Every finding on record at Woodland Grove Healthcare & Rehabilitation Center

Based on resident and staff interviews, clinical record review, and facility policy and procedure review, the facility failed to implement their abuse prohibition policy for reporting allegations of abuse for one (Resident #300) of one resident reviewed for abuse, from a total of 28 sampled residents. Failure to report abuse allegations may place the resident at risk of harm. The findings include: During an interview with Resident #300 on 03/13/2023 at 1:58 PM, she stated the staff rip my clothes off and handle me roughly. She stated the staff were mean to me. When asked to identify the staff that were doing this to her she stated, Honey, I don't know their names. When asked if she reported this to anyone, she stated, I reported it to all of them! During an interview on 03/15/2023 at 11:40 AM with the Director of Nursing (DON), she stated she had not received any reports of abuse allegations. She stated she would look again. She returned to the interview at 1:20 PM and stated she had no reports of abuse. A review of Resident #300's face sheet revealed she was admitted on [DATE]. Her diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, asthma, history of transient ischemic attack (TIA), dysphagia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, lack of coordination, muscle weakness, major depressive disorder, gastric ulcer, seasonal allergic rhinitis, peripheral vascular disease, tinea unguium, osteoarthritis, hypertension, chronic kidney disease, urinary tract infection, history of Corona Virus 2019 (COVID-19), diaphragmatic hernia without obstruction or gangrene, history of falling and overactive bladder. (Copy obtained) A review of the the resident's Care Plan, dated 02/23/2018 and updated on 03/11/2023, revealed problem areas including: Activities of Daily Living (ADL) Self-Care Deficit related to dementia, weakness, impaired mobility, non-ambulatory, dependent on staff for transfers; The resident has Impaired Cognitive Function or Impaired Thought Processes related to dementia, history of hallucinations; The resident has Potential to be Physically Aggressive related to dementia-combative, throwing items at staff, verbally aggressive at times with staff; Potential to be Verbally Aggressive; The resident is dependent, cognitively able to express Leisure/Activity Preferences for meeting emotional, intellectual, physical and social needs; The resident has Impaired Cognitive Function/Dementia or Impaired Thought Processes related to dementia. The care plan did not indicate that the resident confabulated (to fill in gaps in memory by fabrication) allegations of abuse/harm against the staff. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/25/2022, revealed the resident's hearing and vision were not assessed. The resident did not speak during the assessment period. Her recall and mental status were not assessed. She did not display disorganized thinking. She did not display signs or symptoms of depression or anxiety (mood disorder). She had no behaviors indicating psychosis. She had no behaviors of physical or verbal aggression toward staff or herself. She required extensive assistance of one staff member for bed mobility, dressing, and personal hygiene. She required total dependence of two staff members for transfers, locomotion on the unit, toilet use and bathing. She required limited assistance of one staff member for assistance with eating. Walking did not occur during the review period. The resident was noted as having participated in the assessment. (Copy obtained) A review of the Monthly Summary form, dated 02/14/2023, revealed: Hearing: Hears adequately. Speech: Clear and easily understood, Vision: Adequate with or without corrective devices. Mental status: Confused. Behaviors: None. Psychosis symptoms: None. (Copy obtained) During an interview with Certified Nursing Assistant (CNA) D on 03/15/2023 at 4:36 PM, she stated Resident #300 had complained about staff handling her roughly and being mean to her. CNA D stated, Yes, she does say that sometimes. She is not able to tell me who it is. I don't think it's true. She says a lot of things that aren't true and don't make sense. She indicated that she had not reported the allegations to her nurse or to management. During an interview with the Director of Regulatory Compliance and the Chief Clinical Officer on 03/16/2023 at 11:45 AM, they were informed of the interview with CNA D on 03/15/2023 at 4:36 PM. They both stated CNA D should have reported what Resident #300 alleged, and she should report it every time the resident alleges these staff behaviors even if she thinks they are not true. A review of the Town Hall Meeting/Education In-Service sign-in sheet, dated 12/12/2022, revealed that CNA D received training on Abuse, Neglect, and Exploitation (ANE). (Copy obtained) During an interview with the Administrator on 03/16/2023 at 3:20 PM, she stated CNA D confirmed to her that Resident #300 did say that staff handled her roughly and were mean to her. CNA D did not report it because she did not think the allegations were true, however, in the same interview she denied it, saying that she was misunderstood. A review of the facility's policy and procedure titled ANE (Abuse, Neglect, Exploitation) Investigations (implemented 01/02/2021 and last revised on 10/22/2022) revealed: It will be the standard of this facility to ensure that all alleged violations of Federal or State laws, which involve mistreatment, neglect, abuse (verbal, mental, physical or sexual), injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use or physical or chemical restraint not in accordance with regulation to treat resident's symptoms be reported immediately to the Administrator/Director of Nursing/designee. Training will focus on the following topics: Recognizing abuse, neglect, and misappropriation of resident's property. Steps on how to report including to whom and when. Reporting: All allegations of abuse, neglect, mistreatment, exploitation of residents' funds or property are to be reported immediately to the Administrator and according to Federal and State regulations. (Copy obtained)

Based on staff interviews and medical record review, the facility failed to develop and implement a care plan for one (Resident #59) of twelve residents on oxygen therapy, from a total sample of 28 residents, to ensure that the resident's oxygen flow rate was administered as per the physician's order. The findings include: During a tour of the facility on 03/13/2023 at 12:29 p.m., Resident #59 was observed lying in bed with her eyes closed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) On 03/14/2023 at 4:18 p.m., another observation of Resident #59 revealed she was lying in bed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) A review of Resident #59's physician's order, dated 01/23/2023, revealed she was to receive oxygen at 2 L/min via nasal cannula every shift related to chronic obstructive pulmonary disease (COPD) with acute exacerbation. On 03/16/2023 at 11:57 a.m., an observation of Resident #59's oxygen concentrator revealed it was set at 1.5 L/min. (Photographic evidence obtained) A review of Resident # 59's electronic medical record (EMR) revealed she was admitted to the facility on [DATE], and then readmitted on [DATE]. Her diagnoses included COPD with acute exacerbation; congestive heart failure (CHF); vitamin B12 deficiency anemia; altered mental status; adjustment disorder with depressed mood; major depressive disorder; dementia without behavioral disturbance; psychotic disturbance; mood disturbance, and anxiety. A review of the resident's March 2023 Medication Administration Record (MAR), revealed that oxygen at 2 L/min via nasal cannula every shift related to COPD was noted. A review of the quarterly Minimum Data Set (MDS) assessment, dated 12/29/22, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. The assessment also documented that she was receiving oxygen therapy. A review of Resident #59's care plan revealed there was no care plan for oxygen therapy. On 03/16/2023 at 12:00 p.m., Resident #59's room was entered with Registered Nurse (RN) A. When the nurse was asked to verify Resident #59's oxygen concentrator setting, she reached to turn the knob and responded, Now it's on 2. When she was asked to verify Resident #59's oxygen order, she confirmed that the physician's order was for oxygen at 2 L/min via nasal canula every shift related to COPD. She stated nursing provided ongoing monitoring of oxygen therapy, and the night shift nurse was responsible for changing the oxygen tubing. Correct oxygen settings were communicated in report or medication administration records. On 03/16/2023 at 1:49 p.m., an interview was conducted with MDS Coordinator B regarding Resident #59's care plan for oxygen therapy. She reviewed the care plan and confirmed the lack of an oxygen care plan. MDS Coordinator B was then observed initiating Resident #59's care plan, effective 03/16/2023, to reveal she had altered respiratory status/difficulty breathing related to COPD. Interventions included: Administer medications/puffers as ordered. Monitor for effectiveness and side effects. On 03/16/2023 at 2:05 p.m., the Director of Nursing confirmed that correct oxygen settings were identified during shift change verbally or in the medication administration record. Nursing provided on-going monitoring of oxygen therapy and nursing was responsible for changing the oxygen tubing. A review of the facility's policy and procedure for Standards and Guidelines: Oxygen Administration, Manual - Nursing-Pulmonary (Dated: 1/15/2021), revealed, Guidelines: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . 9. The use of oxygen should be reflected in the Resident's plan of care.

Based on observations, interviews, and record review, the facility failed to ensure that a resident requiring respiratory care, received such care consistent with professional standards of practice, by failing to ensure that one (Resident #59) of 12 residents on oxygen therapy, from a total sample of 28 residents, received the oxygen flow rate ordered by the physician. The findings include: During a tour of the facility on 03/13/2023 at 12:29 p.m., Resident #59 was observed lying in bed with her eyes closed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) On 03/14/2023 at 4:18 p.m., another observation of Resident #59 revealed she was lying in bed wearing a nasal cannula. Her oxygen concentrator, located at bedside, was observed to be set at 1.5 Liters per minute (L/min). (Photographic evidence obtained) A review of Resident #59's physician's order, dated 01/23/2023, revealed she was to receive oxygen at 2 L/min via nasal cannula every shift related to chronic obstructive pulmonary disease (COPD) with acute exacerbation. On 03/16/2023 at 11:57 a.m., an observation of Resident #59's oxygen concentrator revealed it was set at 1.5 L/min. (Photographic evidence obtained) A review of Resident # 59's electronic medical record (EMR) revealed she was admitted to the facility on [DATE], and then readmitted on [DATE]. Her diagnoses included COPD with acute exacerbation and Congestive Heart Failure (CHF). A review of the resident's March 2023 Medication Administration Record (MAR), revealed that oxygen at 2 L/min via nasal cannula every shift related to COPD was noted. On 03/16/2023 at 12:00 p.m., Resident #59's room was entered with Registered Nurse (RN) A. When the nurse was asked to verify Resident #59's oxygen concentrator setting, she reached to turn the knob and responded, Now it's on 2. When she was asked to verify Resident #59's oxygen order, she confirmed that the physician's order was for oxygen at 2 L/min via nasal canula every shift related to COPD. She stated nursing provided ongoing monitoring of oxygen therapy, and the night shift nurse was responsible for changing the oxygen tubing. Correct oxygen settings were communicated in report or medication administration records. On 03/16/2023 at 2:05 p.m., the Director of Nursing confirmed that correct oxygen settings were identified during shift change verbally or in the medication administration record. Nursing provided on-going monitoring of oxygen therapy and nursing was responsible for changing the oxygen tubing. A review of the facility's policy and procedure for Standards and Guidelines: Oxygen Administration, Manual - Nursing-Pulmonary (Dated: 1/15/2021), revealed, Guidelines: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observations, interviews and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three (Residents #1, #2 and #3) of six residents sampled for elopement, from a total sample of 8 residents in the facility identified as an elopement risk. The findings include: 1. During a tour of the facility on 09/22/22 at 10:43 am, green Elopement binders were observed at the east wing nurses' station, west wing nurses' station and front lobby. The binders contained demographic information and photographs of 8 residents identified at risk for elopement. Residents #1, #2 and #3 were included in the binders. A record review for Resident #1 revealed she was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's quarterly minimum data set (MDS) assessment, dated 06/16/22 revealed she had impaired cognitive skills for daily decision making and used a walker to ambulate. A review of Resident #1's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence was obtained) A review of facility reports dated 07/27/22 at 9:29 pm, revealed Resident #1 eloped from the facility after following a visitor out of the east wing lobby doors. She was located by nearby Security Guard at approximately 10:00 pm and transported to a local hospital for evaluation. She was returned to the facility unharmed at 12:00 am on 07/28/22. (Electronic copy was obtained) An elopement risk assessment was completed on 07/28/22 and identified Resident #1 as at risk for elopement. She was care planned this same day as an elopement risk/wanderer, disoriented to place, impaired safety awareness and significantly intrudes on privacy or activities. The goals were to: Maintain the resident's safety, to demonstrate happiness with her daily routine and not to leave the facility unattended through the next review date. Approaches included, but were not limited to, a wanderguard. (Photographic evidence was obtained) A record review of Resident #1's Treatment Administration Record (TAR) for August 2022 revealed instructions for the wanderguard placement and function of the device to be checked each shift, day, evening and night. The corresponding signature boxes, intended for the nurse's signature indicating the device was checked, were left blank on the following days: August 1, 7, 9, 10, 15 and 23 on the evening shift and August 1, 6, 9, 19 and 20 on the night shift. There was no explanation noted. A review of the September 2022 TAR revealed omissions for the wanderguard checks on the day shift on September 18th, the evening shift on September 3, 4, 14 and 20 and the night shift on September 4, 9 and 21. (Photographic evidence was obtained) 2. A record review for Resident #2 found she was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Elopement Risk Evaluation for Resident #2, dated 07/28/22 revealed a score of 7, indicating low risk; however, her annual MDS assessment dated [DATE] noted wandering was present and placed the resident at risk, and intruded on the privacy of others. A review of Resident #2's current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Photographic evidence obtained) A review of Resident #2's was care plan, dated 07/29/22 note her as an elopement risk/wanderer and stated resident wanders aimlessly. The goal was to maintain the resident's safety through the next review date. Interventions included, but were not limited to, a wanderguard. (Photographic evidence was obtained) A record review of Resident #2's Treatment Administration Record (TAR) for August 2022 revealed the placement and function check were not signed off as performed on the day shift for August 7 and 28 and the evening shift for August 5, 14, 22 and 24. A review of the September 2022 TAR revealed there was no signature on the day shift for September 8 and 13, the evening shift September 3, 13, 15 and 17 or the night shift September 16. There was no explanation noted. (Photographic evidence was obtained) 3. A record review for Resident #3 found she was admitted on [DATE] and was [AGE] years old, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #3 had an elopement risk evaluation dated 05/18/22 that identified her as at risk for elopement. A second evaluation performed 07/28/22 assessed her at high risk. Resident #3 was care planned on 06/05/22 as elopement risk/wanderer, disoriented to place, impaired safety awareness, significantly intrudes on privacy of others, wanders aimlessly. The goals were for her safety to be maintained, to not leave the facility unattended, and to demonstrate happiness with her daily routine through the next review date. Interventions included to check the proper functioning of audible alarm system regularly and as needed and wanderguard daily. (Photographic evidence was obtained) The resident's physician ordered a wanderguard to Resident #3's left wrist on 06/06/20 with instructions to check for functioning and placement every shift. (Photographic evidence was obtained) A record review of Resident #3's TAR for August, 2022 found the placement and function of the device was not signed as performed on the day shift of August 7, 11, 20 and 28, the evening shift on August 2, 12, 13, 19, 20, 21 and 27 or the night shift August 1, 9, 12, 19 and 20. In September 2022, there were omissions on the day shift on September 1 and 18, evening shift September 1, 5, 7, 12 and 17 and night shift on September 4 and 10. (Photographic evidence was obtained) During an interview with Employee B, Certified Nursing Assistant, on 09/22/22 at 11:20 am, she stated she was still in orientation and had only worked in the facility two days. She explained that yesterday the maintenance director showed the trainees the door alarms and what they sound like if someone tried to get out. She went on to say that Wanderguards were used by some of the residents and that the nurse in charge was responsible for wanderguard placements and checks. Employee A, Licensed Practical Nurse, was interviewed on 09/22/22 at 2:40 pm. She explained that the wanderguard devices have a red flashing light. If the light is on, then the device is working. If there is any question as to its function, they take the resident to the door. The alarm will sound if it is working. If there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR and TAR will give you a color indicator warning whether or not the sign-off has been completed. When asked why there were omissions in the documentation for Resident 1, 2 and 3's wanderguards, she had no explanation why. An interview was conducted with the Director of Nursing (DON) on 09/22/22 at 3:30 pm. She explained residents with wanderguards have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . That is a standard task. The red light illuminates on the device if it is functioning. The DON stated it was her expectation the nurses document every shift. She reviewed the documentation for Residents 1, 2 and 3. She confirmed the omissions but had no explanation why other than it may be related to the propensity of staffing agency nurses being used by the facility. The Administrator, who was present in the room, was provided the dates of missing signatures on the TARs. She also stated her expectation was that nurses document the checks every shift for residents at risk and who wear wanderguards.

Based on observation, resident and staff interviews, and clinical record review, the facility failed to ensure that the pharmacy and nursing services accurately documented and administered controlled medication for one (Resident #45) of three sampled residents reviewed for pain management out of a sample of 34 residents. The findings include: On 07/22/21 at 8:00 AM, during an observation of a controlled medication reconciliation between Employee B, Licensed Practical Nurse (LPN), (outgoing night nurse) and Employee C, LPN, (oncoming day shift nurse), the narcotic count for resident #45 was found to be incorrect. A review of Resident #45's reconciliation sheet in the narcotic logbook revealed he had eight available [MEDICATION(S)] 50 milligrams tablets. A review of Resident #45's narcotic blister card revealed he had seven available [MEDICATION(S)] 50 milligrams tablets. A review of Resident #45's Medication Administration Record (MAR) for July revealed the resident received one tablet of [MEDICATION(S)] 50 milligrams on 7/22/21 at 7:00 AM, documented on the MAR by Employee A, LPN. Employee B, LPN and Employee C, LPN notified Employee D, LPN/Unit Manager (UM) of the incorrect [MEDICATION(S)] count. During an interview with Employee B, LPN and Employee D, LPN/UM on 7/22/21 at 8:15 AM, they both stated that medication is to be signed out once it is removed from the cart and before entering a resident's room. An interview was conducted on 7/22/21 at 8:20 AM with Employee D, LPN/UM, regarding the process for count discrepancies. She stated the discrepancy would be reviewed to ensure there was a discrepancy and determine the responsible parties. If the error occurred on another shift that staff member would be contacted to determine the cause of the discrepancy. On 7/22/21 at 8:35 AM, Resident #45 was interviewed with Employee D, LPN/UM present. Resident #45 confirmed he received his [MEDICATION(S)] medication this morning. On 7/22/21 at 8:40 AM, the Director of Nursing (DON) and Employee D, LPN/UM reported they contacted Employee A, LPN, who confirmed she did not sign out the [MEDICATION(S)] on the reconciliation sheet in the narcotic logbook prior to administering the medication to Resident #45. On 7/22/21 at 8:45 AM, the DON was asked how controlled medications were to be signed out. She stated the nurse was to sign out the medication when removed from the cart and before going into the resident's room. On 7/22/21 at 10:00 AM, during an interview with the Administrator and DON, they confirmed Resident #45's narcotic reconciliation sheet and narcotic blister card did not match. A policy review conducted on 7/22/21 revealed that neither the Medication Administration policy (revised 3/1/21) nor the Control Drug Count policy (revised 3/1/21) included a process for signing out controlled medications.

Based on record reviews and staff interview, the facility failed to ensure medical records were complete and accurately documented for three (Resident #18, #48, and #6) of five residents sampled for unnecessary medication, out of a total sample of 34 residents. The findings include: 1. Record review for Resident #18 revealed he was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #18's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 40 mg on 7/5, 7/10, 7/18 and 7/19 [MEDICATION(S)] 5 mg on 7/10 [MEDICATION(S)] HCI 50 mg on 7/5, 7/10, 7/18 and 7/19 [MEDICATION(S)] HCI 60 mg on 7/2, 7/3, 7/4, 7/5, 7/10, 7/18 and 7/19 [MEDICATION(S)] 100 mg on 7/4, 7/5, 7/10, 7/18 and 7/19 [MEDICATION(S)] solution 100 unit/ML on 7/2, 7/4, 7/5, 7/10, 7/16, 7/18 and 7/19 2. A record review for Resident #48 revealed she was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #48's MAR for July 2021 was conducted and revealed missing documentation for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] on 7/5 and 7/10 [MEDICATION(S)] on 7/4 [MEDICATION(S)] HCI on 7/4 and 7/10 3. A record review for Resident #6 revealed she was admitted on [DATE] and was readmitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #6's MAR for July 2021 was conducted and revealed missing documentation for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] on 7/5, 7/18 and 7/19 [MEDICATION(S)] on 7/7 and 7/10 [MEDICATION(S)] on 7/7 and 7/10 [MEDICATION(S)] 500 mg on 7/7 and 7/10 [MEDICATION(S)] on 7/5, 7/8, 7/10, 7/18 and 7/19 [MEDICATION(S)] HCI on 7/5, 7/18 and 7/19 During an interview with Director of Nursing (DON) on 7/22/21 at 5:21 PM, she confirmed the documentation was missing on the MAR for Resident #18, #48 and #6, and acknowledged the nurses should sign the record when administering medication. No facility policy was provided before exiting the facility.

Based on record review and interview, the facility failed to ensure one of five residents reviewed for unnecessary medications (Resident #79) received medication within the parameters of the physician order. The findings include: Review of the resident record for Resident #79 showed she had a [DIAGNOSES REDACTED]. Records showed multiple orders for insulin, including [MEDICATION NAME], 10 units subcutaneously, one time a day. Instructions were to hold the medication for blood sugars below 100. The Medication Reconciliation Record (MAR) for (MONTH) 2019 was reviewed on 8/1/2019. An entry for the [MEDICATION NAME] showed it was scheduled on 6/13/2019, to be given at 6:00 AM. This MAR indicated [REDACTED]. On 7/28/2019, the blood sugar reading on the MAR for the 6:00 AM [MEDICATION NAME] read 89. Beneath it, a check mark was entered, indicating the medication was given. On 7/29/2019 the blood sugar reading was 93, and it was also checked off as given. On 7/31/2019, the blood sugar reading was 89, and it had a check mark indicating the [MEDICATION NAME] was given. During an interview with Employee C, a nurse, on 8/1/2019 at 1:15 PM, she explained the electronic MAR indicated [REDACTED]. When a medication is administrated, she explained the nurses click indicating the medication was or was not administered. There was a legend that described the codes a nurse would enter if a medication was not given. Employee C reviewed the legend and explained clicking 4 indicated a medication was held according to the parameters. When reviewing Resident #79's (MONTH) 2019 MAR, she confirmed that 7/29/2019, 7/30/2019, and 7/31/2019 all showed a check box, and no code to explain the medication was held. The MAR indicated [REDACTED]. She reviewed the MAR for Resident #79 and opened the file listing all the specific times she received insulin. The Unit Manager confirmed that Resident #79 received the 6:00 AM dose of on 7/29/2019, 7/30/2019, and 7/31/2019. She was asked what the expectation of staff was, following a resident receiving Insulin outside of the parameter. She stated the resident would need to be monitored for side effects, and the physician notified. The staff would need to be reeducated. She was asked if anything had been done for the inaccurate medications given to Resident #79, and she stated she would have to check. At 2:05 PM on 8/1/2019, the Director of Nursing stated the physician was notified following the interview with the Unit Manager, and arrangements were made for reeducation. Nothing in Resident #79's record showed this was done prior to 8/1/2019. Photographic Evidence Obtained Class III

Based on observations, record review, staff interviews, and review of facility policies and procedures, the facility failed to maintain an infection control program to ensure a safe, sanitary environment that prevented possible transmission of infections by failing to ensure hand sanitizing between residents during medication administration and following manufactures recommendation for cleaning the glucometers. The findings include: An observation was made on 7/30/19 at 11:15 am with Licensed Practical Nurse (LPN) Emp C for Resident # 105 for an accu-check. Emp C donned gloves without washing or sanitizing her hands. She then unlocked the medication cart and removed the supplies and glucometer and then entered the room. Without washing her hands or changing her gloves, she performed the fingerstick. She informed Res # 105 of the results and he would require 4 units of insulin. Emp C left the room without removing her gloves and returned the glucometer to the top of the cart. Without removing her soiled gloves, she retrieved a Sani wipe cloth from the container and proceeded to clean the glucometer. Emp C wiped all sides of the glucometer and then continued to rewipe all surfaces with the same Sani-wipe. When she had completed the cleaning, she placed the glucometer on the same paper towel she used when the glucometer was soiled. Emp C was asked how did she ensure the glucometer was not only cleaned, but disinfected. She was asked how long the glucometer was to remain wet to provide proper disinfection. She stated the policy was to continue to clean the glucometer with the Sani-wipe for full two minutes, then let it dry. She was asked how often and when should she wash her hands and change her gloves, she stated she sanitizes hands prior to each resident and after any care was given. She was asked if she washed her hands or sanitized before donning her gloves, she said no. She was asked when should she remove her gloves and wash her hands, she said when you leave the resident room. She was asked why she did not remove her gloves prior to leaving Res # 105's room and washing her hands, she said she should have. She was asked if she had changed her gloves prior to cleaning the glucometer, she said no. An observation of an accucheck was made on 7/31/19 at 11:30 am with Licensed Practical Nurse (LPN) Emp H for Resident # 53. She removed the needed supplies and glucometer from the medication cart. She was asked how did she know the glucometers in the cart had been cleaned prior to placing them in the drawer. She said the nurses clean them with sani wipes before putting them away. She said she does check the glucometer prior to use to make sure there are no traces of blood. She did not sanitize hands prior to donning gloves to perform the fingerstick. After the accu-check was completed she removed her gloves in the room and washed her hands. She placed the glucometer in her [NAME]et pocket. Upon return to the medication cart she donned gloves and removed the container of sani wipes from the cart. She removed a sani-cloth and then retrieved the glucometer from her pocket. She explained that she used the sani cloth to completely clean the glucometer, she said it could be cleaned for 2 minutes or it could be wrapped in the wipe for 2 minutes then left to air dry. After wiping all surfaces with sani wipe she then wrapped the glucometer and placed in plastic cup on the cart. After 2 minutes, she unwrapped and placed the glucometer in a plastic cup to air dry. She was asked why she picked up the soiled glucometer without gloves and placed it in her pocket, She stated that was not good practice and should have used gloves. An interview was conducted with the Director of Nursing on 8/1/19 at 10:45 am. She was asked what was the protocol for hand sanitizing during medication administration, and she stated the nurses are to wash hands or use hand sanitizer between residents. Review of the facility policy Handwashing revealed: facility personal shall wash their hands to prevent spread of infections. Between normal patient contacts hands are to be cleaned with antimicrobial containing waterless cleanser. Hands are to be washed when coming on duty, before preparing and handling medications, before donning gloves and after removing. Review of the manufacturers instruction booklet for Assure Platinum glucometer provided by the administrator on 7/30/19 at 1:30pm revealed: Healthcare professionals should wear gloves when cleaning the Assure Platinum. Wash hands after taking off gloves. Cleaning and disinfecting can be completed by using a commercially available EPA registered disinfectant detergent or germicide wipe. To use wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both cleaner and disinfectant, though if blood is visibly present on meter two wipes must be used, use one wipe for clean and second wipe to disinfect. With all recommended meter cleaning and disinfecting methods, it is critical the meter be completely dry before testing a resident's blood sugar Follow the disinfectant product label instructions to ensure proper drying time. Review of the facility policy Disinfecting Glucometers, it is the policy of the facility to clean and disinfect multi use blood glucose meters. Guidelines: apply gloves before BS test. dispose of used finger stick devices and lancets in an approved sharps container. remove gloves, wash hands, apply new gloves, thoroughly clean all visible soil or organic material from glucometer, perform hand hygiene immediately after removal of gloves and before touching other medical supplies intended for use on other residents. Follow manufacturers guidelines for cleaning and disinfecting of glucometers. KEEP glucometer wet for maximal kill time indicated on disinfecting agent product label. This may be achieved by placing glucometer wrapped in wet disinfecting wipe in a Ziploc type bag to keep moist for recommended time.

Based on observations, record reviews and interviews, the facility failed to ensure that a resident who required respiratory care was provided such care, consistent with professional standards of practice, by failing to provide oxygen therapy as ordered for one (Resident #3) of five sampled residents. Failure to provide oxygen as needed and ordered can result in hypoxemia, which can lead to complications in body tissues and organs. The findings include: A review if Resident #3's clinical record revealed [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. Further review of the clinical record revealed that Resident #3 had a change in condition (altered mental status (AMS) with unclear speech, a low oxygen saturation of 91% after she removed her nasal cannula, and a low blood sugar reading, which required a transfer to hospital for assessment on 11/25/2018. During an observation of this resident on 12/4/2018 at 12:40 PM, she was seen in her wheelchair in the hallway scooting herself with her feet in the direction of the dining room. She had a NC in place with an O2 tank set at 3L (3 liters) on back of her wheelchair. Upon closer inspection of the O2 tank, the canister was observed to be empty. (Photographic evidence obtained) When asked if she knew what her oxygen flow rate should be, she replied that she didn't know. When she was informed that her oxygen tank was empty, she stated it had to be changed out three times today. On 12/4/2018 at 12:45 PM, Employee D, Licensed Practical Nurse (LPN), was observed standing at her medication cart in the hallway. She was informed that Resident #3's O2 tank was reading empty. LPN D checked the O2 tank in use, confirmed it was set at 3L and that it was indeed empty. Additionally, the tank was disconnected. For these reasons, the resident was not receiving oxygen. LPN D located another O2 tank and replaced the one on the resident's wheelchair. She set it at 4 LPM (liters per minute), stating that the physician's orders [REDACTED]. When asked for the resident's baseline oxygen saturation to be maintained, the nurse stated she was unaware of what the resident's baseline was for oxygen saturation, but reported that Resident #3 was to receive continuous oxygen at 4L ATC (around the clock). On 12/4/2018 at 2:01 PM, an interview was conducted with the Director of Clinical Operations. When asked about baseline oxygen saturation orders for Resident #3, she reported she didn't see one in the standing orders. After reviewing Resident #3's O2 saturation documentation, she reported that the O2 levels are above 90%, which are normal. When asked about the O2 saturation of 78% recorded on 10/29/2018 and the 34% recorded on 11/2/2018, she replied that the resident may have been sent out to the hospital around that time. She located a note dated 10/30/2018 and stated the resident removed her O2, it was replaced and levels returned to normal. O2 saturations recorded on that date were 98%, 91% and 93%. She did not address the dates in question (10/29/2018 and 11/2/2018). A review of the record revealed there was no hospital transfer documented on 10/29/2018. Resident #3 was transferred to the hospital on 9/29, 10/9, and 11/25/2018 however. A review of the resident's Oxygen Saturation Summary revealed the following: On 10/25/2018, Resident #3's oxygen saturation level was recorded as 89% via NC at 5:12 PM. There was no progress note, evidence of an assessment or indication the physician was notified. On 10/29/2018, Resident #3's oxygen saturation level was recorded as 78% on room air (RA) at 11:27 PM. There was no progress note, evidence of an assessment or indication the physician was notified. On 10/28/2018, Resident #3's oxygen saturation level was recorded as 89% on RA at 10:39 PM. There was no progress note, evidence of an assessment or indication the physician was notified. On 11/2/2018, Resident #3's oxygen saturation level was recorded as 34% via NC at 5:35 PM. There was no progress note, evidence of an assessment or indication the physician was notified. On 11/15/2018, Resident #3's oxygen saturation level was recorded as 88% on RA at 5:14 PM. There was no progress note, evidence of an assessment or indication the physician was notified. On 11/22/2018, Resident #3's oxygen saturation level was recorded as 81% on RA at 12:11 AM. There was no progress note, evidence of an assessment or indication the physician was notified. On 12/3/2018 at 12:45 PM, Resident #3 was observed with an empty O2 canister which was set to 3 LPM when the physician's orders [REDACTED]. There was no humidification device observed, and the physician's orders [REDACTED]. This had to be brought to the staff's attention in order to have the oxygen canister changed. According to www.ucshealth.org, Your health care provider will write a prescription for when and how much you should wear your oxygen, based on the results of your testing. The prescription should specify the following: · The appropriate oxygen flow rate or setting, expressed as liter flow of oxygen per minute (lpm or l/min) that will keep your saturations at or above 90 percent · When you should wear your oxygen (for instance, during activity, overnight or continuously). According to www.healthline.com, A below-normal blood oxygen level is called hypoxemia. Hypoxemia is often cause for concern. The lower the oxygen level, the more severe the hypoxemia. This can lead to complications in body tissue and organs. Normally, a pulse ox (blood oxygen saturation) below 95 percent is considered low. It ' s important to know what is normal for you, especially if you have a chronic lung condition. Your doctor can provide recommendations as to what ranges of oxygen levels are acceptable for you. When your blood oxygen level goes outside the typical range, you may begin experiencing symptoms including shortness of breath (SOB), chest pain, confusion, headache and/or rapid heartbeat. if you continue to have low blood oxygen levels, you may show signs of cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood). The hallmark sign of this condition is a blue discoloration of your nail beds, skin, and mucus membranes. Cyanosis is considered an emergency. Cyanosis can lead to [MEDICAL CONDITION], which can be life-threatening. If your blood oxygen level is too low, you may need to boost your oxygen saturation. Conditions that can negatively impact your blood oxygen level include [MEDICAL CONDITION] and heart failure. These conditions may prevent your lungs from adequately inhaling oxygen-containing air and exhaling carbon [MEDICATION NAME]. Likewise, blood disorders and problems with your circulatory system may prevent your blood from picking up oxygen and transporting it throughout your body. Any of these problems can lead to declining oxygen saturation levels. As your oxygen levels fall, you may begin experiencing symptoms of hypoxemia.

Based on observations, record review, interviews, and review of the facility's Smoking Policy, the facility failed to maintain an environment as free of accident hazards as is possible, by failing to ensure that one (Resident #103) of seven residents who smoked, did not keep their cigarettes and lighters on their person. This practice has the potential of negatively impacting the safety and well-being of other residents, staff and visitors in the facility. The findings include: A medical record review was conducted for Resident #103 which revealed a readmission date of [DATE] and an original admission date of [DATE]. [DIAGNOSES REDACTED]. The resident was observed outside in the courtyard smoking at 10:45 AM on 4/11/18. She had her cigarettes and lighter in a brown multi-print cloth bag. The resident stayed outside for approximately 20 minutes and smoked several cigarettes. The resident was not supervised by staff. A review of the care plan, updated on 4/4/18, revealed that the resident was non-compliant and resistive to care, refused to keep smoking supplies at the nurse's cart, and refused supervision while smoking. Two of the interventions listed on the care plan included notification of the charge nurse immediately if suspected resident had violated the smoking policy, and smoking supplies were to be stored in the nurse's cart or at the nurse's station. A smoking assessment dated [DATE] was reviewed, which deemed the resident a safe smoker. A review of the Minimum Data Set (MDS) Significant Change assessment dated [DATE] reported a Brief Interview of Mental Status (BIMS) score of 13 out of a possible 15 points, indicating nil to mild cognitive impairment. An interview was conducted with Resident #103 at 11:55 AM on 4/11/18. She reported that the cigarettes and lighter were kept in the bag at her bedside, and she did not wear a smoking apron while smoking. The lighter was observed lying on a bedside table beside the bag. (Photographic evidence obtained) An observation of the resident's room at 1:45 PM on 4/11/18, revealed the cigarettes and lighter were still in the room on the bedside table. The resident was sleeping. An interview was conducted with Employee A, Certified Nursing Assistant (CNA), on 4/11/18 at 2:06 PM. The CNA reported that residents were not allowed to keep their cigarettes and lighter on their person, and they had to get them from the nurse when they wanted to smoke. The CNA stated, (Resident #103) goes outside to smoke, and we can see her through the windows. An interview was conducted with Employee C, Registered Nurse (RN), at 2:29 PM on 4/11/18. Employee C reported that cigarettes and lighters were kept in the nurse's cart. Residents were allowed to smoke in designated areas from 8:00 AM - 8:00 PM. Cigarettes were returned to the nurses when the residents came back into the building after smoking outside. A review of the Smoking Policy, updated on 11/1/16, revealed that residents 'May not keep lighters/ignition material on their person or in their room unless provided by nurse to be used during smoking opportunities. Lighter ignition materials must be maintained at the resident's designated nurses' station or other centralized location specific for this purpose.' Under 'planning', if the Interdisciplinary Team (IDT) members determine that a Resident is a safe smoker, and smokes independently, lighter ignition materials must be returned to the nursing station or designated area and may not remain on their person. Observed resident lying in bed on 4/12/18 at 10:00 AM. Observed cigarette lighter was still at bedside. An interview was conducted with Employee D, RN, at 3:00 PM on 4/12/18. Employee D confirmed the resident had cigarettes and a lighter at bedside in her room. Employee D stated that the son put smoking materials in his parent's bag, and the resident was educated regarding the fact that she could not have the cigarettes and lighter unless she was outside smoking. The resident gave permission for staff to take the cigarettes and lighter. A call was placed to the resident's son to provide education also.

Based on observations and interviews, the facility failed to provide a palatable meal during one meal observed on 2/13/17. The findings include: During the initial dining observation of the main dining room on 2/13/2017 at 12:39 p.m., this surveyor observed residents served the main lunch entrée that consisted of a breaded parmesan patty with pasta, vegetable blend and a breadstick. Residents were observed to be unable to eat the breadstick. During an interview with Resident #66 on 2/13/2017 at 1:17 p.m. she stated, The breadstick is as hard as a rock. She demonstrated by hitting the breadstick on the side of her table. During an interview with the registered dietitian on 2/13/2017 at 1:27 p.m., she confirmed the breadstick was not edible. She stated that she spoke with the certified dietary manager (CDM), and they both decided not to reorder the breadstick and substitute a dinner roll instead. She stated, Because of the length of time that the breadstick sat on the tray line, is hardened.

Based on record reviews and staff interviews, the facility failed to provide the necessary treatment and services consistent with professional standards of practice, to promote healing for Resident #118, 1 of 3 residents sampled with pressure ulcers. The findings include: A record review was conducted for Resident #118 that revealed a date of admission of 1/16/2017 and discharge date of [DATE]. An nursing admission assessment was performed on 1/16/2017 which listed the resident as having a pressure area to her right toe. A review of Resident #118's 5-day Minimum Data Set (MDS) assessment dated [DATE] listed the resident as having an unstageable deep tissue injury (DTI) and 1 stage 1 pressure ulcer. A review of physician progress notes [REDACTED].#1 Deep tissue injury (DTI) to right buttock is non-blanchable, deep red, maroon, purple discoloration measuring 3 centimeters (cm) in length x 3 cm. in width x 0 cm in depth. Wound #2 to left heel is chronic stage 1 which is not healed 3 cm length x 3 cm width x 0 cm depth, Wound #3 is DTI injury to right heel 3 cm x 3 cm x 0 cm. Orders for Wound #1 - cleanse wound with cleanser, apply to wound bed [MEDICATION NAME], change daily and as needed (PRN) for soiling or saturation. Wound #2 left heel - cleanse wound with cleanser, apply to wound bed, skin prep, change daily, and Wound #3 - cleanse wound with cleanser, apply to wound bed, skin prep and change daily. (photographic evidence obtained) A review of Resident #118's Treatment Administration Record (TAR) revealed - apply Zinc Oxide to sacral area every shift for excoriation, apply skin prep to bilateral heels, float heels while in bed. No other wound care treatment orders were found. (photographic evidence obtained) A care plan for Resident #118 dated 1/16/2016 revealed the resident had a DTI to right buttocks. Interventions included but were not limited to - perform wound care as ordered. An interview on 02/16/2017 11:04 AM with Employee G, Registered Nurse (RN), confirmed Resident #118's wound care orders as written by the wound care physician were not entered onto the resident's TAR. She stated that the physician told her something different verbally, and the information she entered on the TAR was the same as what he told her. You can't do wound care on a DTI. She confirmed the physician wrote the wound care order, and it was not listed on the TAR. Employee G was not able to produce a verbal order from the physician indicating that the orders should be changed for the Stage 1 to the right toe or the DTIs to the heels and buttocks. An interview on 02/16/2017 at 12:31 PM with Employee I, RN, confirmed the physician's orders [REDACTED].#118 are not seen on the TAR, and did not list treatment for [REDACTED].

Based on observation, interviews and record review, the facility failed to provide the texture consistency specifications of a pureed diet for Residents #67, #148 and #181; 3 of 17 residents with an order for [REDACTED]. The findings include: During the initial dining observation of the main dining room on 2/13/2017 at 12:39 p.m., this surveyor observed Residents #66, #148 and #181 were served a lunch meal tray that consisted of pureed veal, pasta and mixed vegetables. All three items were in a semi liquefied form, and were running onto each other. During an interview with the certified dietary manager (CDM) and registered dietitian on 2/13/2017 at 1:35 p.m., they confirmed the consistency of the pureed foods was not within acceptable parameters. The registered dietitian stated, The cook was a fill-in cook and not our regular cook, and she will have a teachable moment on the proper consistency of pureed foods. Review of the facility policy, Food Production dated 07/01/2006 on revised 8/26/2008 read as follows: This policy states the standard of a pureed diet as dysphagia puree. All foods served on a pureed diet are processed to a pudding or mashed potato consistency.

Based on observations, record reviews and staff interviews, the facility failed to properly dispose of contaminated disposable items for 1 resident (Resident #121) out of 3 residents, and on 1 out of 6 medication carts (Secured Unit) housed in the facility. The findings include: 1. An observation was conducted on 02/16/2017 at 7:59 AM of Employee D, Licensed Practical Nurse (LPN), performing a blood glucose level finger stick and insulin injection for Resident #121. The nurse was observed placing the contaminated retractable lancet and capped insulin needle into her gloves and folding them into each other with items remaining inside. The employee then washed her hands and placed the gloves with the contaminated sharps on the bathroom counter and walked out of the residents room. (photographic evidence obtained) An interview with Employee D, LPN, on 02/16/2017 at 8:02 AM confirmed she placed the used lancet and capped insulin needle in her gloves and left them on the bathroom counter of Resident #121's room. The employee stated, There wasn't a garbage can in the bathroom, so I left it there until I can get one. The employee was then asked if the items should be placed in a sharps container and she said, Oh yes. The nurse was observed then continuing to pass medications to another resident, and did not remove the items from the resident's bathroom. An interview with Employee D, LPN, on 02/16/2017 at 8:09 AM confirmed all sharps were to be placed in the provided sharps container. Employee D then walked into the bathroom of Resident #121 and observed the gloves with the sharps inside and stated, I will dispose of them properly. 2. An observation was conducted on 02/16/2017 at 8:36 AM of a used retractable lancet on top of the sharps container housed on the medication cart of the secured unit. An interview with Employee F, Registered Nurse (RN), on 02/16/2017 at 8:37 AM confirmed the used lancet was on top of the sharps container. She then picked it up and placed it inside the sharps container housed on the side of the medication cart. An interview with Employee I, RN, on 02/16/2017 at 11:22 AM confirmed all sharps were to be disposed of in approved sharps containers. A review of the facility Standard and Guidelines for obtaining a finger stick glucose level with a revision date of 10/11 read, Dispose of the lancet and insulin syringe in the sharps disposal container. Discard of disposable supplies in the designated containers. (photographic evidence obtained)

Based on observation and staff interview, the facility failed to ensure the privacy curtain in 1 of 35 resident rooms (Room 405) ensured the privacy of 2 residents (Resident # #162 and #131). The findings include: During an observation on 2/14/2017 at 10:08 AM in resident room 405, the privacy curtain located between bed A and bed B could not be pulled over the entire ceiling track leaving an open area between bed A and bed B of 1-2 feet. A second observation was made in resident room 405 on 2/16/2017 at 1:24 PM. When the privacy curtain located between bed A and bed B was pulled it got stuck 1-2 feet before the end of the ceiling track leaving the end of each resident's bed exposed and a gap between 1-2 feet near the end of the beds. The findings were confirmed through interview with the resident's nurse, Employee F, on 2/16/2017 at 1:30 PM. He was invited into the room. He tried to close the curtains and confirmed they could not close due to a problem with the track. He was asked about the residents that reside in the room. He stated Resident #162 in bed B was ambulatory and walked around on his own, and Resident #131 in bed A was chair bound. He was asked if he was aware of a problem with the privacy curtain, and he stated, No.

Based on observation, record review, and staff and family interview, the facility failed to ensure residents with tube feedings received adequate amounts of water as prescribed by the physician for 2 of 2 sampled residents. (Residents #1 & #2) The findings include: 1. Record review for Resident #1 revealed a [AGE] year old male with an admission date of [DATE]. His [DIAGNOSES REDACTED]. He required total care for all activities of daily living. He had a Foley catheter related to a sacral ulcer and [MEDICAL CONDITION]. He had a gastrostomy tube for tube feeding. Resident #1 was unable to speak, however, he could communicate with finger pointing and by blinking his eyes. On 12/7/16, Resident #1 was observed with excessive sweating and [MEDICAL CONDITION] was transferred to the hospital. Review of the emergency room (ER) records dated 12/7/16 revealed the following: impression: recurrent catheter associated with urinary tract infection [MEDICAL CONDITION], following retention. The Foley catheter was changed in the ER. He had sinus [MEDICAL CONDITION] secondary to dehydration and UTI. He was given intravenous fluids and antibiotics. Labs revealed [MEDICAL CONDITION] was likely from dehydration. Resident #1 returned to the facility with new orders for antibiotics on 12/8/16. Review of the physician orders [REDACTED]. An observation of Resident #1 on 12/29/16 at 9:15 a.m. found him lying in bed with the head of the bed elevated, watching TV. his tube feeding was infusing via pump. The tube feeding bag indicated it contained [MEDICATION NAME] 1.5 and was hung on 12/29/16 at 8:58 a.m. Also hanging was a full liter bag of water with the tubing connected to the feeding pump. The water bag was not dated or marked with the time it was hung. The pump was set to infuse the tube feeding at 60 cc/hour and 55 cc/hour of water per hour. A second observation at 10:20 a.m. revealed the water in the bag had remained at the same level. Further observations were made at 12:35 p.m., 1:45 p.m. and 3:20 p.m. The tube feeding bag was half full, however the water bag remained full. An interview was conducted with a family member at 1:50 p.m. She stated that she comes everyday during the day and her children come in the evening. She stated she had concerns that Resident #1 was not receiving enough fluids as he continued to have UTI's. She stated he was in the hospital in November and twice in December with UTI's and dehydration. She stated she had been to administration many times with her concerns but felt they were not addressed. An Interview was conducted with the Assistant Director of Nursing (ADON) and East Wing Unit Manager (UM) on 12/29/16 at 3:10 p.m. When asked how often the water bags for the water flushes were changed, the ADON stated every 24 hours. When asked if they were hung with the tube feeding product, she stated, No, because the tube feeding would infuse faster than the water. When asked which shift was responsible for the change, she said whichever nurse was on duty when the bag ran out was responsible. When asked how the nurse knew how much water infused during the shift, she stated the pump was programmed to deliver the amount ordered. She was asked if the pump could display the amount of feeding and water that infused each shift, she stated she would check. The ADON, UM, LPN (Employee A) assigned to Resident #1, and the surveyor examined the pump at 3:20 p.m. While inspecting the pump, the ADON was asked if she could determine how much water had been infused during the day. The pump did not have capability of providing the information. She was asked if the bag was full, she confirmed it was. She was informed that upon entering Resident #1's room at 9:10 a.m. the water bag was full. It remained at the same level at 10:20 a.m., 12:35 p.m., 1:45 p.m., and 3:20 p.m. Employee A was asked if the water bag was full when she hung the tube feeding at 8:50 a.m., and she stated it was. When asked if she had added water during the day, she stated, No. The resident's mother was present in the room and confirmed no one had added water during the time she was there. The facility could not determine if the resident had received any water during the shift. An interview was conducted with the Registered Dietitian (RD) and Administrator at 4:10 p.m. The RD stated she made rounds every day and checked tube feeding pumps for rate. She stated she had observed Resident #1's pump earlier in the day and it was set at the correct amount for tube feed and water. She was asked if the pump could display the amount of tube feeding and water infused each shift, and she stated she would need to ask the nurse. After speaking with the LPN, she stated the pump could not provide that information. The administrator was asked if intake and output (I&O) was documented for all residents receiving tube feeding, and she stated the facility policy was only if ordered by the physician. When asked how the facility ensured tube feed residents were receiving prescribed amounts of water, she stated they relied upon the pump. 2. On 12/7/16, Resident #2 was transferred to the hospital related to a dysfunctional feeding tube. During an exam in the emergency room , the physician documented the feeding was working fine, however the resident was noted with purulent urine and the catheter was changed. She was admitted with [MEDICAL CONDITION], likely secondary to UTI. She also had electrolyte imbalance with [DIAGNOSES REDACTED] (low potassium) and [MEDICAL CONDITION] (elevated sodium level). She was treated with antibiotics and intravenous fluids. A review of the physician orders [REDACTED]. An interview was conducted on 12/29/16 at 2:50 p.m. with Licensed Practical Nurse (LPN), Employee A. She was asked how much water Resident #2 had received on her shift, she stated the amount was programmed into the pump. When asked whether she compared how much water was in the bag to what was infused, she stated, No she relied on the pump. When asked if she knew how much water Resident #2 should have received on her shift, she stated she would have to check the order. She was asked how much water was in the bag at the beginning of her shift, she stated it was full. When asked if any of the water had infused, she stated, Yes, but she did not know how much.

Based on observations and interviews, the facility failed to maintain accurate disposition and safe storage of five residents' medications stored in the facility's medication storage room refrigerators in 2 of 2 facility medication storage areas. There were 12 labeled expired resident medications, and 30 expired doses of a multidose medication stored in the medication storage refrigerators, potentially affecting 6 of 12 residents who continue to reside in the facility. The findings include: On 6-23-16 at 9:45 AM, a medication room observation was conducted in the West Wing's medication storage room with Employee A. The medication storage refrigerator was observed and revealed two (2) expired Aplisol 0.1 ml intradermal injections (expired on 5/31/16 and 6/3/16); one (1) resident- labeled expired liquid oral antibiotics; and 30 expired doses of 10 mg Bisacodyl suppositories from a 100-dose carton (expiration date of 04/2016). Employee A and the Unit Manager (UM) verified the expiration dates and the medications were removed. The UM stated that the medications should have been removed. She stated that clean Friday sweeps for discontinued and expired medications were done once weekly on Fridays. On 6-23-16 at 10 AM, an observation of the East Wing's medication storage room was conducted with the UM. There were seven (7) expired residents' labeled medications identified in the medication storage refrigerator (Aplisol 0.1 ml intradermal injections). The medications were removed and set aside for disposal. On 6-23-16 at 10:15 AM, an interview with the Director of Nursing (DON) was conducted. The DON stated that expired medications should not be stored in the medication refrigerator and that the medications should be removed for disposition. She stated that the facility performs Clean Fridays, where the Unit's charge nurse checks all the medication carts and the medication storage rooms for outdated medications. A review of the facility's policy and procedures for Storage and Expiration of Medications, Biologicals, Syringes, and Needles, dated 01-1-2013, was conducted. It revealed the following under #4: 4.1 Have an expiration date on the label; 4.2 Have not been retained longer than recommended by the manufacturer or supplier guidelines; or, 4.3 Have not been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. #17 - Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. (Photocopied evidence was obtained.) Class III

Based on observation, staff interviews, and facility policy review, the facility failed to provide medically-related social services related to code status to attain or maintain the highest practical physical, mental, and psychosocial well-being for 8 residents out of 113 residents in the facility (Residents #61, #56, #31, #201, #116, #211, #58 and #206. The findings include: 1. Resident #61 was observed on [DATE] at 10:48 am to have arm bands on her left arm. One band was yellow and read FALL RISK in black letters. One was red that read ALLERGIES and one was white that had the resident's identifying information on it. All three were placed on the resident at the hospital prior to admission to this facility on [DATE]. On [DATE] upon observing in the 400 unit, it was determined that some resident's had on bracelets and others did not. An interview was conducted with Employee P at 1:50 pm on [DATE]. She stated that the yellow bracelets the residents wear are for fall risk, and the white ones were for wandering and elopement. On [DATE] at 1:55 pm an interview was conducted with Employee Q, and she stated that the yellow arm bracelet is for Do Not Resuscitate Orders (DNROs) and the white bracelet is just an identifying bracelet. On [DATE] at 2:00 pm another interview was conducted with Employee P, and she stated that the yellow bracelet is for DNROs and the white one was for identification. When asked if there was a different policy and procedure for the rest of the building she stated, I just don't know. On [DATE] at 2:25 pm an interview was conducted with the Director of Nursing (DON) and she confirmed the bracelets were from the hospital. The DON confirmed that the facility does have DNR bracelets that are used, but the facility does not utilize any fall bracelets. The DON was questioned regarding the yellow fall bracelet that Resident #61 was wearing from the hospital, and the facility's yellow DNR bracelets. The DON was asked if there would be anyway that the two bracelets could be confused with each other, and she stated, No their bracelets here are wider and in a sleeve. Once again the question was asked to the DON if there would be anyway a nurse could mistake the two bracelets, and she replied, I wouldn't. On [DATE] at 2:35 pm an interview was conducted with Employee R and she was shown the yellow fall bracelet and asked if she might ever confuse that with the DNR bracelets used at the facility and she stated, Yes, I could see them being confused. On [DATE] at 2:40 pm an interview was conducted with Employee G, and she was shown the yellow fall bracelet and asked if she might ever confuse that with the DNR bracelets used at the facility and she stated, Oh yes, that could easily be confused, especially in an emergency situation. An interview was conducted with the DON on [DATE] at 3:22 pm. The DON came in with her copy of the DNR policy and procedure and pointed out #10 in the policy which states, In the event of a Cardio/Pulmonary arrest in the resident's own room, the nurse/staff will rely on the yellow armband or the yellow indicator dot on the resident's door. Staff will NOT initiate CPR,but will require confirmation from the resident's medical record. When the DON was asked about what they would do if a resident was in a common area and not in their room, she stated, The staff would check the DNR list that they hang in the dining rooms, and other areas. On [DATE] at 1:47 pm an interview was conducted with the Social Services Director (SSD), and she was asked if she was responsible for keeping the DNRO list and she stated, Yes. When asked about the list she produced not matching the resident's Physician order [REDACTED]. When asked about the orders for the residents, she stated, I am not allowed to put orders in the computer, I tell the nurses, but they must do it. When asking the SSD what was wrong with the DNR system, and why it wasn't working she stated, Poor Communication. Review of the Determination of the DNR Status policy and procedure the DNRO will also be written (either directly by the physician or by the two nurses who took a V.O.) on the T.O. so that this gets communicated to the pharmacy and entered on the POS under CODE STATUS. 2. Upon observation it was observed that Residents #56, #31, and #201 had yellow DNRO forms in their chart, however their orders in the electronic medical record on the physician's orders [REDACTED]. Resident # 116 did not have on a yellow arm band. Resident #211 is a DNR and did not have a yellow dot on the door or chart. Resident #58 is a DNR and did not have any markings on her door to indicate the resident's code status. Resident #206 did not have a dot on the door, yellow armband, or order for code status in the electronic medical record.

Based on record review and interview, the facility failed to ensure that blood glucose monitoring, and timely treatment due to an injury were provided to ensure the highest well-being for 4 of 45 sampled residents (Residents #73, #132, #117, and #49). Failure to monitor the blood glucose of a diabetic resident or timely treatment could lead to potential complications in health status. The findings included: 1. An interview on 1/4/15 at 1:10 pm with Resident #73 revealed he's supposed to have his blood sugar checked before he eats, but the nurse had not checked it yet and he had finished eating. An observation of his lunch tray on his overbed table revealed the meal partially was eaten. Resident #73 said this nurse seldom checks his blood sugars like he's supposed to. On 1/4/15 at 1:15 pm, an interview with Employee B, Registered Nurse (RN) revealed Resident #73 has accu-checks four times a day. He said his last accu-check at 1:00 pm was 110. He said the resident is alert and oriented x 3. He pulled the Medication Administration Record (MAR) for Resident #73 and it documented a blood sugar of 110 at 1313. On 1/4/15 at 2:38 pm, Employee B, RN, was asked to pull the glucometer and turn the machine on. There were 4 glucometers on the cart. He said he wasn't sure which one he used. Employee B went to each glucometer to reveal all of the blood glucose readings recorded on each machine. He went back to January 1, 2015 on each machine to see if a glucose reading of 110 was recorded, and was unable to find the result on any of the 4 glucometers that recorded an accu-check of 110. Employee B was asked who he completed blood glucose monitoring on today. He wrote a list of 4 residents who he said had ordered accu-checks. He said Resident #132 had an accu-check at 11:24 am that was 119; Resident #117 had an accu-check at 11:25 am with a blood sugar of 129; and Resident #49 was out of the facility so he said he documented either 000 or 100 because you have to document something. He was asked if he actually completed the blood glucose monitoring and he said he did, but not for Resident #49 because she was not here. He was asked why the results of the 110 accu-check weren't recorded on any of the 4 glucometers and he said he did not know. On 1/4/16 at 2:50 pm, an interview was conducted with Employee C, RN Unit Manager, who came to the medication cart. She was asked to go through all 4 glucometers to see if we could find the result of 110. She looked through each machine and was unable to find the 110. At approximately 2:58 pm, a second interview was conducted with Resident #73, who told Employee C about his blood sugars not being monitored by Employee B. He told her the nurse did not check his blood sugar before or after lunch today. Employee C asked if his blood sugar was checked this morning and he said 'yes' and was able to tell her who did it and that the reading was 85. Record review of Resident #73's January MAR, dated 1/4/16 at 0630, recorded a blood sugar of 85. Employee C said she was able to find the blood glucose reading of 85 from this morning on one of the glucometers. On 1/4/2016 at 3:30 pm, Employee D, Director of Operations, said they pulled Employee B off the medication cart and are pulling all of the accu-checks for any resident he was to complete blood sugars on. She said she has the 4 glucometers and will compare the results with the machines. She said she replaced the machines on the med cart with new ones. Employee D returned at 4:08 pm and said Resident #117's January MAR recorded a blood sugar of 129. She said she could not find the accu-check on the glucometer for this resident. She was unable to find the blood glucose reading of 119 for Resident #132 on either of the glucometers. She said Residents #49 and Resident #117 were out of the building at the time of the ordered accu-check, and there should not be a number for the accu check for either of those residents recorded on the MAR. Record review of the MAR, dated January 2016 for Resident #73 recorded blood glucose readings as high as 433 on 1/1/2016. He receives sliding scale coverage with [MEDICATION NAME] insulin. On 1/4/16 at 16:38, Resident #73's blood sugar was 390 and the physician was notified due to accu check not being checked earlier in the day. Record review of Resident #49 revealed a blood glucose reading of 100 on 1/4/16 at 1130. Record review of Resident #132 revealed a blood glucose reading of 119 on 1/4/16 at 1130. Record review of Resident #117 revealed a blood glucose reading of 129 on 1/4/16 at 1130. Record review of Resident #73 revealed an order to increase [MEDICATION NAME] to 18 units every am and pm. Review of the facility policy entitled 'Obtaining Finger Stick Blood Sample' revised 12/2013, revealed it stated to verify physician's order for procedure, assemble equipment and supplies needed. On 1/5/16 at 1:40 pm, an interview was conducted with the Director of Nurses and Employee D who said Resident #73's blood sugar was checked yesterday at 1600 with a result of 390. She said the physician was notified, and it was reported to the Department of Children and Family (DCF) yesterday. She said the physician came in earlier today and DCF also came in. She said Resident #117 goes to [MEDICAL TREATMENT], and he wasn't here at the time of the accu check. She said she questioned Employee B, but he didn't give her a good answer as to why he didn't check the blood sugars and why he would record results that weren't obtained. 2. On 1/05/2016 at 9:14 am, an observation of a [MEDICATION NAME] blood saturated bandage was observed on Resident #117's left forearm. dated 1/2/16 with a time of 2245. There were no initials on the dressing. There was also a large bruised area on the forearm. Resident #117 stated at the [MEDICAL TREATMENT] center they were wheeling him in and his left arm scraped the doorjamb. On 1/5/15 at 4:25 pm, an observation of Resident #117's left forearm revealed a bandage, dated 1/5/15 with initials. Resident #117 said he told the nurse what happened when she changed the dressing earlier today. An interview with Employee M, Licensed Practical Nurse (LPN) on 1/5/15 at 4:32 pm revealed she was told in a report Resident #117 got a skin tear today. She said she did not see an incident report or notes in the computer explaining what happened. On 1/5/15 at 4:45 pm, an interview with Employee L, Certified Nursing Assistant, revealed she noticed the bandage on his forearm from [MEDICAL TREATMENT] yesterday when he returned around 4:30 pm. An interview with Employee E, LPN, on 1/5/15 at 5:00 pm, revealed she noticed an open area on his left outer forearm and put a [MEDICATION NAME] dressing on it. She said today she realized she did not get a doctor's order for the treatment and said she did not call the physician or document what happened when she first discovered it a few days ago. She said Resident #117 told her it happened at [MEDICAL TREATMENT]. She said she should have obtained a doctor's order and reported what had happened. On 1/5/15 at 5:05 pm, an interview with Employee C, Registered Nurse (RN) Unit Manager, revealed the nurse should have called the doctor to report the skin tear and to get an order for [REDACTED]. Record review of Resident #117's physician's order, dated 1/6/2016 to clean open area right outer forearm with normal saline, apply triple antibiotic ointment with [MEDICATION NAME] and cover with [MEDICATION NAME] every 3 days until resolved. Record review of a late entry, dated 1/2/16 at 1300 and created 1/5/16 at 15:22, stated, Resident noted to have small open area left forearm, reports that he bumped it during transfer. New order to clean with normal saline and cover with [MEDICATION NAME] daily. Record review was conducted of a Skin Condition report for Resident #117, dated 1/6/15. The only information given was a treatment order, but the site or what happened was not recorded on the note. On 1/7/15 at 12:50 pm, an interview was conducted with the Administrator who said there was an incident report recorded on Resident #117, dated 1/6/2016, that reports he bumped his arm and got a skin tear. She said she had not yet spoken to Resident #117 to ask him how it happened. She said she was not aware of the large bruised area. After she was made aware of what Resident #117 reported, she said the nurse should have reported it the day she first observed it, called the doctor, documented what happened and obtain treatment orders. She said someone should have called the [MEDICAL TREATMENT] center to ask them what happened. She said the family should have also been notified.

Based on record review, interviews, and facility policy, the facility failed to document the education regarding the benefits and potential side effects prior to consent for the Influenza Vaccine per the Centers for Disease (CDC) recommendation for 5 of 5 sampled residents (Residents #116, #164, #89, #119, and #28). The findings include: Record review for Residents #116, #164, #89, #119, and #28 revealed there were no statements or documentation of education provided prior to consenting to receive or decline the influenza vaccine. Review of the computer charting under the immunization tab did not record the education. Review of the Influenza Book located on the unit only had consents for all of the clients, but no education for Vaccination Information Sheet (VIS) as recommended by the CDC. On 1/7/16 at 1:22 pm, an interview was conducted with the infection control nurse who stated she was new to the facility and did not know what the policy was for educating the residents for the influenza vaccine. She said the unit manager would know. An interview with Employee Q, Licensed Practical Nurse (LPN) Unit Manager, on 1/7/16 at 1:45 pm revealed the facility does not document when the patient was educated before or after receiving the influenza vaccine. Review of the facility policy revised October 2006 entitled Influenza Vaccine of Residents, Staff, Volunteers states the VIS will serve as a means for providing education to the resident, a notation will be made in the resident's permanent record, including the time and date the VIS materials were provided.