Every finding on record at Windcrest Health & Rehabilitation

Based on observation and interviews, the facility failed to provide a resident group with private space and prevent staff to attend without the invitation of the group for 1 of 1 group council meeting observed. The facility failed to prevent LVN E from entering a resident council meeting while in progress. This failure placed residents that could participate in a resident council at risk of not having the right to voice their concerns without staff being present or overhearing their concerns and conduct resident council meetings without interference. Findings included: During an observation and interview on 05/12/2026 at 2:05 PM, LVN E entered the resident council meeting. LVN E was informed a resident council meeting was in session and facility staff could not be present during the meeting. LVN E did not leave when requested to do so. LVN E stated she needed to take Resident #18's Blood Pressure and give her medication, before she left and stated she would do it really quick. During an interview on 05/14/2026 at 10:00 a.m., the AD stated resident council should have been private. She stated staff should have only entered the meeting when they were invited. She stated she did attend the meetings because the residents want her to facilitate the meetings. She stated nursing staff should have known there was a meeting in progress by the activity calendar, and did not have to block off the entrance or post signs to inform them of resident council meeting in progress. She stated all staff knew not to go into the resident council meetings. She stated staff should have left when being informed that a resident council meeting was in progress. She stated she did not feel the resident population in the facility would have any negative effect from staff coming into the private setting because of their cognitive status and that was one of the reasons she took notes and made grievances for them. She stated the residents were informed the resident council meetings were private and a reasonable person would not want staff to come in unless invited. During an interview on 05/14/2026 at 10:12 a.m., SW J stated the activities director facilitated resident council meetings. She stated she had never been told that staff had come to those meetings uninvited. She stated it was a resident right to have private resident council meetings, and a reasonable person would not want staff to interrupt the meeting uninvited. Review of the facility policy titled : Resident Council Meetings dated 04/20/2020 stated in part: The group may appoint a resident to take notes/maintain meeting minutes or may elect that the Activity Director/designated liaison to take notes/maintain minutes. Meeting minutes may include, but are not limited to:a. Names of the residents in attendance.b. Follow up from previous meetings.c. Issues discussed.d. Recommendations from the group to facility staff.c. Names of staff members, speakers, and other guests present in the meeting (as invited by thegroup to attend).

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 8 of 21 (Resident #4, Resident #5, Resident #7, Resident #9, Resident #21, Resident #24, Resident #44, and Resident #81) residents reviewed for comprehensive person-centered care plans. The facility failed to develop a comprehensive care plan that included the need to reside on a secure unit for Resident #4, Resident #5, Resident #7, Resident #9, Resident #21, Resident #24, Resident #44, and Resident #81. This deficient practice could place residents in the facility at risk of not being provided the necessary care or services to meet their needs and deficits.The findings include: Record review of Resident #4's face sheet, dated 05/12/2026, revealed a [AGE] year-old male initially admitted [DATE] and most recent admission date of 04/14/2026. Resident #4 was admitted with medical diagnoses of Sepsis (the body's extreme, life-threatening response to an infection), unspecified organism, Type II diabetes (body cannot use insulin correctly and sugar builds up in the blood), Unspecified Dementia (decline in mental ability sever enough to interfere with daily life affecting m, communication, and reasoning), and Essential (primary) hypertension (high blood pressure). Record review of Resident #4's Quarterly MDS, 04/17/2026, revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 15, which indicated an intact cognition. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #4 did not exhibit this behavior. Record review of Resident #4's physician's orders, dated 04/14/2026, revealed Resident #4 had an order to admit to a secure unit for specialized dementia care. Diagnosis: Dementia. Record review of Resident #4's Comprehensive Care Plan, dated 03/19/2026, revealed there was no focus, goal, or interventions in the area of the need for Resident #4 to reside on the secure unit in the facility. Record review of Resident #5's face sheet, dated 05/14/2026, revealed a [AGE] year-old female who was admitted [DATE] with medical diagnoses of Dementia (decline in mental ability sever enough to interfere with daily life affecting m, communication, and reasoning), Major depressive disorder (mood disorder with persistent feelings of intense sadness, hopelessness, and loss of interest) and Essential (primary) hypertension (high blood pressure). Record review of Resident #5's admission MDS, dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 06, which indicated severe cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #5 did not exhibit this behavior. Record review of Resident #5's physician's orders, dated 05/13/2026, revealed Resident #5 did not have an order to admit to a secure unit. Record review of Resident #5's Comprehensive Care Plan, dated 05/12/2026, revealed there was no focus, goal, or interventions in the area of the need for Resident #5 to reside on the secure unit in the facility. Review of Resident #7's face sheet dated 05/14/2026, revealed a [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE]. Resident #7 was admitted with medical diagnoses of Parkinsonism (a group of neurological conditions characterized by slow movement, muscle stiffness, balance issues and tremors), Dementia (decline in mental ability sever enough to interfere with daily life affecting m, communication, and reasoning), Bipolar disorder (mental health condition characterized by extreme shifts in mood, energy, and activity levels), Alzheimer's disease with late onset, major depressive disorder, and anxiety. Review of Resident #7 Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 15, which indicated intact cognition response. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #7 did not exhibit this behavior. Record review of Resident #7's physician's orders, dated 05/14/2026, revealed Resident #7 did not have an order to admit to a secure unit. Review of Resident #7's Comprehensive Care plan reviewed/revised 01/29/2026 revealed there was no focus, goal, or interventions in the area of the need for Resident #7 to reside on the secure unit in the facility. Review of Resident #9's face sheet dated 05/14/2026, revealed a [AGE] year-old female admitted on [DATE] with medical diagnoses of Major depressive disorder (mood disorder characterized by pervasive low mood and loss of interest), Dementia (decline in mental ability sever enough to interfere with daily life), and anxiety. Review of Resident #9 Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 5, which indicated severe cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #9 did not exhibit this behavior. Record review of Resident #9's physician's orders, dated 05/14/2026, revealed Resident #9 did not have an order to admit to a secure unit. Review of Resident #9's Comprehensive Care plan reviewed/revised 04/20/2026 revealed there was no focus, goal, or interventions in the area of the need for Resident #9 to reside on the secure unit in the facility. Record review of Resident #21's face sheet, dated 05/13/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease with late onset, Dementia (decline in mental ability sever enough to interfere with daily life affecting m, communication, and reasoning), and Cognitive communication deficit (when a person has difficulty with verbal and nonverbal communication due to cognitive processes). Review of Resident #21 Annual MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 03, which indicated severe cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #21 did not exhibit this behavior. Record review of Resident #21's physician's orders, dated 05/13/2026, revealed Resident #21 did not have an order to admit to a secure unit. Record review of Resident #21's Comprehensive Care Plan, dated 04/28/2026, revealed there was no focus, goal, or interventions in the area of the need for Resident #21 to reside on the secure unit in the facility. Review of Resident #24's face sheet dated 05/14/2026, revealed a [AGE] year-old female admitted on [DATE] with diagnoses of Type II Diabetes (body cannot use insulin correctly and sugar builds up in the blood) and Major depressive disorder (mood disorder characterized by pervasive low mood and loss of interest). Resident #24's diagnoses revealed there was no diagnosis of Alzheimer's disease or other related dementia. Review of Resident #24 admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 15, which indicated moderate cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #24 did not exhibit this behavior. Record review of Resident #24's physician's orders, dated 05/14/2026, revealed Resident #24 did not have an order to admit to a secure unit. Review revealed #24 did not have diagnoses of Dementia. Review of Resident #24's Comprehensive Care plan reviewed/revised 02/10/2026, revealed there was no focus, goal, or interventions in the area of the need for Resident #24 to reside on the secure unit in the facility. Review of Resident #44's face sheet dated 05/14/2026, revealed a [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE]. Resident #44 was admitted with medical diagnoses including dementia (decline in mental ability sever enough to interfere with daily life affecting memory, communication, and reasoning). Review of Resident #44 admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed a BIMS score of 12, which indicated moderate cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #44 did not exhibit this behavior. Record review of Resident #44's physician's orders, dated 05/14/2026, revealed Resident #44 did not have an order to admit to a secure unit. Review of Resident #44's Comprehensive Care plan reviewed/revised 05/11/2026, revealed there was no focus, goal, or interventions in the area of the need for Resident #44 to reside on the secure unit in the facility. Record review of Resident #81's face sheet, dated 05/14/2026, revealed an [AGE] year-old male initially admitted [DATE] and most recent admission date on 01/06/2022. Resident #81 was admitted with medical diagnoses of Chronic obstructive pulmonary disease (lung disease that restricts airflow), Psychotic disorder with delusions (mental disorder characterized by a disconnect with reality), and Unspecified dementia (decline in mental ability sever enough to interfere with daily life affecting memory, communication, and reasoning). Record review of Resident #81's Quarterly MDS assessment, dated 05/05/2026, revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score a BIMS score of 06, which indicated severe cognitive impairment. Section E0900 - Wandering - Presence and Frequency was coded 0, which indicated Resident #81 did not exhibit this behavior. Record review of Resident #81's physician's orders, dated 04/14/2026, revealed Resident #81 had an order to admit to a secure unit for specialized dementia care. Diagnosis: Unspecified Dementia. Record review of Resident #81's Comprehensive Care plan, dated 09/05/2025, revealed there was no focus, goal, or interventions in the area of the need for Resident #81 to reside on the secure unit in the facility. During an observation on 05/12/2026 at 9:43 a.m., Resident #24 was observed in a room of the 400 hall Alzheimer's secure care unit where he lived. During an observation on 05/12/2026 at 11:18 a.m., Resident #7 was sitting on a couch in the lobby of the 100 hall Alzheimer's secure care unit. During an observation on 05/12/2026 at 11:30 a.m., Resident #9 was standing at the nurse's station of the 100 hall Alzheimer's secure care unit. Resident #9 did not have a walker beside her and ambulated without one. During an observation on 05/12/2026 at 2:14 p.m., Resident #4 was observed in his room on the 200 hall Alzheimer's secure unit. During an observation on 05/12/2026 at 3:14 p.m., Resident #21 was observed as she came out of her room on the 200 hall Alzheimer's secure unit. During an interview on 05/14/2026 at 9:03 a.m., the DON said the MDS Coordinator was responsible for ensuring the MDS assessment was accurate. The DON said the MDS Coordinator was on vacation at the time. The DON said she signed off on the MDS assessments which meant she looked at it and the assessments was accurate. The DON stated the MDS assessment should be accurate and if a resident did not need a walker then it should not be triggered. The DON said if the MDS assessment was not accurate, the care plan could not match the residents' needs. The DON said the care plans were updated after the MDS assessment was completed. During a follow-up interview on 05/12/2026 at 4:32 p.m., the DON said all residents' care plan should be updated with current care needs such as residing in the secure unit. The DON said both she and the ADON were responsible for updating the care plans along with the MDS Coordinator. The DON said the MDS Coordinator was on vacation and not available in the facility at that time. The DON said the IDT including herself monitored the care plans to ensure plans were accurate and she had overlooked that the need for the secure unit was in the plans and reviewed by the IDT. During an interview on 05/14/2026 at 4:34 p.m., the Regional Clinical Nurse said the care plans should be updated with care needs for secure unit if residents resided on the secure unit. The Regional Clinical Nurse said the social workers were responsible for the secure unit section of the care plan, but any IDT member could update the care plan. The Regional Clinical Nurse said the DON and ADON were ultimately responsible for monitoring that care plans were updated to include when a resident resided on the secure unit. The Regional Clinical Nurse denied any negative impacts had occurred. During an interview on 05/14/2026 at 4:40 p.m., the Social Worker K said she would add items to the care plan for residents' cognitive status or preference for discharge but would never update the care plan with secure intervention unless the resident was exit seeking. The Social Worker K stated she did not know who was responsible for monitoring the care plans including the need for the secure unit. During an interview on 05/14/2026 at 4:49 p.m., the Administrator said she expected for residents who resided on the secure units to have care plan updates for the secure unit. The Administrator said the nurse managers were responsible for updating the care plans. The Administrator said the failure may have occurred during the transfer process, but the nurse managers should have monitored prior to the resident entering the unit. The Administrator said she did not feel any negative impact had occurred and that it was an oversite by the nurse managers. The Medical Director (MD) of the facility was traveling by plane and unavailable to interview in person or by phone. Correspondence by text was initiated on 05/14/2026 at 5:44 p.m. The Medical Director responded on 05/15/2026 at 9:18 p.m., and 05/16/2026 at 8:15 a.m., with the following response in regard to the question if he felt admission into the secure unit should be care planned, 3) yes, I believe each admission should be care planned. Record review of the facility's policy, Comprehensive Care Plans dated 09/04/2021, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure orders were provided for the resident's immediate care and needs for 4 (Resident #7, Resident #9, Resident #24, and Resident #44) of 16 residents reviewed for care supervised by a physician. The facility failed to ensure a physician order was put into place/received to admit Resident #7, Resident #9, Resident #24, and Resident #44 to an Alzheimer's certified secure care unit. The facility failed to obtain a diagnosis to admit Resident #24 to an Alzheimer's certified secure care unit. These failures could affect residents by not having their medical care supervised by a physician.The findings included the following: Review of Resident #7's electronic face sheet dated 05/14/2026, revealed a [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE]. Resident #7 was admitted with medical diagnoses of Parkinsonism (a group of neurological conditions characterized by slow movement, muscle stiffness, balance issues and tremors), dementia (impaired memory, thinking, and behavior), Bipolar disorder, Alzheimer's disease with late onset, major depressive disorder, and anxiety. Review of Resident #7's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 15 out of 15, indicating intact cognition. Review of Resident #7's physician's orders dated 05/14/2026 revealed no order to admit Resident #7 to a secure care unit. Review of Resident #7's Comprehensive Care plan reviewed/revised 01/29/2026 revealed no focus, goal or interventions related to a secure care unit were addressed. During an observation on 05/12/2026 at 11:01 a.m., Resident #7's first and last name was posted by a door in the Alzheimer's certified 100 hall room. During an observation on 05/12/2026 at 11:18 a.m., Resident #7 was sitting on a couch in the lobby of the 100 hall Alzheimer's secure care unit. Review of Resident #9's electronic face sheet dated 05/14/2026, revealed a [AGE] year-old female admitted on [DATE] with medical diagnoses of major depressive disorder, dementia, and anxiety. Review of Resident #9's Quarterly MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 5 out of 15, indicating severe cognitive impairment. Review of Resident #9's physician's orders dated 05/14/2026 revealed no order to admit Resident #9 to a secure care unit. Review of Resident #9's Comprehensive Care Plan reviewed/revised 04/20/2026 revealed no focus, goal or interventions related to a secure care unit were addressed. During an observation on 05/12/2026 at 11:08 a.m., Resident #9's first and last name was posted by a door in the Alzheimer's certified 100 hall room. During an observation on 05/12/2026 at 11:30 a.m., Resident #9 was standing at the nurse's station of the 100 hall Alzheimer's secure care unit. Review of Resident #24's electronic face sheet dated 05/14/2026, revealed a [AGE] year-old female admitted on [DATE]. Resident #24's diagnoses revealed no Alzheimer's disease or other related dementia had been diagnosed. Review of Resident #24's admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. Section I - Active Diagnoses, subsection I4200 Alzheimer's disease, 0 - Not checked (No) was entered. Subsection I4800 Non-Alzheimer's Dementia, 0 - Not checked (No) was entered. Review of Resident #24's physician's orders dated 05/14/2026 revealed no order to admit Resident #24 to a secure care unit. Review of Resident #24's Comprehensive Care Plan reviewed/revised 02/10/2026 revealed no focus, goal or interventions related to a secure care unit were addressed. During an observation on 05/12/2026 at 9:43 a.m., Resident #24 was observed in a room of the 400 hall Alzheimer's secure care unit. She stated she had been at the facility for about a month. Review of Resident #44's electronic face sheet dated 05/14/2026, revealed a [AGE] year-old female initially admitted on [DATE] and most recent admission on [DATE]. Resident #44 was admitted with medical diagnoses including dementia. Review of Resident #44's admission MDS dated [DATE], revealed in Section C - Cognitive Patterns, subsection C0500 BIMS Summary Score revealed she had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Review of Resident #44's physician's orders dated 05/14/2026 revealed no order to admit Resident #44 to a secure care unit. Review of Resident #44's Comprehensive Care plan reviewed/revised 05/11/2026 revealed no focus, goal or interventions related to a secure care unit were addressed. During an observation on 05/12/2026 at 3:36 p.m., Resident #44 was in a room of the 400 hall Alzheimer's secure care unit. She was talking to her family member who stated Resident #44 had been at the facility for about one week. During an interview on 05/14/2026 at 4:10 p.m. LVN A stated she had worked in the rehabilitation unit and the secure Alzheimer's (secure care) unit. LVN A stated she was not responsible for putting in physician orders for residents to be placed in the secure unit. LVN A stated she was unsure who was responsible for obtaining those orders and putting them into the computer system. During an interview on 05/14/2026 at 4:30 p.m., the ADON stated she was responsible for putting the physician order into the electronic computer system when a resident was admitted , readmitted , or transferred onto the Alzheimer's secure unit. She stated she would have to reactivate the orders and the computer system would not carry over the order which was usually the may reside on secure unit order. She stated she did not always notice the order did not get carried over. During an interview on 05/14/2026 at 4:32 p.m., the DON stated all residents who reside on the secure units should have had a physician order and diagnoses qualifying them to be placed in the Alzheimer's unit. She stated the admission nurses were responsible to obtain orders when a resident was admitted . The DON stated she and the ADON were responsible to monitor that the orders were in the medical record. She stated the physician orders were reviewed. She stated Resident #7 had an order to reside in the secure unit until she went to the hospital in November 2024, but that order was not put back into the system after she was readmitted . She stated Resident #9's physician order to reside on the secure unit had never been put into the system. She stated Resident #24's physician order to reside on the secure unit had never been put into the system. She stated she had reached out to the physician today and had gotten a diagnosis today that would qualify Resident #24 to reside on secure unit. The DON stated the diagnosis, and order should have been obtained prior to admitting into the secure unit. She stated Resident #44's physician order to reside on the secure unit had never been put into the system. During an interview on 05/14/2026 at 4:34 p.m., the RCN stated residents who resided on the secure unit should have had physician's order to reside on those units. She stated residents should have a documented diagnosis that would qualify them for the Alzheimer's secure unit. She stated the DON and ADMN were ultimately responsible for monitoring the orders were updated when a resident resided on the secure care unit. She stated not having correct diagnoses or physician's order for secure care unit could cause psychosocial unrest if a resident was admitted and did not need to be on the unit. During an interview on 05/14/2026 at 4:49 p.m., the ADMN stated she expected for residents who reside on the secure care units to have a physician order and a diagnosis qualifying them for the secure unit. She stated the nurse managers were responsible for putting in the physician orders with appropriate diagnosis. She stated the failure may have occurred during the transfer process from the hospital or from the skilled nursing unit. She stated the nurse managers should have been monitoring that those things were obtained prior to the resident entering the unit. She stated she did not feel any negative impact had occurred and that it was an oversight by the nurse managers. During a telephone interview on 05/15/2026 at 8:15 a.m., the MD stated his expectation would be for residents admitted to the secure units to have physician orders and a medical diagnosis of dementia prior to being placed on those units. He stated there are certain instances that could arise for a resident to be placed on the secure unit without a diagnosis of dementia but those residents would need to be evaluated case by case and it would need to be care planned. Record review of facility document titled, Alzheimer's Disclosure Statement for Nursing Facilities, dated 05/13/2026, reflected Alzheimer's disease or other dementia were acceptable pre-admission diagnoses for admission to specialized units. Further review reflected Physician's orders were part of the admission process for new residents. Record review of facility's policy titled, Clinical Practice Guideline, dated 05/14/2026, reflected Prior to admission to any designated memory care unit, a physician or other licensed independent practitioner, acting within their scope of practice, shall provide an order for admission to the unit based on the resident's cognitive status, behavioral presentation, safety needs, functional abilities, and overall clinical condition. The interdisciplinary team shall review the resident's clinical needs to ensure placement in the most appropriate unit environment. Documentation supporting the need for placement shall be maintained in the medical record.

Based on interview and record review, the facility must not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 1 of 8 (NA C) non-certified nurse aides reviewed. The facility failed to ensure full-time NA C was certified within four months of the date of hire.This failure placed residents at risk of receiving inappropriate care from an individual whose skill level was not known. Findings included:Record review of the facility's employee files reflected NA C was hired on 10/29/2025 as a full-time nurse aide.During an interview on 05/14/2026 at 11:43 a.m., the DON stated NA C had been working as a full-time nurse aide in the facility and was taken off of the schedule today. During a telephone interview on 05/14/2026 at 1:29 p.m., NA C stated she started working on the floor providing resident care on 11/3/25, she stated she had already taken the online course to start her NA certification prior to being hired. She stated she was told by LVN D, the facility would help with the written test and skills test cost and scheduling for the NA certification. She stated she completed the written test and passed at the end of March 2026 but could not give a specific date. She stated she was then scheduled for the skills test on 4/21/26 and did not pass, she stated she was scheduled for another skills test on 5/26/26.During an interview on 05/14/2026 at 1:50 p.m., LVN D stated she did participate in the hiring and scheduling of staff among other duties. She stated NA C had worked as an NA at another facility prior to working at this facility. She stated she could not remember if she had been told about the NAs needing to be certified by 4 months of being full-time. She stated she does help facilitate the testing for NA certification and had signed NA C up to be tested. She stated NA C failed the skills checkoff and was scheduled to take it again. She stated the facility does allow the NAs to perform direct care on residents at the facility after the facility had done their own skills checkoff. She stated the NAs could perform showers, incontinent care, feeding assistance and other direct care independently but could not operate the mechanical lift transfer. She stated she had issues with scheduling the clinical test for certification of NAs and recently the facility in town was booked up until June for the clinical test. She stated she did not have any concerns with NA performing care with residents. She stated NA C was allowed to continue to perform resident care after failing the clinical test for certification until today.During an interview on 05/14/2026 at 1:58 p.m., the DON stated LVN D was responsible for making sure NAs were certified. She stated she was responsible for monitoring the NAs were certified. She did not provide an explanation for why NA C was allowed to continue to work full-time after 4 months of not being certified. She stated the facility did help pay for and help schedule the certification testing. She stated she did not have any concerns with NA performing direct care tasks. She stated she would provide the skills checkoff the NA had completed before she was allowed to perform resident care independently. She stated they were allowed to provide direct resident care except they could not utilize the mechanical lift for transfers. During an interview on 05/14/2026 at 2:28 p.m., the ADMN stated her expectation was for the NAs to go through a clinical class, have all of their hours and take the CNA test within 180 days of working full-time. She stated if the clinical test was failed, then her expectation would be to have them moved to hospitality aid until they could pass the exam. The ADMN stated she and the DON had just found out that NA C was allowed to continue to provide resident care after failing her clinical exam today. She stated LVN D had been aware and she did not know why it was not conveyed to the DON or herself. She stated LVN D had been told multiple times that NAs had to be certified within the four-month time frame. The ADMN stated she thought the failure came down to not keeping track and monitoring LVN D. She stated if a NA was not competent, it could lead to resident injury or adverse incidents. Record review of the facility's policy titled, Nursing Services and Sufficient Staff, dated 04/10/2022, reflected The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.Record review of the facility's Certified Nurse Aide Nursing Assistant - Job Description, reviewed on 05/14/2026, reflected Must be a Certified Nursing Aide in good standing with the State or must within four (4) months of employment have completed state required training and a competency evaluation program.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen staff properly secured hair in hair nets when handling and serving food. These failures could place residents who received food from the kitchen at risk of cross contamination and food borne illness.The findings include: During an observation on 05/12/2026 at 9:35 a.m., the Dietary Manager was observed in the kitchen with a thin hair net on covered by a gray headband with approximately one (1) inch of hair exposed above her neck where the hair net had moved up and exposed the hair. During an observation on 05/12/2026 at 9:36 a.m., the Lead [NAME] was observed wearing a thin hair net with approximately two (2) inches of hair that hung out of the hair net and down by both her temples and 1/2 inch was exposed above her forehead where the hair net had moved up and exposed the hair. During an observation on 05/12/2026 at 9:55 a.m., Observed [NAME] F as she placed dinner rolls on a baking sheet and placed the pan in the oven. [NAME] F was observed with exposed hair not covered by her hair net. Observed her hair was exposed on the back of her neck, approximately 1/2 inch across and one (1) inch in length by both temples in front of her ears. During an observation on 05/12/2026 at 10:03 a.m., [NAME] G was observed standing by the cooking station, as he stacked cups and picked up silverware to roll into napkins. [NAME] G was observed wearing a thin hair net with 1/2 inch strings of hair exposed on his left temple and behind his left ear and on his right temple. During an observation on 05/12/2026 at 10:15 a.m., Observed [NAME] H as she stack small bowls and placed them on a tray. [NAME] H was observed wearing a thin hair net with strings, approximately two (2) inches in length down the back of her neck and in front of her ears. During an observation on 05/13/2026 at 9:25 a.m., [NAME] I was observed wearing a thin hair net with approximately three (3) inches of hair above her neck exposed. During an observation on 05/13/2026 at 9:31 a.m., [NAME] F was observed standing at the stove as she stirred a large pan of ground met. [NAME] F opened the oven and removed a large pan and placed it on the top of the stove. During an observation on 05/13/2026 at 9:33 a.m., [NAME] I was observed at the ice machine as she scooped ice out and filled cups and placed on a tray. [NAME] I leaned over the ice machine as she scooped the ice. During an interview on 05/13/2026 at 9:41 a.m., the Lead [NAME] said she had been trained in food handling and was aware that her hair net should cover all her hair. Lead [NAME] said that not wearing the hair net properly could cause hair to get into the food and no one wanted hair in their food. The Lead [NAME] said she was aware she should have all her hair covered. The Lead [NAME] said hair in the food could cause cross-contamination or illness. During an interview on 05/13/2026 at 9:46 a.m., the Dietary Manager said an employee's hair not covered while cooking or serving food was an infection control issue and could contaminate the food. During an interview on 05/13/2026 at 10:01 a.m., [NAME] F said she was aware that her hair should be covered while working in the kitchen and serving food. [NAME] F said she had her food handling certificate. [NAME] F said the purpose of wearing a hair net was to prevent hair from falling into the food. [NAME] F said if she found hair in her food she would return the food because it could cause bacteria and make her sick. During an interview on 05/13/2026 at 10:20 a.m., [NAME] I said she had been trained in food handling and was aware that her hair had to be covered. [NAME] I said the hair net provided by the facility would not stay on and cover her hair properly. [NAME] I said the net would ride up and exposed her hair. [NAME] I said the hair net prevented hair from falling into the food which could cause cross contamination and make others sick. During an interview on 05/13/2026 at 10:26 a.m., [NAME] H said she knew she was required to wear a hair net while in the kitchen and cover all her hair. [NAME] H spoke through interpretation as she did not speak English. [NAME] F translated. [NAME] H said would cover her hair to prevent hair from falling in the food. During a follow-up interview on 05/14/2026 at 2:01 p.m., the Dietary Manager said she was not aware that hair exposed from the hair nets was an issue. The Dietary Manager said exposed hair could make the food unappetizing, contaminate the food, and cause food-borne illnesses. The Dietary Manager said the residents in the facility deserved to be served food of the highest quality. During an interview on 05/14/2026 at 2:13 p.m., the Administrator said she was not aware the kitchen employees were not wearing their hair nets appropriately until she was notified by the Dietary Manager. The Administrator said hair exposed and the hair nets that did not properly fit was an issue. The Administrator said hair could drop into the food and anyone who ate out of the kitchen would be exposed to cross-contamination. The Administrator said this was unsanitary and an infection control issue. Record review of the facility's policy, Food & Nutrition Services Policy & Procedure Manual Personal Hygiene dated 11/14/2017, revealed dietary employees will maintain proper food practices through proper personal hygiene. 11. Dietary employees shall wear hair covering, beard restraints, and clothing that covers body hair.

Based on observation, interview and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 10 residents (Resident #18), observed in the confidential group interview. The facility failed to prevent LVN E from taking Resident #18's blood pressure and administering medication during a resident council meeting on 5/14/26., in front of 9 other residents. This failure could result in a diminished quality of life and a loss of self-esteem for the residents. The findings included: Record review of Resident #18's electronic Face Sheet dated 05/14/2026 revealed the resident was a 93 -year-old female admitted to the FacilityFfacility on 05/31/2024 with the following diagnoses: Dementia ( a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), dysphagia (difficulty swallowing), lack of coordination, and cognitive communication disorder a disorder that involves difficulty with speaking, listening, reading, writing, or social interaction, caused by a disruption in thinking processes. Record review of Resident #18's quarterly Minimum Data Set MDS assessment dated [DATE] documented, in part: Resident had a BIMS of 15 which indicated she was cognitively intact. During an observation and interview on 05/12/2026 at 2:05 PM, LVN E entered the resident council meeting. LVN E had a medication cup and blood pressure cup in her hands. The LVN E was informed a resident council meeting was being held and she could not be present during the meeting. LVN E stated that she needed to do this really quick and proceeded to take Resident #18's blood pressure and gave Resident #18 her medication in front of the 10 residents that were attending the meeting. During an interview on 5/12/26 at 2:05 p.m , Resident #18 stated LVN E was just trying to do her job and receiving her medication in a public setting did not happen very often. During an interview on 05/14/2026 at 10:00 a.m., the AD stated resident council should have been private. She stated staff should have only entered the meeting when they were invited. She stated she does attend the meetings because the residents want her to facilitate the meetings. She stated nursing staff would know there was a meeting in progress by the activity calendar and she did not have to block off the entrance or post signs to inform them of resident council meeting in progress. She stated all staff know not to go into the resident council meetings. She stated staff should have left when being informed that a resident council meeting was in progress. She stated she did not feel the resident population in the facility would have any negative effect from staff coming into the private setting because of their cognitive status and that was one of the reasons she took notes and made grievances for them. She stated the residents were informed the resident council meetings were private and a reasonable person would not want staff to come in unless invited. During an interview on 05/14/2026 at 10:12 a.m., the SW J stated it was a resident right to have private resident council meetings, and a reasonable person would not want staff to interrupt the meeting uninvited. The SW J stated residents had the right to having their vitals and medications administered in private. The SW J stated a reasonable person would have wanted for their vitals and medications given in a private location. Review of the Policy titled Resident Rights dated revised last revised 11/05/2024 stated in part: Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. Personal privacy includes accommodations, medical treatment, writing and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #9) of 21 residents whose assessments were reviewed for accuracy. The facility failed to ensure Resident #9's MDS assessment accurately reflected the use of a walker. This failure placed the residents at risk for unmet care needs.Findings included:Record review of Resident #9's electronic face sheet dated 05/14/2026 reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses that included dementia (changes in the brain that affect memory, thinking, and behavior) and osteoarthritis (joint condition where the cushioning cartilage in your joints gradually wears away, causing pain, stiffness, and difficulty moving).Record review of Resident #9's quarterly MDS dated [DATE] reflected Resident #9 had a BIMS of 05 meaning severe cognitive impairment. Further review reflected she used a walker as a mobility device.Record review of Resident #9's comprehensive care plan, reviewed on 05/14/2026, reflected Resident #9 was independent with ambulation using a walker.Record review of Resident #9's physical therapy note dated 02/20/2026 reflected Resident #9 was able to perform a standing activity using no ambulatory aid (walker). Record review of Resident #9's physical therapy note dated 03/18/2026 reflected Resident #9 was able to perform gait training using no ambulatory aid (walker).Record review of Resident #9's physical therapy certification period of 03/13/2026 - 05/11/2026 documentation reflected that due to cognitive status and patient having poor safety education memory, two-wheel walker has recently presented as a safety hazard due to patient leaving it in unsafe areas and not using if for mobility purposes. During observation on 05/12/2026 at 11:30 a.m., Resident #9 was standing by the nurses' station for hall 100 without a walker. During an attempted telephone interview on 05/12/2026 at 3:16 p.m., Resident #9's RR did not answer telephone or return call after voicemail left.During an interview on 05/14/2026 at 9:03 a.m., the DON stated the MDS nurse was responsible for making sure the MDS assessments were accurate. She stated the MDS nurse was on vacation at this time and not available for interview. She stated she signed off on the MDS which meant she verified the MDS assessment had been completed. She stated the MDS should be accurate. She stated if the resident did not need a walker, then it should not have been checked on the MDS assessment. She stated not having an accurate MDS could make the care plan not match the residents needs. She stated the CNAs looked at the Kardex so that they knew what the resident's care needs were. She stated the care plans were updated after the MDS assessment had been completed.During an interview on 05/14/2026 at 2:32 p.m., the ADMN stated she expected the MDS assessment to be filled in accurately by the MDS nurse. She stated the DON should monitor that those assessments were accurate and completed. During an observation on 05/14/2026 at 4:10 p.m., Resident #9 was standing in a doorway on 100 hall without a walker. Resident #9 was looking out into the lobby area and was not holding onto anything to help her stand.During an interview on 05/14/2026 at 4:10 p.m., LVN A stated she worked on the 100 hall unit and was familiar with Resident #9. She stated Resident #9 did not utilize a walker for mobility at this time. She could not remember if Resident #9 ever used a walker but stated she may have when she first came to the facility.During an interview on 05/14/2026 at 4:21 p.m., CNA B stated she was familiar with Resident #9. She stated she thought Resident #9 used to use a walker but that was over a month or two ago. She stated currently Resident #9 did not need to use a walker for ambulation. Record review of facility policy titled, Resident Assessment - RAI, dated 10/24/2022, reflected This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS.The assessment will include at least the following:.h. Physical functioning and structural problems.The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 3 medication carts (medication cart for Unit #1 and medication cart for Unit #2) reviewed for pharmacy services. The facility failed to ensure Resident #33, and Resident #71's natural tears eye drops were labeled with an open date on the medication cart for Unit #1. The facility failed to ensure Resident #12, and Resident #81's natural tears eye drops were labeled with an open date on the medication cart for Unit #2. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications. Findings Included: During an observation on 03/10/25 at 10:00 AM, the medication cart for Unit #1 contained 2 bottles of natural tears eye drops with no open date for Resident #33 and Resident #71. During an observation on 03/10/25 at 10:10 AM, the medication cart for the Unit #2 contained 2 bottles of natural tears eye drops with no open date for Resident #12 and Resident #81. During an interview on 03/10/25 at 3:00 PM, LVN B stated all medications in multiuse vials should have been dated when opened. She stated she thought eye drops where good for 90 days after opening date. She stated it was the nurse's responsibility to date the medication when opened and to check the date prior to administering the medication. She stated not putting the open date could lead to residents receiving expired medications. During an interview on 03/12/25 at 10:15 AM, the DON stated eye drops and all multi use vials should have been dated when opened. She stated this should have been done by the nurse who opened the medication and should be checked each time the medication was administered. She stated not dating the medication could lead to the resident receiving expired medications. She stated the pharmacy did random medication cart checks but ultimately it was the nurse's responsibility to ensure all medications that require dating were dated. During an interview on 03/12/25 at 10:50 AM, the Administrator stated it was her expectation for the facility staff to follow medication storage and labeling procedures. She stated it was the nurse's responsibility to label medications when they were opened. She stated this could lead to residents receiving expired medications. Review of facility policy titled, Over-the counter Medications, dated 09/21/2021, revealed in part: Policy: The facility may maintain a supply of over-the-counter medications supplied by the facility as allowed by state regulations. Procedure . 3. For multi-use eye drops, verify expiration date on the product. The product should be dated when opened and is valid for 28 days .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #50 and Resident #48) and 1 of 2 staff (LVN A) reviewed for blood glucose monitoring. The facility failed to ensure that LVN A cleaned the glucometer (capillary-blood sampling devices) after using it for Resident #50 and before using it for Resident #48. This failure could place residents at risk for cross contamination, infections, and a decrease in quality of life. Findings included: Resident #50 Review of Resident #50's electronic Face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of diabetes, pelvis fractures, and heart failure. Review of Resident #50's Admission MDS dated [DATE], revealed: BIMS of 10 which indicated moderately impaired cognition. Further review of the MDS Section I Active Diagnoses: Type 2 Diabetes. Review of Resident #50's electronic Comprehensive Care plan initiated on 03/07/25, revealed: Focus: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars. Goal: Will remain free from the signs and symptoms of hyper/hypoglycemia. Interventions: Monitor blood sugar as ordered by physician. Review of Resident #50's electronic physicians orders revealed: Fasting Blood Sugar via glucometer before meals and at bedtime, start date 02/27/2025. Resident #48 Review of Resident #48's electronic Face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of diabetes, influenza, and pneumonia. Review of Resident #48's Admission MDS dated [DATE], revealed: BIMS of 12 which indicated moderately impaired cognition. Further review of the MDS Section I Active Diagnoses: Type 2 Diabetes and Pneumonia. Review of Resident #48's electronic Comprehensive Care plan revised on 03/10/25, revealed: Focus: Resident has a diagnosis of diabetes and is at risk for unstable blood sugars. Goal: Will remain free from the signs and symptoms of hyper/hypoglycemia. Interventions: Monitor blood sugar as ordered by physician. Review of Resident #48's electronic physicians orders revealed: Fasting Blood Sugar via glucometer before meals and at bedtime, start date 03/03/2025. During an observation on 03/10/25 at 11:35 AM, blood sugar was being taken by LVN A for Resident #50. LVN A did not wash hands but donned gloves and removed glucometer from the drawer of the medication cart. LVN A did not clean glucometer and entered Resident #50's room. LVN A laid glucometer on Resident #50's bedside table without sanitizing or cleaning the table. LVN A obtain blood sugar reading and returned to medication cart laying glucometer down on the cart without cleaning it. LVN A removed gloves and sanitized her hands. LVN A went to the dining room and brought Resident #48 to her room to perform blood sugar check. LVN A donned gloves and grabbed uncleaned glucometer off the medication cart and entered Residents #48's room. LVN A laid glucometer on Resident #48's bedside table without cleaning the table. LVN A obtained blood sugar reading and returned to medication cart and placed glucometer in the drawer without cleaning it. During an interview on 03/10/25 at 11:55 AM, LVN A stated the glucometer should have been cleaned prior to and after each use. She stated she should not have gone from one resident to another without cleaning in between. LVN A stated she had been trained and she knew the proper procedure. She stated she just was nervous with being watched. LVN A stated this failure could lead to spreading infection. During an interview on 03/12/25 at 10:15 AM, the DON stated glucometers must be cleaned prior to each use and after each use and must be let set to dry. She stated glucometers should have never been used for more than one resident without being cleaned prior to using on the next resident. She stated the nurses were trained on this in their yearly competencies regarding infection control. She stated not cleaning glucometers could lead to cross contamination leading to infection. During an interview on 03/12/25 at 10:50 AM, the Administrator stated it was her expectation for the facility staff to follow all infection control procedures. The Administrator stated nurses performed competencies when hired and yearly and they were trained on infection control and glucometers. She stated ultimately it was the DON's responsibility to ensure nursing staff followed infection control procedures. She stated this could lead to cross contamination resulting in infection. Review of LVN A's personnel file revealed she was current and up to date with all training. Review of the facility document titled, 802 Resident Matrix, printed 03/10/25, revealed no residents in the facility had any bloodborne pathogens. Review of facility policy titled, Glucometer Devices, dated 06/08/2021, revealed in part: Anticipated Outcome: Blood glucose testing and monitoring will be performed according to physicians' orders. The disinfection of capillary-blood sampling devices will be performed in a manner to prevent transmission of bloodborne diseases to residents and employees. Process: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufactures instructions for multi-resident use or single use.

Based on observation, interview, and record review, the facility failed to prevent significant medication error for 1 of 33 residents (Resident #77) reviewed for pharmacy services. The facility failed to follow physician's order by not administering Lasix 20mg (diuretic medication to reduce swelling) as needed every 24 hours for Resident #77. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. Review of Resident #77's Admission MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14' indicated no cognitive impairment. Review of Resident #77's Comprehensive Care Plan initiated 01/22/2024, revealed: Focus: The resident has congestive heart failure. Goal: The resident will be free from complications related to CHF through the review date. Interventions: Monitor/document/report to MD PRN any s/sx of CHF: dependent edema of legs and feet .weight monitoring per physician's orders. Review of Resident #77's electronic physicians' orders revealed: Start date 01/19/2024, Discontinued 01/31/2024: Furosemide (Lasix) oral tablet 20 MG give 1 tablet every 24 hours as needed for swelling Start date 02/01/2024: 1500mL Fluid Restriction: Med Pass Fluids: Up to 600mL. Total AM: 240mL. Afternoon: 120mL. PM: 240mL. Meal Fluids: Up to 600mL. Total Breakfast: 120mL. Lunch: 240mL. Supper 240mL. Free Fluids: 300mL Start date 01/27/2024: Daily Weights Start date 02/02/2024: Edema Bilateral Legs: Monitor every Shift from increase edema or dressing rolling down. 1. Cleanse bilateral Les with dermal wound cleanser. 2. Apply Webril and Tubigrip D from base of toes to just below knees. 3. Change dressings PRN. Start date 01/31/2024: Torsemide Oral Table 20mg Give tablet by mouth two times a day. Review of Resident #77's Admit Evaluation, dated 01/19/2024 completed by RN D, revealed: 3+ edema (swelling) to bilateral lower extremities with discoloration. Review of Resident #77's electronic progress notes revealed: 01/19/2024 at 4:30pm signed by RN D: 3+ edema to bilateral lower extremities with discoloration. 01/20/2024 at 07:14 pm signed by RN E: +2 to +3 edema to BLE and Fluid restriction 1500 cc. 01/21/2024 at 03:47 am signed by RN F: the resident has mild pitting edema. 01/22/2024 at 04:53 pm signed by RN D: resident noted to have an increase in edema this shift to BLE. The resident has deep pitting, the indentation remains for a short time, looks swollen to. 01/23/2024 at 04:57 pm signed RN D: resident noted to have an increase in edema this shift to BLE; Resident requested to be laid in bed. Legs elevated. The resident has deep pitting, the indentation remains for a short time, looks swollen to. 01/24/2024 at 02:52 am signed by RN G: The resident has deep pitting, the indentation remains for a short time, looks swollen to. +2 to +3 edema to BLE; Fluid restriction 1500 cc. 01/25/2024 at 02:53 am signed by RN F: The resident has moderate pitting edema; indentation subsides rapidly to. Further review of electronic progress notes revealed no evidence of notifying the physician. 01/26/2024 at 03:07 pm signed by LVN H: The resident has moderate pitting edema; indentation subsides rapidly to. Resident continues to have increased edema to BLE. Continues to monitor resident for c/o pain to site, continue to provide PRN Lasix per orders for edema. Continue to encourage resident to elevate extremities. Resident dangles legs a majority of the day, unless resting in bed. Resident is aware of edema and our concerns. Lab results in review of physician at this time. Residents' family expresses concern about edema. Resident has history of diuretic secretion disorder. Nurse Practitioner in facility assessed resident this shift. Awaiting response. 01/26/2024 at 03:55 pm signed by LVN I: Edema present to BLE, 3+. Receives Lasix 20mg QD PRN for edema. Residents' family member expresses concern regarding edema and Lasix and would like to have Lasix scheduled daily. Nurse Practitioner aware of family members concerns and is reviewing. Placed on daily weights at this time x7 days. 01/26/24 at 4:27 PM signed by Nurse Practitioner: Resident #77 is lying in bed, alert, and smiling. She states that she does have some slight pain to her legs. Nursing staff reports edema to bilateral lower legs that causes the patient some discomfort with ROM and with transfers. Pitting Edema 3+ pitting edema noted to bilateral lower extremities. No s/sx of cellulitis noted at this time. Will advise to obtain daily weight X7 days and notify provider of >3 lb. wt. gain noted. Follow up in one week. 01/27/2024 at 01:33 pm signed by RN E: Upon daily assessment, resident's BLE noted at +4 edema to BLE with erythema and purple discoloration from feet to knees with erythema and edema moving up the inner and outer bilateral thighs. BLE warm and sensitive. Resident received new order for Lasix. Resident was to lay down with BLE elevated and Lasix administered. Will re-evaluate in 2-hours to re-assess for worsening erythema, warmth, and/or pain. Family member notified via phone with no questions or concerns at this time. 01/27/2024 at 05:57 pm signed by RN E: Resident's BLE re-assessed, and edema and purple discoloration improved and found to be erythematous, warm, and painful with erythema traveling up the inner and outer bilateral thighs. Physician notified and gave new order to send to ER to evaluate for possible cellulitis to the BLE. Resident is sitting up in bed, alert & oriented to baseline without confusion or distress at this time. Pain to BLE rated 4/10 and tender to touch. Family member notified via phone and requested resident be sent to hospital and will meet her there shortly. 01/28/2024 at 05:38 am signed by RN G: Resident returned from ER with new order for Clindamycin 300 mg TID for cellulitis and was initial dosed. Monitor edema. Daily weight. Monitor for s/sx of adverse reaction noted. Monitor for increased redness. Edema continues. Monitor weight No s/sx of adverse reaction noted. Redness continues. Edema continues to be + 3 Encouraged to elevate legs. Weight 206.4lbs 01/28/2024 at 06:28 pm signed by RN J: Resident came back from hospital this morning with new order of Clindamycin 300mg oral capsule TID due to cellulitis. Resident still has +3 Edema in both extremities. Encourage leg elevation to relieve edema. 01/29/2024 at 12:33 pm signed by LVN K: Resident continues to have increased edema to BLE. Continue to monitor resident for c/o pain to site, continue to provide PRN Lasix per orders for edema. Continue to encourage resident to elevate extremities. Resident dangles legs a majority of the day, unless resting in bed. Resident aware of edema and our concerns. Increasing edema to BLE. 01/29/2024 at 1:23 pm signed by LVN I: CHF clinic contacted regarding resident's edema to BLE. Continues with 3-4+ edema to BLE. Discoloration is present and resident is currently being treated for cellulitis with doxycycline. Resident does have mild discomfort when legs are palpated. Sits up in wheelchair most of day with legs extended with footrests per her choice. Current diuretic orders include Lasix 20mg QD PRN for edema. Significant weight gain is noted since admission r/t fluid. CHF clinic contacted to notify Provider and obtain recommendations. 01/30/2024 at 9:15 am signed by LVN I: CHF clinic contacted again to f/u on resident's edema. Spoke with office and informed them of edema to BLE and weight gain. Also requested all notes from previous visits. Office to notify provider and appointment scheduled for 1/31/24 @ 0930. 01/31/2024 at 11:47 am signed by LVN I: Resident attended appointment with CHF clinic today for f/u d/t BLE edema. Weight gain was noted by provider. 3-4+ edema present to BLE. Labs performed at appointment. Orders given by provider for the following: stop Lasix, start torsemide 20mg PO BID. Family member was present at appointment and aware. Review of Resident #77's electronic MAR revealed: 01/20/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/21/2024 at 10:23am Furosemide 20mg was administered 01/22/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/23/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/24/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/25/2024: order for Lasix and no evidence of administration 01/26/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/27/2024 at 11:06am: Furosemide 20mg was administered 01/28/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration 01/29/2024 at 12:21 pm: Furosemide 20mg was administered 01/30/2024: order for Furosemide 20mg Give 1 tablet by mouth every 24 hours as needed for edema and no evidence of administration Review of ER Discharge note dated 01/28/2024 revealed discharged with antibiotic Clindamycin 300mg three times a day for cellulitis. Review of Resident #77's CHF Clinic Patient Summary, date 01/31/2024, revealed: The patient is seen today as emergent work-in appointment. Her weight is up 7 lbs. from the last appointment one week ago. She has 3 to 4+ edema to lower legs bilaterally with weeping from the legs. She was seen in trauma center for cellulitis and was started on antibiotics. She is in a wheelchair. The patient feels like Lasix is no longer effective in keeping her swelling controlled. The patient was given 40 milliequivalents of potassium. She was also given 80 milligrams of IV Lasix for her weight gain and heart failure symptoms. During an observation and interview on 01/29/24 at 12:13 PM, revealed Resident #77 sitting in recliner and resident family member sitting on her bed. Resident #77's legs were swollen, red, and not elevated. No signs or symptoms of respiratory or acute distress noted. Resident denied pain or any shortness of breath. Resident #77's family member stated Resident #77 had a history of problems with swelling and fluid overload. She stated Resident #77 was sent to the emergency roiagnom on [DATE] and was diagnosed with cellulitis (infection of the legs). During an observation and interview on 01/31/24 at 2:00 PM, Resident #77 was up in wheelchair just returning from her visit the CHF clinic No signs or symptoms of respiratory or acute distress noted. Resident denied pain or any shortness of breath. Resident stated she received liquid Lasix for her swelling and that she was going to pee all night. During an interview on 01/31/24 at 03:00 PM, the DON stated all residents with PRN Lasix orders should have also had an order for edema monitoring. She stated Lasix should have been given every day that Resident #77 had edema documented and the physician should have been notified each time. The DON stated not giving the Lasix could have caused the cellulitis and could have prevented the fluid overload and the need for IV Lasix. The DON stated it was a system failure that led to the Lasix not being administered as needed. She stated she was ultimately responsible for monitoring and ensuring that all physicians orders were followed. During an interview on 01/31/24 at 03:30 PM, LVN H stated she was aware that Resident #77 had PRN Lasix orders. She stated she did not give the Lasix because Resident #77 did not tolerate it well. She stated the Nurse Practitioner did not want the Lasix given. LVN H stated she had discussed the edema and Lasix order with the Nurse Practitioner but had not documented the conversation. Attempted interview with RN-D on 01/31/2024 at 1:31 pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-D on 02/14/2024 at 11:30 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-E on 01/31/2024 at 1:33pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-E on 02/14/2024 at 11:32 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-F on 01/31/2024 at 1:35pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-F on 02/14/2024 at 11:37 am via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-G on 01/31/2024 at 1:45pm via phone call with no answer. Voice mail left with no return call. Attempted interview with RN-G on 02/14/2024 at 11:42 am via phone call with no answer. Voice mail left with no return call. Attempted interview with physician on 01/31/2024 at 3:50 PM via phone call with no answer. Voice mail left with no return call. Attempted interview with physician on 02/14/2024 at 11:12 AM via phone call with no answer. Voice mail left with no return call. During an interview on 01/31/24 at 04:00 PM, Resident #77's Nurse Practitioner stated she had seen Resident #77 on 01/26/24 and she had 3+ edema but no signs of cellulitis at that time. She stated she did not order Lasix to be routinely given because she was monitoring her prior labs. Nurse Practitioner stated she had not told any staff not to give the Lasix as needed per physicians' orders. She stated her expectation was for it to be given daily if needed and to be notified. She stated she had never been contacted or notified of Resident #77's edema other than on 01/26/2024 when she visited the facility. Nurse Practitioner stated not administering Lasix as needed could have led to the cellulitis and the fluid overload. During a follow up interview on 02/14/2024 at 12:10pm, Resident #77's Nurse Practitioner stated was concerned about routine Lasix bottoming out the resident's sodium and potassium levels. She stated that the risk of low sodium and potassium levels outweighed the resident's edema because the resident was not in acute distress nor had shortness of breath. The Nurse Practitioner stated that low sodium and potassium levels can lead to cardiac issues such as cardiac arrhythmias. The Nurse Practitioner also stated that the resident was an established patient with the local CHF clinic and when consulting with the resident's physician, the plan of care was to monitor and allow the CHF clinic to address the edema. She stated the facility was able to get the resident an earlier appointment. She stated again that the resident was never in acute distress nor had shortness of breath; therefore, she did not have a concern about the Furosemide being administered. During interview on 01/31/2024 at 8:00pm, DON and Administrator stated the facility did not have a policy for following physician's orders. Review of Center for Disease Control and Prevention website accessed on 02/15/2024 at https://www.cdc.gov/groupastrep/diseases-public/Cellulitis.html revealed: Cellulitis is a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin. Review of the Food and Drug Administration website accessed on 02/15/2024 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/016273s061lbl.pdf revealed: WARNING: Lasix (furosemide) is a potent diuretic which, if given in excessive amounts, can lead to a profound diuresis with water and electrolyte depletion. Therefore, careful medical supervision is required, and dose and dose schedule must be adjusted to the individual patient's needs. Lasix is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure. Review of the Food and Drug Administration website accessed on 02/15/2024 at https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020136s023lbl.pdf revealed: Demadex (torsemide) is a diuretic.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 residents (Resident #77) reviewed for quality of care. The facility failed to follow physician's order for daily weights for Resident #77 for 01/26/2024 and 01/27/2024. These failures could place residents at risk for decreased level of functioning and quality of life. Findings included: Review of Resident #77's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Sepsis, Pneumonia, respiratory failure, and congestive heart failure. Review of Resident #77's Admission MDS dated [DATE], revealed: Section C: Cognitive Patterns a BIMS score of 14 indicated no cognitive impairment. Further review revealed: Section K: Weight 200.4 lbs Review of Resident #77's Comprehensive Care Plan initiated 01/22/2024, revealed: Focus: The resident has congestive heart failure. Goal: The resident will be free from complications related to CHF through the review date. Interventions: Monitor/document/report to MD PRN any s/sx of CHF: dependent edema of legs and feet .weight monitoring per physician's orders. Review of Resident #77's electronic physicians' orders revealed: Daily weight every day shift for edema for 7 days. Notify physician of weight of 3lbs or grater in 24 hours with a date of 01/26/2024. Review on 01/26/2024 of Resident #77's electronic record revealed no evidence of a weight obtained. Review on 01/27/2024 of Resident #77's electronic record revealed no evidence of a weight obtained. Review on 01/28/2024 of Resident #77's electronic record revealed weight of 206.4 lbs. Review on 01/29/2024 of Resident #77's electronic record revealed weight of 209.8 lbs. Review on 01/30/2024 of Resident #77's electronic record revealed weight of 210.1 lbs. Review of Resident #77's electronic progress note, dated 01/30/2024 at 9:15 am signed by LVN I, revealed: CHF clinic contacted again to f/u on resident's edema. Spoke with office and informed them of edema to BLE and weight gain. Also requested all notes from previous visits. Office to notify provider and appointment scheduled for 1/31/24 @ 0930. Review of Resident #77's electronic progress note, dated 01/31/2024 at 11:47 am signed by LVN I, revealed: Resident attended appointment with CHF clinic today for f/u d/t BLE edema. Weight gain was noted by provider. 3-4+ edema present to BLE. Labs performed at appointment. Orders given by provider for the following: stop Lasix, start torsemide 20mg PO BID. Family member was present at appointment and aware. Review of Resident #77's CHF Clinic Patient Summary, date 01/31/2024, revealed: The patient is seen today as emergent work-in appointment. Her weight is up 7 lbs. from the last appointment one week ago. She has 3 to 4+ edema to lower legs bilaterally with weeping from the legs. She was seen in trauma center for cellulitis and was started on antibiotics. She is in a wheelchair. The patient feels like Lasix is no longer effective in keeping her swelling controlled. The patient was given 40 milliequivalents of potassium. She was also given 80 milligrams of IV Lasix for her weight gain and heart failure symptoms. During an observation and interview on 01/29/24 at 12:13 PM, revealed Resident #77 sitting in recliner and resident family member sitting on her bed. Resident #77's legs were swollen, red, and not elevated. No signs or symptoms of respiratory acute distress noted. Resident denied pain or any shortness of breath. Resident #77's family member stated Resident #77 had a history of problems with swelling and fluid overload. During an observation and interview on 01/31/24 at 2:00 PM, Resident #77 was up in wheelchair just returning from her visit the CHF clinic. No signs or symptoms of respiratory acute distress noted. Resident denied pain or any shortness of breath. Resident stated she received liquid Lasix for her swelling and that she was going to pee all night. During an interview on 01/31/24 at 03:00 PM, the DON stated stated she was ultimately responsible for monitoring and ensuring that all physicians orders were followed. During interview on 01/31/2024 at 8:00pm, DON and Administrator stated the facility did not have a policy for following physician's orders.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for meal service. Facility kitchen staff failed to discard food after handles touched with bare hands fell into pureed bread pan and roll bin during meal service. These failures could place residents at risk of food borne illness that ate from the kitchen. Findings included: During an observation on 01/29/2024 at 12:33 p.m., Cook A picked up scoop handle that was lying in puree bread halfway through meal pass and removed . Cook A asked Cook B to bring clean scoop over to steam table. Cook B brought back a clean scoop and placed into puree bread. Cook A started serving pureed bread to two of the pureed meal trays. The pureed bread was taken off the steam table by Cook A only after being asked if the food was okay to be served. During an interview on 01/29/2024 at 12:37 p.m., Cook A denied knowing that handle of scoop had dropped into ready to serve pureed bread, she stated if the handle had touched pureed bread, then all the pureed bread needed to be removed and replaced. She stated the effect not removing pureed bread after contamination would be that residents could get sick. During an observation and interview on 01/29/2024 at 12:42 p.m., Cook B dropped end of tongs into bread roll container and began to serve bread again until, Cook B was asked if bread was still able to be served. After one roll was served, Cook B took container with rolls off food dispensing area and replaced with new tongs and bread sticks. Cook B stated I thought it was empty container when asked why she continued to serve pureed bread after contamination. Cook B stated that food should not be served after handle dropping into food bin. During an interview on 01/29/2024 at 1:23 p.m., the DM stated her expectation would be to discard all food once handle fell into it. She stated after handle fell into food it would be contaminated. She stated she did not know why Cook A and Cook B did not replace food when it had been contaminated with handles. She stated she was responsible for monitoring dietary during meals to make sure that cross contamination did not occur. She stated the effect serving food that handle had fallen in could lead to residents becoming sick. During an interview on 01/30/2024 at 12:59 p.m., the ADMN stated her expectation would be that food would not be served after handle dropped into food. She stated it would be different if staff wore gloves. She stated the DM and herself were responsible for supervising meal passed intermittently. She stated the effect of continuing to serve food after handle fell into it could cause residents to get sick. Review of policy titled Food Safety and Sanitation Plan origination date 9/2005 and revision date on 11/2017 revealed Nursing home residents risk serous complication from food borne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling .Cross contamination means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food and then touching ready-to-eat foods .

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the comprehensive assessment for 2 (Resident #2 and Resident #20) of 4 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that addressed bed and chair alarms for Resident #2. The facility failed to develop and implement a comprehensive person-centered care plan that addressed a chair alarm for Resident #20. These failures could place residents at risk for falls and/or injury, negatively impact the resident's quality of life, as well as the quality of care and services received. Findings included: 1.Review of Resident #2's face sheet revealed a [AGE] year-old male admitted on [DATE] with medical diagnoses of fracture of the pelvic bone, dementia, type 2 diabetes, heart disease, and osteoporosis. Review of Resident #2's Admission MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score of 9 out of 15 indicating moderate cognitive impairment. Review of Resident #2's Comprehensive Care Plan dated 12/06/2023 revealed a focus problem of Falls: Resident has the potential for falls related to recent fall with pubic fx and impaired cognition with poor safety awareness. Interventions for the focus on falls included: Educate the resident/family/caregivers about safety measures and what to do if a fall occurs, Encourage socialization and activity attendance as tolerated, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility., Fall Risk Screening upon admission and quarterly to identify risk factors. and Place the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation on 01/30/24 at 09:20 AM, Resident #2 was sitting in a wheelchair in his room. A pressure pad alarm was noted on his bed and a magnetic pull cord chair alarm was attached to the wheelchair and clipped on the resident. Resident #2 stated when he tried to stand the alarm lets the staff know he needs help. 2.Review of Resident #20's Face Sheet revealed an [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #20's medical diagnoses included kidney disease, psychotic disorder with hallucinations, Type 2 diabetes, blood clots in the legs, back pain, difficulty walking, right shoulder pain, difficulty with swallowing, weakness, night terrors, high cholesterol, heart failure, heartburn, and impaired cognition. Review of Resident #20's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #20's Comprehensive Care Plan initiated 04/18/2018 and reviewed/revised12/27/2023 revealed a focus problem of Falls: Resident has the potential for falls related to cognitive impairment, antihypertensive drug use, Psychoactive drug use, Gait/balance problems, Fall Risk Score >10 and night terrors. Interventions for the focus on falls included: Alarm when in bed due to poor safety awareness, Anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage socialization and activity attendance as tolerated, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, Fall Risk Screening upon admission and quarterly to identify risk factors, Keep bed in lowest position when not providing care, Place the resident's call light is within reach and encourage the resident to use it for assistance as needed, Review information on past falls and attempt to determine cause of falls, Record possible root causes. Alter or remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, and Therapy for strengthening. During an observation on 01/29/24 at 03:25 PM, Resident #20 was self-propelling her wheelchair in the day room. A magnetic pull cord chair alarm was attached to the wheelchair and clipped on the resident. During an interview on 01/31/24 at 11:37 AM, the DON stated Resident #20 had a bed and chair alarm due to her tendency to lean in her chair and the alarm notified staff that the resident needed to be repositioned. The DON stated she was not sure if the facility had a policy to address justifying the use of an alarm. The DON was unable to recall requirements for placing an alarm. During an interview on 01/31/24 at 01:15 PM, the DON stated resident with alarms should have a provider order, an assessment should be completed, and the care plan updated to include the alarm(s). During an interview on 01/31/24 at 02:45 PM, LVN L stated residents on the unit had chair alarms to notify staff that residents were getting up and give them time to get to the resident to prevent the falling. She stated residents with alarms had a history of multiple falls, were assessed for alarms and orders were written and the care plan would be updated. LVN L stated she did not feel residents were being restrained, that it was more a safety issue. During an interview on 01/31/24 at 03:25 PM, with the DON and ADON, the ADON stated a provider order was not required to place bed or chair alarms. The DON stated her expectations when bed and/or chair alarms were placed, an assessment was done first. Once an assessment indicated a need for a bed and/or chair alarm, the care plan was updated, and a monitoring plan was put in place. The DON was not able to state a reason why the failure occurred. Review of the facility policy titled Comprehensive Care Plans dated 02/10/21 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 45216

Based on interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #20) of three residents reviewed for accident hazards. The facility failed to ensure that Resident #20's fall matt was placed beside her bed as ordered by physician. This failure could put residents at increased risk for accidents and injury. Findings include: Review of Resident #20's Face Sheet revealed an [AGE] year-old female initially admitted on [DATE] with a recent admitted [DATE]. Resident #20's medical diagnoses included psychotic disorder with hallucinations, blood clots in the legs, back pain, difficulty walking, right shoulder pain, weakness, night terrors, and impaired cognition. Review of Resident #20's Annual MDS dated [DATE] revealed in Section C - C0500. BIMS Summary Score a BIMS score of 00 indicating the resident was unable to complete the interview. Review of Resident #20's Comprehensive Care Plan initiated 04/18/2018 and reviewed/revised12/27/2023 revealed the following focused areas: *Falls: Resident has the potential for falls related to cognitive impairment, antihypertensive drug use, Psychoactive drug use, Gait/balance problems, Fall Risk Score >10 and night terrors. An Intervention for the focus on falls included using an Alarm when in bed due to poor safety awareness, *Fall Risk Screening upon admission and quarterly to identify risk factors, An intervention was to Keep bed in lowest position when not providing care, Review of Resident #20's physician orders reviewed on 1/31/2024 revealed: Low bed with mat to prevent injuries. Ensue placement of mat beside the bed and furniture away from bed. Every shift for Resident safety. During an observation on 01/30/2024 at 1:24 PM Resident #20 was lying in her bed sleeping, fall mat was not beside the bed. Resident #20's fall mat was observed propped against the opposite wall in her room. During an interview on 01/31/2024 at 02:45 PM LVN L stated Resident #20 was supposed to have floor mat beside her bed when she was laid in her bed. LVN L stated Resident #20 tried to get out of bed and could have hurt herself if the mat was not next to bed. LVN L stated if she had rolled out of bed, she could have hurt herself, if the mat was not in place. LVN L stated CNA and nurse were responsible to ensure the mat was placed back next to bed. LVN L did not have a reason for the failure, she stated the mattress was in room so it should have been put back beside her bed. During an interview on 01/31/2024 at 3:45 PM the DON stated if residents were ordered to have a fall mat they should have had a fall mat beside the bed any time they were in bed. The DON stated nurses and aides were responsible to ensure the fall mats were in place before leaving the resident's room. The DON stated not having the fall mats in place could have caused residents to be injured. The DON stated the failure of not placing the fall mat beside resident's bed could have been staff gotten busy and forgot to replace the fall mat at the bedside. During exit conference on 01/31/2024 at 8:00 PM the DON and ADMN stated they did not have any other policies to provide.

Based on interviews and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 1 of 3 days reviewed. The facility failed to ensure the daily staffing information was posted in a prominent location on 01/30/2024. This failure could place residents, their families, and visitors at risk of not knowing how many staff are currently working to provide care on all shifts. Findings Included: During an observation on 01/30/2024 at 9:12 a.m., daily staffing posted in hallways for previous date of 01/29/2024. During an observation on 01/30/2024 at 3:31 p.m., daily staffing posted in hallways for previous date of 01/29/2024. During an interview on 01/31/2024 at 11:36 a.m., the ADMN stated LVN C was responsible for making sure daily staffing was posted. During an interview on 01/31/2024 at 1:41 p.m., LVN C stated she was responsible for posting staffing daily. She voiced that on 01/30/2024 she had to work on Unit 3 performing direct care and had forgotten to post staffing that day. LVN C stated the effect of not posting daily would be that the resident and family members would not be notified of staffing numbers for that day. She stated that they may not be comforted that their loved ones were taken care of without those numbers. During an interview on 01/31/2024 at 2:26 p.m., the ADMN stated that DON was responsible for monitoring that daily staffing was posted. During an interview on 01/31/2024 at 2:38 p.m., the DON stated it was her responsibility to monitor that daily staffing was posted daily. She stated that LVN C having to fill in on Unit 3 was why it was not posted on 01/30/2024. The DON stated no negative outcome would come of daily staffing not being posted because their residents' and families of the residents new the facility and loved them. Review of policy titled nurse staffing posting guidelines dated 11/04/2017 revealed: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time . The nurse staffing information will be posted on a daily basis and will contain the following information: Facility name, The current date, Facility's current resident census, The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift .registered nurses .licensed vocational nurses .certified nurse aides .the facility will post the nurse staffing data at the beginning of each shift.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 1 of 4 staff (CNA A) reviewed for infection control. The facility failed to ensure staff (CNA A) wore face coverings correctly while providing direct care services. This failure could place the residents at risk of infection. Findings included: During observation on 11/28/22 between 11:00 AM and 11:30 AM on Unit 3, CNA A was observed walking around unit with her nose and mouth uncovered with a surgical mask under her chin. CNA A was observed pushing residents in wheelchairs, standing shoulder to shoulder with residents assisting them walking, bending over talking with residents, and delivering resident's drinks and snacks. During observation on 11/28/22 between 3:00 PM and 3:30 PM on Unit 3, CNA A was observed walking around unit with her nose and mouth uncovered with a mask under her chin. CNA A was observed pushing residents in wheelchairs, standing shoulder to shoulder with residents assisting them walking, patted resident on back, bending over talking with residents, and delivering resident's drinks. During an interview on 11/28/2022 at 3:30 PM, CNA A stated she should have been wearing her mask covering her mouth and nose. CNA A stated she was congested and was not able to breathe. CNA A stated that it was important to wear mask appropriately to prevent spread of COVID, and not wearing mask covering mouth and nose could have caused residents to get sick. CNA A stated she had screened herself before entering the building. During an interview on 11/30/22 at 2:50PM, the DON stated her expectation was that staff follow the rules and mask should be worn covering both their nose and mouth. The DON stated the Community Transmission levels were high, which indicated all staff and visitors needed to wear a mask while in the building. The DON stated the reason for the failure of CNA A not properly wearing a mask was due to the employee having such difficulty in breathing with allergies and congestion, she really was not paying attention to the fact that her mask was not covering her nose and mouth while around the residents. The DON stated the potential for harm for the residents could have been that if she would have had Covid and not allergies, then she could have spread the Covid virus to the residents. Record review of CNA A's employee file revealed that CNA A completed Infection Control training on 11/11/2022. Record review of the facility policy titled Coronavirus Surveillance dated 10/24/2022 revealed, Facemask [NAME] be used by everyone (including staff and visitors), if community Transmission levels are high, when they are in areas of the healthcare facility where they could encounter residents. Review of the CDC website https://covid.cdc.gov/covid-data-tracker accessed on 11/30/2022 revealed the Community Transmission level for [NAME] County was high. Review of the CDC website https://cdc.gov/coronavirus accessed on 11/30/2022 revealed, When putting on a facemask, clean your hands put on our facemask so it fully covers your mouth and nose.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. Foods were not sealed and/or labeled properly in dry food storage and refrigerators. 2. Failed to ensure that food was discarded when it reached expiration date. 3. Resident food trays were not washed and dried correctly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: In an observation on [DATE] at 9:40 AM of the kitchen with the Dietary Manager revealed: Dry storage 1. A box of scalloped potatoes opened, and not sealed with an expiration date of [DATE]. 2. A box of hash brown potatoes with an expiration date of [DATE]. 3. A package of vanilla wafers not in original package not sealed or dated. 4. An open package of cheese puffs not sealed and was not labeled with an open date. 5. 40 individual packages of thickened coffee with an expiration date of [DATE]. Freezer 1. A bag of frozen chicken breasts not sealed. 2. A bag of Frozen beef patties not sealed. 3. A bag of frozen vegetables not sealed. 4. A bag of rib shaped pork patties not sealed. 5. A bag of frozen breaded beef patties not sealed. Fridge 1.A bag of grated cheese not in original package in a plastic container not sealed. 2.A plastic container containing peaches with plastic wrap covering the top not sealed. Counter 1. A cardboard tray of chocolate muffins that were covered with plastic wrap that were not sealed . In an observation on [DATE] at 11:30 AM the kitchen meal trays being placed out for lunch were still wet. The trays had been stacked before they were dried. In observation on [DATE] at 1:55 PM in the kitchen, trays were stored and stacked wet. During interview on [DATE] at 10:00 AM with DM, she stated that the proper way to label items is to write the received date, open date and use by date. DM stated that she uses the month and date. During interview on [DATE] at 10:00 AM with Cook, she stated the appropriate way to seal a bag in the freezer is to tie the bag or place item in a plastic bag with a seal. During interview on [DATE] at 12:00 PM with DM. she stated that the trays should not have water droplets on them, because they were to be air dried before putting them up. DM stated that the reason they needed to be air dried is to prevent cross contamination. DM stated that they would hand dry the trays. During interview on [DATE] at 2:00 PM with DM, DM stated that the failure for items not being sealed, labeled or being expired is that staff get in a hurry, not being thorough, and not following company policies. DM stated that she provided an in-service on [DATE]th and [DATE]th for labeling and food storage. DM stated that the cause of the failure of trays not being dried properly is staff not following company policy. DM stated that she had completed an in-service on [DATE] for labeling, storage and drying ware. During interview on [DATE] at 03:12 PM with ADM, she stated that the cause of the failure of items not being stored correctly, labeled correctly, and washed/dried correctly is that staff are not completing daily check list and not following company policy. Record review of Inservice Program Attendance Record revealed 9 kitchen employees attended an in-service on [DATE] with the topic Shift duties: labeling and storage of food. Record review of Inservice Program Attendance Record revealed 8 kitchen employees attended an in-service on [DATE] with the topic Air drying dishes and properly labeling and storage of food. Record review of policy titled, Dry Food and Supplies Storage dated [DATE] revealed: Expiration or used by dates will be checked and product will be put in order of use by or expiration date. Any product that is found to be out of date will be discarded .All open products must be resealed effectively and properly labeled, dated and rotated for use . Use by, Best by and sell by dates should routinely be checked to ensure that items which have expired are discarded appropriately. Record review of policy titled, Frozen and Refrigerated Foods Storage dated [DATE] revealed: Packaged frozen items that are opened and not used in their entirety must be properly sealed, labeled and dated for continued storage Refrigerated products that are opened must be labeled with an opened on date. Record review of policy titled Ware Washing dated [DATE] revealed: Allow all items to air-dry prior to storage. Items should be stored to allow for proper air circulation. (e.g. inverted, covered or stacked with the top dish or tray inverted.

Based on observation interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 units. The facility staff failed to wear N95 masks properly on 2 of 5 units, (Unit 3, 4). The facility staff wearing N95 masks did not have documentation of a fit-test for the N95 masks. The facility staff failed to change isolation gowns and/or gloves between resident contact and/or rooms that were on the warm units (Units 1, 5). The trash can outside of warm Unit 1 was overflowing with yellow isolation gowns, masks, and gloves. These failures place residents and staff at risk of infection with the Covid 19 virus. The findings include: During an observation and interview on 09/02/2021 at 11:45 AM on unit 4, CNA R was observed wearing a N95 mask with the bottom strap hanging from her chin and not over her head. She said, You should wear both straps on the N95mask. It is not functioning properly if not worn properly. She said she was taught to wear an N95 properly. CNA R said, I just came out of the bathroom and forgot to pull the strap over my head. During an interview on 09/02/2021 at 12:00 PM on unit 3, with RN A, If I see someone not wearing an N95 mask properly, I would ask them why and tell them that they need to wear the N95 mask properly and if needed I would let my supervisor know. During an observation and interview on 09/02/2021 at 12:05PM on unit 3, CNA C was observed with no lower straps attached to her N95 mask. CNA C stated My strap broke and I was just finishing this up and was going to put on a new one. I realize it is not working properly if I am not wearing it properly. I have not been fit tested here in the facility for the N 95 masks. During an interview on 09/02/2021 at 12:10 PM with the Administrator and DON. The Don said that if an N95 mask is not worn properly then it is not effective. During an interview and observation on 09/02/2021 at 4:25PM with LVN A on warm unit 5. She said that the residents on this unit were either new admissions or have had exposure. She said that hospital quarantine residents were mixed with exposure residents. Observed 1 resident door had signage that stated Contact Precautions and Droplet Precautions. All resident room doors were open. LVNA said, We had a resident test positive today and sent him to the Covid unit. She said that they changed their gloves and they perform hand hygiene depending on what type of resident contact and that unit 5 and unit 1 were warm units due to exposure. She said that All the staff on unit 5 should wear a gown, N95 mask, face shield and gloves. Staff put on a gown and N95 mask before coming on the unit and do not change gowns unless gown is visibly soiled. The staff wear the same gown all shift. LVNA stated that There had been a handful of residents from this unit moved to the hot unit. During an observation on 09/02/2021 at 4:37PM of warm unit 5. NA A went in and out of 3 different resident rooms without removing gloves or gown. During an interview on 09/02/2021 at 4:40PM with NA A, she stated, I've only been working here for five days. I change my gown when I go off the unit and I put it back on when I come back to the unit. I have not been fit tested for the N95 mask. During an observation and interview on 09/02/2021 at 5:00PM of warm unit 1. Outside of the unit is a table with PPE supplies and an open trash can overflowing with yellow isolation gowns, masks, and gloves. Observation of warm unit 1, CNA S observed going in and out of two resident rooms with drinks and not changing gowns or gloves, then she entered the kitchen area. CNA S stated I change my gown when I go off the unit and change gloves between residents. I wear my face shield at all the time. During an interview on 09/02/2021 at 5:05PM with CNA H from warm unit 1, he stated, I change my gown about two times a shift. During an interview on 09/02/2021 at 5:15PM with LVN D from warm unit 1, she stated, Put on a clean gown when I get here and hang it up on hooks by the entrance/exit door before I go out and then put it back on when I come in the door to the unit. During an interview on 09/02/2021 at 5:25PM with CNA K on the Covid Hot unit 2, she said she was a new CNA at the facility and that she had not been fit tested for her N95 mask. During a telephone interview on 09/03/21 at 1:27PM with LVN H, she said, I tested positive on Tuesday (8/31/21). Prior to the outbreak I would wear a N95. I was not fit tested here. I've only been here two weeks. Only two times did I go to another unit. I went to unit 2 to deliver meds and supplies. I usually work unit 5. I have not been vaccinated. I would wear a gown for designated Covid rooms for new admits and for any known exposure. There was one resident on quarantine with no exposure when I started working here. Record review of Infection Control Investigation Entrance Checklist provided to facility on 09/02/2021 revealed: Total of residents who have been COVID tested , 102 tested on ,d+[DATE], 90 residents being tested today (9/2/21). Total number of Residents who have been COVID positive. 12-8/31, admitted 2 from hospital 9/1, 7 additional positive 9/2 .Total number of staff-123. Total number of staff who have been COVID tested -121 on 8/31, 42 on 9/1. Total number of staff who have been COVID positive. 3. This made 21 residents total out of 104 residents of the facility that tested positive for Covid-19. This made staff total of 4 out of 123 that tested positive for Covid 19. Record Review of facility fit-testing log dated 11/16-11/19/20 revealed: CNA K.(Covid unit 2) Could not test. Covid 19 Positive . RN A.(Cold unit 3) No documented fit-test . CNA-H.(Warm unit 1) Could not test. Positive for Covid 19. CNA R. (Cold unit 4) No documentation of fit test . CNA C. (Cold unit 3) Could not test. Covid 19 Positive. The N95 fit test documentation revealed 4 of 5 staff working the Covid unit 2 did not have N95 mask fit-test documentation. It was also revealed that staff on warm and cold units 1, 3, 4, and 5, did not have N95 mask fit-test documentation. Record review of facility policy labeled Novel Coronavirus Prevention and Response dated 7/7/2021 revealed: COVID-19 short for coronavirus disease 2019 but it is spread person to person mainly between people who are within six feet of one another through respiratory droplets produced when an infected person coughs or sneezes. It may also be spread through airborne transmission if a person with COVID-19 infects others who are more than six feet away, but this usually occurs within an enclosed space that has inadequate ventilation .Consider designating wing/unit or floor to accept new residents . Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection .Posting signs on the door or wall outside of the resident room that clearly describes the type of precautions needed and required PPE. Make PPE, including face masks, eye protection, gowns, and gloves, available immediately outside of the residence room .Facility staff should be appropriately trained and fit tested for N95 mask if at all possible. Record review of facility policy labeled Surveillance Plan: Infection Control COVID-19 Response, revision date 3/23/21. Isolation precautions are implemented for residents with known or suspected COVID-19 in a private room if available or other actions taken based on national EG CDC state or local public health authority recommendations . Unknown COVID-19 status- a person who is a new admission readmission has spent one or more nights away from a facility has had known exposure or close contact with a person who is COVID-19 positive, or who is exhibiting symptoms of COVID-19 while awaiting test results will immediately be placed in a droplet contact isolation precaution and placed in a private room or cohorted if private room is not available with the door closed in the designated area. Record review of Transmission Based Precautions accessed on 09/12/2021 at https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html revealed: Contact Precautions. Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens Droplet Precautions. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. Use personal protective equipment (PPE) appropriately. Don mask upon entry into the patient room or patient space. Record review of Texas Health and Human Services Covid-19 Response for Nursing Facilities revised 07/20/2021 revealed: Make necessary PPE available in areas where resident care is provided. Put a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room . [The NF is responsible for] implementing a respiratory protection program compliant with the OSHA respiratory protection standard for employees if not already in place. The program should include medical evaluations, training, and fit testing . Personnel who enter the room must wear N95 respirators, if available and staff are fit-tested . Respiratory protection should be worn in addition to gown, gloves, and face shield.

Based on observation, interviews, and record review, the facility failed to ensure its nursing staff had the appropriate competencies and skills to provide nursing and related services for 1 of 2 residents (Resident #2) observed for incontinence care. CNA (Certified Nurse Aide) A failed to demonstrate proper cleansing techniques and hand hygiene when providing Resident #2's incontinence care. This failure could place residents at risk for skin breakdown, urinary tract infections, and the spread of infectious organisms due to inadequate cleansing and improper hand hygiene. Findings include: Review of Resident #2's electronic profile revealed he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's electronic quarterly Minimum Data Set ((MDS) dated [DATE] revealed he required extensive assistance with activities of daily living (ADLs). He was frequently incontinent of urine, always incontinent of bowel, and he had a Brief Interview for Mental Status (BIMS) score of 14, which indicated his cognitive function was intact. Review of Resident #2's Care Plan, revised on 10/2/19, revealed the following: Incontinence-Resident is incontinent of bowel/bladder .The resident will be clean and odor free through next review date .Check frequently for wetness and soiling, every two hours, and change as needed . Observation of Resident #2's incontinence care on 11/25/19 at 3:40 p.m. in the presence of LVN A, revealed, while cleaning his perianal area, CNA A wiped the stool from his buttocks, folded the disposable wipe, and wiped stool from another area of his buttocks. She repeated this procedure four times with the wipe, obtained another wipe and followed the same procedure of wiping, folding and wiping again four times before discarding the soiled wipe. CNA A removed the soiled brief and placed a clean brief under Resident #2, fastened and adjusted his clothing. She did not change her gloves or wash/sanitize her hands after cleaning Resident #2, prior to handling the clean brief and his clothing. In an interview on 11/25/19 at 3:45 p.m., CNA A said she was supposed to wipe one time then discard the wipe. She said after cleaning Resident #2, she was supposed to change gloves before handling the clean brief. In an interview on 11/25/19 at 3:51 p.m., LVN A said she was the risk manager and staff development coordinator. She said she could not really see what CNA A was doing because she was standing behind her. LVN A said she did not know the policy for using disposable wipes. She said the facility had a template on how to provide incontinence care, but she was not sure how you are supposed to do it. LVN A said CNA A should have changed her gloves when she was done with cleaning Resident #2 before she applied the clean brief. In an interview on 11/25/19 at 4:52 p.m., the Administrator said she was not sure about the facility's policy on folding the wipes. She said that was a Director of Nursing (DON) question, but CNA A should have washed her hands and changed her gloves before handling the clean brief. The Administrator said LVN A was their staffing person and goes over the incontinence care with new employees. She said the task should be on their skills checklist. In an interview on 11/26/19 at 11:10 a.m., the DON said, we don't fold the wipes-one wipe, one swipe, trash. She said, after cleaning the resident and prior to putting on the clean brief, staff should wash their hands and change gloves. The DON confirmed that LVN A provided staff training and skills check-offs. Review of the facility's Policy, Incontinence Care dated 4/10/17, revealed: Purpose: to outline a procedure for cleansing the perineum and buttock after an incontinence episode. Procedure: . 5. Put on non-sterile, latex-free gloves . 8. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum toward rectum. Discard soiled materials and gloves. Wash hands. 9. Put on non-sterile, latex-free gloves . 11. Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum . 15. Remove and discard gloves. 16. Wash hands 17. Apply clean linen/underpad, brief or other incontinent products, as needed. Review of the facility's undated skills checklist revealed: Discipline: Nursing Skill: Peri-care Performance Criteria . 5. Washes hands, applies disposable gloves and other PPE (personal protective equipment) as indicated . Female Performance Criteria: . 14. One wipe one swipe technique if using disposable wipes . 20. Cleanses by wiping from vagina toward anus with one stroke. Uses clean area of cloth for each stroke or if using disposable wipes-one wipe one swipe until clean . Male Performance Criteria: . 30. Assist to lie on side, follows steps 18-22 above . All Criteria . 33. Removes gloves, washes hands, disposes/cleans equipment as appropriate .

Based on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 8 residents (Resident #1) that were reviewed for accuracy and completeness. The facility failed to completely and accurately document Resident #1's change of condition: 1) No documentation to wear sling (as directed) for fracture of right humerous received as hospital discharge orders on 5/2/19. This failure could place residents at risk of errors in care and treatment due to incomplete and inaccurate records. The findings were: Record review of Resident #1's Face Sheet, dated 4/24/19, indicated he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS, dated [DATE], indicated BIM's of 09 (indicated moderate cognitive impairment), resident usually understands others and is usually understood by others, requires extensive assistance with dressing, transferring, bathing, hygiene and activities of daily living. Record review of Resident #1's Baseline care plan, dated 4/25/19, indicated Resident has the potential for falls related to Gait/balance problems with interventions of Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, Floor Mat, Keep bed in the lowest position when not providing care, Place the resident's call light is within reach and encourage the resident to use it for assistance as needed and goals of The resident will be free of falls through the next review date and Resident will not sustain a fall related injury by utilizing fall precautions through next review date Record review of Resident's #1's updated care plan, dated 05/08/19, indicated the following intervention added to Fall care plan, Alarm when in bed or up in chair due to poor safety awareness and Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Interview on 5/14/19 at 8:45 a.m. Resident #1's family member stated that Resident #1 was admitted for rehabilitation training to help with strengthening of lower extremities and was a fall risk. Family member stated that facility staff had contacted her by phone asking why Resident #1 was trying to get out of wheelchair, informed that in the past Resident #1 was very active and may need to have gait belt applied and walked around the facility. Stated no other phone calls were received until the following day when she was informed Resident #1 was being transported to emergency room . Stated that Resident #1 returned from emergency roiagnom on [DATE] with orders for sling for Right Humerus and when she visited Resident #1 on 5/3/19 sling was not being worn. Family member stated that when questioned of sling staff were not aware of order. Wife stated she does not recall staff who were on duty that date. Record review of Resident #1's medical chart, LVN B indicated that on 5/2/19 at 11:10 a.m. Noted swelling to the shoulder of right arm this morning, resident reported some pain and discomfort to arm 5 out of 10 on pain scale resident had weak hand grasp in right arm compared to than left limited ROM (range of motion) noted in the right arm, resident able to move fingers with +2 radial pulse in the right arm as well as the left arm, no discoloration noted to right arm at this time, warm upon touch skin color appropriate. will continue to monitor. Contacted physician's nurse to report current condition and possible need for x-ray nurse stated she will give me a call back shortly, so she can report it to physician. Called office back 1hr later to follow up, as well as to request pain medication to administer to resident and was not able to get into contact with staff. Wife has been notified and left voicemail, awaiting further orders. Record review of Resident #1's medical chart indicated that on 5/2/19 at 12:43 p.m. follow up to swelling in the right shoulder/arm, got a call back from physician's nurse, and new order for STAT (Immediately) x- ray of the Right arm and to report results, wife has been notified also requested order for pain medication due to pain and discomfort. Record review of Resident #1's medical chart indicated that on 5/2/19 at 4:03 p.m. Order to send resident to HMC (Hendrick Medical Center) due to fracture and increase swelling and pain to right arm, wife has been notified and will be following facility van to meet at HMC ER (emergency room ). Resident is alert and oriented x 4, report given to ER nurse, appropriate paperwork has been sent, face sheet, med summary list, signed DNR (Do not resuscitate) code, x-ray results, along with transfer sheet. Record review of Resident #1's medical chart indicated that on 5/2/19 at 8:14 p.m. Resident returned from Hendrick Health System in W/C (wheel chair) Wandering throughout unit in W/C, right arm in sling Wife to arrive at later time with discharge orders . Record review of emergency room discharge instructions, dated 5/2/19 indicated Sling as directed. Follow up with orthopedic next week. Record review of Physician order [REDACTED]. Record review of 24- hour Report Worksheet dated 5/3/19 did not reveal new order Sling as directed, which was written in emergency roiagnom on [DATE]. In an interview on 12/01/17 at 10:20 a.m., DON stated she is unsure why change of condition was not documented on 24-hour nurse report but would expect new orders or change of condition to be documented on 24-hour report to ensure the oncoming shifts are made aware. DON stated she was unsure why sling was not entered into orders but would expect the new orders to be entered per protocol (any order received will be initiated by charge nurse on unit which will then be added to MAR's (medication administration record) or TAR's (treatment administration record)).

Based on observation, interview and record review, the facility failed to ensure one (Residents #7) of 7 residents, who were reviewed for medication regimen, were free of significant medication errors. On 1/27/15 LVN A administered 14 medications prescribed for another resident to Resident #7. Resident #7 became diaphoretic (perspiring {sweating} profusely), then unresponsive, and was transferred to the hospital. She was hospitalized for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 03/02/15. While the IJ was removed on 03/06/15, the facility remained out of compliance at a severity level of " Actual harm that is not Immediate Jeopardy" and a scope of " isolated," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure administer physician-ordered medications could affect the facility's 93 residents and placed them at risk for loss of a change in their condition, exacerbation of current health issues, development of new health issues, prolonged healing time and the possibility of hospitalization . Findings included: Record review of Resident #7 ' s admission record revealed that she was a [AGE] year old female admitted on [DATE] with a readmission on 10/6/14. Admission [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] reflected she was alert and disoriented no behaviors and had a BIMS score of 2, which indicated she was cognitively impaired. Resident #7 was also assessed as requiring extensive assistance by one staff for bed mobility, transfers, toileting and bathing, dressing and personal hygiene and only set-up help for eating. Record review of Physician orders [REDACTED].#7 had MEDICATION ORDERS FOR [REDACTED]. And Keflex 500 mg 1 tablet by mouth 4 times a day for left foot infection. Record review of Resident #7's Nurse Notes dated 1/27/15 4:00 p.m. entry revealed that at 7:30 a.m. LVN A administered the wrong medication to Resident #7. Resident #7 was given the following 14 medications; 1. [MEDICATION NAME] 10 milligrams (mg)1 tablet orally (po); used for [MEDICAL CONDITION], 2. aspirin 81 mg chewable 1 tablet by mouth every day; used for [MEDICAL CONDITION], 3. Calcium antacid 500 mg 1 tablet po; used for indigestion , 4. [MEDICATION NAME]-[MEDICATION NAME] 25-250 mg po 1 tablet; used for [MEDICAL CONDITION], 5. Carvedilol 6.25 mg; used for [MEDICAL CONDITION], 6. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet po; used for general discomfort, 7. [MEDICATION NAME] 200 mg 1 tablet po after breakfast; used for discomfort, 8. [MEDICATION NAME] 20 mg po 1 tablet; used for eye health, 9. Multiple vitamin with minerals 1 tablet po; supplement, 10. [MEDICATION NAME] sulfate 325 mg 1 tablet by mouth every day; used for [MEDICAL CONDITIONS], 11. [MEDICATION NAME] 50 mg 1 tablet po; used for psychiatric disorders, 12. Requip 1 mg po 1 tablet; used for [MEDICAL CONDITION], 13. Zinc 220 mg po 1 capsule; used as supplement, 14. vitamin D3 2000 units 1 tablet by mouth every day, used for balance. Of these 14 medications, only 3 were prescribed for Resident #7 - aspirin, vitamin D3, and [MEDICATION NAME] sulfate. In an interview on 2/4/15 at 2:45p.m. LVN A said around 7:30 a.m. on 1/27/15 that it was a crazy day and for some reason she did give Resident #7 the wrong morning medication. LVN A said that 10 or 15 minutes later Resident #7 became diaphoretic and the CNA called to LVN A to come check on the resident. LVN A said that as soon as I looked the resident in the face I realized that I had given Resident # 7 someone else's medication. LVN A screamed for some help and began taking Resident #7 's vital signs, stated-pulse strong, then notified the DON and other staff members of the incident and they came to assist. LVN A said that Resident #7 had become unresponsive and the Emergency Services had to be notified for an emergency transfer to the hospital. LVN A said that after the resident was transferred; the DON pulled her off the floor and took her to the front office for some training. LVN A said that she felt that not having any training in the facility policy and procedures and not having enough help lead to the medication error. LVN A said she had not been trained in the policies and procedure, and was only assigned to work alongside another nurse for one day on a different unit, then turned loose onto another unit by herself the next day. Record review of the nurse notes for 1/27/15 at 7:30 a.m. revealed no vital signs documented at the time of the incident. Record review of the Medication Administration Record [REDACTED]. Blood pressure 112/80 signed at 8:00 a.m. Record review of the personnel file for LVN A revealed date of hire as 1/8/15-full time. No evidence of orientation, dementia training or medication administration training in the personnel file. Record review of the incident report dated 1/27/15 at 8:11 a.m. reflected that LVN A had given the wrong medication to Resident #7. Immediate action taken- notified the DON at 8:10 a.m., and ADON, head to toe assessment with complete vital signs performed, called 911, called physician at 8:15 a.m., family notified at 8:31 a.m. Record review of the hospital admission record for Resident #7 dated 1/27/15 revealed an admission [DIAGNOSES REDACTED]. Record Review of hospital history and physical dated 1/27/15 reflected: Chief complaint-Marked weakness and also low blood pressure and sore on the left foot. History of Present Illness- Resident #7 is a 69 -year old female, who is admitted through the emergency room with a complaint of low blood pressure and weakness. In the emergency room , her blood pressure was about 80 to 90 systolic, and after giving the NS bolus (IV fluids to raise blood pressure) and the patient did not get the pressure up, she had the [MEDICATION NAME] drip (solution to maintain blood pressure). Impression: 1) Sepsis 2) [MEDICAL CONDITION] (low blood pressure) 3) Gross [MEDICAL CONDITION] 4) Probably urinary tract infection 5) Mental [MEDICAL CONDITION] Recommendations: The patient is advised to admit in the ICU. In an interview with Resident #7 ' s physician on 2/4/15 at 3:15 p.m. Physician A said that Resident #7 was a very sick lady and had been admitted to ICU with [MEDICAL CONDITION]. In an interview with DON on 2/4/15 at 4 p.m. said that on 1/27/15 she was called to the unit by LVN A and when she arrived the resident was unconscious and that 911 had been called. The DON said that after the transfer was complete she replaced LVN A and then suspended her pending investigation. She said that LVN A came to the front office and was in-serviced. The DON said that LVN A never re-entered the unit. She found that LVN A did not follow policy for medication administration. The DON said that LVN A had not been trained in the facility policy and procedures and had not had an orientation including medication administration. When questioned about the training the DON said that the facility waited until there were enough people to have a class and that there were not enough hired since LVN A was hired on 1/8/15. Record review of Departmental Notes on 1/27/15 at 6:07 p.m. revealed Called local hospital for current report on resident status. " Resident is in ICU with [MEDICATION NAME] drip for blood pressure stabilization... " Record review of Departmental Notes on 1/29/15 at 12:17 a.m. , 12:25 a.m. and 8:43 am revealed "... call placed to local hospital for updated report on resident condition. Note revealed the blood pressure medication continued and was being adjusted to stabilize the blood pressure ..." Record review of the Medication Administration policy dated 5/1/2011 revealed- Purpose - to administer the following: Right medication, Right dose, Right dosage form, Right route, Right resident/patient, Right time. Procedure- ... 3. Identify resident/patient via wrist band or picture id. An IJ was identified on 03/02/15 at 3:40 p.m. and the Administrator was informed. At 4:08 p.m. on 03/02/15, an interview was conducted with the interim DON. When asked how she monitored her staff to ensure the systems were effective, she stated that she makes rounds and watches and listens to the staff and the residents. When the interim DON was asked why she thought the IJ had occurred she stated staffing went into crisis and agency was used to replace staff, some staff were terminated, others were burned out. She said that the facility did not provide the medication administration training and the medication error reporting as they needed to any of the staff. At 4:39 p.m. on 03/02/15, an interview was conducted with the Administrator When asked how she monitored her staff to ensure the systems were effective, she stated she attended the daily stand-up meeting where they track and trend all issues with the residents. When asked how she evaluated policy and procedures to ensure the effectiveness of the facility processes, she said the policy and procedures were in the computer. The Administrator replied that the facility tries to in-service on the policies and the facility also uses Reliance (a computer program). She said that she makes rounds and as patterns develop, the facility looks at the policies and procedures and redirects, re-educates and makes sure the staff follows the policies. When the Administrator was asked why she thought the IJ had occurred she stated it was the lack of staff training and their lack of knowledge. She said that she was aware of the lack of training and that included the agency staff in the facility. She said that every nurse is now getting a medication pass, medication administration, medication error and what to do if you make a medication error education. Observation on 3/6/15 from 11:45 a.m. until 12:10 p.m. of Unit Medication carts revealed MAR ' s with picture to identify residents for medication administration. Observation of the nurses revealed the use of the photographs to identify the resident. Interviews from 11:30 a.m. until 5:30 p.m. on 3/6/15 with 5 of 5 nurses on duty reflected that the LVN ' s and RN ' s had been trained on medication and administration with emphasis on resident identification via photograph and Medication Pass competencies, medication errors. Interviews confirmed that the staff had been trained prior to resuming duties administering medications. Interviews and record review of the training revealed that staff nurses and agency nurses had completed the training. Record review of the training roster revealed that 10 nurses had completed the training provided by the pharmacist on 2/3/15. The training included- Medication Pass, Controlled Substances-Accountability and Documentation, Expiration dating, Ways to minimize med errors, preventing diversions and Medication Pass observation. Record review of the training revealed that 6 of 6 agency nurses had completed the training in- service and 4 of 6 had completed the medication pass observation. Record review of the training revealed that 19 of 19 staff nurses had completed the training in- service that included medication administration, 6 rights of medication administration and with emphasis on identification of the residents and 19 of 19 staff nurses had completed the medication pass observation. The facility's Plan of Removal, 5th draft dated 03/06/15 received at 3:31 p.m. reflected the following: 1. Resident was administered the wrong medication on 1/27/15: a. Resident became diaphoretic and lethargic. b. Resident was immediately assessed, DON, physician and family were notified, 911 was called and the resident transferred to an acute care facility. c. The root cause was the LVN failed to identify resident prior to administering the medications. Six rights of administration of medication were not followed according to protocol: Right resident, right medication, right dose, right route, right time, and right dosage form. d. LVN was suspended upon discovery of alleged medication error and later terminated, prior to working any additional shifts. Thus eliminating the potential of the staff member posing any further threat of harm. 2. Current residents residing in the facility have the potential to be at risk. 3. In order to validate that appropriate policies and procedures are followed, the following has been implemented: a. An independent auditor completed a Medication none of which resulted in a medication error based on current physician orders. b. Licensed Nurses, including agency staff, have been re-educated on policy regarding administration of medications with emphasis on resident identification via photograph and Medication Pass competencies, effective 3/4/15. 14 of 26 currently employed Licensed Nurses and 5 of 5 agency Licensed Nursing staff that assumed duties have completed education and competencies as of the writing of this plan of Correction. Medication pass competencies and education have been completed by DON, interim DON, and RN Director of Clinical Services, RN Regional Nurse Consultant, LVN M, and Pharmacy consultant c. PRN licensed nursing staff and new agency staff will receive education on medication administration with emphasis on resident identification via photograph and demonstrate medication pass competency prior to assuming duties. Training will be provided by interim DON, Unit Manager, and Regional Clinical Nurses. d. Medication administration education with emphasis on resident Identification via photograph has been added to new hire and new agency Licensed Nurse orientation including medication pass competency observation. New hire orientation is scheduled 3/11/15 -3/13/15. New Director of Education has been hired and will attend this orientation. The Corporate Director of Education will facilitate this orientation with assistance from RN Unit Manager A and B, and LVN M . The new facility Director of Education will assume the responsibility for new hire orientation going forward. 4. DON/Designee will perform medication pass observation three times a week to validate licensed staff identifying residents via photograph, prior to administration of medication. 5. DON/Designee will present results of the audit to the QA/PI Committee weekly until substantial compliance is sustained. Once compliance has been demonstrated, the Performance Improvement team will determine further frequency of audits as deemed necessary, to validate compliance is maintained. 6. Medication errors will be reviewed by the monthly QA/PI committee, results analyzed, trends identified, and subsequent plans of correction determined and implemented. 7. Plan of Correction was implemented and action items completed by 3/4/15. In-servicing began with the all shifts on 02/03/15 by the Corporate Pharmacist including: Medication Pass, Controlled Substances-Accountability and Documentation, Expiration dating, Ways to minimize med errors, preventing diversions and Medication Pass observation. All nurses not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 03/05/15. In addition, this training has been added to the orientation process for licensed nurses presented by the Director of Education. Observation On 03/06/15 from 3:31 p.m. to 5:30 p.m. of the medication passes revealed licensed staff competently performed the medication pass and utilized the photographs to identify the residents. Record review of the training and interviews with the licensed staff revealed that 19 of 19 staff nurses had completed the training in- service that included medication administration, 6 rights of medication administration and with emphasis on identification of the residents and 19 of 19 staff nurses had completed the medication pass observation. On 03/06/15 at 5:57 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 03/06/15, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "isolated," because the facility was still in-servicing staff, and the facility was monitoring the implementation of the Plan of Removal. CMS form 672 provided by the MDS coordinator on 3/6/15 showed a census of 93.

Based on observation, interview and record review, the Administrator and Director of Nurses failed to train, monitor, and supervise staff to prevent a significant medication error for 1 (Residents #7) of 7 residents reviewed for pharmacy procedures, as evidenced by: LVN A, who was hired on 01/08/15, did not receive an orientation, training or assessment of her skills. She was partnered with another nurse for one shift, then began working independently on a different unit. On 1/27/15 LVN A administered 14 medications prescribed for another resident to Resident #7. Resident #7 became diaphoretic (perspiring {sweating} profusely), then unresponsive, and was transferred to the hospital. She was hospitalized for [REDACTED]. An Immediate Jeopardy (IJ) was identified on 03/02/15. While the IJ was removed on 03/06/15, the facility remained out of compliance at a severity level of " Actual harm that is not Immediate Jeopardy" and a scope of " isolated," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. This failure to provide staff orientation, training, and conduct and assessment of their skills could affect the facility's 93 residents and placed them at risk for poor quality of care, and medication errors. Findings included: Record review of Resident #7 ' s admission record revealed that she was a [AGE] year old female admitted on [DATE] with a readmission on 10/6/14. Admission [DIAGNOSES REDACTED]. Record review of Resident #7's MDS assessment dated [DATE] reflected she was alert and disoriented no behaviors and had a BIMS score of 2, which indicated she was cognitively impaired. Resident #7 was also assessed as requiring extensive assistance by one staff for bed mobility, transfers, toileting and bathing, dressing and personal hygiene and only set-up help for eating. Record review of Physician orders [REDACTED].#7 had MEDICATION ORDERS FOR [REDACTED]. And Keflex 500 mg 1 tablet by mouth 4 times a day for left foot infection. Record review of Resident #7's Nurse Notes dated 1/27/15 4:00 p.m. entry revealed that at 7:30 a.m. LVN A administered the wrong medication to Resident #7. Resident #7 was given the following 14 medications; 1. [MEDICATION NAME] 10 milligrams (mg)1 tablet orally (po); used for [MEDICAL CONDITION], 2. aspirin 81 mg chewable 1 tablet by mouth every day; used for [MEDICAL CONDITION], 3. Calcium antacid 500 mg 1 tablet po; used for indigestion , 4. [MEDICATION NAME]-[MEDICATION NAME] 25-250 mg po 1 tablet; used for [MEDICAL CONDITION], 5. Carvedilol 6.25 mg; used for [MEDICAL CONDITION], 6. [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg 1 tablet po; used for general discomfort, 7. [MEDICATION NAME] 200 mg 1 tablet po after breakfast; used for discomfort, 8. [MEDICATION NAME] 20 mg po 1 tablet; used for eye health, 9. Multiple vitamin with minerals 1 tablet po; supplement, 10. [MEDICATION NAME] sulfate 325 mg 1 tablet by mouth every day; used for [MEDICAL CONDITIONS], 11. [MEDICATION NAME] 50 mg 1 tablet po; used for psychiatric disorders, 12. Requip 1 mg po 1 tablet; used for [MEDICAL CONDITION], 13. Zinc 220 mg po 1 capsule; used as supplement, 14. vitamin D3 2000 units 1 tablet by mouth every day, used for balance. Of these 14 medications, only 3 were prescribed for Resident #7 - aspirin, vitamin D3, and [MEDICATION NAME] sulfate. In an interview on 2/4/15 at 2:45p.m. LVN A said around 7:30 a.m. on 1/27/15 that it was a crazy day and for some reason she did give Resident #7 the wrong morning medication. LVN A said that 10 or 15 minutes later Resident #7 became diaphoretic and the CNA called to LVN A to come check on the resident. LVN A said that as soon as I looked the resident in the face I realized that I had given Resident # 7 someone else's medication. LVN A screamed for some help and began taking Resident #7 's vital signs, stated-pulse strong, then notified the DON and other staff members of the incident and they came to assist. LVN A said that Resident #7 had become unresponsive and the Emergency Services had to be notified for an emergency transfer to the hospital. LVN A said that after the resident was transferred; the DON pulled her off the floor and took her to the front office for some training. LVN A said that she felt that not having any training in the facility policy and procedures and not having enough help lead to the medication error. LVN A said she had not been trained in the policies and procedure, and was only assigned to work alongside another nurse for one day on a different unit, then turned loose onto another unit by herself the next day. Record review of the nurse notes for 1/27/15 at 7:30 a.m. revealed no vital signs documented at the time of the incident. Record review of the Medication Administration Record [REDACTED]. Blood pressure 112/80 signed at 8:00 a.m. Record review of the personnel file for LVN A revealed date of hire as 1/8/15-full time. No evidence of orientation, dementia training or medication administration training in the personnel file. Record review of the incident report dated 1/27/15 at 8:11 a.m. reflected that LVN A had given the wrong medication to Resident #7. Immediate action taken- notified the DON at 8:10 a.m., and ADON, head to toe assessment with complete vital signs performed, called 911, called physician at 8:15 a.m., family notified at 8:31 a.m. Record review of the hospital admission record for Resident #7 dated 1/27/15 revealed an admission [DIAGNOSES REDACTED]. Record Review of hospital history and physical dated 1/27/15 reflected: Chief complaint-Marked weakness and also low blood pressure and sore on the left foot. History of Present Illness- Resident #7 is a 69 -year old female, who is admitted through the emergency room with a complaint of low blood pressure and weakness. In the emergency room , her blood pressure was about 80 to 90 systolic, and after giving the NS bolus (IV fluids to raise blood pressure) and the patient did not get the pressure up, she had the [MEDICATION NAME] drip (solution to maintain blood pressure). Impression: 1) Sepsis 2) [MEDICAL CONDITION] (low blood pressure) 3) Gross [MEDICAL CONDITION] 4) Probably urinary tract infection 5) Mental [MEDICAL CONDITION] Recommendations: The patient is advised to admit in the ICU. In an interview with Resident #7 ' s physician on 2/4/15 at 3:15 p.m. Physician A said that Resident #7 was a very sick lady and had been admitted to ICU with [MEDICAL CONDITION]. In an interview with DON on 2/4/15 at 4 p.m. said that on 1/27/15 she was called to the unit by LVN A and when she arrived the resident was unconscious and that 911 had been called. The DON said that after the transfer was complete she replaced LVN A and then suspended her pending investigation. She said that LVN A came to the front office and was in-serviced. The DON said that LVN A never re-entered the unit. She found that LVN A did not follow policy for medication administration. The DON said that LVN A had not been trained in the facility policy and procedures and had not had an orientation including medication administration. When questioned about the training the DON said that the facility waited until there were enough people to have a class and that there were not enough hired since LVN A was hired on 1/8/15. Record review of Departmental Notes on 1/27/15 at 6:07 p.m. revealed Called local hospital for current report on resident status. " Resident is in ICU with [MEDICATION NAME] drip for blood pressure stabilization... " Record review of Departmental Notes on 1/29/15 at 12:17 a.m. , 12:25 a.m. and 8:43 am revealed "... call placed to local hospital for updated report on resident condition. Note revealed the blood pressure medication continued and was being adjusted to stabilize the blood pressure ..." Record review of the Medication Administration policy dated 5/1/2011 revealed- Purpose - to administer the following: Right medication, Right dose, Right dosage form, Right route, Right resident/patient, Right time. Procedure- ... 3. Identify resident/patient via wrist band or picture id. An IJ was identified on 03/02/15 at 3:40 p.m. and the Administrator was informed. At 4:08 p.m. on 03/02/15, an interview was conducted with the interim DON. When asked how she monitored her staff to ensure the systems were effective, she stated that she makes rounds and watches and listens to the staff and the residents. When the interim DON was asked why she thought the IJ had occurred she stated staffing went into crisis and agency was used to replace staff, some staff were terminated, others were burned out. She said that the facility did not provide the medication administration training and the medication error reporting as they needed to any of the staff. At 4:39 p.m. on 03/02/15, an interview was conducted with the Administrator When asked how she monitored her staff to ensure the systems were effective, she stated she attended the daily stand-up meeting where they track and trend all issues with the residents. When asked how she evaluated policy and procedures to ensure the effectiveness of the facility processes, she said the policy and procedures were in the computer. The Administrator replied that the facility tries to in-service on the policies and the facility also uses Reliance (a computer program). She said that she makes rounds and as patterns develop, the facility looks at the policies and procedures and redirects, re-educates and makes sure the staff follows the policies. When the Administrator was asked why she thought the IJ had occurred she stated it was the lack of staff training and their lack of knowledge. She said that she was aware of the lack of training and that included the agency staff in the facility. She said that every nurse is now getting a medication pass, medication administration, medication error and what to do if you make a medication error education. Observation on 3/6/15 from 11:45 a.m. until 12:10 p.m. of Unit Medication carts revealed MAR ' s with picture to identify residents for medication administration. Observation of the nurses revealed the use of the photographs to identify the resident. Interviews from 11:30 a.m. until 5:30 p.m. on 3/6/15 with 5 of 5 nurses on duty reflected that the LVN ' s and RN ' s had been trained on medication and administration with emphasis on resident identification via photograph and Medication Pass competencies, medication errors. Interviews confirmed that the staff had been trained prior to resuming duties administering medications. Interviews and record review of the training revealed that staff nurses and agency nurses had completed the training. Record review of the training roster revealed that 10 nurses had completed the training provided by the pharmacist on 2/3/15. The training included- Medication Pass, Controlled Substances-Accountability and Documentation, Expiration dating, Ways to minimize med errors, preventing diversions and Medication Pass observation. Record review of the training revealed that 6 of 6 agency nurses had completed the training in- service and 4 of 6 had completed the medication pass observation. Record review of the training revealed that 19 of 19 staff nurses had completed the training in- service that included medication administration, 6 rights of medication administration and with emphasis on identification of the residents and 19 of 19 staff nurses had completed the medication pass observation. The facility's Plan of Removal, 5th draft dated 03/06/15 received at 3:31 p.m. reflected the following: 1. Resident was administered the wrong medication on 1/27/15: a. Resident became diaphoretic and lethargic. b. Resident was immediately assessed, DON, physician and family were notified, 911 was called and the resident transferred to an acute care facility. c. The root cause was the LVN failed to identify resident prior to administering the medications. Six rights of administration of medication were not followed according to protocol: Right resident, right medication, right dose, right route, right time, and right dosage form. d. LVN was suspended upon discovery of alleged medication error and later terminated, prior to working any additional shifts. Thus eliminating the potential of the staff member posing any further threat of harm. 2. Current residents residing in the facility have the potential to be at risk. 3. In order to validate that appropriate policies and procedures are followed, the following has been implemented: a. An independent auditor completed a Medication none of which resulted in a medication error based on current physician orders. b. Licensed Nurses, including agency staff, have been re-educated on policy regarding administration of medications with emphasis on resident identification via photograph and Medication Pass competencies, effective 3/4/15. 14 of 26 currently employed Licensed Nurses and 5 of 5 agency Licensed Nursing staff that assumed duties have completed education and competencies as of the writing of this plan of Correction. Medication pass competencies and education have been completed by DON, interim DON, and RN Director of Clinical Services, RN Regional Nurse Consultant, LVN M, and Pharmacy consultant c. PRN licensed nursing staff and new agency staff will receive education on medication administration with emphasis on resident identification via photograph and demonstrate medication pass competency prior to assuming duties. Training will be provided by interim DON, Unit Manager, and Regional Clinical Nurses. d. Medication administration education with emphasis on resident Identification via photograph has been added to new hire and new agency Licensed Nurse orientation including medication pass competency observation. New hire orientation is scheduled 3/11/15 -3/13/15. New Director of Education has been hired and will attend this orientation. The Corporate Director of Education will facilitate this orientation with assistance from RN Unit Manager A and B, and LVN M . The new facility Director of Education will assume the responsibility for new hire orientation going forward. 4. DON/Designee will perform medication pass observation three times a week to validate licensed staff identifying residents via photograph, prior to administration of medication. 5. DON/Designee will present results of the audit to the QA/PI Committee weekly until substantial compliance is sustained. Once compliance has been demonstrated, the Performance Improvement team will determine further frequency of audits as deemed necessary, to validate compliance is maintained. 6. Medication errors will be reviewed by the monthly QA/PI committee, results analyzed, trends identified, and subsequent plans of correction determined and implemented. 7. Plan of Correction was implemented and action items completed by 3/4/15. In-servicing began with the all shifts on 02/03/15 by the Corporate Pharmacist including: Medication Pass, Controlled Substances-Accountability and Documentation, Expiration dating, Ways to minimize med errors, preventing diversions and Medication Pass observation. All nurses not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 03/05/15. In addition, this training has been added to the orientation process for licensed nurses presented by the Director of Education. Observation On 03/06/15 from 3:31 p.m. to 5:30 p.m. of the medication passes revealed licensed staff competently performed the medication pass and utilized the photographs to identify the residents. Record review of the training and interviews with the licensed staff revealed that 19 of 19 staff nurses had completed the training in- service that included medication administration, 6 rights of medication administration and with emphasis on identification of the residents and 19 of 19 staff nurses had completed the medication pass observation. On 03/06/15 at 5:57 p.m., the Administrator was informed the IJ was removed. While the IJ was removed on 03/06/15, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "isolated," because the facility was still in-servicing staff, and the facility was monitoring the implementation of the Plan of Removal. CMS form 672 provided by the MDS coordinator on 3/6/15 showed a census of 93.