Valley Falls Tearrace

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for one of 24 sampled residents (Resident (R)6). R6's MDS was not accurately coded to indicate the continuation of Hospice services with a terminal diagnosis for two quarterly MDS assessments. The failure to accurately code/assess the resident's condition had the potential to affect the care planning for the resident to receive all required services.
Findings include:
Review of pages J27 and J28 of the October 2024 RAI Manual revealed, . Steps for Assessment
1. Review the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness.
2. If the physician states that the resident's life expectancy may be less than 6 months, request that they document this in the medical record. Do not code until there is documentation in the medical record.
3. Review the medical record to determine whether the resident is receiving hospice services.
Coding Instructions
-Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services.
-Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services .
Review of R6's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE] with medical diagnoses that included chronic deep vein embolism and thrombosis (blood clots), Alzheimer's dementia, adult failure to thrive, dysphagia, pain, and type II diabetes.
Review of R6's Orders, located under the Resident tab of the EMR, revealed a physician order for hospice services dated 08/14/24.
Review of R6's RAI [Resident Assessment Instrument] tab of the EMR revealed a significant change in status MDS, with an assessment reference date (ARD) of 08/22/24, revealed R6 was coded as having a terminal (6 months or less to live) diagnosis and as receiving hospice services.
Review of R6's RAI tab revealed two quarterly MDS with ARDs of 11/21/24 and 02/20/25, neither of which was coded for R6 having a terminal diagnosis or as receiving hospice services.
During an interview on 04/15/25 at 11:27 AM, the MDS Coordinator (MDSC) reviewed R6's MDS assessments and stated, I don't see hospice coded for 11/21 or for the 2/20. I can do an education [this MDSC did not complete these assessments]. The MDSC confirmed the assessments should have been coded for terminal diagnosis and hospice services. The MDSC stated she would check for a policy, but there is a button in the MDS [EMR] to open the RAI manual and we follow the RAI manual.
During an interview on 04/16/25 at 8:26 PM, the Administrator stated the expectation was that assessments are accurate. The Administrator stated, We do use RAI but I'll look for a policy. No policy was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure psychotropic medication had target behaviors identified to enable medication efficacy monitoring for one of five residents (Resident (R) 29) reviewed for unnecessary medications from a total sample of 24. This failure had the potential to affect the ability for a physician to prescribe the lowest possible effective dose of psychoactive medication.
Findings include:
Review of the facility policy titled Medication Management: Psychotropic Drugs - Use of, revised 04/17/24, revealed, . The facility will monitor and document the resident's response to psychotropic medication for efficacy and adverse consequences. Monitoring will include:
A. Symptoms/ behaviors / or side effects to be monitored.
B. Progress toward the therapeutic goals.
C. Adverse consequences.
D. Effectiveness of non-pharmacological approaches
E. After initiating or increasing the dose of a psychotropic medication, the behavioral symptoms will be reevaluated during quarterly care plan review, or with observed changes to determine the potential for reducing or discontinuing the dose based on therapeutic goals and any adverse effects or functional impairment .
Review of R29's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R29 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic respiratory failure, restless leg syndrome, insomnia, generalized anxiety disorder, and congestive heart failure.
Review of R29's Care Plan, dated 01/04/23 and located under the RAI [Resident Assessment Instructions] tab of the EMR, revealed a problem of Behavioral Symptoms. Approaches included, . Response to drug therapy will be monitored and treatment will be evaluated for gradual dose reduction (GDR), tapering or discontinuation per facility policy .
Review of R29's facility printed physician orders revealed R29 had a physician's order for
quetiapine (brand name Seroquel, an atypical antipsychotic medication) for unspecified psychosis not due to a substance or known physiological condition
Review of R29's Orders, located under the Resident tab of the EMR, revealed no documented evidence of a target behavior for the use of the quetiapine.
During an interview on 04/16/25 at 2:18 PM, the Administrator confirmed there was no target behavior identified for the use of quetiapine.
During an interview on 04/16/25 at 8:32 PM, the Administrator stated an expectation regarding psychotropic medications that They [staff] should have the target behaviors listed as to what they are monitoring for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R70's annual MDS, with an ARD date of 03/15/25 and located in the RAI tab of the EMR, revealed an admission date of 03/26/24 and diagnoses that included dementia. It was recorded R70 had a BIMS score of three out of 15 indicating R70's cognition was severely impaired.
Review of R70's Order, dated 04/16/25 located in the EMR under the Order tab revealed 1/4 top side rails for safety and bed mobility. Every Shift.
Review of R70's Siderail Review and Consent, dated 03/12/25 and located in the EMR under the Observation tab, revealed the cognition, bed mobility, transfer, history of falling, entrapment risk, and alternative attempted sections were left blank.
On 04/14/25 at 1:45 PM, R70 was observed asleep in bed lying on her right side facing the wall. Both side rails were up.
On 04/14/25 at 4:28 PM, R70 was awake in bed waving hello. Both side rails were up.
During an interview on 04/16/25 at 2:41 PM, UM was asked if she filled out R70's Siderail Review and Consent, dated 03/12/25. UM stated, Yes, [R70]'s side rails are for repositioning. UM was asked if alternatives were attempted before the use of side rails. UM stated, Yes, we always do but confirmed she left the alternative section blank. UM stated they put R70's call light in reach but acknowledged everyone has that. UM was asked if she conducted an evaluation for entrapment as that section was blank. UM stated, Yes we always do but confirmed she left the section blank.
3. Review of R73's Face Sheet, located under the Resident tab of the EMR, revealed R73 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, metabolic encephalopathy, lack of coordination, pressure ulcers, and rheumatoid arthritis.
During an interview on 04/14/25 at 4:41 PM, R73 was observed to have bilateral upper side rails on her bed (R73 was in her bed). When asked if she used the side rails, R73 responded that she did, but did not remember any risks or benefit explanation.
Observation of R73 on 04/14/25 at 4:50 PM and 04/15/25 at 3:55 PM revealed R73 in bed with raised bilateral upper side rails.
Review of R73's Side Rail Review and Consent, completed on 03/01/25 and provided by the facility, showed R73's Responsible Party (RP)'s name was written in with verbal handwritten next to it. The form had sections to be completed regarding risk potential and alternatives. The risk potential was marked for skin tears/scrapes/bruises. The alternatives section was left blank.
During an interview on 04/15/25 at 3:49 PM the Administrator was asked if any alternatives had been attempted prior to the use of side rails. The Administrator responded, No, and that she would have to educate regarding that.
During an interview on 04/16/25 at 2:43 PM, the UM, who had completed R73's side rail evaluation, stated, I asked if she [R73] used them [clarified, side rails] in the hospital and she said yes. When asked how she evaluated R73's safety and entrapment risk, UM responded, I had her roll over and hold on to the rail. We don't prompt her to, just making sure she understands that's what you hold on to. The UM was asked why the risk of entrapment was not checked on the evaluation form. UM stated, Well I guess I really didn't see anything, only the possibility of skin tear that's the only risk I seen. When asked about the Resident or Representative Party (RP) not signing the evaluation form that she/they had been advised of the risks/benefits, UM stated that She [RP] was in the room but rather than have her sign it, I just put in her name and wrote 'verbal' and had two nurses sign it. UM stated the second nurse was in the room during the risk/benefit advisement.
During an interview on 04/16/25 at 8:30 PM, the Administrator stated an expectation that the facility would try alternatives, make sure they [residents] are safe with no entrapment risk, and evaluations are thoroughly completed.
Based on observation, interview, record review, and facility policy review, the facility failed to ensure alternatives were attempted prior to the use of bed rails for three of three residents (Resident (R)5, R70, and R73) reviewed for side rails out of a total sample of 24. This failure had the potential to increase accidental entrapment or injury when an alternate assistive device may have been effective.
Findings include:
Review of the facility policy titled Bed Rails and Side Rails, Installation and Use, revised 05/05/23, revealed, . The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use is determined to be appropriate for the patient/resident.
Procedures
1. Acceptable alternatives will be considered prior to the installation of bed rails. Alternatives include but are not limited to roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed. https://www.fda.gov/medical devices/consumer-products/bed-rail-safety-updated.
2. The resident will be evaluated for the risk of entrapment prior to installation.
4. The risks and benefits of bed rails/side rails will be reviewed with the resident and/or responsible party. Consent . will be obtained prior to the installation of bed rails/side rails.
1. Review of R5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 01/16/25 and located in the Resident Assessment Instrument (RAI) tab of the electronic medical record (EMR), revealed R5 was admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg below the knee, dementia, and muscle weakness. It was recorded R5 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating R5's cognition was severely impaired.
Review of R5's Orders, dated 10/24/24 and located in the EMR under the Order tab, revealed 1/4 bilateral siderails to promote bed mobility. Not used as a restraint and Bed bolsters to sides of bed q [every] shift for positioning.
Review of R5's Care Plan, revised 04/14/25 and located in the EMR under the RAI tab, revealed, [R5] has 1/4 side rails to bed and is at risk for entrapment. Interventions included, Identify appropriate use of 1/4 siderails and Side Rail assessment as required.
Review of R5's Care Plan, revised 04/14/25 and located in the EMR under the RAI tab, revealed [R5] is at risk for falls r/t [related to] hx [history] of recurrent falls, unsteady balance. An intervention included, Bed Bolster to side of bed r/t positioning.
Review of R5's Siderail Review and Consent, dated 04/08/25 and located in the EMR under the Observation tab, revealed the sections for cognition, bed mobility, transfer, history of falling, entrapment risk, and alternative attempted were left blank.
Review of R5's Progress Note, dated 08/05/24 and located in the EMR under the Progress Note tab, revealed, . The res was found on the floor to the right side of her bed between the bed and closet chest. Per the res she didn't hit her head. Res bed booster [sic] was noted hanging off the bed, bed was in semi low position, fall mat was folded noted between the closet chest and the wall, and res bed alarm cord wasn't plugged in. Call light was within reach but wasn't on at the time of the fall .
On 04/14/25 at 10:19 AM, R5's bed was observed with two bolsters on each side of the bed and quarter size side rails.
On 04/15/25 at 5:41 PM, R5 was served her supper in bed with the quarter size side rails in the up position, the bolsters under the covers on each side of the edge of the bed, and the head of the bed up.
During an interview on 04/15/25 at 6:09 PM, Certified Nurse Aide (CNA)2 was asked why R5 had side rails. CNA2 stated she did not work that side of the building very much. CNA2 stated I guess it's to keep her from falling out of bed.
During an interview on 04/15/25 at 6:11 PM, Unit Manager (UM) was asked why R5 had side rails. UM stated R5 used them during care as R5 holds onto them and R5 will use them to reposition herself. UM was asked what the bolsters were for. UM stated, To define the parameters of the bed, so R5 could feel the edge of the bed as she had fallen out of bed before.
During an interview on 04/16/25 at 2:00 PM, the Administrator was shown the blank alternatives and entrapments sections of the side rail assessment for R5 and asked who completed the assessments. The Administrator stated the floor nurse completed the forms.
During a follow up interview on 04/16/25 at 2:41 PM, the UM was asked if she filled out R5's Siderail Review and Consent, dated 04/08/25. UM stated, Yes, [R5]'s side rails were for repositioning. UM was asked if alternatives were attempted before the use of side rails. UM stated, Yes, we always do but confirmed she left the alternative section blank except for checking call light in reach. UM stated they put R5's call light in reach but acknowledged everyone has that. UM stated they placed R5's bed in the low position but did not check that on the assessment. UM was asked if she conducted an evaluation for entrapment as that section was blank. UM stated, Yes we always do but confirmed she left the section blank. UM was asked if the bolsters were evaluated for entrapment as R5 had fallen out of bed and the bolsters were hanging off the bed. UM stated she did not think so. UM was asked since R5 did not have much mobility or stability due to a right below the knee amputation and dementia, if R5 would be able to get herself out of a situation if she was trapped. UM stated R5 had a bed alarm to alert staff if she had fallen. UM was asked what if R5 is trapped in bed and had not fallen out of bed. UM stated she did not know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to investigate the possible underlying issue for significant weight loss, follow nutritional interventions, and assess the resident before the use of a psychotropic drug for weight loss for one (Resident (R)70) of three sampled residents reviewed for nutritional status. This had the potential to cause further weight loss.
Findings include:
Review of the facility's policy titled, Weighing the Resident, revised 05/05/23, revealed . The facility dietitian reviews the patient's/resident's nutritional status and makes recommendations for intervention if significant weight change is noted. 6. Review significant, unplanned changes and insidious gradual weight loss or gain trends in weights at the weekly Long-Term Care Coordination meeting .
Review of R70's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 03/15/25 and located in the Resident Assessment Instrument (RAI) tab of the electronic medical record (EMR), revealed R70 was admitted to the facility on [DATE] with diagnoses that included dementia, diabetes mellitus, and malnutrition.
It was recorded R70 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R70's cognition was severely impaired, It was recorded R70 had weight loss and required substantial/maximal assistance with eating.
Review of R70's Orders, located in the EMR under the Order tab, revealed, House, Pureed, dated 03/19/25; Mighty Shake (nutritional supplement) BID [twice daily], dated 03/19/25;Protein supplement 30 ml TID [three times daily], dated 04/11/24; and mirtazapine tablet; 7.5 mg at bedtime, dated 03/19/25.
Review of R70's Nutritional Assessment, dated 03/19/25 and located in the EMR under the Observation tab, revealed, CBW [current body weight]: 100# [pounds] (3/14/25) wt [weight] down 16.5% [percent] xl month. wt down 19.1% x3 months. BMI [body mass index]:23.24 kg [kilogram] indicating healthy. Diet is CCD [controlled carbohydrate diet]. Mech [mechanical] soft texture. Diet was downgraded to mech soft on 3/12, was downgraded again on 3/18 to puree. PO [oral] intakes average. 0-75% per nsg [nursing] documentation. R70 was transferred out on 3/8-12, noted with 14.8% wt loss since previous weight in facility prior to being transferred out. Rx [medications] includes: B12, fluoxetine, losartan, magox, remeron, novolog, trazodone, protein supplement @ [at] 30 ml TlD. No skin issues noted at this time. Recommended adding mighty shake BlD, and Liberalizing diet to regular non therapeutic, with current texture. Will monitor and f/u [follow up] PRN [ as needed].
Review of R70's Care Plan, revised 03/26/25 and located in the EMR under the RAI tab, revealed, Resident has experienced a significant weight loss x 30 days. An intervention included Supplements as ordered.
Review of R70's Care Plan, revised 03/26/25 and located in the EMR under the RAI tab, revealed, [R70] is at risk for malnutrition R/T [related to] diagnosis of Unspecified protein-calorie malnutrition. Interventions included Protein supplement as ordered, Encourage resident to dine in dining room if appropriate, Monitor and encourage intake of foods and fluids at meals and throughout the day, and Provide assistance with meals/snacks as necessary.
Review of R70's Weight History, located in the EMR under the Vitals tab, revealed a 5% weight loss in one month:
On 03/12/25 at 100.4 pounds lbs
On 03/14/25 at 100.0 lbs
On 03/16/25 at 100.2 lbs
On 03/21/25 at 99.1 lbs
On 03/28/25 at 97.8 lbs
On 04/04/25 at 98.8 lbs
On 04/11/25 at 97.2 lbs
On 04/15/25 at 9:39 AM, R70 was weighed in her wheelchair and after Licensed Practical Nurse (LPN)2 subtracted the wheelchair, R70 weighed 95 lbs.
Review of R70's meal intake documentation, dated 03/15/25 to 04/15/25 and located in the EMR under the Vitals tab, revealed out of 31 days, R70 only consumed six meals at 76-100%.
Review of R70's Nurse Practitioner's Progress Notes, dated 02/24/25 and 03/13/25, located in the EMR under the Resident Document revealed no mentions of mirtazapine.
On 04/14/25 at 5:44 PM, R70 was served her evening meal in her room. Her meal included pureed green beans, pureed mashed potatoes, pureed meat, Jello, a chocolate Mighty shake, and tea. R70 fed herself while sitting on the side of her bed.
On 04/14/25 at 6:01 PM, R70 only drank the chocolate shake. None of her food was consumed except a few bites.
On 04/14/25 at 6:10 PM, Certified Nurse Aide (CNA)3 went into the room and asked R70 if she was finished eating. No encouragement was provided.
On 04/14/25 at 6:11 PM, CNA3 left R70's room and placed R70's tray on the hall cart. CNA3 confirmed that R70 ate only 25% of her meal.
On 04/15/25 at 12:38 PM, CNA5 was asked if R70 was served her lunch. CNA5 stated R70 was at an appointment. CNA5 opened the lunch cart and R70's lunch tray was inside and the meal ticket was torn in half. The tray contained three pureed items, a side dish, ice cream, and a Mighty Shake. All items were covered and untouched. Staff was noted to be loading soiled trays on the cart with R70's tray.
On 04/15/25 at 3:12 PM, R70 was in her room as CNA1 took her vitals. R70 was asked if she ate lunch today and R70 said, No.
Review of R70's meal intake documentation, dated 04/15/25, located in the EMR under the Vitals tab revealed Lunch: None.
On 04/15/25 at 5:49 PM, R70 was served her supper meal in her room that included pureed pizza, pureed mashed potatoes, pureed vegetables, ice cream, and tea. No Mighty shake was on her tray. R70 was feeding herself.
Review of R70's dinner meal ticket, dated 04/15/25, provided by the facility, revealed shake. - 1 Ea [each].
On 04/15/25 at 6:07 PM, R70's tray was observed to be placed on the hall cart with only the ice cream consumed and the other food items untouched except one bite. CNA1 confirmed that R70 did not eat her meal, just the ice cream and no Mighty shake was on R70's tray.
On 04/15/25 at 6:15 PM, the Unit Manager (UM) and the Administrator were asked if R70 ate lunch today, 04/15/25. The Administrator stated R70 went to a dentist appointment as she was having trouble with her dentures fitting and that was why her diet was changed to pureed. UM stated they saved R70's lunch tray and offered it to her when she got back but she only drank the liquids. The Administrator was asked if R70 should have received a Mighty shake at dinner on 04/15/25 as it was not on her tray that was still on the hall cart. The Administrator stated, Yes. The Administrator stated the nurse would have caught it when they checked it off. The Administrator stated she was aware of R70's weight loss. The DON overheard the conversation and then provided the shake.
During an interview on 04/16/25 at 8:11 AM, the Dietary Manager (DM) was asked who added the Mighty shakes to the meal trays. DM stated, We do. DM was then asked if he was aware R70 did not get a shake on her tray at dinner on 04/15/25. DM stated it should be on the meal ticket.
On 04/16/25 at 8:19 AM, R70 was wheeled to the dining room for breakfast.
On 04/16/25 at 8:37 AM, R70 was served pureed scrambled eggs, pureed cereal, pureed sausage, two juices, a Mighty Shake, and ice cream. R70 only ate the ice cream and health shake. Staff did not attempt to feed R70.
On 04/16/25 at 8:40 AM, the UM was asked why R70 was given the Mighty Shake and ice cream with her meal rather than after if she did not eat her meal. UM stated, That's what they do. UM was asked if that was what they did, why ice cream was served with her meal. UM did not comment. UM was asked if staff tried to feed R70 as the MDS stated R70 required assistance and none was observed. UM stated R70 would not allow them.
During a telephone interview on 04/16/25 at 11:09 AM, the Registered Dietitian (RD) was asked if he was aware of R70's weight loss. RD stated, Yes, he charted on it this week. RD stated R70 had been in the hospital from [DATE] to 03/12/25, and her weight was down when she got back to the facility. RD stated her diet was downgraded and he took off the CCD. RD stated R70's weight was stable due to the health shakes in spite of her intake being worse. RD was asked if he was told that R70's recent weight was down more. RD stated he was not told yet. RD was asked what interventions were in place for R70. RD stated the Mighty shakes twice daily, the protein supplement of 30 ml three times daily, and Remeron 7.5 mg. RD was asked if he wanted the Mighty shake ordered with the meal tray. RD reviewed his note to see how it was ordered and stated food should be first before the supplementation or medication. RD was asked what his expectation was for the interventions. RD stated, Ideally, yes, the main food items should be first and as a last resort supplement and medication. RD stated R70 was [AGE] years old so he was not sure how much the mirtazapine would help. RD then stated he left it up to the facility's discretion as to serve the Mighty shakes with the meals or after the meals.
On 04/16/25 at 12:20 PM, LPN2 confirmed R70's new weight was 95 lbs, and it was down from her last weight. LPN2 was asked why it was not documented yet in the EMR. LPN2 stated she gathers the weights during the week and adds them all on Friday.
During an interview on 04/16/25 at 1:33 PM, the Nurse Practitioner (NP) was asked if she was aware of R70's weight loss. NP stated, Yes. NP was asked why R70 was prescribed mirtazapine. NP stated as an appetite stimulant as R70 had dementia. NP stated 7.5 mg was the dose for appetite. NP was asked since mirtazapine was psychotropic, had an evaluation been completed before prescribing. NP stated there should be documentation for the rationale for mirtazapine. NP stated R70 had been on the mirtazapine for a while.
During an interview on 04/16/25 at 8:15 PM, the Administrator and Clinical Services Director (CSD) stated Weighing the Resident was the only policy they had for weight loss. CSD stated nursing followed this policy and nursing and the RD make the decision as to what interventions to use and there was no other policy. CSD was asked if R70's weight was taken yesterday, 4/15/24, and the staff weighing R70 did not add it to the EMR until Friday, should staff know sooner. CSD stated, Yes but they also discuss weights in standup every morning. The Administrator stated R70 likes sweets so that's why R70 has Mighty shakes and ice cream on her meal trays. CSD and the Administrator were asked if R70 should be encouraged to eat her meal first and then follow with the Mighty Shakes. CSD stated, Yes but it depends on the resident. CSD and the Administrator were informed staff said R70 would not allow them to feed her but staff did not try. CSD and the Administrator were asked if R70's supper tray on 04/15/25 was served at 5:49 pm and removed at 6:07, was that enough time to eat. CSD and the Administrator did not comment. CSD and Administrator were asked if their policy addressed cause/risk/analysis and had a cause/risk/analysis been conducted for R70. CSD reiterated R70's supplements and that the NP prescribed mirtazapine to stimulate R70's appetite. CSD and the Administrator were asked if an evaluation was conducted before mirtazapine was prescribed as psychotropic medication. CSD and the Administrator stated they were not sure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature for four of four resident rooms (Rooms 100, 101, 114, and the room of Resident (R) 23) out of a total of 40 resident rooms and one of one shower room where water temperatures were measured. This failure had the potential to cause residents to incur a burn from the high water temperature.
Findings include:
Review of the facility's policy titled, Preventative Maintenance Procedure, revised 07/26/17, revealed, . Adjust temperatures as needed per state regulations .
Review of the facility provided state regulation, which the facility uses revealed, Section 2300 - Water Supply, Hygiene, and Temperature Control A. Plumbing fixtures that require hot water and that are accessible to residents shall be supplied with water that is thermostatically controlled to a temperature of at least one hundred (100) degrees Fahrenheit and not to exceed one hundred twenty (120) degrees Fahrenheit at the fixture.
During an interview on 04/14/25 at 11:17 AM, R23 expressed a concern that he was sometimes worried the bathroom sink water temperature might be hot enough to burn him.
Review of R23's Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R23 was admitted to the facility on [DATE] with diagnoses that included constipation, diarrhea, autistic disorder, and peripheral vascular disease.
Review of R23's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/13/25 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R23 had Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R23 was cognitively intact.
During an observation on 04/16/25 at 2:58 PM, the Maintenance Director (MD) tested the water temperature of R23's sink on the 300 hall. The surveyor saw the thermometer at 125 degrees Fahrenheit (F), and when the MD was asked to confirm, he stated he thought it was 123 degrees F and offered to retest. When he turned the hot water on again and inserted the facility thermometer, within 30 seconds the temperature registered 135.8 degrees F, which the MD confirmed.
Further observations with the Maintenance Director taking water temperatures on the 100 hall revealed the following findings:
04/16/25 05:25 PM sink in room [ROOM NUMBER] was 133 degrees F
04/16/25 05:27 PM sink in room [ROOM NUMBER] was 132 degrees F
04/16/25 05:29 PM sink in room [ROOM NUMBER] was 130 degrees F
04/16/25 05:35 PM sink in the 2nd shower room on 100 hall was 129 degrees F
04/16/25 05:44 PM sink in Room a recheck of R23's bathroom sink water temperature showed 118 F.
The MD stated it takes about one hour to decrease the hot water temperature by three degrees.
During an interview on 04/16/25 at 8:23 PM, the Assistant Director of Nursing (ADON) and Unit Manager (UM) stated if the water is too hot they adjust it and in fact they ask the resident to approve the temperature. They both stated no residents had been burned.
During an interview on 04/16/25 at 8:26 PM, the Administrator stated an expectation that the facility would check water temperatures and adjust them to fall between 100- and 120-degrees Fahrenheit.
During an interview on 04/16/25 at 8:27 PM, Certified Nurse Aide (CNA)3 was asked if the water gets too hot. CNA3 stated, It depends as I add the cold water with the hot to make it comfortable. CNA3 was unaware of any residents being burned.
During an interview on 04/16/25 at 8:29 PM, Licensed Practical Nurse (LPN)1 was asked if the water was ever too hot for activities of daily living such as face washing and peri care. LPN1 stated, No but I adjust it to the resident's preference and have the resident test it and adjust it accordingly.
During an interview on 04/16/25 at 8:33 PM, CNA4 stated, Sometimes in the shower it gets hot, but I always check it before using on the resident and adjust it with cold water. CNA4 was not aware of any residents ever being burned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policy review, the facility failed to ensure foods that were stored in the freezer, refrigerators and dry food storage were properly sealed, labeled, dated with a use by date, and/or discarded after the manufacturer's expiration date. This failure had the potential to cause foodborne illnesses in all residents who received meal trays from the kitchen.
Findings include:
Review of the facility policy titled, Nutrition Orientation & Competency Policies and Procedures, with a complete revision date of 07/21/23, revealed, Food storage: label and date food items removed from their original containers; Always cover, label and date leftovers that are to be stored. They should be date marked with the use by date; tightly reseal open packages, such as pancake mix; Keep all containers of food tightly covered.
Review of the facility policy titled, Nutrition Policies and Procedures with a complete revision date of 06/20/23, revealed, General food storage guidelines: 3. Place food that is repacked in a leak-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and the lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Dry Storage Guidelines: 2. Tightly seal opened packages to prevent contamination or place food in covered containers.
During an initial brief tour of the kitchen on 05/07/24 at 9:38 AM, revealed the following:
The walk-in refrigerator revealed:
1-1 gallon (gal) container of sliced jalapeno peppers opened with no open date.
1 box of lemons not dated or labeled, consisted of 5 lemons with a green fuzzy substance on the outside of the lemons, and 3 lemons were turning brown.
1-25 pound (lb.) box of tomatoes not date labeled.
1-20 lb box [NAME] Spunkmeyer chocolate chip cookies, open with no open date, the box and bag was not tightly sealed.
1-Blue bag containing chocolate chips not labeled with contents, and no open or expiration date.
The walk-in freezer revealed:
1-20 lb box of beef patties opened and not labeled with an open date and the bag and box were not sealed.
1-5 lb bag frozen blueberries, opened with no open or expiration date.
1-Large pan of doughnut dough, not dated or labeled.
1-5 lb bag of hash brown patties opened (not tightly sealed) with no open date.
The dry food storage room revealed:
1-Used/dirty mop head stored on top of storage container of brown rice.
1-Large storage container of oatmeal with no prepared date or use by date,
1-Box containing 31 packs of 0.42 ounce (oz) packs of nectar thickened coffee mix with use by date of 01/05/24.
1-10 lb bag of [NAME] macaroni noodles, open with no open date or expiration date.
1-10 lb bag of [NAME] rice, open with no open date or expiration date.
1-10 lb. bag [NAME] penne pasta open with no open date or expiration date.
1-Box containing 38 packs of 0.42 oz packs honey thicken coffee mix with use by date of 01/19/24.
1-18 quart plastic container of flour not tightly sealed.
1-Bin containing the following: 8 Jell-O cups, 2 snack size apple sauce, 3 packs peanut butter crackers, 3 bags Scooby doo graham crackers, 3 bags Cheez It, 3 fig bars, 6 fudge rounds with a white powdery substance at bottom.
1-Storage bin containing sweet & low sugar packets filled with a white powdery substance under packets.
1-Storage bin containing Splenda sugar packets filled with a white powdery substance under packets.
The kitchen prep area revealed:
1-Loaf of sandwich bread open with no open date.
1-Bag Lays potato chips open with no open date.
Microwave revealed dried food particles on ceiling of the microwave.
Ice maker revealed black spots on the inside of the ice maker and on the ledge of the door.
Ceiling vents revealed orange and brown debris throughout the kitchen.
Kitchen window has thick black dust on window and top window seal.
During a follow-up observation of the kitchen on 05/08/24 at 11:06 AM, revealed the following:
The kitchen door propped open with a black pedestal fan with the fan blowing into the kitchen facing the steam table.
1-Dirty white towel on top of the oatmeal storage container.
1 container of unused tea bags observed in open container uncovered and not labeled or dated
Food particles on top of the plate warmer base.
Plate warmer cart contained debris on top of cart.
Buildup/debris observed in refrigerator doors and handles, bottom vent on refrigerator revealed a bent vent grate and brown substance with the appearance of grease built up on grate.
During an observation on 05/08/24 at 1:39 PM, the 300 Hall nourishment room revealed the following:
1-52 oz. carton of cotton candy mix, open and not dated or labeled.
2-Boxes of [NAME] ice cream cones and 1 open pack of cup lids stored next to 1 spray bottle labeled Peroxide Multiple Surface Cleaner & Disinfectant, in cabinet.
During an observation on 05/08/24 at 2:57 PM, the 100 Hall nourishment room revealed the following:
1 Sandwich not labeled or date,
12- .42 oz Thickened Coffee Mix mildly thick Nectar packets with an expiration date of 01/05/24.
During an interview on 05/07/24 at 10:30 AM, the Dietary Manager (DM) revealed that he usually checks food packages on Fridays to ensure that they are date marked. The DM stated that since he has been at the facility he has been instructing staff to label container/packages with an open date when they open it. The DM explained that he expects staff to twist close bags in boxes and close the box once opened.
During an interview on 05/08/24 at 11:44 AM, the Kitchen Manager (KM) revealed the particles observed on the plate cover warmer was grits and that the warmers needed to be rewashed. The KM explained that the ice machine should be wiped daily by staff, but maintenance cleans the machine once a month.
During an interview on 05/08/24 at 12:11 PM, the DM revealed that the ice machine should be checked daily. The DM stated the microwave should be cleaned after each use and that the container of tea bags on the bottom of the prep table should be covered with a lid. The DM revealed that the kitchen staff should be wiping down the prep areas while working, at the end of each meal, and the kitchen staff should be wiping down the area and sanitizing. Deep cleans are expected to be performed weekly.
During an interview on 05/08/24 at 1:45 PM, the Activities Assistant revealed that the cotton candy mix belongs to the activities department but hasn't been used in a long time and probably should be thrown away.
During an interview on 05/09/24 at 11:23 AM, the Administrator revealed that the KM is responsible for monitoring the food storage and that anyone touching the food should make sure that the food is good before preparing it for the residents. The Administrator states that it is her expectation that any unused food packages be stored with the date it was opened so that it can be discarded at the appropriate time and all goods should be checked before it expires and if any items are found expired, they should be discarded. The Administrator further states that the kitchen should be cleaned according to the cleaning schedule or when there is anything visible it should be addressed and cleaned immediately. The Administrator concluded that a walk through is completed every Thursday and that sanitation audit is sent to the corporate office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and the , the facility failed to accurately code the Minimum Data Set for 1 of 3 records reviewed for assessment, Resident (R)49.
The findings include;
Review of R49's Face Sheet revealed R49 was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure with hypoxia, schizophrenia, and gastro-esophageal reflux disease without esophagitis.
Review of R49's Minimum Data Set (MDS) with an Assessment Reference Date of 03/27/24 revealed R49's Brief Interview for Mental Status (BIMS) score was 13 out of 15, indicating R49 was cognitively intact. Further review of the MDS revealed under Section I, Diagnosis, schizophrenia was not coded.
Review of the Minimum Data Set 3.0 Section I states, Include the primary medical condition coded in this item in Section I: Active Diagnoses in the last 7 days.
During an interview on 05/09/24 at 12:15 PM, the MDS Registered Nurse (RN) stated, [R49's] diagnosis of Schizophrenia should have been coded on the MDS.

Based on interview, record review, and review of facility policy, the facility failed to post daily staffing for 2 days out of 4 months reviewed.
Findings include:
Review of the facility policy titled, Posting of Licensed and Unlicensed Direct Care Staff revised in 2017 states, Direct care staffing for licensed and unlicensed staff is posted on a daily basis.
Review of the facility's posted staffing sheets for 03/01/24 thru 05/07/24, revealed on 03/16/24 and 03/17/24, there was no documentation of hours for Registered Nurses (RN)s, Licensed Practical Nurses (LPN)s, or Certified Nurse Assistants (CNA)s for all three shifts.
During an interview on 05/08/24 at 11:59 AM, the CNA Staffing Coordinator stated, I complete the weekend staffing sheets afterward on Mondays. The CNA Staffing Coordinator confirmed on 03/16/24 and 03/17/24 the posted staffing was not completed.
During an interview on 05/08/24 at 1:15 PM, the Administrator stated, These (posted staffing) are supposed to be filled out on Friday for the weekend staff to post or they could fill it out and post it each day of the weekend.

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. Specifically, insulin administered via an insulin pen was not primed before administration for Resident (R)18. The facility additionally failed to ensure R18 received the correct dose of insulin due to incorrect priming of the pen. Furthermore, the facility failed to ensure that oral tablets were administered according to directions. The medication administration error rate was 12 percent, for 3 of 25 opportunities for error.
Findings include:
Review of the facility policy titled, Pharmacy Services Policies and Procedures with a revision date of 04/17/24, revealed, Section 6-Medication Management. Subject: 6.3 Medication Errors; Prevention, Identification and Management of. Policy: 1. The facility shall strive to prevent medication errors, and will identify and manage them appropriately when they occur and ensure that its- A. Medication error rates are not 5 percent of greater; and B. Residents are free of any significant medication errors. Procedures: 1. The staff and practitioners shall strive to minimize potential for medication error by: A. Following The 8 Rights for administrating medication: 1. The Right Patient/Resident 2. The Right Drug 3. The Right Dose 4. The Right Time 5. The Right Route 6. The Right Charting 7. The Right Results 8. The Right Reason B. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.
Review of the facility's policy titled, Nursing Policies and Procedures with an emailed revision date of 07/13/21 revealed, Subject: Medication Management Program, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standard of practice and regulatory requirements. Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident .7. The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication. 8. G. Tablets should not be split. The pharmacy should be contacted to provide the correct dose. In an emergency situation, if the licensed nurse must split a tablet, the nurse should wear gloves and break only scored tablets. Unscored or coated tablets may not be split.
Review of the facility's Staff Education/Orientation Policies and Procedures dated as new policy 11/18/21 revealed, Discipline: Nursing, Competency: Medication Administration-Insulin Pen. Performance Criteria, Preparing the Pen: 2. Removes the external pen cover and inspects the excessive air in the cylinder . Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. 3. Repeat these steps as needed until a drop or stream of insulin appears at the needle tip. Note: A new pen may have to be primed up to 6 times before it will expel insulin.
Review of R18's Physician Order documented, acetaminophen [OTC] tablet extended release; 650 mg; amt: one tablet; oral Every 8 Hours 12:00 AM, 08:00 AM, 04:00 PM. Additionally, insulin lispro insulin pen; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 299, give 4 Units. If Blood Sugar is 300 to 349, give 6 Units. If Blood Sugar is 350 to 399, give 8 Units. If Blood Sugar is 400 to 449, give 10 Units. If Blood Sugar is 450 to 499, give 12 Units. If Blood Sugar is greater than 499, call MD. Subcutaneous Before Meals and At Bedtime 06:00 AM, 11:30 AM, 04:30 PM, 09:00 PM.
Review of R61's Physician Order documented, famotidine [OTC] tablet; 10 mg; amt: 2 tablets; oral Twice A Day (Take with food) 09:00 AM, 05:00 PM.
During an observation and interview on 05/08/24 at 4:00 PM, Licensed Practical Nurse (LPN)1 did not prime the insulin pen prior to administering the medication for R18. When asked how an insulin pen is primed, she stated that no one ever told her how and that you just dial up the dose. Further observation revealed, LPN1 did not wear gloves to break the Acetaminophen in half and when asked, LPN1 stated that she did not think gloves were needed to be worn since she had just sanitized her hands. LPN1 further stated, she was not aware that there was a pill cutter in the top drawer of the cart and stated that she had never used it.
During an observation and interview on 05/08/24 at 4:10 PM, prior to the administration of Famotidine to R61, LPN1 stated there were no additional instructions for the administration of R61's Famotidine. Surveyor asked LPN1 to take a look at the medication card to see if there was anything she missed. LPN1 was able to identify the instructions that stated to take with food. LPN1 stated that she had seen the resident eating prior to the medication being given. LPN1 also reported that the resident had received something at the last activity that she had just come from.
During an interview on 05/08/24 at 4:13 PM, R61 stated she had not eaten anything recently and did not come back to her room from an activity. R61 further stated just prior to returning to her room, she was at the nurse's station requesting a grilled cheese sandwich and soup for the next meal.

Based on review of facility policy, observation, and interviews, the facility failed to remove expired medications and biologicals in 2 of 2 medication storage rooms, 1 of 2 treatment carts, and 1 of 4 medication carts.
Findings include:
Review of the facility policy titled, Pharmacy Services Policies and Procedures dated 04/17/24, revealed, Section 8-Medication Storage Policy: 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . Procedures: 5. Medications with manufacturer's expiration date expressed in month and year (e.g., May, 2019) will expire on the last day of the month. (unless a sooner expiration date has been placed on the package by the pharmacy). 6. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. 12.) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the Pharmacy, if replacements are needed.
Review of the facility's policy titled, Nursing Policies and Procedures with an emailed revision date of 07/13/21 revealed, Subject: Medication Management Program, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standard of practice and regulatory requirements. Security and Safety Guidelines: 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations. A new supply of medication is obtained, when necessary.
During an observation on 05/08/24 at 5:00 PM, of the medication storage room on B Hall with Registered Nurse (RN) 3 revealed the following:
1. 11 Exel Hypodermic Needles, 27 gauze, with lot number 180615 and expiration date of 05/15/23.
2. 1 Shiley Tracheostomy Tube Cuffed with Disposable Inner Cannula 4 DCT, 5.0 mm ID, 9.4 mm OD, 20.0 mm, 62 mm, with lot number 19C0489JZX and expiration date of 03/23/24.
3. 1 Medline EntraFlo, Nutrition Delivery System, Gastrostomy Feeding Tube & Lubricant Jelly, 20 Fr/15 cc balloon with lot number S19007077 and expiration date of 09/09/22.
During an observation on 05/08/24 at 5:49 PM, of the medication storage room (which also contained a treatment cart), with the Director of Nursing (DON) revealed the following:
1. 3 Major Biscodyl 10 mg Stimulant Laxative Suppository with lot number YD008 and expiration date of 04/24.
2. 1 BD Vacutainer, Red/Yellow top, with lot number 2321343 and expiration date of 04/30/24.
During an observation on 05/09/24 at 9:28 AM, of the Medication Cart 1 on B Hall, with RN2 revealed the following:
1. Medication card for an order for Resident (R)50-Cyclobenzaprine 10 mg 1 tab by mouth daily at bedtime as needed with lot number NB201113 with an expiration date of 03/31/24.
During an interview on 05/08/24 at 5:00 PM, RN 3 verified the expired medications and biologicals, and removed them from the medication storage room on B Hall.
During an interview on 05/08/24 at 5:49 PM, the DON verified the expired medications and biologicals, and removed them from the medication storage room on A Hall.
During an interview on 05/09/24 at 9:28 AM, RN2 verified the expired medications and biologicals, and removed them from B Hall Medication Cart 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, review of Medline EvenCare G2 Blood Glucose Monitoring System User's Guide, and review of facility policy, the facility failed to ensure that Resident (R)18's glucometer was properly cleaned and sanitized. Additionally, the facility failed to ensure that staff wore gloves when breaking a tablet.
Findings included:
Review of the facility's policy titled, Nursing Policies and Procedures with an emailed revision date of 07/13/21 revealed, Subject: Medication Management Program, Policy: The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standard of practice and regulatory requirements. Procedure-Preparing for the Medication Pass K. Blood Glucose meter is available, calibrated, and quality validated. Meters are cleaned between each use, according to policy and manufacturer guidelines. L. Disposable gloves are available. Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident .7. The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication. 8. G. Tablets should not be split. The pharmacy should be contacted to provide the correct dose. In an emergency situation, if the licensed nurse must split a tablet, the nurse should wear gloves and break only scored tablets. Unscored or coated tablets may not be split.
Review of the facility's policy titled Staff Education/Orientation Policies and Procedures with an emailed revision date of 04/09/15 revealed, Discipline: Nursing, Competency: Blood Glucose Monitoring. Performance Criteria, 5. Follows manufacturer's guidelines for Blood Glucose Monitoring. 11. Clean Glucometer utilizing 2-step process with approved EPA disinfectant wipe which is labeled effective against TB or HBV, HCV and HIV to remove any visible contaminants, soil or other debris. Use a second EPA disinfectant wipe to disinfect the device surfaces, ensuring adequate contact time.
Review of the facility's policy titled, Nursing Policies and Procedures with a revision date of 05/05/23 revealed, Subject: Blood Glucose Monitoring, Policy: The facility provides point of care blood glucose monitoring according to standards of practice and infection prevention and control principles. Competency Evaluations: All personnel, including Licensed Individual Practitioners who perform resident blood glucose testing will have successful written and demonstrated competency evaluations completed prior to performing resident testing. Both written and demonstrated competency evaluations for performing resident testing will be completed during initial orientation and annually thereafter. Refer to Staff Education/Orientation Polices and Procedures SD-II Nursing Services. Cross References: 1. Lippincott Nursing Procedures 9th Ed., pages 78-79. 2. Manufacturer Guidelines (attach) (for use of specific meter). 3. #24 Staff Education/Orientation Policy and Procedure Manual.
Review of the Medline Even Care G2 Blood Glucose Monitoring System User's Guide revealed on pages 44-47, Caring for the Meter, Cleaning and Disinfecting your EvenCare G2 Meter, Cleaning and disinfecting your meter and .is very important in prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and .so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter .Your EvenCare G2 Meter .are validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products are validated for disinfecting the EvenCare G2 meter .:Dispatch Hospital Cleaner Disinfectant Towels with Bleach (EPA Registration Number: 56392-8). Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10). Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12). Medline Micro-Kill Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1). These disinfecting wipes are available through major retailers online or call [PHONE NUMBER] to purchase. Other EPA Registered wipes may be used for disinfecting the EvenCare G2 system, however, these wipes have not been validated and could affect the performance of your meter .Cleaning and Disinfecting Your Meter and Lancing Device 3. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean .4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below. Other EPA registered wipes may be used for disinfecting the EvenCare G2 system, however these other wipes have not been validated and could affect the performance of your meter. 5. Wipe meter dry or allow to air dry.
Review of R18's Physician Order documented, acetaminophen [OTC] tablet extended release; 650 mg; amt: one tablet; oral Every 8 Hours 12:00 AM, 08:00 AM, 04:00 PM. Additionally, insulin lispro insulin pen; 100 unit/mL; amt: Per Sliding Scale; If Blood Sugar is less than 60, call MD. If Blood Sugar is 200 to 249, give 2 Units. If Blood Sugar is 250 to 299, give 4 Units. If Blood Sugar is 300 to 349, give 6 Units. If Blood Sugar is 350 to 399, give 8 Units. If Blood Sugar is 400 to 449, give 10 Units. If Blood Sugar is 450 to 499, give 12 Units. If Blood Sugar is greater than 499, call MD. Subcutaneous Before Meals and At Bedtime 06:00 AM, 11:30 AM, 04:30 PM, 09:00 PM.
During an observation and interview on 05/08/24 at 4:00 PM, Licensed Practical Nurse (LPN)1 did not clean or sanitize R18's personal glucometer before or after use. LPN1 stated she did not think that it needed to be cleaned since it was for use for only one resident. Additionally, LPN1 was observed not wearing gloves to break the Acetaminophen in half. LPN1 stated that she did not think gloves were needed to be worn since she had just sanitized her hands. LPN1 further stated she was not aware that there was a pill cutter in the top drawer of the cart and stated that she had never used it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, the facility failed to provide quarterly statements to the Responsible Party (RP) for 1 of 1 resident reviewed for personal funds, Resident (R)65.
Findings include:
Review of the facility's policy titled, Resident Trust Fund revised on 12/2014, states, the Business Office Manager distributes the quarterly Resident Trust fund statements. The facility mails the quarterly statements no later than the 25th of the month following the end of the quarter to each residents legal representative.
Review of R65's Face Sheet revealed R65 was admitted to the facility on [DATE] with diagnoses including but not limited to: intellectual disabilities, dysphagia and acute cystitis with hematuria.
During an interview on 05/07/24 at 11:10 AM, R65 stated, I don't know, when asked if he received a quarterly statement from the facility. R65's RP, who was at bedside, stated she was not aware of any monies, he is always in the red. R65's RP further stated she has not received any statements or been notified about money in his account. I use my money to purchase whatever toiletries he may need.
During an interview on 05/09/24 at 9:20 AM, the Business Office Manager (BOM) stated, [R65] receives $30.00 a month. He had money in his account. When his sister came to see me this week, she didn't realize there was money in his account. The BOM confirmed R65 and his RP should have received the statements, but did not.

Based on observation, interview, and facility policy review, the facility failed to ensure staff maintained appropriate infection control measures for the safe handling of medication during the administration of medication to three out of four residents (Resident (R) 73, R1, and R37) observed during the observation of medication pass.
Findings include:
Review of the facility policy for Medication Administration, effective date: 06/21/17, revealed, Medication will be administered by legally authorized and trained person in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. Suggested supplies included a hand cleansing solution. The procedure of medication administration began with 1. Cleanse hands as appropriate.
During a medication pass on 03/08/22 from 9:14 AM through 9:30 AM, Licensed Practical Nurse (LPN) 3 was observed to prepare and administer R73's oral, by mouth, medication and handheld inhaler. Following the administration of R73's mediation, LPN3 was not observed to perform hand hygiene (wash her hands with soap and water or use Alcohol Based Hand Rub). LPN3 was then observed to prepare and administer R1's oral by mouth medication. Following the administration of R1's medications, LPN3 was not observed to perform hand hygiene. LPN3 was then observed to prepare and administer R37's oral by mouth medication. LPN3 was not observed to perform hand hygiene between the preparation and administration of oral medication between all three residents: R73, R1, and R37.
An interview with the Infection Preventionist (IP) nurse of the facility on 03/09/22 at 12:45 PM revealed a nurse should always wash her hands or disinfect her hands between residents when administering medication. The IP nurse stated, LPN 3 was a new nurse, just out of nursing school and she would re-educate her on medication administration.
An interview with the Director of Nursing (DON) on 03/09/22 at 4:15 PM revealed it was her expectation that all nurses at the facility should wash and or disinfect their hand between medication administration to all residents to prevent the spread of germs.

Based on observation, interview, and manufacturer's recommendations, the facility failed to ensure the proper storage and labeling of blood glucometer testing strips in seven out of seven observed blood glucometer testing strips containers and four out of four observed blood glucose calibration solutions on one out of two medication carts on the 100 hallways.
Findings include:
The undated manufacturer's recommendations for the Even care G2 Blood Glucose Test Strips revealed, under storage and handling, the test strips should be used within six months after first opening the container.
The undated manufacturer's recommendations for the blood glucose calibration monitoring solutions, Even care G2 Glucose control Solutions revealed, under Storage and the Handling, to discard any unused control solution 90 days after first opening or after expiration date.
During an observation of a glucometer check on 03/08/22 at 12:00 PM on Resident (R)45 by Licensed Practical Nurse (LPN) 4, it was observed that R45's blood glucose monitoring strips bottle (Lot 16821072006, Expiration (Exp) 2023-03-21) had not be dated or initialed, when initially opened. Further observation of the individual glucometer boxes on the medication cart revealed the glucometer monitoring test strips for R59 (Lot 16821072003, Exp 2023-03-31), R25 (Lot 16821052012, Exp 2021-02-04), R24 (Lot 16821072006, Exp 2023-03-31), R62 (Lot 16821092004, Exp 2023-06-07), R18 (Lot 16821072003, Exp 2023-03-31), and R19 (Lot 16821092004, Exp 2023-06-07) had not be dated or initialed, when initially opened.
Further observation revealed two blood glucose calibration monitoring solutions had been opened and initialed on 11/04/21 (High control Solution Lot # 16820052204, Exp 2022-05-25 and Low control Solution Lot 16820052104, Exp 2022-05-26).
Further observation revealed two blood glucose calibration monitoring solutions had been opened and initialed on 12/03/21 (High control Solution Lot # 16820052204, Exp 2022-05-25 and Low control Solution Lot 16820052104, Exp 2022-05-26).
Interview with LPN4 on 03/08/22 at 12:00 PM revealed she had not noticed that the glucose monitoring testing strip bottle for R45 had not been dated or initialed when first opened. LPN4 revealed she had not initially opened the testing strip bottle for R45 and stated that it should be initialed and dated when first opened.
During an interview on 03/08/22 at 12:20 PM, LPN1, Unit manager, revealed the night nurse did the blood glucose calibrations for the blood glucose monitors and the blood glucose monitor strips and blood glucose monitoring solutions should be dated and initialed when initially opened. We should follow the manufactures recommendations and date and initially the strips and solution when they are initially opened, otherwise we do not know how long they have been opened and are good for.
Interview with the Director of Nursing (DON) on 03/08/22 at 12:15 PM revealed it was her expectation that the blood glucometer strips and blood glucometer calibration solutions be labeled and initialed when first opened, and the manufacturer's recommendations should be followed regarding the expiration of the strips within six months and the calibration solutions within 90 days after first opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure that one resident of five residents (Resident (R) R51) reviewed for unnecessary medications was free from as needed (PRN) unnecessary psychotropic medication. Specifically, R51 had an order for a PRN antipsychotic medication without a stop date.
Findings include:
Review of the facility's policy dated 11/01/17 and titled, Medication Management, sub-title psychotropic drugs-use of indicated .as needed (PRN) orders for psychotropic drugs are limited to 14 days.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/20/22 indicated R51 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of three out of 15 (which indicated severe cognitive impairment) and diagnoses, including dementia.
Review of the physician order dated 12/01/21 found under the Order tab in R52's paper medical record indicated Haldol (antipsychotic medication) 1 milligram (mg) every six hours as needed.
Review of R51's Medication Administration Record (MAR) provided by the facility indicated R51 received Haldol 1mg on 12/10/21, 12/11/21 and two doses on 01/03/22.
Review of the monthly medication review (MMR) provided by the facility for December 2021 through March 2022 indicated a review was performed monthly by the pharmacy consultant (PC) with no irregularities and no recommendations noted.
In an interview with the Director of Nursing (DON) on 03/08/22 at 4:12 PM she stated, hospice ordered R51's Haldol and told us that it was different for hospice patients, that hospice could order what they thought was needed. The DON continued by stating, we know about the 14-day regulation but assumed that the hospice company knew what they were doing.
In an interview with the Administrator on 03/09/22 at 11:30 AM she stated, I feel like it was an honest mistake, it was missed by everyone. We try to keep antipsychotic and anti-psychotropic medications to a minimum but these outside companies, hospice and our psych service provider, like to use them for behaviors.
In an interview with the PC on 03/09/22 at 12:56 PM he stated, it was discontinued on my end, but I must have overlooked it when comparing the two, the computer program I use and the program that the facility uses, they don't communicate so I have to actually compare them side by side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and pharmacy consultant (PC) interviews, and policy review, the facility failed to ensure one resident of five residents (Resident (R) 51) reviewed for unnecessary medications was provided a thorough evaluation of the medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with psychotropic, as needed (PRN) medications. Specifically, R51's Haldol (an antipsychotic drug that decreases excitement in the brain) was ordered PRN and did not have a stop date on the order.
Findings include:
Review of the policy dated 07/02/20 and titled Pharmacy services policy and procedures, subject: Consultant Pharmacist indicated The medication regimen of each resident is reviewed by a licensed pharmacist according to federal, state, and local regulations as well as current standards of practice. The pharmacist must report any irregularities to the attending physician, the facilities medical director and the director of nursing, and these reports must be acted upon in a manner that meets the needs of the resident. The consultant pharmacist performs a medication regimen review at least monthly and the review must include a review of the resident's medical chart.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 01/20/22 indicated R51 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of three out of 15 (which indicated severe cognitive impairment) and diagnoses, including dementia.
Review of the physician order dated 12/01/21 located under the Order tab in R51's paper medical record indicated Haldol (antipsychotic medication) 1 milligram (mg) every six hours as needed.
Review of R51's Medication Administration Record (MAR) provided by the facility indicated R51 received Haldol 1mg on 12/10/21, 12/11/21 and two doses on 01/03/22.
Review of the monthly medication review (MMR) provided by the facility for December 2021 through March 2022 indicated a review was performed monthly by the pharmacy consultant (PC) with no irregularities and no recommendations noted.
Review of the untitled fax form, provided by the pharmacy via fax, sent to the facility from the pharmacy on 12/01/21 indicated R51's name, facility name, medication, prescriber and in large, bold, colored box, a message to provide stop date for the Haldol.
In an interview with the Director of Nursing (DON) on 03/08/22 at 4:12 PM she stated, hospice ordered R51's Haldol and told us that it was different for hospice patients, that hospice could order what they thought was needed. The DON continued by stating, we know about the 14-day regulation but assumed that the hospice company knew what they were doing.
In an interview with the Administrator on 03/09/22 at 11:30 AM she stated, I feel like it was an honest mistake, it was missed by everyone. We try to keep antipsychotic and anti-psychotropic medications to a minimum but these outside companies, hospice and our psych service provider, like to use them for behaviors.
In an interview with the PC on 03/09/22 at 12:56 PM he stated, it was discontinued on my end, but I must have overlooked it when comparing the two, the computer program I use and the program that the facility uses, they don't communicate so I have to actually compare them side by side. Continued by stating, my system shows a discontinue date of 12/14/21 and a fax was sent to the facility on the day the order was received at the pharmacy to provide stop date with no response from the facility. I should have followed up after the fax wasn't responded to.
In an interview on 03/09/22 at 2:30 PM, after being shown the untitled fax form, the DON stated, I don't remember ever seeing that form, it may have been lost or thrown away, I'm not sure but I know I haven't seen it until now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure humidification was provided for one resident of one resident (Resident (R) 277) reviewed for oxygen therapy.
Findings include:
Review of the facility policy titled Respiratory Policies and Procedures Subject: Humidifier, dated 02/01/20, revealed staff was to evaluate the effectiveness of therapy. The policy did not address changing the humidification bottles.
Review of R277's Face Sheet page located in the electronic medical record under Resident revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to cough, muscle weakness, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), bradycardia (slower than normal heart rate), and respiratory failure.
Review of the Treatment Flowsheet provided by the facility staff dated 03/01/22 through 03/31/22 revealed a physician's order of Change O2 tubing, nasal cannula and humidification weekly.
R277's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/04/22, revealed a Brief Interview for Mental Status (BIMS) was coded as 12 out of 15, which indicated no cognitive impairment.
During an observation on 03/07/22 at 11:20 AM, R277's oxygen humidification bottle was empty while R277 was receiving oxygen therapy. R277 appeared to show no signs of distress during this time but had some coughing.
During an observation on 03/07/22 at 12:45 PM, R277 received his lunch tray in his room. R277's oxygen humidification bottle was observed to be empty while R277 was receiving oxygen therapy. R277 did not appear to be in distress at this time.
Observation and interview on 03/07/22 at 2:15 PM with the Director of Nursing (DON) verified the oxygen concentrator bottle was empty. The DON was observed to take R277 oxygen status (O2) and revealed an O2 stat of 99 and blood pressure 137/56 millimeters of mercury (mmHg). The DON stated the oxygen humidification bottles were changed as needed and on Sunday nights. The DON stated she did not know why the oxygen concentrator bottle was not changed.
Interview on 03/08/22 at 3:10 PM with Licensed Practical Nurse (LPN) 3 stated the oxygen concentrators were monitored every shift and the humidification bottles needed to be changed per the orders or as needed. LPN3 stated if she were to see that a humidification bottle was low or empty, she would change it immediately.
Additional interview on 03/08/22 at 2:34 PM with DON stated her expectation was for staff to assess the resident during rounds and change the humidification bottle when needed and per the facility's policy of every Sunday.