Orchards Of Cascadia, The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, interviews, and BFS portal review the facility failed to ensure a thorough investigation was completed to prevent further resident to resident abuse incidents. This was true for 1 of 3 (Resident #38) and had the potential to cause psychosocial and physical harm to those residents residing in the facility. Findings include:Review of the facility's policy titled, Abuse - Reporting & Response, dated 8/25/25, documented:The facility shall submit a follow-up report within five (5) working days of the incident. This report must include a summary of the investigation findings and identify any corrective actions implemented in response to a substantiated allegation.Any new or revised information that supplements the initial report should be included in the follow-up submission to ensure completeness and accuracy.The facility may choose to submit the follow-up report earlier than the required timeframe Resident #38 was admitted to the facility on [DATE] with multiple diagnoses including chronic respiratory failure and depression.Review of Resident #38's MDS dated [DATE], documented that Resident #38 was cognitively intact.A progress note dated 1/2/26 at 2:47 AM, documented that Resident #38 approached the nurses station stating I can't take it anymore. He's threatening to kick my ass referring to his roommate. Resident was offered to go to another room for the night to get some separation and rest for the night. Initially resident stated I don't want to lose my room. CEO was notified of the incident and was able to assist this RN with educating resident on the benefits of going to another room for the night. Resident did then go to room [ROOM NUMBER] for the remainder of the night and slept peacefully. Resident stated during the interview with this RN that there was no physical altercation that took place and that he felt safe in his room.A progress note dated 1/2/26 at 1:49 PM, documented the resident was interviewed regarding events involving his roommate. He appears with no signs of psychosocial harm or distress. He stated that during the verbal altercation, each individual remained on their side of the room. Resident #38 said that his roommate stated, once I get out of bed, I am going to kick your ass. The resident indicated that despite this statement, he did not feel threatened and felt safe within the facility.On 1/8/26 at 12:20, interview with the Administrator with the CRN present, the Administrator stated he received a call at 2:39 AM and he was informed of the situation, residents were separated. He spoke with Resident #38 and ruled out physical and psychosocial harm. When asked, why was this not reported? the Administrator stated he ruled out physical and psychosocial harm. When asked, Did you investigate the allegation? the Administrator did not respond, the CRN stated, the facility did not do a thorough investigation.

Based on observation, interview, record review, and facility policy review, revealed the facility failed to ensure enhanced barrier precautions (EBP) and hand hygiene were performed after emptying a nephrostomy bag and performing incontinent care for one of 31 sampled residents (Resident (R) 9) reviewed for infection control. This deficient practice had the potential to allow residents to be exposed to pathogens that could cause an infection.Findings include:Review of the facility's policy titled, Transmission-Based Precautions Conventional Plan,revised on 06/16/25, revealed Policy: To protect residents from the spread of infection through the implementation of infection control practices and precautions, Hand hygiene is the single most important factor in the prevention or spread of infection.Hand hygiene indicated, utilizing Alcohol Based Hand Rub (ABHR) and/ or hand washing with soap and water. a. Before and after contact with a resident, b. Before and after contact with objects and surfaces in the resident's environment, c. Before and after wearing gloves, d, Before and after wearing personal protective equipment e. Before eating or assisting a resident with meal f. After using the restroom. Enhanced Barrier Precautions (EBP) are recommended for the use in resident rooms when residents have any of the following conditions, but do not require contact precautions.b. indwelling medical devices, central line, urinary catheter, feeding tube, tracheostomy/ventilator care. A peripheral intravenous line (not a periphery inserted central catheter) is not an indwelling medical device.b. Wear a gown whenever anticipating that clothing will be have direct contact with the resident or potential contaminated environmental surfaces or equipment surfaces or equipment in close proximity to the resident.Review of R9's admission Record located under the Profile tab in the electronic medical record (EMR) revealed an admission date of 09/15/25 with diagnoses of diabetes, chronic kidney disease, and functional quadriplegia.Review of physician orders located under the Orders tab in the EMR revealed on 09/15/25 Enhanced barrier precautions for Nephrostomy Gown and gloves required for high-contact patient care (dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care). Gown and gloves are not required when not performing high- contact care.On 09/29/25 at 10:56 AM, an observation was made when staff came into R9's room to give her pain medication. Licensed Practical Nurse (LPN) 5 and Certified Nursing Assistant (CNA) 11 started to give cares. LPN5 emptied R9's nephrostomy bag into a measurable container. LPN5 wore only gloves while she emptied the bag and then emptied the container down the toilet. LPN5 came out of the bathroom and threw her gloves in the trash and donned a new pair without hand hygiene. LPN5 went to bed to help CNA11 perform cares. R9 had a bowel movement. CNA11 wore a pair of gloves and cleaned R9's incontinence. CNA11 reached into the wipes after wiping R9's buttock and proceeded to pick up clean depends and place it under R9 without changing gloves or performing hand hygiene between the dirty and clean.During an interview 09/29/25 at 11:13 AM, LPN5 was asked about emptying the nephrostomy bag and pouring the urine down the toilet without a gown on. LPN5 stated Yes, should have had a gown on because the resident is on EBP. LPN5 was asked if she should have washed her hands or used the ABHR before donning the second pair of gloves. LPN5 stated Yes.During an interview on 09/29/25 at 11:14 PM, CNA11 was asked if the gloves should have been changed in between going from dirty to clean. CNA11 stated Yes should have changed gloves and performed hand hygiene before putting on clean gloves. During an interview on 10/04/25 at 11:23 AM, Infection Preventionist (IP) was asked about the observation. The IP stated, The expectation is that staff wash their hands when entering room and before they start any cares. Both the LPN and CNA should have changed gloves after they performed hand hygiene. The IP stated that the LPN should have had a gown on when emptying the nephrology bag. That is the expectation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to investigate resident grievances in a timely manner for four of four resident (Resident (R) 70, R15, R57, and R59) reviewed for resident council and eight of eight residents (R48, R8, R61, R77, R82, R4, R27, and R14) reviewed for repeated grievances of noise at night and concerns about customer service of 31 sample residents. This deficient practice had the potential to allow grievances to not be responded to in a timely manner for 93 residents.Findings include:Review of the facility's policy titled, Grievance Process, with a revision date of 08/29/25, revealed: Policy: Residents and their families have the right to file a complaint without fear of reprisal. Residents' rights should be protected when voicing complaints to maximize the quality of life for each individual and to promote customer satisfaction with facility care and services. The Grievance program is utilized to address the concerns of Residents, family members and visitors and the facility should make prompt efforts to resolve grievances. Definitions: Prompt efforts to resolve: This refers to a facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. Procedure.7. The Nursing Home Administration/Designee is responsible for overseeing the grievance process, including receiving tracking, and conclusion/resolution.Responsibility of the Nursing Home administrator and/or Designee. 2. Ensuring that all grievances reports have been reviewed and addressed in a timely and appropriate manner and that concerned individuals feel that some type of resolution has been communicated, achieved, and maintained.1.Review of resident council minutes provided by the facility revealed grievances of noise from night shift. Multiple residents complained of noise during the meeting on 04/16/25. During the meeting on 05/21/25 many residents complained of the noise at night. R70 had stated during the 06/18/25 meeting that the staff came into the room at 4:00 AM and made a noise waking her up. During the 09/17/25 meeting, multiple residents complained of noise in the early morning.During a resident council meeting on 10/01/25 at 1:33 PM, the residents were asked if they had any resolution to the grievance of the noises at night. R15, R57, R59, and R70 confirmed there had been no resolution shared with them and the noise level at night was still loud.2. Review of a complaint investigation in June 2025 revealed there was an undated form in which R48 complained about the roommate's television being loud. R48 asked Certified Nursing Assistant (CNA) 5 to turn it down. CNA5 stated to R48 that the roommate had rights. R48 stated in the statement that she had rights also. R48 stated CNA5 was rude to her.Review of the Complaints/Grievances Log provided by the facility revealed R48 was not on the log for June 2025. The grievance did not appear until 08/20/25.3. a. Review of R8's undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R8 was admitted to the facility on [DATE].Review of the five day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/09/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R8 was moderately impaired in cognition.During an interview on 09/29/25 at 3:15 PM, R8 stated staff came into his room at 2:00 AM, 2:30 AM, and 3:00 AM. R8 stated staff knocked on the door and sometimes turned the lights on when they came in. R8 stated it interrupted his sleep and was concerning. R8 stated he did not know why staff did this.b. Review of R61's undated admission Record in the EMR under the Profile tab revealed R61 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 08/19/25 in the EMR under the MDS tab revealed a BIMS score of nine out of 15 which indicated R61 had moderately impaired cognition.During an interview on 09/29/25 at 2:04 PM, R61 stated a staff member recently came into his room around 2:00 AM, knocked loud on the door and turned the light on. R61 stated this woke him up and he asked the staff member not to knock on his door so loud. R61 stated the staff member then wrote on the whiteboard the name of the CNA and nurse for the day, turned off the light and left the room. R61 stated he heard knocking on his door three times more that night although no one came into the room.c. Review of R77's undated admission Record in the EMR under the Profile tab revealed R77 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 09/11/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R77 was cognitively intact.During an interview on 10/02/25 at 11:13 AM, R77 stated staff came into his room at 3:00 AM to offer him ice water. R77 stated he asked them what they were doing. R77 stated they were checking his trash can and delivering ice water. R77 stated They should not be in my room. It wakes me up.4. Review of R82's admission Record in the EMR under the Profile tab revealed R82 was admitted to the facility on [DATE]; diagnoses included Parkinson's disease and insomnia.Review of the quarterly MDS with an ARD of 09/02/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R82 was cognitively intact. Review of the Care Plan, dated 02/27/24 in the EMR under the Care Plan tab, revealed R82 had a focus area of Sleep. [R82] has a DX [diagnosis] of insomnia and is prescribed antidepressant medication and a supplement to manage his condition. The goal was, [R82] will obtain sufficient quality and quantity of sleep promote optimal daily function through next review date. Interventions in pertinent part included, Investigate and identify potential sources of [R82's] sleep disturbances. i.e., noise. etc. Offer and provide [R82] non-pharmacological interventions to promote sleep: .quiet environment. Rule out . noisy environment other internal/external factors. Solve as able.During an interview on 09/29/25 at 3:09 PM, R82 stated he was not getting sleep due to his roommate's TV that was on all night long at night. R82 stated he had recently moved into this room and had asked numerous staff to assist with the noise at night including the nurses and certified nursing assistants working on night shift. R82 stated the staff turned down his roommate's TV volume if his roommate was sleeping; however, the TV had been turned off only once out of the last six nights. R82 stated that in addition to the noise, the lights from the TV also kept him up. R82 stated he could not go without sleep, and it had been six days since he had slept. R82 stated he was upset, and the lack of sleep affected his Parkinson's with his tremors becoming worse than normal. R82 was observed during the interview with significant tremors to his arms and hands.During an interview on 10/02/25 at 12:16 PM, the Social Services Director (SSD) stated she was aware of R82's concern about his roommate's TV being on and it was too loud at night, affecting his ability to sleep. The SSD stated she had spoken with R82's roommate [R4] about R4 wearing headphones at night when watching TV and had spoken to R82 about wearing earbuds at night to drown out the noise. The SSD stated she had spoken with R82 on 09/30/25. The SSD stated R4 told her he would think about whether he was willing to wear headphones and let her know after a few days. The SSD stated the staff could not force someone to turn their TV off at night and residents were allowed to keep their TVs on all night long because it was their home. The SSD stated staff could ask R4 to turn the volume down. The SSD stated if this could not be resolved, then a room change might be necessary. During an interview on 10/02/25 at 2:30 PM, the SSD stated the facility did not have a policy about TVs. During an interview on 10/03/25 at 11:47 AM, R4 stated the SSD had spoken with him about his TV. The TV was on during the interview at a moderate volume. R4 stated the TV was all he had, and he wanted it on at night and did not want to wear headphones. R4 stated he had turned down the TV when R82 had asked but did not want to turn it off. During an interview on 10/03/25 at 10:35 AM, the Administrator stated he reviewed all grievances to make sure each grievance was handled appropriately. The Administrator stated he did not know about an issue related to R4's TV not being turned off at night. The Administrator stated residents could be asked to be more cognizant of the noise, but they could not be forced to be quieter. During an interview on 10/03/25 at 12:07 PM, R82 stated he considered his complaint about the TV at night a formal complaint/grievance. R82 stated he spoke with the SSD but did not know when she would get back to him about his concern with his roommate's TV. During an interview on 10/04/25 at 2:14 PM, the Administrator and Director of Nursing (DON) stated they could not touch a resident's TV, i.e., turn it down or off unless the resident was sleeping. The Administrator stated they had asked staff to be quiet at night. The DON stated staff should knock on doors at night prior to entering residents' rooms such as when they were making rounds. The Administrator and DON stated they were aware of some residents that did not want to be disturbed at night, and accommodations were made for these individuals. The Administrator and DON stated they had some staff working on night shift that had loud voices and this was a challenge.5. During review of a Facility Reported Incident occurring on 06/26/25 regarding staff to resident abuse, 74 residents were interviewed by staff. Residents were asked if any staff, residents, or other individuals had abused them. Three residents stated they had been abused and the Administrator determined for these three residents; grievances would be completed as follows: a. Review of R57's undated admission Record revealed R57 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 08/12/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R57 was cognitively intact.Review of the undated questionnaire for R57 provided by the facility revealed R57 expressed a concern with verbal abuse that read, [CNA3] yelled at her about transfer. [R57] told her to stop yelling at her. [R57] was on bathroom floor. Follow up [Administrator] Last week, [R57] fell and [CNA3] got frustrated with [R57] that she hadn't asked for help to make the transfer. They (CNAs/nurses) got her up with the Hoyer [mechanical lift]. Is okay with doing a grievance.See customer service grievance.The Grievance Log from 09/01/24 through the survey was reviewed; there was no grievance completed for this incident.b. Review of R27's undated admission Record in the EMR under the Profile tab revealed R27 was admitted to the facility on [DATE].Review of the quarterly MDS with an ARD of 07/03/25 in the EMR under the MDS tab revealed a BIMS score of 15 out of 15 which indicated R27 was cognitively intact.Review of the undated questionnaire for R27 provided by the facility revealed R27 had a concern with verbal abuse with the word uncomfortable documented. The questionnaire read, Workers - very negative words when being addressed after wet. my comments mean nothing. CNA 200. Follow up - [Administrator] Says [CNA6] struggles in her approach and listening to patients. Okay with making this a grievance. [R27] Said she [CNA6] walks in angry and get upset at her for everything. Talks down to her. CNA talks bad about her outside her room. The Grievance Log from 06/01/25 through the survey was reviewed; there was no grievance completed for this incident. c. Review of R14's undated admission Record in the EMR under the Profile tab revealed R14 was admitted to the facility on [DATE].Review of the annual MDS with an ARD of 08/10/25 in the EMR under the MDS tab revealed a BIMS score of 14 out of 15 which indicated R14 was cognitively intact. Review of the undated questionnaire for R14 provided by the facility revealed R14 experienced verbal abuse. The undated questionnaire read, [CNA5] in June, in room. 'Do you think you need that water. You shouldn't drink that much. Follow up - [Administrator] Felt like [CNA5] was telling her that she was drinking too much water because she was going to pee in the night. Says [CNA5's] attitude changes a lot. Feels okay about making this a grievance. The Grievance Log from 06/01/25 through the survey was reviewed; there was no grievance completed for this incident.During an interview on 10/03/25 at 10:14 AM, the Administrator stated grievances had not been completed for R57, R27, and R14. During an interview on 10/02/25 at 12:31 PM, the SSD stated she acted as an intermediary in the grievance process. The SSD stated she collected the initial information and then distributed it to the pertinent department head to address during the clinical/stand up meeting. The SSD stated she followed up with residents to determine if results had been communicated to them by the person completing the investigation and if a resident was not satisfied, she and the Administrator worked with the resident to find a solution. The SSD stated she liked to get grievances completed within about a week. The SSD stated the Administrator signed off on all the grievances once they were complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure an allegation of physical abuse was reported timely to the Administrator and to the State for one out of four Facility Reported Incidents (FRIs) (Resident (R) 82) reviewed for abuse of 31 sample residents. This failure had the potential for abuse to occur and/or continue.Findings include:Review of the facility's policy titled, Abuse, dated 03/01/24, revealed Allegations of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknow source, exploitation, deprivation of foods and services by staff, and misappropriate of resident property are reported to the CEO [Chief Executive Officer] immediately and the state agency. a. Within 2 hours if there was alleged abuse or serious bodily injury as a result of an event. b. Within 24 hours if the event that caused the injury did not involve abuse or did not result in serious bodily injury.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R82 was admitted to the facility on [DATE]; and diagnoses included Parkinson's disease with dyskinesia (difficulty in performing or controlling voluntary movements).Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/02/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R82 was cognitively intact. R82 was impaired in range of motion (ROM) to both upper extremities. R82 required supervision or touching assistance with dressing and partial/moderate assistance with showers/baths. Review of the Care Plan to address activities of daily living (ADLS), dated 02/27/24, under the Care Plan tab of the EMR, revealed [R82] has ADL self-care and mobility deficit r/t [related to] DX [diagnosis] of Parkinson's, failure to thrive, malnutrition, HX [history] of falls, muscle weakness, tremors, and muscle spasms. Interventions in pertinent part included Personal Hygiene: [R82] requires supervision/touching assistance with his personal hygiene cares. Dressing: [R82] requires supervision/touching assistance with upper and lower body dressing and set up/clean up with footwear donning. Bathing: [R82] requires partial/moderate assistance with bathing with assistance of 1.Review of a Nurse's Note late entry for 06/26/25 at 6:45 PM by the Unit Manger/Registered Nurse (RN) 1 in the EMR under the Progress Notes tab, revealed Resident came into Unit Managers office, asking to speak to this nurse. Resident began by stating he wanted to move to a new facility. Nurse stated that that was his right and asked why he was feeling this way. Resident stated that he was angry with [Certified Nursing Assistant (CNA) 4]. Resident described an incident that happened earlier in the day, when [CNA4] was assisting resident to get dressed. [CNA4] pulled resident's shirt down and caught the fabric on resident's umbilical hernia. Resident stated, I told him he was ripping my Fucking guts out. Resident reports that [CNA4] stopped pulling on the shirt and told resident not to say the F-word to him. Resident admitted he continued to swear at [CNA4], and stated, I have a right to say what I want in my own room. Resident reports that [CNA4] Just walked out of my room. Nurse offered resident a room change to another hall with different CNAs, and resident was happy about that idea. Nurse spoke with [CNA4] on hall and instructed him to have another aid provide care for resident. [CNA4] agreed. Discussed event that occurred earlier in the day, and [CNA4] reported the same facts. He had caught the shirt on resident's umbilical hernia, stopped when resident screamed and swore at him, informed resident he did not appreciate being spoken to like that, and when resident continued swearing at him, he left the room having completed his cares and left patient safe and clean.Review of R82's Grievance Resolution Form, dated 06/28/25 at 6:42 PM and provided by the facility revealed R82's concern as follows: On 06/27 [R82] was being changed by [CNA4] and when [CNA4] was taking off [R82's] shirt from behind it got caught on [R82's] hernia, when this happened [R82] told [CNA4] to stop. When he [CNA4] didn't [R82] then stated [CNA4] stated Stop! Your pulling my fucking guts out! [R82] then stated [CNA4] told him he had no power to stop him and You can't go anywhere. [R82] also stated he told the eve CNAs what happened to try and report it and nobody would listen/help him.Review of the Five-Day Follow Up Investigation Report, dated 07/07/25 and provided by the facility, revealed the initial report was made to the State on 06/30/25 at 3:00 PM, four days after R82's initial report. The investigation summary revealed, The alleged victim alleges that on 06/27 (interviews with staff and witness indicate the actual incident occurred 6/26) the alleged perpetrator [CNA4] intentionally caused pain to the alleged victim's umbilical hernia while helping the alleged victim get dressed. The alleged victim stated that he told the alleged perpetrator to stop and then the alleged perpetrator continued to assist him to help him dress further causing discomfort to the umbilical hernia. The alleged victim alleges that the alleged perpetrator told the alleged victim that CNA [CNA3] later that evening swatted away at the alleged victim's hand during cares.During an interview on 09/29/25 at 3:09 PM, R82 stated he had an issue with two CNAs (CNA4 and CNA3). R82 stated CNA4 grabbed his t-shirt from behind (on 06/26/25) and was pulling it up when it caught on his umbilical hernia and his hernia was pulled out. R82 stated he told CNA4 to stop but CNA4 continued to pull on the shirt causing pain. R82 stated CNA4 laughed and told him he wasn't doing anything and CNA4 pulled on the shirt two more times before stopping after R82 swore and yelled at CNA4 that he was pulling his guts out. During an interview on 10/02/25 at 5:27 PM, the Administrator verified that the date the allegation of abuse was reported to the State on 06/30/25 exceeded the initial reporting requirement. The Administrator stated R82's initial report to the Unit Manager on 06/26/25 did not meet the threshold for abuse and R82 seemed to be angrier at CNA4 for leaving the room rather than due to the incident with his shirt catching on the hernia. The Administrator stated he found out about the incident due to the Grievance Form (dated 06/28/25) being placed under his door over the weekend and he first saw it on Monday 06/30/25, when he came to work and he reported the incident to the State on 06/30/25. The Administrator verified that abuse allegations should be reported to him by staff immediately.

Based on interview, record review, and review of facility policy, the facility failed to ensure the resident did not receive the wrong dose contributing to a significant medication error for one of 31 sampled residents (Resident (R) 106) reviewed for medication orders. This deficient practice had the potential to over medicate residents by not following the physician orders.Findings include:Review of the facility's policy titled, Management and Destruction of Controlled Substances, with a date of 11/28/17, revealed Policy: The facility follows a process for management and destruction of controlled substances. Procedures.e. Chief Nursing Officer/designated RN should regularly audit the inventory records to validate accuracy.Review of R106's admission Record located under the Profile tab in the electronic medical record (EMR) revealed an admission date of 05 15/25 with diagnoses of aftercare following surgical amputation, acquired absence of right leg below the knee, and end stage renal disease.Review of R106's Physician Orders located under the Orders tab in the EMR revealed on 05/14/25, an order for hydromorphone oral tablet four milligrams (mg); give one tablet by mouth every six hours for pain. On 06/06/25, the order was written to decrease the hydromorphone oral tablet to four mg; give 0.5 tablet by mouth every six hours for pain.Review of the Controlled Drug Record dated 05/15/25- 07/11/25 and provided by the facility, revealed 14 occasions in which. R106 received a whole four mg pill instead of the ordered two mg.During an interview on 10/03/25 at 11:17 AM, the Registered Pharmacist (RP) stated the pharmacy received the order on 06/10/25. The RP stated that the interface between pharmacy and the facility did not communicate when there was a narcotic order. The RP further stated that the narcotic order must be ordered with a hard copy of the order. The RP was asked about the 14 times in which the medication was given at the wrong dose. The RP stated that it was not caught, and it should have been. The RP agreed the order was not followed.During an interview on 10/03/25 at 11:36 AM, Licensed Practical Nurse (LPN) 9 was asked about the medication order. LPN9 stated the medication should have been taken out of the pack and half the pill given and the other half wasted. It does appear to have been given in whole pill form. LPN9 was asked if any of the initials were on the narcotic sheet. LPN9 stated yes, her initials were on the form, and it looked like she had given a whole pill. LPN9 was asked if the physicians order was followed. LPN9 stated, no.During an interview on 10/03/25 at 12:18 PM, the Director of Nursing (DON) was asked about the wrong dose medication being given to the resident. The DON stated he had to look at a report. At 1:36 PM, the DON returned and stated the orders should have been called to the pharmacy when the order was initially ordered. The DON was shown the 14 opportunities in which the medication was given the wrong dose. The DON agreed the resident was given the wrong dose of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, document review, staff interviews, and facility policy review, the facility failed to ensure appropriate storage of medication and vaccine supplies in one of two facility medication rooms. This failure created the potential for residents to experience a negative outcome related to potentially expired/undated and/or improperly refrigerated medications, immunizations, or immunization supplies. Findings include:Review of the facility's policy titled, Medication Storage -Refrigerator/Freezer Policy, dated [DATE], read, in pertinent part, The facility will ensure that medications which require refrigeration are stored appropriately per manufacturer's instructions; and 2. The facility should monitor the temperature of medication storage areas at least once a day. 3. The facility should monitor the temperature of vaccine storage twice a day; and Safe temperature for refrigeration is between the range of 36 degrees F (Fahrenheit) and 46 degrees F.Review of the facility's policy titled, Medication Management Policy, dated most recently revised [DATE], read, in pertinent part, Medication and treatment supplies are not used beyond their expiration dates; and Medications are discarded by the expiration date unless indicated by the pharmacy and/or manufacturer's instructions to discard sooner.Observation conducted along with the Director of Nursing (DON) in the facility's medication storage room located on the 300 hallway on [DATE] at 11:48 AM revealed one vial of open and undated Tuberculin Skin Testing Solution in one of the two refrigerators located in the medication room. The testing solution packaging indicated the solution had been dispensed from the pharmacy to the facility on [DATE]. In addition, temperature logs to indicate temperatures were monitored for both refrigerators in the medication room (one for storing medication and one for storing immunization materials), could not be located to ensure the management of refrigerator temperatures were within the appropriate range. The Tuberculin (TB) Skin Testing Solution instructions, located on the TB Skin Testing solution box located in the facility's medication room indicated, Tuberculin skin test solution must be discarded 30 days after it is first opened or if it has passed its expiration date, whichever comes first; and store refrigerated at 2-8 C (35-46 F) and protected from light to ensure potency. During an interview with the DON on [DATE] at 11:55 AM, he stated his expectation was multi dose vials, including tuberculin testing solution, should be labeled when opened and discarded within 28 days after opening. The DON stated he was not sure where the refrigerator temperature logs were, but he would look for them. He stated he expected the logs to be posted on the door of each refrigerator. During a follow-up interview with the DON on [DATE] at 12:18 PM, he provided a log, dated [DATE], for one of the medication room refrigerators. The log did not indicate which refrigerator the temperatures were being logged for and the DON stated he was not able to tell which log he was providing. He stated the log had been found in the Unit Manager's Office. The DON confirmed the logs were expected to be located on the door of each refrigerator and labeled appropriately to indicate which refrigerator was being monitored. The DON confirmed both refrigerators in the medication room (one for the storage of medication and one for the storage of immunization/supplies) were expected to be monitored at least daily. He indicated he thought the refrigerator used to store immunizations and immunization supplies was supposed to be monitored twice daily to ensure stability of the immunization supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, the facility's Incident and Accident (I&A) Report, and staff interview it was determined the facility failed to ensure a resident receiving dialysis services were provided appropriate monitoring, emergency response, and staff intervention consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. This was true for 1 of 3 residents (Resident #103) reviewed for hemodialysis. This deficient practice caused actual harm to Resident #103 when her central venous catheter (CVC) experienced a bleeding emergency, followed by loss of consciousness and a Full Code where Cardiopulmonary Resuscitation (CPR) was initiated, EMT called, and she was sent to the hospital where she was pronounced deceased after extensive interventions. Immediate Jeopardy was identified on [DATE] at 3:08 PM and was determined to exist since [DATE], when the facility failed to ensure appropriate nursing response to Resident #103 when her dialysis catheter began to bleed. On [DATE] at 3:08 PM, the facility's Administrator was notified of the Immediate Jeopardy at F698, Dialysis. On [DATE] at 1:30 PM, after the Survey Team verified implementation of the IJ removal plan, the facility Administrator was notified the Immediacy was removed on [DATE]. The noncompliance remained at a scope and severity level of G (isolated actual harm) following the removal of the immediate jeopardy.Findings include:Review of the facility's policy titled, Dialysis Off-Site Policy, revised [DATE], documented, The clinical staff provides ongoing assessment and oversight of the resident before and after dialysis treatments, including monitoring the resident's condition after treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices.Review of the facility's policy titled, Resident Change of Condition Policy, dated [DATE], documented, Designate someone to stay with resident while physician is notified, if necessary; and Monitor and reassess resident's condition and response to interventions until stable or emergency personnel arrive and take over care for transfer to acute care.The National Library of Medicine website titled Care of a Central Line updated [DATE] and accessed on [DATE], documented: All healthcare professionals working in a setting with indwelling CVCs should receive annual training on central line care. Updates regarding indications for the placement of CVCs, maintenance of CVCs, and infection control measures should be included.The Pulmonary Hypertension Association: Best Practices in Catheter Care article, accessed on [DATE], documents: If blood is backing up the catheter or leaking out, use the clamp to close off the catheter if it is still leaking you must clamp off the line. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including end stage renal disease (ESRD). Resident #103's Minimum Data Set (MDS) dated [DATE], documented she was cognitively intact and receiving hemodialysis. A Physician's Order dated [DATE], documented Resident #103 had a right chest central venous catheter (CVC) in place for the administration of her dialysis and she was to receive the following:-Hemodialysis three times a week every Monday, Wednesday, and Friday.-Apixaban (a blood thinner) 5 mg two times a day for her irregular heart rate.A Dialysis Care Plan initiated on [DATE], documented Resident #103 had a central line in her right chest used by dialysis, and she attended dialysis every Monday, Wednesday, and Friday. The Care Plan directed staff to monitor Resident #103 for complications such as site discomfort, signs and symptoms of infection, phlebitis, occlusion, infiltration, displacement, and bleeding.The facility's I&A report documented that on [DATE], LPN #1 found [Resident #103] standing naked with her dialysis catheter leaking blood from the red port only it was flowing onto the floor and down her chest due to the clamp the line with the red end was unclamped and there was no end cap. LPN #1 clamped the line, left to obtain a cap, and returned to find the clamp unclipped again and blood was visibly flowing from the line. The resident was then escorted down the hallway by a CNA without continuous licensed nurse supervision of the access site. Bleeding occurred in the resident's room [Resident #103] was slumped back with her back on the bed and her feet were on the floor. There was blood noted coming from the catheter and had leaked onto the bed and it was also noted on the floor in front of where her feet were followed by loss of consciousness, absent respirations and pulse. CPR was initiated until EMS arrival.The facility was unable to provide evidence that the nursing staff had been trained or deemed competent in responding to dialysis access emergencies. On [DATE] at 3:08 PM, the Director of Clinical Services (DCS) stated that the facility had not provided such training and expected nurses to have learned these skills during their initial licensing preparation. In a follow up interview on [DATE] at 5:00 PM, the DCS acknowledged that the nurse should have applied a hemostat when the clamp failed and could not explain why a new cap was not placed on the CVC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** asBased on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to implement storage of resident smoking materials as directed by residents' care plans. This was true for 2 of 2 residents (#57 and #67) whose care plans were reviewed for smoking. These failures placed residents in the facility at risk of negative outcomes if smoking materials were not stored safely due to lack of information in their care plan. Findings include:
The facility's Smoking Policy, dated 10/15/22, documented Smoking paraphernalia is not permitted to be stored in the resident's room. This includes e-cigarettes and vaping devices/materials.
1. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including tobacco use.
An MDS assessment, dated 4/18/24, documented Resident #57 was cognitively intact.
Resident #57's Care Plan, dated 4/7/23, documented Resident #57 was an independent smoker and his smoking paraphernalia was stored in his room or in the nurse's cart.
During an interview on 6/3/24 at 11:30 AM, Resident #57 stated he was an unsupervised smoker and had his own smoking products in his room.
2. Resident #67 was admitted to the facility on [DATE], with multiple diagnoses including nicotine dependence and use of cigarettes.
An MDS assessment, dated 5/27/24, documented Resident #67 was moderately cognitively impaired.
Resident #67's Care Plan, dated 4/7/23, documented Resident #67 a dependent smoker and his smoking paraphernalia was stored at the nursing station, in a locked box outdoors.
During an interview on 6/3/24 at 11:30 AM, Resident #67 stated he smoked, and he kept his tobacco and lighter in his room. A red bag with tobacco in it was observed in his room.
During an interview on 6/6/24 at 10:16 AM, LPN #5 stated residents that smoked were allowed to keep their smoking material in their rooms.
During an interview on 6/6/24 at 10:19 AM, LPN #11 stated residents that smoked were not allowed to have smoking materials in their room.
During an interview on 6/6/24 at 10:21 AM, CNA #6 stated if a resident were deemed a safe smoker, they could have smoking materials in their rooms.
During an interview on 6/6/24 at 10:23 AM, RN #5 stated residents were not allowed smoking materials in their rooms.
During an interview on 6/6/24 at 10:26 AM, RN #3 stated residents were not allowed smoking materials in their rooms and materials were kept somewhere at the nurses' station.
During an interview on 6/6/24 at 10:28 AM, CNA #7 stated residents who smoked were not allowed smoking materials in their rooms.
During an interview on 6/6/24 at 10:32 AM, the SSD stated he was not sure if residents could have smoking materials in their rooms. He further stated there were lockers outside at the smoking area for residents to keep their smoking materials.
During an interview on 6/6/24 at 2:42 PM, the facility Administrator and DON both stated they were not familiar with the facility's smoking policy due to both being hired recently. They both agreed the facility's smoking policy and resident's care plan should be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, facility Incident Report review, staff interview, and resident and resident representative interview, it was determined the facility failed to ensure adequate supervision and intervention was provided during a resident's transfer to prevent falls. This was true for 1 of 3 residents (Resident #44) reviewed for falls. This resulted in harm to Resident #44 who sustained a hematoma on the right side of her face, eye, and jaw, and chest pain. Findings include:
Resident #44 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including abnormalities of gait and mobility, and contracture (rigidity of muscle or tendons resulting in a fixed deformity of a joint) of muscle to her right upper arm.
An MDS assessment, dated 10/25/23, documented Resident #44 was cognitively intact and required extensive assistance for transfer with the support of two staff.
Resident #44's Care Plan, dated 4/7/23, documented Resident #44 was a fall risk due to impaired mobility, weakness, deconditioning, spinal stenosis, dementia, history of falls, and psychotropic medication use.
A facility Incident Report, dated 1/3/24, documented Resident #44 had a fall the morning of 1/3/24. The report documented the CNA reported to the nurse Resident #44 had her feet at the edge of her bed and while the CNA was getting the wheelchair positioned, Resident #44 started to slide out of bed. The CNA assisted Resident #44 and she fell forward on top of the CNA. The report further documented Resident #44 gave a different description of the fall, reporting she fell to the ground. When the nurse was notified of the fall, a hematoma [collection of blood under the skin] was noted on the right side of Resident #44's forehead. Resident #44's vital signs were obtained and ice was applied to the slightly swollen, bruising area. Initial interventions included the nurse notified Resident #44's spouse of the fall as well as the rounding provider and Resident #44 was sent to the hospital to rule out internal bleeding due to being on anticoagulants [blood thinners]. She returned the same day with no acute findings. Neurological checks were completed with no further findings.
The report documented further interventions included the CNA was provided education on the same day of incident, on timeliness of notifying a Licensed Nurse along with transfer status and following the care plan, although unclear of incident details with investigation. The report documented Resident #44 was healing slowly but had facial bruising due to medication [anticoagulant]. The report further documented Resident #44's pain was at an acceptable pain level at a 5 out of 10 pain scale [0 being no pain and 10 being the worst pain], and tramadol [a narcotic pain medication] helped alleviate the pain.
The hospital Emergency Department notes, dated 1/3/24, documented Resident #44 reported she was being moved by staff at the facility and was dropped hitting her head on the ground. She stated she did not have loss of consciousness but was on blood thinning medication. She also reported pain in the chest wall and described her pain as constant, nonradiating, aching pain, and nothing seemed to alleviate or exacerbate her symptoms.
A CT scan (an imaging test that helps to detect internal injuries and disease) of Resident #44's Maxillofacial region (bones and tissues of the jaw and lower face), dated 1/3/24, documented, Impression: 1. Hematoma in the right frontal scalp. Soft tissue swelling and hemorrhage of the right superficial face involving the periorbital [around the eye] preseptal soft tissues [eyelid], and the soft tissues overlying the right mandibular ramus/right parotid gland [right jaw area]. 2. Pertinent negatives: No fracture of the face or mandible [jawbone]. No globe rupture or retrobulbar hematoma. Normal temporomandibular joints.
During an interview on 6/4/24 at 10:18 AM, Resident #44 stated on the day she fell she remembered a male CNA came into her room, put her on the sit to stand lift, took her to the bathroom, dressed her, and took her back to her bedroom and put her into her wheelchair. Resident #44 stated she remembered being in her wheelchair but does not remember how she got onto her bed, when she fell off her bed onto her face. She stated she did remember the fall.
During a phone interview on 6/4/24 at 3:19 PM, Resident #44's husband stated on the day of the incident it was two to three hours after she had fallen before the fall was mentioned to staff. He stated he entered Resident #44's room around 10:23 AM and saw her eye was swollen and closed. He stated he was worried because his wife takes Eliquis (blood thinner). Resident #44's husband stated she was sent out to the hospital.
During an interview on 6/5/24 at 10:45 AM, LPN #11, who was the unit manager, stated she did not witness the fall, but she was present the day of Resident #44's fall. LPN #11 stated CNA #2 was getting Resident #44 up for breakfast when CNA #2 walked away from Resident #44's bed and she fell. LPN #11 stated CNA #2 put Resident #44 in her wheelchair. CNA #2 brought Resident #44 out of the room with bruising to her face. LPN #11 asked Resident #44 what happened, and she stated she fell off the bed. LPN #11 further stated CNA #2 was terminated from employment at the facility after the incident.
During a phone interview on 6/6/24 at 3:06 PM, LPN #2 stated she remembered Resident #44's incident when she had a fall. LPN #2 stated CNA #2 did not report the fall immediately. LPN #2 stated Resident #44 was up and going into the dining room when she asked her what happened to her face. LPN #2 stated Resident #44's roommate told her what happened, because Resident #44 could not remember. LPN #2 stated she assessed Resident #44, notified the provider and Resident #44's family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review. observation, and resident and staff interview, it was determined the facility failed to ensure a resident's right for self-determination was honored. This was true for 1 of 2 residents (Resident #63) reviewed for choices. This deficient practice had the potential for Resident #63 to experience a decreased sense of well-being, lack of self-worth, and frustration when his preference for bed placement was not accommodated. Findings include:
The facility's Resident Rights policy, undated, documented, Self-Determination: You have the right to self-determination through support of your choice, including the right to: make choices about aspects of your life in the facility that are significant to you.
Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including morbid (severe) obesity, pressure ulcer of the sacral (tailbone) region, spinal disc degeneration, and major depressive disorder.
An MDS assessment, dated 4/9/24, documented was cognitively intact.
During an interview on 6/3/24 at 11:18 AM, Resident #63 stated CNA #1 repositioned her bed without her consent. She stated she asked CNA #1 to turn her bed back up against the wall, and CNA #1 stated she repositioned the bed because it was easier for her to provide care for Resident #63. Resident #63 stated she liked her bed up against the wall because she usually leaned to the right side of her bed, and when lying in the bed in its current position she felt she was going to fall out of the bed. Resident #63 stated she told CNA #3 about CNA #1 repositioning her bed.
During an interview on 6/4/24 at 2:57 PM, LPN #4 stated residents could have their beds positioned how they wanted in their rooms. LPN #1 stated she was unaware of why the bed was repositioned. LPN #1 stated she would have staff reposition the bed back to the way the resident liked it.
During an interview on 6/6/24 at 10:32 AM, the SSD stated a resident had the right to self-determination; it was the staff's responsibility to explain the risk to the resident and family.
During an interview on 6/6/24 at 2:42 PM, the DON stated a resident had a right to make their choices about their life while living in the nursing facility. The DON stated staff did not have the right to move a resident's bed without that resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 14 residents (Resident #7) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of proper foot care. Findings include:
The facility's policy for Nail Care, dated 3/31/18, documented nail care would be provided to promote hygiene, comfort, neatness, wellbeing and prevent injuries and/or infections. Nail care would be provided by nursing personnel, and if the resident had a diagnosis of diabetes a licensed nurse must provide the nail care. Staff were directed to document refusal of nail care.
Resident #7 was readmitted to the facility on [DATE] with multiple diagnoses, including primary osteoarthritis, lack of coordination, weakness, repeated falls, and varicose veins of the lower extremity with ulcer on another part of the lower leg.
Resident #7's quarterly MDS assessment, dated 11/20/18 documented he required extensive assistance of one person with personal hygiene and extensive assistance of two persons with bed mobility.
Resident #7's care plan documented the following:
* He had potential issues with skin integrity related to edema of both legs with a history of venous stasis ulcers. There was a purple hue to the second, third, and fourth toes. The focus area was initiated on 12/8/16 and revised on 2/1/19.
* He had a self care deficit with activities of daily living related to weakness, edema, wounds, and preferring to stay in bed. The focus area was initiated on 12/8/16 and revised on 1/28/19.
On 2/11/19 at 9:47 AM, 2/12/19 at 7:13 AM, and 2/13/19 at 8:14 AM, Resident #7 was in bed and did not respond to verbal stimuli. His toenails on both feet were very long and in poor condition. The skin on his feet was scaling and his feet were discolored with a purple hue.
On 2/13/19 at 8:57 AM, RN #1 said up until about 2 weeks ago Resident #7 would refused everything and it was documented on the MAR he refused cares. RN #1 said a CNA could trim Resident #7's nails.
There was no documentation in Resident #7's clinical record nail care was offered or performed, and no documentation he refused nail care.
On 2/13/19 at 9:10 AM, the CNO said Resident #7 was on the podiatrist list and he could not tolerate getting up, so the facility was trying to find a podiatrist who would come to the facility but was not able to find one.
On 2/13/19 at 1:21 PM, the CNO said said it was not documented the last time Resident #7's nails were trimmed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure residents received respiratory care as ordered by a physician. This was true for 1 of 5 residents (Resident #7) reviewed for oxygen therapy. This failure created the potential for harm if residents did not receive oxygen therapy to maintain adequate oxygen levels. Findings include:
The facility's policy for Oxygen Therapy, dated 11/14/17, documented oxygen was indicated for documented or suspected hypoxia (low oxygen level) and directed staff to verify the physician's order prior to initiating oxygen therapy. Staff were also directed to monitor the resident for tolerating the oxygen, including relief of physical symptoms and improvement of oxygen saturation.
According to the Mayo Clinic website for symptoms of hypoxemia (low oxygen level in the blood), accessed on 2/20/19, normal pulse oximeter readings are usually 95 to 100 percent, and less than 90% is considered low.
Resident #7 was readmitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (stroke) and pulmonary embolism (blood clot that has traveled to the lung) with acute cor pulmonale (dilation of the right side of the heart).
Resident #7's quarterly MDS assessment, dated 11/20/18 documented he received oxygen while a resident.
Resident #7's physician orders, dated 1/31/19, documented the following:
* Monitor oxygen saturation/pulse oximetry every shift, ordered on 9/8/17.
* Oxygen 3 liters per minute per nasal cannula as needed for shortness of breath, use for oxygen saturation less than 92%.
Resident #7's care plan documented he had oxygen as needed and often refused, initiated on 8/25/17 and revised on 2/13/19.
Resident #7's MARs from January and February 2019 documented his oxygen saturation was less than 92 percent on 43 out of 62 opportunities in January 2019 and on 23 out of 25 opportunities in February 2019. The oxygen saturation was not documented by the day shift on 2/2/19. There was no documentation oxygen was administered to Resident #7 or that he refused oxygen on any of the opportunities where his oxygen level was less than 92 percent.
Resident #7 was observed lying in bed in his room on multiple occasions throughout the survey. He was not wearing oxygen and there was no oxygen equipment in his room at any time during the survey.
On 2/13/19 at 8:57 AM, RN #1 said she noticed Resident #7's oxygen saturation was 88 percent a couple times, and she just checked it and it was 91 to 92 percent. RN #1 said Resident #7's oxygen saturation was checked daily, and he thought everything was poison and did not want the oxygen. RN #1 said she did not know whether it was documented Resident #7 refused oxygen.
On 2/13/19 at 9:10 AM, the CNO said she would follow up about Resident #7's oxygen, and she acknowledged the order for oxygen and documentation his oxygen saturation had been less than 92 percent.
On 2/13/19 at 1:21 PM, the CNO said Resident #7's physician was consulted and he said there should never have been an order for oxygen to be administered if the oxygen saturation was less than 92%, but the order should have been for oxygen if there were signs and symptoms of respiratory distress.
Resident #7 did not receive oxygen as ordered by the physician when his oxygen level was less than 92 percent.

Based on policy review, observation, review of the medication refrigerator temperature and maintenance logs, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration, expired biological supplies were removed for resident use, multi-dose vials were dated when opened, and proper refrigerator temperature controls were within range for safe storage. This was true for 2 of 4 medication storage rooms and 2 of 3 refrigerators reviewed for safe storage and labeling medication. This failure created the potential for harm to all residents in the facility should residents receive medications with decreased efficacy, potency and safety. Findings include:
The facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy and procedure, dated 10/31/16, documented:
* Staff were to ensure medications and biologicals having an expiration date on the label were stored separated from other medications until destroyed or returned to the pharmacy or supplier.
* After any medication or biological package was opened, the facility should follow the manufacturer guidelines with respect to expiration dates. Staff should record the date opened on the medication container when the medication had a shortened expiration date after opened.
* Staff were to ensure medications and biologicals were stored at appropriate temperatures according to the Unites States Pharmacopeia guidelines of temperature ranges and monitor the temperature of vaccines twice a day. The refrigerator temperatures should be 36-46 degrees Fahrenheit (F).
The Centers for Disease Control and Prevention website (www.cdc.gov) accessed on 3/14/19, states: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.
On 2/14/19 at 9:00 AM, during medication storage review with the ADON, the following issues were noted:
a. The Tuberculin Vaccine vial in the Unit #3 medication refrigerator was open and dated 1/3/19. The ADON stated the vaccine was opened 1/3/19 and past the 28 day of use, and should be discarded.
b. Five Toothbrush/Suction Kits in the Unit #3 medication storage room had an expiration date of 12/3/18. The ADON stated the kits had expired and should be discarded.
c. The Influenza Vaccine vial in the Unit #5 medication refrigerator was open and not dated. The ADON stated the vaccine was opened, not dated, and should be discarded.
d. The facility's Medication Refrigerator Maintenance policy and procedure, dated 11/28/17, directed staff to review the functionality of medication refrigerators periodically and as needed to ensure acceptable temperature ranges and document corrective actions when applicable. The policy directed staff to implement preventive maintenance protocols when any of the recorded temperatures were outside the acceptable temperature range.
On 2/14/19 at 9:00 AM, during medication storage review, the Unit #3 medication refrigerator/freezer temperature log documented 25 refrigerator temperature entries in January 2019, and 15 refrigerator temperature entries in February 2019, were outside the acceptable temperature range of 36 - 46 degrees F, as noted in the facility's policy. The dates included:
January 2019 -
- 1/5/19 = AM Check 28 degrees F
- 1/6/19 = AM Check 26 degrees F
- 1/14/19 = AM Check 34 degrees F
- 1/15/19 = AM Check 34 degrees F
- 1/16/19 = AM Check 32 degrees F
- 1/17/19 = AM Check 32 degrees F, PM Check 28 degrees F
- 1/18/19 = AM Check 34 degrees F
- 1/19/19 = AM Check 30 degrees F, PM Check 32 degrees F
- 1/20/19 = AM Check 30 degrees F, PM Check 32 degrees F
- 1/21/19 = AM Check 32 degrees F, PM Check 48 degrees F
- 1/22/19 = AM Check 32 degrees F
- 1/23/19 = AM Check 32 degrees F, PM Check 62 degrees F
- 1/24/19 = AM Check 30 degrees F, PM Check 32 degrees F
- 1/26/19 = AM Check 32 degrees F, PM Check 32 degrees F
- 1/25/19 = AM Check 32 degrees F
- 1/29/19 = PM Check 32 degrees F
- 1/30/19 = PM Check 30 degrees F
- 1/31/19 = PM Check 50 degrees F
February 2019 -
- 2/2/19 = PM Check 34 degrees F
- 2/3/19 = PM Check 28 degrees F
- 2/4/19 = AM Check 32 degrees F, PM Check 32 degrees F
- 2/5/19 = AM Check 32 degrees F, PM Check 32 degrees F
- 2/6/19 = PM Check 54 degrees F
- 2/8/19 = PM Check 32 degrees F
- 2/5/19 = AM Check 30 degrees F, PM Check 30 degrees F
- 2/10/19 = AM Check 30 degrees F, PM Check 32 degrees F
- 2/11/19 = AM Check 31 degrees F, PM Check 30 degrees F
- 2/12/19 = PM Check 32 degrees F
The Maintenance Check Medication Room Refrigerator for Unit #3, dated on 1/7/19, 1/14/19, 1/21/19 and 1/28/19, did not document issues with the Unit #3 refrigerator.
On 2/14/19 at 2:45 PM, the CNO stated the nurses documented the medication refrigerator temperatures two times a day at the beginning of each shift when they initially opened the refrigerator. The CNO stated the medication refrigerator was temperamental and when the temperatures were outside the temperature range, they adjusted the temperature to the correct temperature. She said they did not document the adjusted and corrected temperature.

Based on observation, staff interviews, and policy review, it was determined the facility failed to ensure: a) Clean mechanical lift slings were stored on the clean side of the laundry area, b) Staff personal protective equipment was stored on the dirty side of the laundry room, and c) Ventilation in the laundry area did not blow air from the contaminated laundry side to the clean side of the room. These failures created the potential for harm due to the increased the risk of cross contamination, and had the potential to affect all residents in the facility. Findings include:
The facility's policy for Infection Prevention and Control, dated 10/31/17, documented the following:
COMPONENTS:
1. The lnfection Prevention and Control Program include processes to minimize healthcare associated infection through an organization-wide program. These processes include but are not limited to the:
a. As necessary, and at least annually, review and revise the infection control risk assessment.
1) New risks are identified
2) New services have been added,
3) New sites of care have been added,
4) Opportunities for improvement are identified
5) There are emerging or reemerging community healthcare problems
b. Establishing facility wide engineering and work practice to reduce risk of exposure to and transmission of healthcare associated infections.
On 2/14/19 at 10:20 AM, the laundry room was inspected with the Housekeeping and Laundry Manager (HLM). The HLM confirmed the division between dirty and clean was demonstrated by a difference in tile color (the clean side had a light (white/cream tile with a row of red tile, and the dirty side had grayish colored tile). There was no physical barrier separating the clean side from the dirty side. A fan was mounted approximately mid-way up the wall between dirty/clean areas (approximately 6 to 7 feet in height), blowing in an oscillating mode from dirty to clean. This increased the risk for cross contamination due to no barrier to prevent air flow from the dirty area to the area where clean laundry was stored. A rack with mechanical lift slings was mounted on the wall by the washing machine (on the dirty side). The HLM confirmed the slings were clean, but were stored on the dirty side of the laundry room. On the edge of the wall by the handwashing sink, a fire extinguisher hung with a gown and mask hanging over the extinguisher. The HLM confirmed the gown was hanging half on clean side, half on dirty side, and could not be considered clean.
On 2/14/19 at 10:20 AM, the HLM stated all laundry for the facility (including all bed and bath linens) was done in that laundry room.
On 2/15/19 at 12:51 PM, the Administrator stated he was not aware of laundry room issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure: residents were assisted to formulate Advance Directives if necessary, residents' records included documentation of this process, and a copy of the residents' Advance Directives, or documentation of their decision not to formulate Advance Directives, was documented in their clinical record. This was true for 3 of 24 residents (#31, #35, and #44) whose records were reviewed for Advance Directives. These failures increased the residents' risk of not having their decisions honored and respected when unable to make or communicate health care preferences. Findings include:
The facility's policy for Advanced Directives/Health Care Decisions, dated 10/1/17, documented the following:
* Advance Directives include Living Wills and Durable Power of Attorney for Health Care.
* The POST (Physician Orders for Scope of Treatment) is an order from a physician, nurse practitioner, or physician's assistant with instructions that complements an advanced directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders.
* The facility would determine on admission whether the resident had an Advance Directive or other instructions to indicate the resident's wishes.
* If the resident or their legal representative executed an Advanced Directive, the facility obtained a copy upon admission and incorporates and consistently maintains them in the same section of the resident's medical record readily retrievable for any facility staff.
* If the resident had not executed an Advance Directive, the facility advised them of the right to formulate an Advance Directive, offered assistance if the resident wished to execute an Advance Directive, and advised the resident of their option to execute an Advance Directive but did not require the resident to do so.
* The facility documented in the resident's clinical record discussions about Advance Directives and any healthcare decisions executed by the resident.
* If the resident desired to develop an Advanced Directive, a nurse or social worker provided the resident with written information about their right under state law to make decisions about medical care.
* The facility identified, clarified, and reviewed at least quarterly, after a life-altering event, and after returning from hospitalization, the resident's healthcare instructions and whether the resident desired to alter or continue the instructions.
1. Resident #44 was readmitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis (a potentially disabling disease of the brain and spinal cord), muscle weakness, and hypertension (high blood pressure).
Resident #44's admission MDS assessment, dated 12/24/18, documented he had moderate cognitive impairment.
Resident #44's physician orders documented a code status of Full Code was ordered on 12/17/18. Resident #44's POST documented a code status of DNR and was signed by him on 9/29/18.
Resident #44's care plan, initiated on 1/3/19, documented the code status on his POST was DNR.
On 2/12/19 at 9:11 AM, Resident #44's POST documented a code status of DNR and the physician's order documented a conflicting code status of Full Code. There was no Advanced Directive, Living Will, or Durable Power of Attorney found in his clinical record.
On 2/13/19 at 10:56 AM the LSW said she mailed a letter to Resident #44's family to request his Living Will. On 2/13/19 at 1:33 PM, the LSW provided a copy of a letter she sent to families to request a copy of residents' Living Will. The letter was dated 1/30/19 and did not have a resident's name, family member's name, or address. There was no documentation in Resident #44's clinical record the letter was mailed to his family.
On 2/14/19 at 9:04 AM, the LSW said she previously requested Resident #44's Living Will from his family and she did not document it. The LSW said prior to this year (2019) it was not a facility policy for facility staff to request the Living Will from residents on admission.
On 2/15/19 at 9:00 AM, the CNO said Resident #44's code status physician's order was updated to DNR as of 2/12/19, after the facility did an audit and found it did not match the POST.
2. Resident #35 was readmitted to the facility on [DATE] with multiple diagnoses including muscle weakness, Type 2 diabetes mellitus, and hepatic (liver) failure.
Resident #35's quarterly MDS assessment, dated 12/21/18, documented she was cognitively intact.
Resident #35's POST documented her code status was Full Code, and it was signed by her on 1/5/16.
Resident #35's care plan, initiated on 5/10/18 and revised on 1/30/19, documented she had a physician's order for Full Code, and did not wish to have a Power of Attorney,
Resident #35's Progress Notes documented Quarterly Care Conferences were held on 12/9/17, 6/5/18, 9/4/18, and 12/11/18. There was no documentation an Advanced Directive was offered or discussed during the care conferences.
There was no documentation in Resident #35's clinical record of an Advanced Directive.
On 2/14/19 at 9:08 AM, the LSW said she had been talking about Durable Power Of Attorney with Resident #35, and there was no documentation of the discussion. The LSW said there was only a POST in Resident #35's record.
3. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, Type 2 diabetes mellitus, and paroxysmal atrial fibrillation (irregular heart rhythm).
Resident #31's quarterly MDS assessment, dated 12/25/18, documented severe cognitive impairment.
Resident #31's physician orders, documented a code status of Do Not Resuscitate (DNR) was ordered on 4/3/18.
Resident #31's POST documented a code status of DNR, and was signed by her representative on 4/4/18.
Resident #31's clinical record documented a Durable Power of Attorney For Financial Management only.
Resident #31's care plan, initiated on 6/27/18 and revised on 2/6/19, documented she had a code status of DNR on her POST and a copy of Durable Power of Attorney for Health Care/Living Will was requested.
Resident #31's Progress Notes documented Care Conferences were held on 4/5/18, 5/15/18, and 11/20/18. There was no documentation an Advanced Directive was offered or discussed.
There was no documentation in Resident #31's clinical record of an Advanced Directive or Living Will.
On 2/14/19 at 9:09 AM, the LSW said she requested the Living Will and Power of Attorney from Resident #31's son on 1/30/19, and it was documented on the care plan that she requested it.
On 2/15/19 at 10:12 AM, the CNO provided a copy of Resident #31's Power of Attorney, and said it was for financial Power of Attorney only.

Based on policy review, observation, resident and staff interview, and review of the Facility's Assessment, it was determined the facility failed to ensure residents' clothing was appropriately separated by color, washed, sorted, and returned to residents in a timely manner. This was true for 7 of 13 residents (#4, #21, #27, #56, #60, #67, and #71) reviewed for laundry services. This failure placed residents at risk of diminished quality of life and lack of clean and appropriate clothing. The failure also had the potential to place a financial burden on residents if they had to buy new clothes because their clothes were lost or misplaced. Findings include:
The facility's Work Practices - Linen & Laundry policy and procedure, dated 11/28/17, did not address laundry service practices for separating residents' clothes by color, washing clothes, sorting clothes, and returning residents' clothes in a timely manner. The policy also did not include processes to follow when a resident's clothing items were not returned to the resident and were missing.
The Facility Assessment, dated 11/30/18, documented the purpose of the assessment was to determine what resources were necessary to care for residents competently during day-to-day operations. The assessment would help make decisions about direct care staff needs, as well as providing services to the residents in the facility. The assessment for laundry procedures directed staff to handle and keep clean and soiled laundry separate.
The Facility admission Agreement, undated, recommended residents needed four to six complete changes of clothing during their stay at the facility, directed staff to provide quality care for laundry, and to wash personal clothing daily.
a. Resident's voiced the following concerns regarding laundry services:
* On 2/12/19 at 11:05 AM, Resident #4 stated she had not received two pairs of pants and her tank tops back from the laundry for a couple of weeks.
On 2/13/19 at 9:15 AM, Resident #4 stated she had a couple of tank tops and a pair of pants returned to her from the laundry. At 3:30 PM she stated she still had missing items.
* On 2/13/19 at 9:15 AM, Resident #21 stated she was told by housekeeping they were not able to separate her white undergarments with all the clothes. Resident #21 stated housekeeping told her they were not able to wash her sweaters and keep them from bleeding to other clothing, and her daughter would have to wash them. Resident #21 opened her drawers and pointed out her dark gray undergarments. Resident #21 stated since she did not have enough undergarments there were times she had to wear them two or three days in a row because the soiled undergarments had not returned from the laundry.
* On 2/11/19 at 4:26 PM, Resident #67 was observed entering the laundry room and stated to Laundry Staff #2 he was missing two extra-large plaid pants for three days. Laundry Staff #2 told Resident #67 one of the washers had been broken and laundry services were behind. in catching up with Laundry Staff #2 also stated three big bins of clothing were clean and needed to be sorted.
On 2/12/19 at 10:03 AM, Resident #67 stated he had not yet received his pants and he asked staff about it that day. Staff told him they would have to look for them in the bins and had not been able to do so.
b. On 2/13/19 at 11:00 AM, during Resident Council Meeting, the residents stated concerns of missing clothing, clothing not being returned in a timely manner due to the washer being broken for two weeks, and whites and dark items being washed together. The residents' concerns included:
* Resident #27 stated the whites were horrible and she was missing a white top undergarment.
* Resident #56 stated she had been missing two pairs of pants for a while.
* Resident #60 stated Laundry Staff #1 told her the facility could not bleach whites and told her they could not separate whites and colors to be washed because it would take too long to separate the items and get their work done.
* Resident #60 stated she washed her own white undergarments.
* Resident #67 stated he had not received his pants from laundry services.
* Resident #71 stated he was tired of his white undergarments being gray. He also stated he was missing jackets and sweaters for three months to a year. He said staff did not pay attention when they returned laundry to residents and misplaced the items with other residents.
On 2/11/19 at 4:26 PM, Laundry Staff #2 stated the washer had been broken for two weeks and the dryer broke down today, and both were fixed today. She stated the facility tried to catch up with laundry this past weekend and complete the linen and personal laundry for those residents who did not have extra clothing. Laundry Staff #2 stated they were unable to get caught up with all the personal laundry for residents. Laundry Staff #2 also stated housekeeping was short staffed, as there was one person doing laundry and one person in training. She stated she worked on the floor along with other staff who tried to help with the laundry. Laundry Staff #2 stated there were three big bins of clean resident clothing that needed to be sorted and returned to the residents. She also stated residents' personal laundry items were washed together whether they were white or colored clothes.
On 2/12/19 at 2:28 PM, Laundry Staff #2 stated she was not aware of any concerns of residents who needed laundry items separated. Laundry Staff #2 stated residents had been receiving some of their clothes and stated the usual turnaround time for personal laundry was the next day.
On 2/14/19 at 9:30 AM, the CNO stated she did not know there were problems with laundry. The CNO stated the Staff Development Coordinator did not provide competencies for housekeeping staff related to washing clothes. The CNO stated the washer had been broken for two weeks, and the parts were ordered and available to fix the washer.
On 2/15/19 at 8:41 AM, Laundry Staff #1 stated she had been working for the facility and doing laundry the same way for nine years. She stated she received clothes from the CNAs in the bins numbered by floor, tried to keep the clothes together, and stuffed what she could in the washer. Laundry Staff #1 stated she did not separate the white and colored clothes. She stated residents had complained several times about the laundry. Laundry Staff #1 stated she told residents there was nothing she could do because there were not enough staff to separate the laundry. Laundry Staff #1 stated she did let the past administration know of residents' concerns over a year ago and she was told they were working on getting more staff. Laundry Staff #1 stated one washer broke two weeks ago, and after waiting for parts, was finally fixed this week. Laundry Staff #1 stated when residents had clothes missing, she instructed them to complete a grievance form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of grievances, and resident, family, and staff interview, it was determined the facility failed to ensure grievances were responded to, investigated, and prompt corrective action was taken to resolve the grievances. This was true for 1 of 17 residents (Resident #30) reviewed for grievances. This failure created the potential for harm if the resident grievance, both verbal and written, was not acted upon and the resident did not receive appropriate care. Findings include:
The facility's Filing Grievances/Complaints policy and procedure, undated, directed staff to assist residents, their representatives, other interested family members, or advocates in filing grievances or complaints when such requests were made. Concerned persons were encouraged to assist the facility to overcome any shortcomings by calling attention to anything that failed to meet their expectations. The resident, or person filing the grievance and/or complaint on behalf of the resident, would be informed of the findings of the investigation and the actions that would be taken to his or her designee. A written summary of the report would also be provided to the resident, and a copy would be filed in the facility.
1. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses including depression, dementia, contractures, and age-related physical debility.
Resident #30's quarterly MDS assessment, dated 12/21/18, documented her cognition was severely impaired and required extensive assistance with two-person assist with ADLs.
Resident #30's care plan, dated 6/27/18, documented she had an ADL self-care deficit and she required the assistance of two people, and needed encouragement to participate to the fullest extent possible with each interaction. The care plan documented she resisted ADLs and directed staff to reassure her, leave and return, and try again.
Resident #30's ADL flowsheets, dated 1/27/19 from 6:00 AM to 2:00 PM, did not document Resident #30's acceptance, refusal or declination, or staffs' encouragement or offerings of ADLs.
On 2/12/19 at 8:15 AM, Resident #30's daughter was interviewed by phone. She said she had planned a birthday party for Resident #30 on 1/27/19. She said she called ahead to let staff know as she wanted to make sure her mother was up and ready to have a party and celebrate her birthday. Resident #30's daughter stated when she showed up to the facility at 1:30 PM on 1/27/19, her mother was not dressed or groomed, had dirty pants, and had not been provided lunch or water. Resident #30's daughter stated a staff member came to Resident #30's room after she arrived and helped with getting her mother ready. Resident #30's daughter stated she called the facility and filed a grievance with the LSW on 1/28/19. Resident #30's daughter stated the LSW assured her this would not happen again and she would follow up with her regarding the incident. Resident #30's daughter said the facility did not follow up with her related to the incident on 1/27/18.
On 1/28/19, Resident #30's daughter filed a grievance with the facility. The grievance was not available in the grievance binder record. The grievance documented on 1/27/19, Resident #30 was not out of bed until 1:30 PM, was dirty, was not provided with water or lunch, and was in her pajamas. The grievance documented Resident #30's daughter had called ahead because she was having a birthday party for Resident #30.
On 2/13/19 at 9:40 AM, the LSW stated she did not follow up with Resident #30's daughter related to the grievance made on 1/28/19. The LSW stated she assured Resident #30's daughter on the day the grievance was made, the facility would ensure staff provided care and services to Resident #30. The LSW stated the care plan was not updated, but staff met as a group and addressed the incident. The LSW stated she would provide the documentation related to the incident.
On 2/13/19 at 1:30 PM, the LSW stated Resident #30's daughter was not contacted for follow up related to the incident on 1/27/19. The LSW provided the grievance form document and stated there was no other documentation. The LSW stated she did not know why the grievance form was not part of the grievance binder record and stated the CNO said the incident was followed up with the LSW. The LSW stated the facility did follow up with the staff, and they were educated.
On 2/14/19 at 9:30 AM, the CNO stated she did not follow up with Resident #30's family related to the grievance made on 1/28/19, and the issue had been resolved with the LSW the day of the grievance. The CNO stated the facility followed up with staff and provided education. The CNO stated she did not provide a plan to prevent the incident from reoccurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the required documentation was completed and the appropriate information was communicated to the receiving facility when a resident was transferred to the hospital. This was true for 1 of 3 residents (Resident #35) reviewed for transfer to the hospital, and had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information. Findings include:
The facility's policy for Transfer and Discharge, dated 11/28/17, documented the following: Information provided to the receiving facility should include, at a minimum, contact information of the responsible medical practitioner and the resident's representative, Advance Directive information, special instructions and/or precautions for ongoing care, the resident's care plan goals, all information necessary to meet the resident's needs . and additional information as indicated in the transfer agreement. The required information should be communicated as close as possible to the time of transfer.
Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus.
A physician's order, dated 12/19/18 at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because she did not feel well and felt dehydrated.
A Progress Note, dated 12/19/18 at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note also documented the physician was notified and a message was left for Resident #35's family member. There was no documentation of the information that was communicated to the receiving facility or any other information regarding the transfer to the hospital in Resident #35's clinical record.
On 2/14/19 at 10:41 AM, the CNO said she would look for all the required documentation regarding Resident #35's transfer to the hospital.
On 2/15/19 at 9:05 AM, the CNO said there was no transfer form completed for Resident #35's transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure the bed-hold policy was provided to residents. This was true for 2 of 3 residents (#35 and #74) reviewed for transfers to the hospital. This failure created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include:
The facility's policy for Transfer and Discharge, dated [DATE], documented the resident and their family member or representative would be provided written notice of the bed hold policy that identified the duration of the bed hold and criteria for readmission after the bed hold period expired.
The facility's policy for Bed-Hold Readmission, dated [DATE], documented the following:
* The first bed hold notice would be provided well in advance of any transfer .
* The second bed hold notice would be provided to the resident and their representative, if applicable, at the time of transfer, or within 24 hours of transfer in case of an emergency transfer.
* In case of an emergency transfer, the bed hold notice would be provided to the resident or their representative upon transfer and may be included in the papers sent to the hospital with the resident.
* If the facility was unable to notify the resident's representative, they would continue attempts to notify the representative and document the attempts.
1. Resident #74 was admitted to the facility on [DATE] with medical diagnoses that included spina bifida and chronic pain syndrome.
An attempt was made to interview Resident #74 on [DATE] at 3:37 PM and he was in bed and very lethargic, indicating he did not want to talk. On [DATE], at 8:34 AM, Resident #74 was not in his room and a staff nurse stated he was hospitalized on [DATE].
Resident #74's Progress Notes documented the following:
On [DATE] at 5:29 PM: Resident transfer form completed. See form for details.
On [DATE] at 6:45 PM: Resident #74 returned to the facility from being out with family for the weekend. When the nurse administered evening medications at approximately 4:30 PM, Resident #74 was difficult to arouse, had slurred speech, bloodshot eyes, and abnormal vital signs. Resident #74's blood pressure was 85/52 (normal blood pressure is 120/80) and respirations were 10 (normal respirations are 16 to 20 per minute). The CNA also noted red colored urine in the Foley catheter bag. The medical practitioner was notified and ordered to transfer Resident #74 out. He was sent by non-emergent transport to the hospital for further evaluation at approximately 6:30 PM. The nurse called Resident #74's sister and left a message.
On [DATE] at 6:45 AM: Resident #74 was admitted to the hospital.
Resident #74's clinical record did not document he and his resident representative were provided a bed hold notice when he was transferred to the hospital on [DATE].
On [DATE] at 9:45 AM, the CNO stated the provided packet of papers was the same packet sent to the hospital with Resident #74, and no bed hold policy was included or provided to Resident #74 and/or his representative.
2. Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus.
A physician's order, dated [DATE] at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because she did not feel well and felt dehydrated.
A Progress Note, dated [DATE] at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note also documented the physician was notified and a message was left for Resident #35's family member. There was no documentation in Resident #35's clinical record she and/or her family member was provided bed-hold policy information when she was transfer to the hospital.
On [DATE] at 9:05 AM, the CNO said there was no notice of the bed-hold policy being provided to Resident #35 or her family member when she was transferred to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interviews, it was determined the facility failed to ensure there was documented evidence for 3 of 3 residents (#35, #45, and #74) reviewed for hospital transfers, that the resident, and/or the resident's representative, was provided a written transfer notice when the resident was transferred to the hospital. This failure created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers. Findings include:
The facility's Transfer and Discharge policy, dated 11/28/17 documented:
* For residents who are discharged or transferred, the resident and, if known, the family member, surrogate or legal representative, are notified at least 30 days prior to the transfer, unless the transfer is effected when:
- There is endangerment to the health or safety of others in the facility
- The resident has urgent medical needs requiring more immediate transfer
- For exceptions to the 30-day notice rule, notice is given as soon as practicable.
* The written notice of transfer/discharge includes:
- Reason for transfer/discharge
- Effective date of transfer/discharge
- Location to which the resident is transferred/discharged
- Statement that the resident has the right to appeal the action to the state
- Name, address, and telephone number of the state long term care ombudsman
- As applicable, mailing address and telephone number of the agency responsible for
protection and advocacy of developmentally disabled or mentally ill individuals
1. Resident #74 was admitted to the facility on [DATE] with medical diagnoses that included spina bifida (a birth defect where the bones in the vertebral column do not fully cover the spinal cord, leaving it exposed) and chronic pain syndrome.
An attempt was made to interview Resident #74 on 2/11/19 at 3:37 PM and he was in bed and very lethargic, indicating he did not want to talk. On 2/12/19, at 8:34 AM, Resident #74 was not in his room and a staff nurse stated he was hospitalized on [DATE].
Resident #74's Progress Notes documented the following:
On 2/11/19 at 5:29 PM: Resident transfer form completed. See form for details.
On 2/11/19 at 6:45 PM: Resident #74 returned to the facility from being out with family for the weekend. When the nurse administered evening medications at approximately 4:30 PM, Resident #74 was difficult to arouse, had slurred speech, bloodshot eyes, and abnormal vital signs. Resident #74's blood pressure was 85/52 (normal blood pressure is 120/80) and respirations were 10 (normal respirations are 16 to 20 per minute). The CNA also noted red colored urine in the Foley catheter bag. The medical practitioner was notified and ordered to transfer Resident #74 to the hospital. He was sent by non-emergent transport to the hospital for further evaluation at approximately 6:30 PM on 2/11/19. The nurse called Resident #74's sister and left a message.
On 2/12/19 at 6:45 AM: Resident #74 was admitted to the hospital.
Resident #74's clinical record did not document he and his representative were provided a written transfer notice identifying the reason he was transferred to the hospital on 2/11/19.
On 2/15/19 at 9:45 AM, the CNO stated the provided packet of papers was the packet sent to the hospital with Resident #74 and no written transfer notice was provided to him or his representative.
2. Resident #45 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (obstruction of lung airflow that interferes with normal breathing) and cardiac arrhythmia (irregular heart rhythm).
Resident #45's Progress Notes, dated 1/14/19 at 7:01 AM, documented the Resident #45 was found very lethargic, pale, and clammy and was difficult to arouse. The note also documented Resident #45 had a breathing treatment earlier without much effect. The note documented Resident #45's oxygen saturation was 88-89% on 3 liters of oxygen and the physician was called. The note documented a physician order was received to send Resident #45 to the ER for treatment and evaluation. The note also documented the daughter of Resident #45 was informed of his change in condition.
Resident #45's clinical record did not document he and/or his representative were provided a written transfer notice identifying the reason Resident #45 was transferred to the hospital on 1/14/19.
On 2/15/19 at 9:40 AM, the CNO stated there was no written transfer notice provided to Resident #45 and/or his representative.
On 2/15/19 at 4:10 PM, LPN #3 stated when a resident was being transferred from the facility, she would tell the resident about their change of condition, talked about choice of hospitals, and clarified who the resident wanted to be called, but there was nothing in writing.
3. Resident #35 was readmitted to the facility on [DATE], with multiple diagnoses including Type 2 diabetes mellitus.
A physician's order, dated 12/19/18 at 12:35 PM, documented to send Resident #35 to the ER for evaluation and treatment because Resident #35 felt dehydrated and did not feel well.
A Progress Note, dated 12/19/18 at 3:42 PM, documented Resident #35 was transferred to the hospital due to increased confusion, not feeling well, and she thought she was dehydrated. The note also documented Resident #35's vital signs were not within normal parameters. The note documented the physician was notified and a message was left for Resident #35's family member on her cell phone. There was no documentation of written notification being provided to Resident #35 or her representative regarding her transfer to the hospital on [DATE].
On 2/14/19 at 10:41 AM, the CNO said she would look for all the required documentation regarding Resident #35's transfer to the hospital.
On 2/15/19 at 9:05 AM, the CNO said there was no written notice of transfer provided to Resident
#35 or her representative regarding her transfer to the hospital on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were updated to maintain consistency and accuracy. This was true for 1 of 18 residents (Resident #31) whose care plans were reviewed. This failure created the potential for harm if cares and/or services were not provided due to inaccurate information on the care plan. Findings include:
The facility's policy for Care Plans, dated 11/28/17, documented the following:
* A team of qualified individuals monitors the resident's condition and the effectiveness of the care plan. The team revises the care plan quarterly, annually, with significant change assessments, or more frequently as needed.
* The care plan is reviewed following each assessment, except discharge assessments, and is revised according to the resident's changing goals, preferences, and needs.
Resident #31 was admitted to the facility on [DATE] with multiple diagnoses, including chronic obstructive pulmonary disease and obstructive sleep apnea.
Resident #31's physician orders, dated 2/14/18, documented the following:
* CPAP (Continuous Positive Airway Pressure) at 15 cm water on room air with humidification. Start at bedtime, off in AM, ordered on 8/30/18.
* CPAP Machine Daily Care, ordered on 8/31/18.
* CPAP Machine Non-Disposable Tubing Care, ordered on 8/31/18.
* CPAP Machine Weekly Care, ordered on 8/31/18.
* CPAP/BiPap (Bilevel Positive Airway Pressure): Check skin under the mask for skin integrity with applying and removing the mask. Notify the physician as needed, twice a day, ordered on 8/31/18.
Resident #31's current care plan did not document the use of CPAP or orders related to the CPAP machine.
Resident #31's January 2019 and February 2019 MAR documented the CPAP and CPAP care was administered each day and each week as ordered.
Resident #31's Progress Note, dated 1/23/19 at 10:01 AM, documented CPAP machine daily care was completed.
On 2/14/19 at 2:58 PM, the CNO said Resident #31's CPAP was not documented on her care plan and it needed to be on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of Incident and Accident Reports, and staff interviews, it was determined the facility failed to ensure professional standards of practice for completion of neurological assessments after a fall, medications were administered to residents prior to being documented as given, and pain medications were administered timely. This was true for 1 of 18 residents (Resident #31) reviewed for quality of care and 2 of 23 residents (#60 and #61) reviewed for medications. This failure placed residents at risk of a) adverse outcomes if medications were administered when contraindicated, b) increased pain due to delays in administering pain medication, and c) undetected neurological changes after falls. Findings include:
The facility's General Dose Preparation and Medication Administration policy, dated [DATE], directed staff to verify each time a medication was administered it was the correct medication, the correct dose, the correct route, the correct rate, the correct time, and for the correct resident. The policy also directed staff to document necessary medication administration/treatment information, such as when medications were given on appropriate forms.
The facility's Medication Management policy and procedure, dated [DATE], directed staff to develop policy, procedures and clinical practice guidelines to manage medications so they were safely provided and administered to residents. The policy documented authorized staff who administer medications were responsible for staying proficient in administering medication following evidenced-based practice guidelines.
1. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, congestive heart failure, anxiety, depression, diabetes mellitus type 2, generalized muscle weakness, and difficulty walking.
Resident #60's quarterly MDS assessment, dated [DATE], documented she was cognitively intact.
Resident #60's care plan, dated [DATE] and [DATE], documented she had impaired visual function related to dry eyes and directed staff to administer ophthalmic medication as ordered. The care plan also documented she had altered cardiovascular status related to hypertension and directed staff to administer medications as ordered.
a. A physician's order for Resident #60, dated [DATE], documented to instill Olopatadine hydrochloric acid solution 0.7%, instill one drop in both eyes one time a day for dry eyes
On [DATE] at 11:10 AM, during medication administration, LPN #1 asked Resident #60 if she had received her eyedrops in the morning. Resident #60 stated she had received her eyedrops that morning. LPN #1 documented Resident #60 was administered her eyedrops. LPN #1 stated she did not administer eyedrops to Resident #60. LPN #1 stated she trusted what the resident had said about receiving her eyedrops and documented the eyedrops were given by the morning nurse. LPN #1 stated she should not have documented the administration of the eyedrops.
b. A physician's order dated [DATE], documented to administer Hydralazine hydrochloric acid to Resident #60, one 10 mg tablet by mouth every 8 hours for hypertension. The order directed staff to hold the medication if SBP was less than 120.
Resident #60's MAR, documented Hydralazine medication was administered when her SBP was less than 120, on the following dates:
On [DATE] at 9:00 PM, SBP was 99
On [DATE] at 9:00 PM, SBP was 90
On [DATE] at 5:00 AM, SBP was 112
On [DATE] at 9:00 PM, SBP was 97
On [DATE] at 9:00 PM, SBP was 93
On [DATE] at 1:00, SBP was 96
On [DATE] at 9:00 PM, SBP was 117
On [DATE] at 11:51 AM, the CNO stated the February 2019 MAR documented Resident #60 was administered Hydralazine several times when her SBP was less than 120. The CNO stated she interviewed the nurses who administered the medication and they stated they did not administer the medication when Resident #60's SBP was less than 120 and the documentation was in error. The CNO stated the documentation errors were due to medications being documented as given before Resident #60's blood pressure was assessed. The CNO said the medication was then wasted when Resident #60's SPB was found to be less than 120.
2. Resident #61 was admitted to the facility on [DATE] and was readmitted on [DATE] with medical diagnoses that included multiple sclerosis (a potentially disabling disease of the brain and spinal cord), Type 2 diabetes mellitus, chronic pain syndrome, and low back pain.
On [DATE] at 8:26 AM, Resident #61 stated It would be nice to get my pain medications on time instead of an hour or two hours late. She stated that even with her pain medication her pain level was a 7 to 8 (out of 10). Review of Resident #61's pain assessments documented she consistently rated her pain at 7 to 8 on a scale of 1 to 10.
Resident #61's care plan documented she had acute/chronic pain related to arthritis, chronic back pain, history breast cancer, wounds, multiple sclerosis, history of cerebral vascular accident (stroke), and chronic pain syndrome. She often reported pain at a high level due to chronic pain. Staff were directed to administer medications as ordered, and monitor for effectiveness and side effects.
Resident #61's MAR, dated February 2019, documented an order for an Oxycontin Tablet extended release 30 mg be given two times a day for chronic pain, ordered on [DATE]. The medication administration times were scheduled at 8:00 AM and 8:00 PM.
Resident #61's MARs were requested with the documented times of her pain medications. The facility was not able to provide Resident #61's MARs. The facility provided the Narcotic Sign-out sheets for [DATE] through February 13, 2019. A review of the narcotic logs documented the following doses were signed out over an hour late from the scheduled administration time at 8:00 PM as follows:
[DATE] at 9:16 PM
[DATE] at 9:02 PM
[DATE] at 9:24 PM
[DATE] at 9:22 PM
[DATE] at 9:08 PM
[DATE] at 9:10 PM
[DATE] at 9:51 PM
[DATE] at 9:23 PM
On [DATE] at 9:20 AM, Resident #61 stated she was still waiting for her 8:00 AM dose of pain medication.
On [DATE] at 9:28 AM, LPN #3 stated she was getting a dose of pain medication for [a different resident name], who was getting a dressing change. LPN #3 noted the time on the electronic medical record MAR was 9:21 AM and said she was going to Resident #61 next.
On [DATE] at 2:12 PM, the CNO stated the expectation was medications would be administered within one hour before to one hour after the scheduled administration time.
3. The facility's policy for Fall Response and Management, dated [DATE], documented neurological assessments should be done after an unwitnessed fall per the physician's order, or monitor every 15 minutes for one hour, every 30 minutes for one hour, then every hour for two hours or until the condition stabilizes. The resident's condition should be monitored for at least 72 hours after the fall.
The website http://www.hcpro.com/LTC-287387-10704/Neurological-checks-for-head-injuries.html, accessed [DATE], documented the following:
* Neurological assessments include (at a minimum) pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; and equality of hand grip strength.
* Neurological assessments should be performed every 15 minutes for two hours, every 30 minutes for two hours, every hour for four hours, every eight hours for 16 hours, and every eight hours for at least 72 hours and until the resident is stable.
Resident #31 was admitted to the facility on [DATE] with multiple diagnoses, including dementia left leg amputation below the knee, muscle wasting and atrophy, and generalized muscle weakness.
Resident #31's quarterly MDS assessment, dated [DATE], documented she had severe cognitive impairment.
Resident #31's care plan documented she was at risk for falls due to deconditioning and directed staff to follow the facility's fall protocol, initiated on [DATE].
Resident #31's Progress Note, dated [DATE] at 11:02 PM, documented she was found sitting on the floor next to her bed. She attempted to self-transfer from bed to her wheelchair and fell onto her buttocks. The note documented the nurse assessed Resident #31 and would continue to monitor her.
An Incident and Accident Report, dated [DATE] at 8:40 PM, documented Resident #31 was found on the floor next to her bed, and she was attempting to self-transfer from bed to her wheelchair.
A Post Fall Investigation, dated [DATE] at 11:14 PM, documented Resident #31 had an unwitnessed fall on [DATE] at 8:30 PM. She was found in her room sitting on the floor next to her wheelchair.
A Neurological Record documented Resident #31's eye opening, level of alertness, speech, and extremity movement were assessed on [DATE] at 8:30 AM and 12:30 PM, and on [DATE] at 12:30 AM. Her vital signs were documented on [DATE] at 10:00 PM, 10:30 PM, and 11:30 PM, on [DATE] at 12:30 AM, 4:30 AM, 8:30 AM, and 12:30 PM, and on [DATE] at 12:30 AM. A second page of the Neurological Record documented another resident's name that was crossed out and Resident #31's name was written in, and it documented her vital signs and neurological checks were completed at 15 minute intervals three different times, but there was no documented date or time.
On [DATE] at 2:55 PM, the CNO said neurological checks should be done after any unwitnessed fall or when the resident hits their head. The CNO said the neurological checks were not completed appropriately for Resident #31.
On [DATE] at 9:26 AM, LPN #5 said neurological checks should be performed anytime it was known the resident hit their head and anytime there was an unwitnessed fall. LPN #5 said she would have to look it up to see the required intervals and length of time neurological checks should be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and record review, it was determined the facility failed to consistently follow physician orders for treatment of a pressure ulcer for 1 of 3 residents (Resident #44) reviewed for pressure ulcers. The failure created the potential for Resident #44 to experience delayed healing, or further deterioration, of a Stage 4 pressure ulcer, and/or develop additional pressure ulcers. Findings include:
The facility's policy for Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, dated 11/28/17, documented basic or routine care to prevent pressure ulcers could include redistributing pressure, such as repositioning.
The Lippincott Manual of Nursing Practice, tenth edition, documented measures to prevent pressure ulcers include repositioning every 2 hours.
Resident #44 was readmitted to the facility on [DATE] with multiple diagnoses, including Multiple Sclerosis (a potentially disabling disease of the brain and spinal cord), muscle weakness, postprocedural wound closure, disruption of external surgical wound, and Stage 4 pressure ulcer of the sacral region (low back/upper buttock area).
Resident #44's MDS assessment, dated 12/24/18, documented the following:
* One unhealed Stage 4 Pressure ulcer.
* He required extensive assistance for bed mobility and transfers.
Resident #44's physician orders, dated 2/15/19, documented the following:
* Ordered on 12/17/18: Avoid supine (lying on back) position. Position side to side using pillows and wedges. Bed flat. May elevate head of bed up to 30 degrees for meals and for 30 minutes after meals.
* Ordered on 1/15/19: Bedrest with offloading by turning side to side until further evaluation by [a named physician].
* Ordered on 2/12/19: Dressing change twice a week and as needed, with wound vacuum on continuously to Resident #44's sacrum.
Resident #44's care plan directed staff to follow the facility's protocols for treatment of his skin injury, initiated on 8/14/18, and to turn and reposition him every 2 hours, initiated on 2/13/19.
On 2/12/19 at 7:54 AM, Resident #44 was observed lying in bed on his back. LPN #4 said Resident #44 had a pressure ulcer on his sacrum.
On 2/12/19 at 8:45 AM, RN #2 was observed performing a dressing change to Resident #44's sacral wound. The pressure ulcer measured 2.5 cm by 4 cm. LPN #6, also present, said Resident #44 came from the hospital with the pressure ulcer, and he had a wound flap (a flap is a unit of tissue that can be moved to cover a wound while surviving on its own blood source) placed in November 2018 and it failed.
Resident #44 was observed lying in bed on his back on 2/13/19 at 11:47 AM, 2:32 PM, and 3:59 PM, and on 2/14/19 at 2:17 PM.
On 2/13/19 at 11:53 AM, LPN #4 said Resident #44's position was to be alternated from his right side and left side, unless the order changed it when the wound vacuum was resumed. LPN #4 said Resident #44 was not to be positioned on his back.