not know if fluid restrictions could be added or not. The Charge Nurse (CN) was interviewed on 07/07/21 at 10:33 AM. The CN stated that the admission nurse was responsible for entering care plan when a resident admitted to the unit. She added that when she completed the comprehensive MDS she would ensure that all care plans that were needed were in place and update them as needed. The CN was not aware if there was a care plan for fluid restrictions or not. She said they have 1000 care plans to choose from but was not sure if they included fluid restrictions or not, but she would look into it. 2. Resident #156 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to Resident #156's recent admission, a Minimum Data Set Assessment review was unable to be completed. A review of Resident #156's electronic physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #156's care plan dated 07/03/21 revealed no care plan for the use of anticoagulants. An interview with Nurse #2 on 07/07/21 at 2:42 PM revealed she was familiar with Resident #156 and was aware Resident #156 was receiving anticoagulation medications. She was unaware if the facility had a specific anticoagulant medication care plan and reported the Charge Nurse would know. An interview with the Charge Nurse on 07/07/21 at 3:57PM revealed nursing was responsible for entering care plans into the resident's electronic medical records and she verified them when she completed the comprehensive assessments. She reported staff monitor all the residents for potential side effects of prescribed medications, but the facility did not have a specific anticoagulant medication care plan built into their electronic medical record system. She stated most, if not all of the residents in the facility are on anticoagulant medications and was certain the nurses monitored for side effects. She stated she thought that they could create an anticoagulation care plan and would look into it.

Based on record review and staff and Medical Doctor interviews the facility failed to follow a resident's wishes for Do Not Resuscitate (DNR) status as specified in their advance directives when Resident #61 went into [CONDITION(S)] (heart stopped) and the facility began Cardiopulmonary Resuscitation (CPR) for 1 of 1 death records reviewed. The findings included: Resident #61 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of admission Minimum Data Set (MDS) dated [DATE] indicated that Resident #61 was moderately impaired for daily decision making and required limited to extensive assistance with activities of daily living. Review of a nurses note dated [DATE] read in part, Nurse Aide (NA) in room to check resident and he was noted to have agonal (abnormal breathing) breathing with oxygen in place, rapid response was called at 2236 (10:36 PM). Resident stopped breathing and was unresponsive at 2238 (10:38 PM) Code Blue was called and CPR started. Shock given at 2243 (10:43 PM) for VFib (heart quiver). Medical Doctor (MD) in room to assess and called code at 2245 (10:45 PM) and pronounced resident dead at that time. Family notified. The note was signed by Nurse #1. Nurse #1 was interviewed on [DATE] at 2:16 PM. Nurse #1 stated that she generally worked the night shift from 7:00 PM to 7:00 AM on the unit. She stated she kind of remembered the event on [DATE] but nothing specific. She stated she was sure she was aware of Resident #61's code status but could recall anything specific about the situation as to why Resident #61 was coded. Nurse #1 stated that generally they obtained code status during report and then it was kept on a resident's bracelet and in the computer. She explained if she found a resident not breathing, the first thing she would do was to determine the resident code status by looking on their bracelet and then verify that by looking in the computer. Again Nurse #1 stated that she could not recall that far back and could not speak to any details about the incident. Review of note from the Medical Doctor (MD) dated [DATE] read in part, I was working in the emergency department (ED) when code blue was called at 2238 (10:38 PM). I and a nurse responded to the code. When we arrived Cardiopulmonary Resuscitation (CPR) was in process. Patient was being bagged by Respiratory Therapist (RT) without difficulty. Shortly after I arrived rhythm checked and showed VFib. Patient was shocked unsynchronized at 200 joules and CPR was resumed. Nursing then notified me that patients chart indicated he was a DNR. Patient then noted to have a DNR bracelet on. At that time another pulse check was performed, and patient was noted be pulseless. In accordance with the patient's wishes resuscitative efforts were stopped at 2245 (10:45 PM). I notified the hospitalist of the events and Nursing contacted the family. Signed by the MD. The MD was interviewed on [DATE] at 3:35 PM. The MD explained that he was working in the ED on [DATE] when a code blue was called and per their protocol, he and a Nurse from the ER responded. The MD stated that when he entered the room there were various staff members actively trying to resuscitate Resident #61. The MD stated he did not know any of the staff in the room as he was assigned to the ER. The MD stated that shortly after he arrived the staff did a rhythm check which showed Vfib and we provided a shock to Resident #61 and continued with CPR. During this scene one of the nurses stated that she saw something in his chart that stated he was a DNR and then another staff member stated oh yes, I see his DNR bracelet. The MD stated when he saw that he did a rhythm check and Resident #61 was pulseless, so the resuscitative efforts were stopped, and Resident #61 was pronounced dead. The MD stated if he had known that Resident #61 was a DNR he would not have shocked him, and the CPR would have been stopped. He continued to say that he was informed that when Resident #61 went to the ER earlier that day the computer software had erased his code status. The MD stated that the issue had since been corrected with their software company and that when a resident was transferred from one unit to another the orders stayed the same unless changed by the provider including code status. The RT was interviewed on [DATE] at 3:20 PM. The RT confirmed she responded to Resident #61's code on [DATE]. She stated when she arrived at the room, it was full of other staff members and they had the code cart and were actively coding or performing CPR on Resident #61. The RT stated that at the time she assumed the staff had already verified his code status but at some point, during this code the nursing staff had discussion about his code status and someone stated he was a DNR. She added that the MD arrived around the same time she did and when he heard that the resident was a DNR the code was called, and Resident #61 was pronounced deceased by the MD. The RT stated she did not recall if Resident #61 had a DNR bracelet on or not, she explained she was responsible for airway and did not generally pull a chart or look at bracelet when she entered a room and the resident was already being actively coded with CPR in progress. The Charge Nurse (CN) was interviewed on [DATE] at 3:56 PM. The CN explained that when Resident #61 went to theER on [DATE] the staff had transferred him on a leave of absence and when they did that the computer software erased the code status from Resident #61's chart. When the staff reentered Resident #61 from the leave of absence, they should have had the provider reenter the code status, but they did not know that it had been erased and had no code status. When Resident #61 went into [CONDITION(S)] the staff coded him even though he had a DNR bracelet on and they should not have. The CN stated that they worked with the IT department to fix the software issue and during that time talked to the staff individually and gave them a copy of our DNR policy and posted it in the nurses station. She added that the Nurse Manager placed the information on the hot topic that was electronically sent out to all staff and we continued to discuss code status during each shift report so that everyone was aware of the code status. The CN stated that the software had been corrected and no longer erased any orders when a resident was placed on leave of absence. The Nurse Manager (NM) was interviewed on [DATE] at 11:00 AM. The NM stated that Resident #61 had [CONDITION(S)] and was coded by the staff and he should not have been because he had a DNR in place. The NM stated that what occurred was earlier in the day on [DATE] Resident #61 had a fall in his room and had hit his head and was transferred to the emergency room (ER) for a scan of his head. When Resident #61 left the facility to go to the ER the staff placed Resident #61 on a leave of absence. Resident #61 returned to the facility a short time later and the staff took him off the leave of absence but unknown to them his code status had been wiped clean from the electronic medical record. The NM explained after the event we began to look at why that occurred and discovered it was something in our software design that occurred when a resident was placed on a leave of absence. When a resident was on a leave of absence the software was prompting for the code status to be reentered however the staff did not know that it needed to be reentered. The NM stated that they worked with Information Technology (IT) to correct the issue and a new software version was released on [DATE] that corrected the issue. So now when a resident was placed on a leave of absence (sent to the ER) and returned everything stayed the same with code status and nothing was wiped out.

Based on record review and staff interview the facility failed to develop a baseline care plan that included minimum healthcare information to provide effective person-centered care for 1 of 1 resident with an ostomy (Resident #110). The findings included: Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No Minimum Data Set (MDS) information was available for Resident #110. Review of a physician order [REDACTED]. Empty and measure drainage every 4 hour and as needed. Change ostomy bag every 4 days and as needed. Review of Resident #110's medical record revealed no baseline care plan for ostomy care on the admission of 06/17/19. An interview was conducted with the Night Charge Nurse on 06/27/19 at 3:26 PM. The Night Charge Nurse confirmed that she was responsible for initiating baseline care plans when a resident admitted to the facility. She stated that they were currently working with the nursing staff to get the direct care nurses involved with the care planning process but at this time she was responsible for the care plans. The Night Charge Nurse stated that she initiated baseline care plans based on verbal report given and the residents active diagnoses. She added that the omission of the ostomy care plan was an oversight on her part and confirmed that Resident #110 would need an ostomy care plan and she would initiate it. The Day Charge Nurse was on vacation and unavailable for interview on 06/26/19 and 06/27/19. The Administrator was on vacation and unavailable for interview on 06/26/19 and 06/27/19.

Based on observations and staff interviews the facility failed to clean a large oscillating fan used to dry dishware. The findings included: An initial tour was made on 08/14/14 at 11:00 AM of the facility's kitchen. During the tour, observations of the dish room were made that revealed a large oscillating fan in use. The fan was positioned at the end of the dish machine's conveyor belt blowing air directly over the clean dishware as it exited the dish machine. Observations of the oscillating fan revealed thick dust accumulated on the back of the fan and along the sides. On 08/14/14 at 1:50 PM additional observations were made of the large oscillating fan in the dish room. The fan was in use and noted to have thick dust accumulation on the back of the fan and along the sides. The fan was blowing air directly onto clean plates, dome lids and pellet inserts as they exited the dish machine. The racks of clean dishware were left in front of the fan to dry. During the observations two dietary aides were working in the dish room. Dietary aide #1 was interviewed and reported that he had a daily assignment for cleaning that included mopping the floor and walls of the dish room. Dietary aide #2 was interviewed and explained that the large oscillating fan was used to quicken the drying process for the clean dishware. Dietary aide #2 stated that the fans in the kitchen were cleaned on the weekend. He reported that he cleaned the large oscillating fan the weekend prior but noted the fan accumulated dust after a few days of use and needed more frequent cleaning. He observed the fan and reported that it had dust build up and needed to be cleaned. On 08/14/14 at 2:10 PM the Registered Dietitian (RD) was interviewed and reported that oscillating fans in the kitchen were cleaned weekly. She explained that all kitchen equipment was on a cleaning schedule but she expected that at anytime a piece of equipment was identified dirty or dusty the staff member should clean the item right then. She added that the large oscillating fan had the potential for being a problem for contaminating clean dishware because the fan accumulated dust so quickly. The RD stated that her general expectation was that items in the kitchen were cleaned as needed.

Based on observations, staff interviews, policy and manufacturer instructions review, the facility failed to properly disinfect blood glucose monitors (glucometers) prior to use for 1 of 3 residents observed for blood glucose monitoring. (Residents #16, #84 and #85). Findings included: A review of the section from the facility's Nursing Service, Home Health and Laboratory Manual addressing use of glucometers, titled Infection Control Measures, revealed "the meter must be disinfected after each patient use in order to prevent transmission of pathogens between patients." Listed approved disinfectant products for use on glucometers included a product containing ammonium chloride. A review of the approved disinfectant used by the facility on glucometers, applied by disposable wipes saturated with the disinfectant solution, revealed the presence of ammonium chloride and that it was effective against all blood-borne pathogens. Instructions printed on the container of the disinfectant directed users to unfold a wipe and thoroughly wet the surface. The treated surface must remain visibly wet for a full 2 minutes, with use additional wipes if needed, to assure a continuous 2 minute wet contact time. On 06/11/13 at 4:43 PM two glucometers were observed in the medication room, inserted into docking stations for charging and data transmission. Nurse #1 was observed removing a glucometer from its docking station and she stated the glucometer had been previously disinfected and was ready for use. Nurse #1 gathered supplies and the glucometer and proceeded to the room of Resident #84. Nurse #1 obtained a blood glucose level for Resident #84. Nurse #1 returned to the medication room with the glucometer, removed a disinfecting wipe from the container, wiped the surface of the glucometer for approximately 10 seconds then placed it on a paper towel. The wiped glucometer was observed as dry in approximately 1 minute. Nurse #1 obtained insulin for Resident #84, returned to the Resident's room to administer the insulin, then returned to the medication room. Nurse #1 removed the other glucometer from a docking station and proceeded to the room of Resident #16. Nurse #1 obtained a blood glucose level for Resident #16. Nurse #1 returned to the medication room with the glucometer, removed a disinfecting wipe from the container, wiped the surface of the glucometer for approximately 10 seconds then placed it on a paper towel. The wiped glucometer was observed as dry in approximately 1 minute. Nurse #1 obtained insulin for Resident #16, returned to the Resident's room to administer the insulin, then returned to the medication room. Nurse #1 picked up the previously wiped glucometer from the paper towel, placed it on the medication cart and proceeded to leave the medication room stating she had another blood glucose level to obtain from a resident. Nurse #1 was asked to remain in the medication room. On 06/11/13 at 5:15 PM Nurse #1 was interviewed in the medication room. Nurse #1 read the instructions on the container of the disinfecting wipes and stated the instructions directed 2 minutes of wet contact time for disinfection. Nurse #1 stated she did not stand in the medication room to make sure glucometers remained wet for a full two minutes which would require a timer. Nurse #1 stated she was told in training not to leave glucometers overly wet due to risk of damage. Nurse #1 removed a disinfecting wipe from the container and re-wiped a glucometer for approximately 10 seconds, after which she looked at the clock on the wall of the medication room. Nurse #1 stated the wiped glucometer was completely dry between 45 seconds and 1 minute. Nurse #1 stated based on her method of wiping, the glucometer would not remain wet for 2 minutes as stated in the instructions. Nurse #1 re-wiped a glucometer with two disinfecting wipes over a 2 minute period, ensured the glucometer was dry, gathered other supplies and proceeded to the room of Resident #85. Nurse #1 obtained a blood glucose for Resident #85. On 06/12/13 at 12:14 PM the infection control officer was interviewed. She stated her expectation that glucometers be disinfected between each resident. She further stated each disinfecting solution had a different wet time and dry time, revealing the name of the disinfecting wipes used for glucometers. She stated during training on disinfection of glucometers, staff are told to continually wipe them for two minutes or to re-wipe to achieve full wet time as recommended by manufacturer of the disinfecting wipes. On 06/12/13 at 3:00 PM the nursing unit manager was interviewed. She stated her expectation that glucometers be disinfected between each resident, be wiped down for two minutes and be allowed to dry. She stated nurses must follow manufacturer's recommendations and two glucometers were available on the unit was to minimize time delays for nurses. The nursing unit manager stated there was a focus on the drying time of the disinfectant and not the wet time. She stated nurses are trained on disinfection of glucometers at time of hire and annually, as a part of their competencies, and this training is based on what the policy directs.