Fletcher Rehabilitation And Healthcare Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and resident, and staff interviews, the facility failed to provide setup assistance with oral hygiene for 1 of 3 residents reviewed for activities of daily living (Resident #1). Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including thoracic vertebrae fractures (T1 through T6) with routine healing and diabetes mellitus. Review of the Kardex (a care plan reference guide) utilized by Nurse Aide (NA) staff specified Resident #1's routine oral care included brush teeth, rinse dentures, clean gums and rinse with mouthwash. The activities of daily living care plan revised on 1/9/26 revealed Resident #1 had a self-care performance deficit related to thoracic vertebrae fractures, weakness, and pain. Interventions included provide partial to moderate set up assistance with oral care. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1's cognition was intact, his upper extremity range of motion was impaired on both sides, and he needed setup or clean-up assistance with oral hygiene. An observation and interview with Resident #1 was conducted on 3/24/26 at 12:38 PM. Resident #1 revealed he had an upper denture and his own lower teeth and stated he could not recall the last time he was provided setup assistance for oral care. Resident #1 showed his upper denture had a buildup of a white colored substance on the gums and teeth. Resident #1 revealed he could brush his upper denture and lower teeth if given a toothbrush and toothpaste but did not know if he had a denture cup. There was no denture cup observed in Resident #1's bathroom or room. An interview with NA #1 was conducted on 3/25/26 at 8:50 AM. NA #1 confirmed she was assigned to provide care for Resident #1 on 3/24/26 and 3/25/26 on day shift. When asked if oral hygiene was provided for Resident #1, NA #1 stated Resident #1 had his own teeth he could brush, and she provided setup assistance for oral hygiene. NA #1 explained for setup assistance she sat Resident #1 up in the bed or in the wheelchair and gave him a toothbrush and toothpaste for him to perform oral hygiene. NA #1 stated to her knowledge Resident #1 did not have an upper denture and there was no denture cup in his room to indicate he did. NA #1 did not state she provide Resident #1 setup assistance with oral hygiene on 3/24/26 or 3/25/26 during her shift. During an observation on 3/25/26 at 11:48 AM, there was no change in the appearance of Resident #1's upper denture that continued to have a buildup of a white colored substance on the gums and teeth. An interview and observation with the Director of Nursing (DON) was conducted on 3/25/26 at 11:48 AM. The DON observed Resident #1 had an upper denture. Resident #1 removed his upper denture to show that it continued to have a buildup of a white colored substance around the gums and teeth. The DON stated oral hygiene included brushing teeth and dentures and was done daily. She revealed a denture cup should have been provided for Resident #1 to soak his upper denture overnight and confirmed Resident #1 did have a toothbrush but there was no denture cup in the room or bathroom. During an interview on 3/25/26 at 3:58 PM, the Administrator stated she expected NA staff to review the Kardex that specified if a resident had dentures and that oral hygiene was offered daily. The Administrator stated oral hygiene was done daily and she expected NA #1 to be aware Resident #1 had an upper denture and his own lower teeth and setup assistance for oral hygiene was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to safely transfer a dependent resident from the bed to the reclining wheelchair using a mechanical lift which resulted in an avoidable injury for 1 of 3 residents reviewed for accidents (Resident #1). On 11/18/25 around 6:30 AM, Nurse Aide #1 independently transferred Resident #1 to the reclining wheelchair and was unhooking the sling straps when the mechanical lift tilted and the sling bar of the mechanical lift hit Resident #1 above the left eyebrow causing a laceration. Resident #1 was sent to the Emergency Department for evaluation, a Computed Tomography (CT, detailed x-ray imaging of the inside of the head) revealed no negative findings, the laceration was repaired with sutures and Resident #1 returned to the facility the same day (11/18/25).Findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury (TBI, injury to the brain caused by an external force), abnormal posture, and contracture of muscles-multiple sites.The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severely impaired cognitive skills for daily decision making. He had impairment on both sides of the upper and lower extremities and was totally dependent on staff for self-care, transfers and ambulation.An Activity of Daily Living (ADL) care plan, last revised 09/12/25, revealed Resident #1 had an ADL self-care performance deficit related to TBI and contractures. Included was an intervention that noted Resident #1 required a mechanical lift and 2-person assistance for all transfers. Review of Resident #1's electronic health record revealed Resident #1 was not prescribed an anticoagulant. A nurse progress note dated 11/18/25 at 6:33 AM written by Nurse #1 revealed Resident #1 sustained a laceration above the left eye after bumping it on the mechanical lift during a transfer.A second nurse progress note dated 11/18/25 at 7:40 AM written by Nurse #1 revealed Resident #1 was sent to the Emergency Department (ED) via Emergency Medical Services (EMS) transport.During a phone interview on 12/12/25 at 11:12 AM, Nurse Aide (NA) #1 revealed she was no longer employed at the facility and confirmed she was assigned to provide Resident #1's care on 11/17/25 to 11/18/25 during the hours of 7:00 PM to 7:00 AM. NA #1 confirmed she had transferred Resident #1 from his bed to the wheelchair using a mechanical lift without additional staff assistance on 11/18/25. NA #1 explained as she was getting Resident #1 ready for the day toward the end of her shift, she independently used the mechanical lift to transfer Resident #1 from the bed and lowered him down inside the reclining wheelchair. NA #1 recalled as she was unhooking the sling straps, the mechanical lift tilted and the sling bar of the mechanical lift hit Resident #1 in the face. NA #1 stated at first, she thought Resident #1 was ok, she finished unhooking the straps and then noticed that he was bleeding. NA #1 stated she then went and informed Agency Nurse #2 what had happened. NA #1 stated they had been instructed to always have 2-person assistance when using a mechanical lift and prior to transferring Resident #1, she had reached out to other staff to see if anyone was available to help but no one was. NA #1 stated she knew she shouldn't have transferred Resident #1 on her own but at the time thought that she could do it without additional staff assistance.During a phone interview on 12/12/25 at 11:28 AM, Agency Nurse #2 revealed she had worked during the hours of 7:00 PM to 7:00 AM on 11/17/25 to 11/18/25 but was not assigned to provide care to Resident #1. Agency Nurse #2 recalled it was a hectic morning on 11/18/25 when NA #1 came to inform her that Resident #1 had gotten hit with the sling bar of the mechanical lift during a transfer. Agency Nurse #2 stated she could not recall all the details that NA #1 had told her about what happened but did remember NA #1 stating she had transferred Resident #1 on her own using a mechanical lift without additional staff assistance. Agency Nurse #2 recalled when she and Agency Nurse #1 assessed Resident #1's injury, the laceration above the left eyebrow was open and they both felt he would need stitches to repair. Agency Nurse #2 stated upon assessment Resident #1 seemed to be at his normal baseline, smiling and not displaying any indicators of pain. During a phone interview on 12/11/25 at 2:50 PM, Agency Nurse #1 confirmed she was Resident #1's assigned nurse from 11/17/25 to 11/18/25 during the hours of 7:00 PM to 7:00 AM but did not witness the incident. Agency Nurse #1 stated from what she could recall, she was told by NA #1 that sometime between 6:30 AM and 7:00 AM, as NA #1 was transferring Resident #1 from the bed to the reclining wheelchair, the sling bar of the mechanical lift hit Resident #1 in the face. Agency Nurse #1 stated when she got to the room to assess Resident #1, he had a laceration above his left eyebrow. She stated the bleeding was mostly controlled at that point and she applied first aid. Agency Nurse #1 stated the laceration was open and she immediately knew that Resident #1 would need to go the hospital for stitches to repair the laceration. Agency Nurse #1 stated when she assessed Resident #1, he was smiling, appeared at his normal baseline and did not display any indicators of pain. Agency Nurse #1 explained both she and NA #1 knew that transfers using a mechanical lift required 2-person assistance and when she asked NA #1 why she did not ask her or another staff member to assist with the transfer, NA #1 never gave her a reason. Agency Nurse #1 stated Resident #1 was sent out to the hospital for treatment, and the laceration was repaired with stitches but could not recall how many. She stated when Resident #1 returned back to the facility later that same day (11/18/25) he was still at his normal baseline. A Hospital ED After Visit Summary note dated 11/18/25 for Resident #1 revealed Resident #1 was seen for evaluation and treatment of a facial laceration. The note indicated a head CT was obtained and looked good (no negative findings). The laceration was repaired with sutures and Resident #1 was sent back to the facility with orders for an antibiotic ointment to be applied twice a day for seven (7) days and to keep the laceration covered, clean and dry. Review of Resident #1's November 2025 treatment administration record revealed a physician order dated 11/18/25 to apply bacitracin ointment (topical antibiotic used to prevent infection in minor skin injuries) 500 unit/grams to the left upper eyebrow every shift for 7 days. The treatment was started on 11/18/25 during the evening shift (7:00 PM to 7:00 AM) and completed on 11/25/25 during the day shift (7:00 AM to 7:00 PM). Treatments were initialed each shift as completed per the physician order except for 11/19/25 during the day shift and 11/20/25 during the evening shift.During an observation on 12/11/25 at 9:21 AM, Resident #1 was lying in bed in fetal position with noticeable bilateral hand contractures. Resident #1 was alert and smiled when greeted but provided no response other than repetitive verbalizations. He had a thin, red healing scar above the left eyebrow that was approximately 2 to 2.5 inches in length with no signs of infection or bruising noted. Resident #1 displayed no signs of discomfort or pain.During an interview on 12/12/25 at 3:05 PM, the Director of Nursing (DON) stated she was informed by a nurse working the morning of 11/18/25 that Resident #1 was being sent out to the ED due to a facial laceration, but the nurse had not witnessed what had happened. The DON stated the laceration above Resident #1's left eyebrow was repaired while at the ED with approximately 4 or 5 stitches and he returned to the facility that afternoon (11/18/25). The DON stated when she and the Administrator spoke with NA #1 about what happened, NA #1 admitted to transferring Resident #1 independently using a mechanical lift and NA #1 explained during the transfer, the mechanical lift tilted causing the sling bar to hit Resident #1 in the face. The DON stated NA #1 was immediately suspended and subsequently terminated due to not following the facility's policy which required 2-person assistance with mechanical lift transfers. The DON stated it was an unfortunate but avoidable accident as NA #1 had received previous training on mechanical lifts but just made the bad decision not to follow the facility policy. The DON stated an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held to discuss the incident, and a decision was made to develop and implement a corrective action plan on 11/18/25. During interviews on 12/12/25 at 1:02 PM and 3:30 PM, the Administrator confirmed she was notified via the facility group nurse chat (messaging system) of the transfer incident on 11/18/25 involving Resident #1. The Administrator stated when interviewed, NA #1 admitted she had transferred Resident #1 using a mechanical lift without additional staff assistance. She recalled NA #1 explained that when lowering Resident #1 into the reclining wheelchair, the sling bar swung and hit Resident #1 in the face causing a laceration that required stitches to be repaired. The Administrator stated NA #1 informed the nurse right away and recalled NA #1 felt very remorseful about the incident. The Administrator verified that NA #1 had received training, along with other nursing staff, back in April 2025 regarding the facility's policy on safe transfers using a mechanical lift that required 2-person assistance. The Administrator stated she felt it was an unfortunate accident. She explained although NA #1 was a good NA, she made a bad decision not to follow facility policy by transferring Resident #1 independently with the mechanical lift and that was why the decision was made to terminate NA #1's employment. The Administrator verified on 11/18/25 they held an Ad Hoc QAPI meeting to discuss the incident and the decision was made to implement an internal plan of correction that included staff re-education, audits and monitoring with no further concerns identified. The facility provided the following Corrective Action Plan with a completion date of 11/20/25:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 11/18/25, Nursing Aide (NA) #1 transferred Resident #1 independently, not following the facility policy. During transfer the lift tilted, causing the arm to hit Resident #1 in the left eye which caused a laceration head injury during transfer. Resident #1 was assessed by the nurse and transferred to the hospital for higher level of care. Nursing Aide (NA) #1 was re-educated by the Director of Nursing on the facility mechanical lift policy and safe lifting policy on 11/18/25. NA #1's employment was terminated on 11/21/25.Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents using mechanical lifts have the potential to be affected. This was determined utilizing the transfer evaluation/therapy recommendations. Transfer evaluation assessments were reviewed in the individual electronic medical record for each resident to ensure mechanical lifts status were updated and correct. Therapy recommendations were reviewed for each resident to ensure transfer evaluation and therapy recommendations were updated and correct. No concerns were identified. Audits were completed on 11/18/2025 by the Director of Nursing.The Director of Nursing/Designee completed skin assessments on all residents that required mechanical lifts. No concerns were identified. Audits were completed on 11/18/2025.Residents that use mechanical lifts with a Brief Interview for Mental Status (BIMs) score of 13 or higher were interviewed by the Social Service Director to ensure they did not have any concerns with use of mechanical lift. No concerns were identified. Audits were completed on 11/18/25. The Regional Clinical Director reviewed all incident reports for the last 30 days to ensure there were no issues with transfers using mechanical lifts. No concerns were identified. This audit was completed on 11/19/2025.Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 11/18/25, the Director of Nursing or Designee educated all nursing staff, including agency staff on the facility mechanical lift policy and safe lifting policy with emphasis on ensuring 2 staff were present with all lift transfers. All Nursing Staff including Licensed Nurses and Nursing Aide (NA) will perform mechanical lift use competency prior to the start of their shift which will be completed by the Director of Nursing/Nursing Administration. This education was completed on 11/18/25. This education will be added to the facility orientation program for all newly hired nursing staff, including new agency staff and will be the responsibility of the Director of Nursing. An ADHOC Quality Assurance Performance Improvement Committee Meeting was held on 11/18/2025 to discuss, review and approve the plan that had been initiated and implemented by the Director of Nursing on 11/18/2025. The Quality Assurance Performance Improvement Committee also reviewed the policy and procedure for mechanical Lift and Safe Lifting Policy. The decision to monitor the plan was also decided during the Quality Assurance Performance Improvement Committee meeting on 11/18/2025. Root Cause Analysis was completed and determined that the Nurse Aide failed to follow the facility policy and procedure for mechanical Lift use.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. To monitor and maintain ongoing compliance, the Director of Nursing or designee will observe 2 lift transfers randomly on all shifts weekly for 8 weeks to ensure proper use of mechanical lift and to ensure that 2 staff members are present. The Director of Nursing or designee will interview 3 residents with a Brief Interview for Mental Status (BIMs) of 13 or higher on lift use weekly for 8 weeks. The Director of Nursing or designee will randomly interview 4 staff members on all shifts weekly for 8 weeks. These audits will be completed by January 27, 2026. The DON or designee will be responsible for reporting results of these audits to the facility's monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of these audits. Compliance Date: 11/20/2025. The Corrective Action plan was validated on 12/12/25 and concluded the facility had implemented an acceptable corrective action plan on 11/20/25. Alert and oriented residents who required a mechanical lift for transfers were interviewed and confirmed there were 2-staff present when utilizing the mechanical lift. Nursing staff interviewed on all shifts confirmed receipt of education on the facility's mechanical lift policy that included performing a return demonstration. Nursing staff were able to verbalize how to prepare for and perform a safe transfer using a mechanical lift and that all mechanical lift transfers required 2-person assistance. Staff also verbalized they would wait for someone to assist before attempting a mechanical lift transfer. Review of the audits and monitoring tools revealed they were completed as outlined in the facility's corrective action plan with no concerns noted as identified. The corrective action plan date completion date of 11/20/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to ensure a food preference listed on the meal card was received for 1 of 3 residents reviewed for preferences (Resident #67).
Findings included:
Resident #67 was admitted to the facility on [DATE].
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was cognitively intact and required setup or clean-up assistance with meals.
A review of the active physician's order dated 7/15/24 revealed Resident #67 received a regular textured diet.
A review of Resident #67's meal card revealed a bacon, lettuce, and tomato sandwich was included on the list of food items to be served for lunch. The meal card did not include the food items Resident #67 disliked.
An observation of the lunch meal on 05/12/25 at 12:44 PM revealed Resident #67 was served a ham and cheese sandwich instead of the bacon, lettuce, and tomato sandwich.
During an interview on 05/12/25 at 12:44 PM, Resident #67 revealed he received an extra sandwich with the lunch meal and was supposed to get a bacon, lettuce, and tomato sandwich. Resident #67 revealed he did not like the ham and cheese sandwich and was not going to eat it. Resident #67 stated he wanted the bacon, lettuce, and tomato sandwich. Resident #67 revealed most of the time he did not receive a bacon, lettuce, and tomato sandwich and had discussed his food preferences with someone but could not recall who.
An interview was conducted 05/12/25 at 01:14 PM with the Dietary Manager. The Dietary Manager confirmed a ham and cheese sandwich was served with the lunch meal instead of the bacon, lettuce, and tomato sandwich that was listed on Resident #67's meal card. The DM was unsure why a ham and cheese sandwich was served with the lunch meal instead of the bacon, lettuce, and tomato sandwich and confirmed dislikes were not included on the meal card and she would need to discuss those with Resident #67.
During an interview on 05/16/25 at 10:10 AM, the Administrator revealed Resident #67's choice of a bacon, lettuce, and tomato sandwich should have been served as listed on the meal card. She revealed food dislikes were reviewed with residents but have not been added to the meal cards. She revealed there had been a turnover of kitchen staff and updating the dislikes on resident meal cards was still a work in progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview with an individual resident, resident council and staff, the facility failed to serve the lunch meal at the scheduled times and in accordance with resident preferences on 05/11/25 and 05/12/25 in the main dining room for 2 of 3 meal observations.
Findings included:
Review of the facility's mealtimes revealed lunch was to be served at 12:00 PM in the main dining room.
An observation of the lunch meal being served in the main dining room on 05/11/25 revealed meal trays arrived at 12:38 PM.
An observation of the lunch meal being served in the main dining room on 05/12/25 revealed meal trays arrived at 12:48 PM.
An interview with Resident #49 on 05/12/25 at 12:48 PM in the main dining room revealed she was frustrated at having to wait so long to receive her lunch meal.
Resident #49 was admitted to the facility 01/09/25. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact and required set-up assistance with eating.
A Resident Council group interview was conducted on 05/13/25 at 10:26 AM with Resident #70, Resident #63, Resident #41, Resident #14, Resident #11, Resident #18, Resident #23, Resident #69, and Resident #42 in attendance. The residents voiced that meal trays were often served late regardless if they ate in their rooms or in the main dining room.
The Dietary Manager was unavailable for an interview.
An interview with the Regional Director of Operations on 05/14/25 at 3:15 PM revealed he and the Administrator recently met and revised the meal schedule in an attempt to ensure meals were sent out in a timely manner. He stated he felt it was still a new process but he felt the change in scheduled meal times would ensure meals were sent to the main dining room and halls on time.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected residents to receive meals at their scheduled serving time.

2. An observation of the dry storage room on 05/13/25 at 11:35 AM revealed 2 opened and undated bags of egg noodles and one opened and undated bag of croutons sitting on a shelf.
An interview with the Regional Director of Operations on 05/13/25 at 11:40 AM revealed all opened food items should be dated when they were opened, and the Dietary Manager was responsible for ensuring all opened food items were labeled and dated.
The Dietary Manager was unavailable for interview throughout the remainder of the survey.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected all opened food items to be dated when opened by the staff member opening the item.
3. An observation of the walk-in cooler on 05/13/25 at 12:00 PM revealed an undated plastic bag of red potatoes sitting on a shelf.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected all items in the cooler to be dated.
4. An observation of the walk-in freezer on 05/13/25 at 12:25 PM revealed a box of hamburger patties that were open to air and did not have an opened date.
An interview with the Regional Director of Operations on 05/13/25 at 12:26 PM revealed the hamburger patties should be covered and should have an opened date.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected all food to covered appropriately and should have an opened date.
5. (a). An observation of Dietary Aide #1 on 05/13/25 at 12:45 PM revealed she opened the ice machine in the kitchen used for resident beverages, removed a handful of ice with her ungloved right hand and touched ice that remained in the ice machine, placed the ice in her personal beverage, closed the lid to the ice machine, and immediately walked out of the kitchen.
In an interview with Dietary Aide #1 on 05/13/25 at 12:50 PM she confirmed she removed ice from the ice machine with her bare hand but stated she had just washed her hands. She declined to answer if she had received training on using the ice scoop to obtain ice instead of reaching directly in the ice machine.
An interview with the Regional Director of Operations on 05/14/25 at 3:15 PM revealed all dietary staff had received training on using the ice scoop to obtain ice rather than obtaining it with their bare hands. He stated all the ice in the ice machine was discarded on 05/13/25 after Dietary Aide #1 obtained ice without using the scoop.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected staff to use the ice scoop rather than using their bare hands to obtain ice.
(b). A continuous observation of Dietary Aide #2 on 05/13/25 from 1:42 PM until 2:00 PM revealed with gloved hands, she removed the food from dirty dishes and dumped the liquids from used coffee cups and glasses in a plastic bin, loaded the used coffee cups and glasses onto a dishwasher rack, slid the dishwasher rack into the dishwasher and started the dishwasher, wiped the counter where the coffee pots were sitting with a cloth, rinsed out 3 coffee dispensers and placed them back on the shelf with the coffee pots, wiped down the reach-in cooler with a cloth, removed the dishwasher rack containing clean coffee cups and glasses from the dishwasher and sat the rack at the end of the table on the clean side of the dishwasher, loaded a dishwasher rack with used coffee cups and glasses, poured the liquid in the plastic bin from used coffee cups and glasses down the drain, placed the dishwasher rack with dirty coffee cups and glasses into the dishwasher and started the dishwasher, removed her gloves, and walked away from the dishwasher. Dietary Aide #2 did not remove her gloves and perform hand hygiene after handling dirty dishes and before touching other items in the kitchen.
An interview with Dietary Aide #2 on 05/13/25 at 2:00 PM revealed she thought she removed her gloves and performed hand hygiene after touching dirty plates, coffee cups, and glasses and it was an oversight.
An interview with the Regional Director of Operations on 05/14/25 at 3:15 PM revealed he expected dietary staff to remove their gloves and perform hand hygiene any time they moved from a dirty task to a clean task.
An interview with the Administrator on 05/16/25 at 9:47 AM revealed she expected staff to wash their hands after handling dirty dishes.
Based on observations and staff interviews, the facility failed to discard food with signs of spoilage in 1 of 1 walk-in cooler; date and use or discard open food items on or before the best-by date in 1 of 1 walk-in cooler; date open food items in 1 of 1 dry storage room; date and cover an open food item in 1 of 1 walk-in freezer; and failed to implement their infection control policies when Dietary Aide #1 handled ice in the ice machine used to serve residents with her bare hands and when Dietary Aide #2 failed to remove her gloves and perform hand hygiene after handling dirty dishes and before touching other items in the kitchen. These failures had the potential to affect food served to 71 residents.
1. An initial observation of the walk-in cooler with the Dietary Manager on 05/11/25 at 10:55 AM revealed the following:
a) An opened 16-ounce container of chicken base with the date of 2/4 written on top of the lid and no use-by date. There was no pre-printed expiration date on the container.
b) An opened 16-ounce container of chicken base with the date of 4/5 written on top of the lid and no use-by date. There was no pre-printed expiration date on the container.
c) An opened 16-ounce container of beef base with an illegible date written on top of the lid. There was no pre-printed expiration date on the container.
d) A carton of apples stored together and open to air were 2 apples with visible signs of spoilage. One apple had white spots around the surface and one apple had a large, round, brown soft spot at the base of the stem.
During an interview on 05/11/25 at 10:55 AM, the Dietary Manager explained the dates of 2/4 and 4/5 that were written on the lids of the chicken base containers were the dates the containers were opened. She stated the containers should have also been labeled with a use-by date which she thought was 30-days after opening. She confirmed the date written on the container of beef base was illegible and was not sure when it was opened and placed in the walk-in refrigerator. The Dietary Manager stated all three containers should have been removed and discarded. The Dietary Manager confirmed the two apples both had visible signs of spoilage and should have been discarded. She stated all dietary staff were responsible for checking the cooler and discarding any food items with signs of spoilage or past the expiration date.
During an interview on 05/16/25 at 9:47 AM, the Administrator revealed she expected for all food items to be labeled, dated and for dietary staff to check the coolers and discard any items that were expired or had visible signs of spoilage.

3.During a continuous observation on 05/13/25 from 12:23 PM through 12:35 PM, NA #1 and NA #2 entered the room of Resident #35 and closed the door. Upon entry to the room NA #1 and NA #2 had gloves on and stated they had performed hand hygiene prior to donning. NA #1 and NA #2 used a mechanical lift to transfer Resident #35 from the chair to bed to provide incontinence care. Resident #35's brief was heavily soiled with a bowel movement that had leaked onto her inner thighs and pants. Both NA #1 and NA #2 removed Resident #35 pants. NA #1 unfastened Resident #35's brief and used moistened wipes to clean bowel movement from the front perineal area and between the skin folds. NA #2 repositioned Resident #35 onto her side and NA #1 continued to wipe bowel movement from the buttock until clean and removed the absorbent pad and soiled brief. Wearing the same gloves NA #1 placed a clean absorbent pad and clean brief underneath Resident #35. NA #2 repositioned Resident #35 onto her back and used moistened wipes to clean bowel movement from the resident's inner thighs. Wearing the same gloves used to clean bowel movement both NA #1 and NA #2 fastened the clean brief and covered Resident #3 with the bed linens. Wearing the same gloves NA #1 repositioned the pillow underneath Resident #35's head and NA #2 moved the mechanical out of the way. Both NA #1 and NA #2 removed their gloves when exiting the room and performed hand hygiene. NA #1 washed her hands using soap and water at a sink located in the nutrition room and NA #2 sanitized her hands with an alcohol based rub located by the nurse station.
During an interview on 05/13/25 at 12:35 PM, NA #1 and NA #2 revealed they were trained to remove their gloves after contact with body fluids including urine and bowel movement and to perform hand hygiene after gloves were removed. NA #1 and NA #2 revealed it was an oversight on their part they did not remove their gloves and perform hand hygiene as trained.
An interview was conducted on 05/15/25 at 12:40 PM with the DON. The DON revealed gloves were removed and hand hygiene performed after contact with bowel movement as needed.
An interview was conducted with the Administrator on 05/16/25 at 6:33 PM. The Administrator revealed for incontinence care when stool/bowel movement was cleaned gloves were removed and hand hygiene performed.
Based on observations, record review, and staff interviews the facility failed to implement their infection control policies when Nurse Aide (NA) #3 and NA #5 did not don (put on) a gown while providing incontinence care to Resident #31 who required enhanced barrier precautions (EBP) due to the presence of a pressure ulcer and failed to follow their Hand Hygiene policy when NA #3 did not remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #31; when Nurse #4 and Nurse #5 did not don gowns while providing pressure ulcer care to Resident #45 who required EBP due to the presence of a pressure ulcer; and failed to follow their Hand Hygiene policy when NA #1 and NA #2 did not remove their soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment while providing incontinence care to Resident #35. These deficient practices occurred for 6 of 11 staff members observed for infection control practices (NA #3, NA #5, Nurse #4, Nurse #5, NA #1, and NA #2).
Findings included:
Review of the facility's Hand Hygiene/Handwashing Policy last revised 06/01/24 read in part as follows: Hand washing is the most important component for preventing the spread of infection. Use of gloves does not replace the need for hand cleaning by either hand rubbing or hand washing. Perform hand hygiene before and after having direct contact with residents, after removing gloves, and after contact with body fluids or excretions and wound dressings.
Review of the facility's Enhanced Barrier Precautions policy last revised March 2024 read in part as follows: Enhanced barrier precaution (EBP) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, providing hygiene, and changing briefs. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Wounds generally include chronic wounds (i.e. pressure ulcers). Indwelling medical devices include urinary catheters and feeding tubes. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk.
1. An observation of Resident #31's door on 05/15/25 at 10:43 AM revealed a sign taped on the door indicating she was on EBP and a shelf containing gowns was hanging on the door.
A continuous observation of NA #3 and NA #5 on 05/15/25 from 11:04 AM until 11:13 AM revealed they both performed hand hygiene, donned gloves, entered Resident #31's room, pulled back the bed covers, unfastened her brief, and rolled Resident #31 on her left side. NA #3 performed incontinence care for stool by removing the stool with a resident care wipe, discarded the soiled wipe in a trash bag, placed a clean brief under Resident #31, and assisted the resident to roll on her right side. NA #5 assisted with positioning the clean brief under Resident #31. NA #3 fastened Resident #31's brief, removed her gloves, opened the resident's closet doors, removed a shirt and pants, closed the closet door, applied clean gloves and placed the shirt and pants on Resident #31, placed the mechanical lift sling under the resident, removed her gloves and performed hand hygiene. NA #3 and NA #5 did not don a gown before entering Resident #31's room and NA #3 did not remove her gloves and perform hand hygiene after cleaning stool and before touching other items in the resident's room.
A joint interview with NA #3 and NA #5 on 05/15/25 at 11:13 AM revealed they did not know that the sign on Resident #31's meant they were supposed to don a gown when providing care. They stated the EBP sign had been on Resident #31's door for quite a while but they had not received any education on when to use EBP precautions. NA #3 stated she should have removed her gloves after cleaning stool and performed hand hygiene before touching other items in Resident #31's room and it was an oversight.
An interview with the Director of Nursing (DON) on 05/15/25 at 12:40 PM revealed staff should follow the EBP signage on the door and don gowns before providing care. She stated gloves should be removed and hand hygiene should be performed after cleaning stool and before touching other items.
An interview with the Administrator on 05/16/25 at 6:33 PM revealed she expected staff to follow EBP signage and to remove gloves and perform hand hygiene after cleaning stool and before touching other items.
2. An observation on 05/15/25 at 2:55 PM of Nurse #4 and Nurse #5 entering Resident #45's room that had a sign on the door for Enhanced Barrier Precautions which instructed staff to don gloves and gown. Nurse #4 and Nurse #5 entered the room and informed Resident #45 they were going provide wound care, washed their hands, and applied clean gloves. Nurse #4 and Nurse #5 proceeded to position Resident #45 to provide wound care. This surveyor stopped Nurse #4 and Nurse #5 and asked about the sign for Enhanced Barrier Precautions. Nurse #4 and Nurse #5 stopped what they were doing, removed their gloves, sanitized their hands and put on gowns and new gloves.
A joint interview with Nurse #4 and Nurse #5 on 05/15/25 at 3:05 PM revealed that they should have put gowns and gloves on. Nurse #5 stated that they had been trained on Enhanced Barrier Precautions. Nurse #4 stated that they overlooked the Enhanced Barrier Precautions sign and PPE hanging on the door.
An interview with the DON/ Infection Preventionist on 05/15/25 at 3:39 PM revealed that her expectation was for staff to put on the appropriate PPE for all residents who are on Enhanced Barrier Precautions when providing direct resident care such as wound care.
An interview with the Administrator on 05/16/25 at 10:06 AM revealed that her expectation was for staff to put on the appropriate PPE for the residents who were on Enhanced Barrier Precautions when providing direct patient care such as wound care.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets accurately reflected the nursing staff who worked for 16 of 16 days reviewed (11/09/24, 11/10/24, 11/23/24, 12/07/24, 12/08/24, 12/28/24, 12/29/24, 04/13/25, 04/19/25, 04/20/25, 04/26/25, 04/27/25, 05/03/25, 05/04/25, 05/10/25, and 05/11/25).
Findings included:
Review of the facility's daily nurse staffing sheet revealed underneath the facility's name was a space to specify the date along with columns to specify the resident census, number of staff and hours worked for Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) for each 8-hour shift, 7:00 AM to 3:00 PM (first shift), 3:00 PM to 11:00 PM (second shift) and 11:00 PM to 7:00 AM (third shift).
a. The daily nurse staffing sheet dated 11/09/24 revealed on third shift there were 2 LPNs, 4 NAs and no RNs. The nursing staff time clock report for 11/09/24 revealed on third shift there were 2 LPNs, 2 NAs and no RNs.
b. The daily nurse staffing sheet dated 11/10/24 revealed on first shift there 2 RNs, 2 LPNs and 7 NAs. On second shift there were 2.5 RNs, 1.5 LPNs and 5 NAs. The nursing staff time clock report for 11/10/24 revealed on first shift there were 2 RNs, 2 LPNs and 5.5 NAs. On second shift there were 1.5 RNs, 1.5 LPNs and 4 NAs.
c. The daily nurse staffing sheet dated 11/23/24 revealed on first shift there were 4 RNs, 1 LPN and 7 NAs. On second shift there were 1.5 RNs, 1.5 LPNs and 6.5 NAs. The nursing staff time clock report for 11/23/24 revealed on first shift there were 3.5 RNs, 1 LPN and 6 NAs. On second shift there were 1.5 RNs, 1.5 LPNs and 6 NAs.
d. The daily nurse staffing sheet dated 12/07/24 revealed on second shift there were 2 RNs, 2 LPNs and 4 NAs. On third shift there were 2 LPNs, 4 NAs and no RNs. The nursing staff time clock report for 12/07/24 revealed on second shift there were 2.5 RNs, 1.5 LPNs and 4 NAs. On third shift there were 2 LPNs, 2 NAs and no RNs.
e. The daily nurse staffing sheet dated 12/08/24 revealed on first shift there were 2 RNs, 2 LPNs and 8 NAs. On third shift there were 1 RN, 1 LPN and 3 NAs. The nursing staff time clock report for 12/08/24 revealed on first shift there were 1.5 RNs, 3 LPNs and 7 NAs. On third shift there were 2 LPNs, 5 NAs and no RNs.
f. The daily nurse staffing sheet dated 12/28/24 revealed on third shift there were 2 LPNs, 3 NAs and no RNs. The nursing staff time clock report for 12/28/24 revealed on third shift there were 2 LPNs, 2 NAs and no RNs.
g. The daily nurse staffing sheet dated 12/29/24 revealed on first shift there were 4 LPNs, 8 NAs and no RNs. On third shift there were 1 RN, 1 LPN and 3 NAs. The nursing staff time clock report for 12/29/24 revealed on first shift there were 3 LPNs, 6 NAs and no RNs. On third shift there were 3 LPNs, 4 NAs and no RNs.
h. The daily nurse staffing sheet dated 04/13/25 revealed on first shift there were 2 RNs, 2 LPNs and 8 NAs. On second shift there were 1 RN, 1 LPN and 7 NAs. The nursing staff time clock report for 04/13/25 revealed on first shift there were 1 RN, 2 LPNs and 8 NAs. On second shift there were 1 RN, 1 LPN and 6 NAs.
i. The daily nurse staffing sheet dated 04/19/25 revealed on first shift there were 2 RNs, 2 LPNs and 7 NAs. On second shift there were 2 RNs, 2 LPNs and 5 NAs. The nurse staffing time clock report for 04/19/25 revealed on first shift there were 1 RN, 1.5 LPNs and 7 NAs. On second shift there were 2 RNs, 2 LPNs and 3 NAs.
j. The daily nurse staffing sheet dated 04/20/25 revealed on first shift there were 2 RNs, 2 LPNs and 7 NAs. On second shift there were 1.5 RNs, 2.5 RNs and 5 NAs. There was no resident census listed on the sheet. The nursing staff time clock report for 04/20/25 revealed on first shift there were 1.5 RNs, 1 LPN and 8 NAs. On second shift there were 1.5 RNs, 2.5 LPNs and 3 NAs.
k. The daily nurse staffing sheet dated 04/26/25 revealed on first shift there were 2 RNs, 2 LPNs and 8 NAs. The nursing staff time clock report revealed on first shift there were 3 RNs, 1 LPN and 7 NAs.
l. The daily nurse staffing sheet dated 04/27/25 revealed on second shift there were 1 RN, 2 LPNs and 5 NAs. On third shift there were 1 RN, 1 LPN and 3 NAs. The nursing staff time clock report for 04/27/25 revealed on second shift there were 1 RN, 4 LPNs and 4 NAs. On third shift there were 1 LPN, 3 NAs and no RNs.
m. The daily nurse staffing sheet dated 05/03/25 revealed on first shift there were 2 RNs, 2 LPNs and 9 NAs. On second shift there were 3 RNs, 1 LPN and 7 NAs. On third shift there were 1 RN, 1 LPN and 4 NAs. The nursing staff time clock report for 05/03/25 revealed on first shift there were 1 RN, 3 LPNs, 1 Certified Medication Aide (CMA), and 7 NAs. On second shift there were 2 RNs, .5 LPN and 4.5 NAs. On third shift there were 1 RN, 1 LPN and 3 NAs.
n. The daily nurse staffing sheet dated 05/04/25 revealed on second shift there were 1 RN, 1 LPN and 7 NAs. The nursing staff time clock report for 05/04/25 revealed on second shift there were 1 RN, no LPNs and 4.5 NAs.
o. The daily nurse staffing sheet dated 05/10/25 revealed on first shift there were 1 RN, 2 LPNs and 4 NAs. The staff assignment schedule and nursing staff time clock report for 05/10/25 revealed on first shift there were 2 RNs, 1 LPN, 1 CMA, and 3 NAs.
p. The daily nurse staffing sheet dated 05/11/25 revealed on first shift there were 1 RN, 2 LPNs and 8 NAs. On second shift there were 1 RN, 1.5 LPNs and 5 NAs. The staff assignment schedule and nursing staff time clock report for 05/11/25 revealed on first shift there were 1 RN, 1 LPN, 1 CMA, and 6 NAs. On second shift there were 1 RN, 1.5 LPNs, .5 CMA, and 3.5 NAs.
During an interview on 05/16/25 at 5:38 PM, the Scheduler revealed she was responsible for posting the daily staffing sheets and usually posted them first thing in the morning. The Scheduler stated she did not update the daily staffing sheets to reflect call-outs and/or staff schedule changes and was not aware she needed to do that.
During an interview on 05/16/25 at 8:39 AM, the Administrator revealed the Scheduler was responsible for posting and updating the daily nurse staffing sheets. The Administrator stated she would expect for the daily nursing staffing sheets to be updated as needed to reflect the correct number and hours of nursing staff that worked each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to secure an opened tube of antifungal cream for 1 of 2 residents reviewed for medication storage (Resident #40).
The findings included:
Resident #40 was admitted to the facility on [DATE].
The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #40 with severely impaired cognition.
A review of Resident #40's medical records revealed she had never been assessed for self-administration of medication.
During an observation conducted on 05/12/25 at 9:40 AM, one opened tube of Miconazole nitrate cream (an over-the-counter antifungal medication used to treat fungal infections of the skin, such as athlete's foot, jock itch, and ringworm) with the concentration of 2% was left unattended on top of the bedside table in Resident #40's room and was ready to be used.
An attempt to interview Resident #40 was unsuccessful. She was unable to answer questions.
During a joint observation and subsequent interview conducted with Nurse #3 on 05/12/25 at 9:44 AM, she stated the antifungal cream should be kept in the medication cart instead of leaving unattended in Resident #40's room. She did not notice the tube of antifungal was in Resident #40's room when she did medication pass on 05/12/25 in the morning. She confirmed Resident #40 had not been assessed for self-administration of medication.
An interview was conducted with Nurse Aide #2 (NA) on 05/25/25 at 10:38 AM. She stated she had provided care for Resident #40 in the past few weeks. She did not notice the tube of antifungal cream was left unattended on Resident #40's bedside table when she rounded her on 05/12/25 in the morning
During an interview conducted with the Director of Nursing (DON) on 05/14/25 at 8:45 AM, she expected all the nursing staff to be more attentive to residents' room when providing care to ensure none of the medications were left unattended in the facility.
An interview was conducted with the Administrator on 05/16/25 at 10:46 AM. She expected nursing staff to pay attention to residents' living environment when providing care. It was her expectation for the facility to remain free of unattended medications at all time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with the Medical Director, resident and staff, the facility failed to monitor the resident's urinary catheter for complications of skin breakdown and ensure the catheter tubing was kept clean. A buildup of a white colored substance was observed on the urinary meatus (the opening at the tip of the penis where urine exits the body) where the catheter tubing was inserted, on the scrotum and between the skin folds of the groin. There was redness and irritation present on the genitals and skin folds between the groin and a strong odor resembling yeast. The deficient practice occurred for 1 of 3 residents reviewed for urinary catheters (Resident #86).
Findings included:
Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and acute and chronic congestive heart failure.
A review of Resident #86's active physician orders included tamsulosin (a medication used to promote urine flow) give 0.4 milligrams at bedtime for urine retention started 04/24/25; empagliflozin (sodium-glucose cotransporter-2 inhibitors) give a 10 mg tablet one time a day for congestive heart failure started 4/26/25; provide catheter cleansing and perineal hygiene daily and as need if soiled; monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter started 04/28/25. There were no orders for antifungal medications or treatments for skin redness and irritation.
The baseline care plan dated 04/25/25 identified the placement of an indwelling urinary catheter with the goal Resident #86 would not show signs or symptoms of a urinary tract infection. Interventions included position catheter bag and tubing below the bladder and hand washing before and after delivery of care.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86's cognition was moderately impaired, partial to moderate assistance was needed with toileting hygiene, an indwelling urinary catheter was in place and always incontinent of bowel. No genitourinary diagnoses were checked. The MDS indicated Resident #86 had no rejection of care behaviors during the lookback period.
A review of Resident #86's Medication Administration Record (MAR) and Treatment Administration Record (TAR) from 05/01/25 through 05/14/25 revealed the physician's order to provide catheter cleansing and perineal hygiene daily and as need if soiled; monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria, or leakage around the catheter were not included. There was no treatment order for skin related redness or irritation, or for the use of an antifungal powder or cream.
A review of the Nursing Daily Skilled Charting dated 05/13/25 included a skin/wound assessment and indicated Resident #86's skin was intact and there were no skin integrity changes. Nurse #6 documented the assessment.
An observation was made on 05/14/25 at 12:12 PM of Resident #86's catheter care provided by the Unit Manager (UM). When the brief was removed, the skin on Resident #86's genitals including the urinary meatus where the catheter tubing was inserted and skin folds between the groin was red and irritated. There was a buildup of a white colored substance on the genitals and between the groin skin folds and a strong odor resembling yeast was present. The UM revealed it appeared Resident #86's catheter care had not been done and noted the presence of a strong odor resembling yeast. The UM cleaned the catheter tubing, genitals and between the skin folds and removed the white substance from Resident #86's skin and revealed it appeared an antifungal powder had been applied. There was a small area of skin on the scrotum that was peeling and red. There was no drainage or leakage noted from the catheter insert site. Resident #86 tolerated catheter care and did not voice pain when asked by the UM.
During an interview on 05/14/25 at 12:12 PM, Resident #86 revealed he did not refuse catheter care. Resident #86 revealed he was unsure why the urinary catheter was placed and did not recall the last time catheter care was provided. Resident #86 did not share he was itching or had pain related to his urinary catheter.
An interview was conducted on 05/14/25 at 4:09 PM with Nurse #6. Nurse #6 confirmed she completed the Nursing Daily Skilled Charting on 05/13/25. Nurse #6 revealed she did not visually check Resident #86's skin integrity when she completed the skin/wound assessment.
An interview was conducted on 05/14/25 at 12:44 PM with Nurse Aide (NA) #3, Resident #86's assigned NA. NA #3 confirmed she worked the day shift on 05/14/25 starting at 7:00 AM and was assigned to provide catheter care for Resident #86. NA #3 stated she had emptied Resident #86's catheter bag and checked for a bowel movement and there was no incontinence. NA #3 revealed she had done catheter care earlier today (05/14/25) and cleaned the catheter tubing at the insert site. When asked if she cleaned the perineal area and between the skin folds to remove a white substance NA #3 stated, yes. NA #3 revealed she noted Resident #86's skin was red, but did not report it to the nurse.
During an interview on 05/14/25 at 1:39 PM and 05/15/25 10:43 AM, the Director of Nursing (DON) stated it was obvious NA #3 had not provided Resident #86's catheter care based on the observation made by the UM and surveyor. The DON revealed catheter care was provided as needed and she expected it was done. The DON revealed the expectation for completing the skin/wound assessments was for the nurse to visually check the resident's skin and identify existing and new skin breakdown.
During an interview on 05/16/25 at 8:57 AM, the Administrator stated it appeared NA staff were just emptying Resident #86's catheter bag. The Administrator revealed Resident #86 should be check every two hours for bowel incontinence and at some point someone should have noticed his catheter needed cleaned and his perineal hygiene care needed to be done.
During an interview on 05/16/25 at 3:43 PM, the Medical Director stated catheter care should be done as ordered and if not provided could put Resident #86 at risk of an infection. When asked about the strong body odor resembling yeast and the skin redness, the Medical Director stated Resident #86 received empagliflozin a medication that could cause yeast. He revealed on 04/22/25 Resident #86 could not urinate and the catheter was placed at the hospital then Resident #86 was admitted to facility with no instructions for a trial to remove it. The Medical Director revealed based on his initial visit progress note dated 04/26/25 Resident #86 was put on tamsulosin (a medication used to increase urine flow) for urinary retention and in a male that was obstructive uropathy and why the urinary catheter was in place.
During an interview on 05/16/25 at 4:03 PM in the presence of the Medical Director, Resident #86 was unsure why he needed an indwelling urinary catheter. The Medical Director explained to Resident #86 a voiding trial period would be started, and the urinary catheter would be removed and if Resident #86 could urinate the catheter was not needed.

Based on observations, record review and interviews with residents and staff, the facility failed to provide sufficient nursing staff to ensure residents received bathing, incontinence care and personal hygiene assistance as needed and requested for 4 of 8 sampled residents (Residents #35, #43, #74, and #86) reviewed for activities of daily living.
This tag is cross-referenced to:
F 677: Based on observations, record review, resident and staff interviews, the facility failed to provide assistance with incontinence care upon request (Resident #35), oral hygiene and nail care (Resident #86), and showers (Resident #43, #74, and #86) for 4 of 8 dependent residents reviewed for activities of daily living.
During an interview on 05/11/25 at 10:05 AM and follow-up interview on 05/14/25 at 12:55 PM, Confidential Staff Member #1 revealed for the past few months staffing had been ok during the week but had been short on the weekends. Confidential Staff Member #1 stated this past weekend on (05/10/25) there were only 3 Nurse Aides (NA) for the entire shift (7:00 AM to 3:00 PM) and they weren't able to get many residents up out of bed or provide residents with bathing assistance. Confidential Staff Member #1 stated when working short staffed, they were only able to complete rounds and primarily focused on keeping the residents clean, dry and fed.
During an interview on 05/11/25 at 10:09 AM and follow-up interview on 05/15/25 at 8:48 AM, Medication Aide (MA) #1 revealed weekend staffing had been short since she had been working at the facility. MA #1 revealed on 05/10/25 she was assigned to a medication cart and there were only 3 Nurse Aides (NAs) during the shift to provide resident care. MA #1 explained while working on the medication cart, she helped the NAs as she could and she did assist with providing incontinence care to 2 residents but did not provide any residents with bathing assistance. MA #1 stated there were only 2 other nurses working with her today (05/11/25) and they were all behind with getting the residents morning medications passed. She explained when short-staffed and covering more than one hall, it was difficult for them to get the medications passed on time and she just did the bed she could.
During an interview on 05/11/25 at 10:15 AM, Nurse #1 revealed she worked every weekend and they usually had to work short-staffed. Nurse #1 explained staffing was really good when she first started her employment in February 2025 but since then, staff either called-out or just not showed up to work and administration wasn't always able to get the shifts covered at the last minute. Nurse #1 stated yesterday (05/10/25) there were 3-4 staff members that called out which left her covering the rehab hall with 17 residents who all required max assistance and she just did her best to focus on her priorities which were getting medications passed, fluids passed and feeding assistance provided. She stated today (05/11/25) there were only 2 nurses (including herself) and a MA and they were all behind on getting residents morning medications passed on time. Nurse #1 stated when working short-staffed, she felt rushed and it was very difficult to get everything done in a timely manner.
During an interview on 05/11/25 at 10:28 AM, Nurse #2 revealed staffing was hit or miss with some days/shift being better than others. Nurse #2 stated today had been rough as they only had 2 Nurses (including herself) and a MA. Nurse #2 stated she was covering 2 resident halls and still had not finished the morning medication pass. Nurse #2 expressed when working short-staffed, it was difficult to get things done timely and residents were getting their medications late.
During an interview on 05/11/25 at 3:33 PM, NA #10 revealed she only worked weekends and some days staffing was good and other days they might only have 1-2 NAs for the entire shift. NA #10 expressed when working short-staffed, it was rough getting dinner served, making rounds every 2 hours and answering call-lights quickly. She explained she might not get to take a break but she did her best to make sure everything was done for the residents, it just took her longer.
During an interview on 05/11/25 at 11:30 AM, the former Interim Director of Nursing (DON) confirmed staffing had been a challenge. She explained they had been utilizing a lot of agency staffing to supplement the schedule but still had a lot of call-outs. The former Interim DON stated this past Friday (05/09/25) she worked all day on the weekend schedule (5/10/25 and 5/11/25), had the shifts covered and then staff either called-out or didn't show up for their scheduled shift(s). The former Interim DON stated the previous DON had switched back to 8-hour shifts, which made it even more difficult to get shifts covered, especially the 3:00 PM to 11:00 PM shift, and they had recently made the decision to go back to 12-hour shifts which she hoped would get them back on the right track with ensuring there was adequate staff coverage each shift.
During a Resident Council group interview on 05/13/25 at 10:26 AM, Resident #70, Resident #63, Resident #41, Resident #14, Resident #11, Resident #18, Resident #23, Resident #69, and Resident #42 all voiced there was an issue with the facility being short-staffed on the weekends and as a result, showers were not given as scheduled and call-lights took longer to be answered by staff.
During an interview on 05/16/25 at 5:38 PM, the Staffing Scheduler revealed daily staffing coverage was based on the resident census and/or acuity (level of care an individual required) needs of the residents. She stated facility staff were currently scheduled for 8-hour shifts with the following preferred minimums: on the day shift (7:00 AM to 3:00 PM) she tried to have 4 nurses and 7-8 NAs; on the evening shift (3:00 PM to 11:00 PM) she tried to have 4 nurses and 5-6 NAs; and on the night shift (11:00 PM to 7:00 AM) she tried to have 2 nurses and 4 NAs. The Staffing Scheduler confirmed staffing had been a challenge, especially on the weekends. The Staffing Scheduler explained she made the schedule out a month in advance and for shifts needing coverage, she started with in-house staff to request volunteers and then reached out to staffing agencies to fill in the gaps. She stated she would get the shifts covered but then at the last minute, staff would call-out or not show up as scheduled. When that happened, they tried to find someone to cover the shift but if unable, she or other administrative nursing staff would help out. The Staffing Scheduler revealed the current open positions at the facility were 2 Nurses and 2-3 NAs for the day shift, 3 Nurses and 2 NAs for the evening shift, and 1 full-time nurse, 1 part-time nurse and 1-2 NAs for the night shift.
During an interview on 05/16/25 at 8:39 AM, the Administrator confirmed staffing was a challenge and she realized it was an area that needed more attention. She stated that they were actively trying to hire more staff and in the interim, they were using several different staffing agencies to supplement the schedule. The Administrator stated with the current resident census, only having 2-3 NAs on first shift (7:00 AM to 3:00 PM) and second shift (3:00 PM to 11:00 PM) was not adequate and explained they were supposed to be able to get agency staffing coverage last minute but it didn't always happen. The Administrator stated she felt that part of the reason for the current staffing issues was due to the previous administration had changed back to 8-hour shifts because facility-hired staff had threatened to quit; however, agency staff did not want to work 8-hour shifts, they wanted to work longer hours. She stated agency staff would sign up for shifts and then call-out or not show up for the shift because they were able to find more hours elsewhere. She stated they had recently made the decision to return back to 12-hour shifts, which she felt would help with having adequate staffing coverage.

Based on record review and staff interviews, the facility failed to provide effective orientation to a new nurse on the facility's admission process when Nurse #6 failed to obtain and document code status information, obtain treatment orders for pressure ulcers, and complete accurate head-to-toe skin checks used to identify skin breakdown and new or existing pressure ulcers. In addition, the facility also failed to ensure nursing staff were able to demonstrate the competency and skills necessary for providing care to meet the individual care needs of residents when Nurse Aide (NA) #3 failed to inform the nurse she had noticed a resident's skin was red and irritated during catheter care, Nurse #1 failed to identify a resident prior to administering medication prescribed for another resident, Nurse #7 failed to request a prescription from the physician when refilling a controlled medication, and Nurse #8 failed to utilize the medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications). This occurred for 5 of 8 staff reviewed for competency (Nurse #6, NA #3, Nurse #1, Nurse #7 and Nurse #8).
Findings included:
This tag is crossed referenced to:
F 578: Based on record review, Medical Director (MD) interview, and staff interviews, the facility failed to obtain and document an advanced directive that included code status information upon admission for 1 of 4 residents reviewed for advance directive (Resident #283).
F 686: Based on observations, record review, interviews with the Wound Care Medical Doctor (MD), the Medical Director and staff, the facility failed to obtain treatment orders for pressure ulcers identified on 04/24/25 resulting in a seven-day delay of treatment. Additionally, the facility failed to complete accurate head-to-toe skin checks used to identify new or existing pressure ulcers that include the site (location), type of wound, the length, width, depth, and stage. The skin/wound assessment completed on 05/13/25 indicated the resident's skin was intact with no new pressure ulcer. On 05/14/25 a tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the left heel was identified and measured 4 centimeters (cm) in length and 4.1 cm with width. The deficient practice occurred for 1 of 5 residents reviewed for pressure ulcers (Resident #86).
F 690: Based on record review, observations, and interviews with the Medical Director, resident and staff, the facility failed to monitor the resident's urinary catheter for complications of skin breakdown and ensure the catheter tubing was kept clean. A buildup of a white colored substance was observed on the urinary meatus (the opening at the tip of the penis where urine exits the body) where the catheter tubing was inserted, on the scrotum and between the skin folds of the groin. There was redness and irritation present on the genitals and skin folds between the groin and a strong odor resembling yeast. The deficient practice occurred for 1 of 3 residents reviewed for catheters (Resident #86).
F 760: Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a significant medication error when Nurse #1 administered antidepressant, diuretic, blood pressure, hypoglycemic (oral medication used to treat diabetes) and steroid medications to Resident #283 that were prescribed for Resident #86. In addition, the facility failed to request a prescription from the physician to avoid a gap in medication administration when refilling a controlled medication and failed to utilize medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications) which resulted in the Resident #11 missing 3 doses of nerve pain medication, 3 doses of diabetic medication, and 1 dose of insulin. This deficient practice occurred for 2 of 2 residents reviewed for significant medication error (Resident #283 and Resident #11).
During an interview on 05/11/25 at 10:40 AM the Administrator revealed there had been a recent change in administration, the Director of Nursing (DON) just started her position the week prior and the Assistant DON was starting her position this week.
During follow-up interviews on 05/16/25 at 8:30 AM and 6:36 PM, The Administrator revealed she realized there were issues with staff orientation and training dating back to the previous DON and management team. She stated they had put performance improvement plans in place to work on the various issues and going forward, the current DON and Assistant DON would be responsible for ensuring skills competencies for nursing staff were completed annually. The Administrator expressed she felt they now had a strong management team in place, and she had no doubt that processes would be fixed and improvement achieved but it would take time for them to get things turned around.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #11 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus with diabetic polyneuropathy.
The care area assessment dated [DATE] revealed Resident #11 was diagnosed with diabetic polyneuropathy and bilateral osteoarthritis of knee with chronic pain. She was cognitively intact and had reported experiencing almost constant pain within the 7-day review period.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #11 with intact cognition. She had adequate vision and hearing with clear speech. The MDS indicated Resident #11 received both scheduled and as needed (PRN) pain medications, insulin, antianxiety, antidepressant, and hypoglycemic during the 7-day review period.
The care plan for pain initiated on 03/27/25 revealed Resident #11 had pain related to osteoarthritis. The goals were for her to verbalize adequate pain relief through the review date. Interventions included anticipating Resident #11's need for pain relief and responding immediately to any complaint of pain.
The physician's orders dated 03/17/25 revealed Resident #11 had obtained orders to receive insulin glargine (a long-acting insulin used to control high blood sugar) 8 units subcutaneously once daily for diabetes and 2 tablets of metformin (an oral antidiabetic medication used to treat diabetes) 500 milligrams (mg) by mouth twice daily for diabetes. On 03/19/25, the physician started Lyrica (a fibromyalgia agent used to treat nerve pain) 100 mg, 1 capsule by mouth 3 times daily for pain.
A review of nurse's progress notes dated 05/11/25 at 6:04 AM, 05/12/25 at 8:37 AM, and 05/12/25 at 6:12 PM revealed 3 different nurses working in 3 different shifts documented metformin was unavailable and it was not administered to Resident #11. A further review of nurse's progress notes dated 05/12/25 at 7:33 AM revealed Nurse #7 documented the pharmacy needed prescription of Lyrica for Resident #11. She notified the Nurse Practitioner (NP) regarding the need of a prescription for Lyrica immediately. Then, she checked on Resident #11 who stated she did not have any pain or discomfort at that time. On 05/12/25 at 8:23 PM, Nurse #8 documented insulin glargine was unavailable. He could not find the insulin in the medication cart or refrigerator.
A review of Pyxis records and inventory list revealed 251 different medications were kept in the Pyxis for emergency uses. Further review of the Pyxis Inventory Replenishment Report dated 05/11/25 revealed the facility had 8 tablets of Metformin 500 mg and one 3 milliliters (ml) pen of insulin glargine in the Pyxis.
The Medication Administration Records (MAR) revealed Resident #11 did not receive 3 doses of metformin scheduled on 05/11/25 at 8 AM, 05/12/25 at 8 AM and 6 PM; 3 doses of Lyrica scheduled on 05/11/25 at 8 PM, 05/12/25 at 6 AM and 2 PM; and 1 dose of insulin glargine scheduled on 05/12/25 at 9 PM.
A further review of Resident #11's medical records revealed the refill order for Lyrica was submitted to the pharmacy by Nurse #7 on 05/11/25 at 2:50 AM when there were 2 tablets remaining in the medication cart. The last tablet of Lyrica was administered on 05/11/25 at 2 PM. When Nurse #7 called on 05/12/25 at 7:30 AM to follow up with the Lyrica order, the pharmacy staff stated they needed the prescription as it was a controlled medication. Nurse #7 notified the NP to submit a prescription for Lyrica immediately. When Lyrica arrived at the facility on 05/12/25 at 11 PM, Resident #11 had already missed 3 doses of Lyrica. On the other hand, both metformin 500 mg and insulin glargine were available in Pyxis but not being administered by the nurse.
During an interview conducted on 05/12/25 at 3:31 PM, Resident #11 stated she had not received her Lyrica for 3 days and added she started to feel the pain since 05/10/25. She wanted to know why her Lyrica had not been refilled yet and indicated this was not the first time it had happened.
A further review of MAR indicated Resident #11 had missed 3 doses of Lyrica at the time of interview on 05/12/25 at 3:31 PM, but not 3 days. She received Lyrica 3 times per day until she missed the first dose on 05/11/25 at 8 PM, then 2 more doses on 05/12/25 at 6 AM and 2 PM. Further review of MAR revealed Resident #11 had a scheduled order of hydrocodone/acetaminophen (a semi-synthetic opioid used to treat pain) 5/325 mg that was discontinued on 05/06/25, and a new order of tramadol (an analgesic/opioid used to relieve pain) was initiated on 05/12/25.
During a phone interview conducted on 05/15/25 at 1:23 PM, Nurse #7 stated she was the nurse who submitted the refill order of Lyrica for Resident #11 on 05/11/25 morning when 2 tablets remained in the medication cart. She recalled she could not put in a STAT order as she did not even have a prescription when submitting the refill order through the computer system. When she returned to work on 05/12/25 in the morning and found that Lyrica had still not arrived at the facility, she called the pharmacy to follow up and was told that the pharmacy needed a prescription. She could not recall whether she had told the pharmacy staff to code this Lyrica order as a STAT order during the phone call. She notified the NP that the pharmacy needed a prescription for Resident #11's Lyrica and went to check Resident #11. She recalled Resident #11 did not appear to be in pain or distress. She explained to Resident #11 that the pharmacy needed a prescription, and she had notified the NP about it. She asked Resident #11 if she was suffering any nerve pain Resident #11 replied that she was okay.
During a subsequent observation and interview conducted on 05/12/25 at 4:12 PM, Resident #11 appeared to be calm, pleasant, and free of signs and symptoms of pain or distress. She stated her nerve pain was okay and manageable, but she was upset about not getting her Lyrica as ordered.
An interview was conducted with Nurse #8 on 05/13/25 at 4:44 PM. He stated Resident #11's Lyrica was delivered from the pharmacy on 05/12/25, arrived at the facility around 11:00 PM, and was administered right after receiving it. He stated he could not find metformin and insulin glargine in the medication cart or refrigerator on 05/12/25 in the evening and added he did not check for both medications in Pyxis. Nurse #8 acknowledged that he did not check with the pharmacy on 05/12/25 in the evening to ensure both medications had been re-ordered.
During an interview conducted on 05/13/25 at 4:53 PM, the Interim Director of Nursing stated the facility had Pyxis that provided emergency medications including several narcotics and controlled substances as needed. Not only did the facility have metformin and insulin glargine in the Pyxis, but the facility also had a back-up pharmacy approximately 0.25 miles from the facility. She did not receive any notification regarding availability of metformin and insulin glargine on 05/12/25. Otherwise, she could have gotten both medications from Pyxis. She stated Pyxis had 8 tablets of metformin 500 mg and one insulin glargine pen on regular basis and this resources should be fully utilized. She stated the pharmacy would not dispense any controlled medication such as Lyrica without a prescription issued by the physician. It was her expectation for nurses to start refilling procedures at least 5 days before the last pill was used to avoid a gap, especially controlled medication that required a prescription.
A phone interview was conducted with the Pharmacy Manager on 05/15/25 at 12:20 PM. He stated the pharmacy computer system received the refill order of Lyrica for Resident #11 on 05/11/25 at 2:50 AM. As the order was not coded as a STAT (signified the order needed to be done immediately, with the highest priority) order and the pharmacy did not receive a refill prescription from the physician, the pharmacy could not process and fill the medication until the next day after the prescription for Lyrica was received on 05/12/25 at 9:07 AM. Lyrica was filled and then placed in the pharmacy totes at 3:17 PM and delivered to the facility as a regular order. He stated the delivery typically arrived at the facility before mid-night. The Pharmacy Manager stated if the facility staff specified it was a STAT order, they would try to deliver it to the facility within the specified time frame. Otherwise, the pharmacy had designated a back-up pharmacy locally near the facility. He confirmed the facility had Pyxis for medication needed after hours or emergency, and it consisted of insulin glargine and metformin 500 mg, but not Lyrica 100 mg. He indicated tramadol could alleviate nerve pain, but not to a great extent. He stated if the refilled order for Lyrica was submitted with a prescription and specified as a STAT order, the pharmacy could have filled and delivered the ordered Lyrica to the facility on [DATE] before midnight. He stated nurses should retrieve both metformin 500 mg and insulin glargine in Pyxis instead of charting it as missed doses.
A phone interview was conducted on 05/16/25 at 9:57 AM with the MD. He stated Resident #11 had a personality disorder and drug seeking behavior. Almost each time he visited her, she would ask for more pain medications, including Lyrica. He stated Resident #11 had been taking Lyrica since 03/19/25 and it typically took approximately 35 hours to be fully eliminated from the body. As Resident #11 was out of Lyrica for approximately 24 hours, clinically, she should still have certain level of Lyrica in her system to prevent her from triggering nerve pain. In addition, Resident #11 received Depakote 500 mg daily for bipolar disorder which had also been used as off-label to treat neuropathic pain. Resident #11 used to have an order of Norco 5/325 mg for 14 days and it was just discontinued on 05/06/25, about a week before Lyrica was run out. Besides, Resident #11 was taking other medications such as trazodone, clonazepam, and methocarbamol which could alleviate her pain level. He stated there were many factors that could affect her pain level and Resident #11 could have confused about muscular pain versus nerve pain. He would not rule out the possibility of Resident #11 experiencing nerve pain 24 hours without Lyrica, but the chances were very low. It was his expectation for the nursing staff to start the refilling process at least a few days before the supply ran out, especially for those controlled substances that required a prescription. He also expected nursing staff to pay attention to the content of Pyxis and fully utilize it as needed as indicated.
During a phone interview conducted on 05/16/25 at 10:46 AM, the Administrator expected nursing staff to submit refill order at least 3-5 days before the medication ran out and ensure refill order for controlled medication was submitted with the prescription. It was her expectation for all nursing staff to be proficient in the content of Pyxis and fully utilized it as needed as indicated.
Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a significant medication error when Nurse #1 administered a steroid medication to Resident #283 that were prescribed for Resident #86. In addition, the facility failed to request a prescription from the physician to avoid a gap in medication administration when refilling a controlled medication and failed to utilize medication resources stored in the Pyxis (an automated dispensing machine that provided secure medication storage on patient care units, along with electronic tracking of the use of narcotics and other controlled medications) which resulted in the Resident #11 missing 3 doses of nerve pain medication, 3 doses of diabetic medication, and 1 dose of insulin. This deficient practice occurred for 2 of 2 residents reviewed for significant medication error (Resident #283 and Resident #11).
The findings included:
1. Resident #283 was admitted to the facility on [DATE] with diagnosis that included parkinsonism, type 2 diabetes mellitus, chronic kidney disease stage 3, myocardial infarction type 2 (a heart attack that occurs due to an imbalance between the hearts oxygen supply and demand), hypertension (high blood pressure), and edema (swelling).
Review of the 5-day Prospective Payment System (PPS) assessment dated [DATE] revealed that Resident #283 was cognitively intact. He received antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medications.
Review of the change in condition communication form written by Nurse #1 and dated 4/28/25 at 8:50 AM revealed Resident #283 was administered the wrong medications as follows: Lexapro (antidepressant) 10 milligrams (MG), Lasix (diuretic) 40 MG, Jardiance (a medication used to treat type 2 diabetes) 10 MG, Lisinopril (a medication used to treat high blood pressure) 40 MG, Metoprolol extended release (ER, a medication used to treat high blood pressure) 12.5 MG, and Prednisone (steroid medication used to treat many diseases and conditions that are associated with inflammation) 40MG. Resident #283 was informed of the medication that was given in error and the plan to notify the provider now. Things that made the condition or symptom worse were unknown. Things that made the condition or symptoms better were noted as keeping Resident #283 and the family informed and monitoring Resident #283's vital signs every 15 minutes for 2 hours, then every 30 minutes for one hour, then every 4 hours. Other relevant information noted Resident #283 was provided with a list of medications given in error. Each medication was explained, including the indications for use and possible side effects. Resident #283's vital signs remained normal. Mental status changes included Resident #283 became anxious when informed of the medication errors, all questions were answered, and he was seen by the Nurse Practitioner (NP) within 30 minutes. The NP assured Resident #283 he would be ok, and he seemed less anxious after the NP visit. Resident #283 had no functional status, respiratory, abdomen, or urine changes noted. The NP determined that Resident #283 did not need to be sent to the hospital, but staff would continue to monitor him at the facility.
An interview on 5/15/25 at12:03 PM with Nurse #1 revealed that she was Resident #283's assigned nurse on 4/28/25 during the hours of 7:00 AM to 3:00 PM. Nurse #1 stated that she entered Resident #283's room and called him by Resident #86's name but she did not think he had heard her because he had his continuous positive airway pressure (CPAP, a machine that is used to treat sleep apnea and other breathing disorders) machine on. She stated that his nasal canula needed to be put on and there was no oxygen tubing in the room, so she left the room to go get Resident #283 oxygen tubing. Nurse #1 stated it was at this point she felt very overwhelmed and when she returned to the medication cart, she pulled out Resident #86's medications to administer to Resident #283. Nurse #1 stated she then reentered Resident #283's room and administered the medications. After Resident #283 took the medications, she called him by Resident #86's name and Resident #283 replied that was not his name. Nurse #1 stated she realized she had administered the wrong medications to Resident #283 and immediately took his vital signs, called the physician, and notified the Director of Nursing (DON). Nurse #1 further stated she also printed off a list of the medications that she had given Resident #283 in error and notified him that she would be monitoring him every 15 minutes. Nurse #1 recalled Resident #283 stating that he was scared but he refused the offer to go to the hospital. Nurse #1 further revealed that Resident #283 never displayed any side effects from having received the wrong medications.
Review of the April 2025 MAR for Resident #86 revealed the following significant medication prescribed for Resident #86 was administered to Resident #283 in error on 04/28/25:
- Prednisone (steroid) 20 mg - two tablets by mouth one time a day for pneumonia, chronic obstructive pulmonary disease (COPD, lung disease that makes it difficult to breathe) for 5 days.
Review of the April 2025 medication administration record (MAR) for Resident #283 revealed physician orders for the following routine medications to be administered at 8:00 AM daily:
- Aspirin (antiplatelet) 81 MG - one tablet by mouth one time a day for supplement
- Bumetanide (diuretic) 1 MG - one tablet by mouth one time a day for chronic kidney disease.
- Citalopram (antidepressant) 20 MG - one tablet by mouth one time a day for depression.
- Glucotrol extended release (oral hypoglycemic) 5 MG - one tablet by mouth one time a day for diabetes.
- Valsartan (antihypertensive) 320 MG - give 0.5 tablet by mouth one time a day for hypertension.
- Famotidine (treats gastroesophageal reflux) 20 MG - one tablet by mouth one time a day for gastroesophageal reflux disease (GERD, chronic condition where stomach acid flows back into the esophagus causing heartburn).
- Enoxaparin injection (anticoagulant) 40 MG/0.4 milliliter (ml) - inject 0.4 ml (40 mg) under the skin in the morning and at bedtime.
- Sodium Bicarbonate (treats heartburn) 650 MG - one tablet by mouth two times a day for supplement.
- Multivitamin with minerals - one capsule by mouth two times a day for supplement.
- Carbidopa-Levodopa (medication used to treat Parkinson's disease) oral tablet 25-250 mg - one tablet by mouth four times a day for Parkinson's.
Further review of Resident #283's April 2025 MAR revealed all 8:00 AM medications were held on 04/28/25 except for the Carbidopa-Levodopa 25-250 mg.
Review of the vitals monitoring form for Resident #283 initiated on 04/28/25 at 9:00 AM revealed his vitals (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) were checked every 15 minutes for the first 2 hours, then every 30 minutes for one hour, then every 4 hours for 24 hours, and then every shift for 48 hours with no issues noted.
Review of a nurse progress note written by the former DON dated 4/28/25 revealed that Resident #283 was seen by the NP after a reported medication error. There were no adverse effects noted for Resident #283. Resident #283 and his family chose not to be transferred to the hospital. Monitoring was put in place immediately and vital signs were stable.
Review of a NP progress note dated 4/28/25 revealed in part, that Resident #283 was found sitting up in his bed, tearful. Nursing staff told the NP that Resident #283 had received medications that were not prescribed to him. The NP assessed Resident #283 and found his vital signs were within normal limits and instructed nursing staff to continue ongoing assessment of Resident #283's vital signs. Resident #283's heart, lung and bowel sounds were all normal and there was slight trace edema on the lower extremities (legs). Resident #283 had oxygen via nasal cannula present on admission and was alert and oriented. Resident #283's medications were reviewed.
An interview on 5/16/25 at 12:33 PM with the former DON revealed that she recalled Resident #283. The former DON stated that when Nurse #1 made a medications error on 4/28/25, Nurse #1 informed Resident #283, the NP and the DON. She stated that she and Nurse #1 assessed Resident #283 after the medication error and put in place continued monitoring every 15 minutes. The former DON further revealed that Resident #283's vital signs remained stable after the incident. The former DON indicated that she reviewed the 5 rights of medication administration education with all nurses and medication aides (MA). She stated that there were no adverse effects noted for Resident #283. The former DON stated that Nurse #1 should have identified Resident #283 prior to pulling the medications and then again before administering the medications by asking Resident #283 to state his name, since Resident #283 was alert and oriented and a new resident. She stated that the facility offered to take Resident #283 to the hospital, but he declined.
An interview on 5/15/25 at 11:20 AM with the NP revealed that Nurse #1, who administered the wrong medications, called her when she was on her way to the facility. The NP stated that she told Nurse #1 to lock her cart, tell the DON, and assess Resident #283. The NP stated that when she arrived at the facility, she assessed Resident #283 and reviewed the medications that were given in error. The NP stated that she offered to send Resident #283 to the hospital, but he refused. She further revealed that she informed Nurse #1 to hold his regular medications for the remainder of the day. The NP stated that the medications Resident #283 received in error were similar to the medications that he was prescribed. She further stated that he suffered no ill effects to his health or well-being because of the medication error. The NP stated that after she was done assessing Resident #283, she went to speak with the DON about the medication error. She revealed that she checked on Resident #283 the following day and he remained stable and continued to refuse transfer to the hospital.
An interview on 5/16/25 at 3:36 PM with the Medical Director revealed that he was familiar with Resident #283 and was aware of the medication error. The Medical Director stated that the doses of the medication Resident #283 received in error were low and the medications were similar to what Resident #283 was prescribed. He stated that they had no negative effect on Resident #283 and they did not harm him.
An interview on 5/16/25 at 5:21 PM with the Administrator revealed that Nurse #1 gave the wrong medication to Resident #283 and she was very up front about it and notified Resident #283, the NP, and the family. She stated that she was not sure why the medication error occurred. The Administrator stated that there were 2 new admissions that day and maybe Nurse #1 got confused. She stated that Nurse #1 should have asked Resident #283's name before she pulled the medications and then asked him again before she gave the medications to him. The Administrator stated that Resident #283 was monitored for 48 hours after the medication error occurred and he had no adverse effects because of the error. She stated that her expectation was that the 7 rights of medication administration were completed which included verifying the right resident got the right medications before medication was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with residents and staff, the facility failed to ensure resident's accessibility to the light switch located behind the bed and failed to provide a bed with adequate length to prevent a resident's feet from hanging off at the end of the mattress for 2 of the 2 residents reviewed for accommodation of needs (Residents #58 and #43).
The findings included:
1. Resident #58 was admitted to the facility on [DATE].
The quarterly MDS assessment dated [DATE] coded Resident #58 with intact cognition and impairment on one side of his upper and lower extremities. The MDS indicated walking between locations inside the room for more than 10 feet was not attempted during the assessment period due to medical condition or safety concerns.
During an observation conducted on 05/12/25 at 11:43 AM, the switch for the light fixture behind Resident #58's bed was attached with a broken cord 2.5 inches in length. The switch cord was 5 feet from the floor and 6 feet from the bed. Resident #58 was unable to reach the switch cord from the bed if needed.
An interview was conducted with Resident #58 on 05/12/25 at 11:45 AM. He stated he was bedbound and unable to stand up and walk. He recalled the switch cord was broken since he moved into his room a few months ago. He did not have any control of the light fixture behind his bed as he could not stand up to reach the broken switch cord on the wall. He enjoyed reading before bedtime and had to rely on nursing staff to switch off the light fixture before sleeping. It was frustrating and inconvenient as he had to ask for assistance repeatedly. He wanted the maintenance staff to fix the switch cord to accommodate his needs immediately.
Subsequent observation conducted on 05/13/25 at 11:49 AM revealed the switch cord for the light fixture behind Resident #58's bed remained inaccessible.
During joint observation and subsequent interviews with Nurse Aide (NA) #2 and Nurse #2 on 05/13/25 at 12:15 PM, both nursing staff acknowledged that the broken switch cord needed to be fixed as soon as possible. NA #2 stated she provided care for Resident #58 frequently in the past few weeks and she had notified the Maintenance Manager about the broken switch cord. However, she did not follow up with the Maintenance Manager. Nurse #2 stated she had provided care for Resident # 58 frequently, but she did not notice the switch cord was broken and inaccessible for Resident #58.
An interview was conducted with the Maintenance Director on 05/13/25 at 12:33 PM. He stated he walked through the facility at least once daily to identify repair needs. He also depended on nursing staff to report repair needs either verbally or with work order via facility website electronically. He could not recall receiving any work orders for Resident # 58's broken switch cord so far. He acknowledged that all the broken switch cords needed to be fixed immediately to accommodate residents' needs.
During an interview conducted on 05/14/25 at 8:45 AM, the Director of Nursing expected the staff to be more attentive to residents' living environment and reported repair needs in a timely manner. It was important to accommodate residents' needs and ensure full accessibility to their light fixture.
A phone interview was conducted with the Administrator on 05/16/25 at 10:46 AM. She stated it was her expectation for all the residents to have full accessibility to their light fixture to accommodate their needs all the time.
2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included incomplete quadriplegia C1-C4 (spinal cord injury between the vertebrae in the upper neck resulting in loss of some motor functions but not all).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. He had impairment of both sides of the upper extremities and was dependent on staff assistance with self-care tasks, bed mobility and transfers. It was noted Resident #43 had a height of 75 inches.
During an observation and interview on 05/11/25 at 11:30 AM, Resident #43 was observed sitting up in bed watching TV. The head of the bed was slightly elevated, Resident #43's head was aligned with the top edge of the mattress and the footboard had been removed from the bed frame. Resident #43's legs were in a straight position with his ankles resting on the bottom edge of the mattress and his feet extending past edge of the mattress. Resident #43 stated when he was first admitted to the facility, he was placed in a bed that was very narrow and shortly afterwards, he could not recall when, the facility brought him another bed that was much wider. Resident #43 stated he was 76 inches tall and the Maintenance Director told him that the bed he was currently in was 80 inches in length but anytime he was positioned up in bed, his feet hung off the end of the bed. Resident #43 stated it was an uncomfortable position for him to have his feet extending past the bottom edge of the mattress.
Additional observations on 05/12/25 at 12:22 PM and 05/13/25 at 9:20 AM revealed Resident #43 lying supine (face upward) in bed with the head of the bed elevated and his feet extending past the bottom edge of the mattress.
During an observation and interview on 05/13/25 at 9:40 AM, the Maintenance Director revealed he had removed the footboard of the bed so that Resident #43's feet wouldn't press up against it. He stated he had been in and out of Resident #43's room several times since then but had not noticed his feet extending past the edge of the mattress. The Maintenance Director stated Resident #43's current bed was 80 inches in length and wasn't sure if he could order one any longer but he would research to see what he could find.
During an observation and interview on 05/14/25 at 8:45 AM, the Director of Nursing (DON) confirmed Resident #43 was positioned correctly up in bed and his feet still extended past the bottom edge of the mattress. The DON expressed the back of Resident #43's ankles rested at the bottom edge of the mattress which was concerning because that was a vulnerable area and he was already at risk for skin breakdown. The DON stated she would have expected for someone to have noticed and gotten him a longer bed so that his feet didn't extend past the bottom edge of the mattress.
During an interview on 05/16/25 8:39 AM, the Administrator revealed that most of the times when she had been in Resident #43's room, he was either up in his wheelchair or he was lying in bed with his feet covered and she hadn't noticed his feet extending past the edge of the mattress. The Administrator stated she would have hoped that someone would have noticed Resident #43's bed was not long enough but no one had voiced any concerns to her. She explained there were bed extensions that could have been placed on Resident #43's bed or his bed switched out with one that would extend in length which would have prevented his feet from extending past the edge of the mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Medical Director (MD) interview, and staff interviews, the facility failed to obtain and document an advanced directive that included code status information upon admission for 1 of 4 residents reviewed for advance directive (Resident #283).
Findings included:
Resident #283 was admitted to the facility on [DATE] with diagnosis that included acute respiratory failure with hypoxia (a condition where the lungs fail to adequately oxygenate the blood, leading to low oxygen levels in the blood and tissues).
Review of the admission progress note dated 4/25/25 at 11:00 PM and written by Nurse #6 revealed there was no mention of Resident #283's advanced directive or code status.
A phone interview on 05/14/25 at 4:09 PM with Nurse #6 revealed she admitted Resident #283 on 4/25/25. She stated that she had not been shown the full process of completing a new admission and learned by word of mouth when asking another nurse or after being told she had done something wrong. She stated that she had asked other nurses on many different occasions to show her the admission process, but it never happened. Nurse #6 further revealed that she had not asked about Resident #283's code status during the admission process on 04/25/25.
An interview on 5/16/25 at 12:33 PM with the former DON revealed that when a resident was admitted to the facility the admitting nurse should review the residents advanced directive wishes with them and begin filling out the advanced directive form. She stated that she was not sure why Resident #283's advanced directive was never filled out as it should have been completed upon admission. She further revealed that the admitting nurse should also have put the order for the code status in the medical record. She stated that if the Social Worker was available to begin the advanced directive form with the resident, the Social Worker would hand the advanced directive form to the admitting nurse and the admitting nurse would place the initial order. The admitting nurse would then communicate to the Nurse Practitioner (NP) or the MD about the new advanced directive form and code status orders.
An interview on 5/15/25 at 3:38 AM with the MD revealed that normally on admission a staff member obtained the resident's code status and put in an order. Then the staff member notified him, and he confirmed that with the resident. He further revealed that the code status was usually gotten from the hospital paperwork.
An interview on 5/16/25 at 5:21 PM with the Administrator revealed that she was familiar with Resident #283. The Administrator indicated that the admitting nurse should have asked for Resident #283's code status. She stated that Resident #283's admission paperwork wasn't done either and she was not sure why. She further stated that part of the admission paperwork involved advanced directives. She stated that her expectation was that residents had an advanced directive completed and code status ordered upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Medical Director and staff, the facility failed to notify the physician when pressure ulcers were identified on admission for 1 of 5 residents reviewed for pressure ulcers (Resident #86).
Findings included:
Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and moderate protein-calorie malnutrition.
The admission data collection assessment dated [DATE] identified Resident #86 had existing pressure ulcers on the right, and left buttock and sacrum.
A review of Resident #86's physician orders revealed no wound care treatments were put in place until 04/30/25.
During an interview on 05/14/25 at 4:09 PM, Nurse #6 confirmed she was the admitting nurse when Resident #86 arrived at the facility, and she completed the admission data collection assessment dated [DATE]. She revealed when Resident #86's was admitted she identified pressure ulcers on the left, and right buttock and sacrum she described as red in color with no open skin or drainage and were on the surface of the skin. Nurse #6 revealed she did not notify the physician to obtain wound care orders on 04/24/25 but did report the pressure ulcers to the oncoming nurse. She revealed she wrote a note in the communication book for the Nurse Practitioner (NP) to see Resident #86 on the next scheduled visit to the facility and the NP came to the facility to see residents on Monday through Thursday.
An interview with the former DON was conducted on 05/14/25 at 4:37 PM. The former DON revealed if pressure ulcer wounds were identified on the admission data collection assessment dated [DATE] the admitting nurse should notify the physician and obtain wound care orders.
A review of the Medical Director progress note revealed Resident #86 was seen on 04/25/25 for a new patient assessment. The Medical Director's physical exam of the skin noted Resident #86 had no rashes. The Medical Director's plan of treatment indicated nursing was instructed to notify the provider or the on-call provider of any new or worsening changes in condition. The progress note did not mention pressure ulcers and no wound care orders were provided.
An interview was conducted on 05/15/25 at 9:10 AM with the Medical Director. The Medical Director revealed he wanted to be notified when a resident was identified as having pressure ulcers. He further revealed wound care treatments should have been implemented when Resident #86 was admitted with existing pressure ulcers on 04/24/25.
During an interview on 05/16/25 at 8:57 AM, the Administrator revealed the admitting nurse (Nurse #6) was responsible for notifying the physician when Resident #86's pressure ulcers were identified on 04/24/25 to obtain treatment orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews with the resident and staff, the facility failed to protect a resident's right to be free from neglect when Nurse Aide (NA) #1 disregarded a resident's request for incontinence care and did not check the resident for incontinence prior to going on break (Resident #35). Resident #35 was left sitting in a chair in her room that had a strong odor resembling bowel incontinence for approximately one hour. When Resident #35's incontinence care was provided her brief was heavily soiled with a bowel movement that had leaked onto her inner thighs and clothing. Resident #35 voiced she could smell herself and it was not the first time that had happened to her. The deficient practice occurred for 1 of 2 residents reviewed for abuse/neglect.
Findings included:
Resident #35 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, vascular dementia, cerebrovascular accident, hemiparesis (weakness) and hemiplegia (partial or total paralysis) affecting the left non-dominate side.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's cognition was intact with no rejection of care behaviors during the lookback period. Resident #35's range of motion was impaired on both sides of the upper and lower extremities, she was always incontinent of bladder and bowel, and dependent on staff for transfers and toileting hygiene.
The care plan revised on 4/03/25 identified Resident #35 had a self-care deficit in performing activities of daily living related to a stroke with hemiplegia and hemiparesis, incontinence, and vascular dementia. The care plan interventions included Resident #35 was dependent on two staff for toilet use.
A continuous observation was conducted on 05/13/25 from 11:52 AM through 12:35 PM in conjunction with an interview with Resident #35. Resident #35 stated she needed incontinence care and Nurse Aide (NA) #1 was aware she needed to be changed. When asked how long she had waited Resident #35 stated, It's been a while but gave no specific time. In the room there was a strong odor resembling bowel movement. Resident #35 stated she could smell herself and this was not the first time this had happened. NA #1 was observed to enter and exit the room at 12:18 PM and again at 12:23 PM. Resident #35 was sitting in a reclined position in a chair and continued to need incontinence care. The strong odor resembling incontinence remained in the room and had lingered onto the hallway. At 12:35 PM, NA #1 and NA #2 provided a two person transfer and moved Resident #35 from the chair to the bed using a mechanical lift. When Resident #35's brief was removed it was heavily soiled with bowel movement. The bowel movement had leaked from the brief onto Resident #35's left and right inner thighs and clothing. The bowel movement was moist and had not dried on to Resident #35's skin and when removed there were two areas of intact pink colored skin resembling previously healed scar tissue.
An interview was conducted with NA #1 on 05/13/25 at 12:35 PM. NA #1 confirmed Resident #35 stated she was incontinent prior to her (NA #1) going on break at 11:30 AM. NA #1 revealed she did not physically check Resident #35 for incontinence at that time and stated there was no odor resembling incontinence. NA #1 described Resident #35 as having attention seeking behaviors that included saying she was incontinent but was not. NA #1 revealed she did not provide Resident #35 incontinence care when she returned from break at 12:00 PM due to it being almost time for her to begin delivering meal trays and she was told not to provide incontinence care for residents during meal tray service.
An interview was conducted on 05/16/25 at 10:43 AM with the Director of Nursing (DON). It was explained Resident #35 requested incontinence care prior to NA #1 going on break at 11:30 AM but it was not provided until 12:35 PM. The DON stated it was poor quality of care to not provide incontinence care, and she would expect incontinence care to be provided when a resident asked to be changed. The DON stated she would expect incontinence care was completed regardless if it was during meal tray service or meal time.
During an interview on 05/16/25 at 6:04 PM the Administrator stated she never told nurse or NA staff incontinence care was not provided during meal tray service. The Administrator stated she expected if Resident #35 asked to be changed, NA #1 would have done the care before going on break and was poor customer service it was not done. The Administrator stated it was not neglect as she did not think NA #1 intentionally neglected Resident #35 request for incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the Care Area Assessment (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 1 of 1 sampled resident reviewed for comprehensive assessment (Residents #48).
The findings included:
Resident #48 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, aphasia, dementia, and cognitive communication deficit.
The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #48 with severely impaired cognition.
A review of Section V (Care area assessment summary) of the annual MDS assessment dated [DATE] revealed a total of 9 care areas were triggered for Resident #48. The MDS Coordinator did not provide any information in analysis of findings for 8 of the 9 triggered areas to describe the nature of Resident #48's problems, possible causes, contributing factors, risk factors related to the care area, and reasons to proceed with care planning for the following triggered care areas:
1. Visual functions
2. Communication
3. Functional abilities
4. Urinary incontinence and indwelling catheter
5. Falls
6. Nutritional status
7. Pressure ulcer/injury
8. Psychotropic drug use
During an interview conducted on 05/13/25 at 12:53 PM, the MDS Coordinator confirmed 8 of the 9 triggered care areas for Resident #48's annual MDS dated [DATE] were submitted without providing pertinent information in the analysis of findings in Section V to address the underlying causes and contributing factors of the triggered areas. She indicated Resident #48's annual MDS dated [DATE] was completed by the MDS Coordinator who worked remotely. The MDS Coordinator indicated she had only worked part-time (3 days per week) during the past 3 months.
An interview was conducted with the Director of Nursing on 05/14/25 at 8:45 AM. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinators to complete the analysis of findings for all the triggered areas in Section V comprehensively before submission.
An attempt to conduct a phone interview on 05/14/25 at 4:36 PM with the MDS Coordinator who completed Resident #48's annual MDS dated [DATE] was unsuccessful.
During a phone interview conducted with the Administrator on 05/16/25 at 10:46 AM, she expected the MDS Coordinator to follow MDS guidelines to ensure all the CAAs include at least the nature of problems, causative factors, and reasons to proceed to care plan before submission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of medications (Resident #3, Resident #6, Resident #36), pressure ulcer (Resident #86, Resident #74), and Preadmission Screening and Resident Review (PASRR), (Resident #23) for 6 of 8 residents reviewed for resident assessments.
Findings included:
1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included heart disease.
The significant change MDS assessment dated [DATE] revealed Resident #3 was coded as receiving anticoagulant medication.
Review of the April 2025 medication administration record (MAR) for Resident #3 revealed there was no physician order for anticoagulant medication and none was administered.
During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the April 2025 MAR for Resident #3 and confirmed she did not receive anticoagulant medication during the MDS assessment period. The MDS Coordinator stated the significant change MDS assessment dated [DATE] was coded incorrectly.
During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately.
2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included heart failure and end-stage renal disease.
The significant change MDS assessment dated [DATE] revealed Resident #6 was coded as receiving insulin and hypoglycemic (used to lower blood sugar levels) medication.
Review of the March 2025 medication administration record (MAR) for Resident #6 revealed there were no physician orders for insulin or hypoglycemic medication and none was administered.
During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the March 2025 MAR for Resident #6 and confirmed she did not receive insulin or hypoglycemic medication during the MDS assessment period. The MDS Coordinator stated the significant change MDS assessment dated [DATE] was coded incorrectly.
During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately.
3. Resident #23 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and Post-Traumatic Stress Disorder (PTSD).
The annual MDS assessment dated [DATE] revealed Resident #23 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
Review of a PASRR Level II determination notification letter provided by the Social Worker (SW) on 05/15/25 revealed Resident #23 had a Level II PASRR effective 05/28/24 with no end date.
During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator explained when conducting an audit of Level II PASRR, they realized Resident #23's annual MDS assessment dated [DATE] was not coded correctly to reflect that she had a Level II PASRR. She stated it was an oversight.
During an interview on 05/26/25 at 12:55 PM, the SW revealed the MDS Coordinator was the person responsible for coding Level II PASRR on the MDS assessments. The SW explained she tried to audit Level II PASRR weekly, or at the very least, every other week and then emailed the MDS Coordinator an updated list of residents who had a Level II PASRR to use when completing MDS assessments.
During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately.
4. Resident #36 was admitted to the facility on [DATE] with diagnoses that included diabetes.
The quarterly MDS assessment dated [DATE] revealed Resident #36 was coded as receiving insulin injections daily during the MDS assessment period.
Review of the February 2025 medication administration record (MAR) for Resident #36 revealed there was no physician order for insulin and no insulin was administered.
During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator reviewed the February 2025 MAR for Resident #36. She confirmed there was no physician order for insulin and he did not receive insulin during the MDS assessment period. The MDS Coordinator stated the quarterly MDS assessment dated [DATE] incorrectly indicated Resident #36 received insulin and it was an oversight.
During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately.
5. Resident #86 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy (gradual decrease in size of an organ or muscle tissue) multiple sites and moderate protein-calorie malnutrition.
A nurse admission data collection dated 04/24/25 revealed Resident #86's skin was not intact and he had pressure ulcers and non-pressure areas/other skin conditions. It was noted Resident #86 had a blister to the mid-back and pressure ulcers to the right buttock, left buttock and sacrum with no measurements specified.
An admission nurse progress note dated 04/25/25 revealed in part that Resident #86 had pressure sores in the middle of his right buttock, left buttock and sacrum with no drainage noted and all were less than the size of a quarter. There was no stage (system used to categorize the severity of pressure injuries) or measurements for the pressure ulcers noted.
The admission MDS assessment dated [DATE] revealed Resident #86 had no unhealed pressure ulcers or other skin conditions present upon admission.
During an interview on 05/16/25 at 10:48 AM, the MDS Coordinator stated she was not sure why the admission MDS assessment dated [DATE] did not reflect Resident #86 had a pressure ulcer based on the nurse admission note dated 04/25/25. The MDS Coordinator explained she did not complete the MDS assessment but if she had, she would have asked the wound nurse, doctor or someone else who would be knowledgeable to clarify what the nurse note didn't include, such as stage of the pressure ulcer.
During an interview on 05/16/25 at 5:11 PM, the Administrator stated she expected MDS assessments to be completed accurately.
6. Resident #74 was admitted to the facility 02/06/25 with a diagnosis including acute (new onset) pancreatitis (inflammation of the pancreas).
The Wound Care Physician #1's note dated 02/19/25 revealed Resident #74 was receiving wound care for an unstageable pressure wound with 100% necrotic (dead) tissue to the posterior (back) of his head that was present on admission.
Review of Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he had a stage three pressure ulcer (full-thickness skin loss that extends into subcutaneous tissue but doesn't involve muscle or bone) that was not present on admission.
An interview with the MDS Coordinator on 05/16/25 at 11:17 AM revealed Resident #74's quarterly MDS assessment should have been coded to reflect he had a pressure ulcer that was present on admission and it was an oversight.
An interview with the Director of Nursing (DON) on 05/16/25 at 4:52 PM revealed she expected MDS assessments to be coded correctly.
An interview with the Administrator on 05/16/25 at 5:11 PM revealed she expected MDS assessments to be coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and Nurse Practitioner (NP), Medical Director (MD), resident and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered an antidepressant, diuretic, hypoglycemic and blood pressure medications to Resident #283 that were prescribed for Resident #86. This deficient practice occurred for 1 of 2 residents reviewed for medication errors (Resident #283).
The findings included:
1. Resident 283 was admitted to the facility on [DATE] with diagnosis that included parkinsonism, type 2 diabetes mellitus, chronic kidney disease stage 3, myocardial infarction type 2 (a heart attack that occurs due to an imbalance between the hearts oxygen supply and demand), hypertension (high blood pressure), and edema (swelling).
Review of the 5-day Prospective Payment System (PPS) assessment dated [DATE] revealed that Resident #283 was cognitively intact. He received antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medications.
Review of the change in condition communication form written by Nurse #1 and dated 4/28/25 at 8:50 AM revealed Resident #283 was administered the wrong medications as follows: Lexapro (antidepressant) 10 milligrams (MG), Lasix (diuretic) 40 MG, Jardiance (a medication used to treat type 2 diabetes) 10 MG, Lisinopril (a medication used to treat high blood pressure) 40 MG, Metoprolol extended release (ER, a medication used to treat high blood pressure) 12.5 MG, and Prednisone (steroid medication used to treat many diseases and conditions that are associated with inflammation) 40MG. Resident #283 was informed of the medication that was given in error and the plan to notify the provider now. Things that made the condition or symptom worse were unknown. Things that made the condition or symptoms better were noted as keeping Resident #283 and the family informed and monitoring Resident #283's vital signs every 15 minutes for 2 hours, then every 30 minutes for one hour, then every 4 hours. Other relevant information noted Resident #283 was provided with a list of medications given in error. Each medication was explained, including the indications for use and possible side effects. Resident #283's vital signs remained normal. Mental status changes included Resident #283 became anxious when informed of the medication errors, all questions were answered, and he was seen by the Nurse Practitioner (NP) within 30 minutes. The NP assured Resident #283 he would be ok, and he seemed less anxious after the NP visit. Resident #283 had no functional status, respiratory, abdomen, or urine changes noted. The NP determined that Resident #283 did not need to be sent to the hospital, but staff would continue to monitor him at the facility.
An interview on 5/15/25 at12:03 PM with Nurse #1 revealed that she was Resident #283's assigned nurse on 4/28/25 during the hours of 7:00 AM to 3:00 PM. Nurse #1 stated that she entered Resident #283's room and called him by Resident #86's name but she did not think he had heard her because he had his continuous positive airway pressure (CPAP, a machine that is used to treat sleep apnea and other breathing disorders) machine on. She stated that his nasal canula needed to be put on and there was no oxygen tubing in the room, so she left the room to go get Resident #283 oxygen tubing. Nurse #1 stated it was at this point she felt very overwhelmed and when she returned to the medication cart, she pulled out Resident #86's medications to administer to Resident #283. Nurse #1 stated she then reentered Resident #283's room and administered the medications. After Resident #283 took the medications, she called him by Resident #86's name and Resident #283 replied that was not his name. Nurse #1 stated she realized she had administered the wrong medications to Resident #283 and immediately took his vital signs, called the physician, and notified the Director of Nursing (DON). Nurse #1 further stated she also printed off a list of the medications that she had given Resident #283 in error and notified him that she would be monitoring him every 15 minutes. Nurse #1 recalled Resident #283 stating that he was scared but he refused the offer to go to the hospital. Nurse #1 further revealed that Resident #283 never displayed any side effects from having received the wrong medications.
Review of the April 2025 MAR for Resident #86 revealed the following medications prescribed for Resident #86 that were administered to Resident #283 in error on 04/28/25:
- Jardiance (medication used to lower blood glucose levels) 10 mg - one tablet by mouth one time a day for congestive heart failure.
- Lasix (diuretic) 40 mg - one tablet by mouth one time a day for edema (swelling).
- Lexapro (antidepressant) 10 mg - one tablet by mouth one time a day for depression.
- Lisinopril (antihypertensive) 40 mg - one tablet by mouth one time a day for hypertension.
- Metoprolol Succinate (antihypertensive) ER 25 mg - give 0.5 tablet by mouth one time a day for hypertension.
Review of the April 2025 medication administration record (MAR) for Resident #283 revealed physician orders for the following routine medications to be administered at 8:00 AM daily:
- Aspirin (antiplatelet) 81 MG - one tablet by mouth one time a day for supplement
- Bumetanide (diuretic) 1 MG - one tablet by mouth one time a day for chronic kidney disease.
- Citalopram (antidepressant) 20 MG - one tablet by mouth one time a day for depression.
- Glucotrol extended release (oral hypoglycemic) 5 MG - one tablet by mouth one time a day for diabetes.
- Valsartan (antihypertensive) 320 MG - give 0.5 tablet by mouth one time a day for hypertension.
- Famotidine (treats gastroesophageal reflux) 20 MG - one tablet by mouth one time a day for gastroesophageal reflux disease (GERD, chronic condition where stomach acid flows back into the esophagus causing heartburn).
- Enoxaparin injection (anticoagulant) 40 MG/0.4 milliliter (ml) - inject 0.4 ml (40 mg) under the skin in the morning and at bedtime.
- Sodium Bicarbonate (treats heartburn) 650 MG - one tablet by mouth two times a day for supplement.
- Multivitamin with minerals - one capsule by mouth two times a day for supplement.
- Carbidopa-Levodopa (medication used to treat Parkinson's disease) oral tablet 25-250 mg - one tablet by mouth four times a day for Parkinson's.
Further review of Resident #283's April 2025 MAR revealed all 8:00 AM medications were held on 04/28/25 except for the Carbidopa-Levodopa 25-250 mg.
Review of the vitals monitoring form for Resident #283 initiated on 04/28/25 at 9:00 AM revealed his vitals (temperature, pulse, respiratory rate, blood pressure, and oxygen saturation) were checked every 15 minutes for the first 2 hours, then every 30 minutes for one hour, then every 4 hours for 24 hours, and then every shift for 48 hours with no issues noted.
Review of a nurse progress note written by the former DON dated 4/28/25 revealed that Resident #283 was seen by the NP after a reported medication error. There were no adverse effects noted for Resident #283. Resident #283 and his family chose not to be transferred to the hospital. Monitoring was put in place immediately and vital signs were stable.
Review of a NP progress note dated 4/28/25 revealed in part, that Resident #283 was found sitting up in his bed, tearful. Nursing staff told the NP that Resident #283 had received medications that were not prescribed to him. The NP assessed Resident #283 and found his vital signs were within normal limits and instructed nursing staff to continue ongoing assessment of Resident #283's vital signs. Resident #283's heart, lung and bowel sounds were all normal and there was slight trace edema on the lower extremities (legs). Resident #283 had oxygen via nasal cannula present on admission and was alert and oriented. Resident #283's medications were reviewed.
An interview on 5/16/25 at 12:33 PM with the former DON revealed that she recalled Resident #283. The former DON stated that when Nurse #1 made a medications error on 4/28/25, Nurse #1 informed Resident #283, the NP and the DON. She stated that she and Nurse #1 assessed Resident #283 after the medication error and put in place continued monitoring every 15 minutes. The former DON further revealed that Resident #283's vital signs remained stable after the incident. The former DON indicated that she reviewed the 5 rights of medication administration education with all nurses and medication aides (MA). She stated that there were no adverse effects noted for Resident #283. The former DON stated that Nurse #1 should have identified Resident #283 prior to pulling the medications and then again before administering the medications by asking Resident #283 to state his name, since Resident #283 was alert and oriented and a new resident. She stated that the facility offered to take Resident #283 to the hospital, but he declined.
An interview on 5/15/25 at 11:20 AM with the NP revealed that Nurse #1, who administered the wrong medications, called her when she was on her way to the facility. The NP stated that she told Nurse #1 to lock her cart, tell the DON, and assess Resident #283. The NP stated that when she arrived at the facility, she assessed Resident #283 and reviewed the medications that were given in error. The NP stated that she offered to send Resident #283 to the hospital, but he refused. She further revealed that she informed Nurse #1 to hold his regular medications for the remainder of the day. The NP stated that the medications Resident #283 received in error were similar to the medications that he was prescribed. She further stated that he suffered no ill effects to his health or well-being because of the medication error. The NP stated that after she was done assessing Resident #283, she went to speak with the DON about the medication error. She revealed that she checked on Resident #283 the following day and he remained stable and continued to refuse transfer to the hospital.
An interview on 5/16/25 at 3:36 PM with the Medical Director revealed that he was familiar with Resident #283 and was aware of the medication error. The Medical Director stated that the doses of the medication Resident #283 received in error were low and the medications were similar to what Resident #283 was prescribed. He stated that they had no negative effect on Resident #283 and they did not harm him.
An interview on 5/16/25 at 5:21 PM with the Administrator revealed that Nurse #1 gave the wrong medication to Resident #283 and she was very up front about it and notified Resident #283, the NP, and the family. She stated that she was not sure why the medication error occurred. The Administrator stated that there were 2 new admissions that day and maybe Nurse #1 got confused. She stated that Nurse #1 should have asked Resident #283's name before she pulled the medications and then asked him again before she gave the medications to him. The Administrator stated that Resident #283 was monitored for 48 hours after the medication error occurred and he had no adverse effects because of the error. She stated that her expectation was that the 7 rights of medication administration were completed which included verifying the right resident got the right medications before medication was administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #43 was admitted to the facility on [DATE] with diagnoses that included incomplete quadriplegia C1-C4 (spinal cord injury between the vertebrae in the upper neck resulting in loss of some motor functions but not all).
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had intact cognition. He had impairment of both sides of the upper extremities and was dependent on staff assistance with self-care tasks, bed mobility and transfers. He displayed no behaviors and did not reject care during the MDS assessment period.
A review of Resident 43's comprehensive care plans, last reviewed/revised on 05/07/25, revealed he had an activities of daily living self-care performance deficit related to quadriplegia. Interventions included dependence on staff with showering twice weekly on Wednesday and Saturday and 2-person staff assistance with transfers using a mechanical lift.
Review of the master shower schedule revealed Resident #43 was scheduled to receive a shower on Wednesday and Saturday during the hours of 3:00 PM to 11:00 PM.
Review of the Nurse Aide (NA) point of care documentation report for 05/01/25 through 05/14/25 revealed no documentation that Resident #43 received his showers on Wednesdays or Saturdays as scheduled.
During an observation and interview on 05/11/25 at 11:30 AM and follow-up interview on 05/12/25 at 12:22 PM, Resident #43 was lying in bed with the head of bed slightly elevated and his hair was unkempt. Resident #43 stated he was supposed to receive two showers per week on Wednesday and Saturday, but he did not always receive a shower on Saturdays due to there not being enough help on the weekends. He stated when he did not get a shower, staff did not offer him a bed bath and the last shower he received was this past Wednesday (05/07/25). Resident #43 stated he was supposed to get a shower yesterday (05/10/25) but was told by Nurse Aide (NA) #7 that he wouldn't be getting a shower because they didn't have enough staff. He stated that although he would have liked to have gotten his shower, he knew it wasn't the staff's fault. Resident #43 stated not getting a shower made him feel nasty and embarrassed to be seen this way.
During an interview on 05/11/25 at 1:00 PM, NA #8 revealed she worked on 05/10/25 during the hours of 7:00 AM to 3:00 PM and provided care to Resident #43. NA #8 stated there were only 3 NAs for the entire shift and they were not able to get a lot of the residents up out of bed or provide residents with any showers or bed baths. She expressed when working short-staffed, it was very difficult to get resident care provided and they basically had to focus on keeping the residents dry and fed.
During an interview on 05/14/25 at 2:45 PM, NA #7 revealed she worked on 05/10/25 during the hours of 7:00 AM to 3:00 PM and provided care to Resident #43. NA #7 stated there were only 3 NAs for the entire shift and they basically had to focus on completing rounds and making sure the residents were kept dry and fed. NA #7 stated she explained to the residents, including Resident #43, that they were short-staffed and they wouldn't be able to get them up out of bed or give them a shower.
During a phone interview on 05/15/25 at 2:27 PM, NA #6 confirmed she was assigned to provide Resident #43's care on 05/03/25 and 05/10/25 during the hours of 3:00 PM to 11:00 PM but she did not give him a shower or bed bath during her shifts. NA #6 explained resident showers were almost always provided on first shift (7:00 AM to 3:00 PM) and she usually didn't have to give any showers during her shift unless first shift wasn't able to get them all done.
During an interview on 05/16/25 at 4:52 PM, the DON revealed she expected Resident #43 to receive his showers as scheduled.
During an interview on 05/16/25 at 9:45 AM, the Administrator stated she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the Director of Nursing (DON) should be notified.
Based on observations, record review, and resident and staff interviews, the facility failed to provide assistance with oral hygiene and nail care (Resident #86), and showers (Resident #43, #74, and #86) for 3 of 8 dependent residents reviewed for activities of daily living.
Findings included:
1 a. Resident #86 was admitted to the facility on [DATE] with diagnoses including obstructive pulmonary disease, pneumonia, and acute respiratory failure.
The admission MDS assessment dated [DATE] revealed Resident #86's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #86 had no natural teeth and required setup/cleanup assistance with oral hygiene and partial/moderate assistance with personal hygiene.
The care plan revised on 5/11/25 identified Resident #86 had a self-care deficit in performing activities of daily living. The care plan interventions included Resident #86 required assistance from staff with oral care and personal hygiene.
During observations and interviews with Resident #86 on 05/12/25 at 9:30 AM, 05/13/25 at 8:39 AM and 05/14/25 at 11:43 AM, the upper denture had a white colored buildup of debris. Resident #86 revealed he had an upper denture but not a lower one and had no difficulty with eating. Resident #86 stated he was not assisted with denture care or oral hygiene and did not know if he had a denture cup or denture brush and was unable to locate those items. The resident went on to say he was able and willing to take care of his own denture care, but due to not being able to locate, or having the supplies to complete the denture care, he was unable to take care of the denture himself.
An observation and interview were conducted with the DON on 05/14/25 at 12:11 PM. Resident #86 removed his upper denture upon request to show there was no change and the denture continued to have white colored buildup of debris. The DON stated denture care should have been done daily, Resident #86 should have a denture cup for soaking overnight, a denture brush for cleaning, and she expected assistance with oral hygiene to be provided.
An interview was conducted with NA #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 confirmed she worked the 7:00 AM to 3:00 PM shift on 05/14/25 and assigned to assist Resident #86 with activities of daily living including oral hygiene. NA #3 stated she had not assisted Resident #86 with oral hygiene due to the resident taking a long time to eat breakfast. NA #3 stated she was not given report during shift change, typically did not work on that hall, was not familiar with Resident #86, and unsure if he had dentures.
During an interview on 05/16/25 at 8:57 AM, the Administrator stated the expectation was for residents to receive assistance with oral hygiene and denture care twice a day, and dentures to be soaked overnight.
b. A review of the shower schedule binder located at the nurse station revealed Resident #86's showers were scheduled on Tuesday and Friday to be completed during the 3:00 PM to 11:00 PM second shift. Included in the binder were paper body audits for the Nurse Aide (NA) staff to document skin issues and care provided. There were completed body audit sheets in the binder, but none of them were for Resident #86.
A review of NA documentation for the previous 30 days indicated on 04/25/25 Resident #86 refused a shower. On 04/26/25 received a shower and on 05/13/25 refused the shower. There was no further documentation of shower activity or refused showers for Resident #86.
An observation and interview were conducted with Resident #86 on 05/12/25 at 9:30 AM. Resident #86 stated he was supposed to get shower today (Monday) and his showers were scheduled twice a week. Resident #86 thought he had a shower on Wednesday (05/07/25) but was not sure. Resident #86's hair was uncombed but not greasy.
An observation and interview were conducted with Resident #86 on 05/13/25 at 08:39 AM. Resident #86 stated he did not get a shower yesterday (Monday) and was told he would, but no one came to get him. He thought maybe he was asleep when the person came and stated he did not refuse his shower. Resident #86 stated it does not bother him he missed a shower but does want a shower twice week. Resident #86's hair was observed to be uncombed but not greasy.
During an interview on 05/14/25 at 12:44 PM, NA #9 revealed she was the assigned shower person and stated Resident #86 refused his scheduled shower due to be completed on 05/13/25 (Tuesday) when she offered. NA #9 revealed she did not report, or document Resident #86 had refused his shower.
During an interview on 05/14/25 at 1:39 PM, the DON stated she would expect if Resident #86 consistently refused showers that documentation would be included in the resident's medical record, progress notes, and care planned.
During an interview on 05/16/25 at 9:45 AM, the Administrator stated she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the DON should be notified.
c. During observations and interviews with Resident #86 on 05/12/25 at 9:30 AM, 05/13/25 at 8:39 AM and 05/14/25 at 11:43 AM the fingernails on the right and left hand were approximately one forth inch long from the tip of the finger with a black-colored buildup of debris underneath the nails. Resident #86 revealed he did not recall being offered nail care and denied he refused nail care.
An interview was conducted with NA #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 confirmed she worked the 7:00 AM to 3:00 PM shift on 05/14/25 and assigned to assist Resident #86 with activities of daily living including personal hygiene and nail care. NA #3 stated she noticed Resident #86's had a black colored buildup under his nails but he had refused nail care from her when offered.
An observation and interview were conducted with the DON on 05/14/25 at 12:11 PM. The DON observed Resident #86's fingernails continued to have a buildup of black colored debris and stated nail care was provided during showers/bathing or as needed. Resident #86 agreed to have his fingernails clipped, cleaned, and nail care was provided.
During an interview on 05/16/25 at 8:57 AM the Administrator stated nail care was provided during showers or as needed. The Administrator explained she was made aware Resident #86's nail care was not being done, and the resident had refused showers.
3. Resident #74 was admitted to the facility 02/06/25 with a diagnosis including diabetes.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #74 was cognitively intact and had no rejection of care during the lookback period. Resident #74 had impaired range of motion affecting one side of the upper extremity and required partial/moderate assistance with showers.
The activities of daily living (ADL) care plan last revised 02/19/25 revealed Resident #74 had an ADL self-care performance deficit related in part due to a diagnosis of diabetes and interventions included assisting him with showering on Wednesday and Saturday.
Review of the master shower schedule revealed Resident #74 was scheduled to receive a shower every Wednesday and Saturday on the 3:00 PM to 11:00 PM shift. Review of shower documentation revealed he did not receive a shower on 05/10/25. There was no documentation in Resident #74's medical record that he received a bed bath if he did not receive a shower.
An interview with Resident #74 on 05/12/25 at 9:21 AM revealed he was scheduled to receive his showers on Saturday and Wednesday, but he frequently missed his showers on Saturdays and if he missed his shower on Saturday, he had to wait until Wednesday to receive his shower. He stated he would like to receive his showers as scheduled. Resident #74 stated if he missed a shower he did not want or receive a bed bath instead.
In an interview with Nurse Aide (NA) #4 on 05/14/25 at 4:47 PM she confirmed she was assigned to care for Resident #74 on 05/10/25 on the 3:00 PM to 11:00 PM shift. She stated her assigned residents included all residents on 400 hall and all residents on 300 hall until 5:00 PM or 5:30 PM, when another NA came in to help. NA #4 stated from 5:00 PM or 5:30 PM she was assigned to care for all of 400 hall and the bottom half of 300 hall, and she did not have time to give Resident #74 his shower. NA #4 stated she did not specifically notify the nurse on 400 hall that Resident #74 did not receive his shower on 05/10/25 because the nurse was aware she was assigned to the 300 hall and 400 hall.
An interview with the Administrator on 05/16/25 at 9:45 AM revealed she expected residents to receive their showers as scheduled and if they did not receive a shower then she or the Director of Nursing (DON) should be notified.
An interview with the DON on 05/16/25 at 4:52 PM revealed she expected Resident #74 to receive his showers as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews with the Wound Care Medical Doctor (MD), the Medical Director and staff, the facility failed to obtain treatment orders for pressure ulcers identified on 04/24/25 resulting in a seven day delay of treatment. Additionally, the facility failed to complete accurate head-to-toe skin checks used to identify new or existing pressure ulcers that include the site (location), type of wound, the length, width, depth, and stage. The skin/wound assessment completed on 05/13/25 indicated the resident's skin was intact with no new pressure ulcer. On 05/14/25 a tissue injury (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) on the left heel was identified and measured 4 centimeters (cm) in length and 4.1 cm with width. The deficient practice occurred for 1 of 5 residents reviewed for pressure ulcers (Resident #86).
Findings included:
Resident #86 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (decreased muscle mass and strength) at multiple sites and moderate protein-calorie malnutrition.
The admission data collection tool dated 04/24/25 was documented by Nurse #6 and included Resident #86's skin conditions. The tool noted Resident #86's skin was not intact and identified pressure ulcers were present. The site/location of the pressure ulcers were on the right and left buttock, and sacrum. The information related to the length, width, depth, and stage of the pressure ulcers was left blank. Nurse #6 documented left foot/heel pain was noted and Resident #86's skin integrity was at moderate risk for pressure ulcers. Included was a skin integrity care plan with the goal Resident #86's skin would remain intact without signs of breakdown by next review. Interventions were to provide wound care and preventive skin care per physician's order, weekly skin checks per facility protocol and document findings, turn and reposition frequently to decrease pressure.
Resident #86's Treatment Administration Record (TAR) revealed no treatments were administered for pressure ulcers from 04/24/25 through 04/30/25.
The baseline care plan dated 04/25/25 completed by the former/interim Director of Nursing (DON) identified Resident #86 had pressure ulcers and/or potential for developing pressure ulcers with the goal the ulcer would show signs of healing and remain free from infection by the review date. Interventions were to administer treatments as ordered and observe effectiveness, reposition and/or turn at frequent intervals, observe dressing to ensure it was intact and adhering, and report loose dressing to the treatment nurse.
An interview with the former/interim DON was conducted on 05/14/25 at 4:37 PM. The interim/former DON revealed for a newly admitted resident the baseline care plan, admission data collection, nurse note, and skin assessment needed to be completed and should be done by the admitting nurse. She revealed newly admitted residents were discussed during their next morning Interdisciplinary Team meeting to ensure if pressure wounds were identified treatments orders were care planned and initiated by admitting nurse. The interim/former DON revealed at the time of Resident #86's admission nurse staffing had little to no support and on 04/24/25 there were three other new admissions to complete. The interim/former DON revealed if pressure ulcer wounds were identified on the baseline care plan there should be physician orders in place for treatment and stated she did the best she could with three admissions and sometimes the Interdisciplinary Team meetings were short and might not have the entire team present.
The nurse progress note dated 4/25/25 was documented by Nurse #6 and identified Resident #86 as having pressure sores on the middle right and left buttock and sacrum. Nurse #6 noted there was no drainage from the ulcers, the ulcers were red, and all were less than the size of a quarter.
A review of Resident #86's head-to-toe skin checks used to identify skin integrity concerns of new or existing pressure ulcers and documentation of the site (location), type of wound, the length, width, depth, and stage completed on 05/01/25 indicated the skin was intact but did note changes to the skin integrity as redness under a dressing but no open areas. On 05/03/25, 05/05/25, and 05/09/25 the checks indicated Resident #86's skin was intact with no changes to skin integrity.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86's cognition was moderately impaired with no rejection of care behaviors during the lookback period. Resident #86 needed setup assistance with rolling left to right in bed and partial to moderate assistance with transfers. The MDS skin conditions indicated there were no unhealed pressure ulcers at stage one (intact skin with non-blanchable redness over a localized area) or higher.
A review of the Wound Care MD note dated 04/30/25 revealed Resident #86's visit was rescheduled. There were no other Wound Care MD notes in Resident #86's medical records to indicate the pressure ulcers were evaluated by the provider.
An interview was conducted on 05/15/25 at 1:38 PM with the Wound Care MD. The MD revealed she was the wound care provider for the facility and visited every Wednesday. She relied on the facility to inform her which residents she needed to evaluate and was provided a list of who to see. She was not aware of any pressure ulcer wounds for Resident #86 and confirmed on 04/30/25 the visit was rescheduled. She was unsure why Resident #86 fell off her list of residents to evaluate after 04/30/25 and revealed it could have been an oversight.
A review of Resident #86's current physician orders revealed on 04/30/25 an order was obtained to cleanse an area on the sacrum with normal saline or wound wash, pat dry and apply a hydrocolloid dressing (a moist insulated bandage used to promote healing) and cover with a clean and dry dressing every day shift for wound care.
A review of Resident #86's TAR revealed the physician order was transcribed to cleanse the area to sacrum with normal saline or wound wash, pat dry and apply hydrocolloid dressing, and cover with clean and dry dressing every day shift for wound care. On 05/01/25 wound care treatments were started and continued daily except on 05/02/25, it was noted as Resident #86 refused and on 05/03/25 and 05/06/25 the TAR was blank with no nurse initials to indicate it was done.
The nursing daily skilled charting dated 05/13/25 was documented by Nurse #6 and noted Resident #86's skin was intact and there were no changes in the resident's skin integrity.
During an interview on 05/14/25 at 4:09 PM, Nurse #6 confirmed she completed Resident #86's admission data collection dated 04/24/25. She described the areas on Resident #86's left, and right buttock and sacrum were not open or draining and were on the surface of the skin. Nurse #6 revealed she did not check if the pressure ulcers were blanchable and she did not measure the wounds. She further revealed she was not aware measuring the pressure ulcers was an expectation until approximately one month later and stated she had not been shown the full process of completing a new admission and learned by word of mouth or after being told she did something wrong. Nurse #6 stated she was not provided education on how to complete the nursing daily skilled charting when hired and had asked for that on many different occasion. Nurse #6 confirmed she completed the nursing daily skilled charting on 05/13/25 and her documentation incorrectly noted Resident #86's skin was intact. Nurse #6 stated it was an error on her part, and she knew Resident #86 continued to have pressure ulcer wounds on his buttock and sacrum and stated she must have hit the wrong button. Nurse #6 revealed she did not visually check Resident #86's skin integrity when she completed her nursing daily skilled charting on 05/13/25 but knew Resident #86's skin was not intact based on the admission assessment she completed on 04/24/25.
An observation of Resident #86's head-to-toe skin check was made on 05/14/25 at 12:12 PM with the Unit Manager who completed the check. There was no hydrocolloid dressing in place as ordered on the sacrum. A stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) sacrum pressure ulcer with no visible drainage or odor was identified. Several small, different shaped scattered red and purple areas were observed on the left and right buttock that were blanchable. A non-blanchable deep tissue injury was observed on the left heel that was circular in shape and colored dark purple with surrounding redness. When touched Resident #86 did not verbalize pain.
An interview was conducted with Nurse Aide (NA) #3 on 05/14/25 at 12:44 PM and 12:54 PM. NA #3 revealed she was assigned to assist Resident #86 with activities of daily living on 05/14/25 from 7:00 AM through 3:00 PM. NA #3 revealed the care she had provided included emptying the catheter bag and catheter care. NA #3 stated she did not recall if she saw a dressing on the sacrum but did observe the skin on Resident #86's buttock was red, but she did not report that to the nurse. NA #6 revealed Resident #86 was already wearing socks, and she did not observed the resident's left foot and normally she was not assigned to the hall and not very familiar with Resident #86 and did not receive report at the beginning of her shift.
An interview was conducted on 05/15/25 at 2:38 PM with Nurse #3. Nurse #3 confirmed she was assigned to complete wound care for residents on 05/14/25. Nurse #3 revealed the Wound Care MD did not see Resident #86 and confirmed the resident was not on the list. Nurse #3 revealed Resident #86's hydrocolloid dressing was in place on the sacrum when she went to provide wound care on 05/14/25. She revealed the hydrocolloid dressing was soiled and she placed a new dressing on the sacrum.
A review of Resident #86's head-to-toe skin check dated 05/14/25 documented by the Unit Manager revealed a new pressure ulcer was identified. The new ulcer was located on the left heel and measured 4 cm in length, 4.1 cm in width, had no depth and staged as a deep tissue injury. The existing pressure ulcer on the sacrum measured 3.8 cm in length, 4.9 cm in width, and 0.2 cm in depth and was a stage 2.
A review of Resident #86's current physician orders included a Wound MD consult and to treat as needed dated 05/14/25. For a left heel deep tissue injury cleanse the area with mild soap and water, apply a protective foam dressing to heel and secure with stretch gauze every Monday, Wednesday, Friday, and as needed dated 05/14/25. For the resident to wear multi-podus boot (a device used to offload pressure) to left foot while in bed for offloading/skin integrity dated 05/14/25.
During an interview on 05/15/25 at 10:43 AM and on 05/16/25 at 4:41 PM, the DON revealed she expected inventions were implemented on 04/24/25 when Resident #86 was admitted with pressure ulcers and measurements of those ulcers were completed and used as a reference for monitoring. She revealed skin assessments were not consecutively completed, and she expected those were done weekly as the facility's standard of practice. The DON revealed the expectation for completing the skin/wound assessments was for the nurse to visually check the resident's skin and identify existing and new skin breakdown.
An interview was conducted on 05/15/25 at 9:10 AM with the Medical Director. The Medical Director revealed the Wound Care Nurse completed treatments and notified the Wound Care MD who followed pressure ulcer wounds. The Medical Director revealed he expected pressure ulcer treatments were obtained for Resident #86 when first admitted on [DATE] and the dressing was in place as ordered. He was unsure if Resident #86's pressure ulcers were avoidable and described Resident #86 as being emaciated (thin and frail) weighing 126 pounds on admission with a diagnoses of muscle wasting and atrophy placing the resident at high risk for worsening or developing a pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to protect a resident's right to privacy when the Assistant Director of Nursing (ADON) received a medical report from Emergency Medical Services (EMS) personnel about a resident returning to the facility while standing in the hallway by the resident's room for 1 of 1 sampled resident (Resident #1). A reasonable person would not have wanted their private medical information discussed out in the hallway where other staff, residents and visitors could overhear.
Findings included:
Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease.
The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had severe cognitive impairment.
During an observation on 03/25/25 at 10:38 AM, EMS personnel were observed bringing Resident #1 back to her room. The Director of Nursing (DON) was in the room assisting Resident #1's roommate as staff assisted Resident #1 back to bed. The ADON and EMS personnel stepped out into the hallway just outside Resident #1's room door and EMS personnel proceeded to give the ADON a detailed medical report, including Resident #1's name, regarding Resident #1's transport to the hospital for her follow-up Orthopedic appointment. The conversation could have been easily heard by other staff, residents and visitors in the vicinity, going up and down the hallway.
During an interview on 03/26/25 at 3:40 PM, the ADON confirmed she had received a medical report from EMS regarding Resident #1 while standing out in the hallway. The ADON stated she thought they were just going to have her sign paperwork, but the EMS personnel kept talking. The ADON stated she should have interrupted the EMS personnel to take her back into Resident's room to finish the report in order to ensure Resident #1's privacy.
During an interview on 03/25/25 at 5:10 PM, the DON explained EMS personnel typically gave report to nursing staff in a resident's room when bringing them back to the facility. The DON confirmed she was in the room assisting Resident #1's roommate at the time and she had not noticed that the ADON and EMS personnel had stepped outside into the hallway to discuss Resident #1's medical information. The DON stated she would want Resident #1's privacy maintained.
During an interview on 03/26/25 at 4:15 PM, the Administrator revealed she would expect for staff to maintain Resident #1's privacy and not receive a medical report from EMS personnel while standing out in the hallway. The Administrator stated staff should have intervened to let EMS personnel know to step inside Resident #1's room and pulled the door closed to have the discussion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure fluids were available within reach for staff to offer and assist a resident with fluid intake in-between meals for 1 of 3 residents reviewed for hydration (Resident #2).
Findings included:
Resident #2 was admitted to the facility on [DATE]. Her cumulative diagnoses included dysphagia (difficulty swallowing), contracture of the right and left elbows, contracture of the right and left hands, and vascular dementia.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate impairment in cognition, impairment on both sides of the upper and lower extremities and was dependent of staff for assistance with eating.
A physician order dated 03/09/25 for Resident #2 revealed she was to receive a pureed diet with honey consistency thickened liquids.
A care plan, last revised on 03/12/25, revealed Resident #2 was dependent on staff for feeding assistance, received a mechanically altered and thickened liquids diet and was at risk for dehydration. Interventions included to provide and serve diet as ordered and assist with all meals.
An observation and interview was conducted with Resident #2 on 03/25/25 at 10:23 AM. Resident #2 was in her room sitting up in her reclining wheelchair, alert and well-groomed. On the top of the nightstand located in back of Resident #2's recliner was a red, soft fabric cooler that had a warm ice pack and no fluids. Beside the cooler was a 4-ounce cup that contained a milky colored fluid substance and covered in saran wrap that was not dated or labeled to indicate the contents. On the back of the nightstand by the wall was an opened 46-ounce carton of honey thick lemon flavored water with a date of 02/04 written in red ink on top of the carton. When asked if she was thirsty, Resident #2 replied yes. When asked if staff assisted or offered her something to drink throughout the day, she stated she only received something to drink with meals and nothing in-between. During the conversation, staff were informed at 10:25 AM that Resident #1 voiced she was thirsty and requested something to drink. At 10:35 AM when no one had returned to assist Resident #2, a second request was made to the Director of Nursing (DON) for assistance with getting Resident #2 something to drink. The DON brought Resident #2 a 4-ounce cup of thickened water that she had gotten from the kitchen, assisted Resident #2 with taking a drink and Resident #2 consumed the 4-ounces of fluid provided.
During an interview on 03/26/25 at 1:27 PM, Nurse Aide (NA) #1 revealed Resident #2 received thickened liquids and usually there were individual containers of thickened liquids kept in the cooler in her room but the kitchen had been out of those for a while. NA #1 stated she did not notice the container of thickened liquid or cup of thickened liquid on top of Resident #2's nightstand. She explained if Resident #2 wanted something to drink in-between meals, she went to the kitchen to get her something to drink. NA #1 stated she asked Resident #2 if she wanted something to drink during rounds and if she did, NA #1 assisted her. NA #1 stated Resident #2 usually drank about 8-ounces of fluid with meals but she could not recall if she had offered and assisted Resident #2 with a drink of fluids in-between meals on 03/25/25 or 03/26/25.
During an interview on 03/26/25 at 1:45 PM, NA #2 revealed Resident #2 was not able to use her hands and required staff assistance with eating and drinking. NA #2 explained she normally offered fluids when doing rounds, at meals or when passing ice. NA #2 stated she didn't pay attention to the cooler nor did she notice the carton of thickened liquid that were both placed on top of Resident #2's nightstand. She explained when a resident wanted something to drink and was on thickened liquids, she typically got something from the kitchen. NA #2 could not recall if she had offered and assisted Resident #2 with a drink of fluids in-between meals on 03/25/25 or 03/26/25.
During an interview on 03/26/25 at 4:15 PM, the Administrator stated nursing staff should be offering and assisting residents as needed with a drink of fluids in-between meals, during rounds.
During a joint interview on 03/26/25 with the Administrator present, the District Dietary Manager explained when containers of thickened liquids arrived, they were dated with the received date and once opened, should be marked with a use-by date of 3 days if not refrigerated. The District Dietary Manager stated they had been out of the individual 4-ounce containers of thickened liquids to keep in the coolers at bedside, so dietary staff had been pre-pouring thickened liquids into 4-ounce cups that were covered with saran wrap and stored in the kitchen refrigerator for staff to request when needed. He stated that dietary staff should be putting a date on the pre-poured cups of thickened liquids that were used when staff requested something for a resident but they did not put dates on the cups that went out with the resident's meal because they assumed the resident would be drinking it with the meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to post cautionary and safety signs that indicated the use of oxygen, ensure oxygen concentrators were clean of debris, and ensure nebulizer masks were covered when not in use for 4 of 10 sampled residents (Residents #2, #4, #5, and #6).
Findings included:
a. Resident #2 was admitted to the facility on [DATE]. Her cumulative diagnoses included respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions).
A physician's order dated 12/18/24 for Resident #2 read, oxygen at 2 liters per minute (LPM) via nasal cannula every shift.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had moderate impairment in cognition and received oxygen therapy during the MDS assessment period.
An observation conducted on 03/25/25 at 10:23 AM revealed Resident #2 lying in her reclining wheelchair receiving supplemental oxygen via nasal cannula at 2 LPM. There was dried debris on the top of the concentrator and on the dial used to adjust the amount of oxygen. There was no sign posted on the door, doorframe or in Resident #2's room to indicate oxygen was in use.
During an observation and interview on 03/25/25 at 5:10 PM, the Director of Nursing (DON) confirmed there was no signage posted to indicate Resident #2 used oxygen. The DON acknowledged the oxygen concentrator had dried debris and explained staff should clean the oxygen concentrator weekly when the tubing was changed and as needed when visibly soiled.
b. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD; lung disease that blocks airflow making it difficult to breathe).
A physician's order dated 02/06/25 for Resident #4 read, formoterol fumarate inhalation nebulization solution (used to treat COPD by opening the airways of the lungs making it easier to breathe) 20 micrograms (mcg)/2 milliliters (ml) - inhale 2 ml via nebulizer two times a day for COPD.
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had intact cognition.
During an observation and interview on 03/25/25 at 9:29 AM, Resident #4's nebulizer machine was sitting on top of his nightstand with the mask lying directly behind the machine dirty and uncovered. Resident #4 stated the nebulizer treatments helped his breathing and he last used the machine approximately 30 minutes ago.
During an observation and interview on 03/25/25 at 4:45 PM, the Director of Nursing (DON) acknowledged the mask for the nebulizer machine appeared dirty and was uncovered on top of Resident #4's nightstand. The DON explained when not in use, the nebulizer mask should be covered and stored in a plastic bag.
c. Resident #5 was admitted to the facility on [DATE] with diagnoses that included respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), obstructive sleep apnea (intermittent airflow blockage during sleep) and dependence on supplemental oxygen.
A Nurse admission Data Collection assessment dated [DATE] noted Resident #5 was alert and oriented to person, place and time and needed assistance with decisions at times.
Review of the physician orders for Resident #5 revealed the following:
-03/07/25: oxygen at 4 liters per minute (LPM) via nasal cannula, continuous every shift.
-03/07/25: Levalbuterol HCL nebulization solution (used to treat COPD by opening the airways of the lungs making it easier to breathe) 0.63 milligrams (mg)/3 milliliters (ml) - inhale 3 ml orally via nebulizer every 6 hours as needed for COPD, shortness of breath.
During an observation of Resident #5's room on 03/25/25 at 10:02 AM, an oxygen concentrator was observed on with oxygen administration set at 4 LPM. There was no sign posted on the door, doorframe or in Resident #5's room to indicate oxygen was in use. On the nightstand was a nebulizer machine with the uncovered mask placed on top of the machine.
During an observation and interview on 03/25/25 at 5:03 PM, the Director of Nursing (DON) confirmed there was no signage posted to indicate Resident #5 used oxygen. The DON also confirmed the mask for the nebulizer machine was uncovered and stored on top of Resident #5's nightstand. The DON explained when not in use, the nebulizer mask should be covered and stored in a plastic bag.
d. Resident #6 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD; lung disease that blocks airflow making it difficult to breathe).
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had intact cognition and she did not receive oxygen therapy during the MDS assessment period.
A physician order dated 03/17/25 for Resident #6 read, ipratropium-albuterol (used to treat COPD by opening the airways of the lungs making it easier to breathe) 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml) solution - administer one ampule (small, sealed container used to store and administer sterile solutions) every 6 hours as needed for shortness of breath/wheezing.
A physician order dated 03/17/25 for Resident #6 read, oxygen at 2 liters per minute (LPM) via nasal cannula as needed for oxygen saturation under 90%.
During observations on 03/25/25 at 10:19 AM and 3:20 PM, an oxygen concentrator was observed on with oxygen administration set at 2 LPM and a nebulizer machine was placed on top of the nightstand. There was no sign posted on the door, doorframe or in Resident #6's room to indicate oxygen was in use. The nebulizer tubing and uncovered mask were hanging down the side of the nightstand with the mask almost touching the floor. Resident #6 was not present in the room during the observations.
During an observation and interview on 03/25/25 at 5:06 PM, the Director of Nursing (DON) confirmed there was no sign posted on the door, doorframe or in Resident #6's room to indicate oxygen was in use. The DON acknowledged the nebulizer tubing and uncovered mask were hanging down the side of the nightstand with the mask almost touching the floor. The DON explained when not in use, the nebulizer mask should be covered and stored in a plastic bag.
During an interview on 03/26/25 at 4:15 PM, the Administrator stated they had received conflicting information regarding the posting of oxygen signage for residents receiving supplemental oxygen. She explained the facility would be cited during federal surveys for oxygen signage not being in place but then Life Safety would tell them the oxygen signage did not need to be placed outside of or in individual resident rooms. The Administrator stated staff should be checking nebulizer masks during rounds to ensure they were stored in a bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to secure nasal sprays and medicated creams stored in resident rooms in clear view at the bedside for 3 of 10 sampled residents (Residents #3, #4 and #5).
Findings included:
a. A Nurse admission Data Collection assessment dated [DATE] noted Resident #3 was alert and oriented to person, place and time with intact short-term and long-term memory recall. It was further noted Resident #3 did not wish to self-administer medications.
During an observation and interview on 03/25/25 at 9:47 AM, in clear view on Resident #3's overbed table was a 2-ounce tube of skin protectant paste with an active ingredient of 17% zinc oxide. Resident #3 stated the skin protectant was applied by staff and they must have left it in the room.
During an observation and interview on 03/25/25 at 4:48 PM, the Director of Nursing (DON) observed the skin protectant paste on Resident #3's overbed table and stated it should not have been left in the room. The DON explained the skin protectant paste was applied by the nurse and should be stored on the treatment cart when not being used.
b. A Nurse admission Data Collection assessment dated [DATE] noted Resident #4 did not wish to self-administer medications.
During an observation on 03/25/25 at 09:29 AM in clear view on top of Resident #4's nightstand was a 1.5 ounce bottle of saline nasal spray with an active ingredient of sodium chloride and a 1.5 ounce tube of skin cream with an active ingredient of 1.5% dimethicone.
During an interview on 03/26/25 at 9:49 AM Resident #4 explained staff applied the cream to his abdomen and he hadn't noticed it was left on his nightstand. Resident #4 could not recall when he last used the nasal spray or who had provided it for him.
During an observation and interview on 03/25/25 at 4:45 PM, the Director of Nursing (DON) observed the nasal spray and skin cream on Resident #4's nightstand. The DON explained the saline nasal spray should have been stored in the nurse medication cart, not left in the resident's room and the skin cream was usually left in a resident's room for staff and/or residents to use when needed.
c. A Nurse admission Data Collection assessment dated [DATE] noted Resident #5 was alert and oriented to person, place and time and needed assistance with decisions at times. It was further noted Resident #5 did not wish to self-administer medications.
During an observation on 03/25/25 at 10:02 AM, in clear view on Resident #5's desk table was a 3 ounce bottle of nasal spray with active ingredients of 65% sodium chloride, disodium phosphate, phenylcarbinol, monosodium phosphate, and benzalkonium chloride.
During an observation and interview on 03/25/25 at 5:03 PM, the Director of Nursing (DON) observed the nasal spray on Resident #5's table and stated it should have been stored in the nurse medication cart, not left in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with the Resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to provide recommendations when the facility failed to transcribe four physician orders for a scheduled opioid pain medication to the medication administration record (MAR) from [DATE] through [DATE] and ensure there was a current order on the MAR to administer the pain medication for 1 of 5 residents reviewed for unnecessary medications (Residents #30).
The findings included:
Resident #30 was admitted to the facility on [DATE] with diagnoses including osteoarthritis.
A review of Resident #30's care plan for pain dated [DATE] revealed he was at risk of pain due to osteoarthritis. The goal was to decrease the frequency and intensity of pain. Interventions included administering pain medications as ordered.
A review of the physician's order dated [DATE] indicated Resident #30 had an order to receive 1 tablet of oxycodone 10 milligrams (mg) by mouth once every 6 hours for pain for 14 days. This order expired after 14 days on [DATE].
A review of the MAR for the months of [DATE] and [DATE] revealed Resident #30 continued to receive 10 mg of oxycodone 4 times daily until [DATE] with the expired order initiated on [DATE].
Further review of Resident #30's physicians orders revealed four orders for oxycodone that were not transcribed to the MAR.
[DATE] - Oxycodone 10 mg, 1 tablet by mouth every 6 hours for pain.
[DATE] - Oxycodone 10 mg, 1 tablet by mouth every 6 hours for pain.
[DATE] - Oxycodone 10 mg, 1 tablet by mouth every 6 hours for pain.
[DATE] - Oxycodone 10 mg, 1 tablet by mouth every 6 hours for pain.
The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #30 with intact cognition and revealed he had received opioid each day of the 7-day assessment periods.
A review of medical records indicated the Consultant Pharmacist had conducted monthly medication regimen reviews (MRRs) for Resident #30 on [DATE] and [DATE]. There was no documentation regarding the orders for oxycodone written on [DATE], [DATE], [DATE], and [DATE] not being transcribed to the MAR or the order for oxycodone written on [DATE] expiring on [DATE].
During an interview conducted on [DATE] at 2:15 PM, Resident #30 confirmed he had received 10 mg of oxycodone four times daily as ordered from [DATE] through [DATE].
During a phone interview conducted on [DATE] at 11:18 AM, Nurse #5 acknowledged that she had transcribed the scheduled oxycodone order into the computer system when Resident #30 re-admitted to the facility from hospital on [DATE]. She could not recall transcribing any other scheduled oxycodone orders for Resident #30 from [DATE] through [DATE].
A phone interview was conducted with the Family Nurse Practitioner (FNP) on [DATE] at 3:28 PM. She confirmed the physician had issued 4 new orders of scheduled oxycodone for Resident #30 from [DATE] through [DATE]. She did not know why these orders were not being transcribed into the MAR.
During a phone interview conducted with the Consultant Pharmacist on [DATE] at 3:08 PM, she acknowledged that she had conducted MRRs for Resident #30 on [DATE] and [DATE]. She did not notice that the oxycodone order written on [DATE] had expired after [DATE]. She attributed the incident as an oversight.
An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:35 PM. She expected the Consultant pharmacist to identify the drug irregularities related to expired order and report the findings to the facility in a timely manner when performing the monthly MRR.
During an interview conducted on [DATE] at 12:42 PM with the MD, he stated it was his expectation for the Consultant Pharmacist to identify the drug irregularities related to expired order and report the findings to him and the facility in a timely manner.
During a phone interview conducted on [DATE] at 12:17 PM, the Clinical Services Director stated the physician had issued four new prescriptions of scheduled oxycodone for Resident #30 on [DATE], [DATE], [DATE], and [DATE]. She added when the Consultant Pharmacist performed monthly MRRs for Resident #30, she had full access to the MAR and was expected to notice the scheduled oxycodone order initiated on [DATE] had expired by [DATE] and subsequent orders of scheduled oxycodone were not transcribed. It was her expectation for the Consultant Pharmacist to identify the errors and notify the facility in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with the Health Care Power of Attorney (HCPOA), the Resident Representative, staff, and the Medical Director, the facility failed to honor an immunization declination when Resident #376 was administered an influenza vaccine after her HCPOA had declined the vaccination. This was for 1 of 6 residents reviewed for vaccination status (Resident #376).
The findings included:
Resident #376 was admitted to the facility on [DATE].
Review of Resident #376's medical record revealed The Statutory Form Health Care Power of Attorney dated 3/2/21. The form indicated Resident #376 appointed her Health Care Power of Attorney (HCPOA) to act for her and in her name to make health care decisions for her. It further indicated that Resident #376 granted her HCPOA full power and authority to make health care decisions on her behalf, including, but not limited to: to give consent for, to withdraw consent for, or to withhold consent for, x-ray, anesthesia, medication, surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed physician, dentist or podiatrist.
The Informed Consent for Influenza Immunization for Resident #376 dated 8/14/22 indicated Resident #376's HCPOA marked the box for: having been educated on the benefits and risks associated with not receiving the influenza vaccine, (she) hereby declined permission for this facility to administer the vaccination. The form was signed by Resident #376's HCPOA and the Admissions Director on 8/14/22.
A Palliative Care Nurse Practitioner note dated 9/20/22 for Resident #376 indicated Resident #376 had altered mental status. Resident #376 did not consistently answer questions asked. She was alert but did not appear to fully understand what was being asked of her.
The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #376 was severely cognitively impaired.
An Informed Consent for Influenza Immunization for Resident #376 dated 9/29/22 indicated the box was checked for: having been educated on the benefits and risks associated with receiving the influenza vaccine, (she) hereby give this facility permission to administer the vaccination, unless medically contraindicated. The form was signed by the Director of Nursing on 9/29/22 with a notation of: resident gave verbal consent.
A nurses' progress note dated 10/13/22 at 8:37 PM by Nurse #3 in Resident #376's medical record indicated influenza vaccine was given this morning without any adverse reaction. Resident #376 denied any pain. Vital signs were within normal limits.
A phone interview with Nurse #3 on 1/30/24 at 9:28 AM revealed Resident #376 received the influenza vaccine in the morning shift on 10/13/22. Nurse #3 stated he worked the evening shift on 10/13/22 and received report from the outgoing nurse that Resident #376 got the flu shot that morning. Nurse #3 could not remember Resident #376 or which nurse gave Resident #376 the flu shot but he remembered receiving a phone call from Resident #376's HCPOA on 10/13/22. Resident #376's HCPOA was upset about Resident #376 receiving a flu shot despite her signing the declination form as witnessed by the Admissions Director. Nurse #3 told Resident #376's HCPOA that he would get someone to follow-up with her.
A phone interview with Resident #376's HCPOA on 1/30/24 at 8:40 AM revealed Resident #376 was admitted to the facility to receive comfort care due to a terminal illness. The HCPOA stated that she and Resident #376's Resident Representative visited Resident #376 every day while she was at the facility and Resident #376 was confused and not responding appropriately the whole time she was there. On 10/13/22 while the Resident Representative was at the bedside, a nurse administered the flu shot to Resident #376. The Resident Representative notified the HCPOA about this, so the HCPOA called the Director of Nursing (DON) and asked her why Resident #376 was given the flu shot when she did not consent to this. The HCPOA stated that the DON told her that they had assumed she consented to the flu vaccine because she had consented to the COVID-19 booster. The HCPOA further stated that Resident #376 had brain cancer, and should not have been given the flu vaccine which was not necessary and was not approved by her. The HCPOA reiterated that she had the right to make healthcare decisions for Resident #376 and that Resident #376 did not have the ability to give an informed consent to the flu vaccine.
A phone interview with the Resident Representative on 1/30/24 at 9:25 AM revealed she witnessed Nurse #2 administer a shot to Resident #376 on 10/13/22. The Resident Representative stated she asked Nurse #2 what it was, and Nurse #2 told her it was the flu vaccine. She further stated she did not observe Nurse #2 ask Resident #376 if she wanted to receive the flu shot before administering it to her. Nurse #2 also did not ask the Resident Representative if she was fine with Resident #376 receiving the flu shot. She also shared that Resident #376 was awake that day, but she was confused.
An interview with Nurse #2 on 1/30/24 at 9:54 AM revealed she did not remember Resident #376 but stated that it was possible that she had given Resident #376 her flu shot on 10/13/22. Nurse #2 stated she was sometimes asked to give flu immunizations and the DON would normally give her a list of residents who were supposed to receive the flu shot. Nurse #2 stated she did not look at the consents prior to administering the flu shots and assumed that the residents on the list had signed consent forms. Nurse #2 also stated that she later found out that Resident #376's HCPOA had declined for her to receive the flu vaccine.
An interview with the Admissions Director on 1/30/24 at 1:07 PM revealed she witnessed Resident #376's HCPOA decline the influenza immunization when she signed her paperwork during admission. The Admissions Director stated she had a copy of the paperwork regarding Resident #376's HCPOA which meant that Resident #376 had chosen her HCPOA to make medical decisions for her.
An interview with the Medical Director (MD) on 2/1/24 at 11:46 AM revealed Resident #376 had intermittent periods of confusion when he saw her on 9/29/22 but with Resident #376's medical diagnosis of brain tumor, it would be a bonus to get anything out of her cognitively and he wouldn't expect her to able to give an informed consent. The MD stated the staff probably should have consulted with the HCPOA regarding the immunization and hospice because they were more familiar with the resident.
An interview with the Director of Nursing (DON) on 2/1/24 at 8:44 AM revealed she could vaguely remember Resident #376 or having conversations with her HCPOA. The DON stated when residents were admitted to the facility, the family member would initially sign the paperwork which included the immunization consent/declination forms. The DON stated when Resident #376 was admitted , it was not flu season, so she obtained a verbal consent from Resident #376 on 9/29/22. The DON stated Resident #376 was probably alert that day and she would have asked her if she wanted to receive the flu shot or not. The DON stated she normally just told the residents that possible adverse reactions were flu-like symptoms and soreness on the injection area, but she did not usually ask them to repeat the information she provided regarding the flu shot. The DON stated she did not know that Resident #376's HCPOA had declined for her to receive the flu shot initially and did not look back at the consent/declination forms for Resident #376. The DON further stated that the Admissions Director should have written in the immunization consent forms that the flu shot was not in season to alert the HCPOA that they would be asked again during flu season. The DON added that she did not ask Resident #376's HCPOA again or friend at the bedside about whether Resident #376 should receive the flu shot because she obtained the verbal consent from Resident #376. The DON maintained that based on the nurses' progress notes in Resident #376's medical record, she had been alert but the DON was not aware that Resident #376 had been assessed as severely cognitively impaired. The DON stated that they would call the responsible party to obtain consent for severely cognitively impaired residents. She also shared that she vaguely remembered receiving a phone call from Resident #376's HCPOA who questioned her why Resident #376 received a flu vaccine despite her having declined to it.
An interview with the Administrator on 2/1/24 at 12:41 PM revealed he did not remember Resident #376 and did not remember the issue with her receiving the flu vaccine even though her HCPOA declined for her to receive it. The Administrator stated they would usually obtain consent from the resident or the family member prior to administering immunizations. If the resident was able to give consent and make their own decisions, they would ask the resident. The Administrator stated that residents who had moderate cognitive impairment and intact cognition would be able to give their consent to immunizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff and physician, the facility failed to protect residents' rights to be free from misappropriation of controlled medication for 5 of 5 residents (Resident #40, #126, #128, #129, and #130) reviewed for misappropriation of resident property.
The findings included:
The facility's Abuse Prevention, Intervention, Reporting, and Investigation policy, last revised February 2021, revealed in part the facility would ensure all residents were free from misappropriation of property.
A review of the initial allegation report dated [DATE] revealed the facility became aware of the incident on [DATE] at 8:30 AM when 5 tablets of Ativan (medication used to treat anxiety) for Resident #128 and 6 tablets of oxycodone (pain medication) for Resident #129 were reported missing.
All the Residents were in the facility when the incident occurred on [DATE]. Residents #126, #128, #129, and #130 had been discharged from the facility when the surveyor started the investigation on [DATE].
The 5-day investigation report dated [DATE] revealed during the facility's investigation, additional medications that were prescribed to Resident #40, Resident #126, and Resident #129 were unaccounted for. The allegation of diversion of Residents' drugs was substantiated and Nurse #1 was terminated on [DATE].
During an interview conducted with Nurse Aide (NA) #1 on [DATE] at 3:09 PM, she stated while she was working on the 400 hall on [DATE], she saw Nurse #1 putting 2 cards of controlled medications into her personal bag in the 400 Hall charting room around 7:15 PM. She added Nurse #1 was aware that she had witnessed the incident; however, they did not talk to each other at that moment. She was shocked to see the incident and immediately notified the DON via text message. The DON wanted to know which medications were stolen and she replied, Ativan and oxycodone and the DON told her that she would handle the case. She stated when she approached Nurse #1 around 6:00 AM as one resident was asking for pain medication, Nurse #1 was sleeping and acting weird and upon waking up. NA #1 left the facility after completing her shift on [DATE] morning around 6:45 AM.
An interview was conducted with the DON on [DATE] at 3:50 PM. She stated she was at home when NA #1 reported the incident during the evening on [DATE]. She called the local law enforcement agency immediately, and the police came to the facility to take a statement from Nurse #1. When she came into the facility the next morning, Nurse #1 had already left the facility. She called Nurse #1 on the morning of [DATE] and informed her that she was suspended for 5 days pending an investigation of potential drug diversion. During the investigation, she confirmed Nurse #1 had handled the returning totes (a plastic cage contained medications to be returned to the pharmacy) in medication storage room on [DATE] evening and 5 tablets of Ativan 0.5 milligrams (mg) for Resident #128 and 6 tablets of oxycodone 5 mg for Residents #129 were reported missing. On [DATE] morning, the Assistant Director of Nursing (ADON) reported seeing torn count sheets in the sharp container in a medication cart. She instructed the ADON to put the sharp container in the medication storage room and she would investigate the next morning. When she pieced the torn sheets back together on [DATE] morning, she found that 2 tablets of Norco (a pain medication containing hydrocodone and Tylenol) 5/325 mg for Resident #130, 6 tablets of Norco 5/325 mg for Resident #126, and 6 tablets of oxycodone 10 mg for Resident #40 were missing. The DON stated all the Residents affected by the incident were assessed immediately without any adverse effects noted. She notified the Board of Nursing and DEA on [DATE], and the Medical Director on [DATE]. She started the in-service to educate all the licensed nurses on [DATE] and it was completed by [DATE]. She stated Nurse #1 was terminated on [DATE] and all the missing controlled medications were replaced at the cost of the facility. The families of the Residents involved in the incident were notified on [DATE].
An attempt to conduct a phone interview with Nurse #1 on [DATE] at 4:11 PM was unsuccessful. She did not return the call.
During an interview conducted on [DATE] at 12:42 PM, the Medical Director (MD) stated he was informed on [DATE] of the missing controlled substances and the list of Residents affected. He stated all the affected Residents were assessed immediately without any adverse consequences noted as the missing drugs were used on as needed basis. He added all the missing medications were replaced and paid for by the facility.
The facility provided the following corrective action plan with a completion date of [DATE]:
Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice:
CNA #1 reported to Director of Nursing on [DATE] Licensed Nurse (Nurse #1) had potentially taken PRN (as needed) controlled substances from two resident PRN-controlled substance cards. No negative outcomes for the 2 residents as they were PRN medication and facility had the controlled substances in backup. Medication was replaced prior to residents requesting them.
Director of Nursing suspended the Licensed Nurse (Nurse #1) who was suspected of misappropriation during the investigation immediately on [DATE] upon learning of the incident. Director of Nursing completed the 24-hour report to the Department of Health and Human Services (DHHS) on [DATE]. The Director of Nursing then began an investigation of missing controlled substances and completed interviews with all licensed nurses who had worked on the cart of missing controlled substances. Director of Nursing submitted the five-day report upon completion of investigation on [DATE] to DHHS.
The facility Director of Nursing Notified the Board of Nursing on [DATE], the DEA was notified on [DATE], and the local Police Department on [DATE] upon the discovery of the missing controlled substances.
Facility notified the Medical Director on [DATE] of the missing PRN controlled substances and the residents involved. Residents were assessed on [DATE] with no adverse effects as the medications were PRN and replaced by facility prior to being needed.
Address how the facility will identify other residents having the potential to be affected by the same deficient practice:
100% Audit was conducted [DATE] by the Director of Nursing and Charge Nurses of the control sheets and each medication on all medication carts to verify that all controlled substances and control sheets and discovered all PRN-controlled substances were not accounted for.
The Director of Nursing found that there was a total of 5 affected residents following the audit. The facility replaced all medications as required for missing medications. Facility replaced all missing medication as of [DATE].
Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur:
Education was provided in person for all licensed nursing staff by the Director of Nursing on the pharmacy policy related to maintaining controlled medications and narcotics on the medication carts and signing of shift-to-shift count sheets and was completed by [DATE]. Education also included counting and verifying the count is correct education to be completed by [DATE]. Also included in the education the nurses will document the number of sheets in the narcotic and controlled medications count book for the number of medication packages are located in the locked medication cart. If a medication is discontinued the nurse will remove the card and the medication record and document the number of cards and the sheets that remain on the cart. The nurse will give the removed sheet to the DON to maintain, the sheets will be placed under the Director of Nursing office door if he/she is not available or out of facility. Two nurses will return the discontinued meds to the pharmacy and two nurses will sign and verify. The medications will be placed in a locked tote and placed in the locked medication room to return to pharmacy. The nurses will give a copy of the record and a copy of the returned to pharmacy sheet to the DON to maintain in a file cabinet in her office. Two nurses will complete a shift-to-shift count to verify that the number listed on the controlled medications record matches the amount of medication in the cart and verify that the numbers of sheets are correct. Staff will not be permitted to work until education is completed, including agency staff. Education will be a part of orientation for all new hires and agency licensed staff prior to working their first shift.
The Director of Nursing will continue to maintain file folders for controlled medications in the facility for receiving and returning controlled medications. The Director of Nursing will verify controlled medications count of delivery manifest sheets received from the pharmacy. Manifest sheets will be maintained by the month received as of [DATE]. The facility will follow the facility's policy in maintaining control medications. The licensed nurses will receive and document receiving the controlled medication from pharmacy. The nurses will document the number of sheets in the narcotic count book for the number of medication packages are located in the locked med cart. If a medication is discontinued the nurse will remove the card and the medication record and document the number of cards and the sheets that remain on the cart. The nurse will give the removed sheet to the DON to maintain, the sheets will be placed under the Director of Nursing office door if he/she is not available or out of facility. Two nurses will return the discontinued meds to the pharmacy and two nurses will sign and verify. The medications will be placed in a locked tote and placed in the locked medication room to return to pharmacy. The nurses will give a copy of the record and a copy of the returned to pharmacy sheet to the DON to maintain in a file cabinet in her office. Two nurses will complete a shift-to-shift count to verify that the number listed on the controlled medications record matches the amount of medication in the cart and verify that the numbers of sheets are correct.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained:
The Director of Nursing and/or Designee will audit medication carts related to narcotic count being correct and the medication cards matches the control sheets, and the shift-to-shift count sheet are being signed at the start and at the end of the shift. Auditing will be completed 5 times Per week for 4 weeks then weekly for 4 weeks. The Director of Nursing will report all findings of audits to the Quality Assurance Performance Improvement (QAPI) committee monthly for 3 months for any needed improvement.
The facility completed Ad Hoc QAPI to review the investigation and current action plan to ensure all components were done and followed on [DATE].
Compliance Date: [DATE].
The facility's corrective action plan with a correction date of [DATE] was validated onsite by observations and interviews with the DON and nursing staff.
An observation was conducted during a shift transition for a medication cart between 2 nurses. Nurses started with counting the total number of blister cards that contained controlled medication in the medication cart and verified the balance in the count sheet. Then, they counted each blister card of controlled medication to ensure the quantity listed in the narcotic sheet was consistent with the actual counts. After all the counts were completed without any issues, the incoming nurse signed the controlled medication count sheet before the outgoing nurse passed the medication cart key to her.
Medication Administration observations were conducted on [DATE] and it consisted of 25 medications, 5 different residents, and 4 Nurses. There was one medication error identified but it was not related to misappropriation of medications.
Nursing staff confirmed they had received in-service training regarding pharmacy policy on safeguarding of controlled medications in medication carts, signing of shift-to-shift count sheets, tracking of total number of sheets of controlled medications in the locked medication cart with the count sheet, and proper procedures of returning discontinued controlled medications to the pharmacy. Nursing staff were assigned to review the policy related to proper handling and storage of all controlled substances prior to the training. The training was conducted in-person by DON, and it included multiple examples and scenarios.
Interview with the DON revealed she launched an in-service immediately after the incident to re-educate all the licensed nurses and to introduce a new tracking system for receiving of new additional controlled medication cards and removal of expired or empty cards. She audited the medication cart randomly to ensure all controlled medication counts were conducted appropriately and the count sheets were documented properly. She stated the interventions were successful as the facility did not have any similar diversion issues since then.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete Care Area Assessments (CAAs) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 5 sampled residents (Residents #30 and #58).
The findings included:
1a. Resident #30 was admitted to the facility on [DATE] with diagnoses including depression.
A review of the most recent admission Minimum Data Set (MDS) dated [DATE] revealed Resident #30 was coded with intact cognition. A review of Section V which consisted of care area assessment summary indicated the care area for psychotropic drug use was triggered for Resident #30. Other than checking a list of psychotropic drugs received by Resident #30 and the adverse consequences of using the psychotropic drugs, the facility did not provide any information in analysis of findings that described the nature of Resident 30's problems, possible causes and contributing factors, risk factors related to the care area, and reasons to proceed with care planning.
A further review of the above admission MDS revealed a total of 11 care areas were triggered. 7 out of the 11 triggered areas for CAAs in Section V which included activities of daily living functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, psychotropic drug use, and pain were submitted without any pertinent information in analysis of findings.
1b. Resident #58 was admitted to the facility on [DATE] with diagnoses including congested heart failure.
A review of the most recent admission MDS dated [DATE] revealed Resident #58 was coded with severely impaired cognition. A review of Section V indicated the care area for urinary incontinence and indwelling catheter was triggered for Resident #58. Other than indicating Resident #58 was diagnosed with congested heart failure and receiving diuretic and antipsychotic medications, the facility did not provide any information in analysis of findings that described the nature of Resident 30's problems, possible causes and contributing factors, risk factors related to the care area, and reasons to proceed with care planning.
A further review of the above admission MDS revealed a total of 8 care areas were triggered. All the 8 triggered areas for CAAs in Section V which included cognitive loss/dementia, activities of daily living functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dental care, pressure ulcer, and psychotropic drug use were submitted without any pertinent information in analysis of findings.
During an interview conducted on 01/30/24 at 1:42 PM, the MDS Coordinator confirmed 7 of the 11 triggered care areas for Resident #30's MDS dated [DATE] and all the 8 triggered care areas for Resident #58's MDS dated [DATE] were submitted without any pertinent information in analysis of findings in Section V. She explained she started her role about 3 weeks ago and was unable to explain how it happened. She acknowledged that it was an error to submit an admission MDS without the completion of analysis of findings for all the triggered areas.
An interview was conducted with the Regional MDS Coordinator on 01/30/24 at 1:47 PM. She stated Section V for Resident #30's MDS dated [DATE] and Resident #58's MDS dated [DATE] were submitted by the former MDS Coordinator without completion of analysis of findings. She could not explain how it happened and acknowledged that it was an error.
On 01/31/24 at 3:35 PM an interview was conducted with the Director of Nursing. She stated all the CAAs must be individualized and completed comprehensively. It was her expectation for the MDS Coordinator to complete the analysis of findings for all the triggered areas in Section V before submission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the area of falls for 1 of 5 residents reviewed for Resident Assessments (Resident #51).
Findings included:
Resident #51 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or loss of strength on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, dementia without behavioral disturbance, and anxiety.
Review of the facility's incident log for January 2023 to March 2023 revealed Resident #51 had the following documented falls:
•
On 02/03/23 she was observed on the floor of her room with no apparent injuries upon assessment.
•
On 02/20/23 she was observed on the floor of her room with no apparent injuries upon assessment.
•
On 03/03/23 she was observed on the floor of her room with no apparent injuries upon assessment.
The quarterly MDS assessment dated [DATE] assessed Resident #51 with severe cognitive impairment. She required partial/moderate assistance with moving from a lying position on the bed to sitting on the side of the bed with feet flat on the floor and walking was not attempted due to medical condition or safety concerns. Resident #51 had no falls since the previous MDS assessment which was coded as a quarterly and dated 01/20/23.
Review of the facility's incident log for March 2023 to April 2023 revealed Resident #51 had the following documented fall:
•
On 03/23/23 she was observed on the floor in the hallway with no apparent injuries upon assessment.
The quarterly MDS assessment dated [DATE] assessed Resident #51 with severe cognitive impairment. She required partial/moderate assistance with moving from a lying position on the bed to sitting on the side of the bed with feet flat on the floor and walking was not attempted due to medical condition or safety concerns. Resident #51 had no falls since the previous MDS assessment which was coded as a quarterly and dated 03/17/23.
During an interview on 02/01/24 at 10:35 AM, the MDS Coordinator revealed the previous MDS Coordinator left employment prior to her starting in January 2024 and she was still trying to get assessments caught up that had not been done. She confirmed that Resident #51's falls were missed by the previous MDS Coordinator and were not captured on the corresponding MDS assessments. The MDS Coordinator stated the MDS assessment dated [DATE] should have indicated Resident #51 had 3 falls with no injury and the MDS assessment dated [DATE] should have indicated Resident #51 had one fall with no injury.
During a joint interview on 02/01/24 at 4:10 PM, both the Director of Nursing and Administrator stated they expected for MDS assessments to be completed accurately.
During an interview on 02/01/24 at 4:13 PM, the Regional MDS Consultant explained they had previously identified issues with MDS inaccuracy specific to the coding of antiplatelet and hypoglycemic medications and had developed a Performance Improvement Plan (PIP) to address the issue. The Regional MDS Consultant stated she was unaware of the MDS inaccuracy specific to the coding of falls until it was recently brought to her attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews with the Family Member, Medical Doctor, and staff, the facility failed to obtain a physician's order and initiate wound care treatments and failed to document characteristics including the location, size, and type of wound upon first observation of an existing venous ulcer for 1 of 1 resident reviewed for professional standards (Resident #30).
Findings included:
Resident #30 was admitted to the facility on [DATE] with the current diagnoses including diabetes mellitus, hypertension, and chronic respiratory failure.
The skin assessments for Resident #30 revealed on 07/15/23 the skin was intact and on 07/22/23 the skin was not intact. Both assessments were completed by the Wound Care Nurse. The skin assessment dated [DATE] did not provide information including a description, size, or location of the skin that was not intact.
Review of the nurse progress notes revealed no documentation Resident #30's skin was not intact, or treatment was provided on 07/22/23 through 07/24/23.
During an interview on 01/28/24 at 2:49 PM Resident #30 stated several months ago his Family Member noticed an open sore on his leg and complained there was no bandage. Resident #30 denied any current open wounds or blisters on his lower legs and stated after the Family Member complained, the Wound Care Nurse consistently checked his legs and applied a cream for dry skin.
An interview was conducted on 01/31/24 at 10:37 AM with the Family Member of Resident #30. The Family Member stated she visited Resident #30 on 07/23/23 and described his legs were huge, edematous (excess fluid trapped in body tissue), weeping, and oozing serosanguinous fluid (thin, watery fluid secreted from a wound) and she was concerned for risk of an infection if left open. The Family Member stated Resident #30 was wearing shorts and the wound was visible to her from the hall as she entered the room. She revealed Resident #30 had a history of venous ulcer wounds and it was important he get wound care. The Family Member stated after speaking with Nurse #6 the nurse did not know about the area and had no Medical Doctor (MD) orders for treatment.
During an interview on 01/31/24 at 7:32 PM Nurse #6 recalled the incident when the Family Member was upset about a wound on Resident #30's leg with no bandage. Nurse #6 stated she told the Family Member she was not aware of the wound and there were no treatment orders or documentation of any wound. She asked Nurse #7 for help and to assess Resident #30's leg and to apply a dressing. Nurse #6 stated a temporary treatment for wound care would be added to Resident #30's Treatment Administration Record (TAR) but she did not because she did not see the wound or provide the treatment Nurse #7 did.
During an interview on 01/31/24 at 7:54 PM Nurse #7 recalled the Family Member of Resident #30 was upset about a wound on his leg with no bandage. Nurse #7 stated what she observed on the lower leg of Resident #30 was a blister that was draining fluid and appeared as a blister caused by edema (swelling caused by retention of fluid), but she was not sure if the blister had opened. Nurse #7 stated wound care protocol for a blister was to provide general first aid meaning to clean the area and apply a clean and dry dressing and notify the MD. Nurse #7 stated a communication book was used to notify the MD and if there was a wound, she would obtain orders and notify the Wound Care Nurse. Nurse #7 stated she did not recall if she provided wound care for Resident #30 on 07/23/23 but did relay what she saw to Nurse #6 assigned to care for Resident #30 and returned to her assignment.
Review of the physician orders revealed treatment for a venous ulcer on the right shin with a start date 07/25/23 provided directions to clean with normal saline, apply silver alginate, and cover with a foam dressing on Monday, Wednesday, and Friday.
Review of the July 2023 TAR revealed there were no treatments for a blister or venous ulcer started on 07/22/23. A treatment for a venous ulcer on the right shin ordered on 07/25/23 was initialed by the Wound Care Nurse to indicate treatments were done Monday, Wednesday, and Friday.
Review of the Wound Assessment for Resident #30 dated 07/27/23 identified the type of wound as a venous ulcer located on right lateral shin. The ulcer measured 5.50 centimeters (cm) in length, 3 cm in width, and 0.10 cm in depth with a moderate amount of serous drainage (clear, watery drainage from a wound). The wound assessment was documented by the Wound Care Nurse.
The quarterly Minimum Data Set, dated [DATE] indicated Resident #30 was cognitively intact with no unhealed pressure, venous, or arterial ulcers.
Resident #30's comprehensive care plan revised on 01/24/24 identified skin alteration as a problem related to cellulitis (bacterial infection of the skin) and history of a septic knee. Interventions included assess skin daily with routine care, assess wound healing weekly, and provide treatment as ordered by the physician.
During a telephone interview on 01/31/24 at 9:22 AM the Wound Care Nurse recalled the Family Member of Resident #30 was upset about an open wound on the lower leg with no bandage. The Wound Care Nurse stated a note was left for her check Resident #30 on Monday (07/24/23) which she did. She described what she saw appeared as a blister on the lower leg that had popped and was weeping and stated it was a significant venous ulcer. The Wound Care Nurse revealed the Nurse Practitioner saw the wound and provided the treatment order and now the ulcer was healed.
An observation of Resident #30's lower extremities on 01/31/24 at 9:29 AM revealed stretchable stockings were placed on both lower legs. The stockings were removed by the Wound Care Nurse and revealed no unhealed venous ulcers or blisters.
During a follow-up telephone interview on 02/01/24 at 3:00 PM the Wound Care Nurse stated she worked Monday through Friday and was not the person that completed the skin assessment on 07/22/23 (Sunday) and was unsure why her name was on the assessment.
During an interview on 02/01/24 at 12:01 PM the MD revealed he was familiar with Resident #30's history of lower extremity edema. The MD stated if the skin assessment on 07/22/23 identified the skin was not intact and there was no treatment order in place the nurse should call the MD provider and obtain orders and initiate in the resident's medical record (TAR) to ensure the wound treatments were consistently done.
During an interview on 02/01/24 at 12:47 PM the Administrator stated he would want the nurse to follow the facility's policy related to wound care.
An interview was conducted on 02/01/24 at 1:03 PM with the Director of Nursing (DON). The DON stated if the wound was open and weeping, she would expect the nurse to initiate standing orders in Resident #30's medical record on the TAR to ensure a clean and dry dressing was applied until the area could be assessed by the Wound Care Nurse for her to obtain MD orders for the treatment of the venous ulcer.

Based on observations and staff interviews the facility failed to cover, label, and date open food items in 1 of 1 walk-in cooler; discard potentially hazardous food from 1 of 1 walk-in cooler; label and date food stored in 1 of 1 kitchen; indicate the expiration date of thawed milkshakes and label and date food and beverage items in 2 of 2 nourishment room refrigerators and freezers (100/200 Hall and 400 Hall); and maintain clean refrigerator and freezers in 2 of 2 nourishment rooms (100/200 Hall and 400 Hall). These practices had the potential to affect food and drink items served to residents.
Findings included:
1. An initial tour of the walk-in cooler on 01/28/24 at 10:31 AM revealed the following:
(a). a re-sealable plastic bag of sliced tomatoes with no date
(b). a metal pan containing pureed bread with no date
(c). a box of apple pie open to air with no open date
(d). an opened and undated container of chicken salad
(e). a bag of sliced onions with a use by date of 01/27/24
2. An observation of the kitchen on 01/28/23 at 10:42 AM revealed a bin of sugar and a bin of flour were stored under a counter and were not labeled or dated.
3. An observation of the 100/200 Hall nourishment room on 01/28/24 at 10:50 AM revealed the following:
(a). the refrigerator contained 2 thawed milkshakes sitting on a shelf. The manufacturer's instructions stamped on each carton of milkshake indicated the product was good for 14 days after being thawed. Neither of the milkshakes had a date indicating when they were placed in the refrigerator or when they expired.
(b). multiple areas of dried debris to the shelves and inside door of the refrigerator
(c). three opened and undated pints of ice cream, an opened and undated half-gallon of ice cream, an opened and undated gallon of ice cream, and an opened and undated 16.9-ounce bottle of soda in the freezer
(d). multiple areas of dried debris inside the freezer
4. An observation of the 400 Hall nourishment room on 01/28/24 at 11:00 AM revealed the following:
(a). an opened and undated container of nectar thickened water with lemon sitting on a shelf in the refrigerator
(b). multiple areas of dried debris to the freezer
An interview with the Dietary Manager on 01/30/24 at 8:24 AM revealed food items should be labeled and dated by the person who placed item in the cooler and dietary staff should be checking the walk-in cooler for expired food items daily. The Dietary Manager stated a dietary aide and a member of the nursing staff checked the nourishment rooms daily for unlabeled and undated food items. She stated the dietary department was responsible for cleaning the nourishment room refrigerators and freezers when needed. The Dietary Manager stated the dietary department did not place thawed milkshakes in the nourishment room refrigerators and a nursing staff member probably removed them from a resident's tray and placed them in the refrigerator. She stated the thawed milkshakes should not be in the refrigerator since they did not have an expiration date.
An interview with the Administrator on 02/01/24 at 12:42 PM revealed he expected all food and beverage items to be labeled and dated or used or discarded by the use-by date. He stated he expected nourishment room refrigerators and freezers to be clean and it was the dietary department's responsibility to make sure they were clean. The Administrator stated milkshakes should be dated by the dietary department when they were removed from the freezer and used or discarded within 14 days of thawing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff the facility failed to develop a comprehensive care plan to address diabetes care for 1 of 7 residents reviewed for unnecessary medications (Resident #42).
The findings included:
Resident #42 was admitted to the facility on [DATE] with multiple diagnoses that included diabetes mellitus (DM).
Review of physician's order dated 03/23/22 revealed Resident #42 was ordered to receive sliding scale Novolog before meals and at bedtime. On 05/07/22, the physician added an order for Resident #42 to receive 15 units of Levemir subcutaneously once daily at bedtime.
Review of medication administration records (MARs) from May through July 2022 indicated Resident #42 had received both insulins as ordered.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period.
Review of Resident #1's comprehensive care plans on 07/26/22 revealed no care plan was developed for diabetes care.
During an interview conducted on 07/26/22 at 4:01 PM the MDS Coordinator stated care plan was determined by the facility's interdisciplinary team (IDT) as a group decision. She acknowledged that there were no care plans in place to address Resident #42's diabetes care. She explained a care plan for diabetes care was not needed as physician's orders had included all the assessments, medications, and monitoring perimeters to address Resident #42's diabetic condition.
Interview with the Director of Nursing (DON) on 07/26/22 at 4:11 PM revealed the MDS Coordinator was responsible to develop care plan as indicated for Resident #42. It was her expectation for the MDS Coordinator to develop a person-centered comprehensive care plan to address Resident #42's diabetes care.
During an interview on 07/29/22 at 6:17 PM the Administrator stated it was his expectation for the facility to develop a comprehensive care plan to address Resident #42's diabetes needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident, staff and the Wound Doctor interviews, the facility failed to provide wound care to pressure ulcers per physician orders for 1 of 3 residents (Resident #33) reviewed for pressure ulcers.
The findings included:
Resident #33 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the sacrum and pressure ulcer to the right heel.
Resident #33's care plan initiated on 5/25/22 indicated Resident #33 had a pressure ulcer to her sacrum and right heel. Interventions included treatments as ordered, routine wound assessment, pressure reducing device to bed, observe for signs/symptoms of infection and notify physician as needed.
The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #33 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with all activities of daily living and was always incontinent of urine. The MDS further indicated Resident #33 was at risk of developing pressure ulcers/injuries and had two unstageable slough/eschar (necrotic tissue that adheres to the wound bed and has a spongy or leather-like appearance) present upon admission to the facility.
A physician order dated 7/7/22 for Resident #33 indicated the following treatment to the stage 4 pressure ulcer to the left and right sacrum: cleanse with normal saline, apply zinc oxide to peri-wound, pack with ¼ (antiseptic) solution soaked gauze and cover with and abdominal pads once daily.
A physician order dated 7/23/22 for Resident #33 indicated the following treatment to the stage 3 pressure ulcer to the right heel: cleanse with normal saline, apply a honey-based gel wound dressing and cover with a foam adhesive dressing once daily.
A review of Resident #33's Treatment Administration Record (TAR) for July 2022 indicated the treatment orders for Resident #33's sacrum and right heel were marked as completed by Nurse #4 on 7/25/22.
A follow-up interview with Nurse #4 on 7/28/22 at 4:04 PM revealed when she documented Resident #33's wound care after she had done it on 7/26/22 on her electronic medical record, she had noted that the slot for 7/25/22 was red which meant it hadn't been done on that day, but she mistakenly clicked that it had been done. Nurse #4 stated she should have crossed it out and documented for the right day which was on 7/26/22.
An interview with Nurse #4 on 7/27/22 at 3:14 PM revealed she usually did all the treatments from Mondays to Fridays on the day shift, but she got pulled to work on a hall on 7/25/22 due to a nurse who had called in sick. Nurse #4 stated that whenever she got pulled to work on a hall, the nurse on the hall was supposed to be doing wound care to the residents assigned to them. Nurse #4 stated she did not have Resident #33 on her assignment on 7/25/22 and she did not have time to change her pressure ulcer dressings. Nurse #4 stated she found out on 7/26/22 from Resident #33 that her pressure ulcer dressings did not get changed on 7/25/22. Nurse #4 stated she was concerned because Resident #33's sacral pressure ulcer had bright green drainage when she changed her dressing on 7/27/22. She notified the Nurse Practitioner who ordered a wound culture.
An interview with Resident #33 on 7/27/22 at 3:51 PM revealed she didn't get the dressings to her pressure ulcers changed on 7/25/22 and the nurses were supposed to be changing them daily. Resident #33 stated it had happened before when her wound dressings didn't get changed daily whenever Nurse #4 was either not working or she was getting pulled to work on a medication cart. Resident #33 stated she had just completed a round of antibiotics for wound infection and was told by Nurse #4 that she observed bright green drainage which might mean her sacral wound could be infected again.
An interview with Nurse #5 on 7/27/22 at 3:38 PM revealed she knew Nurse #4 got pulled to work on a hall instead of doing treatments on 7/25/22 but she didn't get to change Resident #33's wound dressings because she was so busy and didn't have time to do it. Nurse #5 stated she got caught up with everything that it didn't even cross her mind that she needed to do wound care on Resident #33. She also forgot to tell the night shift nurse that she didn't get to do Resident #33's wound care on 7/25/22.
An observation of wound care on Resident #33 was made on 7/28/22 at 2:01 PM. Nurse #4 cleaned Resident #33's right heel pressure ulcer with normal saline, applied a honey-based gel to the wound bed and covered it with a foam dressing. The pressure ulcer to the right heel measured approximately 1 cm (centimeters) in length, 0.6 cm in width and 0.2 cm in depth. 80% of the wound bed was covered with slough (necrotic tissue that needs to be removed from the wound for healing to take place). The surrounding skin did not have any redness. Nurse #4 removed her gloves and washed her hands. She then proceeded to remove the dressing on Resident #33's sacral pressure ulcer which was dated 7/27/22. Resident #33's sacrum had two pressure ulcers, and both had a large amount of green drainage with a foul odor. The right sacral pressure ulcer measured approximately 2.5 cm in length, 1.6 cm in width and 0.5 cm in depth. The left sacral pressure ulcer measured approximately 1.5 cm in length, 1.8 cm in width and 2 cm in depth. Nurse #4 cleaned each ulcer separately and packed them with an antiseptic solution soaked gauze. She applied zinc oxide to the surrounding skin, covered both ulcers with an abdominal pad and secured it with tape.
A phone interview with the Wound Doctor on 7/28/22 at 3:30 PM revealed Resident #33 had a previous infection with Pseudomonas (Pseudomonas is a common type of bacteria usually found in soil and water. It is a main cause of hospital-acquired infections.) and he believed that she might have been colonized and this was a reactivation of the infection based on the characteristics of the wound, drainage, and odor. The Wound Doctor stated that it was suboptimal that Resident #33 missed a dressing change on 7/25/22 but he didn't think this contributed to the current wound infection that she might be having. The Wound Doctor didn't think Resident #33 had a systemic infection and he thought the infection was localized to the wound bed, so he went ahead and changed the treatment order to include an antibiotic ointment to prevent worsening of the wound infection. The Wound Doctor further stated that it was unfortunate that Nurse #4 had to be pulled to work on a hall, but he still expected Resident #33's wound dressings to be done daily as ordered.
An interview with the Director of Nursing (DON) 7/29/22 at 3:49 PM revealed the nurses on the hall were supposed to do the treatments whenever Nurse #4 was not working or whenever she got pulled to work on a hall. The DON stated she expected the nurses to do wound care on Resident #33 as ordered by the Wound Doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to provide nectar thickened liquids as ordered by the Physician for 1 of 6 residents reviewed for nutrition (Resident #59).
Findings included:
Resident #59 was admitted to the facility 06/23/22 with a diagnosis of dysphagia (difficulty swallowing) following a cerebral infarction (stroke).
Review of Resident #59's Physician orders dated 06/23/22 revealed an order for nectar thickened liquids.
The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #59 was severely cognitively impaired and had a swallowing disorder which included loss of liquids or solids from mouth, holding food in mouth/cheeks, coughing/choking with meals/medications, and having pain or difficulty when swallowing. The MDS also indicated Resident #59 received a mechanically altered therapeutic diet.
The nutrition care plan for Resident #59 initiated 06/30/22 revealed in part she was at risk for aspiration (the accidental breathing of food or fluids into the lung) related to her medical diagnosis and swallowing difficulty. Interventions included providing her diet as ordered and encouraging adequate hydration.
An observation of Resident #59 on 07/25/22 at 03:57 PM revealed she reported she was thirsty to Nurse #8 and would like some water to drink. Nurse #8 poured Resident #59 a cup of water from the pitcher on the medication cart and handed the cup to Resident #59. Resident #59 began drinking water from the cup with no coughing or difficulty swallowing noted.
During an interview with Nurse #8 on 07/25/22 at 04:02 PM she confirmed she gave Resident #59 regular water to drink. She stated Resident #59 should have received nectar thickened water instead of regular water. Nurse #8 stated giving Resident #59 regular water instead of nectar thickened water was an oversight because she usually worked as an MDS Coordinator and was not normally assigned to a medication cart. She stated a list of residents who received modified liquids was kept in the nourishment room and she had not had an opportunity to check the nourishment room before being assigned to a medication cart the afternoon of 07/25/22.
An interview with the Speech Therapist (ST) on 07/27/22 at 11:56 AM revealed she had been working with Resident #59 and Resident #59 required nectar thickened liquids because she was at risk for silent aspiration (aspiration of food or liquids into the lungs without causing symptoms such as coughing or choking). She stated if a resident had an order for nectar thickened liquids, they should receive nectar thickened liquids.
An interview with the Director of Nursing (DON) on 07/27/22 at 06:15 PM revealed she expected residents to receive liquids as ordered by the Physician. She explained if a resident had an order for modified liquids that information was on the resident's Medication Administration Record (MAR). The DON stated Nurse #8 did not usually work on the floor, had not started her evening medication pass, and it was an oversight that she provided Resident #59 with regular water instead of nectar thickened water.
An interview with the Administrator on 07/29/22 at 04:33 PM revealed he expected residents to receive liquids according to the Physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with resident, staff and the Medical Director, the facility failed to administer oxygen as prescribed by the physician for 1 of 2 residents reviewed for oxygen therapy (Resident #52).
The findings included:
Resident #52 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).
A physician order dated 6/14/22 for Resident #52 indicated oxygen therapy at 2 liters per minute via nasal cannula continuous for COPD every shift.
The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact, had no rejection of care behaviors, required extensive physical assistance with most activities of daily living and used oxygen therapy while a resident at the facility.
Resident #52's Treatment Administration Record (TAR) for July 2022 included an order for oxygen therapy at 2 liters per minute via nasal cannula every shift.
During an initial observation and interview with Resident #52 on 7/25/22 at 10:21 AM, Resident #52 was sitting in a wheelchair in her room with an oxygen tank behind her. Resident #52 did not have a nasal cannula on, and a coiled oxygen tubing was observed on top of the oxygen tank. The dial on the oxygen tank was pointed towards the red area at 0 level. Resident #52 stated she was supposed to be on oxygen continuously, but her oxygen tank was empty, and the staff needed to get her a new one. Resident #52 also had an oxygen concentrator in her room, but it wasn't on, and the nasal cannula connected to the oxygen concentrator was on top of her bed. Resident #52 did not show any signs of respiratory distress.
A second observation of Resident #52 on 7/25/22 at 2:21 PM revealed her participating in an activity in the dayroom without using her oxygen. Resident #52 did not have a nasal cannula on, and her oxygen tank continued to have coiled tubing on top. Resident #52 continued to show no signs of respiratory distress.
A third observation with Resident #52 on 7/25/22 at 3:30 PM revealed her sitting in her wheelchair in her room with the same oxygen tank at the back of her wheelchair. Resident #52 did not have an oxygen nasal cannula on. Resident #52 stated staff had not been in her room to replace her oxygen tank.
An interview with Nurse #2 on 7/25/22 at 3:38 PM revealed when she went in to give Resident #52's morning medications at 8:30 AM, Resident #52 was still in bed, and she had a nasal cannula on which was connected to her oxygen concentrator. She went back into Resident #52's room around 12:00 PM to check her vital signs and observed Resident #52 sitting in her wheelchair but she was connected to her oxygen concentrator. Nurse #2 stated she did not know Resident #52 had an empty oxygen tank behind her wheelchair and that she needed a new oxygen tank. Nurse #2 stated whoever got Resident #52 up out of the bed should have notified her that Resident #52 needed a new oxygen tank. Nurse #2 stated Resident #52 would sometimes remove the nasal cannula off her nose, but she had never seen her turn off her oxygen concentrator. During the interview, Nurse #2 went into Resident #52's room and checked her oxygen saturation which was at 95% on room air.
A follow-up interview with Resident #52 on 7/25/22 at 4:26 PM revealed she didn't have her oxygen on all shift, and she wasn't on her concentrator at 12:00 PM. Resident #52 stated she waited all day for staff to change her oxygen tank which was behind her wheelchair.
An interview with Nurse Aide (NA) #1 on 7/28/22 at 9:39 AM revealed she took care of Resident #52 on 7/25/22 on the day shift from 7:00 AM to 11:00 AM. NA #1 stated she got Resident #52 up out of her bed but as soon as she had gotten her up, a therapy staff member came to get her. NA #1 stated she could not remember if she had put Resident #52 on oxygen prior to therapy getting her. NA #1 stated she didn't see Resident #52 again before 11:00 AM and another nurse aide took over.
An interview with the Rehabilitation Director on 7/28/22 at 9:46 AM revealed he had worked with Resident #52 on 7/25/22 in the morning right after breakfast but he couldn't remember the exact time he got her out of her room. The Rehabilitation Director stated he had changed Resident #52's oxygen tank a few times before but he couldn't remember if he did on 7/25/22. He couldn't remember if Resident #52 had her oxygen on while he worked with her on 7/25/22.
An interview with the Medical Director on 7/28/22 at 11:41 AM revealed the nurses should administer Resident #52's oxygen according to the physician's order and that he expected Resident #52's oxygen orders to be followed.
An interview with the Director of Nursing on 7/29/22 at 3:49 PM revealed any staff member could have changed Resident #52's oxygen tank when it needed to be changed and the nurse should have made sure Resident #52's oxygen was delivered per physician's order.

Based on record review and staff interviews, the facility failed to provide sufficient nursing staff to provide wound care for 1 of 3 residents reviewed for pressure ulcers (Resident #33).
The findings included:
This tag was cross-referenced to F-686:
F-686: Based on record review, observation and resident, staff and the Wound Doctor interviews, the facility failed to provide wound care to pressure ulcers per physician orders for 1 of 3 residents (Resident #33) reviewed for pressure ulcers.
A review of the Resident Council Meeting minutes dated 2/24/22 indicated a concern brought up by the residents about staffing on second and third shift being too thin and on 6/23/22 about not having enough staff on the weekends.
An interview with Nurse #6 on 7/27/22 at 10:18 AM revealed staffing on second shift and the weekends was still a problem but it was not as worse as when she first started working at the facility. Nurse #6 stated she still had to stay over and work second shift once or twice every 2 weeks to help out.
An interview with Nurse #7 on 7/27/22 at 11:41 AM revealed there had been days when they were short-staffed especially on second shift and the nurses had been on their feet trying to help the nurse aides. Sometimes, they had staff members coming in at 7:00 PM to help on second shift.
An interview with Nurse #8 on 7/27/22 at 5:31 PM revealed she was supposed to work as the second MDS (Minimum Data Set) nurse, but she had been pulled to work on the hall twice this week. Nurse #8 stated staffing was still an issue on second shift, and she had been asked to stay over and work on the hall until she had administered the 4:00 PM medications. Nurse #8 stated she also used to be the treatment nurse, but she often got pulled to work on the hall.
An interview with Nurse #9 on 7/29/22 at 2:35 PM revealed Nurse #4 always got pulled to work on a hall on Mondays because they didn't have enough nurses on first shift on Mondays and if they got an agency nurse to work, they often called in sick. Nurse #9 stated they used to have a supervisor who alternated with Nurse #4 about getting pulled to a hall, but the supervisor had been gone for about 2-3 weeks.
A phone interview with Nurse #10 on 7/28/22 at 9:30 PM revealed she didn't have time to change a resident's wound dressing on 7/25/22 because she barely got done with her medication pass when it was time to leave at 3:00 PM. She reported to the second shift nurse that she didn't get the dressing changed.
An interview with the Scheduler on 7/29/22 at 2:03 PM revealed he was supposed to staff the facility with 5 nurses and 9 nurse aides (NA) on first shift, 4 nurses and 5 NA on second shift and 2 nurses and 4 NA on third shift. The Scheduler stated he had staffing challenges on the weekends and on second shift because it was hard to get people to work this shift. He stated the facility currently had contracts with 4 staffing agencies and utilized them to obtain nurses and NA. The Scheduler also stated the facility had 10 open positions for NA and 5 open positions for nurses. They had been trying to recruit staff by posting employment advertisements on different websites and had talked about raising their wages to attract more employees. He stated that when there were scheduled staff members who couldn't make it in to work, he often tried to get a replacement by asking their staff first and then reaching out to a staffing agency if they had available staff members. The Scheduler stated on 7/25/22 when an agency nurse had called in, it was hard to get a nurse to come in because of the short notice so they ended up pulling Nurse #4 to work on the hall instead of doing treatments.
An interview with the Director of Nursing (DON) and the Administrator on 7/29/22 at 4:39 PM revealed they tried to schedule enough staff to work but when things come up and they couldn't find anybody to replace them, then it was out of their control. The DON stated they used to have a supervisor who helped take over when a nurse called in, but she had been gone for about 2-3 weeks. The Administrator stated staffing hadn't been an issue until recently when the supervisor quit but they had just hired a nurse to replace her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with staff and Medical Director (MD) the facility failed to acquire and administer insulin per physician order. As a result, Resident #42 missed 3 doses of insulin within 8 days. This affected 1 of 7 residents reviewed for unnecessary medications (Resident #42).
The findings included:
Resident #42 was admitted to the facility on [DATE] with multiple diagnoses included diabetes mellitus (DM).
Review of physician's order dated 03/23/22 stated Resident #42 was to receive sliding scale insulin (SSI) before meals and at bedtime. She would receive 2 units of Novolog, fast acting insulin, with capillary blood glucose (CBG) of 151 - 200 milligram per deciliter (mg/dl), and 4 units with CBG of 201- 250 mg/dl.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period.
Review of the medication administration records (MAR) for July 2022 indicated Resident #42 did not get her 6:00 AM SSI when her CBG was 220 mg/dl and the 12:00 noon SSI when her CBG was 177 mg/dl on 07/02/22. On 07/09/22, Resident #42 did not get her 6:00 AM SSI when her CBG was 160 mg/dl.
Review of medication administration histories revealed Nurse #1 was unable to locate Resident #42's Novolog on 07/02/22. On 07/09/22, Nurse #1 documented that the insulin was unavailable in the facility.
An interview was conducted on 07/26/22 at 9:50 AM with Resident #42. She stated there were a few occasions that she did not get her SSI as indicated by the CBG. When she brought it up to the nurse, she was told that the facility had run out of her insulin.
During a phone interview conducted with Nurse #11 on 07/26/22 at 6:47 PM. She confirmed she cared for Resident #42 on 07/01/22 from 3:00 PM through 11:00 PM. Resident #42 was not indicated to receive the 4:30 PM and 9:00 PM doses of SSI as her CBGs were low for both occasions. She could not recall the availability of Novolog in the medication cart in that evening.
During a phone interview with Nurse #1 on 07/27/22 at 6:04 PM, she confirmed she was assigned to Resident #42 on 07/02/22 and 07/09/22. She stated the 6:00 AM doses of SSI on 07/02/22 and 07/09/22 were not administered as Novolog was unavailable for both occasions. She added once she realized that the facility had run out of Novolog, she reordered it through the pharmacy immediately. She did not know why the facility was out of Novolog and who was responsible to reorder the insulin before it ran out.
An interview was conducted on 07/27/22 at 6:26 PM with the Director of Nursing (DON). She stated the nurses had the control of the medication carts and the medication records. They should check the availability of medication regularly to ensure reordering was in place before the last dose was to be given. It was her expectation for all the residents to receive insulin as ordered in timely manner.
During a phone interview with the MD on 07/28/22 at 11:45 AM, he expected nursing staff to check the availability of insulin in medication cart regularly and communicate with each other to ensure reordering was in place in timely manner.
An interview with the Administrator was conducted on 07/29/22 at 6:17 PM. He stated he expected the staff to follow the pharmacy protocol for reordering medications so that doses were not missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Physician interviews, the facility failed to prevent a significant medication error when they failed to acquire and administer insulin as ordered by the physician. As a result, Resident #42 missed 3 doses of insulin within 8 days. This affected 1 of 7 residents reviewed for unnecessary medications (Resident #42).
The findings included:
Resident #42 was admitted to the facility on [DATE] with multiple diagnoses included diabetes mellitus (DM).
The physician's order dated 03/23/22 stated Resident #42 was to receive sliding scale insulin (SSI) before meals and at bedtime. She would receive 2 units of Novolog, rapid acting insulin, with capillary blood glucose (CBG) of 151 - 200 milligram per deciliter (mg/dl), and 4 units with CBG of 201- 250 mg/dl.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #42 with intact cognition and indicated she had received insulin daily in the 7-day assessment period.
Review of the medication administration records (MAR) for July 2022 indicated the facility had failed to acquire and administer Novolog for Resident #42 per SSI when her 6:00 AM CBG was 220 mg/dl and the 12:00 noon CBG was 177 mg/dl on 07/02/22. On 07/09/22, the facility failed again to acquire and administer Novolog for Resident #42 when her CBG was 160 mg/dl. Further review of medication administration histories revealed Nurse #1 was unable to locate Resident #42's Novolog on 07/02/22. On 07/09/22, Nurse #1 stated the insulin was unavailable in the facility.
An interview was conducted on 07/26/22 at 9:50 AM with Resident #42. She stated there were a few occasions that she did not get her SSI as indicated by the CBG. When she brought it up to the nurse, she was told that the facility had run out of her insulin.
During a phone interview conducted on 07/26/22 at 6:47 PM. Nurse #11 confirmed she cared for Resident #42 on 07/01/22 from 3 PM through 11 PM. Resident #42 was not indicated to receive the 4:30 PM and 9:00 PM doses of SSI as her CBGs were low for both occasions. She could not recall the availability of Novolog in the medication cart in that evening.
A phone interview conducted with Nurse #1 on 07/27/22 at 6:04 PM confirmed she was assigned to Resident #42 on 07/02/22 and 07/09/22. She stated the 6:00 AM doses of SSI on 07/02/22 and 07/09/22 were not administered as Novolog was unavailable for both occasions. She did not know why the facility was out of Novolog and who was responsible to reorder the insulin before it ran out.
An interview was conducted on 07/27/22 at 6:26 PM with the Director of Nursing (DON). She stated the nurses had the control of the medication carts and the medication records. They should check the availability of medication regularly so that they could reorder before the last dose was to be given. It was her expectation for all the residents to receive insulin as ordered in timely manner.
During a phone interview with the Medical Director (MD) on 07/28/22 at 11:45 AM, he stated missing 3 doses of insulin within 8 days was a significant medication error as it could trigger diabetic ketoacidosis (DKA), a life-threatening problem that affected people with diabetes. It occurred when the liver started to break down body fat too fast into a fuel consumed by body called ketones, in which it could cause the blood to become acidic. He expected nursing staff to check the availability of insulin in medication cart regularly and communicate with each other to ensure reordering was in place in timely manner.
An interview with the Administrator was conducted on 07/29/22 at 6:17 PM. He expected the staff to follow the pharmacy protocol for reordering medications so that doses were not missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews the facility failed to remove expired medications in accordance with the manufacturer's expiration date for 1 of 2 medication storage rooms (Main medication storage room), failed to lock the medication cart for 1 of 4 medication carts reviewed for medication storage, and failed to store eye drops prescribed for glaucoma in the medication cart for 1 of 1 resident observed with medications at bedside (Resident #68).
The findings included:
During an observation made on 07/27/22 at 10:28 AM, 7 unopened boxes of Flucelvax quadrivalent 2021-2022 formula influenza vaccines expired on 06/30/22 were found in the refrigerator in the main medication storage room. Each box contained 10 doses of 0.5 milliliter (ml) single-dose prefilled influenza vaccine, and they were available for use.
An interview conducted with Nurse #2 on 07/27/22 at 10:32 AM revealed she did not know who was responsible to check the medication storage room on regular basis. She stated when she pulled medication from the medication storage room, she would check the expiration date before putting it in her medication cart and check again each time before administration.
During an interview conducted on 07/27/22 at 10:45 AM, the Assistant Director of Nursing (ADON) stated the Unit Manager (UM) was responsible to check the medication storage room at least once monthly to ensure all the medications were stored in proper temperature, condition, and free of expired medication. She explained the facility did not have an UM for about 3 weeks. She knew that those influenza vaccines were expired and planned to return them to the pharmacy but had forgotten to do it due to her oversight.
An interview with the Director of Nursing (DON) on 07/27/22 at 11:02 AM revealed typically the night shift nurses who worked when the medication shipment arrived were responsible to put up the medications in the medication storage room. Other than the ADON or her designee checking the medication storage room at least once monthly or as needed, the consultant pharmacist had been checking the medication storage rooms during the monthly visit. In addition, she had checked the medication storage room randomly or as needed. She explained the facility had not been administering influenza vaccine for a while and it was an oversight. It was her expectation for the facility to be free of expired medication or vaccines.
During an interview conducted on 07/29/22 at 6:17 PM, the Administrator stated it was his expectation for the facility to remain free of expired medication.
3. Resident #68 was admitted to the facility on [DATE] with multiple diagnoses including glaucoma.
Review of a physician's order written on 05/31/22 was for Resident #68 to receive latanoprost 0.005% with directions to instill one drop into both eyes nightly for glaucoma. There was no order to self-administer medications.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68's cognition as being intact.
Review of the July 2022 Medication Administration Record (MAR) revealed Nurse #3 initialed Resident #68's eye drops were administered at 9:00 PM on 07/25/22.
An observation on 07/26/22 at 8:33 AM revealed an opened bottle of latanoprost labeled with Resident #68's name was located on the bedside table available for use.
During an interview on 07/26/22 at 8:33 AM Resident #68 revealed she had received her eye drops from the nurse on the night shift on 07/25/22. Resident #68 stated her eye drops were administered at night and thought the night nurse on 07/25/22 forgot and accidentally left the drops on her bedside table. Resident #68 stated she didn't self-administer her eye drops the nurses did it for her.
An interview was conducted on 07/29/22 at 8:56 AM with Nurse #3. Nurse #3 confirmed his initials on the MAR meant that he administered eye drops for Resident #68 on 07/25/22 at 9:00 PM. Nurse #3 confirmed Resident #68 didn't have a physician order to self-administer, and the eye drops should be kept on the medication cart.
During an interview on 07/29/22 at 3:55 PM the Director of Nursing (DON) indicated finding latanoprost eye drops at the beside was mostly likely human error and thought it was possible Nurse #3 was distracted and left the drops in Resident #68's room. The DON revealed she knew Resident #68 didn't have a physician's order to self-administer and stated the eye drops should be kept on the medication cart.
2. During a continuous observation at the Main nurses' station on 7/25/22 from 2:24 PM to 2:47 PM, the 300 hall medication cart was observed with the lock mechanism in the unlocked position (the push-button to lock the medication cart was protruding about an inch from the medication cart). The medication cart was parked in front of the Main nurses' station. A housekeeper, a nurse aide and a nurse were all observed walking back and forth the hallway and passed the unlocked medication cart. Resident #3 parked his wheelchair beside the unlocked medication cart at 2:39 PM and was looking for the nurse to ask her a question about his medications.
An interview with Nurse #10 on 7/25/22 at 2:57 PM revealed she knew she was supposed to lock the medication cart before leaving it unattended, but it probably didn't click all the way when she pushed the button to lock the medication cart. Nurse #10 stated she was in a hurry trying to get the new residents' medications in the cart which was probably how she missed locking the medication cart.
An interview with the Director of Nursing on 7/29/22 at 3:49 PM revealed Nurse #10 should have made sure the medication cart was locked before leaving it unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff the facility failed to accurately document in the medical record an influenza vaccine was not administered for 1 of 6 residents reviewed for immunizations (Resident #20); and failed to accurately document in the medical record a pressure ulcer treatment was not provided for 1 of 5 residents reviewed for pressure ulcers (Resident #33).
The findings included:
1. Resident #20 was admitted to facility on 01/08/21 with diagnoses including dementia and history of stroke.
Review of Resident #20's consent form for the influenza vaccine revealed it was declined on 01/07/21.
Review of the significant change Minimum Data Set (MDS) dated [DATE] assessed Resident #20's cognition as being severely impaired. The MDS documentation indicated Resident #20 received the influenza vaccine in the facility on 10/19/2021.
Review of the electronic medical record for immunizations revealed Resident #20 received an influenza vaccine on 10/19/21 in the facility and included the lot number and expiration date and location as given in the right deltoid.
During an interview on 07/29/22 at 10:45 AM the Director of Nursing (DON) revealed the administration of the influenza vaccine on 10/19/21 in the electronic medical record for Resident #20 was inaccurate. The DON stated the information was entered by mistake and she expected the documentation in the residents electronic medical records to be accurate.
2. Resident #33 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer to the sacrum and pressure ulcer to the right heel.
A physician order dated 7/7/22 for Resident #33 indicated the following treatment to the stage 4 pressure ulcer to the left and right sacrum: cleanse with normal saline, apply zinc oxide to peri-wound, pack with 1/4 (antiseptic) solution soaked gauze and cover with and abdominal pads once daily.
A physician order dated 7/23/22 for Resident #33 indicated the following treatment to the stage 3 pressure ulcer to the right heel: cleanse with normal saline, apply a honey-based gel wound dressing and cover with a foam adhesive dressing once daily.
A review of Resident #33's Treatment Administration Record (TAR) for July 2022 indicated the treatment orders for Resident #33's sacrum and right heel were marked as completed by Nurse #4 on 7/25/22.
An interview with Nurse #4 on 7/28/22 at 4:04 PM revealed she didn't have time to do Resident #33's treatments to her sacrum and right heel because she got pulled to work on a hall. When she documented Resident #33's wound care after she had done it on 7/26/22 on her electronic medical record, she had noted that the slot for 7/25/22 was red which meant it hadn't been done on that day, but she mistakenly clicked that it had been done. Nurse #4 stated she should have crossed it out and documented for the right day which was on 7/26/22.
An interview with the Director of Nursing (DON) on 7/29/22 at 3:49 PM revealed Nurse #4 should have paid attention to what she was documenting before clicking on the computer. The DON stated she should have crossed it out and not documented that the treatment was done when she didn't do it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 02/02/22 indicated the following information under Manage Residents with Close Contact:
*Manage Residents who had Close Contact with Someone with SARS-CoV-2 infection:
*Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP (healthcare personnel) caring for them should use full personal protective equipment (PPE) (gowns, gloves, eye protection, and N95 or higher-level respirator).
The facility's infection control policy under COVID-19 Response Guidelines revised on 06/27/22 indicated HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for newly admitted residents who are not up to date with all recommended COVID-19 vaccine doses.
Resident #127 was admitted to the facility on [DATE].
Review of Resident #127's vaccination records revealed she had never been vaccinated with COVID-19 vaccine.
Resident #128 was admitted to the facility on [DATE].
Review of Resident #128's vaccination records revealed his COVID-19 vaccination was not up to date according to the facility's COVID-19 response guidelines.
An observation on the 400 hall on 07/25/22 at 10:02 AM revealed the rooms for Resident #127 (room [ROOM NUMBER] B) and Resident #128 (room [ROOM NUMBER] A) were not under quarantine. No signage or PPE were seen outside the rooms. Nurse #4 and Nurse Aide (NA) #2 were observed entering both rooms without gown, gloves, and N95 mask to provide care to both residents between 10:02 AM through 11:18 AM.
When this writer returned to the 400 hall on 07/25/22 at 12:15 PM, a special droplet/contact precaution signs were posted on Resident #127's and Resident #128's door. A plastic drawer cart which contained N95 masks, face shields, gowns and gloves was located beside Resident #127's and Resident 128's door respectively. The sign indicated the following instructions: clean hands before entering and when leaving room, wear a gown when entering and remove before leaving, wear N95 or higher-level respirator before entering the room and remove after exiting, wear protective eyewear and gloves when entering room and remove before leaving, place resident in private room and keep door close (if safe to do so).
An interview with NA #2 on 07/25/22 at 1:14 PM revealed neither the PPE nor the special droplet/contact precaution signs were in place for Resident #127's and Resident #128's room when she worked last Friday and this morning. The Assistant Director of Nursing (ADON) told her around noon that Resident #127 and Resident #128 were now under special droplet/contact precaution because of their COVID-19 vaccination status.
During an interview with Nurse #4 on 07/25/22 at 2:27 PM, she acknowledged that she had administered medications to both Resident #127 and Resident #128 this morning without wearing gown, gloves, and N95 mask. She did not know both residents were under special droplet/contact precaution as there were no signage's to identify that she needed to wear additional PPE's before entering. The ADON put both residents under special droplet/contact precaution just before lunch and told her that they had not been fully vaccinated. Typically, the Director or Nursing (DON) or the ADON reviewed all new admissions and would inform the floor nurse during admission to place the resident under special droplet/contact precaution as indicated.
An interview with the ADON on 07/25/22 at 2:56 PM revealed she and the DON were responsible to track COVID-19 vaccination status for new admission and place resident under special droplet/contact precaution as indicated. However, she was off last Friday through Sunday. She ordered to place Resident #127 under special droplet/contact precaution for 7 days on 07/21/22 and did not know why the order was not implemented. The ADON explained she was not working when Resident #128 was admitted . She added when she reviewed the admission list and vaccination status this morning, she noticed that both Resident #127 and Resident #128 were not up to date with all the recommended COVID-19 vaccine doses and required a 7-day quarantine.
During an interview conducted on 07/26/22 at 2:09 PM, the DON acknowledged that she had failed to communicate with the floor nurse last weekend causing residents who required quarantine were not properly quarantined. It was her expectation for the staff to follow CDC's recommendations and facility's infection control policy when admitting new resident.
An interview with the Administrator on 07/29/22 at 6:17 PM revealed he expected the facility to follow CDC's recommendations to quarantine newly admitted residents as indicated.
Based on observations, record review, and staff interviews, the facility: 1) failed to follow the Special Droplet Contact Precautions signage posted by the door of a resident's room when 1 of 1 nursing staff (Nurse #12) did not sanitize hands and don gloves, gown and N95 mask prior to entering 1 of 4 resident rooms on droplet/contact precautions (Resident #180); 2) failed to follow their infection control policy and the Centers for Disease Control and Prevention (CDC) guidance by not placing newly admitted residents who were unvaccinated or not up-to-date with all recommended COVID-19 doses under quarantine for 4 of 4 sampled residents (Residents #127, #128, #229, and #230); and 3) failed to implement their infection control policies and procedures for hand hygiene when Nurse Aide #3, Nurse Aide #4, and Nurse Aide #5 did not remove their gloves and perform hand hygiene after providing incontinence care to soiled residents for 2 of 2 sampled residents (Resident #50 and #68).
Findings included:
1. The Special Droplet Contact Precautions (SDCP) signage, with a revised date of 02/09/22, noted staff should follow the instructions listed on the signage before entering the resident's room which included: all healthcare personnel must: 1) clean hands before entering and when leaving the room, 2) wear a gown when entering room and remove before leaving, 3) wear N95 or higher level respirator before entering the room and remove after exiting, 4) wear protective eyewear (face shield or goggles), and 5) wear gloves when entering room and remove before leaving.
The facility's infection control policy, COVID-10 Response Guidelines with a revised date of 06/27/22 read in part, healthcare personnel should wear a N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown when caring for newly admitted residents who are not up-to-date with all recommended COVID-19 vaccine doses.
Resident #180 was admitted to the facility on [DATE].
A physician's order for Resident #180 dated 07/26/22 read in part, Resident #180 was unvaccinated for COVID-19. Quarantine for a minimum of 7 days, monitor for signs/symptoms of COVID, and perform a COVD test upon admission and every 3-5 days for 7 days. May discontinue quarantine on 08/02/22 if all COVID tests were negative and no signs or symptoms of COVID-19.
During an observation on 07/26/22 at 1:30 PM, SDCP signage was posted on the wall beside Resident #180's room door and a 3-drawer plastic container containing extra Personal Protective Equipment (PPE) was located on the floor of the hallway beside Resident #180's room door. Nurse #12 was observed walking down the hall toward Resident #180's room wearing goggles and a pink KN95 facemask. Upon arriving at Resident #180's door, Nurse #12 opened the door and entered the room without sanitizing her hands and donning gloves, gown and N95 facemask.
During an interview on 07/26/22 at 1:32 PM, Nurse #180 revealed she had received infection control education related to sanitizing hands and donning/doffing PPE when entering and exiting resident rooms on isolation precautions. Nurse #12 confirmed she did not perform hand hygiene or don the appropriate PPE as instructed on the SDCP signage prior to entering Resident #180's room. Nurse #12 explained she had been in and out of Resident #180's room all day and had doffed the PPE she exited the room to go and get something for Resident #180 but forgot to don any additional PPE when briefly reentering Resident #180's room just now. Nurse #12 confirmed she was instructed to don/doff PPE every single time when entering and exiting rooms on SDCP.
During an interview on 07/26/22 at 2:17 PM, the Director of Nursing (DON) stated staff were trained to read precaution signage and follow the instructions for PPE to be worn. The DON stated she would have expected Nurse #12 to don/doff PPE as instructed on the SDCP signage when entering/exiting Resident #180's room.
During an interview on 07/29/22 at 6:17 PM, the Administrator stated all staff were expected to follow the instructions for donning/doffing PPE as specified on the SDCP signage.
3. The Centers for Disease Control and Prevention (CDC) guidance entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 02/02/22 indicated the following information under Manage Residents with Close Contact:
*Manage Residents who had Close Contact with Someone with SARS-CoV-2 infection:
*Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP (healthcare personnel) caring for them should use full personal protective equipment (PPE) (gowns, gloves, eye protection, and N95 or higher-level respirator).
The facility's infection control policy under COVID-19 Response Guidelines revised on 06/27/22 indicated HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for newly admitted residents who are not up to date with all recommended COVID-19 vaccine doses.
Resident #229 was admitted to the facility on [DATE].
Review of immunization records for Resident #229 revealed one dose of a multi-dose COVID-19 vaccine was received on 03/17/21.
Resident #230 was admitted to the facility on [DATE].
Review of immunization records for Resident #230 revealed one dose of a single dose COVID-19 vaccine was received on 04/12/21.
An observation made on 07/25/22 at 10:58 AM revealed no sign on the entry doors to indicate special droplet/contact precautions were in place for Resident #229 and #230. There was signage beside the entry doors with instructions on how to properly don and doff personal protective equipment (PPE), but no visible storage bins of PPE located on hall 400.
During an interview on 07/25/22 at 11:05 AM Nurse Aide (NA) #2 revealed she was assigned to provide care for residents residing on the 400 hall, rooms 400 through 411. NA #2 revealed the 400 hall was designated for newly admitted residents and she was not aware of anyone placed on special droplet/contact precautions or being quarantined. NA #2 revealed the signs for PPE with instructions on how to don and doff were kept in place as a reminder and always posted.
An observation made on 07/25/22 at 1:12 PM revealed new signage posted on the entry doors to Resident #229 and #230's room along with a storage bin of PPE placed in the hall outside each door. The sign read in part; special droplet contact precautions with directions to clean hands before entering and when leaving the room. Wear gloves and gown when entering and remove before leaving. Wear a N-95 or higher-level respirator before entering the room and remove after exiting and wear protective eyewear.
During an interview on 07/25/22 at 1:14 PM NA #2 revealed the storage bins of PPE and special droplet/contact signage were not in place when she last worked hall 400 on 07/22/22. NA #2 revealed the Assistant Director of Nursing (ADON) told her Residents #229 and #230 were not fully vaccinated and were being placed on special droplet/contact precautions. NA #4 revealed she hadn't donned PPE prior to entering either room until after the signage was placed to inform her.
During an interview on 07/25/22 at 2:27 PM Nurse #4 revealed she was not aware Residents #229 and #230 should've been placed on droplet/contact precautions or quarantine until just before lunch when the ADON placed the signage on the doors and storage bins of PPE in the hall. Nurse #4 revealed she didn't don or doff PPE prior to administering morning medications to Residents #229 and #230 when there was no signage posted to inform her. Nurse #4 explained typically the Director of Nursing (DON) or ADON reviewed newly admitted residents vaccination status and inform the admitting nurse to place the resident under droplet/contact precautions or quarantine.
An interview was conducted on 07/25/22 at 3:10 PM with the ADON. The ADON revealed either her or the DON inform the nurses when to quarantine a resident. The ADON explained her, and the DON were at a conference on 07/22/22 and she didn't work over the weekend and unsure who was responsible to check the vaccination status for newly admitted residents when they were not available. The ADON revealed when she reviewed the list of new admissions and their vaccination status on 07/25/22 Residents #229 and #230 were not up to date with their recommended COVID-19 vaccines therefore she placed the special droplet/contact precaution signage and storage bins of PPE. The ADON revealed Residents #229 and #230 should have been quarantined and placed under special droplet/contact precautions for 7 days upon their admission.
During an interview on 07/26/22 at 2:09 PM the DON stated they had dropped the ball to ensure Residents #229 and #230 were placed on quarantine with special droplet/contact precautions. The DON added the admitting nurses also didn't take the initiative to check Residents #229 and #230's vaccination status. The DON explained the hospital sent the resident's vaccination status prior to admission and either her or the ADON would communicate the information to the admitting nurse. The DON explained neither her or the ADON worked on 07/22/22 and there was a lack of communication between Department Heads and the admitting nurse. The DON revealed she expected newly admitted residents who were not up to date with their COVID-19 vaccines were placed under quarantine with special droplet/contact precautions upon admission.
An interview was conducted on 07/29/22 at 6:17 PM with the Administrator. The Administrator revealed he expected the facility to follow CDC's recommendations to quarantine newly admitted residents as indicated.
4. Review of the facility's policy titled Hand Hygiene revised July 2022 read in part as follows, The purpose of the Hand Hygiene policy is to provide guidelines for staff in utilizing hand hygiene. Appropriate hand hygiene is essential in preventing transmission of infectious agents. This facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and the environment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections.
A continuous observation of NA #3 and NA #4 provide care to Resident #68 for an episode of urinary incontinence was made on 07/27/22 from 5:40 PM to 5:50 PM. NA #3 entered the room and washed her hands using soap and water from the sink located in the resident's room. A dispenser of alcohol-based hand sanitizer was attached to the inside wall by the entry door of the room and Resident #68's bed was located by the window. NA #4 started incontinence care for Resident #68 by wiping the front perineal area clean. Without performing hand hygiene, NA #4 repositioned Resident #68 onto her side while NA #3 cleaned the buttocks area. Without performing hand hygiene both NA #3 and NA #4 repositioned Resident #68 to put on a clean brief then elevated the legs off the bed with a pillow then adjusted the bed linens to cover Resident #68. Without performing hand hygiene NA #4 also used the remote to adjust the head of the bed.
An interview was conducted on 07/27/22 at 5:50 PM with NA #3. NA #3 revealed she missed a step with infection control during incontinence care for Resident #68. NA #3 revealed she should have removed her gloves and washed her hands after Resident #68 was wiped clean for an episode of urine incontinence before she continued care.
An interview was conducted on 07/27/22 at 5:55 PM with NA #4. NA #4 confirmed she did not remove her gloves or perform hand hygiene during incontinence care for Resident #68. NA #4 revealed she was unsure when to perform hand hygiene during incontinence care and was uncomfortable leaving a resident to wash her hands in fear they might fall from the bed and get hurt.
An interview was conducted on 07/27/22 at 6:11 PM with the Director of Nursing (DON). The DON stated she would expect after a resident was wiped clean during incontinence care NA staff would remove their gloves and perform hand hygiene. The DON stated she did stress to nursing staff they should wash their hands before and after care.
5. Review of the facility's policy titled Hand Hygiene revised July 2022 read in part as follows, The purpose of the Hand Hygiene policy is to provide guidelines for staff in utilizing hand hygiene. Appropriate hand hygiene is essential in preventing transmission of infectious agents. This facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and the environment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections.
A continuous observation of Nurse Aide (NA #5) on 07/27/22 from 09:20 AM to 09:28 AM revealed NA #5 provided urinary incontinence care for Resident #50 who was in the bed closest to the door of the room. With gloved hands, NA #5 cleaned urine with resident care wipes, removed the wet brief and placed it in a trash bag, placed a clean brief under Resident #50, secured the tabs of the brief, pulled down Resident #50's gown, pulled up Resident #50's bed cover, and removed her soiled gloves. NA #5 performed hand hygiene, tied up the trash bag containing the soiled brief, placed the trash bag in the soiled utility, and performed hand hygiene by using the dispenser of alcohol-based hand rub attached to the wall by the entry door of the room. NA #5 did not remove her gloves and perform hand hygiene after removing urine during incontinence care and touched Resident #50's gown and bed covers while wearing soiled gloves.
An interview with NA #5 on 07/27/22 at 09:35 AM revealed she had been trained to remove her gloves and perform hand hygiene after performing incontinence care. She stated it was an oversight that she did not remove her gloves and perform hand hygiene after performing incontinence care for Resident #50.
An interview with the Director of Nursing (DON) on 07/27/22 at 06:15 PM revealed she expected staff to remove soiled gloves and perform hand hygiene after cleaning urine.
An interview with the Administrator on 07/29/22 at 04:33 PM revealed he expected staff to follow the hand hygiene policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Medical Doctor (MD), Nurse Practitioner (NP) and staff interviews, the facility failed to notify the MD or NP of laboratory results when received for 1 of 7 sampled residents reviewed for unnecessary medications (Resident #65).
Findings included:
Resident #65 was admitted to the facility on [DATE].
The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #54 with intact cognition and was receiving dialysis.
A physician's order for Resident #65 dated 06/06/22 read in part, liver function test (blood test to check the status of the liver) and thyroid-stimulating hormone (blood test to check if the thyroid hormone is functioning as it should) every six months, in June and December.
Review of Resident #65's medical record revealed no lab results for liver function and thyroid-stimulating hormone tests obtained in June 2022.
The laboratory results for Resident #65's liver function and thyroid-stimulating hormone tests were provided for review by the Medical Records staff member on 07/29/22 at 12:34 PM. The lab results showed they were reported to the facility on [DATE]. The results of the liver function test revealed Resident #65 had a low albumin (a protein made by the liver that enters the bloodstream and helps keep fluid from leaking out of the blood vessels into other tissues) of 3.13 grams/deciliter (g/dl) with 3.50-5.70 g/dl being within normal limits. Further review revealed Resident #65 had a low total protein (amount of protein in the blood) of 5.9 g/dl with 6.0-8.3 g/dl being within normal limits.
Review of the nurse progress notes for June 2022 revealed no documentation the MD or NP were notified of Resident #65's lab results dated 06/07/22.
During interviews on 07/29/22 at 12:34 PM and 5:27 PM, the Medical Records staff member stated she was current with scanning all lab results reviewed by the MD or NP into Resident #65's electronic medical record and the only lab result not scanned was the one dated 06/07/22. The Medical Records staff member explained she printed of the lab results from the facility's lab system today and confirmed the results were not printed off from the lab system when received on 06/07/22 and had not been given to the MD or NP to review.
During a telephone interview on 07/29/22 at 3:07 PM, the NP stated typically lab results were received from the lab the following day and nursing staff should have printed off the results for Resident #65 when received on 06/07/22 for her or the MD to review.
During a telephone interview on 07/29/22 at 3:28 PM, the MD stated if lab results for Resident #65 were not printed off when received, it was unlikely he or the NP were notified of the results. The MD stated nursing staff knew they were responsible for printing off lab results the day they were received but must have forgot.
During a joint interview on 07/29/22 at 4:25 PM, the Director of Nursing (DON) explained all orders for lab tests were placed in the lab communication book for them to be obtained when due. The DON stated nursing staff were responsible for checking the lab system daily to print off the results received for the MD or NP to review and she tried to follow-up weekly to double-check and make sure none were missed. The DON confirmed the lab tests ordered for Resident #65 were documented in the lab communication book; however, they had not been marked off to indicate the results were received. The DON stated she was not sure where the breakdown occurred between receiving the results and getting them printed off for the MD or NP to review.
During a joint interview on 07/29/22 at 4:25 PM, the Administrator stated he would have expected for lab results to have been provided to the MD or NP when received.