Every finding on record at Wilora Lake Healthcare

Based on record review and resident and staff interviews, the facility failed to protect a resident from misappropriation of personal funds when the former Business Office Manager used a resident's debit card to pay the former Business Office Manager's personal bills. This deficient practice affected 1 of 3 residents reviewed for prevent misappropriation of resident property (Resident #14). The findings included:Resident #14 was admitted to the facility on [DATE]. Resident #14 was her own Responsible Party.A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #14 was cognitively intact.A review of the Initial Allegation Report dated 3/6/2026 indicated the facility became aware of the misappropriation of Resident #14's funds by the former Business Office Manager on 3/6/2026 when the Travel Business Office Manager assumed the former Business Office Manager's duties of assisting Resident #14 with an ongoing Medicaid application. The former Business Office Manager had resigned her position as of 2/20/2026. The Travel Business Office Manager noted charges listed on Resident #14's bank statements that were for personal expenses for the former Business Office Manager. The misappropriation occurred between 9/30/2025 and 12/22/2025 and the total amount stolen was $4,945.62. Resident's 14's debit card was immediately cancelled and a new one was ordered on 3/6/2026. The Travel Business Office Manager notified the former facility Administrator of the misappropriation. The Administrator notified and interviewed Resident #14 who confirmed the charges were not authorized. The former Administrator filed reports with local law enforcement, Adult Protective Services (APS) and the State Agency. Resident #14's family was notified and an investigation was initiated immediately. The Initial Report was signed by the former Administrator.A review of the 5-Day Investigation Report revealed the facility had contacted local law enforcement and was waiting for a detective to be assigned to the case. APS had been notified but screened out the report and forwarded the information to the State Agency. The facility attempted numerous times to reach the former Business Office Manager for a statement but the former Business Office Manager did not respond to any of the attempted contacts. The Administrator and Regional Business Office Manager contacted the current residents, the resident representatives and the discharged residents from 3/1/2025 to 3/1/2026 to inquire if any unauthorized charges had been noted in their accounts. No concerns were noted. The former Business Office Manager was employed at the facility from 3/13/2025 to 2/20/2026. The facility held a Resident Council Meeting on 3/9/2026 to discuss misappropriation and that staff should not be using resident funds or receiving gifts. All staff members including contracted staff received education regarding abuse, neglect, and misappropriation on 3/9/2026. The facility requested a check from their corporate office in the amount of $4,945.62 to reimburse Resident #14. The 5-Day Investigation Report was signed by the former Administrator. A review of Resident #14's bank statements revealed that the former Business Office Manager had used Resident #14's debit card on 9/30/2025 for a credit card payment in the amount of $386.87; on 10/3/2025 for a credit card payment in the amount of $184.00; on 10/31/2025 for a natural gas payment in the amount of $567.88; on 11/5/2025 for a credit card payment in the amount of $544.04; on 11/25/2025 for a credit card payment in the amount of $334.71; on 11/25/2025 for a credit payment in the amount of $504.33; on 12/9/2025 for a credit card payment in the amount of $309.16; on 12/9/2025 for a credit card payment in the amount of $521.48; on 12/16/2025 for a credit card payment in the amount of $316.53; on 12/16/2025 for a credit card payment in the amount of $349.04; on 12/18/2025 for a credit card payment in the amount of $386.91; on 12/18/2025 for a credit card payment in the amount of $490.33 and on 12/22/2025 for an internet service fee in the amount of $50.34.A review of a report filed by local law enforcement on 3/6/2026 at 6:59 PM indicated that local law enforcement had been advised of credit card fraud as the suspected individual had used the victim's credit card to make unauthorized charges at multiple online locations.An interview was conducted with Resident #14 on 4/19/2026 at 3:13 PM. Resident #14 reported the former Business Office Manager used her debit card for the former Business Office Manager's own personal bills. Resident #14 stated she did not give the former Business Office Manager permission to use her card. Resident #14 went on to say she was disappointed in the former Business Office Manager as she had trusted her but that these things happened. Resident #14 stated she would not have known any money was missing from her account if the Travel Business Office Manager had not been reviewing past bank statements for the Medicaid application. Resident #14 handled her own financial affairs. Resident #14 indicated she initially was not going to press charges but decided that theft was theft and that was wrong. Resident #14 spoke with local law enforcement but had not heard anything further. Resident #14 thought the matter was in the hands of the police now. Resident #14 stated that the money taken had been reimbursed to her and had been put in her facility trust account per her preference. Resident #14 was satisfied with the resolution.An interview with the Director of Nursing (DON) was held on 4/22/2026 at 8:35 AM. The DON stated that once the misappropriation was identified that the former Business Office Manager had used the Resident 14's funds for her own personal use, the State Agency, APS and local law enforcement were notified. Resident #14 was notified by the former Administrator that the misappropriation had occurred and an investigation began immediately. The DON stated the former Business Office Manager had already left the position when the misappropriation was discovered. The facility had attempted to contact the former Business Office Manager but had been unsuccessful. The DON reported that no other issues with misappropriation of resident funds were identified during the investigation. The DON stated Resident #14 had been reimbursed for the amount of money misappropriated. A telephone interview with the former Business Office Manager was attempted on 4/22/2026 at 10:36 AM. The former Business Office Manager endorsed that she had worked at the facility a very short time but she would have to call back as was in a meeting and could not talk at that time. The former Business Office Manager disconnected the call and did not respond to future attempts to contact her by text message on 4/22/2026 at 1:51 PM and voice mail on 4/23/2026 at 8:35 AM.A telephone interview with the former Administrator was conducted on 4/22/2026 at 10:45 AM. The former Administrator indicated she had been advised on 3/6/2026 by the Travel Business Office Manager that unauthorized charges had been made on Resident #14's debit card by the former Business Office Manager for personal expenses. The Travel Business Office Manager had taken over assisting Resident #14 with her Medicaid application as the former Business Office Manager had resigned. When Resident #14's bank statements were reviewed by the Travel Business Office Manager, the misappropriation of funds was discovered. The former Administrator stated she contacted the State Agency, APS, and local law enforcement. An investigation began immediately. The former Administrator stated she was never able to contact the former Business Office Manager to obtain a statement. Resident accounts were reviewed and no other residents (both current and residents present (but now discharged ) during the time the former Business Office Manager worked in the facility) were identified as having funds misused. The former Administrator stated she had no idea why Resident #14 was targeted. The former Administrator stated there had been no employment issues with the former Business Office Manager and she had worked a notice and resigned under good standing. The former Administrator stated she never had any idea that the former Business Office Manager would have misappropriated any resident's funds and thought she was a good employee.An interview was conducted with the Travel Business Office Manager on 4/22/2026 at 11:10 AM. The Travel Business Office Manager stated that she identified the misuse of Resident #14's funds while reviewing Resident #14's bank statements. The Travel Business Office Manager indicated she had taken over the former Business Office Manager's duties after she had left the position. The Travel Business Office Manager reported she was assisting Resident #14 with her ongoing Medicaid application. The Medicaid office had asked for the past 3 years of bank statements to confirm the pension amounts Resident #14 received on a monthly basis. Resident #14's bank records from 5/2023 to 12/2025 were received and when the Travel Business Office Manager began to review these on 3/6/2026, she stated she noted transactions made in the name of the former Business Office Manager beginning 9/30/2025 and ending 12/22/2025. The Travel Business Office Manager immediately reported the misappropriation to the former Administrator, the Business Office Supervisor at corporate and an investigation began immediately. The Travel Business Office Manager stated she had no idea why Resident #14 had been targeted. Reviews of all resident accounts during the time the former Business Office Manager worked in the facility were conducted and no other unauthorized transactions were identified. The Travel Business Office Manager stated it was a rare occasion when there was a resident filing a Medicaid application and needed the facility's assistance with the application process. The Travel Business Office Manager stated usually a resident's Responsible Party, Financial Power of Attorney or Guardian handled the application process. Resident #14 handled her own finances and did not have involved family to assist her with the Medicaid application process. An interview with the Regional President of Operations was conducted on 4/22/2026 at 12:10 PM. The Regional President of Operations reported she was involved in the investigation and had contacted Resident 14's bank fraud unit. The Regional President of Operations was told the charges were over 90 days old so the bank fraud unit could not assist Resident #14 and this was a matter for local law enforcement. The Regional President of Operations stated the facility audited all resident accounts that were active when the former Business Office Manager was employed at the facility and no other issues were noted with those accounts. The Regional President of Operations did not know why Resident #14 was targeted for misappropriation by the former Business Office Manager.An interview with the Administrator was conducted on 4/22/2026 at 11:45 AM. The Administrator indicated the misappropriation had just been identified as she was taking over the position of facility Administrator. Reports to the State Agency, APS, and local law enforcement had been made. Resident #14 had received a letter from local law enforcement dated 3/31/2026 that the case had been assigned but law enforcement had not yet contacted the facility or Resident #14. The Administrator stated a reimbursement check for the total amount of the misappropriated funds had been deposited into Resident #14's facility trust account on 4/13/2026.On 4/23/2026 at 10:44 AM the assigned local law enforcement officer investigating the misappropriation responded via email. The Officer stated he was following up with the reporting person and the investigation was ongoing. The Officer stated he had advised his contact at the Medicaid Department of the Department of Justice regarding the status of the case.The facility provided a corrective action plan that was not accepted by the State Agency as it did not contain evidence that addressed prevention of misappropriation of resident funds.

Based on observations, record reviews, and staff interviews, the facility failed to follow their Infection Control policies and procedures for Hand Hygiene when Nurse Aide (NA) #1 failed to sanitize his hands in between changing his gloves while providing suprapubic urinary catheter care to Resident #24. The facility also failed to follow their Enhanced Barrier Precautions (EPB) policy and procedure when NA #1 failed to wear a gown while providing incontinence care and while transferring Resident #24 and then NA #1 and NA #2 adjusted the same resident up in the bed after placing a turn sheet under her without wearing a gown. The deficient practice occurred for 2 of 8 staff observed for infection control practices (NA #1 and NA #2).The findings included:1. a. Review of the facility's Hand Hygiene policy and procedure which is part of the Infection Control policies and procedures last revised on 11/13/25 revealed the following:Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and Compliance Guidelines:1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table.3. Alcohol-based hand rub (ABHR) with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Hand Hygiene Table:Alcohol based hand rub is preferred:After handling contaminated objects.Before applying and after removing personal protective equipment (PPE), including gloves.When during resident care, moving from a contaminated body site to a clean body site.When in doubt.An observation of suprapubic urinary catheter care on 04/20/26 at 2:29 PM with NA #1 on Resident #24 who was on Enhanced Barrier Precautions (EBP) with a sign on her door and a caddie of personal protective equipment attached to her door was completed. The observation revealed NA #1 washing his hands with soap and water and donning a gown, face shield and gloves. NA #1 proceeded to prepare 2 basins of water one with soap and water and one with just water. He placed the basins on the overbed table on top of a towel. NA #1 began by removing Resident #24's soiled brief and tossed it in the trash. NA #1 then removed his gloves and without sanitizing his hands, donned a clean pair of gloves and began cleaning the suprapubic catheter with soaped washcloths. After cleaning the catheter, he removed his gloves and without sanitizing his hands donned a clean pair of gloves and rinsed the catheter with a wet washcloth and then proceeded to apply a new pull up on the resident. After applying the pull up, he emptied the basins and doffed his face shield, gown, and gloves, washed his hands with soap and water and removed the dirty linen and trash from the resident's room and left the room.An interview on 04/20/26 at 2:46 PM with NA #1 revealed he realized after providing care that he had not followed appropriate hand hygiene when he didn't sanitize his hands after removing his gloves and before applying clean gloves. He stated he was nervous about being watched and said he just forgot to sanitize his hands and said he even kept hand sanitizer in his pocket.An interview on 04/20/26 at 2:51 PM with the Assistant Director of Nursing (ADON), who was the Infection Preventionist (IP) revealed NA #1 should have sanitized his hands each time he removed his gloves before putting on clean gloves. The IP stated she had done education with all the staff about hand hygiene and doffing and donning personal protective equipment (PPE).A telephone interview with the Director of Nursing (DON) on 04/23/26 at 11:19 AM revealed she would have expected NA #1 to have sanitized his hands each time he removed his gloves and before putting on clean gloves.b. Review of the Enhanced Barrier Precautions policy and procedure which is part of the Infection Control policies and procedures last revised on 11/13/25 revealed the following:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Policy Explanation and Compliance Guidelines:Implementation of Enhanced Barrier Precautions (EBP): a. Make gowns and gloves available immediately near or outside of the resident'sroom. Note: face protection may also be needed if performing activity with risk of splash or spray.b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room).High-contact resident care activities include: c. Transferring f. Changing briefs or assisting with toileting.An observation of incontinence care on 04/20/26 at 2:58 PM revealed a sign on the door indicating Resident #24 was on EBP with a caddie on her door containing PPE. The observation revealed NA #1 walking into Resident #24's room and donning gloves, obtaining a clean pull up and wipes and without donning a gown proceeding to remove the resident's pull up. NA #1 removed the pull up and began cleaning the resident in the front and then cleaned her behind. NA #1 was having difficulty getting the resident clean in bed and assisted her to stand with her walker so he could finish cleaning her behind and ensure her pull up was pulled up in the back. NA #1 then assisted the resident back on her bed, removed his gloves, sanitized his hands and left the room to get another staff member to assist in getting her pulled up and adjusted in the bed. NA #2 and NA #1 returned to Resident #24's room and donned clean gloves and without putting on a gown proceeded to assist the resident in moving side to side in the bed to place her turn sheet under her. After adjusting the turn sheet, NA #1 and NA #2 pulled the resident up in bed with the turn sheet and placed her covers over her. NA #1 and NA #2 removed their gloves; NA #1 removed the trash from the room and they both sanitized their hands after leaving the room.An interview with NA #1 and NA #2 on 04/20/26 at 3:04 PM revealed they were not aware they were supposed to wear a gown when providing incontinence care, transferring a resident, and adjusting a resident up in the bed. NA #1 and NA #2 stated they saw the sign and the caddie when going into the room but did not realize they had to wear PPE when adjusting a resident up in the bed. The EBP sign on the resident's door was reviewed with NA #1 and NA #2 and they both agreed they should have worn a gown while providing care to Resident #24.An interview on 04/20/26 at 3:15 PM with the IP revealed she would have expected NA #1 and NA #2 to have worn a gown while providing incontinence care, transferring the resident and adjusting the resident up in the bed. A telephone interview with the Director of Nursing (DON) on 04/23/26 at 11:19 AM revealed Resident #24 was on EBP due to her suprapubic urinary catheter and she would have expected NA #1 and NA #2 to have worn a gown during high-contact resident care activities.

Based on observation, record review, and staff interviews, the facility failed to provide toileting hygiene after a bowel movement and prior to placing a new and clean pull up on a resident dependent on staff for assistance with activities of daily living (ADL) for 1 of 4 residents (Resident #24).The findings included:Resident #24 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, neurogenic bladder with suprapubic urinary catheter, muscles weakness and lymphedema.Resident #24's care plan dated 02/26/26 revealed a focus area for impaired physical mobility with goal for resident to be able to perform activity within physical limits. The interventions included:Consult physical therapy per order.Determine level of assistance needed based on activities of daily living (ADL) evaluation.Encourage resident to increase activity as indicated.Evaluate resident's ability to perform ADL.Monitor for environment barriers to mobility.Observe resident's posture and gait.Observe range of motion in all joints.Resident #24's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and required substantial to maximal assistance of one staff member with toileting hygiene, bed mobility and sitting to standing with her walker. The assessment also revealed the resident was occasionally incontinent of her bladder and frequently incontinent of her bowels.An observation on 04/20/26 at 2:29 PM of suprapubic catheter care revealed Nurse Aide (NA) #1 providing care and the Assistant Director of Nursing (ADON) observing care as well.NA #1 began by removing Resident #24's pull up which had visible brown substance on the pull up and an odor of stool. The NA removed the pull up from the resident and without cleaning the resident from the bowel movement began care of her suprapubic catheter. After completing the care of the catheter and without cleaning the resident he placed a new pull up on the resident and placed her covers over her in the bed. NA #1 gathered his supplies and trash and left the resident's room.An interview on 04/20/26 at 2:40 PM with Resident #24 revealed she was not aware earlier that day that she had a bowel movement because she could not always tell but said if she had a bowel movement she would have wanted to be cleaned prior to having another pull up placed on her. Resident #24 stated she was a large resident and knew that it was sometimes difficult to clean her up but said she preferred to be clean and not have the smell of stool.An interview on 04/20/26 at 2:46 PM with NA #1 revealed he was aware Resident #24's pull up had a brown liquid substance on it earlier that day and said he didn't know why he had not cleaned her but said he was nervous about being observed providing suprapubic catheter care and had just forgotten to clean her. NA #1 stated he had seen the brown liquid substance on Resident #24's pull up and had smelled it when he removed it and said he should have cleaned her up prior to proceeding with her suprapubic catheter care. NA #2 further stated he would go back and clean her and place a clean pull up on her.An interview on 04/20/26 at 2:51 PM with ADON, who is also the Staff Development Coordinator and Infection Preventionist, revealed she had not seen the pull up was soiled with a brown liquid substance but stated she had smelled it and did not know why NA #1 had not cleaned the resident before putting on a clean pull up. She stated she should have stopped him and made him clean her but was not positioned where she could see what was on the pull up. The ADON stated she would have expected NA #1 to have cleaned the resident when he saw the brown liquid substance on her pull up.A telephone interview on 04/23/24 at 11:19 AM with the Director of Nursing (DON) revealed she expected the staff to clean all residents after a bowel movement before placing clean pull ups or briefs on them.

Based on record review and interviews with the Regional Ombudsman and staff, the facility failed to provide a written discharge notice to the resident and send a copy of the notice to the Regional Ombudsman for a resident discharged home for 1 of 1 resident reviewed for discharge (Resident #83). The findings included: Resident #83 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. The resident's overall goal was for discharge to the community and active discharge planning was already occurring with referrals made to the local contact agency. A nursing note dated 3/31/26 at 7:21 PM stated Resident #83 was discharged home. She was alert and oriented and medication administration was explained and Resident #83 verbalized understanding by repeating the process.A review of Resident #83's electronic medical record (EMR) revealed no transfer or discharge notice was issued to Resident #83. A telephone interview with Resident #83 was attempted but was unsuccessful as the phone number had been disconnected. A telephone interview on 4/22/26 at 4:25 PM with the Regional Ombudsman revealed she had not received any notices of transfer or discharge, to include Resident #83's discharge, since December 2025 when the Former Social Worker left the facility. A telephone interview occurred with the Former Administrator on 4/22/26 at 4:12 PM. She stated she left the facility at the beginning of March 2026, did not recall Resident #83 and did not recall if a written transfer or discharge notice was given to Resident #83. She indicated the Former Social Worker (SW) would send transfer and discharge notices to the Regional Ombudsman. The Former Administrator stated when the Former SW left the facility in December 2025, the Former Medical Records Coordinator oversaw sending the notices to the Regional Ombudsman. The Former Administrator stated she did not personally send a transfer or discharge notice for Resident #83 to the Regional Ombudsman. An interview with the SW on 4/22/26 at 4:23 PM revealed she came to the facility at the beginning of April 2026 and was not familiar with Resident #83. She stated she had taken over the responsibility of sending the transfer and discharge notices to the Regional Ombudsman. A telephone interview with the Former Medical Records Coordinator occurred on 4/23/26 at 12:38 PM. She stated she was employed at the facility from November 2024 to the end of February 2026. The Former Medical Records Coordinator stated the Former Administrator had a background in social work and handled all the tasks of the SW's role after the Former SW left in December 2025. The Former Medical Records Coordinator stated she did not recall Resident #83 or if she had received a transfer or discharge notice from the facility. The Former Medical Records Coordinator indicated she did not have access to any transfer and discharge notices to send to the Regional Ombudsman. A telephone interview with the Administrator on 4/24/26 at 8:59 AM revealed she came to the facility in the middle of March 2026. She had the expectation that a designated staff member would have provided Resident #83's discharge notice and would have sent copies of all written transfer and discharge notices to the Regional Ombudsman.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of prognosis for a resident receiving Hospice services and discharge location for 2 of 27 reviewed for accuracy of assessment (Resident #9 and Resident #73). The findings included: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and adult failure to thrive. A Hospice contract dated 01/14/2025 certified that Resident #9 was admitted under the care and services of Hospice for end of life. Further review of the Hospice admission documentation for Resident #9 indicated that a certification of Resident #9's prognosis of 6 months or less was received on 01/14/2025 at 9:24 AM. A significant change MDS assessment dated [DATE] had been completed. Resident #9 was cognitively intact and received Hospice services. Resident #9's prognosis of 6 months or less was coded no. A telephone interview on 02/13/2025 at 3:28 PM with the previous MDS Coordinator revealed that she coded no for the significant change MDS assessment dated [DATE] as she had no certification of the prognosis of 6 months or less. She explained she had coded yes to Section O-Special Treatments/ Services as she had been advised that Hospice services had been initiated for Resident #9. An interview on 02/14/25 at 11:27 AM with the Administrator indicated that the MDS assessment should be accurate. 39613 2. Resident #73 was admitted to the facility on [DATE]. His diagnoses included muscle weaknessand adult failure to thrive. Resident #73 had a discharge home with spouse care plan in place initiated on 11/07/2024. Interventions included discuss with the resident/resident's representative/caregivers the prognosis for independent or assisted living and identify, discuss and address limitations, risks, benefits and needs for maximum independence. The discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #73's discharge location was an acute hospital. Resident #73 was moderately cognitively impaired and had active discharge planning in process. Review of Resident #73's electronic medical record on 2/12/2025 revealed documentation that Resident #73 discharged home on 11/27/2024 with family. An interview was completed with the Social Worker on 2/12/2025 at 9:47 AM who stated Resident #73 was admitted to the facility for short term rehabilitation with discharge plans to return home with family. The Social Worker explained she arranged home health services, and no durable medical equipment was indicated. The Social Worker was not aware of Resident #73 discharging to the hospital from the facility. The Social Worker expressed Resident #73 discharged from the facility on 11/27/2024 to home with family. An interview was completed on 2/12/2025 at 10:04 AM with the traveling MDS Nurse. The traveling MDS Nurse stated she would have reviewed the resident's progress notes and would have been involved with discharge planning- inclusive of discharge location. The traveling MDS Nurse was not certain why the discharge location was not coded accurately. The traveling MDS Nurse further stated the discharge location should be accurately reflected in the MDS for discharge location. An interview with the Administrator was completed on 2/12/2025 at 11:00 AM. The Administrator voiced the MDS should be coded accurately to reflect the actual discharge location of the resident. A telephone interview was completed on 2/13/2025 at 3:28 PM with the previous MDS Nurse. She explained she coded the discharge location in error for Resident #73.

Based on record review, and resident, staff, Resident Representative, and Department of Social Services (DSS) Guardian interviews, the facility failed to ensure residents were given the right to participate in the revision of their person-centered care plans for 2 of 2 residents reviewed for care planning (Resident #12 and Resident #14). The findings included: 1. Resident #12 was admitted on [DATE] with diagnoses that included rheumatoid arthritis, frequent falls, depression, degenerative joint disease, and chronic joint pain. The quarterly Minimum Data Set (MDS) assessments dated 10/31/2024 and 01/24/2025 specified Resident #12 was cognitively intact. Review of Resident #12's electronic medical record revealed no evidence that she was invited to attend care plan meetings to discuss and provide input regarding her plan of care. An interview with Resident #12 on 02/10/2025 at 2:42 PM revealed that she did not recall being invited to a care plan conference or having her goals/progress discussed with her. Resident #12 indicated she would have liked to have talked about her progress and would have attended a care conference. An interview on 02/12/2025 at 11:06 AM with the Social Services Director indicated the care plan conference notification process began when Social Services received the MDS schedule from the MDS Coordinator. Social Services then verbally invited the Resident Representative via phone. Social Services provided the Resident with the Care Plan Conference Notification Letter. Social Services documented the care plan conference discussion and attendance in a social services progress note in the electronic medical record. The Social Services Director indicated she had invited Resident #12's Representative by telephone call and provided Resident #12 with the Care Plan Conference Notification Letter when care plan conferences were scheduled. Resident 12's last documented care plan conference listed on the care conference record was 08/07/2024. A review of the care conference record revealed no care conference documentation or invitation for the care plan conference scheduled following the 10/31/2024 and 01/24/2025 MDS assessments. An interview via telephone call on 02/13/2025 at 11:25 AM with Resident #12's Resident Representative (RR) revealed the RR did not recall participating in a care plan conference or ever discussing Resident #12's goals or progress with the facility. An interview on 02/14/2025 at 11:27 AM with the Administrator indicated that the care plan conference process was a Social Services responsibility. Social Services should contact the Resident and/or Resident Representative and arrange the date and time of the conference and then advise the team. The Administrator explained that the Social Worker would document the care plan conference and attendance in the resident's electronic medical record. 2. Resident #14 was admitted on [DATE] with diagnoses that included peripheral vascular disease, paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, Stage 3 chronic kidney disease, moderate dementia without behavioral disturbance, and depression. Resident #14's care plan revised on 11/25/2024 specified that Resident #14 had impaired cognitive function/dementia. A care plan intervention stated staff would communicate with the Resident/Resident's Representative regarding the Resident's capabilities and needs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 was cognitively intact. An interview with Resident #14 on 02/11/2025 at 9:12 AM revealed Resident #14 did not recall being invited to a care plan conference or a care plan conference being held. An interview on 02/12/2025 at 11:06 AM with the Social Services Director indicated the care plan conference notification process began when Social Services received the MDS schedule from the MDS Coordinator. Social Services then verbally invited the Resident's Guardian via phone. Social Services provided the Resident with the Care Plan Conference Notification Letter. Social Services documented the care plan conference discussion and attendance in a social services progress note in the electronic medical record. The Social Services Director indicated that she had invited Resident #14's Guardian and provided the Care Plan Conference Notification Letter to Resident #14. Resident #14's last care plan conference documented on the conference record was 06/20/2024 and Resident 14's signature was on the care conference record as having attended. There was no Social Service progress note that documented the 06/20/2024 care plan conference in the electronic medical record. A review of the care conference record revealed no care conference documentation or invitation for the care plan conference scheduled following the 09/01/2024 and 12/03/2024 quarterly MDS assessments. In a telephone interview on 02/13/2025 at 1:38 PM with Resident #14's DSS Guardian, she disclosed she had not received a care plan conference invitation for Resident #14 for some time including December 2024. An interview on 02/14/2025 at 11:27 AM with the Administrator indicated that the care plan conference process was a Social Services responsibility. Social Services should contact the Resident and/or Resident Representative and arrange the date and time of the conference and then advise the team. The Administrator explained that the Social Worker would document the care plan conference and attendance in the resident's electronic medical record.

Based on observations, record review, and resident and staff interview, the facility failed to provide personal privacy during incontinent care when the Nurse Aide exited the room during care and left the door to Resident #48's room open while the resident was unclothed and uncovered resulting in the resident being visible from the hallway while he was exposed. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident 48). The findings included: Resident # 48 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #48 was cognitively intact, frequently incontinent, and dependent on assistance for activities of daily living (ADL). An observation of incontinent care provided by Nurse Aide (NA) #1 for Resident #48 was conducted on 2/12/25 at 6:22 AM. NA #1 placed gloves on her hands outside the room. She was observed to have washcloths and linen supplies in the room with running water in the bathroom sink. She wiped Resident #48 with the washcloth and placed a clean pad and draw sheet underneath Resident #48. NA #1 then placed Resident #48 on his back and gave him a urinal. Resident #48 was without clothing or covering when NA #1 opened the door to leave the room to get gloves. NA #1 did not cover Resident #48 or offer Resident #48 to be covered. NA #1 left the door open with Resident #48 exposed to the hallway. When NA #1 returned, she closed the door, then continued to assist Resident #48 in dressing for the day. An interview with Resident #48 was conducted on 2/12/25 at 6:40 AM. Resident #48 stated NA #1 would leave his room while his entire body was exposed. Resident #48 stated he was tired of NA #1 coming in his room like she was angry and leaving him exposed to the hallway for others to see him. Resident #48 verbalized he was unable to cover himself due to weakness after he had a stroke. An interview with NA #1 on 2/12/25 at 6:50 AM stated her normal process was to have all supplies in the room when providing incontinent care. If she needed to leave the room she would cover the resident, close the curtain and the door. NA #1 stated she had not realized she left the door open leaving Resident #48 exposed when she left the resident's room. The NA stated she should have shut the door since the resident was exposed. On 2/12/25 at 6:45 AM an interview with Nurse #4 stated the normal process when providing incontinent care was to take the linen bin and cart to the room to have all supplies and place dirty linen in bags. If staff needed to leave the room, privacy was provided with the curtain or covering the resident. The Director of Nursing (DON) interview was conducted on 02/13/25 at 1:16 PM. The DON stated that all supplies for incontinent care should be in all residents' rooms. The DON stated that when staff needed to leave the resident's room for any reason, staff should cover the resident for privacy and drop bed down in the lowest position for safety. The DON stated no staff member should leave a resident exposed. An Administrator interview was conducted on 02/14/25 at 11:02 AM. The Administrator stated staff should maintain privacy during incontinence care and keep doors closed and the curtain pulled to maintain privacy.

Based on observations, record reviews, resident, and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse when Resident #20 hit Resident #7 on the back of his head and neck with a metal cane after Resident #7 entered back into their shared room to retrieve a personal item. Resident #7 had a raised red area on the back of his neck. This affected 1 of 3 residents reviewed for abuse (Resident #7). The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and essential primary hypertension. A review of Resident #7's care plan updated on 12/23/24 read he had a psychosocial wellbeing problem potentially related to disease process. The goal read Resident #7 will demonstrate adjustment to nursing home placement through review date. The interventions included allowing time to answer questions and verbalize feelings perceptions, and fears and initiate referrals as needed. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #7 was cognitively intact and had no behaviors. Resident #20 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease, essential primary hypertension, and unspecified intellectual disabilities. The quarterly MDS dated [DATE] indicated Resident #20 was moderately cognitively impaired, had no physical or verbal behavioral symptoms directed towards others, but did reject evaluation or care on a daily basis. A review of Resident #20's care plan last reviewed on 1/15/25 read he had potential to be physically aggressive when parting with possessions and trash, due to his belief he needed to save them. The goal read Resident #20 would not harm self or others, he would seek staff when agitation occurred and verbalize understanding of need to control physically aggressive behavior. Interventions included analyzing times of day, places, circumstances, triggers, and de-escalate behavior and document, assessing for contributing sensory deficits, and intervening before agitation escalated, guiding away from sources of distress, and engaging calmly in conversation. An initial allegation report dated 2/2/25 read Resident #7 was hit by Resident #20 with a cane. Residents were immediately separated, and Resident #7 had a bump on his head and a reddened area on his neck. Both residents remained separated. The report was signed by the Administrator on 2/2/25. A progress note for Resident #4 written by Nurse #5 dated 2/2/25 at 6:37 PM indicated Resident #7 was hit twice on the head with a cane by Resident #20 at 4:00 PM. Resident #7 was assisted to safety and assessed. The note further revealed a small red spot at the back of his head. The note read Resident #7 denied pain or discomfort and neurological checks were completed and Resident #7 was noted stable within his clinical baseline. He refused transport for evaluation at the emergency room . Nurse #5 was interviewed on 2/13/25 at 11:39 AM. She stated Resident #20 hit Resident #7 with his cane from behind when Resident #7 went back into his room to retrieve a personal item. She stated Resident #7 originally left the room because Resident #20 had been upset. Nursing Aide #8 separated them. She removed the cane and other metal objects from the room. Nurse #5 revealed Resident #7 had some redness on the back of his head but there was no swelling. She explained that she completed neurological checks as he refused transport to the hospital for evaluation, and he was fine. Nurse #5 stated Resident #7 wanted to be left alone and did not want to file charges with the police. A review of NA #5 witness statement was conducted. She heard Resident #7 crying out and saying he was being assaulted. She opened the door and found Resident #20 beating Resident #7 with his four-pronged cane while holding on to his chair. She stated Resident #20 was the only person fighting. She separated them. Multiple attempts were made to interview Nursing Aide (NA) #5 but were unsuccessful. An interview with Resident #7 on 2/13/25 at 12:34 PM revealed he was near the bathroom when he was hit on the head by Resident #20 with an object. He stated that he was moved to a different room after the incident. Resident #7 stated he couldn't recall exact details of the incident but stated he was not hurt, and he tried to get along with everyone in the building. The Social Worker (SW) was interviewed on 2/13/25 at 10:30 AM. She revealed Resident #20 did not like people near his belongings and it caused him to have aggressive behaviors. He had a roommate for a long time, and they were very compatible. When the roommate was discharged , she stated Resident #7 was a good match as Resident #7 had a lot of belongings. The SW explained staff was optimistic but after a couple of days together, Resident #20 became upset with Resident #7 in his space. The SW stated Resident #7 was moved to a private room for a day or two and wanted to move back. She stated when the incident occurred, Resident #7 removed himself from the room after Resident #20 became upset and he went back in to get his glasses. The SW explained Resident #7 took accountability for going back into the room when she discussed the incident with him the following day. She stated he was moved to the 400 hall and she set up counseling services for him. The DON was interviewed on 2/13/25 at 12:52 PM. She revealed Resident #7 went into the room to retrieve his glasses and then Resident #20 struck him with the cane. Resident #7 called out and staff separated them. The DON stated Resident #7 did not want to press charges and Resident #20 was sent to the hospital for evaluation. The Administrator was interviewed on 2/13/25 at 1:09 PM. He explained Resident #20 was aggressive when others were near his belongings, but he had not exhibited this level of aggressive behavior before this incident and wasn't generally a mean person. The Administrator stated Resident #20 was sent out for evaluation to the hospital after the incident.

Based on record review, staff and physician interviews, the facility failed to maintain documented evidence of a thorough investigation of an allegation of misappropriation of medication for 2 of 4 residents (Residents #278 & #279) reviewed for misappropriation of property. Findings included: a. Resident #278 was admitted to the facility on [DATE] with diagnoses that included hypertension and non-Alzheimer's dementia. b. Resident #279 was admitted to the facility on [DATE] and discharged home on 7/31/24. Her diagnoses included Diabetes Mellitus. The Initial Allegation Report dated 2/20/24 revealed the facility became aware of an allegation of drug diversion of resident drugs on 2/20/24 at 8:30 AM. Resident #278 was noted to be the affected resident. The Facility Investigation Report dated 2/22/24 read in part on the summary of the investigation for alleged narcotics missing for Resident #278. The Director of Nursing (DON) was notified that the narcotic medication was unable to be located in the narcotic lock box for Resident #278. At approximately 8:05 AM on 2/20/24 Nurse #6 was interviewed, urine drug screen tested negative, and suspended until further investigation of the missing narcotic. The DON called Nurse #7 to request she come into the facility. Nurse #7 stated she was out of town and would report to the facility the next day when she was scheduled to work. Nurse #7 did not come or call out for work on her scheduled shift. She did not answer her phone when the DON called her. There was no documentation related to Resident #279. The Facility Investigation Report dated 2/22/24 continued to read the facility put the following interventions in place to ensure ongoing safety of residents. - Audit of Narcotics for residents from 2/17 through 2/22, no resident's affected. - Staff interviewed. - Review of Narcotic records of residents receiving narcotics, no resident's affected. - Quality Assurance monitoring was completed for staff, no staff witnessed any other staff member appropriating facility property. - Education for licensed nurses started on 2/22/24 provided for Misappropriation of Resident's Property. Education will be ongoing upon hire, annually, and as needed to ensure proper protocol for Narcotics. An interview on 2/12/25 at 8:55 AM with Nurse #8 revealed that on 2/20/24 around 8:00 AM during morning shift narcotic medication count with Nurse #6, she had noted that Resident #278's discontinued narcotic medication had not been returned to the pharmacy. She also noted that Resident #279 had a new narcotic medication card and her previous card, which should have had pills on it, was missing. She stated she declined to take control of the narcotic keys from Nurse #6 and notified the DON of the medication abnormalities. An interview on 2/12/25 at 1:39 PM with the former Administrator revealed that the former DON completed the drug diversion investigation, and he had no direct knowledge of the investigation. An interview on 2/12/25 at 3:23 PM with the former DON revealed she was employed at the facility in February 2024 and completed this missing narcotic medication investigation. She stated she remembered the drug diversion and had left the completed investigation folder in the DON office. She stated the missing narcotics for Resident #278 and Resident #279 were not located. The former DON stated she did not know why only one resident, Resident #278, was identified on the facility reported investigation report faxed to the state agency or why Resident #279 was not listed on the report. An interview on 2/13/25 at 12:26 PM with the former Administrator and the [NAME] President of Clinical Operations revealed they had looked through the drug diversion investigation folder from the former DON's office and were unable to find the narcotic count sheets, substance inventory count sheets, staff interviews or audit sheets. An additional interview on 2/13/25 at 1:07 PM with the former DON revealed that all the investigation information was in the folder, and she had no further information. An additional interview on 2/13/25 at 1:37 PM with the former Administrator and the [NAME] President of Clinical Operations revealed they had been unable to locate any further documentation. Review of the facility investigation report documentation revealed that there were no documents for Resident #279 missing narcotics or that the BON was notified. The investigation folder revealed no shift control substance inventory count sheets for February 2024, no narcotic sign out sheets for Resident #278 or #279, no staff interviews, and no narcotic medication audit sheets. An interview on 2/13/25 at 1:40 PM with the Administrator revealed that he was not employed at the facility during this missing narcotic investigation and had no additional information.

Based on record review, and staff and Regional Ombudsman interviews, the facility failed to provide a complete written notice of transfer/discharge that included the Nursing Home Hearing Request form to the Resident and Resident Representative for 1 of 3 residents (Resident #20) reviewed for facility-initiated discharge. The findings included: Resident #20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #20 was moderately cognitively impaired. A review of the record revealed Resident #20 had a Resident Representative (RR) listed as an emergency contact. A review of a nurse's progress note written by the Director of Nursing (DON) dated 2/2/25 revealed Resident #20 was sent to the emergency room for a psychological evaluation and treatment due to behaviors. The facility did not readmit Resident #20. An interview with the DON on 2/13/25 at 12:52 PM revealed she called Resident #20's RR on 2/3/25 and informed him that Resident #20 was admitted to the hospital and the facility would not accept him back due to his behaviors. She stated the Administrator consulted with the Regional Ombudsman and a discharge notice was issued to the hospital Social Worker for Resident #20. She stated she was unsure if Resident #20 or his RR received the notice sent to the hospital Social Worker. She stated she was not aware of any discussion related to issuing both pages of the transfer/discharge notice. A review of Resident #20's record revealed a notice of transfer/discharge form was completed by the Administrator on 2/3/25 but did not include the second page entitled Nursing Home Hearing Request form. A telephone interview was conducted with the Regional Ombudsman on 2/13/25 at 8:05 AM. She stated she had a telephone discussion with the Administrator and the DON regarding Resident #20's discharge from the facility. The facility emailed a copy of the transfer/discharge notice and upon receiving it, she informed the Administrator over email the form was not complete as it did not contain the second page of the notice for Resident #20 to appeal the discharge. An interview was conducted with the Administrator on 2/13/25 at 1:09 PM. The Administrator stated he did not attach the second page of the transfer/discharge notice on 2/3/25. He stated when he pulled up the form on his computer, it only included one page. He was not aware there was a second page for a Hearing Request until the Regional Ombudsman alerted him to it.

Based on record review, and Hospital Case Manager and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for a medical evaluation using the residents' behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #20). The findings included: Resident #20 was admitted to the facility on [DATE]. Diagnosis included end stage renal disease, essential primary hypertension, and unspecified intellectual disabilities. A review of a nurse's progress notes dated 2/2/25 revealed Resident #20 struck another resident with a cane, attempted to hit staff with objects and barricaded himself in his room. Resident #20 was sent to the emergency room for a psychological evaluation. A review of a second nurse's progress note dated 2/2/25 revealed Resident #20 was sent to the emergency room for a psychological evaluation and treatment due to behaviors. An interview with the Director of Nursing on 2/13/25 at 12:52 PM revealed she called Resident #20's Resident Representative (RR) on 2/3/25 and informed him that Resident #20 was admitted to the hospital and the facility would not accept him back due to his behaviors. She stated she called Resident #20's RR on 2/3/25 and explained that the facility was not an appropriate placement for him due to his aggressive behaviors. The DON stated a transfer/discharge notice was issued on 2/3/25 and a copy was given to the hospital social worker. She explained the hospital social worker initially pressured them to accept Resident #20 back to the facility. She stated Resident #20's family came and retrieved his belongings. Multiple attempts were made during the survey to interview the hospital social worker and were unsuccessful. An interview with the Administrator on 2/13/25 at 1:09 PM revealed he was aware Resident #20 was sent to the hospital after an incident where Resident #20 struck another resident with a metal cane. He stated Resident #20 would not return to the facility due to his behaviors and his diagnosis of an intellectual and developmental disability (IDD). The Administrator stated his other residents in the facility would not be safe if Resident #20 returned to the facility due to his aggressive behavior he exhibited when others were near his belongings. He stated the hospital social worker pushed to have Resident #20 return to the facility, but he stated she understood after a notice of transfer/discharge was issued. He stated the hospital would have to find placement for him. He indicated the hospital social worker would have a hard time placing Resident #20 in another facility. The Administrator was informed by the survey team on 2/14/25 at 11:08 AM that there was an expectation for the facility to allow Resident #20 to return. A telephone interview with the hospital case manager occurred on 2/19/25 at 9:31 AM. She stated she was familiar with Resident #20 as he was inpatient at the hospital as of 2/19/25. She explained the case management team was actively looking for placement in another facility for him. The Hospital Case Manager stated she had a discussion with the Administrator on the afternoon of 2/14/25. She indicated the facility would not accept Resident #20 back to the facility due to his ongoing verbal and physical aggression towards staff and other residents. She stated Resident #20 had been cleared for medical discharge for many days and was currently waiting on placement in a facility.

Based on record review, observations,and family, staff, and Nurse Practitioner interviews, the facility failed to implement fall prevention interventions consistent with resident's care plan (Resident #5 and Resident #6) and failed to provide a safe transfer using a mechanical lift for Resident #36. This deficient practice occurred for 3 of 6 residents (Resident #5, Resident #6 and Resident #36) reviewed for accidents. The findings included: Resident # 6 was admitted to the facility on [DATE]. Diagnosis included cerebral infarction with right side weakness, muscle weakness, unspecified dementia, and unsteady on feet. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was severely cognitively impaired, required partial to moderate assistance for transfers, walking not attempted due to safety, no falls prior to admission and one fall since admission with no injury. The incident report dated 1/28/25 revealed that an aide and nurse observed resident sitting on buttocks on the floor in front of wheelchair at nurse's station. Resident #6's predisposing physiological factors were confused, gait imbalanced, and impaired memory. No injuries were observed, Resident #6 denied pain and was not sent to the hospital. Fall was reported to Physician and family member. The incident report dated 2/5/25 revealed the nurse was in the middle of her medication pass when an aide notified her Resident #6 was on the floor. Resident #6's was ambulating without assistance. Resident #6's predisposing physiological factors were confused, gait imbalanced, and impaired memory. No injuries were observed, Resident #6 denied pain and was not sent to the hospital. Fall was reported to Physician and family member. Resident #6's care plan updated 02/05/25 revealed a focus on resident was a fall risk related to weakness. Goal to minimize the risk of falls. Interventions included anticipating resident's needs (1/27/25), maintaining call bell in in resident's reach (1/27/25), Dycem (sticky nonslip material) to wheelchair cushion (1/28/25), fall mat x1 while resident was in bed (2/5/25), and low bed position (2/5/25). An observation completed on 2/10/ 25 at 1:07 PM revealed Resident #6 was asleep in the bed which was in the lowest position and a fall mat was not observed in the room. An observation completed on 2/11/25 at 2:00 PM revealed Resident #6 was sleeping in the bed which was in the lowest position and a fall mat was not observed in the room. An in person interview with Resident #6's family member on 2/10/25 at 12:13 PM revealed Resident #6 fell twice in her room while in the facility. The family member verbalized she was notified of both falls and that Resident #6 was not injured. The family member stated the facility informed her that a fall mat would be placed in Resident #6's room after Resident #6's first fall on 01/28/25 and she had never observed a fall mat in Resident #6's room. Nurse #4 stated during an interview on 2/12/25 at 6:20 AM, Resident #6 would try to get out of bed without assistance during the 11:00 PM to 7:00 AM shift; however, Resident #6 has not had a fall while she was assigned to Resident #6. Nurse #4 verbalized she would observe Resident #6 often for fall risk and if she observed Resident #6 getting out of bed without assistance, Nurse #4 would assist Resident #6 into a wheelchair and have Resident #6 sit by Nurse #4 at the nurse's station. Nurse #4 stated she had never seen a fall mat in Resident #6's room and did not recall if a fall mat was included in Resident #6's care plan. An interview with Nurse #3 on 2/13/25 at 10:20 AM stated she had been assigned to Resident #6 and was not aware Resident #6 did not have a fall mat in her room or required a fall mat. Nurse #3 verbalized that she did not know who would place the fall mat if ordered and did not know where fall mats were stored. Nurse Aide (NA) #4 was interviewed on 2/13/25 at 12:46 PM and stated that NA #4 had not worked with Resident #6 before being assigned to Resident #6 on 2/13/25 and had not observed a fall mat in the room. NA #4 also verbalized if she needed a fall mat she would ask the assigned nurse for assistance. An interview was conducted with the Director of Nursing (DON) on 02/13/25 at 1:02 PM. The DON stated when a resident had a fall it was discussed during the morning meeting with representatives from each facility discipline. The DON verbalized fall interventions were discussed and decided as a group, then the Minimum Data Set (MDS) Nurse would add the intervention to the resident's care plan. The representative from maintenance or housekeeping would retrieve the fall mat and place the fall mat in the resident's room. The DON stated that the nurse would assess if the fall mat was in place and the intervention was completed. DON verbalized the fall mat should have been in the room. An interview with the Administrator on 02/14/25 10:52 AM stated falls would be communicated in the facility team morning meeting to address prevention for future falls. The Administrator verbalized fall mats were placed by nursing, maintenance, or unit manager who all have access to storage. Fall mats were cleaned in a resident's room and removed once the resident was discharged from the facility. The Administrator stated that the method of fall prevention was communicated with family and then should be validated by nursing that fall mat was in place. 40200 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident and Diabetes Mellitus. Review of Physician's orders for Resident #5 revealed an order dated 4/23/24 for a fall mat to the left side of bed every shift. Review of Resident #5's care plan last revised 12/22/24 revealed a focus that read in part that the resident has potential for falls related to impaired mobility, incontinence, and unawareness of safety needs. An intervention read for a floor mat at bedside. Review of Resident #5's fall report dated 12/22/24 at 5:00 PM revealed the resident was found on the floor laying on the fall mat with no visible injuries noted. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #5 had moderately impaired cognition, was dependent on staff for most activities of daily living and had no refusals of care. She was coded for one fall with no injury during the 7 days look back period. An interview on 2/10/25 at 6:09 PM with Resident #5's responsible party revealed that the resident had a history of falls and used to have a fall mat, but it had not been in the resident's room lately. She was unable to say when she last saw the fall mat but thought it should be by her bed when she was in the bed. An observation on 2/11/25 at 12:45 PM revealed Resident #5 in bed with no fall mat by her bed. There was no fall mat observed in the room or adjoining bathroom. An observation on 2/11/25 at 3:20 PM revealed Resident #5 in bed with no fall mat by her bed. There was no fall mat observed in the room or adjoining bathroom. An observation on 2/12/25 at 8:10 AM revealed Resident #5 in bed with no fall mat by her bed. There was no fall mat observed in the room or adjoining bathroom. An observation and interview on 2/12/25 at 8:11 AM with the Director of Nursing (DON) in Resident #5's room revealed the resident was in the bed and no fall mat was by her bed. There was no fall mat observed in the room or adjoining bathroom. The DON stated the resident was supposed to have a fall mat and she did not know why there was no fall mat by Resident #5's bed or in the room. An interview on 2/12/25 at 8:19 AM with Nursing Assistant (NA) #5 revealed she was assigned to provide care for Resident #5 that day and provided care for her regularly. She stated she was not aware Resident #5 was supposed to have a fall mat and had not seen one in her room. An interview on 2/12/25 at 11:24 AM with Nurse #5 revealed she was assigned to Resident #5 that day and had been assigned to her in the past. She stated she was not aware the resident was care planned for a fall mat. She stated she had observed a fall mat in the resident's room a week or so ago when she assisted housekeeping and doesn't know what happened to it. An interview on 2/12/25 at 1:49 PM with the Administrator revealed that Resident #5 should have a fall mat beside her bed. He stated he thought that when the room was deep cleaned by housekeeping, they removed the fall mat to clean it and had not returned it to the room. He stated this was an oversight on the facility's part. An interview on 2/12/25 at 1:58 PM with the Housekeeping District Manager revealed that fall mats or equipment were not removed from the room during deep cleaning. He stated they were wiped and left in the room. 49366 3. Resident #36 was admitted to the facility on [DATE] with diagnoses including a chronic neurologic disorder and hypertension. The care plan dated revised 04/13/22 and revealed Resident #36 had a problem area related to activities of daily living self-care performance deficit due to impaired mobility and one intervention was to use a mechanical lift and two-person assistance for transfers (added 08/09/21). The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #43 was cognitively intact. An interview conducted with Resident #36 on 02/11/25 at 9:10 AM revealed that Resident #36 had no recollection of the fall that occurred on 02/08/24. A review of the facility incident report dated 2/8/24 at 7:02 PM written by the previous Director of Nursing (DON) revealed Resident #36 was being transferred with the mechanical lift when Nurse Aide (NA) #8 attempted to lift Resident #36 on mechanical lift and Resident #36's weight shifted causing the lift to tilt. The report indicated Resident #36 slid off the bed to the floor. Assessment was completed and no injuries were noted, and Resident #36 was able to move all extremities without difficulty and denied hitting her head. A review of a nursing progress note written by the former DON on 2/8/24 revealed she spoke to the Nurse Practitioner (NP) regarding Resident #36's fall as well as Resident #36's Resident Representative (RR). She noted no injuries were present. A telephone interview with Resident #36's RR on 2/12/25 at 10:39 AM revealed NA #8 was bringing Resident #36 back to her room from a shower. When she was transferring her into the bed, she proceeded to move Resident #36 to her bed and the lift tilted over and she fell on the other side of the bed. The RR stated she asked to have mobile x-rays completed and she stated the results were negative for any fractures. The RR indicated she was not present during the incident but was notified after it occurred. An interview with NA #8 on 2/12/25 at 5:13 PM revealed she worked with Resident #36 on 2/8/24 and was bringing her back to her room after a shower. When she transferred her using the mechanical lift, the lift tilted forward, and Resident #36 ended up on the other side of the bed, in between the wall and the bed. She stated Resident #36 remained in the lift pad which was near the floor. She called for help and NA #7 assisted her with the mechanical lift. NA #8 stated she believed the base of the lift was caught on a part of the bed and Resident #36's weight shifted causing the lift to lean forward. NA #8 did not indicate a reason why she transferred Resident #36 alone but acknowledged that she was aware all mechanical lifts required two-person assistance. An interview with NA #7 occurred on 2/12/25 at 5:25 PM. She stated she happened to be walking down the hallway on 02/08/24 when NA#8 called for help. She stated she went in to assist her and saw Resident #36 on the other side of the bed between the bed and the wall seated in the mechanical lift pad which was near the floor. She explained she helped lower Resident #36 to the floor with the mechanical lift for Unit Manager #1 to assess her. NA #7 stated that after Resident #36 was assessed by Unit Manger #1, she and NA #8 used the mechanical lift to put Resident #36 back into the bed. A telephone interview with the former DON on 2/12/25 at 3:39 PM revealed NA #8 was using the mechanical lift to place Resident #36 in bed. The bed was not against the wall and the lift leaned forward and the Resident #36 fell in the lift pad towards the floor. She stated NA #8 did not have an additional NA to assist her with the mechanical lift transfer as their staff has been instructed to do. The former DON stated Resident #36's skin assessment was clear upon assessment with no injuries noted and she was noted to have normal range of motion. The former DON confirmed that she responded to the room at the time of the incident and assisted Unit Manager #1 with assessing Resident #36, who was noted to have no injury. Multiple attempts were made to contact Unit Manager #1 during the survey and were unsuccessful. An interview with the NP on 2/14/25 at 9:08 AM revealed she was unsure if she took the call on 2/8/24 when the incident occurred, but stated their office was notified of the incident. An interview with the Director of Maintenance on 2/12/26 at 3:20 PM revealed he inspected the mechanical lifts after the accident on 02/08/24 and took one lift out of circulation because the manual lever was not operating correctly to open the legs on the base of the lift. The Director of Maintenance could not confirm that the lift that did not work properly was the lift used on Resident #36 on 2/08/24 but he did take it out of service. An interview was conducted with the Former Administrator on 2/13/25 at 1:18 PM revealed he was made aware of the mechanical lift incident with Resident #36 when the lift titled forward and placed Resident #36 on the other side of the bed, between the wall and her bed. He noted the staff assisted her by lowering her down with the mechanical lift to the ground for assessment. He stated NA #8 should not have used the mechanical lift by herself and the accident was caused by operator error.

Based on record review, and Dialysis Nurse, staff and physician interviews, the facility failed to maintain ongoing communication with the dialysis center and failed to consistently document assessments of the dialysis access site post dialysis including monitoring for bleeding, pain, and condition of skin for 1 of 1 resident reviewed for dialysis (Resident #53). The findings included: Resident #53 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease (ESRD) and dependent on dialysis. A physician's order written on 11/12/24 revealed Resident #53 to receive dialysis on Monday, Wednesday, and Friday; check dialysis access site each shift for bruit (sound) and thrill (pulsation); assess site (left lower forearm) for bruising/symptoms of infection. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was moderately cognitively impaired and received dialysis services. Resident #53's active care plan dated 11/29/24 revealed a plan of care for requiring hemodialysis with a goal the resident would have no signs or symptoms of complications from dialysis. Interventions included: check and change dressing daily at access site, document assessment. Monitor/document/report as needed any signs or symptoms of infection to access site such as redness, swelling, warmth or drainage. Record review revealed the hemodialysis communication form for the post dialysis section was not completed for January (2, 4, 6, 8, 13, 15, 17, 20, 24. 29) of 2025. The electronic health record (EHR) dialysis section was not completed for January (6,8, 13, 15,17, 20,24) of 2025. EHR documentation in the dialysis section that described the site location, appearance and assessment for signs and symptoms of infection was not documented by staff for the month of January 2025. An interview was conducted with Nurse #1 on 2/11/25 at 1:05 PM. Nurse #1 stated when Resident #53 returned from dialysis the staff would assess dialysis access site, pain, vital signs and provided medications that were scheduled. Nurse #1 stated staff would communicate assessment and dialysis information to the physician if needed. Nurse #1 discussed staff should document in the dialysis communication book and electronic health record (EHR). Nurse #1 was observed accessing the dialysis documentation in the EHR to show the completed access assessment documentation completed by the day and night staff for the past week February (4-11) of 2025. The EHR revealed that staff assessed the bruit and thrill of the dialysis access site but there was no documentation for the appearance of dialysis access site for signs and symptoms of infection. A telephone interview with the Dialysis Nurse on 02/12/25 at 2:09 PM stated the dialysis center did not always receive the communication book/form from the facility for Resident #53. All the dialysis nurses and technicians were trained to complete the clinic's section on the dialysis communication form. If there was a change in condition or updated order, the Dialysis Nurse stated the clinic would call or fax the facility staff. The Dialysis Nurse stated Resident #53 had a bandage on the dialysis access site and that the access site should be assessed by facility staff after removing the bandage from Resident #53. The Dialysis Nurse stated leaving the dressing on for an extended period caused indents to the arterial venous fistula (the access used for dialysis treatment) and made it difficult to access the fistula to receive dialysis. An interview completed on 02/12/25 at 3:31 PM with Nurse #2 stated when a resident returned from dialysis, nurses completed the communication form and assessed the dialysis access site and documented their assessment on the form. Nurse #2 stated the care plan has a place in the EHR to document dialysis access site assessment. She stated both forms and the EHR should be completed by the nurse post dialysis. The interview with the Physician on 02/13/25 at 10:15 AM stated he did not recall reviewing the dialysis book or any other form of dialysis communication. He discussed depending on the nursing staff to notify him of any changes or new orders from dialysis. The Physician explained the nursing staff should follow the standing orders for communicating with dialysis and assessing residents pre and post dialysis services. An interview was conducted with the Director of Nursing (DON) on 02/13/25 at 1:10 PM. The DON stated there was a dialysis book for each dialysis resident. She explained the book went to and from dialysis with the resident. The facility nursing staff were responsible for completing the pre-dialysis section (top part of the dialysis communication form) prior to the resident leaving for dialysis services and the post-dialysis section (bottom part of the dialysis communication form) when the resident returned to the facility. The dialysis clinic completed the dialysis section (middle section of the dialysis communication form.) In the EHR, there was another area for nursing staff to document the monitoring of the access site. Both areas of documentation should be completed by nursing staff when the resident returned from dialysis. An interview with the Administrator on 02/14/25 at 10:46 AM stated a dialysis communication book was sent with the resident to allow the facility and dialysis clinic to communicate regarding the resident. The Administrator stated he was not familiar with the sections on the dialysis communication form, but nursing staff should complete the form with the required information.

Based on observations, record reviews, and staff interviews, the facility failed to disinfect a resident's dedicated glucometer according to manufacturer's guidelines for cleaning and disinfecting glucometers for 1 of 2 residents observed for infection control practices (Resident #69). The findings included: Review of the glucometers manual revealed only wipes with environmental protection agency (EPA) registration number listed in the tables could be used to clean the glucometers. Resident glucometers should be cleaned with EPA regulatory wipe once for cleaning followed by one wipe for disinfecting. Then allow the glucometer to dry for 3 minutes. The facility's infection control policy on disinfecting glucometer (Not Dated) included: 1. Wear appropriate protective gear such as disposable gloves. 2. Open the cap of disinfectant container and pull out 1 towelette to clean the meter and close the cap. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette. Carefully wipe around the test strip port. 4. Properly dispose of the used towelette. 5. Open the towelette container and pull out 1 towelette to disinfect the meter and close the lid. 6. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using 1 towelette. Carefully wipe around the test strip port. 7. Properly dispose of the used towelette. 8. Treated surface must remain wet for recommended contact time. Please refer to the Assure Prism Multi BGMS User Manual for hepatitis B contact times. For all other contact times, refer to the wipe manufacturers' instructions. DO NOT WRAP THE METER IN A WIPE. Once contact time is complete, wipe meter dry. 9. After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. During a medication pass/continuous observation on 02/13/25 at 4:25 PM, Nurse #3 was observed taking Resident #69's glucometer out of medication cart and obtained a blood sample from Resident #69 to monitor blood sugar level with Resident #69's personal use glucometer. When Nurse #3 completed monitoring Resident #69's blood sugar, she placed the glucometer on the medication cart, removed gloves from her hand, retrieved an alcohol 4 x 4-inch pad, and began to clean the glucometer with the one alcohol pad. Nurse #3 placed the glucometer in Resident #69's storage case immediately after cleaning with alcohol pad and placed glucometer back in the medication cart. Nurse #3 stated she cleaned all the residents' individual glucometers with the white top wipes (EPA approved wipes) in the morning and used the alcohol pads for the rest of the day because it was just the way she cleaned glucometers. Nurse #3 verbalized she completed the facilities online computer-based glucometer training when she was hired two months ago. During the interview with the Director of Nursing (DON) on 02/13/25 at 04:35 PM, the DON stated staff should use white top wipes with bleach and wait for a wet (3-minute dry time) time after the use of the glucometer and should have gloves on when cleaning the glucometer. The DON verbalized that all nursing staff have a supply of white top wipes or could request more white top wipes if needed. DON stated there was never a reason to use any other form of disinfecting and cleaning of the glucometer other than using the white top wipes. In an interview with the Administrator on 2/14/25 at 10:42 AM, he stated that all staff received training on operating and cleaning glucometers based on the manufacturer's booklet. The Administrator verbalized glucometer training took place at the time of hire and then validated by return demonstration by the staff member. A copy of the skills validation was kept by the Director of Nursing per the Administrator. The Administrator stated the type of wipes needed to clean the glucometer was included in staff training.

Based on observations, interviews and record review, the facility failed to maintain and serve a potentially hazardous cold food (milk) at least 41 degrees Fahrenheit (F) and remove expired yogurt from 1 of 3 nourishment refrigerators. Milk was placed on a meal cart for delivery to residents at 45.6 degrees F and yogurt for Resident #41 remained in refrigeration after its manufacturer expiration date. This failure had the potential to affect 9 of 62 residents. 1. A continuous observation of the lunch meal tray line occurred on [DATE] from 12:04 PM until 12:54 PM. A bin which contained 7, 8-ounce cartons of milk was stored on the bottom shelf of a cart, from 12:04 PM until 12:24 PM. At 12:24 PM, Dietary Aide (DA) #1 covered the milk with ice. Temperature monitoring, conducted by Cook #1 occurred on [DATE] at 12:26 PM and revealed the temperature of the milk was 45 degrees F. Cook #1 was observed to show the thermometer, which was inserted into the carton of milk with a temperature of 45 degrees F, to the Certified Food Manager (CFM). The CFM put more ice on the milk cartons and instructed DA #1 to Next time put the milk in the freezer. The bin with 7, 8-ounce cartons of milk remained on the bottom shelf of the cart. Milk was placed on the cart for delivery to residents and at 12:54 PM the CFM walked out of the kitchen with the meal cart that contained milk for delivery to residents. At the request of the surveyor, temperature monitoring of the milk at 12:55 PM revealed milk was 45.6 degrees F. An interview on [DATE] at 12:55 PM with DA #1 revealed she removed the bin of milk cartons from refrigeration for the lunch tray line at 11:50 AM, placed the bin of milk on the cart and put ice on the milk just before the tray line started. The CFM stated in an interview on [DATE] at 12:56 PM that milk should be served 41 degrees F or below. A follow-up interview on [DATE] at 3:35 PM with CFM revealed that Cook #1 showed him the thermometer, but that he really could not see the temperature, so he just added more ice to the milk to make the milk colder. He then stated, It gets really hot in the kitchen. The CFM stated that staff should not bring the bin of milk out to the tray line until it's time to start. He stated that the milk was out of refrigeration too long and by the time ice was added it was probably too late to help cool the milk down. He stated, the milk was already too hot. An interview with the Administrator occurred on [DATE] at 05:47 PM and revealed that milk should be maintained at the correct temperature and kept on ice when out of refrigeration especially because that kitchen was so hot. 2. An observation of the 200-hall nourishment room refrigerator occurred on [DATE] at 3:30 PM. The refrigerator contained 8, 4-ounce containers of Greek style yogurt with a manufacturer expiration date of [DATE]. The yogurt was labeled with the name of Resident #41. On [DATE] at 03:56 PM, The Certified Food Manager (CFM) and surveyor observed the nourishment room refrigerator with the expired yogurt. The CFM stated that he saw the expired yogurt in refrigeration that morning when he rounded, but that he did not discard it because it upset residents/family when their personal food items were discarded. An interview with the Administrator occurred on [DATE] at 05:47 PM and revealed that the facility's policy was to discard all food items, which included personal food items kept for residents, if the food item was out of date.

Based on observations, staff interviews and record review, the facility failed to discard expired medications for 2 of 3 medication carts (400 hall and 100 hall). Findings included: 1a. An observation on 6/21/22 at 9:12am of the medication cart on the 400 revealed three cards of [MEDICATION(S)] 500 mg(milligrams) (anticonvulsant) prescribed to Resident #33 with expiration dates of 9/30/21, 10/31/21, and 3/31/22. An interview with the Nurse #1 on 6/21/22 at 9:20am revealed that it was the nurse's responsibility to check the medication cart and discard expired medications. She further revealed she checked the medication cart before she started her medication pass, but somehow missed the expired medications. Nurse #1 revealed the medication was last given on 6/20/22. 1b. An observation on 6/21/22 at 9:45am of the medication cart on the 100-hall revealed [MEDICATION(S)] (antiemetic) 4mg prescribed to Resident #45 with an expiration date of 12/31/20. An interview with the Nurse #2 on 6/29/22 at 9:50am revealed the expired medication should have been taken from the medication cart and sent back to the pharmacy. She stated it was the nurse's responsibility to check the medication cart daily for expired medications. Nurse #2 stated the antiemetic was prn (as needed) and the nurses should have removed it from the medication cart. She further revealed 5/19/22 was the last time this medication was given. An interview with the Director of Nursing (DON) on 6/23/22 at 10:05am revealed that expired medications should be remove from the cart and sent back to the pharmacy. She further revealed it was the nurse's responsibility to monitor the back of the cards for the expiration dates. She stated the nurses were to place the older medication to the front and the newest medication to the back, and as the expiration date became closer it should be discarded. An interview was conducted on 6/23/22 at 10:35am with the Pharmacist that revealed she was in the building to do audits monthly. She further revealed the medication carts were audited on a rotating basis and in the last 6 months all the carts had been checked at least twice. She stated during her audits there was no medications found from 2020. She further revealed the facility may have pulled medications from overstock and inadvertently placed on the medication carts. She stated the medications were expired and should not have been given. An interview was conducted on 6/23/22 at 11:31am with the Medical Director revealed there was no harm to Resident #33 or #45. He stated the expiration date does not render the medication ineffective and was a recommended use by date. He further revealed both patients were stable. He stated the facility should do a better job of monitoring the expired medications. An interview with the Administrator on 6/23/22 at 3:17pm revealed the nurses were responsible for checking the medication carts daily for expired medications. He stated expired medications was not to be given and should be discarded. He further revealed that the pharmacy also checked the medication carts monthly.

Based on record review, staff, Nurse Practitioner and physician interview, the facility failed to document blood glucose results for 1 of 3 residents reviewed for change of status (Resident #253). Resident #253 was admitted to the hospital 4/24/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Elevated blood glucose can contribute to dehydration, which resulted in Resident #253 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Resident #253 was admitted to the facility 4/19/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The sliding scale insulin was ordered to be administered 2 units of insulin for results between 201 to 250; 4 units of insulin for results between 251 and 300; 6 units of insulin for results between 301 and 350; 8 units of insulin for results between 351 and 400; 12 units of insulin for results between 401 and 450; 14 units of insulin for results 501 and 550 and instructions to call the physician (MD) for results over 501. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, [MEDICATION(S)] N (intermediate acting insulin) was ordered on 4/19/2021 to administer 18 units daily at 8:00 AM. Resident #253's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The last documented blood glucose was 101 on 4/23/2021 at 5:00 PM. Blood glucose levels were not documented on 4/24/2021 for 8:00 AM or 11:00 AM. Sliding scale insulin for 8:00 AM and 1:00 PM were not documented. A late entry (made on 7/21/2021 for 4/24/2021) documented the blood glucose as Hi and the administration of 14 units of [MEDICATION(S)] insulin at 5:00 PM. A nursing note dated 4/24/2021 at 11:33 AM was reviewed. No blood glucose results were documented in the note. A nursing note dated 4/24/2021 at 6:55 PM written by Nurse #1 was reviewed. The note documented Resident #253 had a Hi blood glucose result and she was clammy and lethargic. The note documented an order by the Nurse Practitioner (NP) to send Resident #253 to the hospital for evaluation. A facility to hospital transfer form dated 4/24/2021 at 6:45 PM was reviewed. The form documented Resident #253 had a blood glucose result of Hi. The note further documented Resident #253 had received insulin: [MEDICATION(S)] N 18 units at 8:00 AM, [MEDICATION(S)] 16 units at 8:00 AM, [MEDICATION(S)] 24 units at 1:00 PM and [MEDICATION(S)] 18 units at 5:00 PM. Hospital records for Resident #253 were reviewed. The emergency room history and physical admitting note dated 4/24/2021 included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the emergency room note documented Resident #253's high lactic acid blood level was thought to be a result of the possible [CONDITION(S)] and dehydration. The emergency room note of 4/24/2021 documented Resident #253 presented with acute metabolic [CONDITION(S)] felt to be multifactorial (due to multiple issues) and secondary to [CONDITION(S)] and [CONDITION(S)]. The emergency room note documented Resident #253 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital laboratory blood work for Resident #253 documented blood glucose results of 677 (normal 80-150) on 4/24/2021 at 7:53 PM. Nurse #1 was interviewed on 7/21/2021 at 11:38 AM. Nurse #1 reported she provided care to Resident #253 on 4/24/2021. Nurse #1 reported Resident #253 became lethargic and could not state her name on 4/24/2021. Nurse #1 reported Resident #253's blood glucose at 5:00 PM registered Hi on the glucometer and Nurse #1 called the NP to report the results. Nurse #1 reported the NP ordered Resident #253 to go to the emergency room for evaluation. A follow-up interview was conducted with Nurse #1 on 7/21/2021 at 2:25 PM. Nurse #1 reported she did not remember the blood glucose results from 8:00 AM or 1:00 PM on 4/24/2021 for Resident #253. Nurse #1 reported she was not certain why she did not document the blood glucose results from earlier in the day on 4/24/2021. Nurse #1 further reported she did not remember if she gave the sliding scale insulin to Resident #253 on 4/24/2021 at 8:00 AM or 1:00 PM. The NP was interviewed on 7/22/2021 at 10:26 AM. The NP reported she thought the facility contacted her on 4/24/2021 regarding Resident #253's elevated blood glucose, but because she did not make a physical visit, the NP did not write a note. The NP reported she gave verbal orders to the facility and it was the receiving nurse's responsibility to write the verbal order. The NP reported she expected the blood glucose results to be documented to track blood glucose trends. The Director of Nursing (DON) was interviewed on 7/22/2021 at 1:15 PM. The DON reported she thought Nurse #1 had forgotten to document the blood glucose at 8:00 AM and 1:00 PM on 4/24/2021. The DON reported she expected blood glucose to be monitored as ordered. The facility physician (MD) was interviewed on 7/22/2021 at 1:40 PM. The MD reported he had not assessed Resident #253 during her stay at the facility. The MD reported without documented blood glucose results, it was difficult to determine what care Resident #253 received and if she had elevated blood glucose prior to 5:00 PM on 4/24/2021. The MD reported the blood glucose results and sliding scale insulin should have been documented on 4/24/2021. The MD felt the elevated lactic acid was due to dehydration and this also caused the extreme elevated blood glucose results. A follow-up interview was conducted with the DON on 7/22/2021 at 4:33 PM. The DON reported she expected all blood glucose levels to be documented as well as administered insulin.

Based on observations, staff interviews, review of the Centers for Disease Control and Prevention (CDC) recommended guidance and review of the facility's Personal Protective Equipment (PPE), the facility failed to ensure a staff member, Nursing Assistant (NA) #2, wore a mask concealing her mouth and nose as she was within 6 feet of 6 of 6 residents, Residents #2, #43, #21, #5, #38, and #18, on the dementia unit during the observation. This failure occurred during a global pandemic. Findings included: CDC guidance titled How to Wear Masks, dated 6/11/2021 was reviewed. It read in part: Put the mask over your nose and mouth and secure it under your chin. Review of a facility policy titled, Personal Protective Equipment, with a revision date of October 2018 read in part, Training of the proper donning, use and disposal of Personal Protective Equipment (PPE) is provided upon orientation and at regular intervals. A continuous observation was conducted on the dementia unit on 7/21/21 from 8:48 AM through 9:08 AM. Nursing Assistant (NA) #2 was observed to be wearing a facemask below her nose. The NA was observed to go and assist Resident #2, Resident #43, Resident #21, Resident #5, then walked past Resident #38, before entering into room [ROOM NUMBER] where there was no resident. The NA exited room [ROOM NUMBER] with the mask still improperly positioned which did not conceal her nose and walked past Medication Aide (MA) #1. The NA then proceeded to get eyeglasses for Resident #18 and place them on her face and moved the resident's wheelchair. The resident then went into room [ROOM NUMBER] where there was no resident and was observed to make the bed, with mask remaining below her nose. The NA went to get linens and passed in front of Housekeeper #1 on the unit and returned to room [ROOM NUMBER]. The NA then left the room, was observed to put her hand on the mask to reposition the mask, and the mask remained below her nose. The NA then passed in front of NA #3. Nurse #1 was observed to have been in the dementia unit during a portion of the observation period passing out drinks from a beverage cart. An interview was conducted with NA #2 on 7/21/21 at 9:08 AM. At the start of the interview, the NA was observed pulling her mask down to speak during the interview. The NA stated she had [CONDITION(S)] and she said she had to keep the mask down below her nose to breath. She also stated the mask kept slipping down on her face. She explained she was instructed to wear the mask covering her mouth and nose. She further state this was the first day she had been wearing a KN95 mask because she had just received the mask yesterday but had not talked to anyone about the mask slipping down or that she had [CONDITION(S)]. An interview was conducted with NA #3 on 7/21/21 at 9:13 AM. She stated she did not notice NA #2's mask was below her nose. She said all staff were instructed to wear the masks properly, to cover their nose and their mouth. She said she was not aware of other staff not wearing their masks properly and they have been wearing masks throughout the pandemic. During an interview conducted on 7/21/21 at 9:29 AM with Nurse #1 she stated she was responsible for overseeing the Medication Aides and the NAs on the dementia unit. She said she remembered NA #2 assisting residents when she was back on the dementia unit but did not see her mask was below her nose. She said the staff at the facility had been taught to wear their mask, so it covers their nose and mouth. She said if she would have seen the mask on NA #2 was below her nose, she would have asked her to move it up and cover her nose. An interview was conducted on 7/21/21 at 1:09 PM and the Director of Nursing (DON) stated NA #2 had told her that her mask slides down and she was holding it at her nose because she had [CONDITION(S)]. The DON stated she had told the NA to bring in a note about her [CONDITION(S)] and she had provided a surgical mask to the NA as an alternate to the N95 mask. The DON explained the NA should have come to her if she was having problems with the mask. During an interview conducted on 7/21/21 at 4:09 PM the Administrator stated it was his expectation for the facility staff to wear masks properly. He further stated he had not seen NA #2 wearing her mask under her nose, but he had become aware the NA had [CONDITION(S)], and she was supplied with a surgical mask to replace the N95 mask.

Based on record review, family member interview, and staff interviews, the facility had imposed a schedule which determined not only limited visitation duration, but also limited the opportunity to visit to weekdays during a specified time period, and restricted visitation to supervised visits either outside of the facility in a courtyard or a supervised visit in a common area inside of the facility. This practice impacted a resident receiving hospice services for one of one resident reviewed for visitation (Resident #43). This deficiency was cited at a higher scope and severity, E, due to the potential to impact multiple residents beyond just the sampled resident, Resident #43. Findings included: Resident #43 was admitted to the facility on [DATE]. The resident was residing in a semi-private room at the time of the recertification. Review of an untitled and undated document revealed a section titled Visitation. The document contained information the facility would follow federal and state regulations on visitation. Further review revealed a second section which documented visitation may occur either outdoor (preferred) or indoor and was followed by multiple bullet points including, but not limited to, screening visitors, performing hand hygiene, wearing a face covering, and maintaining physical distance. Bullet point K stated, Center will schedule visits and determine the length of the visits. A sixth section provided information for Compassion Care visits and that compassion care visits did not exclusively refer to end of life situations but may also apply to multiple other situations including, but no limited to, a resident who was struggling with a change in environment or lack of physical family support. There was a note section at the end of the Compassionate Care visits section which documented Compassionate Care visits and visits required under federal disability rights law are permitted at all times, regardless of the resident's vaccination status, the county rate or outbreak testing. An undated letter provided by the facility which was reported to have been sent to the residents and family of the facility provided updated information to the residents and their families regarding visitation. The letter documented the visitor needed to contact reception during regular business hours to schedule visitation, visitations would be limited to 3 visitors, and the visitation area would either be the covered patio (outdoor) or the indoor activity/living room area. The letter provided no information regarding times when or days of the week when visits may occur and did not provide information regarding compassionate care visits. The Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 6/18/21 indicated Resident #43 was unable to be assessed for cognition due to having been rarely/never understood. Further review revealed the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months and was receiving hospice care. Review of Resident #43's care plan revealed a focus area which documented the resident was at risk for alteration in psychosocial well being related to fear of COVID 19, restriction on visitation and social isolation due to COVID 19. Listed interventions included to assure the resident and family the facility is taking all necessary precautions to keep them safe, encourage and provide alternate methods of communication with visitors and family, and to update the resident and family as needed. The resident had a focus area for having a terminal prognosis related to dementia and the local hospice agency was being utilized for the agency. A phone interview was conducted on 7/20/21 at 9:09 AM with a family member of Resident #43. The family member stated she was only allowed to visit the resident between the hours of 8:30 AM and 2:30 PM, Monday through Friday. She stated she had to call the facility to make an appointment to visit the resident and she was only allowed to visit with the resident for 15 minutes. She said she would like to be able to visit the resident more often because she was receiving hospice services but was unable to. She explained with her work schedule, it was difficult to come see the resident during the limited hours. She further explained she would have liked to visit with the resident for a longer period than just the 15 minutes which she was allowed. An interview was conducted on 7/20/21 at 2:36 PM with Nurse #1. She stated if the resident was passing, the family member was allowed to have compassionate care visits. She said if a family member wanted to visit a resident, they had to call a day ahead of time to reserve the visit. She further explained a family member could visit any day, including weekends, evenings, and some visits were 15 minutes while other visits could last 30 minutes. She stated sometimes visits were in the resident's room but were usually in the snack machine room or outside in the courtyard. During an interview conducted with the receptionist on 7/20/21 at 2:44 PM the Receptionist she stated if a family member wanted to visit a resident, the family member needed to call her, and she would make an appointment. She explained visitation was limited to 30 to 60 minutes, and they tried not to restrict the visitation. An interview was conducted with the Social Worker on 7/20/21 at 3:36 PM. She said visitors had to call the receptionist between 8:30 AM and 2:30 PM to make an appointment to visit with a resident. She said if a family member requested to visit on Saturday or Sunday, the request would have to be accommodated. She further explained the visits were supervised by one staff member to make sure the resident and the family member stayed at least 6 feet apart if one or both were not vaccinated. She said there was a time limit for visitations, but they made accommodations for a resident who was on compassionate care. She said most visits took place in a common area, but some visits could take place in a resident's room. She explained as far as she knew, the facility was following the guidelines from the Centers for Disease Control (CDC) and it was not a corporate or facility policy. She stated they tried not to have more than one visitation taking place at a time due to the need of staff to supervise the visitation and the need to clean and sanitize the area for the next scheduled visitation. The Director of Nursing (DON) stated during an interview conducted on 7/22/21 at 10:13 AM the way they did their visitation was changed during the previous week. She said there was not a current restriction on visitation times and visitation could occur at any time, including weekends. The DON noted they had been communicating information about family members visiting residents to family members through robo calls (an automated system which contacts family members with a recorded message via a voice message on the phone). She said up until last week, visitation was not as wide open as it was at the time of the interview. She explained the week prior, the visitation by a family member was restricted by a certain amount of time and to restricted areas. She further explained those restrictions no longer applied. She said the facility was currently able to accommodate visits on the unit or in the resident's room. During an interview conducted with the Administrator on 7/22/21 at 4:09 PM he stated the visiting hours for family members at the facility had not changed. He said family members were able to visit resident 7 days a week, there were not time limitations on the length of the visits, and it had been that way for at least 3 or 4 months. He did state visitations were limited to about 30 minutes for the common area they used for visitation because of the need to clean the room between visitations, but visitation time for family members who visited with residents outside was unlimited.

Based on record reviews, observations, resident, and staff interviews, the facility failed to determine whether the self-administration of medications was clinically appropriate for 1 of 1 resident who was observed to have over-the-counter topical medicated anti-itch cream at the bedside (Resident #31). Findings included: Resident #31 was admitted to the facility 12/6/2012 with the most recent readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent significant change Minimum Data Set assessment dated [DATE] assessed Resident #31 to be moderately cognitively impaired. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical chart was reviewed and there was no assessment related to self-administration of medication for Resident #31. Resident #31 was observed on 7/19/2021 at 11:19 AM. Two tubes of medicated anti-itch cream were noted on her over-the-bed table. Resident #31 reported she had itching all over and used the medicated anti-itch cream wherever I need it on my body. Resident #31 stated her family member sent her care packages and always included medicated anti-itch cream in the care package. Resident #31 was observed again on 7/22/2021 at 11:58 AM. Two tubes of medicated anti-itch cream were noted on her over-the-bed table. Resident #31 was not oriented to interview during that observation. Nurse #1 was interviewed on 7/21/2021 at 11:38 AM. Nurse #1 reported Resident #31's family member sent her care packages with over-the-counter medications, such as the medicated anti-itch cream. Nurse #1 went on to explain the staff would remove the anti-itch cream, but Resident #31 would hide the cream from staff. Nursing assistant (NA) #1 was interviewed on 7/21/2021 at 3:10 PM. NA #1 reported Resident #31 would complain of itching. NA #1 reported she would assist Resident #31 to apply the medicated anti-itch cream to her back. Nurse #3 was interviewed on 7/21/2021 at 9:56 PM. Nurse #3 reported Resident #31's family member sent in medicated anti-itch cream and Resident #31 would hide the cream from staff. Nurse #3 reported if she saw medicated anti-itch cream on Resident #31's over-the-bed table, she removed it. The Nurse Practitioner (NP) was interviewed on 7/22/2021 at 10:26 AM. The NP reported she was not aware Resident #31 had medicated anti-itch cream at the bedside. The NP reported that because Resident #31 had impaired cognition, she was not safe to have the medicated anti-itch cream at the bedside for self-administration. The Director of Nursing (DON) was interviewed on 7/22/2021 at 4:25 PM. The DON reported Resident #31's family member sent her frequent care packages and staff would remove any over-the-counter creams her sister sent in; however, Resident #31 would hide items from staff. The DON reported it was her expectation that nursing staff removed any over-the-counter medicated creams from Resident #31's room.

Based on observations, resident and staff interviews, and record review, the facility failed to remove portable oxygen that was in use at 4 liters per minute prior to assisting a resident to the smoking area while other residents were outside actively smoking for 1 of 4 residents (Resident #59) reviewed for smoking. Staff assisting Resident #59 to the smoking area with her oxygen running placed her and all of the other residents in the smoking area at risk for catching on fire. Immediate jeopardy began on 10/4/2018 when Resident #59 was assisted to the smoking area by nurse aide (NA) #3 with her nasal cannula in her nares and her portable oxygen flowing at 4 liters per minute continuous. Resident #59 was within 3 to 5 feet of other residents that were already in the smoking area actively smoking. Immediate jeopardy was removed on 10/5/2018 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. Finding included: Review of the Smoking Policy dated 11/30/2014 with a revision date of 1/20/2017 read in part: The Center will provide a safe designated smoking area for residents. Smoking is only allowed in designated areas and oxygen is not permitted. Smoking materials will be retained and stored by the nursing staff for all residents who have been granted smoking privileges. Residents Smokers Agreement read in part (no date): Residents who smoke will be evaluated for smoking safety upon admission, quarterly, change in condition and if a smoker has not abided to the facility safety guidelines. Oxygen use is not allowed in smoking areas. Resident #59 was admitted to the facility on [DATE]. Resident #59's [DIAGNOSES REDACTED]. Review of the Admission/ Readmission Data Collection dated 8/22/2018 had Resident #59 assessed as a non-smoker. An interview with Nurse #1 stated that he completed Resident #59's admission assessment. Nurse #1 stated that on admission, Resident #59 was not smoking. Nurse #1 further stated that a few weeks after admission and once Resident #59 started to gain her strength and make friends at the facility, she began to smoke about one week ago. Further review of the medical record revealed that Resident #59 had no smoking assessment completed until 10/4/2018 when Resident #59 was observed in the smoking area with her portable oxygen. Review of Admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #59 was cognitively intact. Review of Section J (Health Conditions) revealed that Resident #59 was assessed as not using tobacco. Review of Section O (Special Treatments and Programs) revealed that Resident #59 was assessed as receiving oxygen therapy. Review of the care plan dated 9/4/2018 revealed that Resident #59 had a focus area identified for safety with a goal that included that Resident #59 would not a pose threat to self/ others or surroundings during smoking and Resident #59 would comply with facility smoking protocols which stated no oxygen in use in smoking area. The interventions included completion of a safe smoking assessment on admission and quarterly, instruct/ educate on the smoking protocol which included no oxygen in use in smoking area, and monitor for continued safe smoking. There was no current smoking assessment for Resident #59 until 10/4/2018 after Resident #59 was observed in the smoking area with her portable oxygen. The interventions that were identified for Resident #59 were not followed as evidenced by Resident #59 having her oxygen in the smoking area. There was no smoking contract in place for Resident #59. On 10/3/2018 at 8:39am an entrance conference was conducted with the Administrator and Director of Nursing (DON). They stated that the facility had 20 smokers and that the residents utilized the courtyard as their smoking area. The Administrator and DON stated that the residents were all assessed as independent smokers. Resident #59 was included in this list. On 10/4/2018 at 10:55am Resident #59 was observed being wheeled out to the smoking area by the nurse aide (NA) #1. Resident #59 had her portable oxygen on the back of her wheelchair and her nasal cannula in her nares which ran continuously at 4 liters per minute. Resident #59 and NA #3 were approximately 3 to 5 feet from the other residents that were actively smoking. NA #3 was observed through the window of the conference room, with visibility to the smoking area, turning off Resident #59's portable oxygen tank. Resident #59 was observed removing her nasal cannula from her nares and placed the tubing on the back of her wheelchair. Resident #59 stood from her wheelchair and went to sit at a table and NA #3 took the wheelchair with the portable oxygen tank inside to the dining area and secured it. Resident #59 was observed getting a cigarette from another resident to smoke. Resident #59 did not go to the lock box to get smoking materials. On 10/4/2018 at 10:58am an interview with NA #3 stated that he wheeled Resident #59 to the smoking area per her request. NA #3 stated that the oxygen was still turned on while out on the smoking patio. NA #3 stated that once he realized the oxygen was on, he turned the oxygen off and took the wheelchair with the portable oxygen tank and parked it inside the dining room. A follow up interview was completed with NA #3 on 10/4/2018 at 11:24am. NA #3 stated that he had not previously taken care of Resident #59, including taking her out to smoke. NA #3 stated that he was not aware that Resident #59 used oxygen and had a portable oxygen tank on the back of her wheelchair. NA #3 stated that flammable substances are not supposed to be around active smokers or the smoking patio. NA #3 stated that he would consider oxygen a flammable substance. NA #3 stated that Resident #59's oxygen usage was intermittent and that Resident #59 did not smoke much. NA #3 further stated that once he and Resident #59 was on the smoking patio, he realized that she had on oxygen and knew that she was not supposed to have the oxygen on while out in the smoking patio. NA #3 stated that he turned off the portable oxygen tank and once Resident #59 rose from the wheelchair, he placed the wheelchair in the dining room and secured it. NA #3 stated that he was not trained on the smoking policy in orientation. NA #3 stated that he used general knowledge regarding smoking. An observation was made on 10/4/2018 at 11:15am of the smoking area. The smoking area revealed signage posted that stated, oxygen in use not allowed in smoking area. The signage was only visible from the smoking area. The signage could not be read from inside the dining room approaching the smoking area. An observation of the smoking area revealed a metal storage unit with multiple lock boxes. Residents were assigned a lock box and key that would store their smoking materials. On 10/4/2018 at 1:52pm an interview with Resident #59 was completed. Resident #59 stated that the first week or so she was not able to get out smoke. Since working with therapy services, Resident #59 stated that she started smoking during her stay here at the facility. Resident #59 could not give an exact date as to when she started smoking. Resident #59 stated that several staff members have watched her smoke in the smoking patio but could not recall if she was assessed for her ability to smoke safely or the staff person's names who observed her smoking. Resident #59 stated that she saw NA #3 this morning when she was wheeling to the smoking area. Resident #59 stated that she asked NA #3 to take her to the smoking patio. Resident #59 further stated that she removed her portable oxygen and placed the tubing on the back of her wheelchair and the NA #3 turned off her portable oxygen tank. Resident #59 stated that she proceeded to walk and sit at a table and NA #3 proceeded to take the wheelchair and portable oxygen tank and placed it inside the dining room area. Resident #59 could not recall any prior occasions where she had her portable oxygen running in the smoking area. Resident #59 stated that she had a lock box for her smoking materials. On 10/4/2018 at 4:52pm an interview with the Administrator and Director of Nursing stated that smoking training was a part of their general orientation. As a part of the facility's general orientation, safe smoking, smoking materials, the location of the smoking area and the smoking mailboxes were mainly reviewed. The nurses were trained to complete the smoking assessments which are a part of the admission assessment. The DON stated that she also educated nursing staff on reporting if they see residents with smoking materials on their person other than in their mailboxes in the smoking area. The Administrator stated that the Social Worker completed the Resident Smoking Contracts. The Administrator stated that a smoking meeting was recently held within the past two months to review smoking policies and procedures, resident smoking agreements and the use of the mailboxes. The DON stated that her expectation would be for the resident to not take the oxygen outside in the smoking area. The expectation of staff would be for the oxygen not to go outside in the smoking area. The Administrator stated that his expectation would be for the nurse aide to never assist a resident in the smoking area if they had any type of oxygen. On 10/06/18 at 9:00am an interview with the Social Worker (SW) was completed. The SW stated that she was not responsible for completing the smoking assessment once a resident decided that they wanted to smoke. The SW stated that nursing would complete the smoking assessment. The SW stated that she would complete the resident smoking agreement. The SW stated that staff did not communicate to her that Resident #59 was smoking. The SW stated that she completed the resident smoking agreement on 10/4/2018 when she was notified of Resident #59 going outside to the smoking area with her oxygen. The Administrator was informed of Immediate Jeopardy at 7:00pm on 10/4/2018. On 10/5/2018 at 12:36pm, the facility provided the following Credible Allegation of Immediate Jeopardy removal: *Plan of correcting the specific deficiency: Resident (#59) affected was reassessed for safe smoking and re-educated on the smoking policy and procedure to include no smoking with oxygen by the Unit Manager on 10/4/18. No injuries noted or s/s of adverse effects. Unit manager educated Resident #59 to not enter the designated smoking area with oxygen on 10/4/18. Resident #59 was asked to park her wheelchair with oxygen inside the activity/ vending room door and then walk out to the smoking area. When resident desires to smoke using her wheelchair she was instructed to have a staff member remove oxygen prior to entering designated smoking area. Resident #59 has a BIMS of 14. The Certified Nursing Assistant who rolled the resident out to the smoking area with the oxygen tank on the back of her wheelchair received education on the smoking policy and the hazards of oxygen around Fire/ cigarettes by the Director of Clinical Services on 10/4/18. *The procedure for implementing the acceptable plan of correction for the specific deficiency cited: Current residents who smoke were reassessed for safe smoking by the Nurse Managers and/ or Director of Clinical Services (DCS) on 10/4/18. Current residents who smoke were re-educated on the smoking policy by the Executive Director, Social Services, Activity Director, with a specific review of the fact that oxygen is prohibited in the smoking area on 10/4/18. Current residents to receive education by the Executive Director and or Social Services on the smoking process to include oxygen use is prohibited in designated Smoking Area in a Resident Council meeting which has been scheduled for 11:30am on 10/5/18. Any resident may sit in the smoking area if that is their choice therefore current residents Instructed not to enter the designated smoking area with oxygen, to park their wheelchair with oxygen inside the activity / vending room door and then walk out to the smoking area. If for any reason a resident elects to go to the designated smoking area with wheelchair and they are on oxygen and they require assistance they were instructed to have a staff member remove the oxygen prior to entering designated smoking area. Education was provided by the Nurse Managers and or Director of Clinical Services (DCS) on 10/4/18. Currently there are four residents with oxygen and the four residents were instructed not to enter the designated smoking area with oxygen. They were instructed to park their wheelchair with oxygen inside the activity/ vending room door and then walk out to the smoking area. If for any reason they require assistance they were instructed to have staff remove oxygen prior to entering designated smoking area. Education was provided by the Nurse Managers and or Director of Clinical Services (DCS) on 10/4/18. *In-servicing: Unit Managers, DCS and or Clinical Quality Specialist and designee provide Re-education to the facility staff on the Smoking policy and Procedure, hazards of oxygen around Fire/ cigarettes and identifying oxygen storage holders that are attached to the back of wheelchairs on 10/4/18. Current staff will not be permitted to work until re-educated. Current facility staff was instructed to remove oxygen from the back of wheelchairs and place E-cylinder into oxygen holder that is inside of the activity/vending room prior to rolling Residents out to the designated smoking area. Staff will be educated regarding this facility practice prior to working. Newly hired staff will be educated during orientation regarding Smoking policy and procedure, hazards of oxygen around Fire/ cigarettes and identifying oxygen storage holders that are attached to the back of wheelchairs also newly hired staff will be instructed in orientation regarding removing oxygen tanks from wheelchair bags and placing in oxygen rack located in Activity room. On 10/4/18 Signage has been place on the door that leads to the designated smoking area that reads: NO oxygen beyond this point in designated smoking area. On 10/5/18 the executive Director placed signage to the left of the door above the tank storage unit to remind the staff to remove Oxygen from the wheelchair bag and place it in the tank holder prior to rolling resident into the designated smoking area. The signage reads, ALL OXYGEN TO BE PLACED IN TANK STORAGE UNIT BELOW. *The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/ or in compliance with the regulatory requirements: Ad Hoc QAPI: Executive Director conducted an Ad Hoc QAPI Committee Meeting on 10/5/18 to review Root Cause Analysis and agreed upon plan to decrease likelihood of reoccurrence. Review Quality Reviews monthly at QAPI until compliance is achieved. Medical Director, Dr. Abaquetta was present and was in agreement. Executive Director and or Director of Nursing/designee to Quality Monitoring: 1. Administrator/Director of Nursing/Designee to conduct Quality Improvement Monitoring of Smoking Area every shift times 30 days to ensure Oxygen not in use, then 3 times per week x 30 days, then weekly x 30 days, then monthly and as needed. Findings to be reviewed at Monthly QAPI Committee Meeting. Monitoring schedule modified based on findings. 2. Administrator/Director of Nursing/Designee to conduct Random validation of staff education on smoking and oxygen use in smoking area daily times 30 days to ensure Oxygen not in use then, 3 times per week x 30 days, then weekly x 30 days, then monthly and as needed. Findings to be reviewed at Monthly QAPI Committee Meeting. Monitoring schedule modified based on findings. Completion date: 10/5/18 *The title of the person responsible for implementing the acceptable plan of correction: The Administrator or DON will be responsible for the implementation of the plan to ensure the facility provides supervision to prevent accidents related to smoking. Immediate jeopardy was removed on 10/5/2018 at 5:30pm when interviews with direct care and supervisory staff confirmed they had been in-serviced/ educated on the policy and procedure for safe smoking, including those residents that required oxygen therapy who desired to smoke. In addition, staff were aware of the specific needs of Resident #59, including removing her oxygen prior to going out in the smoking area. Observations of the smoking area and residents out in the smoking revealed no oxygen present. Resident #59's smoking assessment and care plan had been updated, as well as, all residents that smoked, including those residents that required oxygen therapy. The facility remains out of compliance at a lower scope and severity.

Based on observations, staff interviews, and review of facility recipes/manufacturer's instructions, the facility failed to 1) thaw and thoroughly cook a raw frozen turkey breast, prepared for 27 residents, to prevent the growth of bacteria and potential food borne illness as evidenced by a minimum internal temperature of 165 degrees Fahrenheit (F) for 15 seconds and 2) failed to obtain a temperature of the turkey breast on the tray line. The undercooked turkey breast was sliced, plated and put on a delivery cart for delivery to 2 of 27 residents on a regular diet (Residents #68 and #98). Immediate jeopardy began on 01/03/17 when the facility began to deliver a turkey breast that was not thoroughly cooked to 2 of 27 residents (Residents #68 and #98), after it was sliced and plated, as evidenced by turkey juices that were pink/red in color and internal temperatures that reached 142.7 degrees F and 155.5 degrees F in the center of the turkey breast. Immediate jeopardy was removed on 01/05/17 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (a pattern deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) for monitoring of the revised systems put in place related to food preparation and temperature monitoring of time/temperature control for safety (TCS) food items. The findings included: The facility policy Food Preparation, revised May 2014, recorded the following, in part: · The cook would prepare all cooked food items in a fashion that permits rapid heating to appropriate minimum internal temperatures. · TCS hot food items would be heated according to these guidelines .Poultry - 165 degrees F. · Temperature for TCS foods would be obtained/recorded at the point of service (on tray line) and monitored periodically during meal service. The facility policy Food Storage: Cold, revised May 2014, recorded the following, in part: · The cook was responsible to thaw frozen items requiring defrosting, before preparation, under refrigeration, in a microwave for immediate use, or in a sealed container immersed in cold running water. On 01/03/17 at 10:51 AM, an 8 - 10 pound turkey breast was observed covered with foil wrap and in a conventional oven at 350 degrees F. Interview with dietary staff (DS) #1 (morning cook) revealed the turkey breast was for the lunch meal that day (01/03/17). On 01/03/17 at 11:50 AM, DS #1 was observed to remove the turkey breast from the oven, removed a thermometer from a cup of ice water and inserted the thermometer (twice) into the center of the turkey breast (thickest part of the breast). The turkey juices were observed with a pink/red color. DS #1 obtained the following temperatures in the center of the turkey breast where the juices were observed with a pink/red color: · 142.7 degrees F · 155.5 degrees F Additionally, DS #1 conducted temperature monitoring to the right/left outer portions of the turkey breast (thinnest part of the breast) and obtained the following temperatures: · 164.7 degrees F (right) · 171.4 degrees F (left) DS #1 was interviewed during the observation of temperature monitoring and stated that she calibrated the thermometer prior to use. DS #1 also stated that she was trained to cook the turkey until the internal temperature reached above 140 degrees F, but that the turkey was still frozen in some places when she started cooking it. She further stated I was trying to get it done for lunch. On 01/03/17 from 11:52 AM until 12:03 PM, DS #1 was observed to remove the turkey breast from the pan it was cooked in, placed the turkey breast on a cutting board and cut the turkey breast in half. The juices coming from the center of the turkey were observed pink/red in color and made contact with other parts of the turkey. Then DS #1 sliced and weighed each turkey slice using a kitchen scale. DS #1 returned the sliced turkey breast to the pan it was cooked in, and at 12:03 PM placed the sliced turkey (uncovered) on the steam table for the lunch tray line. The sliced turkey breast remained uncovered on the steam table until the lunch tray line meal service began. DS #1 stated at the time of the observation that she obtained 30 servings of turkey, 3 ounce portions each for lunch to be served to residents who received a regular consistency diet with the exception of 2 residents who received regular consistency diets, but ordered a salad instead. DS #1 further stated that she used a pre-cooked turkey product to prepare turkey for residents who received mechanical soft or pureed consistency diets. On 01/03/17 from 12:07 PM to 12:24 PM DS #1 conducted temperature monitoring of the lunch food items, but did not monitor the temperature of the sliced undercooked turkey that remained uncovered on the steam table. On 01/03/17 at 12:25 PM, DS #1 began the lunch meal tray line. The undercooked sliced turkey was plated for Residents #68 and #98 and their plates were placed on a delivery cart. On 01/03/17 at 12:35 PM the delivery cart was taken out of the kitchen by dietary staff at which time the surveyor intervened and stopped the delivery of the undercooked turkey to these residents. Temperature monitoring by district dietary manager (DDM) #1 conducted on 01/03/17 at 12:36 PM at the request of the surveyor revealed the sliced undercooked turkey on the steam table was 121.7 degrees F. DDM #1 stated that he would place the sliced turkey in the steamer and reheat it to at least 165 degrees F. DDM #1 further stated that he did not see DS #1's process of temperature monitoring for the turkey breast, because he was making gravy, but that he did see her slice and weigh the turkey. DDM #1 further stated that due to his vantage point, he could not see the color of the turkey juices because the pan was blocking his view. On 01/03/17 at 12:37 PM, the facility policy Food Preparation revised May 2014, was reviewed with DS #1 and district dietary manager (DDM) #1. In review of the policy, DS #1 stated she was not aware of the expectation to cook poultry to an internal temperature of at least 165 degrees F. DDM #1 stated he was aware of the safe food handling practice to cook poultry to a minimum internal temperature of 165 degrees F and expected this practice to be followed. On 01/03/2017 at 12:48 PM, during an interview with the dietary manager (DM) and DS #1, the DM was asked to provide recipes for the 01/03/17 lunch meal for review. The DM stated that she was off the previous weekend and had just returned to work on Monday, 01/02/17. The DM stated she had not previously printed the recipes for DS #1's use and would have to print the recipes from the computer. The DM further stated I usually print out recipes and keep them in a book for the cook, but I did not today, I am hands on, I work along with them (cooks), but today my delivery from (named vendor) was late and I was trying to get those items put away. The DM provided the turkey recipe for review and during review of the recipe the DM stated DS #1 should have known to cook the turkey breast to an internal temperature of at least 165 for 15 seconds. The DM also stated that she was not present while DS #1 conducted temperature monitoring of the turkey, but was putting her stock away. DS #1 confirmed that she did not refer to a recipe when she prepared the raw frozen turkey breast for lunch on 01/03/17. Review of the recipe Turkey, Roast 3 ounce portion, revealed the following instructions: · Roast raw frozen turkey in the oven at 350 degrees F for 2 - 4 hours or until done. · Let stand 20 minutes before slicing. · Cook to a minimum internal temperature of 165 degrees F for 15 seconds. On 01/03/17 at 1:41 PM, during a follow up interview, DS #1 stated the turkey breast she prepared for lunch that day was frozen when she arrived to work at 5:30 AM. DS #1 stated she removed the turkey breast from the freezer, placed it in a pan under cold running water, uncovered, to thaw. DS #1 further stated that there was a frozen turkey breast in the freezer just like the one she cooked that morning. Review of the manufacturer's instructions on the box of the frozen turkey breast revealed the following: · The case contained 2, raw, ready to cook, in a bag, boneless turkey breasts, 8 - 10 pounds each. · Cooking instructions included to cook in bag. · Safe handling instructions recorded in part Some food products may contain bacteria that could cause illness if the product is mishandled or cooked improperly. For your protection follow these safe handling instructions, keep refrigerated or frozen, thaw in refrigerator or microwave, cook thoroughly in the bag. DS #1 stated she did not cook the turkey in the safe oven plastic bag, but rather removed the plastic bag prior to cooking, nor did she review the box for cooking/safe food handling instructions. On 01/03/17 at 1:56 PM, a follow up interview with the DM and review of the vendor invoice revealed the DM received the frozen turkey breast from the vendor on Tuesday, 12/27/16 and placed it in the freezer. The DM stated her usual practice was to remove frozen foods that required cooking, from the freezer, 3 days in advance and put them in the refrigerator to thaw, but that she forgot. The DM stated that she should have put the turkey in the refrigerator on Friday, 12/30/16 to thaw before taking the weekend off. On 01/03/17 at 1:58 PM, DS #1 stated in a follow up interview that she started cooking the turkey breast on 01/03/17 at 8:30 AM. DS #1 stated that she had never cooked a turkey that was frozen before because in the past the turkey breast was either thawed or already cooked for her by another cook. DS #1 also stated that she was not familiar with cooking meats in a plastic bag and had not seen this particular turkey product before. DS #1 stated she did not know internal temperature of the turkey breast had to reach 165 degrees or higher. DS #1 stated when she arrived to work at 5:30 AM and saw that the turkey was still frozen she started thawing it, in the plastic bag, uncovered, under cold running water, but that the turkey was still frozen in the middle when she put in the oven at 8:30 AM to cook at 350 degrees F. On 01/03/17 at 3:55 PM, during an interview with the administrator, director of nursing (DON), and the regional director of clinical services, the administrator stated that once he was made aware of the concern with the turkey breast prepared for the lunch meal that day, he re-educated the DM and DDM #1 on dietary services regarding sanitary conditions and safe food handling practices of raw frozen poultry. The administrator stated that it was his expectation that the dietary staff utilize and follow the facility's policies/recipes regarding food preparation and thawing foods to ensure safe food handling practices were followed and that these practices were monitored by the DM/DDM. On 01/04/17 at 11:25 AM, a follow up interview with the DM revealed she arrived to the facility on [DATE] after 8:00 AM. When the DM arrived, she stated she was informed by DS #1 that she was thawing a turkey breast in the sink under cold running water to cook for lunch that day. The DM stated she did not observe the thawing process DS #1 used, but told DS #1 to make sure the turkey was submerged in water. The DM reviewed the facility policy Food Storage: Cold, during the interview and stated she did not instruct DS #1 to thaw the turkey breast per the facility policy, but to make sure the turkey was submerged in water. The DM stated she did not discuss plans for cooking the turkey or what the final cooking temperature of the turkey should be with DS #1. DM stated she did not observe the full process of temperature monitoring by DS #1, but rather I was putting stock away. I did not see that the (turkey) juices still had blood in it. The DM stated that she ordered a raw/frozen turkey product for delivery on 12/27/16 that she was familiar with and it usually came in a foil pouch, but the facility received an unfamiliar raw/frozen turkey product that was in a plastic bag. The DM stated that she had been the DM for the facility for 3 months and that this was the first time that she forgot to take a frozen turkey breast out ahead of time to thaw. The DM stated she did not provide more oversight regarding the cooking process of the raw/frozen turkey to DS #1 because DS #1 had been trained and knew the cooking process. A review of the facility resident diet list with the DM revealed 34 residents received a regular consistency diet, but that 7 residents were either out of the facility or requested an alternate meal on 01/03/17 which left a total of 27 residents who could have received the undercooked turkey breast for lunch. On 01/04/17 at 12:01 PM, DDM #2 was interviewed and stated he visited the facility bi-monthly, but that he had not observed a problem with temperature monitoring or cooking raw poultry to safe final internal temperatures. DDM #2 further stated that on Tuesday, 01/03/17 there was sufficient management oversight to ensure safe food handling practices were being followed. DDM #2 stated that he expected and trained dietary staff to thoroughly cook TCS food items to the correct internal temperatures, conduct temperature monitoring on the tray line and to serve TCS foods at the correct temperature/per facility policy. DDM #2 stated dietary staff should take temperatures of all foods on the tray line and follow menus/recipes, had we done that for the turkey this would not have happened. On 01/04/17 at 3:36 PM, an interview with the consultant registered dietitian (RD) revealed she primarily provided the facility with weekly clinical support, but that she was available for dietary support when needed. The RD stated when she visited the facility she observed some of the meal preparation in the kitchen, but that routine observations for dietary support/operations was conducted by the district manager. The RD stated that the facility missed the step of obtaining a temperature of the turkey breast on the tray line, she stated that should have been done. The RD confirmed that there were currently 34 residents who received a regular consistency diet, but that 7 residents who were either out of the facility for lunch or requested an alternate meal did not receive turkey for lunch that day and that the remaining 27 residents could have received the undercooked turkey. The RD stated that she expected/trained dietary staff that raw poultry should be cooked to an internal temperature of at least 165 degrees F for 15 seconds per facility policy, and served at least 140 degrees F. The RD stated that she expected dietary staff to use/follow facility policies/menus/recipes for preparing raw/frozen poultry. On 01/05/17 at 12:32 PM, a follow up interview with DDM #1 was conducted via phone. DDM #1 stated he arrived to the facility at 11:30 AM on Tuesday, 01/03/17. The DDM #1 stated he was the routine DDM for the facility from August 2015 to May 2016, but that on Tuesday, 01/03/17 he was filling in for DDM #2. DDM #1 stated he was responsible for monitoring dietary practices/operations and served the facility in a dietary operations support role. DDM #1 stated he had worked with DS #1 during previous visits to the facility, but that it was his first time meeting the current DM. DDM #1 stated he was not aware that turkey was being served for lunch on Tuesday, 01/03/17 until the turkey breast was removed from the oven. DDM #1 also stated he was accustomed to seeing the facility cook a turkey breast in a foil package, not a plastic bag and that the turkey product prepared on Tuesday, 01/03/17 was a new product to him. DDM #1 stated he was not aware that the manufacturer for the turkey product the facility received recommended to cook the turkey breast in an oven safe plastic bag. DDM #1 also stated that since he did not know that the turkey breast was not cooked to an internal temperature of at least 165 degrees F for 15 seconds or that the juices still contained blood, he did not intervene, but had he known he would have placed the turkey back in the steamer/oven to obtain a temperature of at least 165 degrees F. DDM #1 stated We should have obtained another temperature of the turkey before the tray line started, I did not notice that we did not. DDM #1 stated that he attributed the drop in temperature of the turkey breast to 121.7 degrees F to not reaching an initial internal minimum temperature of at least 165 degrees F and that the turkey was not covered on the tray line. On 01/05/17 at 1:14 PM, DDM #2 provided a copy of the vendor's cooking instructions dated 01/05/17 at 8:41 AM that he received via electronic mail for the raw/frozen turkey breast. Review of the instructions revealed to bake the thawed turkey breast in the oven at 350 degrees for 2-3 hours or 20 mins per pound, bake in the original bag to an internal temperature of 160 degrees F; let the turkey breast rest for 30 minutes before slicing. The immediate jeopardy was identified on 01/04/17. The facility administrator was notified of the immediate jeopardy on 01/04/17 at 12:20 PM. The facility provided an acceptable credible allegation of compliance which included: · On 1/3/17 at approximately 11:45am, the line cook recorded an internal temperature of turkey breast <165 degrees coming from the oven and dietary staff immediately stopped plate delivery when indicated by state surveyor. · The turkey was immediately reheated in the streamer by the cook to the internal temperature of >165 degrees and lunch delivery by dietary staff continued. No harm resulted. · On 1/3/17 at 2:00pm, the secondary District Dietary Manager (DDM) provided 1:1 reeducation to identified cook on sanitary food preparation and safe serve temperatures. Identified cook verbalized and documented by signature understanding. · On 1/3/17 by 3:00pm, the facility Dietary Manager and secondary DDM reeducated dietary staff on site regarding sanitary food preparation to include thawing procedures as appropriate and serve safe temperatures. Emphasized was cooking and serving temperatures. Additional cooks/dietary staff will be educated prior to next shift. · On 1/3/17 from 2:30-3:00pm, Impromptu QAPI meeting held with the Executive Director, Director of Clinical Services, Dietary Manager, District Dietary Manager, Regional Director of Clinical Services, District VP of Operations and District VP of Clinical Services to discuss and develop immediate plan of correction. · On 1/4/17 by 7:00pm, the primary DDM provided detailed re-education to onsite dietary staff to include; 1.) thawing frozen items requiring defrosting before preparation under refrigeration in the microwave for immediate use or in a sealed container immersed in cold running water per policy 022 Food Storage: Cold, 2.) preparing menu items according to standardized recipes achieving minimum internal temperatures within guidelines provided by printed meal tracker recipes per Policy 014 Food Quality and Palatability, and 3.) ensuring safe serve minimum temperatures by using a calibrated thermometer placed in the thickest portion of the meat away from the bone, fat or gristle and in alternate meat depths, then allowing the thermometer to stop moving for at least 15 seconds and finally sanitizing probe using quaternary food sanitizer or wipes per Thermometer Use Guidelines. Dietary staff not attending initial training will receive education prior to starting next worked shift. Dietary Manager and dietary staff will be educated by the Primary District Dietary Manager upon hire and quarterly thereafter to ensure understanding of sanitary food practices for resident safety. · To ensure meat is cooked to proper temperatures before serving, the cook will use a calibrated thermometer probe to insert into the center of the meat when removing from oven/cooking source to ensure internal temperature is within required guidelines and per policy and procedures. Once meat is within guidelines from the oven/cooking source, the cook will record on temperature log and place meat in warming tray to maintain safe serve temperatures. Prior to plating meat, the cook will again monitor and record line temperature of meat from heating tray to be within requirements for safe food holding temperatures of at least 140 degrees Fahrenheit. The cook will also utilize the Cooks Log which includes printed recipes, temperature logs for each meal and policies and procedures for reference. · The Dietary Manager and cook are responsible for food preparation per policies and the DM will be responsible for randomly observing the cooks meal preparations to ensure proper procedures are being followed. Reeducation and/or disciplinary action will be implemented as appropriate to maintain compliance for the safety of the residents. · QAPI team concluded root cause to be isolated human error. Identified cook has 1.) Serve Safe Certification, 2.) Education completed on 9/29/16 on safe food temperatures and preparation, 3.) Visual references posted in kitchen of sanitary food temperatures and 4.) Meal tickets specific to food product which indicates appropriate food temperatures. QAPI representative ED assured that cook involved in incident was educated and validated understanding of thawing, cooking and serve temperature requirements. QAPI representative ED also assured/will assure all staff educated or at oncoming shift and validate understanding of same. DDM and FSM were educated by District Registered Dietitian on 1/04/2016. DM has also been directed to randomly monitor staff and assist in temperature verification. · On 1/3/17 by 4:00pm, the Unit Managers completed quality assurance monitoring on facility residents for gastrointestinal signs and symptoms during past 72 hours. No issues identified. · On 1/3/17 during dinner preparation and on 1/4/17 during breakfast and lunch preparation, the staff cook tested and documented food temperatures within serve safe guidelines for protein as well as other items to assure reaching appropriate and safe internal temperature after cooking. The ED/DM/DDM visually validated compliance. The staff cook will continue to ensure appropriate food temperatures by testing food items per serve safe guidelines after cooking to ensure proper internal temperature for protein items is reached per recipe as well as on the service line. This will be monitored by the ED, FSM, DDM or other trained designated staff in their absence to assure continued compliance. The immediate jeopardy was removed on 01/05/17 at 5:43 PM following observations of dietary staff thawing/cooking/monitoring temperatures of raw/frozen TCS food items according to recipes and interviews with dietary staff related to education received regarding thawing/cooking/monitoring temperatures of raw/frozen TCS food items. On 01/05/17 from 3:00 PM to 5:41 PM observations occurred of dietary staff thawing, cooking and monitoring temperatures of raw, frozen beef patties and raw, frozen pork chops per the recipe. Documentation was reviewed regarding staff in-services related to thawing/cooking/monitoring temperatures of TCS food items.

Based on staff interview and record review the facility failed to implement an appropriate plan of action to correct 1 of 4 identified quality deficiency in a plan of correction for failure to administer scheduled pain medication. Findings included: Cross reference F309 On 7/17/2015 the facility received a citation for failure to administer scheduled pain medication. The facility submitted a plan of correction on 8/7/2015 and set a completion date for 8/12/2015. The plan of correction included re-education of nurses currently working at the facility on 7/23/2015 on the need to follow up on resident issues affecting their wellbeing such as pain. A record review of the plan of correction in-services included (in part) Understand the need to be diligent to prevent medication errors, understand the need to be accurate to prevent errors, can verbalize the need to complete RED LINE (tool) every night, understands that the RED LINE was to be a quality check of the days ' events, each physician order [REDACTED]. On 8/21/2015 the facility was recited for F309 for failure to administer scheduled pain medication and provide wound treatments as ordered. On 8/21/2015 at 11:28 AM an interview with the corporate staff revealed the nursing staff was in-serviced on the procedure for ordering and receiving medications. The expectation for the nursing staff was to follow the procedure for ordering the medication timely. When the medication tablet levels got low they were to notify the physician for a hard script and fax the hard script to the pharmacy. The expectation was for the new prescription to be in the building before the medication card stock was empty. It was not acceptable to go 3 days without chronic pain medication. There was the expectation that the nurses write why they did not give a medication on the back of the medication administration record. In addition there was an emergency supply kit (e kit) in the building that was not utilized. QI was in process. We did the staff education for some reason there was a breakdown. The QI started with a full house audit on all resident charts and it was decreased to a random sample. The relief nurses should have been up-to-date on pharmacy procedure, using the backup pharmacy and e kit. On 8/21/2015 at 12:20 PM the corporate nurse reported the Quality Improvement (QI) committee consisted of the management team, Administrator and Medical Director. The committee met monthly. On 8/21/2015 at 12:54 PM an interview with the Administrator and chair of the QI committee reported the facility citation was in July. He reported the committee met on the last Thursday of the month. The QI committee meeting was not held on the last Thursday of July (7/30/2015) because of a conflict with the physician on the day of the meeting. The Administrator reported he did not reschedule the committee meeting because the facility was working on the Plan of Correction. He reported the staff was in-serviced on the procedure of ordering and receiving medications and the pharmacy helped facilitate the in-service. Management created memos with instructions on obtaining medications after hours. The process for obtaining medications after hours and how to use the backup pharmacy. He reported management developed an audit tool with the original citation. The staff in-service included face to face education and return demonstration. The administrator reported his expectation was that after the plan of correction and staff training the staff would be able to follow the procedure for ordering and receiving correctly and accurately. He reported, it was not acceptable for residents to miss a dose of medication.

Based on record review, staff interview, physician interview, family interview and observation the facility failed to provide daily wound care as ordered by the physician for 1 of 3 residents (Resident #20) that resulted in a wound infection and hospitalization and the facility failed to administer a scheduled pain medication ([MEDICATION NAME]) to alleviate chronic pain, for 5 opportunities for 1 of 3 residents (Resident #10) reviewed for well-being. Findings Included: 1) Resident #20 was admitted to the facility on [DATE] and discharged to an acute care facility on 8/2/2015. [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #20 was cognitively intact. She required extensive assistance from two staff members for bed mobility and dressing, extensive assistance from one staff member for personal hygiene, total assistance from two staff members with toileting, and transferring (moves between surfaces) occurred only once or twice in the 7 day look back period. Resident #20 was coded on the MDS as admitted with other open [MEDICAL CONDITION], no pressure ulcers, and no venous and arterial ulcers. A record review of the Care Plan for Resident #20 included a focus category of skin/wound. The etiology included the disease process of leg ulcers. The care plan goal dated 7/11/2015 included 1) The resident ' s wound will show signs of healing and remain free from infection through the next review and 2) The resident will not develop additional skin integrity problems or wounds through the next review. The care plan approaches included obtain and monitor lab/diagnostic work as ordered, administer treatments as ordered, weekly skin checks, and administer medications as ordered. A record review of Resident #20 ' s treatment record for July included a treatment order to change dressings daily to both legs with Normal Saline, apply [MEDICATION NAME] and Santyl to both legs with Kerlix and compression bandages. The treatment record was initialed for the 12th of the month and the 14th of the month. A record review of Resident #20 ' s treatment record dated 7/16/2015 through 7/31/2015 included a wound treatment of [REDACTED]. In addition give [MEDICATION NAME] 30 minutes prior to wound dressing. The treatments were initialed indicating the task was completed on all 5 sites for the dates of 7/16/2015 -7/19/2015. No indication the wound care was provided on 7/20/2015. The treatments were initialed on 7/21/2015 -7/24/2015. The treatment record indicated the order and treatment was discontinued on 7/24/2015. There were no further treatment records or indication that treatment had been provided in Resident #20 ' s medical record for care from 7/25/2015 until Resident #20 ' s transfer to an acute care hospital on [DATE]. A record review of Resident #20 ' s treatment record dated 8/1/2015 through 8/31/2015 included an order dated 7/17/2015. Dakin ' s solution, Santyl, Calcium Alginate and dry protective dressing once daily to wounds 1) right shin, 2) right medial thigh, 3) left lateral shin, 4) left upper shin, 5) left medial thigh. The order was not signature initialed for 8/1/2015 and 8/2/2015 indicating the treatment was completed and the order was marked as rewritten and no additional treatment records were found in the Resident #20 ' s medical record with the same handwriting. A record review of Physician order [REDACTED]. Continue Calcium Alginate and apply protective dressing once daily. An additional verbal order dated 7/23/2015 included Santyl clarification. The Santyl Ointment was to be applied directly to three wounds indicted on the written verbal order as directed once daily for 30 days. A record review of a physician order [REDACTED]. No results were found in the medical record. A record review of daily nurse notes dated 7/12/2015 through 7/26/2015 (the dates available in the medical record) revealed on 7/13/2015 a notation was made for treatment to areas, seen by wound doctor, Santyl, special delivery of medications. Daily notes dated 7/14/2015, 7/15/2015, 7/16/2015, 7/20/2015, 7/22/2015, and 7/25/ included dressing intact to bilateral legs (no notation of treatment). The daily note dated 7/17/2015 included dressing intact right and left extremities draining serous bloody drainage both dressings reinforced. The daily nurse note for 7/23/2015 included the wound physician assessed the wounds and pain medication was provided prior to the dressing change. The daily nurse note for 7/24/2015 included pain medication was provided prior to the dressing change and treatment to wound per order. No weekly skin assessments were found in Resident #20 ' s medical record. A record review of wound care specialist initial evaluation dated 7/16/2015. Five Lymphedemic wound sites were noted 1) right shin 2) right medial thigh, 3) left lateral shin, 4) left upper shin, and 5) left medial thigh. Surgical excisional debridement of subcutaneous tissue was performed on all 5 sites. A record review of a wound care specialist evaluation dated 7/23/2015 revealed no change to the five wound sites. There were treatment changes made to site 4) left upper shin and 5) left medial thigh to discontinuing the Santyl. Surgical excisional debridement of subcutaneous tissue was performed on all 5 sites. A record review of a wound care specialist evaluation dated 7/30/2015 revealed no change to wound site 1, 3, 4, or 5 and improved noted to site 2 for decreased surface area. On 8/21/2015 at 2:25 PM an interview with the wound care specialist physician revealed on 7/23/2015 Resident #20 ' s wound care was not discontinued. She discontinued the Santyl on two of Resident #20 ' s Lymphedemic wound sites. She revealed she specifically discussed with the facility wound nurse and the facility corporate nurse at Resident #20 ' s bedside why the remaining three wound sites needed the Santyl and where on the wound the nurse could apply the Santyl to conserve supply. The physician recalled there being concern from the facility about the price and need of the Santyl. The physician reported she was not at the facility enough to determine whether the nursing staff was providing daily wound care to Resident #20. The wound care nurse was unavailable for an interview. On 8/20/2015 at 5:50 PM and interview with the interim Director of Nursing (DON) revealed her knowledge that Resident #20 had some troublesome sites over and above dry dressing. She reported after reviewing records she asked the wound nurse to start using the weekly pressure ulcer record and the pressure ulcer quality improvement log before she went on vacation. The interim DON only reports she herself had only been at the facility for 2 weeks and was not sure of facility procedure or practice. On 8/21/2015 at 11:09 PM an interview with the Regional Director of Human Resources revealed the facility was in transition with staffing and current nurse positions were being supplemented with nurses from sister facilities. The primary staff for Resident #20 during her admission was unavailable. On 8/21/2015 at 11:44 AM an interview with a corporate nurse revealed she was unable to find any addition medical records showing that daily wound care treatments were completed for Resident #20. A record review of a nursing home to hospital transfer form dated 8/2/2015 and a Situation, Background, Assessment, Recommendation communication form dated 8/2/2015 revealed Resident #20 was noted to have an altered mental status and was sent to the hospital for an evaluation. A nurse note dated 8/2/2015 included (in part) Resident (#20) was noted with increased confusion. Resident (#20) sent to Emergency Department for evaluation. At 10:30 PM the nurse communicated with the hospital and documented Resident (#20) was being admitted to intensive care unit (ICU) related to infection in wounds bilaterally. A record review of the hospital records dated 8/2/2015 to 8/8/2015 for Resident #20 revealed she presented to the acute care hospital with altered mental status. Resident #20 had a history of [REDACTED]. Resident #20 developed lower extremity ulcerations in February and was treated at the burn center. She was discharged from the hospital and was residing in a skilled nursing facility. Per family she was not on antibiotics in the nursing facility. The Emergency Department records from 8/2/2015 included areas of green purulent thick fluid in her right leg wound. The Physician noted he did not think that she likely had appropriate wound care at her nursing facility . The Microbiology culture of the right thigh obtained at the hospital and resulted on 8/7/2015 included heavy growth of Pseudomonas Aeruginosa (bacteria), scant growth of Acinetobacter Baumannii (pathogen), and one colony of Staphylococcus Aureus [MEDICAL CONDITION] Resistant (bacteria). She was admitted to ICU with septic shock secondary to wound infections. 2) Resident #10 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] revealed Resident #10 was severely cognitively impaired and was totally dependent on staff (two person physical assistance) for her activities of daily living. Resident #10 was assessed as frequently experiencing pain. The pain had made it hard to sleep at night and limited her day to day activities. The Physician order [REDACTED].#10 included an order for [REDACTED]. It was scheduled at 9:00 AM and 9:00 PM. A record review of the pharmacy controlled medication utilization record for Resident #10 ' s [MEDICATION NAME] revealed that the last dose on the active card stock was administered on 8/16/2015 at 9:00 AM. The Medication Administration Record [REDACTED]. There was no indication on the back of the MAR indicated [REDACTED]. A Physician order [REDACTED].#10 included: May hold [MEDICATION NAME] 10 mg tablet ER for one dose. Follow up with Physician Assistant in the morning 8/17/2015. The MAR indicated [REDACTED]. There was no indication on the back of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The record indicated by initials that on 8/17/2015 two doses were administered to Resident #10. On the back of the MAR indicated [REDACTED]. A prescription dated 8/18/2015 for resident #10 in the physician orders [REDACTED]. A grievance log revealed a concern dated 8/18/2015 for Resident #10 for medications were received late. On 8/21/2015 at 9:45 AM an interview with Resident #10 ' s Responsible Party (RP) revealed Resident #10 had a chronic fracture in her right shoulder that was not operable so she had chronic pain. The RP reported Resident #10 needed to be positioned for comfort and her shoulder protected in care. She reported resident #10 rubbed, guarded and covered up her right shoulder and verbalized pain in her right shoulder. The RP reported she had filed grievances for Resident #10 not receiving her medications. The RP reported she was at the facility daily and it would take up to a week to get medications ordered, in stock, and administered to Resident #10. A record review of the pharmacy controlled medication utilization record for Resident #10 ' s [MEDICATION NAME] revealed it was received on 8/18/2015 and the first dose administered was on 8/19/2015. On 8/20/2015 at 4:30 PM an interview with Nurse #1, a relief nurse from a sister facility, who was Resident #10 ' s nurse on 8/16/2015 reported she did know the reason the [MEDICATION NAME] was held on 8/16/2015. Resident #10 ' s primary nurse the evening of 8/16/2015 was unavailable for an interview. The primary nurse for day shift on 8/17/2015 was unavailable. The primary nurse on the schedule for the evening shifts for 8/17/2015 and 8/18/2015 was a contract nurse and unavailable. On 8/20/2015 at 4:40 PM an interview with Nurse #2 (a relief nurse from a sister facility) who was Resident #10 ' s nurse on 8/18/2015 reported she did not give Resident #10 her [MEDICATION NAME] on the 18th because it was not available. She reported Nurse #3 processed a new order on day shift 8/18/2015. She could not verify when the order was processed because she did not have access to the facility electronic pharmacy ordering system. Nurse #2 reported Resident #10 will share with you she is in pain if you ask her. Nurse #3 was unavailable for an interview. On 8/20/2015 at 11:24 PM an interview with the second shift unit manager Nurse #4 revealed when a medication was not administered the nurse was to circle her initials and write on back of the MAR indicated [REDACTED]. On 8/20/2015 at 9:15 PM an observation of Resident #10 was made during care where she was guarding her right shoulder, verbalizing to staff to be careful with her right arm (during movement). On 8/21/2015 at 9:34 AM an interview with the pharmacy revealed Resident #10 had a hard script (legal prescription) for [MEDICATION NAME] 10 mg filled on 7/21/2015. The regulatory law only allowed the pharmacy to dispense a 14 day supply of a narcotic medication, 28 tablets were provided to the facility. On 8/18/2015 a hard script was filled for [MEDICATION NAME] and 28 tablets were dispensed to the facility. On 8/21/2015 at 9:30 AM an interview with Resident #10 ' s facility Nurse Practitioner (NP) revealed she was not aware that Resident #10 had not been receiving her scheduled pain medication. In reviewing the order written on 8/16/2015, the order was managed by the on call service. The NP (whose name was transcribed on the order) reported she did not personally get a call from the facility staff. She further reported she was on call on 8/16/2015. The NP shared she felt the facility had a big problem with ordering and receiving medications timely and the problem never got corrected. She reported there was no communication between nurses and other disciplines. The NP reported the residents are in a skilled nursing facility and a level of care is required. It is inexcusable to be out of a scheduled pain medication for even one dose. It is not acceptable to use an as needed pain medication as a substitution for coverage of chronic pain. On 8/21/2015 at 11:28 AM an interview with the corporate staff revealed the nursing staff was in-serviced on the procedure for ordering and receiving medications. The expectation for the nursing staff was to follow the procedure for ordering the medication timely. It was not acceptable to go 3 days without chronic pain medication. There was the expectation that the nurses write why they did not give a medication on the back of the MAR.

Based on record review, staff interview, family interview the facility failed to administer a scheduled pain medication ([MEDICATION NAME]), for 5 opportunities (Resident #10). Findings included: 1) Resident #10 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] revealed Resident #10 was severely cognitively impaired and was totally dependent on staff (two person physical assistance) for her activities of daily living. Resident #10 was assessed as frequently experiencing pain. The pain had made it hard to sleep at night and limited her day to day activities. Record review of a grievance log revealed a concern dated 8/18/2015 for Resident #10 for medications were received late. The Physician order [REDACTED].#10 included an order for [REDACTED]. Scheduled at 9:00 AM and 9:00 PM. The Medication Administration Record [REDACTED]. There was no indication on the back of the MAR indicated [REDACTED]. A Physician order [REDACTED].#10 included: May hold [MEDICATION NAME] 10 mg tablet ER for one dose follow up with Physician Assistant in the morning 8/17/2015. A record review of the pharmacy controlled medication utilization record for Resident #10 ' s [MEDICATION NAME] revealed that the last dose on the active card stock was administered on 8/16/2015 at 9:00 AM. The MAR indicated [REDACTED]. There was no indication on the back of the MAR indicated [REDACTED]. A record review of the MAR indicated [REDACTED]. The record indicated by signature initial that on 8/17/2015 two doses were administered to Resident #10. On the back of the MAR indicated [REDACTED]. A prescription dated 8/18/2015 for resident #10 in the physician orders [REDACTED].#60. A record review of the pharmacy controlled medication utilization record for Resident #10 ' s [MEDICATION NAME] revealed it was received on 8/18/2015 and the first dose administered was on 8/19/2015. On 8/20/2015 at 4:30 PM an interview with Nurse #1 (a relief nurse from a sister facility) who was Resident #10 ' s nurse on 8/16/2015 reported she did not know the reason the [MEDICATION NAME] was held on 8/16/2015. Resident #10 ' s primary nurse the evening of 8/16/2015 was unavailable for an interview. The primary nurse for day shift on 8/17/2015 was unavailable. The primary nurse on the schedule for the evening shifts for 8/17/2015 and 8/18/2015 was a contract nurse and unavailable. On 8/20/2015 at 4:40 PM an interview with Nurse #2 (a relief nurse from a sister facility) who was Resident #10 ' s nurse on 8/18/2015 reported she did not give Resident #10 her [MEDICATION NAME] on the 18th because it was not available. She reported Nurse #3 processed a new order on day shift 8/18/2015. She could not verify when the order was processed because she did not have access to the facility electronic pharmacy ordering system. Nurse #2 reported Resident #10 will share with you she is in pain if you ask her. Nurse #3 was unavailable for an interview. On 8/20/2015 at 11:24 PM an interview with the second shift unit manager Nurse #4 revealed the process for reordering medications was when the stock card became low the staff would re-order medications in the computer or fax a request to the pharmacy. The request for re-order should have been completed 3 to 4 days before the card stock was out of medication. If the staff sent a fax before 5:00 PM the medication order would arrive the same day. After 5:00 PM the staff would call for a stat delivery if the medication was out. The facility does not keep a record of medications ordered by fax. To know if a request was sent a nurse would have to call the pharmacy. If a medication was missing for 3 days it meant the nurse did not request the order in time. The unit manager reported he did not have access to the facility electronic pharmacy ordering system, after (business) hours the nurses fax medication orders to the pharmacy. The unit manager reported when a medication was not administered the nurse was to circle her initials and write on back of the MAR indicated [REDACTED]. On 8/21/2015 at 9:34 AM an interview with the pharmacy revealed Resident #10 had a hard script (legal prescription) for [MEDICATION NAME] 10 mg filled on 7/21/2015. The regulatory law only allowed the pharmacy to dispense a 14 day supply of a narcotic medication, 28 tablets were provided to the facility. On 8/18/2015 a hard script was filled for [MEDICATION NAME] and 28 tablets were dispensed to the facility. On 8/21/2015 at 9:45 AM an interview with Resident #10 s Responsible Party (RP) revealed Resident #10 had a chronic fracture in her right shoulder that was not operable so she had chronic pain. The RP reported Resident #10 needed to be positioned for comfort and her shoulder protected in care. She reported resident #10 rubs, guards, covers up, and verbalized pain to her right shoulder. The RP reported she had filed grievances for Resident #10 not receiving her medications. The RP reported she was at the facility daily and it would take up to a week to get medications ordered, in stock, and administered to Resident #10. On 8/21/2015 at 11:09 PM an interview with the Regional Director of Human Resources revealed because of staffing changes the nurses scheduled to work at the facility were from sister facilities. Corporate policies and practices are consistent for all facilities. Her expectation would be the nurse on staff would be familiar with corporate policy but the building would need to provide building specific orientation. The nurses from sister facilities had building specific electronic pharmacy access. They had the ability to fax an order. There were nursing supervisors on staff who were available to order the medications. The Director of Nursing was responsible for ordering house stock medications and narcotics. On 8/21/2015 at 9:30 AM an interview with Resident #10 ' s facility Nurse Practitioner (NP) revealed she was not aware that Resident #10 had not been receiving her scheduled pain medication. In reviewing the order written on 8/16/2015, the order was managed by the on call service. The NP (whose name was transcribed on the order) reported she did not personally get a call from the facility staff. She further reported she was on call on 8/16/2015. The NP shared she felt the facility had a big problem with ordering and receiving medications timely and the problem never got corrected. She reported there was no communication between nurses and other disciplines. The NP reported the residents are in a skilled nursing facility and a level of care is required. It is inexcusable to be out of a scheduled pain medication for even one dose. It is not acceptable to use an as needed pain medication as a substitution for coverage of chronic pain. On 8/21/2015 at 11:28 AM an interview with the corporate staff revealed the nursing staff was in-serviced 7/23/2015 on the procedure for ordering and receiving medications. The expectation for the nursing staff was to follow the procedure for ordering the medication timely. When the medication tablet levels got low they were to notify the physician for a hard script and fax the hard script to the pharmacy. The expectation was for the new prescription to be in the building before the medication card stock was empty. It was not acceptable to go 3 days without chronic pain medication. There was the expectation that the nurses write why they did not give a medication on the back of the MAR.

Based on record review, interview with the legal guardian, interviews with the Nurse Practittioner, and the staff the facility failed to follow through with obtaining a physician order for [REDACTED].#16). Immediate Jeopardy began on [DATE] at 7:15 PM when a resident with an advance directive to be a DNR was resuscitated and placed on ventilator support due to the facility staff not obtaining a physician order after receiving the written advance directive from the legal guardian. Immediate Jeopardy was removed on [DATE] at 6:30 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for examples 2, 3, 4, and 5 and to complete education and to ensure monitoring systems put into place are effective. The findings included: 1) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired on [DATE] at 10:30 AM. A review of the medical record revealed Resident #2 was admitted to the facility on [DATE] from an acute hospital with the hospital discharge summary dated [DATE] at 2:48 PM, which indicated Resident #2 was to be a Do Not Resuscitate (DNR). The resident's legal guardian had indicated on the discharge summary that the resident's code status was DNR and the resident had continued to not do well with feedings and to not consider any feeding tube placement. Further review of Resident #2's medical record revealed there was no admission orders [REDACTED]. The facility could not provide the admission orders [REDACTED]. A review of the nurse's notes dated [DATE] through [DATE] revealed no other nurse's notes in Resident #2's medical record after the date of [DATE]. A physician order dated [DATE] in Resident #2's medical record under the tab Admission Records indicated Full Code until Guardian/Facility Discussion. A review of the admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #2 had impairment in short term and long term memory and was moderately impaired in cognition for daily decision making and required extensive assistance from staff for activities of daily living. A review of a physician progress notes [REDACTED].#2's code status and an order for [REDACTED]. A review of a care plan dated [DATE] indicated Advanced Directives and under the heading problem: resident has advanced directives of: DNR was indicated by a check mark, under the heading of goal: DNR was indicated by a check mark, and under the heading of approaches/interventions indicated a check mark by physician order for [REDACTED].>A review of the Palliative Consultants evaluation/initial consultation dated [DATE] indicated on page 1 of 2 the document under the area of Advance Directives: an X was marked inside of the DNR checkbox and above the DNR check was a handwritten note no golden rod. In the consultant's notes was written seen by palliative care, discussed code status with guardian and resident was made a Do Not Resuscitate (DNR) and the guardian had also indicated to not proceed with feeding tube, and no golden rod DNR form in the chart. Further review of the consultation on page 2 of 2 read resident was a DNR in the hospital, no documentation on skilled nursing facility chart, and feeding tube would not be pursued. The Palliative Care Consultant had hand-written recommend Do Not Resuscitate (DNR) as resuscitation at this stage would likely be over-burdensome and offer little benefit to the resident, and feeding tube would not be recommended secondary to lack of benefit in advanced dementia. A review of a physician progress notes [REDACTED].#2's code status. Further review of the record revealed there was no physician's order to match the resident's DNR code status as indicated in the physician progress notes [REDACTED]. Further review a physician's progress note dated [DATE] had DNR circled as to indicate Resident #2's code status. Further review of the record revealed there was no physician's order to match the resident's DNR code status as indicated in the physician progress notes [REDACTED]. During a telephone interview on [DATE] at 3:43 PM, Resident #2's legal guardian stated 3 days after the resident was admitted to the facility she had met with the former Admissions Director (AD) and the former Administrator related to Resident #2's code status and the resident's wishes to be a DNR. She indicated on that day she provided to the AD and the Administrator, a letter on Department of Social Services letterhead which indicated she was the guardian of Resident #2, the facility's admission paperwork advance directive which also had the DNR code status information, and the DNR golden rod form. She further indicated she was advised on [DATE] by the local hospital's physician that she was needed at the hospital to make the decision as to continue Resident #2 on life support or to remove the resident from life support. During the interview she indicated that she advised the hospital physician that Resident #2 had a DNR code status and was not supposed to be on life support. She revealed the hospital physician indicated to her that he was aware Resident #2 was a Do Not Resuscitate code status back in [DATE] but the guardian would need to come to the hospital to make the determination as to continue or withdraw the life support from Resident #2. The guardian stated she advised the hospital physician to withdraw the life support as to honor the wish of Resident #2. The guardian indicated she went to the facility after she left the hospital and spoke with the current Administrator in regards to Resident #2's wishes not being honored by the facility and CPR being started by the facility staff. She indicated during their conversation/meeting the Administrator reviewed Resident #2's medical record and explained to her that a mistake was made, all of the paperwork was not in the medical record, and he was aware the resident was supposed to be that of a DNR code status, that CPR should not have been started. During an interview on [DATE] at 5:30 PM the Director of Nursing (DON) stated she expected a resident's code status to be honored as either a full code with CPR initiated or a no code which indicated Do Not Resuscitate (DNR) and no CPR to be initiated. The DON further indicated every resident was considered a full code status until the resident, family, or legal representative signed the paperwork regarding the resident's code status choice. The DON stated she expected all the admission paperwork, code status documents, DNR golden rod form, and nurse's notes to be part of the resident ' s medical record. The DON reviewed and confirmed Resident #2's medical record was incomplete and did not contain that information. She further stated she would have expected CPR to not have been started on Resident #2 regarding the resident ' s code status to be that of Do Not Resuscitate (DNR). During an interview on [DATE] at 7:21 PM, the former Admissions Nurse/Director stated she was responsible to obtain, check, and compare the admission orders [REDACTED]. She indicated she remembered the guardian coming to the facility on or around [DATE] and had all of Resident #2's admission paperwork, the letter which indicated Resident #2's legal guardian, the golden rod DNR form, which was on the very top of the stack of papers, and a yellow colored sticky note which obtained the legal guardian's name and her phone number. The Admissions Nurse/Director indicated she escorted the guardian to the Administrator's office at which time she obtained all of the papers from Resident #2's guardian. The former Admissions Nurse/Director further indicated she was unable to recall if she had obtained a physician's order as to indicate Resident #2 was to be a DNR on [DATE] when the legal guardian brought in the advance directive information. During an interview on [DATE] at 3:23 PM, the Nurse Practitioner (NP) stated she was aware Resident #2 was supposed to be a DNR code status. She indicated her expectation of the facility nursing staff was to not initiate CPR on a resident with a code status of Do Not Resuscitate (DNR). The NP stated the physician was out of town and was unavailable for an interview. She indicated she was unable to recall if a physician's order as to indicate Resident #2 was a code status of DNR was in the resident's medical record. During an interview on [DATE] at 5:15 PM, the former Unit Manager stated Resident #2 was being returned to her room after dinner on [DATE] when he observed the resident to be pale, with irregular breathing, and to be lifeless. He indicated he looked in the resident's medical record under the tab labeled advanced directives and there was a physician's order that indicated Resident #2 was a full code. He stated upon his return to the resident's room she was unresponsive, not breathing, and had no pulse, and he and a nurse aide immediately started CPR and the hall nurse called 911 for the Medics/Emergency Medical Services (EMS). The Unit Manager indicated the day after the resident was sent out to the hospital he had spoken with the resident's guardian by telephone on [DATE] at which time the guardian made him aware that Resident #2 was supposed to have a code status of DNR. He further indicated he immediately went and spoke with the DON and Administrator and they started looking for the code status paperwork and the DNR form. He stated they found the admission advance directive paperwork, the letter which indicated the resident's guardian, the golden rod DNR form, and the physician's order which indicated Resident #2 was to be a DNR code status in a drawer in the business office. He stated had the DNR form and physician's order for DNR had of been in the resident ' s medical record then CPR would not have been started. During an interview on [DATE] at 11:40 AM with the Regional Director of Clinical Services (RDCN) stated they had identified a problem on [DATE] when it was brought to their attention by the legal guardian that Resident #2 was supposed to be a DNR. The RDCN stated under her direction, the Director of Nursing (DON) was to re-educate all of the nursing staff, newly admitted residents were to have a chart audit completed within 36 hours of admission for verification of advance directive code status, and weekly chart audits were to be done on the in-house resident's. She further indicated the DON and the Administrator had put together a plan of correction to ensure the resident's medical desires would be honored related to their advanced directive and the physician's order would match. The facilities monitoring tools, training records, and audits were provided for review. During the review of the facility provided records the following information was identified: a) There was documented training of 13 out of approximately 60 employed nursing staff relating to the advance directive code status and upon request of the training records for the other nursing staff the facility was unable to provide the training records. b) The 3 nurses working on [DATE] from 7:00 AM until 3:00 PM were interviewed and confirmed they had in-service training in February 2015 in regards to obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. During a follow-up interview on [DATE] at 1:45 PM with the RDCS, DON, and Administrator confirmed that all nursing staff were not trained and no other training records could be found and/or provided, and the resident charts had not been audited as to ensure the physician's order and the advance directive code status paperwork matched. The Administrator was informed of Immediate Jeopardy on [DATE] at 12:37 PM for Resident #2. The following Credible Allegation of Compliance was accepted on [DATE] at 6:30 PM. Credible allegation of compliance Resident Choice 1) On February 2, 2015, resident #2 experienced an episode of respiratory arrest. The nurse in charge and another nurse checked the medical record and did not find any documentation regarding an advance directive or Do Not Resuscitate (DNR), so the nurses initiated Cardiopulmonary Resuscitation, according to policy, and the resident was transported to the hospital for emergency care and was admitted . Thereafter, the Guardian notified the Executive Director on February 3, 2015 that Resident #2 was to have an advance directive in the medical record for Do Not Resuscitate. She stated she had brought the papers into the building and had given them to the admissions director. An investigation was initiated immediately by the Executive Director and the Director of Clinical Services at the direction of the Regional Director of Clinical Services. The Executive Director interviewed the Admissions Director who confirmed that the Do Not Resuscitate papers had been brought to the facility by the Guardian but she did not recall where she placed the papers. All files regarding the resident and other resident's records were audited to find the papers. The papers were found in the resident's business office file by the 4th of February. 2) All residents in the facility have the potential to be affected. On [DATE] and 17, 2015, the Executive Director, Director of Clinical Services, and the Social Services Director immediately completed a review of all resident records to assure the presence of advanced directives from the resident or guardian, telephone orders for code status, SS 121 forms (Consulate form for documentation of do not resuscitate status which is part of the admission packet to be completed upon admission), the North Carolina Department of Health and Human Services Golden Rod Form (universally accepted form to document advanced directives - do not resuscitate orders) or MOST (Medical Orders for Scope of Treatment form to document do not resuscitate and other advanced directives including hospitalization , IV, tube feeding). The team compared the physician orders to the above forms present in the records and to the Medication Administration Records. Any noted discrepancies were corrected at this time. 3) System to assure continued compliance On [DATE], the Director of Clinical Services retrained all nurses, the admission coordinator, and the social service person currently working for the facility on the policies and procedures for advanced directives to include: · The necessity of determining the Do Not Resuscitate status of all newly and readmitted residents to assess if this status has changed and actions to take if a code status cannot be established. · The requirement of a physician's telephone order for code status upon admission · The proper location of the advanced directive information · What forms are accepted as indicators of advanced directives · Action to take if no code status can be determined - notify the Director of Nursing Services and or the Executive Director. · No nurse will be allowed to work until receiving this training prior to the start of their next scheduled shift. · Newly hired nurses will receive training on the Red Light/Green Light - the Consulate policies and procedures on advanced directives and do not resuscitate orders in orientation including the above. · The Director of Clinical Services or other management nurse will review each admission to assure the presence of documentation of advanced directives supporting the resident's wishes and the physician's order during the next morning following admission. Immediate jeopardy was removed on [DATE] at 6:30 PM when interviews of nursing staff, nurse aides, and the Admissions Coordinator confirmed they had received in-service training on obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. The nursing staff explained they were taught that it was a resident's choice to make decisions regarding their advanced directives and code status and if they were not able to make the decision, a legal guardian/responsible party could make the decision for them. Nursing staff explained they were expected to always check the resident's chart for a physician's order and advance directive code status first when they found a resident unresponsive so that they would provide CPR if the resident was a full code and they should not start CPR on a resident who had DNR orders. Record reviews were also made to verify accurate code status was available in the front of the resident's medical record. The Admissions Coordinator and Interim Director of Nursing verified all new admissions would have chart audits completed and documented to ensure the correct advanced directives, code status forms, and the physician's order matched and were present on the resident's chart. 2) Resident #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #14 was moderately cognitively impaired and required extensive assistance with activities of daily living (ADLs). A random review of the resident's medical record indicated the DNR (golden rod form) was dated [DATE] and the physician's order for the resident to be a DNR code status was dated [DATE]. The admission advance directive paperwork was not available in the resident's chart. During an interview on [DATE] at 11:40 AM with the Regional Director of Clinical Services (RDCN) stated they had identified a problem on [DATE] when it was brought to their attention. The RDCN stated under her direction, the Director of Nursing (DON) was to re-educate all of the nursing staff, newly admitted residents were to have a chart audit completed within 36 hours of admission for verification of advance directive code status, and weekly chart audits were to be done on the in-house resident's. She further indicated the DON and the Administrator had put together a plan of correction to ensure the resident's medical desires would be honored related to their advanced directive and the physician's order would match. The facilities monitoring tools, training records, and audits were provided for review. During the review of the facility provided records the following information was identified: a) There was documented training of 13 out of approximately 60 employed nursing staff relating to the advance directive code status and upon request of the training records for the other nursing staff the facility was unable to provide the training records. b) The 3 nurses working on [DATE] from 7:00 AM until 3:00 PM were interviewed and confirmed they had in-service training in February 2015 in regards to obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. During a follow-up interview on [DATE] at 1:45 PM with the RDCS, DON, and Administrator confirmed that all nursing staff were not trained and no other training records could be found and/or provided, and the resident charts had not been audited as to ensure the physician's order and the advance directive code status paperwork matched. 3) Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed Resident #15 was cognitively intact and required limited assistance with ADLs. Resident #15's admission advance directive paperwork was in the chart and was dated [DATE] which indicated the resident was a full code status, with a physician's order dated [DATE]. During an interview on [DATE] at 11:40 AM with the Regional Director of Clinical Services (RDCN) stated they had identified a problem on [DATE] when it was brought to their attention. The RDCN stated under her direction, the Director of Nursing (DON) was to re-educate all of the nursing staff, newly admitted residents were to have a chart audit completed within 36 hours of admission for verification of advance directive code status, and weekly chart audits were to be done on the in-house resident's. She further indicated the DON and the Administrator had put together a plan of correction to ensure the resident's medical desires would be honored related to their advanced directive and the physician's order would match. The facilities monitoring tools, training records, and audits were provided for review. During the review of the facility provided records the following information was identified: a) There was documented training of 13 out of approximately 60 employed nursing staff relating to the advance directive code status and upon request of the training records for the other nursing staff the facility was unable to provide the training records. b) The 3 nurses working on [DATE] from 7:00 AM until 3:00 PM were interviewed and confirmed they had in-service training in February 2015 in regards to obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. During a follow-up interview on [DATE] at 1:45 PM with the RDCS, DON, and Administrator confirmed that all nursing staff were not trained and no other training records could be found and/or provided, and the resident charts had not been audited as to ensure the physician's order and the advance directive code status paperwork matched. 4) Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #13 was severely cognitively impaired and required extensive assistance with ADLs. Further review of the resident's chart revealed a physician's order for the resident to be a full code dated [DATE]. The admission advance directive paperwork was not available in the resident's chart. During an interview on [DATE] at 11:40 AM with the Regional Director of Clinical Services (RDCN) stated they had identified a problem on [DATE] when it was brought to their attention. The RDCN stated under her direction, the Director of Nursing (DON) was to re-educate all of the nursing staff, newly admitted residents were to have a chart audit completed within 36 hours of admission for verification of advance directive code status, and weekly chart audits were to be done on the in-house resident's. She further indicated the DON and the Administrator had put together a plan of correction to ensure the resident's medical desires would be honored related to their advanced directive and the physician's order would match. The facilities monitoring tools, training records, and audits were provided for review. During the review of the facility provided records the following information was identified: a) There was documented training of 13 out of approximately 60 employed nursing staff relating to the advance directive code status and upon request of the training records for the other nursing staff the facility was unable to provide the training records. b) The 3 nurses working on [DATE] from 7:00 AM until 3:00 PM were interviewed and confirmed they had in-service training in February 2015 in regards to obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. During a follow-up interview on [DATE] at 1:45 PM with the RDCS, DON, and Administrator confirmed that all nursing staff were not trained and no other training records could be found and/or provided, and the resident charts had not been audited as to ensure the physician's order and the advance directive code status paperwork matched. 5) Resident #16 was admitted to the facility on [DATE]. The resident's MOST form was dated [DATE] and a physician's order was dated [DATE]. The admission advance directive paperwork was not available in the resident's chart. During an interview on [DATE] at 11:40 AM with the Regional Director of Clinical Services (RDCN) stated they had identified a problem on [DATE] when it was brought to their attention. The RDCN stated under her direction, the Director of Nursing (DON) was to re-educate all of the nursing staff, newly admitted residents were to have a chart audit completed within 36 hours of admission for verification of advance directive code status, and weekly chart audits were to be done on the in-house resident's. She further indicated the DON and the Administrator had put together a plan of correction to ensure the resident's medical desires would be honored related to their advanced directive and the physician's order would match. The facilities monitoring tools, training records, and audits were provided for review. During the review of the facility provided records the following information was identified: a) There was documented training of 13 out of approximately 60 employed nursing staff relating to the advance directive code status and upon request of the training records for the other nursing staff the facility was unable to provide the training records. b) The 3 nurses working on [DATE] from 7:00 AM until 3:00 PM were interviewed and confirmed they had in-service training in February 2015 in regards to obtaining a physician's order to match the advance directive of a resident's choice which included full code status and DNR. During a follow-up interview on [DATE] at 1:45 PM with the RDCS, DON, and Administrator confirmed that all nursing staff were not trained and no other training records could be found and/or provided, and the resident charts had not been audited as to ensure the physician's order and the advance directive code status paperwork matched.

Based on observation, resident and staff interviews, and record review the facility failed to administer a scheduled pain mediation as prescribed for a resident with chronic pain for 1 of 4 sampled residents reviewed for well-being (Resident #4). The findings included: Resident #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact, independent for activities of daily living (ADLs), frequently with pain, and rating the pain intensity as a 5 on a scale of 1 to 10 (zero being no pain and ten as the worst pain imaginable). Review of a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Resident #4 was observed on 07/17/15 at 12:20 PM lying in her bed, awake, and turning from side to side the resident stated I have not had my pain medication in 3 days and I am miserable can you please help me. The resident indicated her pain was an 8 or 9 on a scale of 1 to 10. Further review of the MAR indicated [REDACTED]. Nurse #2 was interviewed on 07/17/15 at 1:30 PM. Nurse #2 confirmed she had administered Resident #4's pain medication, [MEDICATION NAME] ER 20 mg on 07/14/15 at 9:00 AM, which was the last pill in the packet, and the resident had indicated to the nurse her pain to be a 5 on a scale of 1 to 10. Nurse #2 confirmed Resident #4 had not had any pain medication on 07/14/15 at 9:00 PM, 07/15/15 at 9:00 AM, 07/15/15 at 9:00 PM, 07/16/15 at 9:00 AM, 07/16/15 at 9:00 PM, or 07/17/15 at 9:00 AM. Nurse #2 further confirmed she had administered [MEDICATION NAME] ER 30 mg on 07/17/15 at 1:20 PM and the resident had reported to the nurse that her pain was an 8 on a scale of 1 to 10. Nurse #2 indicated when a resident ran out of a narcotic medication the nurse practitioner or physician had to write a new order and the new order had to be faxed to the pharmacy. She further indicated the Nurse Practitioner (NP) had increased the dosage of the resident's pain medication from 20 mg to 30 mg and had written the new order on 07/15/15. Nurse #2 indicated she had faxed the new order to the pharmacy on 07/15/15 but she had not kept the faxed confirmation to the pharmacy and there was no documentation which indicated the pharmacy had received the order. Nurse #2 stated she was going to call the pharmacy on 07/16/15 but she had gotten too busy and had forgotten to call. Nurse #2 further stated she called the pharmacy on 07/17/15 at 10:30 AM, the pharmacy had requested a clarification of the order and after she clarified the order with the pharmacist the pain medication was sent to the facility. Nurse #2 confirmed she had administered the pain medication to Resident #4 on 07/17/15 at 1:20 PM. Nurse #2 stated she should have called the pharmacy on 07/15/15 to ensure that Resident #4's pain medication was available but had no answer as to why she failed to do so. A telephone interview was conducted with the Pharmacist on 07/17/15 at 3:15 PM. The pharmacist stated they had received the faxed physician's orders [REDACTED]. The pharmacist stated she had called the facility on 07/16/15 at 9:30 AM for clarification of the physician's orders. She stated she called back to the facility on [DATE] at 4:30 PM and no one answered the telephone at the facility. The pharmacist further stated Nurse #2 called on 07/17/15 at 10:27 AM, clarified the physician's orders [REDACTED]. An interview was conducted with the Director of Nursing (DON) on 07/17/15 at 5:30 PM. She stated she expected the nurses to fax orders to the pharmacy and obtain the medications as quickly as possible. She further stated she was unaware Resident #4 had gone 3 days without her pain medication.

Based on observations, record review and staff interviews the facility failed to provide treatment to promote healing of pressure ulcers on the right buttock and left calf for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) The findings included: Resident #1 was admitted to the facility 12/03/08 with [DIAGNOSES REDACTED]. Further review of Resident #1's MDS revealed she needed extensive assistance with bed mobility and transfer. The MDS assessed Resident #1 as being at risk for pressure ulcers but not having a pressure ulcer. Review of Resident #1's care plan updated 10/11/13 revealed she was at risk for pressure ulcers related to decreased mobility and intermittent incontinence of bowel and bladder. The goal was for Resident #1 not to have any pressure sores through the review date of 01/03/13. Interventions were in place to prevent pressure ulcers which included an air mattress on bed, to keep resident off of affected area, and limit head of bed elevation to 30 degrees while in bed. physician's orders [REDACTED]. physician's orders [REDACTED]. Change dressing daily and as needed, assess pain prior to, during and after dressing change. This was a telephone order signed by the Nurse Practitioner. Nurse's notes dated 12/16/13 revealed notes from Interdisciplinary Team meeting there was no mention of the wound on the resident's right buttock. Nurse's notes dated 12/26/13 at 11:30 AM revealed "open area noted to posterior calf." The note further revealed Resident #1's family was notified and an attempt was made to call the wound doctor and a message was left. There was no further mention to provide treatment to this wound. On 12/30/13 at 2:17 PM an observation was made of wound care to Resident #1's wounds. Wound care was provided by Nurse #1 and Nurse #2. Nurse #2 then removed the dressing from Resident #1's right buttock wound. The dressing was saturated with tan drainage. The wound was approximately the size of a 50 cent piece; the area was very red and raw with the top layer of skin off. Nurse #2 cleaned the wound and applied the bordered foam dressing. During wound care Nurse #1 or Nurse #2 did not assess or provide treatment to the wound on Resident #1's calf area. On 12/30/13 at 4:16 PM an interview was conducted with the Unit Manager (UM). The UM stated she was unaware of the wounds on Resident #1's buttocks area but she was aware of the wound on her calf area. She was unable to explain why there was no treatment ordered for the resident's calf wound. On 12/30/13 at 4:30 PM an observation was made with the UM of Resident #1's calf area. The wound was approximately the size of a quarter and beefy red. There was no dressing to this wound which was covered by the multi-podus boots the resident was wearing. On 12/30/13 at 4:40 PM an interview with the UM was conducted. The UM explained the area on Resident #1's calf was where the multi-podus boot had stuck to the skin and when it was removed it caused the wound. She stated she had measured the wound on Resident #1's left buttock but did not notice the wound on her right buttock. She stated she did not see the wound because of the way the resident was laying. On 12/31/13 at 8:40 AM an interview was conducted with the Wound Doctor (WD). The WD stated he sees Resident #1 at an outside wound clinic. He stated the last time he saw Resident #1 on 12/19/13 he assessed the wounds on her sacral area. He stated the resident's immobility, incontinence and her size are factors in her skin breakdown. The WD stated the wounds on the residents buttocks were superficial but where still considered pressure wounds. On 12/31/13 at 9:53 PM an interview was conducted with the Nurse Practitioner (NP). The NP stated the order on 12/11/13 was because a nurse had called her to notify her of the wound on the resident's right buttock and she gave the order for the dressing to the right buttock. On 12/31/13 at 9:35 AM an interview was conducted with the UM. The UM explained the process for wound assessment and treatment. The UM stated during their morning meeting they go over the 24 hour report and telephone orders are reviewed. She stated between those two things she generated her list for skin issues. She stated she would then assess and measure the wounds and make sure there are treatments in place. The UM explained if they require a wound care consult she would obtain those orders. The UM further explained there was a meeting every week to discuss wounds and care plans were looked at to make sure they are updated. The UM stated she was not sure what happened with Resident #1's order for the treatment for [REDACTED]. She stated she was aware of the wound on the resident's left calf. The UM explained there should have been an order for [REDACTED]. On 12/31/13 at 11:42 AM an interview was conducted with the Director of Nursing (DON). The DON stated there should have been a treatment ordered for the calf wound. She stated this wound should have been documented and treated. The DON explained normally the wounds would have been brought up in the weekly meeting when they went over new orders and the 24 hour reports. Then they should have been followed up on. The DON stated the care plan should have been updated to reflect the buttock wounds with measurements.

Based on observation, record review, resident, and staff interviews the facility failed to assess pain levels during a dressing change for one (1) of three (3) sampled residents observed during skin care. (Resident #3). The findings are: Resident #3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum (MDS) data set [DATE] indicated no long or short term memory problems, and no impairment in cognition for daily decision making. The resident required extensive assistance by staff for personal care. The plan of care dated 12/29/10 indicated the resident had very fragile skin, was admitted with multiple skin tears, was at risk for poor healing of open areas and further skin impairment. The approaches listed on the plan of care indicated in part to use gentle touch when caring for resident to prevent skin tearing or bruising. On 01/31/11 the plan of care was updated to re-educate nurses and nurse aides regarding being careful during care due to extremely fragile skin. The physician orders [REDACTED]. The physician orders [REDACTED]. The treatment record dated 04/01/11 - 04/30/11 stated check pain level prior to dressing change. On 04/05/11 at 1:53 p.m. LN #2 was observed entering Resident #3's room with dressing supplies. Resident #3 was sitting in a wheelchair next to her bed and LN #2 started to lift Resident #3's legs up onto the bed. Resident #3 grabbed the arms of her wheelchair and grimaced. LN #2 told Resident #3 to bend her legs and proceeded to lift her legs up onto the bed. LN #2 placed all of the dressing supplies on a clean towel on the overbed table and placed a plastic trash bag on the resident's bed. LN #2 washed her hands, put on gloves and began removing dressings on a large open wound on the inner side of Resident #3's right leg below her knee and two smaller skin tears on the back of her right leg. As LN #2 was removing the dressings Resident #3 was firmly grasping the arms of her wheelchair, held her head back, grimaced and said it hurt. LN #2 continued to remove the dressings, removed her gloves and washed her hands. She put on clean gloves and poured saline solution onto a sterile gauze dressing. LN #2 firmly pressed the saline gauze around and on top of the large wound, wiped firmly in a circular motion and repeated cleaning the wound in a circular motion three (3) times. During the cleaning, Resident #3 continued to firmly grasp the arms of her wheelchair and held her head back with a grimace on her face. LN #2 disposed of the soiled dressings into the trash bag on Resident #3's bed and removed her gloves. She applied a xeroform dressing to the wound, placed gauze dressings on top, wrapped kling wrap around the dressings and secured them with tape. LN #2 stated that the dressing was secure and Resident # 3 stated that it might be too tight. LN #2 patted the dressing with her hand, proceeded to put on gloves and clean the two skin tears on the back of Resident #3's leg using separate saline saturated gauze to firmly wipe around each wound in a circular motion. Resident #3 continued to grasp each arm of her wheelchair and hold her head back with a grimace on her face. LN #2 applied dressings to these wounds, removed her gloves and washed her hands. LN #2 put on clean gloves and removed the dressings on two small wounds on the shin of Resident #3's left leg. LN #2 changed her gloves and cleaned each wound with saline saturated gauze using firm circular pressure to each one while Resident #3 continued to firmly grasp each arm of her wheelchair and leaned her head back with a grimace on her face. LN #2 applied clean dressings to each wound, discarded the soiled dressings, removed her gloves and washed her hands. Resident #3 was then transported in her wheelchair to a resident group meeting. On 04/05/11 at 2:28 p.m. an interview with LN #2 stated she usually talks to Resident #3 before the dressing changes but Resident #3 never complains of pain. LN #2 stated that she does not usually ask Resident #3 about her pain during a dressing change because Resident # 3 doesn't complain of pain. She explained the dressing changes are painful but the pain goes away when the dressing change is finished. LN #2 stated she cleaned the wounds with firm pressure to make sure that she got all of the old dressing material off of Resident #3's skin. LN #2 acknowledged Resident #3's skin is very fragile and she has had multiple skin tears and wounds on her legs. On 04/05/11 at 4:35 p.m. an interview with Resident #3 revealed staff don't ask her if she needs pain medication during the dressing changes. She stated it's very painful when they peel off the dressings and when they clean the wounds. She further stated she just bears the pain until the procedure is over and she would like for staff to have more conversation with her but they just do the dressing changes in silence. On 04/06/11 at 10:48 a.m. an interview with the director of nurses (DON) revealed it is her expectation for nurses to assess residents for pain before and during dressing changes and document it in nurses notes. The DON verified there was no documentation regarding pain assessment on the pain intervention flowsheet or nurses notes for the dressing change on 04/05/11.