Ararat Post Acute

Based on interview and record review, the facility failed to implement its policy and procedure to provide the Medicare change status form: Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, notice of liability) and Notice of Medicare Non-Coverage (NOMNC) letters/forms to one of three sampled residents (Residents 45) within two (2) days of the last Medicare part A covered day. This deficient practice had the potential for Resident 45 not to exercise the right to appeal and not be aware of possible charges for services rendered that were not covered after her last Medicare part A coverage day. Findings: During a concurrent interview and record review on 1/23/2026 at 11:41 AM with the social service coordinator (SSC), the facility document notices provided to Resident 45: SNF-ABN date of notice 6/19/2025 and NOMNC dated 6/18/2025 was reviewed. The documents SNF-ABN and NOMNC was signed by Resident 45 on 6/18/2025. SSC stated, he was responsible in providing the notices to resident or responsible party. SSC stated, it is facility's policy to provide the notices to Resident 45 a minimum of 2 days prior to the last day of Medicare part A coverage, and Resident 45 last Medicare Part A covered day was 6/18/2025, which made the notices late. SSC stated providing the notices late, did not give Resident 45 time to appeal the change in medical coverage, and had the potential to incur charges that was no longer covered by Medicare part A. During an interview on 1/23/2026 at 11:50 AM with the Director of Nurses (DON), DON stated, facility document notices SNF-ABN and NOMNC should be provided to the resident a minimum of 2 days prior to the last day of Medicare part A as per policy, to ensure the resident had ample time to make medical coverage decisions, as well as appeal the change of medical coverage. DON stated, Resident 45's SNF-ABN and NOMNC notices was late which did not give Resident 45 time to exercise the right to appeal the change of coverage and potentially can incur charges no longer covered by Medicare part A. A review of the facility's policy and procedure titled, Medicare Denial Process, dated 10/24/2022 indicated: a) Medicare Status Change form maybe completed by designee a minimum of 2 days prior to the last Medicare Part A covered day, and b) the designee prepares and issues the Medicare Status Change which includes SNF-ABN and NOMNC to the beneficiary or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 39 and Resident 41) and their representatives, reviewed for resident's rights were offered an information regarding Advance Directives (AD a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) in accordance with facility policy titled Advance Directives and regulatory requirements. This deficient practice has the potential for care and services to not be performed during medical emergencies according to the residents and/or family wishes.
1. During a record review of Resident 41's admission Record (AR) dated 1/17/2026 indicated Resident 41 was admitted on [DATE], with the diagnoses of pneumonia (an infection/inflammation in the lungs), dysphagia (difficulty swallowing), history of malignant neoplasm of the prostate (cancerous tumor that can spread (metastasize) to other parts of the body).
During a record review of Resident 41's Initial History & Physical dated 1/20/2026, indicated that Resident 41 has fluctuating capacity to understand and make decisions.
During a concurrent interview and record review on 1/21/2026 at 9:50 AM with Social Services Coordinator (SSC), indicated Resident 41's Advance Directive Acknowledgement dated 1/17/2026, was not signed by the responsible party. SSC stated that he understands that AD should had been done when the resident was admitted to the facility to honor residents wishes and preferences, but SSC stated the AD was not completed.
During an interview on 1/23/2026 at 1:42 PM with Director of Nurses (DON) stated that the AD was supposed to be initiated upon admission to ensure residents wishes and preferences are followed and to ensure that during medical emergencies residents and Responsible Party (RP) wishes and preferences are followed.


2. During a review of Resident 39's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] , with diagnoses that included congestive heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should), and diabetes (chronic condition where blood sugar (glucose) levels are too high because the body does not make enough insulin or cannot use it proper).
During a review of Resident 39's History and Physical (H&P) dated 1/11/2026, the H&P indicated Resident 39 was alert and oriented to place and time and able to make decisions.
During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 1/12/2026, indicated the resident cognitive status (level of mental functioning) was moderately impaired.
During a concurrent interview and record review on 1/20/2026 at 2:56 PM with Registered Nurse (RN) 3, Director of Nurses (DON), and Social Service Coordinator (SSC), Resident 39's physical chart was reviewed. There was no documented evidence in Resident 39'clinical record to indicate that an Advance Directive or acknowledgement of Advance Directive was offered and/or if the resident was informed. DON stated, Advance directive acknowledgement should have been done upon admission, and it should be in Resident 39's physical chart. SSC stated, he was responsible ensuring Resident 39 had an advance directive or an acknowledgement of an advance directive, he stated he must have missed informing the RP about the advance Directive acknowledgement. SSC stated, not having an Advance Directive was important to ensure residents' healthcare wishes and preferred care during medical emergencies were clearly identified, documented, and honored.
During an interview on 1/21/2026 at 3:01 PM with the DON, DON stated, Resident 39's Advance Directive should have been initiated upon admission to ensure Resident 39 and/ or family wishes are followed. DON stated, not having an advance directive had the potential for care and services to not be performed during medical emergencies according to the residents and/or family wishes.
During a review of the facility's policy and procedure (P&P) titled Advance Directives, dated 6/1/2021, the P&P indicated: a) the facility will honor resident's advance directive and will provide the resident information related to advance directive upon admission, b) upon admission designee will inform the resident their right to execute an advance directive, if one does not already exist. and c) a copy of the advance directive is maintained as part of Resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide privacy and a homelike environment for two of two sampled residents (Resident 29 and Resident 39) by failing to report the missing to the maintenance supervisor to replace the missing horizontal window blind slats in Resident 29 and Resident 39's room. This deficient practice resulted in having a non-homelike environment and a violation of the residents' rights for privacy when the residents were exposed to the other people outside in the walkway and neighboring building near the facility. In addition, the loss of privacy had the potential to affect their psychosocial wellbeing of the residents. Findings: During a review of Resident 29's admission Record, the admission Record indicated the facility originally admitted Resident 29 on 4/30/2024 and readmitted on [DATE] with diagnoses that included heart failure (the heart is unable to pump blood around the body properly), diabetes mellitus (a disease that affects how the body uses blood sugar) and osteoarthritis (chronic joint disease, often called wear-and-tear arthritis) of both knees. During a review of Resident 29's Minimum Data Set (MDS, a Resident assessment tool), dated 11/13/2025, indicated Resident 29's cognition (ability to think and reason) was intact. During a concurrent observation and interview on 1/20/2026 at 9:46 AM with Resident 29 in Resident 29's room, Resident 29's bed was near by the window with opened vertical blinds that had two pieces of slats missing exposing the room from outside walkway and neighboring building. Resident 29 stated, she was not sure who she who she reported the missing slats on the blinds to which has been missing for at least two days. Resident 29 stated, the blinds help with the sun for shade and provides her privacy. 2. During a review of Resident 39's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] , with diagnoses that included congestive heart failure (the heart can't pump enough oxygen-rich blood to meet your body's needs), chronic kidney disease (a long-term condition where the kidneys do not work as well as they should), and diabetes mellitus. During a review of Resident 39's History and Physical (H&P) dated 1/11/2026, the H&P indicated Resident 39 was alert and oriented to place and time. During a review of Resident 39's MDS dated [DATE], indicated the resident's cognitive status was moderately impaired. During a concurrent observation and interview on 1/20/2026 at 9:55 AM with Resident 39 in Resident 39's room, Resident 39's bed was near by the window, with opened vertical blinds that had two pieces of slates missing exposing the room from outside walkway. Resident 29 stated, she was not sure who she reported the missing blinds to which has been missing for at least two days. Resident 29 stated, the blinds help with the sun for shade and provides her privacy. from outside walkway. Resident 39 pointing at the missing vertical blinds, nodded yes when asked if the missing vertical blinds bothers her. During a concurrent observation and interview on 1/20/2026 at 10 AM with Registered Nurse (RN) 3 in Resident 29's room and then Resident 39's room. RN 3 stated both rooms for Residents 29 and 39 were missing window slates on the vertical blinds which exposes the residents from outside walkway, and neighboring building. RN 3 stated, the rooms with missing window vertical blinds slate was not homelike, it could affect residents' comfort and privacy. During an interview on 1/21/2026 at 2:27 PM with the Maintenance Director (MTD), MTD stated, he was not aware of Resident 29 and Resident 39's missing slats on the window blinds. MTD stated, it was probably missed when they check the rooms. MTD stated, it was important to replace the missing blinds right away for Residents comfort (shade from the sun) and privacy. During an interview on 1/21/2026 at 3:10 PM with the Director of Nurses (DON), DON stated, it was not homelike for Resident 29 and Resident 39 to have missing window blinds in their room, it should have been replaced right away. DON stated the missing slats on the window blinds in Resident 29 and 39's room could potentially affect Resident 29 and Resident privacy that may negatively affect their psychosocial wellbeing. A review of the facility's policy and procedure (P&P) titled Resident Rooms and Environment, dated 11/1/2017, the P&P indicated, facility provides residents with safe, comfortable and homelike environment. A review of the facility's policy and procedure (P&P) titled Privacy and Dignity, dated 7/1/2016 indicated, facility promote and/or enhance privacy, dignity and overall quality of life, and facility respect's the resident's private space.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 32) reviewed for pressure ulcer ( a skin breakdown due to prolonged unrelieved pressure and skin friction) receives care, consistent with professional standards of practice, to prevent pressure ulcers had recommended inflation/adjustment setting for the low air loss mattress (LAL - therapeutic mattress that uses blower and airflow to relieve pressure and keep the skin dry and prevent moisture build up). This deficient practice had the potential to result in the resident to be at risk of developing pressure ulcers. Findings: During a review of Resident 32's admission Record (AR) the AR indicated Resident 32 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (total paralysis (no movement) of the arm, leg, and trunk on the same side of the body), dementia (a progressive state of decline in mental abilities), left knee and hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 32's Minimum Data Set (MDS - a resident assessment and care screening tool) dated 11/20/2025, indicated, Resident 32 has severe impaired cognitive skills (ability to think and reason). The MDS indicated that Resident 32 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene and turning and repositioning in bed. During a review of Resident 32's Initial History and Physical dated 2/11/2025, the initial History and Physical assessment indicated that Resident 32 does not have the capacity to understand and make decisions. During a review of Resident 32's Order Summary Report dated 1/5/2026, the summary report indicated a physician's order to apply a low air loss mattress for skin integrity. During a review of Resident 32's Braden Scale for Predicting Pressure Sore Risk dated 8/21/2025, indicated the resident was at high risk of developing pressure ulcer. During a review of Resident 32's Risk for Pressure Ulcers Care Plan dated 1/4/2024. Indicated Resident 32 was at risk for developing pressure ulcers and skin breakdown due to impaired mobility with intervention to apply pressure relieving/reducing device when in bed low air loss mattress. During an observation on 1/20/2026, at 9:51 AM in Resident 32's room was observed Resident 32 lying on a low air loss mattress with a setting for a person that weights 350 pounds (lb.) the maximum possible setting on the mattress. During an interview on 1/20/2026 at 10:25 AM with the Treatment Nurse (TX1) stated, Resident 32 weighs 140 pounds and the low air loss mattress setting was at set at the maximum setting of 350 lbs. stated that nursing did not monitor the bed setting every shift of the resident every shift. The TX 1 stated not be sure why the low air loss mattress was set at the maximum setting of 350 lbs. During an interview on 1/23/2026 at 1: 42 PM with the Director of Nurses (DON) stated that Resident 32's low air loss mattress setting should not have been left at maximum of 350 lbs. and should have been adjusted by nursing. DON stated the low air loss mattress constantly circulates air to keep the skin cool and dry to prevent moisture and the mattress should not have kept rigid. DON stated Resident 32 was at risk for pressure ulcers, falls or injury since the low air loss mattress maximum setting is to be used when transferring out of the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 41's) with intravenous (IV- a catheter inserted with a needle into the vein) peripheral catheter (a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) on the left arm had dried up blood on the site covered with transparent dressing and was not changed in accordance to the facility's policy and procedure titled Peripheral Venous Catheter Insertion. This deficient practice can potentially cause infection on the on the IV site that can lead to severe infection. Findings: During a record review of Resident 41's admission Record (AR) dated 1/17/2026 indicated Resident 41 was admitted on [DATE], with the diagnoses of pneumonia (an infection/inflammation in the lungs), dysphagia (difficulty swallowing), History of malignant neoplasm of the prostate (cancerous tumor that can spread (metastasize) to other parts of the body). During a review of Resident 41's Progress Notes dated 1/18/2026 at 7:42 AM indicated that Resident 41 was to continue with intravenous medication (IV -fluids given directly into the blood stream), Ceftriaxone (Antibiotic Medication) for three days from the admission date of 1/17/2026. During a record review of Resident 41's Initial History & Physical dated 1/20/2026, indicated that Resident 41 has fluctuating capacity to understand and make decisions. During an observation on 1/20/2026 at 10 AM in Resident 41's room, Resident 41 was lying in bed with a peripheral catheter inserted to the left forearm between the elbow and the wrist area transparent clear dressing covered with dried up blood around the peripheral catheter site. A review of the Physician's order, dated 1/17/2026 timed at 4:47 PM, indicated Resident 41 was to receive Ceftriaxone1 gram (medication used to treat infection) intravenously (into the vein) on 1/18/2026, 1/19/2026, and 1/20/2026. During an interview on 1/20/2026 at 10:42 AM with Registered Nurse (RN3) stated, that Resident 41 had the peripheral catheter upon admission. RN3 stated to have noticed the red dry fluid around the peripheral catheter site but due to the risk of dislodgement and believing Resident 41 was a difficult stick (difficult to insert a peripheral catheter into the vein) RN3 felt comfortable leaving the dressing on until discontinuation of the intravenous catheter. During an interview on 1/23/2026 at 1:42 PM with the Director of Nurses (DON) stated, that nursing should have change the peripheral catheter dressing to prevent infection and to be able to assess new findings such as redness. During a review of the facility's policy and procedure titled, Peripheral Venous Catheter Insertion dated 3/2023, indicated that peripheral intravenous catheter sites will be changed when clinically indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident evaluations including a written report of a physical examination was completed within 72 hours following admission and the initial comprehensive visit was not done by the Nurse Practitioner, Physician Assistant, and the Clinical Nurse Specialist for one of six sampled residents (Resident 17). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services. Findings: During a review of Resident 17's admission Record (AR) indicated Resident 17 was admitted on [DATE] and readmitted on [DATE] with admitting diagnoses of acute embolism and thrombosis of left femoral vein (sudden blood clots that block blood flow), pneumonia (an infection/inflammation in the lungs). During a review of Resident 17's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/28/2025, the MDS indicated Resident 17 had a cognition (ability to think and reason) was intact. The MDS indicated that Resident 17 was partial/moderately dependent on staff for personal hygiene, putting on and taking off footwear, lower body dressing, upper body dressing, toileting hygiene, and supervision or touching assistance with oral hygiene, and eating. During a review of Resident 17's History and Physical assessment report, dated 1/19/2026 after being readmitted from the hospital on 1/16/2026 was performed, documented and signed on 1/20/2026 by the Physician Assistant PA). During an interview on 1/22/2026 at 10:25 AM with Director of Nurses (DON), stated, the PA came in today (1/22/2026) and not the primary physician to assess the resident (Resident 17). The DON stated the initial comprehensive assessment needs to be performed, documented, completed and signed by the attending physician. During a review of the facility's policy and procedure (P&P) titled, Physician Services & Visits, dated 10/24/2022, indicated, resident evaluations including a written report of a physical examination within 5 days prior to admission or within 72 hours following admission. The P&P indicated that the initial comprehensive visit cannot be done by the Nurse Practitioner, Physician Assistant, and the Clinical Nurse Specialist.

Based on interview and record review, the facility failed to post an accurate nurse staffing information worked by License Vocational Nurse (LVN) and Certified Nurse Aides (CNA) in accordance with the facility's policy and procedure titled Nursing Department - Staffing, Scheduling & Posting, when posted document on 1/20/2026 at 11:34 AM titled Posted Nurse Staffing Information indicated 11 to 7 shift actual staff are one LVN and two CNA's during morning facility rounds. (actual staff for 11 to 7 shift was posted in advance, during the day not at the beginning of the 11 to 7 shift). This deficient practice of posting inaccurate nurse staffing information in advance mislead information provided to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. Findings: During a concurrent interview and record review of Posted Nurse Staffing Information on 1/20/2026 at 11:34 AM with Registered Nurse (RN) 1 at the nurses' station, the posting indicated there were one LVN and two CNAs assigned to work during the 11PM to 7AM shift. RN 1 stated, she works as a Director of Staff Development (DSD), and she was responsible as well as charge nurses in posting actual nursing staff per shift. RN 1 stated actual nursing staff for 11 to 7 shifts should have been blank until the beginning of 11 to 7 shift as per policy and should not be filled out in advance to ensure accurate nursing staff working that shift. RN 1 stated, the nursing posting was an error and a misleading information for to the residents, resident's responsible parties and visitors about the nursing staffing for the residents. During an interview on 1/21/2026 at 3:30 PM, the DON stated, the daily nursing postings are intended to inform the residents, resident's responsible parties and the visitors about the type and hours of nursing care provided in the facility. DON stated, it is not acceptable to write ahead of time the actual nursing staff per shift, it needs to be done at the beginning of each shift as per policy. DON stated these nursing posting must be accurate to prevent misinformation and confusion. A review of the facility's policy and procedure (P&P) titled, Nursing Department - Staffing, Scheduling & Posting. revised 10/24/2022, indicated: a) the facility will post the total number and the actual hours worked by licensed nursing and unlicensed nursing staff directly responsible for resident care per shift (RNs, LVNs, and CNAs), and b) the facility will post the nursing staffing data on a daily basis at the beginning of the each shift.

Based on observation, interview and record review, the facility failed to remove a lidocaine patch (a medicated sticky patch placed on the skin to numb an area and relieve pain) at 9 PM and place a new patch at 9 AM to ensure the patch was on for 12 hours and off for 12 hours as ordered by the physician order for one of two sampled residents (Resident 10) reviewed for pharmacy services. This failure resulted in Resident 10 receiving lidocaine in excess duration as prescribed which had the potential to cause adverse effects (undesired effect) of medication that include increased systemic absorption (process by which medication moves from its site of administration into the bloodstream, allowing it to travel throughout the entire body), skin irritation, or medication toxicity (the medicine becomes harmful because there is too much of it in the body), that could lead to a decline in Resident 10's condition, harm or hospitalization. Findings: During a review of Resident 10's admission Record (AR), the AR indicated the facility admitted Resident 10 on 12/4/2025 with diagnoses that included but not limited to spinal stenosis (the spaces in the spine have narrowed, which puts pressure on the spinal cord or nerves), lumbar (refers to the lower part of the back) region with neurogenic claudication (means leg pain, weakness or numbness caused by pressure on the nerves), fracture of second to fifth lumbar vertebrae (small bones that stack on top of each other to make up the spine), low back pain, and chronic kidney disease (CKD- damage to the kidneys so they cannot filter blood the way they should). During a review of Resident 10's untitled Care Plan (CP), initiated on 12/05/2025, the CP indicated Resident 10 was at risk for pain due to spinal stenosis, lumbar fracture and low back pain. The CP goals indicated Resident 10 would not have an interruption in normal activities due to pain and Resident 10 would verbalize adequate relief of pain. The CP intervention indicated for licensed nursing staff to administer lidocaine patch every 12 hours as ordered. During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 12/8/2025, the MDS indicated Resident 10 had intact cognition (ability to think, reason, and function). The MDS indicated Resident 10 required moderate assistance with toileting, showering and personal hygiene. During a review of Resident 10's physician's order dated 12/12/2025, the order indicated Resident 10 had an order for a lidocaine external patch four percent, apply to left lower back topically (applying a medicine, cream, or treatment directly onto a specific, localized part of the body) one time a day for pain management. Apply one (1) patch at 9 AM and remove at 9 PM, per schedule. During a concurrent observation and interview on 1/21/2025 at 8:52 AM with LVN 1 inside Resident 10's room, LVN 1 removed the lidocaine patch from Resident 10's left lower back and then placed a new patch on the same area. LVN 1 stated the patch should have been removed last night at 9 PM and a new patch to be placed at 9 AM as scheduled. LVN 1 stated the physician's order was to put the patch on for 12 hours and off for 12 hours. LVN 1 stated the doctor's order should be followed because the patch can cause skin irritations after prolonged use. During an interview on 1/23/2026 at 10:46 with the Director of Nursing (DON), the DON stated the lidocaine patch should be placed by the licensed nurse at 9 AM and removed at 9 PM. The DON stated the lidocaine patch should be removed after 12 hours to prevent absorption of the drug that the resident does not need. The DON stated excessive absorption of lidocaine in the body can be harmful to the residents. During a review of the facility's policy and procedure (P&P) titled, Medication administration, dated 7/2016, the P&P indicated, Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner. During a review of the facility's P&P titled, Transdermal patches, dated 7/2016, the P&P indicated, At a minimum every shift, the licensed nurse will verify that the patch is present, intact and the skin around patch is free of skin irritation or other reactions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 4), reviewed for use of unnecessary medications, was monitored for complications of Apixaban (a blood thinner medication) such as bruising and bleeding as indicated in the resident's care plan and the physician's order. This deficient practice had the potential for the resident not to receive immediate care or no care that can lead to a resident decline in well-being. for complication of Apixaban such as discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds. Findings: During a review of the admission Record (AR) indicated Resident 4 was admitted on [DATE] and readmitted on [DATE] with admitting diagnoses of atrial fibrillation (heart dysrhythmia), dementia (a progressive state of decline in mental abilities). During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/31/2025, indicated Resident 4 cognitive (ability to think and reason) level was intact. During a review of Medication Administration Record (MAR), indicated that Resident 4 received Apixaban 5 milligrams (mg - a unit of measurement) twice a day from 1/1/2026 through 1/20/2026. During a review of the Order Summary Report dated 1/1/2026, indicated anticoagulant medication monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath, nose bleeds every shift. During an observation on 1/20/2025 at 9:39 AM in Resident 4's room, Resident 4 was observed with purplish skin discoloration of irregular shape to left anterior hand. In an interview Resident 4 stated he does not know how he obtained the bruise and that might have accidentally bumped hand onto the furniture. During an interview with the Treatment Nurse (TXN 1) on 1/21/2025 at 3:45 PM stated that on 1/20/2026 she did not receive a report regarding bruising and skin abnormalities from the certified nurse assistants (CNA's). TX Nurse1 stated that the attending CNA should have reported the bruise for continuous monitoring and investigation. During an interview on 1/23/2026 at 2:20 PM with the Director of Nursing (DON), stated, that the CNA's who provide daily care should have reported to the license nurse the bruise that was on Resident 4's left hand. DON stated monitoring of anticoagulant side effects helps prevent serious complications such as uncontrollable bleeding. During a review of Resident 4's care plan titled Anticoagulant Therapy dated 1/30/2025, indicated that Resident 4's skin will be inspected daily and will report any abnormalities to the nurse. The care plan also indicated that all adverse reactions will be monitored, documented and reported. During a review of the facility's policy and procedure titled, Pressure Ulcer Prevention dated 2/1/2015, indicated that CNAs are required to inspect the resident's skin during ADL care and will report unusual findings to the License Nurse.

Based on observation, interview, and record review, the facility failed to ensure to store, prepare, distribute and serve food for all the 24 residents in the facility receiving food from the kitchen in accordance with professional standards for food service safety, and the facility's policy and procedure titled, Food Storage, dated 11/1/2014. This deficient practice had the potential for the residents to acquire food-borne illnesses (a life threatening infection due to consuming contaminated food) from ingesting expired food. Findings: During an initial tour of the facility's kitchen on 1/20/2026 at 8:35 AM with the Dietary Manager (DM) there were undated and expired food items stored in the refrigerator: Undated uncooked celery stored in a box. Expired cabbage stored in a refrigerator with a label to use by 1/16/2026. During a concurrent observation and interview on 1/20/2026 at 8: 35 with the Dietary Manager (DM) stated that all kitchen stored food is labeled and someone must have forgotten to label the celery. DM stated that the cabbage was not going to be used and that someone must have forgotten to throw it away. During an interview on 1/21/2026 with Dietary Supervisor (DS) stated that all food that is expired gets thrown away immediately and the cabbage must have been left behind by accident. During a review of the facility's policy and procedure titled, Food Storage, dated 11/1/2014, indicated, that all food items will be stored, thawed and prepare in accordance with good sanitary practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the documentation in the Licensed Nursing Weekly Summary (LNWS) accurately documented one of six sampled residents (Resident 5) reviewed for identifyable residents records, the actual status of having unplanned weight loss and behavior of yelling requiring the use of psychotropic medications (a medication that affects mood and behavior) in the weekly assessment from 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026. This deficient practice can result in a lack of or a delay in communication between the staff and can interrupt provision of care/intervention to the resident. Findings: During a review of Resident 5's admission Record (AR), indicated Resident 5 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dementia (a progressive state of decline in mental abilities) with agitation, chronic kidney disease stage 4 (severe kidney function loss). During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/10/2025, the MDS indicated Resident 5 had severely impaired cognitive skills (ability to reason) and never/rarely made decisions. that was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking footwear, and personal hygiene. The MDS dated [DATE], indicated Resident 5 receives hospice services. During a review of Resident 5's Nutritional Risk Care Plan Report, dated 5/30/2024, indicated hospice care and services was discontinued on 12/2/2025. During a review of Resident 5's Order Summary Report (Physician Orders), dated 12/12/2025 indicated, Resident 5 was placed on weekly weight x 4 weeks for poor oral intake and weight loss. On 12/22/2025, a physician order indicated Resident 5 was started on Depakote (medication use to treat and manage symptoms for psychiatric disorders) 125 milligrams (mg - Metric unit of measurement, used for medication dosage and/or amount) twice a day for mood disorder for constant yelling. During a review of Resident 5's Licensed Nursing Weekly Summary (LNWS) dated 12/1/2025, 12/8/2025, 12/22/2025, 1/12/2026, and 1/19/2026, the LNWS indicated Resident 5 had no weight loss issues, and no antipsychotic medications administered for mood manifestation and its side effects, and no documentation of the weekly episodes of mood or behavioral changes. During a review of Resident 5's Unplanned/Unexpected weight loss Care Plan Report dated 12/11/2025, indicated monitor and evaluate any weight loss. During a review of Resident 5's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/1/2026 - 1/23/2026, indicated Resident 5 received Depakote twice a day from 1/1/2026 - 1/23/2026 and had a total of 8 episodes of yelling in the day shift (7 - 3:30 PM), 25 episodes in the evening shift (3 - 11:30 PM) , and 11 episodes in the night shift (11 - 7:30 AM). During an interview on 1/22/2026 at 2:21 PM with Director of Nurses (DON) stated that the weight loss and the medication administered Depakote with the episodes of yelling which were being monitored should have been reflected in the LNWS the The documentation in the LNSW about Resident 5's behavior of yelling requiring administration of psychotropic medication and current un planned weight loss did not reflect the actual status of the resident. DON stated that not reflecting accurate residents' information in the documentation it is an opportunity to missed important information as well as communication to the physician and other interdisciplinary members. During a review of the facility's policy and procedure (P&P) titled, Licensed Nurse Weekly Progress Notes, dated 1/1/2016, indicated, the Licensed Nurse will document the resident's response and progress toward the goal and will identify possible skin, weight, medication, hydration and behavioral risk factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control practices in accordance with the facility's policy and procedure by failing to: 1.Ensure a humidifier bottle (a small bottle attached to the oxygen tubing that holds water to keep oxygen from drying out a person's nose and lungs) was changed for one of six sampled residents (Resident 26) reviewed for infection control that required oxygen therapy in accordance with the facility's policy and procedure (P&P) titled Oxygen administration. 2. Ensure the staff were using a gown while assisting the resident that was on enhanced barrier precaution (EBP- an infection control measures that involve wearing gowns and gloves for all high-contact activities with residents in nursing homes to stop the spread of multidrug-resistant organism [MDRO- is a type of bacteria that has developed resistance to multiple antibiotics, making infections difficult to treat and requiring enhanced infection prevention measures to reduce transmission]) for 1 of 6 sampled residents (Resident 6) reviewed for infection control. These failures had the potential for the residents to be at increased risk of infection and transmission of infection to other residents, staff and visitors that could result in a wide spread of infection in the facility.Findings: 1.During a review of Resident 26's admission Record (AR), the AR indicated the facility admitted Resident 26 on [DATE] with diagnoses that included but not limited to hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness caused by a disruption of the brain, spinal cord, or nerves connected to the affected muscles) following cerebral infarction (part of the brain didn't get enough blood and oxygen, so brain cells were damaged or died) affecting left non-dominant side, muscle weakness, and atrial fibrillation (an irregular heartbeat where the heart beats fast and unevenly instead of steady and strong). During a review of Resident 26's physician's order, dated [DATE], the order indicated Resident 26 to receive continuous oxygen at two liters per minute (LPM), keep oxygen saturation (how much oxygen the blood is carrying) above 92 percent. During a review of Resident 26's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 26 had severely impaired cognition (ability to think, reason, and function). The MDS indicated Resident 26 was dependent on helpers for toileting and personal hygiene. During an observation on [DATE] at 9:49 AM in Resident 26's room, Resident 26 observed in bed on oxygen at 2 LPM connected to a humidifier bottle labeled [DATE]. During a concurrent observation and interview on [DATE] at 10:52 AM with Treatment Nurse (TX) 1 inside Resident 26's room, TX 1 stated the humidifier bottle was dated [DATE] and should have been changed when the oxygen tubing was changed which was labeled [DATE]. TX 1 stated, oxygen tubing and humidifier bottles were changed every Sunday mainly for infection control by preventing harboring of bacteria. During an interview on [DATE] at 10:46 with the Director of Nursing (DON), the DON stated, humidifier bottles and oxygen tubing should be changed every Sunday by the night shift licensed nurses and should be labeled by writing the date it was changed on the humidifier bottle. The DON stated humidifier bottles should be changed every Sunday for infection control, to prevent growth of bacteria in the water that can make residents sick. During a review of the facility's P&P titled, Oxygen administration, revised 8/2014, the P&P indicated, All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen will be changed weekly and when visibly soiled. 2. During a review of Resident 6's admission Record (AR), the AR indicated the facility admitted Resident 6 on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to neuromuscular dysfunction of bladder ( a condition in which impaired nerve and muscle coordination affects the bladder's ability to store or empty urine appropriately), benign prostatic hyperplasia with lower urinary tract symptoms (an overgrowth of the prostate tissue that pushes against the urethra and the bladder, blocking the flow of urine), and retention of urine. During a review of Resident 6's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], the MDS indicated Resident 6 had moderately impaired cognition (ability to think, reason, and function). The MDS indicated Resident 6 required moderate assistance with toileting hygiene, showering and personal hygiene. During a review of Resident 6's physician's order, dated [DATE], the order indicated Resident 6 had an order for indwelling urinary catheter (a thin, flexible, sterile tube inserted into the bladder to drain urine into a bag outside the body) to gravity drain every shift. During a review of Resident 6's physician order dated [DATE], the order indicated Resident 6 had an order for EBP precaution due to indwelling urinary catheter use. During a review of Resident 6's Care Plan (CP), initiated on [DATE], the CP indicated Resident 26 was on EBP due to indwelling urinary catheter use. The CP goals indicated Resident 26's risk of developing and or transmitting infection would be minimized or reduced. The CP intervention indicated for staff to wear gowns and gloves while performing any care activity where close contact with the resident was expected to occur such as assisting with toileting. During an observation on [DATE] at 9:22 AM in Resident 6's room, EBP precaution signage observed posted outside the door indicated providers and staff must wear gloves and gowns for high-contact resident care activities that included assisting with toileting of residents. Certified Nursing Assistant (CNA) 2 put on gloves but did not wear a gown when CNA 2 assisted Resident 6 to the bathroom who had an indwelling urinary catheter. During an interview on [DATE] at 11:37 AM with CNA 2, CNA 2 stated, I forgot to wear a gown. CNA 2 stated gowns and gloves must be worn when in direct contact with residents on EBP precautions to prevent infection, spread of bacteria to the residents and to the staff. During an interview on [DATE] at 9:02 AM with Registered Nurse (RN) 1, RN 1 stated, proper Personal Protective Equipment (PPE- the gear healthcare workers wear to protect themselves and the patient, like gloves, gowns, masks or face shields to stop germs from spreading) must be used for residents on EBP precautions during direct contact care to prevent spread of any infections and protect high risk residents like those with indwelling urinary catheters from MDROs. During an interview on [DATE] at 10:46 with the Director of Nursing (DON), the DON stated staff, visitors and anybody must wear gowns and gloves when in close contact with residents on EBP precautions to prevent spread of infection to other residents, the staff and the community. During a review of the facility's policy and procedure (P&P) titled, Standard and enhanced precautions dated 4/2024, the P&P indicated, EBP refers to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high contact resident care activities that are associated with a high risk of MDRO colonization when contact precautions do not otherwise apply and/or transmission such as presence of indwelling devices (e.g., urinary catheter.). For residents whom EBP are indicated, EBP should be used when performing high-contact resident care activities such as changing briefs or assisting with toileting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and secured environment for Resident 1, who was identified as being at high risk for elopement (when a person with cognitive impairment leaves a safe area, such as a care facility or home, without awareness of potential dangers) and wandering (when a person roams and becomes lost or confused about their location) for one of two sampled residents (Resident 1). The facility failed to: Ensure that facility staff supervise Resident 1 and did not leave the resident unattended in the Activity/Dining Room, which was located adjacent to an exit door. Ensure that Activity Staff (AS) 1 was informed of Resident 1's high risk for elopement and need for monitoring, when Licensed Vocational Nurse (LVN) 1 observed the resident wandering out of her room and left the resident with AS 1 in the Activity Room. 3. Ensure that Resident 1 was continuously monitored and supervised by a facility staff in the Activity Room when AS 1 left the facility at the end of her shift on 10/28/2025 at around 5 PM. As a result of these deficient practices, on 10/28/2025 between the hours of 5 PM to 6 PM, Resident 1 wandered out of the facility unsupervised. Resident 1 was later found the same day, on 10/28/2025, at approximately 6:07 PM, sitting at a bus stop on a busy street 0.4 miles from the facility. Resident 1 was located and returned to the facility by a family member (Responsible Party [RP] 1). Resident 1 was placed at significant risk and exposure from falls, injury from motor vehicular accidents, and extreme weather conditions due to the facility's failure to provide Resident 1 with a safe and secure environment, in accordance with the resident's care plan. Findings: During a review of the facility's Policy and Procedures (P&P) titled Wandering and Elopement revised 8/1/2014, the P&P indicated that resident's risk for elopement and preventative interventions will be documented in the resident's medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change of condition according to the RAI (Resident Assessment Instrument- a standardized process that nursing homes use to evaluate a resident's needs and develop an individualized care plan) guidelines. The P&P further indicated that the IDT may consider interventions listed in the Elopement Risk Reduction Approaches for residents identified to be at risk for elopement. During a review of the facility's P&P titled Elopement Risk Reduction Approaches, the P&P indicated As necessary, provide new residents (to the facility, wing, unit, etc.) with additional staff assistance until they are comfortable in their new environment. The P&P further indicated that for residents identified at risk for wandering, facility staff needs to know the following information: i. How to identify and understand the resident's needs. ii. The resident's propensity to wander and the triggering conditions. iii. Recognition of the consequences of limited mobility. iv. The consequences of unsafe wandering, the protocols to follow to minimize successful exiting During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included multiple fracture (a broken bone) of left side ribs, repeated falls, and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Elopement- Wandering Risk Scale assessment dated [DATE], the Assessment indicated Resident 1 was identified at high risk for wandering/elopement due to forgetful/short attention span, diagnosis of dementia with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and a known wanderer, including history of wandering. The Assessment did not indicate any recommendations from the facility's licensed nurse who completed the Elopement- Wandering Risk Scale Assessment. During a review of Resident 1's Care Plan titled At risk for wandering/elopement dated 10/22/2025, the Care Plan indicated the goal was to ensure Resident 1 would remain safe within the facility and free from injury and interventions included the following interventions: 1. Keep environment free from clutter; 2. Monitor resident whereabouts every 1 hour; 3. Redirect resident calmly when attempts to ambulate unassisted occurs. The Care Plan did not include to have all interdisciplinary care team made aware of Resident 1's high risk for elopement and the type of supervision required for Resident 1 to remain safe and secured between hours when no staff was monitoring the resident's whereabouts. During a review of Resident 1's Care Plan titled At risk for falls dated 10/22/2025, the care plan indicated that Resident 1 had cognitive impairment and history of recent falls resulting in rib fracture. The care plan interventions indicated that Resident 1 needs a safe environment including even floor, free from spills and clutters, adequate lighting, an accessible call light, and handrails on walls. During a review of the facility Minimum Data Set (MDS - a resident assessment tool) dated 10/25/2025, the MDS indicated Resident 1 had severely impaired (significantly limits one person's physical or mental ability to do basic work activities) cognition (thought process). The MDS also indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or contact guard assistance as resident completes activity) during sit-to-stand, and partial/moderate assistance (helper does less than half the effort) on walking 50 feet. During a review of Resident 1's Monitoring Log dated 10/28/2025, the log timed 4 PM marked R indicated that Resident 1 was in the resident's room, and another one timed at 5 PM marked D indicated that Resident 1 was in the Dining Room (Activity Room). During a telephone interview conducted on 11/05/2025 at 11:30 AM, Certified Nurse Assistant (CNA) 1 stated that she was assigned to care for Resident 1 on 10/28/2025. CNA 1 stated that Resident 1 was identified as being at risk for elopement and required hourly monitoring. CNA 1 recalled that at approximately 5:00 PM on 10/28/2025, Licensed Vocational Nurse (LVN 1) escorted Resident 1 to the Activity Room. CNA 1 stated she was attending to another resident at that time and was not asked by LVN 1 to supervise or monitor Resident 1 while the resident was in the Activity Room. CNA 1 further stated that she became aware that Resident 1 was missing from the facility at approximately 5:30 PM on 10/28/2025 and immediately reported the incident to the charge nurse. During a telephone interview conducted on 11/05/2025 at 11:44 AM, LVN 1 stated that on 10/28/2025, between the hours of 4:00 PM and 5:00 PM, LVN 1 observed Resident 1 walking out of his room. LVN 1 noted that Resident 1 was dressed and appeared to be wandering. LVN 1 stated that she redirected and accompanied Resident 1 to the Activity Room, where she handed off the resident to AS 1. LVN 1 stated that she was not certain whether AS 1 was aware of Resident 1's high risk for elopement and the need for close monitoring. LVN 1 further stated that she assumed AS 1 would supervise Resident 1, as it is the facility's expectation that no resident should be left unsupervised. During an interview conducted on 11/05/2025 at 12:20 PM, AS 1 stated that she was not informed by LVN 1 that Resident 1 was at risk for elopement and was not familiar with the resident's medical history. AS 1 stated that she does not typically know most residents' diagnoses but acknowledged that no resident should be left unsupervised. AS 1 stated that on 10/28/2025 at around 5:00 PM, as she was preparing to leave for the day, she went to the Nursing Station to inform Registered Nurse (RN) 1 that someone needed to get Resident 1 from the Activity Room. AS 1 stated that there were two dietary staff members present in the Activity/Dining Room when she stepped out to look for the nurse. AS 1 stated that it was not appropriate to expect dietary staff to supervise Resident 1 and stated that she should not have left Resident 1 unsupervised in the Activity Room on 10/28/2025. During an interview on 11/05/2025 at 2:45 PM, RN 1 stated that she completed an elopement risk assessment for Resident 1 upon admission. RN 1 stated that all staff, including nurses and activity staff, were informed about Resident 1's high risk for elopement. RN 1 stated that on 10/28/2025, at around 5:00 PM, while making resident rounds prior to her 30-minute meal break, she observed Resident 1 with AS 1 in the Activity Room. RN 1 stated that she was on her meal break and was not aware of the time AS 1 ended her shift. RN 1 stated AS 1 did not inform her that Resident 1 needed someone to supervise Resident 1 in the Activity Room prior to leaving the facility at end of her (AS 1) shift, on 10/28/2025. RN 1 stated that upon returning from her break at approximately 5:35 PM, RN 1 stated she was notified by LVN 1 that Resident 1 was missing. During a telephone interview on 11/06/2025 at 2:10 PM, RP 1 stated that she received a call from the facility on 10/28/2025 at around 5:30 PM, informing her that Resident 1 was missing from the facility. RP 1 stated that she and other family members immediately took their car out to search for Resident 1. RP 1 stated that they found Resident 1 while driving toward the facility. Resident 1 was sitting at a bus stop near a busy street intersection, 0.4 miles away from the facility. RP 1 stated Resident 1 appeared to be sweating heavily from walking. RP 1 stated that Resident 1 looked lost and was surprised to see her and the other family members. Resident 1 did not respond when asked why he was there. During an interview on 11/05/2025 at 3:50 PM with the Administrator (ADM) and Director of Nursing (DON), the DON stated that the supervision and safety of residents is very important, and that staff communication should be thorough at all times. The ADM stated that AS 1 should not have assumed that any dietary or non-clinical staff present would be responsible for monitoring or supervising a resident. The ADM further stated that AS 1 should have remained with Resident 1 until relieved by a clinical staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure medically related social services were provided to one of two (Resident 11) sampled residents, in accordance with the facility ' s policy and procedure titled Social Services Program, when the Social Services Director [SSD] by failing to follow-up or assist when Resident 11's representative requested for additional information about the Advance Directive (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions).
These deficient practices led to a delay in receiving AD information as requested by Resident 11 and the Responsible Party from the facility that could result in the resident not to receive the healthcare needed in an event of an emergency where the resident and/or responsible party was unable to participate in making healthcare decisions.
Findings:
During a review of Resident 11 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), unspecified dementia (loss of memory, language, problem solving and other thinking abilities).
During a review of Resident 11 ' s History and Physical [H&P] dated 3/15/2024, the H&P indicated the resident was not able to make her own decisions.
During a review of Resident 11 ' s Physicians Order of Life Sustaining Treatment(POLST) dated 12/04/2020, the POLST indicated the resident did not have an Advance Directive.
During a review of Resident 11 ' s Advance Healthcare Directive Acknowledgement form dated 3/1/2023, was signed by Resident 11 ' s Responsible Party (RP1) and indicated Resident 11 did not have an Advance Directive and would like to receive more information.
During a review of facility provided list titled Advanced Directives Request for Ombudsman, Resident 11 ' s name was not observed in the list.
During a concurrent interview and record review of Resident 11 ' s medical chart with the Social Services Director (SSD) on 12/13/2024 at 11:52 AM, the SSD stated his responsible to assists with resident admissions with the admission Coordinator and licensed nurses. The SSD stated he explains the forms to all the Residents and their representatives on admission. SSD stated when a Resident or Resident Representative marks that they would like more information on Advance Directives on the Advance Directive Acknowledgement form, he calls the Ombudsman to coordinate a visit between Ombudsman and the family to ensure their questions of how to create and Advance Directive were addressed by the Ombudsman. SSD stated he had not referred Resident 11 ' s RP to the Ombudsman as he was unaware, they had requested more information with the previous SSD.
During a telephone interview on 12/14/2024 at 4:34 PM with Resident 11 ' s Representative (RP 1), RP 1 stated she had requested more information regarding Advance directive over a year ago from SSD, but no one had followed up. RP 1 stated the facility has had a few different SSD since her initial request and she had followed up this year with the previous SSD but never got a response.
During a review of facility ' s P&P titled Social Services Program revised on June 01, 2021, the P&P indicated Medically related social services are provided to residents in order to maintain and improve the resident ' s wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling in accordance with the facilities policy and procedure by failing to ensure:
1. Rotten plums were not kept in the food supply for residents and stored in the plastic container in kitchen walk in refrigerator.
2. A half full box of Kale vegetable was discarded as indicated in the label to with discard date 12/9/2024.
3. A plastic bag with five Danishes were kept sealed in the freezer with used by date 12/11/24.
4. A sliced can of apple was discard as indicated in the label to be discarded on [DATE]
These deficient practices had the potential to place residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
Findings:
On 12/12/2024 at 9:30 AM, during an initial observation of the kitchen refrigerator with Dietary Supervisor a plastic container containing plums was observed in the walk-in refrigerator with 2 rotten plums and a carton box with kale half full labeled with discard date of 12/9/2024.
On 12/12/2024 at 9:35 AM, there was an observation of the facilities walk in freezer of an opened clear plastic bag half full the bag was labeled as Danishes with a use by date of 12/11/2024.
During a subsequent observation and interview on 12/12/2024 at of the kitchen dry storage area rack where canned food is stored there was an observation of a metal can containing sliced apples with a label
On 12/12/2024 at 9:50 AM during a subsequent interview with Dietary Supervisor, DS stated all staff should be checking the refrigerator every morning for spoiled food and produce. DS stated spoiled plums, kale and Danishes found in freezer should have been discarded by the discard date or once they were observed to be spoiled in the morning when the refrigerator is checked. DS stated cans such as the sliced apple can with discard date of September should be removed from can storage on the discard date to prevent them from being served and possibly making the residents sick and prevent any food borne illness to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed implement the policy and procedure for infection control by ensuring resident care equipment utilized for residents was sanitary, labeled and properly stored for eight of 8 sampled residents:
For Residents 20 and 70 cloth gait belts (safety device used to help people move around safely, especially when they are at risk of falling) were inside the restroom.
For Residents 2,3,5,9,11 and 15.the cloth gait belts were inside the restroom that any resident could readily access.
This deficient practice had the potential for the residents to share resident care equipment, which can spread infection and cross contamination (transfer disease causing organism) to other residents.
Findings:
1a. During a review of Resident 70 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (a broken bone that occurs near or around a hip or knee replacement) around internal prosthetic (an artificial device that replaces a missing body part) left knee joint, repeated falls, and muscle weakness.
During a review of Resident 70 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident did not have the capacity to understand and make decisions.
During a concurrent observation and interview in Resident 70 ' s room on 12/12/2024 at 11:50 AM, a soiled cloth gait belt with no resident name was observed in the resident restroom. Resident 70 ' s Family Member (FM) 1 stated Resident 70 had a roommate when she was admitted to facility but does not share a room with anyone at the moment. FM 1 stated Resident 70 does not use the restroom. FM 1 stated she was not sure who the belt belonged to.
During a concurrent observation and interview in Resident 70 ' s room on 12/12/2024 at 12:15 PM, Registered Nurse (RN) 1 confirmed soiled cloth gait belt was in Resident 70 ' s restroom with no resident name. RN 1 stated the cloth gait belt did not belong to Resident 70 and must have been for someone else.
1b. During a review of Resident 20 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included pulmonary aspergillosis (fungal lung infection caused by inhaling certain mold spores), acute embolism (a clot that moves through the bloodstream) and thrombosis (a clot in a blood vessel) of left femoral vein (a large blood vessel in the thigh), left tibial vein (deep veins in the lower extremities [legs]), and left peroneal vein (fibular vein that runs on the lateral side of lower extremity), and malignant neoplasm (cancer) of lower lobe, left bronchus or lung.
During a review of Resident 20 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident had the capacity to understand and make decisions.
During a review of Resident 20 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition.
During an observation in Resident 20 ' s room on 12/12/2024 at 11:53 AM, a cloth gait belt labeled Rehab was observed in the resident restroom.
During a concurrent observation and interview in Resident 20 ' s room on 12/12/2024 at 12:18 PM, Infection Prevention Nurse (IPN) confirmed cloth gait belt labeled Rehab was in Resident 20 ' s restroom. IPN stated the cloth gait belt belonged to the Rehab department. IPN stated the gait belt was being sanitized.
2a. During a review of Resident 15 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood).
During a review of Resident 15 ' s History and Physical Assessment, dated 7/2/2024, indicated Resident 15 has the capacity to understand and make medical decisions.
During a review of Resident 15 ' s Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 9/16/2024 indicated Resident 15 ' s cognition (ability to think and reason) was intact.
During a review of Resident 3 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus (high levels of sugar in the blood) with diabetic neuropathy (a complication of diabetes that damages nerves in the body),Hypertensive heart disease (a group of heart conditions that occurs when high blood pressure is left unmanaged over a long period of time).
During a review of Resident 3 ' s History and Physical Assessment, dated 3/23/2024, the HPA indicated Resident 3 has the capacity to understand and make medical decisions.
During a review of Resident 3 MDS, dated [DATE], indicated Resident 15 ' s cognition was intact.
During an observation on 12/12/24 at 11:47 AM of Resident 15 ' s and 3 ' s shared restroom there was a cloth gait belt with no resident name was observed inside the resident restroom hanging from a metal hook attached to the door.
During a concurrent observation and interview in Resident 15 ' s and 3 ' s restroom on 12/12/2024 at 11:55 AM, Registered Nurse (RN) 1 confirmed soiled cloth gait belt was in Resident 15 ' s and 3 ' s shared restroom with no resident name. RN 1 stated she believed the cloth gait belt belonged to Resident 3 but was unsure as there was no name on the gait belt.
2b. During a review of Resident 2 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a long term condition where the kidneys are damaged) and Type 2 Diabetes mellitus (high levels of sugar in the blood).
During a review of Resident 2 ' s History and Physical Assessment [HPA] dated 1/12/2024, the HPA indicated Resident 2 does not have the capacity to understand and make decisions.
During a review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition.
During a review of Resident 9 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included polyneuropathy (a disease affecting the nerves outside the brain and spinal cord), rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet)
During a review of Resident 9 ' s History and Physical Assessment [HPA] dated 2/15/2024, the HPA indicated Resident 9 does not have the capacity to understand and make decisions.
During a review of Resident 9 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, indicated the resident had moderately impaired cognition.
During a review of Resident 11 ' s Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), unspecified dementia (loss of memory, language, problem solving and other thinking abilities).
During a review of Resident 11 ' s History and Physical [H&P] dated 3/15/2024, the H&P indicated the resident was not able to make her own decisions.
During a review of Resident 5 ' s Face Sheet indicated the resident was readmitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing foods or liquids), chronic kidney disease stage 3 (a moderate level of kidney damage that results in reduced kidney function).
During a review of Resident 5 ' s History and Physical [H&P] dated 2/21/2024, the H&P indicated the resident does not have the capacity to understand and make her own decisions.
During an observation on 12/12/24 at 12:00 PM of Resident 2,9,11 and 5 ' s shared restroom there was a cloth gait belt with no resident name was observed inside the resident restroom hanging from a metal hook attached to the door.
.
During a concurrent observation and interview in Resident ' s 2, 9,11 and 5 ' s room on 12/12/2024 at 12:05 PM with Certified Nursing Assistant (CNA 1), CNA 1 stated she will use the cloth gait belt for Resident ' s 2 and 11. CNA 1 stated she was not instructed how to clean the gait belt sometimes she would wipe it down with a wipe in between resident uses but the cloth gait belt was shared for the resident ' s in that room.
During a concurrent interview and observation of Resident 2, 9, 11 and 5 shared restroom on 12/12/2024 at 12:08 PM with Infection Prevention Nurse (IPN) , IPN stated there was no identifier in the cloth gait belt in the restroom and gait cloth gait belts should not be shared among different residents as there was no way to properly clean them in between residents use. IPN stated each Resident should have their won personal cloth gait belt labeled with their name and be kept next to residents' bedside.
During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:59 PM, the DON stated there was no way to sanitize cloth gait belts. The DON stated all cloth gait belts were removed from resident restrooms and plastic gait belts were ordered to sanitize the gait belts when used between patients. The DON stated it was important to disinfect the gait belts after each use for infection control.
During a review of the facility ' s policy and procedure (P&P) titled Cleaning & Disinfection of Resident Care Equipment, dated 5/1/2017 indicated resident- care equipment, including reusable items and durable medical equipment is cleaned and disinfected per current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 15 ' s Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone),hyperlipidemia(a condition in which there are high levels of fat particles in the blood).
During a review of Resident 15 ' s History and Physical Assessment [HPA] dated 7/02/2024, the HPA indicated Resident 15 has the capacity to understand and make medical decisions.
During a review of Resident 15 ' s MDS, dated [DATE] indicated Resident 15 ' s cognition was intact.
During a review of Resident 15 ' s POLST dated 7/4/2024, the POLST did not indicate if Resident 15 had an Advance directive.
During an interview and concurrent record review on 12/13/2024 at 11:58 AM with the Social Services Director (SSD), the SSD stated there was no advance directives or evidence that indicated an Advance Directive acknowledgment form was offered to Resident 15 or the responsible party [RP]. The SSD stated advance directives is completed on admission as part of the resident ' s admission paperwork and it should be in the paper chart to indicate Resident 15 ' s wishes. The SSD stated it was important to get this information, so the facility know what the resident ' s or the RP ' s wishes are in case of an emergency.
During a review of the facility ' s policy and procedure titled Advanced Directives with a revision date of 06/01/2021, indicated to provide residents with the opportunity to make decisions regarding their health care .The admission staff will inform and provide written information to all adult residents concerning the right to accept or refuse medical treatment.
Based on interview and record review for two of three sampled residents, the facility failed to ensure:
1. Resident 20 ' s Physician Orders for Life Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatment that can or cannot be done at the end-of-life) and Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) Acknowledgment Form reflected resident's wishes.
2.Resident 15 ' s POLST and Advance Directive Acknowledgment Form reflected Resident 15 Advance Directive.
This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident's wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.
Findings:
1. During a review of Resident 20 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included pulmonary aspergillosis (fungal lung infection caused by inhaling certain mold spores), acute embolism (a clot that moves through the bloodstream) and thrombosis (a clot in a blood vessel) of left femoral vein (a large blood vessel in the thigh), left tibial vein (deep veins in the lower extremities [legs]), and left peroneal vein (fibular vein that runs on the lateral side of lower extremity), and malignant neoplasm (cancer) of lower lobe, left bronchus or lung.
During a review of Resident 20 ' s History and Physical (H&P), dated 12/11/2024, indicated the resident had the capacity to understand and make decisions.
During a review of Resident 20 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/7/2024, indicated the resident had intact cognition.
During a review of Resident 20 ' s POLST dated 12/11/2024 did not indicate if resident received information about an Advance Directive or if resident had an advance directive on file.
During a review of Resident 20 ' s Advance Directive Acknowledgement form dated 12/3/2024 indicated Resident 20 had an Advance Directive.
During a review of Resident 20 ' s medical chart on 12/13/2024 at 12:24 PM, indicated no evidence that Advance Directive was formulated.
During a concurrent interview and record review of Resident 20 ' s POLST and Advance Directive Acknowledgment form on 12/14/2024 at 3:15 PM, the Social Services Director (SSD) stated he was aware that Resident ' s 20 ' s POLST and Advance Directive Acknowledgment form did not match. SSD stated the POLST should be filled out to its entirety, to know what the resident ' s healthcare decisions and wishes are. SSD stated the POLST should not be left blank. SSD stated he clarified with family on 12/13/2024 regarding Resident 20 ' s Advance Directive and was told resident did not have an advance directive and would like more information to obtain an AD. SSD stated it was important for all documentation like the POLST and Advance Directive to be the same, in the case of an emergency to know what the resident ' s wishes are.
During an interview on 12/14/2024 at 5:01 PM, the Director of Nursing (DON) stated resident ' s POLST and Advance Directive Acknowledgment form should indicate resident ' s wishes. The DON stated if the information is not the same, staff should verify and clarify with the family and resident. The DON stated it was important to make sure all documents indicate the same thing so that resident ' s wishes can be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified for one of one sampled residents (Resident 18), who refused to receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions.
This deficient practice had the potential for Resident 18 to not receive appropriate care, treatment and/or services and increased the risk for Resident 18 to be hyperglycemic (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: urinating large amounts of urine, excessive thirst, feeling tired, blurred vision) and suffer from complications of high blood sugar levels such as ketoacidosis (a life-threatening condition that occurs when the body produces too many ketones), kidney failure (failure of the kidney to get rid of toxins and extra fluids, and blindness.
Findings:
During a review of Resident 18 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (a broken bone that occurs near or around an orthopedic implant, such as a hip or knee replacement) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision).
During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition.
During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders:
On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 mg/dL (milligrams per deciliter) = 0 UNIT; 151 - 200 mg/dL = 1 UNIT; 201 - 250 mg/dL = 2 UNIT; 251 - 300 mg/dL = 3 UNIT; 301 - 350 mg/dL = 4 UNIT; 351 - 400 mg/dL = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, mg/dL subcutaneously before meals for DM
On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS)
During a review of Resident 18 ' s Medication Administration Record (MAR) from 11/2024 to 12/2024 indicated Resident 18 refused Insulin Lispro on the following occasions:
On 11/30/2024 at 5:00 PM, Resident 18 had a BS of 202 mg/dL
On 12/3/2024 at 7:00 AM, Resident 18 had a BS of 217 mg/dL
On 12/4/2024 at 5:00 PM, Resident 18 had a BS of 234 mg/dL
On 12/7/2024 at 7:00 AM, Resident 18 had a BS of 209 mg/dL
On 12/7/2024 at 11:30 AM, Resident 18 had a BS of 248 mg/dL
On 12/7/2024 at 5:00 PM, Resident 18 had a BS of 171 mg/dL
On 12/8/2024 at 11:30 AM, Resident 18 had a BS of 180 mg/dL
On 12/9/2024 at 5:00 PM, Resident 18 had a BS of 178 mg/dL
On 12/11/2024 at 5:00 PM, Resident 18 had a BS of 180 mg/dL
During a review of Resident 18 ' s Progress Notes from 11/2024 to 12/2024 indicated the following:
On 11/30/2024 at 5:37 PM, Resident family member (FM) 1 at bedside and resident declined medication three times, risks and benefits explained and FM 1 said, I know, but I don ' t want her to have any insulin this evening. Her BS was low in the afternoon, and I don ' t want her BS to go down again. No insulin, please. Rights honored.
On 12/1/2024 at 5:55 PM, Only 1 unit was administered, FM 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down.
On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes.
On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware.
On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident.
On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 mg/dL and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response.
On 12/6/2024 at 4:02 PM, FM 1 was made aware that MD has not given any order per the requested Insulin Glargine. FM 1 said okay that means resident wouldn ' t be having it again today. never mind again. The note indicated no response was received from MD and was endorsed to the next shift.
On 12/7/2024 at 5:28 PM, FM 1 was at Resident ' s bedside and decline medication 3 times, risks and benefits explained, verbalized understanding, but declined medication.
On 12/9/2024 at 4:40 PM, Resident refused three times, explained risks and benefit but continued to refuse.
On 12/11/2024 at 4:56 PM, Resident refused three times, explained risk and benefit, but continued to refuse.
During a concurrent interview and record review of Resident 18 ' s MAR from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the Minimum Data Set Registered Nurse (MDS RN), verified Resident 18 refused Insulin Lispro on: 11/30/2024 at 5 PM, 12/3/2024 at 7AM, 12/4/2024 at 5PM, 12/7/2024 at 7AM, 11:30 AM, and 5PM, 12/8/2024 at 11:30 AM, 12/9/2024 at 5:00 PM, and 12/11/2024 at 5:00 PM.
During a concurrent interview and record review of Resident 18 ' s Progress notes from 11/2024 to 12/2024 on 12/14/2024 at 2:32 PM, the MDS RN stated she could not find documented evidence of notification to Resident 18 ' s physician regarding resident ' s refusal to take Insulin Lispro. MDS RN stated staff should inform the physician that Resident 18 was refusing Insulin, to better plan resident ' s care and communicate with the interdisciplinary team.
During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated the staff was supposed to notify the physician if a resident refuses medication like Insulin. The DON stated it was important to notify the physician so that the physician can give new orders or add something else in Resident 18 ' s care plan. The DON stated resident refusal to receive insulin was considered a significant change in condition and should be documented in progress notes to include the physician notification. The DON stated a care plan should have been initiated for Resident 18 ' s refusal to take Insulin.
During a review of the facility ' s policy and procedure (P&P) titled Refusal of Treatment, dated 10/1/2017 indicated the charge nurse or DON will document information relating to the refusal/discontinuance in the resident ' s medical record that will include at least the date and time the Attending Physician was notified and his or her response. The P&P indicated the Attending Physician will be notified of refusal or discontinuance of treatment in a time frame determined by the resident ' s condition and potential serious consequences of the refusal or discontinuance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan that included for one of one sampled resident (Resident 18), that indicated alternative interventions were implemented for refusal receive insulin Lispro injection (a medication that is injected into the skin with a needle to lower the blood sugar level and help keep blood sugar level under control for Resident 18 with diabetes [a group of diseases that result in too much sugar in the blood] complications) on multiple occasions.
As a result, Resident 18 ' s blood sugar remained high which can result in complications such as high blood sugar levels such as ketoacidosis (a life-threatening condition that occurs when the body produces too many ketones), kidney failure (failure of the kidney to get rid of toxins and extra fluids, and blindness.
Cross Reference to F580
Findings:
During a review of Resident 18 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (bone fracture) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with unspecified diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision).
During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition.
During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders:
On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 = 0 UNIT; 151 - 200 = 1 UNIT; 201 - 250 = 2 UNIT; 251 - 300 = 3 UNIT; 301 - 350 = 4 UNIT; 351 - 400 = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, subcutaneously before meals for DM
On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS)
During a review of Resident 18 ' s Medication Administration Record (MAR) from 11/2024 to 12/2024 indicated Resident 18 refused Insulin Lispro on the following occasions:
On 11/30/2024 at 5:00 PM, Resident 18 had a BS of 202 mg/dL
On 12/3/2024 at 7:00 AM, Resident 18 had a BS of 217 mg/dL
On 12/4/2024 at 5:00 PM, Resident 18 had a BS of 234 mg/dL
On 12/7/2024 at 7:00 AM, Resident 18 had a BS of 209 mg/dL
On 12/7/2024 at 11:30 AM, Resident 18 had a BS of 248 mg/dL
On 12/7/2024 at 5:00 PM, Resident 18 had a BS of 171 mg/dL
On 12/8/2024 at 11:30 AM, Resident 18 had a BS of 180 mg/dL
On 12/9/2024 at 5:00 PM, Resident 18 had a BS of 178 mg/dL
On 12/11/2024 at 5:00 PM, Resident 18 had a BS of 180 mg/dL
During a review of Resident 18 ' s Progress Notes from 11/2024 to 12/2024 indicated the following:
On 11/30/2024 at 5:37 PM, Resident family member (FM) 1 at bedside and resident declined medication three times, risks and benefits explained and FM 1 said, I know, but I don ' t want her to have any insulin this evening. Her BS was low in the afternoon, and I don ' t want her BS to go down again. No insulin, please. Rights honored.
On 12/1/2024 at 5:55 PM, Only 1 unit was administered, FM 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down.
On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes.
On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware.
On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident.
On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 mg/dL and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response.
On 12/4/2024 at 4:50 PM, Resident refused 3 times, explained risk and benefit, but continue to refuse, respected resident wishes.
On 12/6/2024 at 6:57 AM, Resident refused BS to be checked, FM 1 made aware.
On 12/6/2024 at 6:59 AM, Resident refused BS to be checked; informed FM 1 and asked to talk with the resident. The note indicated FM 1 asked to pass for now for BS check until FM 1 comes to see resident.
On 12/6/2024 at 11:37 AM, received report from night shift, resident declined BS check and ordered insulin could not be given. The note indicated FM 1 approached the nursing station and requested for Insulin Glargine to be given. The note indicated the medication nurse explained the situation to FM 1, BS checked to be 195 and FM 1 insisted Insulin Glargine to be given at this time because Resident 18 missed it in the morning. The note indicated medication nurse made FM 1 aware that the MD would be communicated and made aware, awaiting MD ' s response.
On 12/6/2024 at 4:02 PM, FM 1 was made aware that MD has not given any order per the requested Insulin Glargine. FM 1 said okay that means resident wouldn ' t be having it again today. never mind again. The note indicated no response was received from MD and was endorsed to the next shift.
On 12/7/2024 at 5:28 PM, FM 1 was at Resident ' s bedside and decline medication 3 times, risks and benefits explained, verbalized understanding, but declined medication.
On 12/9/2024 at 4:40 PM, Resident refused three times, explained risks and benefit but continued to refuse.
On 12/11/2024 at 4:56 PM, Resident refused three times, explained risk and benefit, but continued to refuse.
During a concurrent interview and record review of Resident 18 ' s MAR from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the Minimum Data Set Registered Nurse (MDS RN), verified Resident 18 refused Insulin Lispro on: 11/30/2024 at 5:00 PM, 12/3/2024 at 7:00 AM, 12/4/2024 at 5:00 PM, 12/7/2024 at 7:00 AM, 11:30 AM, and 5:00 PM, 12/8/2024 at 11:30 AM, 12/9/2024 at 5:00 PM, and 12/11/2024 at 5:00 PM.
During a concurrent interview and record review of Resident 18 ' s Progress notes from 11/2024 to 12/2024 on 12/14/2024 at 2:28 PM, the MDS RN could not find documented evidence of a plan of care that addressed Resident 18 ' s refusal to take Insulin Lispro. MDS RN stated staff should inform the physician that Resident 18 was refusing Insulin, to better plan resident ' s care and communicate with the interdisciplinary team.
During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated she expects her staff to notify the physician if a resident refuses medication like Insulin. The DON stated it was important to notify the physician so that the physician can give new orders or add something else in Resident 18 ' s care plan. The DON stated a care plan should have been initiated for Resident 18 ' s refusal to take Insulin.
During a review of the facility ' s policy and procedure (P&P) titled Refusal of Treatment, dated 10/1/2017 indicated the Interdisciplinary Team will assess the resident ' s needs, and offer the resident alternative treatments while continuing to provide other services in the Care Plan. The P&P indicated when the resident ' s refusal or discontinuance brings about a significant change in the resident ' s condition, a reassessment is made, and new information is incorporated into the resident ' s Care Plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow physician ' s orders for one of one sampled resident (Resident 18) who was receiving Insulin (medication that helps keep blood sugar under control and prevents diabetes [a group of diseases that result in too much sugar in the blood] complications).
This deficient practice increased the risk of Resident 18 to experience adverse effects (unwanted and dangerous side effects of medication) that could lead to health complications, such as hyperglycemia (a condition in which the level of glucose (sugar) in the blood is higher than normal, symptoms include: urinating large amounts of urine, excessive thirst, feeling tired, blurred vision)
Findings:
During a review of Resident 18 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included periprosthetic fracture (bone fracture) around internal prosthetic (an artificial device that replaces a missing body part) right knee joint, displaced fracture of base of neck of right femur, and type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar [BS] and using it for energy) with unspecified diabetic retinopathy (complication of diabetes that affects the eyes, caused by damage to the blood vessels in the tissue at the back of the eye [retina]) with macular edema (when blood vessels leak in to a part of the retina called the macula, makes the macula swell, causing blurry vision).
During a review of Resident 18 ' s History and Physical (H&P), dated 11/30/2024, indicated the resident did not have the capacity to understand and make decisions.
During a review of Resident 18 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/1/2024, indicated the resident had severely impaired cognition.
During a review of Resident 18 ' s Order Summary indicated the following prescribed physician orders:
On 11/27/2024, physician prescribed Insulin Lispro Injection Solution 100 Unit (unit of measure) per Milliliter (mL, unit of measure) (Insulin Lispro) Inject subcutaneously (injection is given in the fatty tissue, just under the skin) before meals for Diabetes Mellitus (DM), Inject as per sliding scale: if 0 - 150 = 0 UNIT; 151 - 200 = 1 UNIT; 201 - 250 = 2 UNIT; 251 - 300 = 3 UNIT; 301 - 350 = 4 UNIT; 351 - 400 = 5 UNIT IF GREATER THEN 400 GIVE 6 UNITS NOTIFY Physician (MD), NOTIFY MD IF BS is less than 60, subcutaneously before meals for DM
On 11/28/2024, physician prescribed Insulin Glargine Solution 100 UNIT/ML Inject 22 unit subcutaneously one time a day for DM (DO NOT MIX WITH OTHER INSULINS)
During a review of Resident 18 ' s Progress Notes on 12/1/2024 timed at 5:55 PM indicated only 1 unit was administered, Resident 18 ' s Family Member (FM) 1 at bedside and declined full dose of 2 units. Risks and benefits explained and FM 1 I know, but I don ' t want her to have 2 units only 1 unit this evening. Her BS was low in the afternoon. I don ' t want her BS to go down.
During a concurrent interview and record review of Resident 18 ' s Progress notes on 12/14/2024 at 2:28 PM, the MDS RN stated the progress note dated 12/1/2024 timed at 5:55 PM indicated the nurse did not give Insulin as ordered by the physician. The MDS RN stated the nurse should have not given the medication.
During an interview with the Director of Nursing (DON) on 12/14/2024 at 4:55 PM, the DON stated she expects her staff to always follow the physician orders. The DON stated it was important for staff to follow physician orders to ensure there would not be any negative reaction.
During a review of the facility ' s policy and procedure (P&P) titled Medication Administration, dated 7/1/2016 indicated medication will be administered by a licensed nurse per the order of an Attending Physician or licensed independent practitioner. The P&P indicated the Rule of 3 the licensed nurse administering medications will perform 3 checks comparing the physician ' s order, pharmacy label, and medication administration record (MAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was provided appropriate care and services, that was resident centered, by failing to:
1. Develop an individualized care plan that includes resident specific care needs and interventions for Resident 1 who was assessed at moderate risk for falls in accordance with the facility's policy and procedure for Care Planning.
2. Develop an individualized care plan that includes resident specific care needs and interventions for Resident 1 who had a history and diagnoses of osteoporosis (a bone disease that causes bones to become weak and more likely to break) to prevent fractures (a break in a bone, either partial or complete).
3. Monitor and document a neurological assessment (neurocheck: a non-invasive procedure that can help identify and treat injuries sustained after a fall) after Resident 1 fell on [DATE] (5 days after admission), in accordance with the facility's P&P titled Neurological Assessment.
4. Assess and inform the Physician before the administration of Resident 1 ' s prescribed medication, Apixaban (medication to thin the blood and prevent blood clots) 2.5mg (unit of measure) by mouth (PO) twice a day (BID) at 5PM, after Resident 1 fell on [DATE], in accordance with professional standards of practice and the facility P&P on Neurological Assessment.
5. Review and address the Black Box warning (when serious adverse reactions or special problems occur, particularly those that may lead to death or serious injury) of the drug-to-drug interaction automatically populated in the facility ' s electronic medical record system for licensed nurse to monitor risk for adverse consequences (an undesired effect of a drug or other type of treatment) while on a black box warning medication (Apixaban), in accordance with the facility ' s P&P titled, Medication- Black Box Warning and care plans for the use of Anticoagulant and Antiplatelet.
This deficient practice of not addressing automatic generated prompts for drug warnings had the potential for licensed nurses (LN) to disregard potential adverse effects to Resident 1 and other residents in the facility who were on a black box warning medication.
6. Promptly assess and complete a post fall assessment, investigation, document notification of physician and responsible party, a detailed progress note, document the resident's condition in the resident's medical record every shift for 72 hours and revise resident's care plan as necessary for Resident 1 ' s unwitnessed fall on [DATE], as verbalized by Resident 1, on [DATE], in accordance with the facility ' s P&P, titled Response to Falls.
The deficient practices of failing to develop a care plan, monitor and document Resident 1 ' s neurocheck consistently, and not notifying the physician and assessing Resident 1 after an alleged fall on [DATE] resulted in Resident 1 sustaining a fall on [DATE] resulting in a 2x2 size bump on the forehead and altered level of consciousness (ALOC: reduced alertness or inability to be aroused), requiring the resident to be transferred to the General Acute Care Hospital (GACH) on [DATE] and had the potential to place other residents at risk for not obtaining care and services tailored to residents specific needs.
Findings:
During a review of Resident 1 ' s GACH Records dated [DATE], prior to resident ' s admission to the facility, the GACH Records indicated Resident 1 had a history of osteoarthritis and osteoporosis. The GACH record did not indicate that Resident 1 had any previous fractures.
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included osteoporosis and atrial fibrillation (a heart condition that causes an irregular and often fast heartbeat).
During a review of Resident 1 ' s Nursing admission Screening/History dated [DATE] at 4:08 PM, the Nursing admission Screening/ History indicated Resident 1 was alert and orientated to person, place and time. The Screening indicated that Resident 1 had bilateral (affecting to both the right and left side of the body) upper and lower extremities (part of the body) discoloration.
A Review of Resident 1 ' s Fall Risk assessment dated [DATE] at 6:50 PM, the Fall Risk Assessment indicated Resident 1 was assessed as moderate risk for falls.
During a review of Resident 1 ' s Risk for Fall Care Plan initiated on [DATE], the Risk for Fall Care Plan indicated, Resident 1 was at risk for fall related to weakness, poor safety judgment, side effects of multiple medications and requires assistance with toileting. The care plan indicated interventions including a safe environment, reachable call light and bed in low position.
During a review of Resident 1 ' s Order Summary Report for 11/2024, the Order Summary Report indicated Resident 1 was prescribed Apixaban (a blood thinner medication to thin the blood and prevent blood clots) 2.5mg (unit of measure) by mouth twice a day (BID), Aspirin (prevents blood clots) 81mg by mouth once a day and Plavix (prevents blood clots) 75mg my mouth once a day. The Report indicated anticoagulation (prevents blood clots) medication required monitoring for discolored urine, black tarry stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status, shortness of breath and nose bleeds.
During a review of Resident 1 ' s Anticoagulant (medications that prevent or reduce blood clotting) and Antiplatelet (medications that prevent blood cells called platelets from clumping together and forming clots) Care Plan , initiated [DATE], the Anticoagulant and Antiplatelet Care Plan indicated goals that Resident 1 would be free from adverse reactions related to anticoagulant use. The care plan interventions indicated daily skin inspection and to monitor for bruising and sudden changes in mental status.
During further review of Resident 1's clinical record from [DATE]-[DATE], the clinical record indicated no documented evidence of a care plan for resident's diagnoses of osteoporosis.
During a review of Resident 1 ' s Nursing Progress Notes dated [DATE] at 2:47 PM, indicated a drug-to-drug interaction alert/warning generated by the facility ' s electronic medical record, which indicated that the system had identified a possible drug interaction with the following orders: Aspirin oral capsule 81 mg, severity: severe, and interaction: Aspirin may enhance the anticoagulant effects of direct oral anticoagulant Apixaban 2.5mg.
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated Resident 1 had moderately impaired cognition (thought process) and required substantial/maximum assistance for activities of daily living and getting in and out of the bed or chair.
During a review of Resident 1 ' s Post Change in Condition (COC)/Situation, Background, Assessment, Recommendation (SBAR) dated [DATE] at 4:04 PM, the Post COC/SBAR indicated Resident 1 sustained a fall and the Medical Doctor 1(MD 1) was notified, and MD 1 ordered to monitor, observe, and apply ice to bump, located on the left side of Resident 1 ' s forehead.
During a review of Resident 1 ' s Medication Audit Report dated [DATE], the Medication Audit Report indicated Apixaban 2.5mg oral tablet was administered at 5:10 PM by Licensed Vocational Nurse (LVN) 1.
During a review of Resident 1 ' s Nursing Progress Notes dated [DATE] at 4:45 PM, the Nursing Progress Note indicated Certified Nursing Assistant (CNA 2) found Resident 1 on the floor, laying on the right side with Resident 1 ' s head located beside the foot of the bed (bottom of bed).The progress note indicated Resident 1 sustained a bump to the left side of the forehead measuring 2cm (unit of measurement) by 2cm, and that MD 1 was notified regarding Resident 1 ' s fall. The Progress Note indicated MD ordered for monitoring and to apply and ice pack to Resident 1 ' s bump.
During a review of Resident 1 ' s 72 hours Neuro-check List for unwitnessed fall with left forehead bump, dated [DATE], the 72 hours Neuro Check List indicated Resident 1 ' s neuro assessment was not documented at 5:30PM to assess Resident 1 ' s blood pressure, vital signs, level of consciousness, pupils, and hand grip.
During a review of Resident 1 ' s Nursing Progress Note dated [DATE] at 6:25 PM, the Nursing Progress Note indicated at 5:00PM Resident 1 ' s prescribed medication, apixaban was administered. The progress note indicated at 5:45PM Family Member (FM 2) 2 was screaming from Resident 1 ' s room requesting assistance. The progress note indicated Resident 1 was agitated and his body was shaking, his eyes were closed, and FM 2 was holding Resident 1 ' s body down. The progress note indicated Resident noted with shakiness body and eyes closed and daughter holding him down to bed/ controlling the shakiness. The progress note indicated that FM 2 called 911 (emergency services) on her personal phone.
During a review of Resident 1 ' s Nursing Progress Noted dated [DATE] at 6:45 PM, the Nursing Progress Note indicated Resident 1 was non-verbal, with all extremities shaking, and was not responding to FM 2 ' s verbal calls to Resident 1. The Progress Note indicated Registered Nurse (RN) 1 could not obtain vital signs (measurements of breathing rate, temperature, pulse rate and blood pressure) due to Resident 1 ' s continuous shaking.
During a review of Resident 1 ' s Order Summary Report, the Order Summary Report indicated an order to transfer Resident 1 to the GACH via 911 (emergency services) for evaluation on [DATE].
During a review of Resident 1 ' s GACH Records dated [DATE], the GACH Records indicated Resident 1 was transferred to the GACH for altered mental status and concerns for seizures (uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness). The GACH record indicated after Resident 1 had a computed tomography (CT – a scan that helps detect injuries) scan to rule out intercranial hemorrhage (Bleeding in the head) at 6:50PM Resident 1 went into bradycardia (slow heart rate) and one dose of epinephrine (medication to treat slow heart rate) 20 micrograms (mcg - unit of measure) intravenous (in the vein) was administered to Resident 1 ' s right arm. The GACH records indicated Resident 1 continued to have bradycardia and went into pulseless electrical activity (PEA – a condition where the heart stops beating). The GACH records indicated that Resident 1 received a total of 4 doses of epinephrine with high quality cardiopulmonary resuscitation (CPR – a procedure to restart breathing and heartbeat) performed, as well as required 2 doses of sodium bicarbonate (medication used to treat too much acid in the body fluids) and calcium chloride (medication used during CPR to help regain a heartbeat). The GACH records indicated Resident 1 was intubated (inserting a breathing tube through the mouth) during the cardiac arrest. The GACH records indicated that an electrocardiogram (EKG – a test to record electrical signals in the heart) was obtained postcardiac arrest at 7:40PM and Resident 1 ' s heart rate was 70 beats per minute (a unit of measurement). The GACH records indicated Resident 1 was transferred to the intensive care unit (ICU – a hospital ward that provides critical care and life support for patients who are seriously injured) while on Levophed (medication used to treat life threating low blood pressure) 25 mcg/kilogram (kg – unit of measurement) and Resident 1 ' s condition was critical.
During further review of the GACH records, the GACH Records indicated that on [DATE] at 11:36 PM an x-ray was performed on Resident 1 and indicated a proximal (closer to the center of the body) right femur (longest and heaviest bone in the body) fracture.
During an interview on [DATE] at 9:30 AM with the Director of Nursing (DON), the DON stated that Resident 1 was admitted on [DATE] with diagnosis of pneumonia (infection in the lungs) and had no previous fractures upon admission. The DON stated Resident 1 was alert and able to answers questions appropriately and was initially assessed as moderate risk for falls. The DON stated that Resident 1 required frequent observations due to Resident 1 ' s history of dementia (neurological conditions affecting the brain that worsen over time). The DON stated that Resident 1 had an unwitnessed fall on [DATE] around 3pm and was found on the floor in a right-side lying position and a body check was conducted by RN 1. The DON stated that Resident 1 had a head injury from the fall and sustained a bump to the left side of Resident 1 ' s forehead. The DON stated on Saturday, [DATE] around 4:30 PM, FM 2 arrived at the facility to assist Resident 1 with meals. The DON stated that FM 2 came to the nursing station at around 5:40 PM calling for help because Resident 1 was nonresponsive, and the resident ' s entire body was shaking. The DON stated that RN 1 went to assess Resident 1 and FM 2 had called 911. The DON stated the paramedics arrived around 6pm and Resident 1 was transferred to the GACH.
During a telephone interview on [DATE] at 10:01AM with FM 2, FM 2 stated that LVN 1 entered Resident 1 ' s room at 5:10 PM and administered Apixaban 2.5 mg to Resident 1.
During a telephone interview on [DATE] at 10:05AM with FM 2, stated that on Saturday, [DATE] she received a call from the facility at 4:10PM and was informed that Resident 1 sustained a fall with a head injury. FM 2 stated she arrived at the facility at 4:35 PM and observed a golf ball size bump on the left side of Resident 1 ' s forehead. FM 2 stated that Resident was alert but was having episodes of confusion and had difficult time speaking and could not formulate words. FM 2 stated Resident 1 was alert prior to his admission to the facility on [DATE]. FM 2 stated that at 5:40 PM Resident 1 became nonresponsive and started having seizure like shaking to his upper and lower extremities. FM 2 stated she ran to the nursing station and called for help, and RN 1 and LVN 1 came to Resident 1 ' s room. FM 2 stated that she informed RN 1 to call 911 because Resident 1 was nonresponsive and the resident ' s upper and lower extremities were shaking nonstop. FM 2 stated that CNA 1 told FM2 that this had happened before and not to panic. FM 2 stated the paramedics arrived at the facility at approximately 6pm.
During an interview on [DATE] at 2:37 PM with licensed vocational nurse (LVN) 1, LVN 1 stated that on [DATE] at 3:45 PM CNA 1 called for assistance in Resident 1 ' s room since Resident 1 was found lying down on the floor. LVN 1 stated that she entered Resident 1 room with RN 1 and found Resident 1 positioned on his right side with a bump observed to the left side of Resident 1 ' s head measuring 2x2 cm. LVN 1 stated that Resident 1 had an unwitnessed fall, then sustained a bump on the left side of his head which contacted the side of bed.
During a concurrent interview and record review of Resident 1 ' s Neuro Check List on [DATE] at 2:41 PM, LVN1 stated she was responsible for conducting Resident 1 ' s neurocheck after Resident 1 ' s fall on [DATE]. LVN1 the assessment for 5:30 PM was missing, and that LVN1 was busy passing out medications to other residents. LVN 1 stated she should have conducted Resident 1 ' s 5:30 PM neuro check, especially since LVN1 was aware Resident 1 was on three anticoagulation medications and just sustained a fall.
During a concurrent interview and record review of Resident 1 ' s medication administration record (MAR) for [DATE], on [DATE] at 2:45 PM, the MAR indicated Resident 1 was prescribed Apixaban 2.5mg PO BID (two times a day at 9 AM and 5 PM) and Resident 1 required to be monitored for bleeding. LVN 1 stated administering Resident 1 ' s dose of Apixaban at 5:10 PM. LVN1 stated at approximately 5:40 PM, FM 2 came out of Resident 1 ' s room, requesting for help because Resident 1 was nonresponsive with his eyes closed, and upper and lower extremities were shaking.
During a follow up interview on [DATE] at 3:50 PM with RN1, RN1 stated on [DATE], Resident 1 was observed lying on the floor at approximately 3:45PM after CNA2 called for assistance. RN1 stated Resident 1 was on the floor, in a right-side lying position and Resident 1 ' s head was at the foot of the bed. Resident 1 was unclothed, with diapers (briefs) pulled halfway down that had bowel movement in the diaper. RN1 stated Resident 1 was still able to follow simple commands but was confused. RN 1 stated Resident 1 had a 2x2 bump to the left side of the forehead, and that after Resident 1 was assessed, Resident 1 was placed back into bed. RN1 stated notifying Resident 1 ' s FM and physician and applied an ice back to the bump on Resident 1 ' s forehead. RN1 stated at approximately 5:30 PM on [DATE], after being administered Resident 1 ' s 5 PM scheduled dose of Apixaban, RN1 was called by CNA1 and licensed vocational nurse (LVN) who were in Resident 1 ' s room. RN1 stated once entering Resident 1 ' s room, Resident 1 was observed continuously being startled while unresponsive. RN1 stated Resident 1 was continuously shaking and RN1 could not obtain Resident 1 ' s VS. RN1 stated Resident 1 was transferred to the GACH on [DATE] at approximately 6:15 PM.
During an interview on [DATE] at 12:45 PM with the facility ' s Pharmacist Consultant (PHARM 1), PHARM 1 stated when residents were prescribed and administered three (3) anticoagulation medications, residents were at high risk for bleeding. PHARM 1 stated Resident 1 was at risk for internal bleeding after his fall with a head injury.
During an interview on [DATE] at 2 PM with the DON, the DON stated on Resident 1 ' s electronic medical record, prompts would automatically populate that indicated a drug-to-drug interaction, due to Resident 1 being prescribed multiple anticoagulation medications. The DON stated the prompts were a warning to the medication nurse that Resident 1 was at risk for bleeding.
During a concurrent interview and record review of Resident 1 ' s progress notes on [DATE] at 2 PM with the Director of Nursing (DON), DON stated there were several drug to drug interaction warning regarding the three anticoagulation medications (Apixaban 2.5mg PO BID (9 AM & 5 PM), Aspirin 81mg PO Daily and Plavix 75mg PO Daily) with a severity level of severe indicating that the medication may enhance the anticoagulation effects when all 3 medications were taken together. DON stated this warning was to inform the medication nurse that Resident 1 had the potential for bleeding and altered level of consciousness (ALOC: a change in a patient's state of awareness (ability to relate to self and the environment) and arousal (alertness). DON stated that LVN 1 should have contacted MD 1 on [DATE] regarding Resident 1 ' s afternoon 5PM dose of Apixaban prior to administering the medication to Resident 1, knowing Resident 1 sustained a fall on [DATE] at approximately 3:45 PM.
During a telephone interview on [DATE] at 8 AM with CNA 2, CNA 2 stated that she heard yelling coming from Resident 1 ' s room on [DATE] at approximately 3:15 PM. CNA 2 stated when she entered Resident 1 ' s room, Resident 1 was observed on the floor lying on his right side, and face facing the foot of the bed with a bump on the left side of his head. CNA 2 stated she called for help and RN 1 and LVN 2 came into the room.
During a telephone interview on [DATE] at 3:41 PM with Medical Director (MD) 2, MD 2 stated when a resident was prescribed three different anticoagulant medications, the resident was at high risk for bleeding internally and externally. MD 2 stated after Resident 1 sustained a fall on [DATE], a CT scan should have been ordered to rule out any internal bleeding, since Resident 1 sustained a head injury with a bump to the left side of the forehead. MD 2 stated withholding of the 5PM dose of Apixaban 2.5mg PO BID should have been done until the CT scan was cleared since there was a risk for bleeding.
During a review of the facility ' s P&P titled Response to Falls revised [DATE], the P&P indicated to ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both resident ' s immediate needs and longer-term fall prevention. The P&P indicated resident experiencing the fall will be promptly assessed and treated for injuries. The P&P indicated after each fall, a licensed nurse will complete a post-fall assessment and investigation. The P&P indicated the licensed nurse will notify the attending physician of the fall and implement any new physician orders. The P&P indicated following each resident fall, the Licensed Nurse will complete an incident report and perform a Post-Fall Assessment & Investigation. The P&P indicated the Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall or witnessed fall with known head injury for 72 hours following the fall. The P& P indicated a Licensed Nurse will: document all falls on the 24-hour report, document notification of physician and responsible party, compete an incident report and a detailed progress note, and complete the Post-Fall Assessment & Investigation, complete Neurological Flow Sheet for 72 hours following an un-witnessed fall or fall with known head injury, document the resident's condition in the resident's medical record every shift for 72 hours and revise resident's Care Plan as necessary.
During a review of the facility ' s P&P titled Fall Management Program revised [DATE], the P&P indicated to prevent resident falls and minimize complications associated with falls through the development of a Fall Management Program. The P&P indicated the Nursing Staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls. The P&P indicated the Interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall. The P&P indicated following a resident's fall, the licensed nurse will complete an incident report and a Post-Fall Assessment & Investigation within 24 hours or as soon as practicable, the Licensed Nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated, the IDT-Falls Committee will meet within 72 hours of a fall and the IDT-Falls Committee will review and document: summary of event following a fall, root cause analysis, referrals, as necessary; and interventions to prevent future falls.
During a review of the facility ' s P&P titled Neurological Assessment revised [DATE], The P&P indicated the purpose to provide guidelines for the performance of a neurological assessment on residents. The P& P indicated nursing Staff will perform a neurological assessment in the following circumstances: upon Attending Physician order, following an unwitnessed fall, following a fall or other accident/injury involving head trauma; or when indicated by resident's condition and Neurological checks will be performed as follows or otherwise ordered by the Attending Physician: Every 15 minutes for 1 hour, then, every 30 minutes for 1 hour, then, Every hour for 2 hours, then every 4 hours for a combined total of 72 hours. The P&P indicated take temperature, pulse, respirations, blood pressure, intracranial Pressure (ICP): Respirations are increased and shallow with ICP. The P&P indicated Notify the Attending Physician of any change if a resident's neurological status, Early signs of neurologic compromise include changes in the resident's level of consciousness, pupillary activity and report other information in. accordance with Facility policy and professional standards of practice.
During a review of the facility ' s P&P titled Care Planning revised [DATE], the P&P indicated the purpose was to ensure that a comprehensive person-centered Care Plan is developed for each resident based on their individual assessed needs. The P&P indicated a Licensed Nurse will initiate the Care Plan and updated as indicated for change in condition, onset of new problems and on as needed bases. The P&P indicated the Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission.
During a review of the facility ' s P&P titled Change of Condition Notification revised on [DATE], the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The P&P indicated the definition of acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. The P&P indicated the Facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition\caused by, but not limited to an injury/accident, a significant change in the resident's physical, cognitive, behavioral, or functional status, and a significant change in treatment.
During a review of the facility ' s policy and procedure (P&P) titled Medication – Black Box Warning revised [DATE], indicated ensure that residents and Staff are aware of the high-risk factors for medications identified in the Black Box Warning category. The P&P indicated the pharmacy will alert the Facility when a medication ordered falls into the Black Box Warning medication category. Nursing Staff will monitor residents receiving these medications for side effects. A Black Box warning appears on the label of certain prescription medications to alert consumers and health care providers about serious side effects, safety concerns and life-threatening risks concerning medications. The P&P indicated the Licensed Nurse will review the Black Box Warning medication(s) for health risks and will monitor the resident for signs and symptoms of those risks, monitoring will involve periodic planned evaluation of the resident ' s progress toward the therapeutic goals, continued vigilance for adverse consequences, and evaluation of potential adverse consequences as set forth in the Black Box Warning, the Licensed Nurse will document the monitoring parameters in the resident ' s Care Plan, the Licensed Nurse will document signs and symptoms related to monitoring parameters and document any adverse consequences in the nursing progress notes or on the Medication Administration Record (MAR), the Licensed Nurse will inform the Attending Physician of any signs and symptoms related to monitoring parameters and/or any adverse consequences and all documentation related to signs and symptoms or adverse reactions will be maintained in the resident ' s medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician, for one of three sampled residents (Resident 1), who was assessed as a moderate risk for falls, and sustained an unwitnessed fall on 11/13/214.
This deficient practice had the potential to result in the delay of care and services to Resident 1.
Findings:
During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included osteoporosis and atrial fibrillation (a heart condition that causes an irregular and often fast heartbeat).
During a review of Resident 1 ' s Nursing admission Screening/History dated 11/11/2024 at 4:08 PM, the Nursing admission Screening/ History indicated Resident 1 was alert and orientated to person, place, and time. The Screening indicated that Resident 1 had bilateral (affecting to both the right and left side of the body) upper and lower extremities (part of the body) discoloration.
A Review of Resident 1 ' s Fall Risk assessment dated [DATE] at 6:50 PM, the Fall Risk Assessment indicated Resident 1 was assessed as moderate risk for falls.
During a review of Resident 1 ' s Risk for Fall Care Plan initiated 11/13/24, the Risk for Fall Care Plan indicated Resident 1 was at risk for fall related to weakness, poor safety judgment, side effects of multiple medications and requires assistance with toileting. The care plan indicated interventions including a safe environment, reachable call light and bed in low position.
During a review of Resident 1 ' s Anticoagulant (medications that prevent or reduce blood clotting) and Antiplatelet (medications that prevent blood cells called platelets from clumping together and forming clots) Care Plan, initiated 11/13/24, the Anticoagulant and Antiplatelet Care Plan indicated goals that Resident 1 would be from adverse reactions related to anticoagulant use. The care plan interventions indicated daily skin inspection and monitor for bruising and sudden changes in mental status.
During a review of Resident 1 ' s History and Physical Examination (HPE, a comprehensive physician ' s note regarding the assessment of the Patient ' s health status) dated 11/14/2024, the HPE indicated Resident 1 had fluctuating (changing frequently) capacity to understand and make decisions.
During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 11/15/2024, the MDS indicated Resident 1 had moderately impaired cognition (thought process) and required substantial/maximum assistance (helper did more than half the effort) for activities of daily living (basic tasks such as: eating, dressing, bathing, using the toilet and getting in and out of the bed or chair.
During an interview on 11/21/2024 at 9:30 AM with the Director of Nursing (DON), the DON stated Resident 1 was alert and able to answers questions appropriately and was initially assessed as moderate risk for falls. The DON stated that Resident 1 required frequent observations due to Resident 1 ' s history of dementia (neurological conditions affecting the brain that worsen over time).
During a telephone interview on 11/21/2024 at 10:01 AM with family member (FM) 2, FM 2 stated that FM 1 ' s family member reported to her on Friday, 11/15/2024 that Resident 1 reported falling on 11/13/2024 with an injury to his left elbow which was reported to registered nurse 1. FM2 stated she was not informed regarding Resident 1 falling on 11/13/24.
During an interview on 11/21/2024 at 4:32 PM with the DON, the DON stated that she forgot that the Dietary Manager (DM) reported to the DON that Resident 1 fell on [DATE] with an injury to his left elbow. The DON stated on 11/13/2024, the DON conducted a body assessment on Resident 1 and that there was no injury observed on Resident 1 ' s left elbow. The DON stated that she did not document the unwitnessed fall on 11/13/24 because there was no injury. The DON stated she did not notify the physician (MD 1) regarding the reported unwitnessed fall. The DON stated she should have notified MD 1 regarding Resident 1 ' s fall on 11/13/24 to prevent further injury.
During a telephone interview on 11/25/2024 at 10:30 AM with the DM, DM stated Resident 1 informed the DM in the afternoon of 11/13/2024 that Resident 1 fell the morning of 11/13/24. Resident 1 stated he could not reach his call light and was barely able to get back in bed. DM stated that Resident 1 could not recall what specific time he fell or the reason for attempting to get out of bed. DM stated that she immediately notified the DON and that the DON went into the room and assessed Resident 1.
During a review of the facility ' s policy and procedure (P&P) titled Change of Condition Notification revised on 1/1/2017, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner. The P&P indicated the facility would promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's legal representative when the resident endures a significant change in their condition\caused by, but not limited to: an injury/accident, a significant change in the resident's physical, cognitive, behavioral or functional status, and a significant change in treatment.
During a review of the facility ' s P&P titled Response to Falls revised 3/1/2015, the P&P indicated to ensure the facility responds quickly and appropriately to resident falls in a manner that addresses both resident ' s immediate needs and longer-term fall prevention. The P&P indicated resident experiencing the fall will be promptly assessed and treated for injuries. The P&P indicated the licensed nurse will notify the attending physician of the fall and implement any new physician orders. The P& P indicated a Licensed Nurse will document notification of physician and responsible party.

Based on observation, interview, and record review, the facility failed to properly dispose of refused or contaminated medications in a safe, and secure manner.
This deficient practice had the potential to result in misuse, drug loss, accidental exposure and/or potential diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended) of prescription drugs.
Findings:
During an observation on 5/1/24 at 11:10AM, in the presence of licensed vocational nurse (LVN)1, medication cart 1 (med cart 1) and the contents within med cart 1 was observed. The first drawer from the top of med cart 1 was observed with a blue container that had a transparent lid. The container was labeled indicating pharmaceutical waste.
During a concurrent observation and interview on 5/1/2024 at 11:12 a.m. with LVN 1, Med Cart 1's top drawer was observed. In the first drawer, there was a blue container, labeled pharmaceutical waste that had a transparent lid, that could be easily opened by lifting the lid, and closed by placing the lid back on. The pharmaceutical waste container had multiple unknown medications in it. LVN 1 stated, when the resident refused medications, or if medications fell on the floor, these medications were placed in this container and then discarded in the drug and medication biohazard (waste contaminated with potentially infectious agents or other materials that are deemed a threat to public health or the environment) bin located in the biohazard waste room. LVN 1 stated the medications inside the container labeled pharmaceutical waste were medications for the entire facility for residents who refused their medication, or for medication that fell on the floor. LVN1 could not state what all the medications were inside the pharmaceutical waste container or when the container was last emptied into the drug and medication biohazard bin.
During an interview on 5/1/2024 at 3:19 p.m., with LVN 2, LVN 2 stated, when a resident refused their medication, LVN 2 would document the refusal in the resident's chart and discard the medication into the blue container labeled Pharmaceutical Waste. LVN 2 stated the pharmaceutical waste container should be later disposed into the large biohazard waste bin each end of the shift (Day shift 7AM-3PM, evening shift 3PM-11PM, and night shift 11PM- 7AM).
During an interview on 5/1/2024 at 3:48 p.m., with the Director of Nursing (DON), the DON stated, staff would bring the controlled medications (controlled medications are substances that have an accepted medical use [medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V], have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) with the count sheet (a document used to document and track the administration of controlled substances). The DON stated the controlled medications were locked up in the DON's office until the pharmacist came to the facility. The DON stated, both the DON and the pharmacist would document in the controlled substances disposition folder. The DON stated, for non-controlled medications (medication not tightly controlled by law because it is not considered to be dangerous or to cause addiction) for residents who were discharged or transferred to the hospital, the medications were removed from medication cart, and placed into the medication room's locked cabinet, documented, and then thrown away in the biohazard bin. The DON stated licensed nurses (LN) should not use the container labeled pharmaceutical waste, located in medication cart 1's first drawer. The DON stated the method of discarding medications in the blue container labeled as Pharmaceutical Waste increases the risk for accidental exposure and diversion of prescription drugs because it was not secured and properly disposed.
During an interview on 5/3/2025 at 11:44 a.m., with LVN 4, LVN 4 stated, if a resident refused to take a medication during medication administration, LVN 4 would document the resident's refusal on the resident's medical record. LVN 4 stated putting refused medications into the labeled pharmaceutical waste container in Med cart 1's top drawer. LVN 4 could not state how long the medications in the labeled pharmaceutical waste container was there until the medications were properly discarded into the incineration bin (burns drugs and related materials rendering them to a non-retrievable state to prevent their diversion to illicit purposes). LVN 4 stated the blue container labeled Pharmaceutical Waste contained daily medications, over the counter medications, and was an accumulation from previous residents. LVN 4 stated a biohazard bin should be a proper container for safe disposal of medications.
During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications, and Medication-Related Supplies, dated October 2017, the P&P indicated, All medications are placed in the proper waste container per facility policy.
During a review of the facility's P&P titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, 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 medications disposal, and reordered from the pharmacy if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the basis for the discharge and/or the discharge summary was documented by the attending physician for one (1) of three (3) sampled residents (Resident 34).
This deficient practice resulted in incomplete records for Resident 34.
Findings:
A review of Resident 34's Face Sheet (admission record) indicated the facility admitted Resident 34 on 9/24/2014, with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke, when something blocked blood supply to part of the brain or when a blood vessel in the brain busted) affected the left non-dominant side. The admission record indicated Resident 34 was admitted to the facility on [DATE] and discharged on 10/29/2023.
A review of a document titled, Family Medicine Office/Clinic Note, dated 8/10/2023, indicated Resident 34 was alert and oriented to self, time, place, and situation. The note indicated Resident 34 was able to make daily decisions. The Note indicated Resident 34 was doing well.
A review of Resident 34's physician notes did not indicate that the physician completed a discharge summary.
During an interview with the Medical Records Staff (MRS) 1 on 12/18/2023 at 6:23 PM, the MRS 1 stated the discharge summary for Resident 34 was not completed. The MRS 1 stated the discharge summary should be initiated by the discharging nurse and printed out for the physician to sign. The MRS 1 stated upon Resident 34's discharge, the MRS 1 is supposed to make sure the discharge summary was signed.
During an interview with the Director of Nursing (DON) on 12/18/2023 at 7:01 PM, the DON stated it is the responsibility of the licensed nurse doing the resident's discharge to provide the discharge summary paper, all medications, and education to whoever is responsible for the resident. The DON stated, for death, there is no discharge summary. When asked if death was considered a discharge from facility, the DON stated No.
A review of the facility's policy and procedure titled Transfer and Discharge Planning, dated 6/1/2021 indicated a copy of the Discharge Summary and Discharge Care Plan will be maintained in the resident's medical record. The policy indicated the discharge summary will include recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness, treatment, and pertinent lab, radiology, and other consultation results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the residents' needs for seven (7) of 13 sampled residents (Resident 6, 13, 87, 4, 19, 14, and 4) by failing to:
1. Develop an individualized/person- centered care plan for Resident 6 while receiving Eliquis (blood thinner - a medication that thins the blood and could cause bruising or bleeding)
2. Develop an individualized/person-centered care plan with goals and interventions for Resident 13 who has a diagnosis of type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) while receiving insulin.
3. Develop an individualized/person- centered care plan for Resident 87 who has a diagnosis of type 2 diabetes mellitus while receiving insulin and Aspirin (a medication that prevents blood clot to form).
4. Developed a plan of care for Resident 4 for management of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and a care plan to monitor the resident for side effects and specific behaviors to monitor for the use of Paxil (a medication used to treat depressive disorder and anxiety [having the fear of the unknown]) as ordered by the physician.
5. Developed a plan of care to monitor Resident 19, for the side effects of Aspirin (a medication that prevent the blood clots to form which could lead to serious bleeding and bruising) used for prophylaxis (action taken to prevent disease) and Depakote (also known as Divalproex Sodium- an anticonvulsant [prevent epilepsy or abnormal brain activity], medication to used treat seizure disorders and manage bipolar disorder (mental illness causes extreme mood swings that include emotional highs [mania] or emotional lows [hypomania or depression]) as ordered by the physician.
6. Developed a plan of care to monitor Resident 14 for side effects of Aspirin as ordered by the physician.
7. Developed a plan of care for Resident 7 to manage Diabetes Mellitus (a group of diseases that affect how the body uses blood sugar [glucose]), and the use of Insulin (an essential hormone that helps the body turn food into energy and controls by lowering glucose levels in the body).
These deficient practices had the potential for the residents to not receive appropriate care treatment and/or services to achieve their highest potential.
Findings:
1. During a review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 4/30/2023 with diagnoses that included paroxysmal atrial fibrillation (irregular and often faster heartbeat) and type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/18/2023, the MDS indicated, Resident 6's cognition for daily decision making was intact. The MDS indicated, Resident 6 required moderated assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene.
During a review of Resident 6's Physician Order, dated 4/30/2023, indicated to administer Eliquis oral tablet 5 milligrams (mg-unit of measurement) one tablet by mouth, twice daily for paroxysmal atrial fibrillation.
During a concurrent interview and record review on 12/16/2023 at 12:10 pm with the facility's Director of Nursing (DON), Resident 6's medical record was reviewed. The DON stated there was no other clinical documentations that a CP was developed for Resident 6 who was on Eliquis therapy. The DON stated care plan should have been developed and implemented for the management of Eliquis to ensure Resident 6 receive the proper care and effective interventions from the nursing staff as needed.
2. During a review of Resident 13's admission record indicated, the facility admitted Resident 13 on 4/14/2023 with diagnoses that included type 2 DM and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning).
During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13's cognition for daily decision making was intact. Resident 13 required moderated assistance with toileting, shower, and lower body dressing.
During a review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar Kwik Pen insulin (Insulin Glargine - long-acting insulin [a hormone that works by lowering levels of sugar in the blood]) 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for type 2 DM.
During a concurrent interview and record review on 12/16/2023 at 12:15 pm with the facility's DON, Resident 13's medical record was reviewed. The DON stated there was no clinical documentations that CP was developed and implemented for Resident 13 who has a type 2 DM and receiving insulin therapy. The DON stated a care plan should have been developed and implemented for the management of diabetes for Resident 13 to ensure the resident receive the proper care and effective interventions from the nursing staff as needed.
3. During a review of Resident 87's admission record indicated, the facility admitted Resident 13 on 12/8/2023 with diagnoses that included type 2 DM and long term use of insulin (a hormone that helps control your body's blood sugar level) use.
During a review of Resident 87's History and Physical (H&P), dated 12/11/2023, indicated Resident 87 did not have the capacity to understand and make decisions.
During a review of Resident 87's Physician Order, dated 11/10/2022, indicated to
administer Humulin R (type of insulin) subcutaneously per sliding scale coverage (progressive increase in the insulin dose, based on pre-defined blood glucose ranges) before meals and at bedtime for diabetes.
During a review of Resident 87's Physician Order, dated 12/08/2022, indicated to
Administer Aspirin tablet 81 milligrams (mg) one tablet by mouth, in the evening for Cerebrovascular Accident (CVA, death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) prophylaxis (prevention) with dinner.
During a concurrent interview and record review on 12/16/2023 at 12:28 pm with the facility's DON, Resident 87's medical record was reviewed. The DON stated there was no other clinical documentations that CP was developed and implemented for Resident 87 with a diagnosis of type 2 diabetes mellitus and receiving insulin therapy. The DON stated a care plan should have been developed and implemented for Resident 87 for the management of diabetes to ensure the resident receive the proper care and effective interventions from the nursing staff as needed.
During a review of the facility's Policy and Procedure (P&P) titled, Care Planning, revised 10/24/2022, indicated the facility's Interdisciplinary Team (IDT) will develop a Baseline and/or Comprehensive Care Plan for each resident.
4. A review of Resident 4's Facesheet (a document that gives a patient's information at a quick glance) indicated an admission to the facility on 9/8/2022 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affection left non-dominant side, dysphagia (difficulty swallowing), and major depressive disorder.
A review of Resident 4's History and Physical assessment dated [DATE], indicated Resident 4 had previous medical history of age-related cognitive decline (natural process in which older adults typically experience decline in many functions, such as memory, thinking, concentration).
A review of Resident 4's Order Summary Report dated 9/8/2022, indicated a physician order was made for Paxil Oral Tablet 10 milligrams (mg-a unit of measure) give 1 tablet by mouth at bedtime related to major depressive disorder, single episode, severe without psychotic (psychosis, refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality) features, manifested by verbalization of sadness. Resident 4's Order Summary indicated to monitor behavior for verbalization of sadness every shift for Paxil use.
During a concurrent interview and record review of Resident 4's care plans on 12/17/2023 at 10:42 AM, the Director of Nursing (DON) stated there was no documented evidence that indicated how Resident 4 was monitored for the use of Depakote and management of major depressive disorder. The DON stated it was important to have a care plan to know how to take care of the resident. The DON stated it was her fault the care plans were not transferred from the old documentation software (computerized charting) to the new documentation software they are currently using.
5. A review of Resident 19's Facesheet indicated an admission to the facility on 4/15/2022 with diagnoses that included transient cerebral ischemic attack (stroke, occurs when the blood supply to part of the brain is briefly interrupted), hypertensive heart disease (problems with heart that can develop because of high blood pressure that is present over a long time) with heart failure (also known as congestive heart failure, a condition that develops when the heart doesn't pump enough blood for your body's needs) and bipolar disorder.
A review of Resident 19's History and Physical assessment dated [DATE] indicated Resident 19 had age-related cognitive decline.
A review of Resident 19's Order Summary Report:
a. Dated 11/01/2023, indicated the physician ordered Resident 19 to receive chewable Aspirin 81 mg, one oral (given by mouth) tablet time a day for cerebrovascular accident (CVA, stroke) prophylaxis (prevention).
b. Dated 7/27/2023, indicated the physician ordered Resident 19 to receive an anticoagulant (blood thinner)/Aspirin medication and to monitor the resident for discolored urine, black tarry stools, sudden severe headache, nausea & vomiting, diarrhea, muscle joint pain, lethargy (lack of energy and enthusiasm), bruising, sudden changes in mental status, shortness of breath and nosebleed, every shift.
c. Dated 7/27/2023, indicated the physician ordered Resident 19 to receive Depakote Delayed Release 125 mg, one oral tablet, three times a day related to bipolar disorder, manifested by irritable mood with hallucinations (a false perception of objects or events involving your senses: sight, sound, smell, touch, and taste) seeing people from past.
d. Dated 7/27/2023, indicated the physician ordered to monitor Resident 19 for behavior related to Depakote use that included: irritable mood with hallucinations seeing people from past, every shift, related to bipolar disorder.
During a concurrent interview and record review of Resident 19's care plans on 12/17/2023 at 10:45 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 19 was monitored for the use of Aspirin and the use of Depakote.
6. A review of Resident 14's Facesheet indicated an admission to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, aftercare following explanation of shoulder joint prosthesis (a device designed to replace a missing part of the body or to make a part of the body work better), and unspecified atrial fibrillation (an abnormal heartbeat).
A review of Resident 14's History and Physical assessment dated [DATE] indicated Resident 14 had the capacity to understand and make decisions.
A review of Resident 14's Order Summary Report:
a. Dated 12/02/2023, indicated the physician ordered Resident 14 to receive chewable Aspirin 81 mg one tablet by oral, two times a day for CVA prophylaxis.
b. Dated 11/30/2023, indicated the physician ordered to monitor Resident 14 for signs and symptoms of bruising/bleeding and to monitor for signs and symptoms of thromboembolism (occurs when a blood clot breaks off and blocks another blood vessel) every shift for Aspirin use.
During a concurrent interview and record review of Resident 14's care plans on 12/17/2023 at 10:47 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 14 was monitored for the use of Aspirin.
7. A review of Resident 7's Facesheet indicated an admission to the facility on 6/29/2023 with diagnoses that included cerebral infarction (stroke), surgical aftercare following surgery on the digestive system and type 2 diabetes mellitus (chronic condition that happens when one has persistently high blood sugar levels) without complications.
A review of Resident 7's History and Physical assessment dated [DATE] indicated Resident 7 did not have the capacity to make her own decisions.
A review of Resident 7's Order Summary Report, dated 10/12/2023, indicated the physician ordered Resident 7 to receive NovoLOG (rapid-acting insulin that lowers the blood sugar level) FlexPen Subcutaneous (injection with a syringe and needle under the skin) Solution Pen-Injector 110 UNIT/ML, inject as per sliding scale: if 150-200 = 1 unit; 201-250= 2 units; 251-300=3 units; 301-350= 4 units; 351-400= 5 units; >400= 6 units, call physician if blood sugar (BS) > 400 or <60, given subcutaneously before meals and at bedtime.
During a concurrent interview and record review of Resident 7's care plans on 12/17/2023 at 10:50 AM, the DON stated there was no documented evidence of a care plan that indicated how Resident 7 was monitored for the use of insulin and how Resident 7's diabetes was being managed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure, consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe], performed when the heart stops beating or beats ineffectively and/or to restore breathing), and call 911 (emergency services and/or emergency transfer to the general acute care hospital) for one (1) of three (3) sampled residents (Resident 34), who had a full code status (when resident's heart stopped beating and/or the resident stopped breathing, the resident or his/her representative wished for all lifesaving procedures to be provided to keep the resident alive) by failing to:
1. Ensure Licensed Vocational Nurse (LVN) 1 started CPR on [DATE] at around 11 AM when LVN 1 found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment (POLST, a written medical order that indicated a patient/resident lifesaving treatment wishes), Medical Emergencies- Code Blue (an announcement used to indicate a patient/resident requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a cardiac arrest [the heart stopped beathing/pumping blood) or respiratory arrest [the lungs stopped working/breathing]), and Emergency Care - General.
2. Ensure Registered Nurse (RN) 1 started CPR immediately, provided full CPR with rescue breathing (inhaling into the patient's/resident's airway and lungs using mouth-to-mouth breathing or mechanical breathing), and sent LVN 1 to call 911 after RN 1 entered Resident 34's room on [DATE] at 11:02 AM, and found Resident 34 unresponsive, in accordance with the facility's policies titled, Physician Orders For Life Sustaining Treatment, Medical Emergencies- Code Blue, and Emergency Care - General.
As a result, on [DATE], Resident 1 did not receive immediate and full CPR with rescue breathing as indicated in Resident 34's POLST that Resident 34 wished to be resuscitated (to revive [restore to life] from apparent death or from unconsciousness or provided with CPR, to prolong life by all medically effective means). RN 1 pronounced Resident 34 expired on [DATE] at 11:02 AM and informed Resident 34's Attending Physician (Physician 1) on [DATE] at 11:06 AM that Resident 34 had expired.
On [DATE] at 8:47 PM, while onsite at the facility, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation have caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified. The surveyor notified the Administrator (ADM) and the Director of Nursing (DON), regarding the facility's failure to provide basic life support (BLS, the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway), including immediate, full CPR with rescue breathing, and call 911 for Resident 34, who had a full code status on [DATE] at 11:02 AM, and the risk for 20 other residents who were residing in the facility with full code status not receiving immediate and full CPR when those residents' hearts stopped beating and or when they stopped breathing. The IJ was called in the presence of the facility's ADM and DON.
On [DATE], at 11:45 AM, the facility submitted an acceptable IJ Removal Plan ([Plan of Action] a list of steps taken to correct the deficient practices). The IJ was removed on [DATE] at 5:12 PM, in the presence of the facility's ADM and DON, while onsite at the facility, after the surveyor verified and confirmed the facility's approved IJ Removal Plan (a detailed plan to address the IJ findings) was fully implemented through observations, interviews, and record reviews, in a manner that eliminated the likelihood of serious injury, serious harm, serious impairment, or death with 20 other residents residing in the facility with full code status.
The acceptable IJ Removal Plan, dated [DATE] included the following:
a. On [DATE], the Director of Staff Developer (DSD) created the BLS (Basic Life Support) Skills Competency Checklist about Code Blue situation. The DSD would provide the in-service about the BLS and Cod Blue situation to LVN 1 by [DATE] after LVN 1 returned from vacation.
b. On [DATE], the DON initiated the in-service education for all Licensed Nurses (LVNs and RNs) from three shifts (morning [7 AM to 3 PM,] evening [3 PM to 11 PM,] and night shifts [11 PM to 7 AM,] on Emergency Care Policy, CPR and calling 911.
c. On [DATE], the DSD and the DON initiated the BLS Skills Competency checklist for 15 Licensed Nurses and 16 Certified Nurses Assistants (CNAs) with a target completion date of [DATE]. The BLS Skills Competency Checklist would be completed once a week for four (4) weeks, once a month for three (3) months, then quarterly for one year.
d. On [DATE], the DON initiated in-service education for all licensed nurses (in general) who worked on [DATE] for the morning, evening, and night shifts on the facility's policy and procedure [NAME], Change of Condition Notification, for residents who have no pulse, unresponsive, and have undetected vital signs (clinical measurements, specifically pulse rate [number of heart beat per minute], temperature [a measurement of the body making and releasing heat], respiration rate [number of breaths per minute], and blood pressure [the force of the blood pushing against the walls of the arteries/blood vessels]). Any nursing staff (RNs, LVNs and CNAs in general) who did not complete the BLS Skills Competency checklist by [DATE] would not be scheduled to work until they completed the in-service education for the BLS Skills Competency Checklist.
e. On [DATE], the DSD initiated weekly mock (simulation/pretend) code blue medical emergency drills for 4 weeks to monitor nursing staff's (in general) compliance with the facility's Emergency Care policy.
f. On [DATE], the DON completed the BLS Skills Competency Checklist about Code Blue situation that was created by the DSD for RN 1.
g. On [DATE], Medical Record Staff (MRS) 1 completed the audit of all Active Resident POLST forms and uploaded the forms into the online documentation software for electronic medical records for quick reference.
h. On [DATE], outside BLS Trainer with BLS instructor credentials from the American Heart Association initiated First Aid CPR training for RNs, LVNs, and CNAs (in general). The BLS trainer would be completed the CPR training for all nursing staff from 3 shifts (morning, evening, and night shifts) by [DATE].
Findings:
A review of Resident 34's Face Sheet (admission record) indicated the facility admitted Resident 34 on [DATE], with diagnoses that included hemiplegia (paralysis/loss of the ability to move of one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (stroke, when something blocked blood supply to part of the brain or when a blood vessel in the brain busted) affected the left non-dominant side.
A review of a document titled, Family Medicine Office/Clinic Note, dated [DATE], indicated Resident 34 was alert and oriented to self, time, place, and situation. The note indicated Resident 34 was able to make daily decisions. The Note indicated Resident 34 was doing well.
A review of Resident 34's Physician Orders for Life Sustaining Treatment (POLST) dated [DATE], and signed by Resident 34, indicated under Cardiopulmonary Resuscitation (If patient has no pulse and not breathing, showed a handwritten check mark on Attempt/Resuscitation/CPR. The POLST indicated under Medical Interventions showed a check mark on Full Treatment (primary goal of prolonging life by all medically effective means.
A review of Resident 34's Progress Notes dated [DATE] timed at 12:53 PM, authored by RN 1 indicated the following events:
- At 7 AM, Resident 34 was alert and able to make needs known. The progress note indicated The resident's RR (respiratory rate) was even and unlabored (produced without difficulty or exertion). No SOB (shortness of breath) noted at this time. The resident denied pain. There is no distress noted at this time. The resident is resting comfortably in bed. The resident's VS (vital signs): 98/60 (blood pressure), 61 (pulse rate), 97.8 (temperature), 19 (respiratory rate), PS (pain status): 0/10 (0 equal no pain, 10 equal the worst pain). The resident's oxygen saturation (oxygen level in the blood; 95% to 100% are generally considered normal) was 96%.
- At 9 AM, Resident 34 was alert and able to make needs known. The note indicated There is no distress noted at this time.
- At 10 AM, Resident (34) was alert and able to make needs known. The resident's RR was even and unlabored. No SOB noted at this time. The note indicated the resident is resting comfortably on the bed at this time.
- At 11:02 AM, Resident 34 was noted to look pale. The RN could not detect the resident's pulse and blood pressure. The RN pronounced the resident expired at 11:02 AM.
- At 11:06 AM, RN 1 notified the resident's primary doctor. The note indicated RN 1 received new order to endorse the resident's body to the mortuary service (as) requested by the family.
During an interview with RN 1 and a concurrent review of Resident 34's Progress Notes dated [DATE] timed at 11:02 AM, on [DATE], at 2:49 PM, RN 1 stated on [DATE], when RN 1 entered Resident 34's room, RN 1 checked Resident 34's pulse and blood pressure. RN 1 stated Resident 34 had no vital signs on [DATE]. RN 1 stated Resident 34 looked pale, not responsive, but Resident 34's body was warm to touch. RN 1 stated RN 1 attempted CPR but RN 1 did not call 911 because Resident 34 had expired. RN 1 stated when the vital signs were not detected in a resident (in general), RN 1 would not call 911. RN 1 stated RN 1 attempted to perform CPR on Resident 34, but he did not document that he attempted the CPR on Resident 34 in Resident 34's Nurses Notes.
During a continued interview with RN 1 on [DATE] at 3:03 PM, RN 1 stated that on [DATE], RN 1 was alone when RN 1 went into Resident 34's room. RN 1 stated RN 1 did not see Resident 34's chest rose, and Resident 34 looked pale, on [DATE]. RN 1 stated RN 1 tried to get Resident 34's vital signs, on [DATE] but RN 1 could not get any vital signs. RN 1 stated RN 1 left Resident 34's room to check on Resident 34's POLST and immediately went back to Resident 34's room and started to perform CPR by himself. RN 1 stated at the time, Resident 34's skin color looked gray. RN 1 stated, RN 1 performed chest compressions for five minutes. RN 1 stated There was no pulse or vitals, the patient's (Resident 34's) vital signs were gone.
During a telephone interview with LVN 1 on [DATE] at 3:05 PM, LVN 1 stated on [DATE] (did not remember exact time) about 30 minutes prior to finding Resident 34 unresponsive, Resident 34 was alert and awake. LVN 1 stated LVN 1 found Resident 34 unresponsive and LVN 1 notified RN 1. LVN 1 stated they (RN 1 and LVN 1) assessed Resident 34 and the resident had no pulse, no blood pressure, nothing. LVN 1 stated Resident 34 was a full code, and they (RN 1 and LVN 1) did not perform CPR on Resident 34. LVN 1 stated LVN 1 did not see RN 1 performed CPR on Resident 34 and they (LVN 1 and RN 1) did not call 911. LVN 1 did not respond when asked why LVN 1 did not perform CPR for Resident 34 knowing Resident 34 was a full code.
During an interview with the DON on [DATE], at 3:07 PM, the DON stated when a resident had a full code status, facility staff (in general) needed to attempt CPR, and call 911. The DON stated it was important to call 911 due to the paramedics (medical professionals who specializes in emergency treatment) might be able to revive Resident 34. The DON stated, Full code means you call 911 and at least you try to save the patient (resident).
During another interview with RN 1 on [DATE] at 3:28 PM, RN 1 stated on [DATE] (did not state the time) before RN 1 attempted CPR on Resident 34, RN 1 called a code blue but there was nobody (no staff available). RN 1 stated LVN 1 was in Resident 34's room helped RN 1 with putting the papers. RN 1 stated LVN 1 helped immediately, but RN 1 could not recall exactly what LVN 1 did during that time. RN 1 stated after 5 minutes of performing CPR on Resident 34, RN 1 notified Physician 1 that Resident 34 had expired.
During an interview with Certified Nursing Assistant (CNA) 1 on [DATE] at 3:28 PM, CNA 1 stated she was assigned to Resident 34 and was on lunch break on [DATE] (did not remember the time), when RN 1 found Resident 34 unresponsive. CNA 1 stated when she returned from lunch break, Resident 34 had already expired. CNA 1 stated she did not recall any code blue being called on [DATE].
During a telephone interview with CNA 2 on [DATE] at 4:22 PM, CNA 2 stated she worked on [DATE] (with CNA 1) during the 7 AM to 3 PM shift. CNA 2 recalled that on [DATE] (did not remember exact time), during the morning shift, Resident 34 was alert and awake. CNA 2 stated on [DATE], none of the facility's staff called a Code Blue.
During a telephone interview with Resident 34's family member (Family) 1 on [DATE] at 4:25 PM, Family 1 stated Resident 34 changed Resident 34's POLST around a month before Resident 34 passed away to full code status. Family 1 stated Resident 34 wished to receive full medical treatment including CPR.
During a concurrent review of Resident 34's Progress Notes, dated [DATE], timed 11:02 AM, and interview with the DON on [DATE] at 5:03 PM, the DON stated a physician (in general) needed to pronounce Resident 34 expired and not RN 1. The DON stated RN 1 should have called 911 and 911's staff (paramedics) would pronounce when Resident 34 expired. The DON stated the paramedics needed to check if there was no more life or if they (the paramedics) can provide Advance Life Support (ALS, referred to as Advanced Cardiac Life Support [ACLS], was a set of life-saving protocols and skills that extend beyond BLS) to revive Resident 34, especially Resident 34 had a full code status.
During another interview with RN 1 on [DATE] at 5:12 PM, RN 1 stated he needed to call 911 and performed CPR until the physician (in general) pronounced the resident's death. RN 1 stated he could not recall how many chest compressions he performed and RN 1 stated he did not use a bag valve mask (BVM, a type of device known as a bag valve mask, used to provide respiratory support to patients/residents) to provide rescue breathing, RN 1 stated I just try to pump her heart.
During a telephone interview on [DATE] at 5:24 PM with Physician 1, who was also the facility's Medical Director, stated that the expectation for the licensed nurses during emergency situations was to perform CPR for full code residents and someone is delegated to call the attending physician or 911. Physician 1 stated it was acceptable for licensed nurses to call 911 first before calling the physician if the resident was not breathing. Physician 1 stated they (licensed nurses) do have the ability to call 911 . for a full code resident.
During a concurrent interview and record review on [DATE] at 6:01 PM. The facility's policy and procedure titled, Emergency Care, dated [DATE] (the current policy and procedure provided by the facility), indicated for staff to immediately call 911 for medical emergency assistance during an emergency. The DON stated during emergency situations, facility's staff (in general) needed follow the facility's policy. The DON stated 911 emergency services needed to be called when Resident 34 was not breathing, pulseless, and/or unresponsive, to get help from the paramedics and preserve Resident 34's life.
A review of the facility's policy and procedure titled, Emergency Care - General, revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to give emergency treatment to residents .to prevent further harm, and promote recovery. The policy indicated for facility's staff to determine the nature of the injury/illness .and to summon help and immediately call 911 for medical emergency assistance. The policy indicated these emergency situations would include but are not limited to Cessation of breathing (stop breathing), blockage of airway, pulseless victim .new onset of unconsciousness or unresponsiveness to verbal or physical stimuli. The policy indicated the licensed nurse's role during a code blue included to lead the code blue in the absence of a physician and coordinate the resuscitation efforts until paramedics arrive. The policy indicated that the licensed nurse would assure that . CPR has been initiated, 911 had been called, code blue had been paged overhead, and emergency cart was on the scene.
A review of the facility's policy and procedures titled, Medical Emergencies- Code Blue, revised on [DATE] (the current policy and procedure provided by the facility), indicated the following information:
1. The first of facility personnel to arrive and find a resident with any of the above condition . that included Respiratory or Cardiac arrest, should call for help.
2. Send available staff to call a Code Blue and retrieve emergency medical equipment:
3. Assess the resident's level of consciousness, circulation, airway, and breathing; begin CPR according to current practice.
A review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST), revised on [DATE] (the current policy and procedure provided by the facility), indicated the purpose of the policy was to help ensure that Facility honors residents' treatment wishes concerning resuscitation and life sustaining treatment. The policy indicated The POLST is a voluntary form used statewide as a physician order form that converts a resident's wishes regarding life-sustaining treatment and resuscitation into physician orders. The policy further indicated A valid POLST form is to be honored across treatment settings.
A review of the facility's policy and procedure titled Change of Condition Notification, revised on [DATE] (the current policy and procedure provided by the facility), indicated the definition of an acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. The policy indicated If the resident deteriorates, the symptoms are serious, and the most rapid intervention available by a physician would place the resident in great jeopardy, call 911 for transport to hospital.
A review of the American Heart Association CRP & First Aid Emergency Cardiovascular Care website titled, Algorithms, for the year of 2023, the website indicated for adults, look for no breathing or only gasping and check pulse (simultaneously) and if pulse is felt within 10 seconds with no normal breathing, then to provide rescue breathing, one (1) breath every six (6) seconds or 10 breaths per minute, check pulse every two (2) minutes and if no pulse, start CPR. The website indicated, when CPR is started, perform cycles of 30 chest compressions and two (2) breaths and resume CPR cycles until an ALS provider arrived over or the victim started to move.
[https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms#adult]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed prevent unnecessary use of medication for three of five sampled residents (Resident 6, Resident 88, and Resident 7) who were not assessed and monitored for complications related to anticoagulant therapy (a medication prevent or delays blood clot to form, also known as blood thinner ) such as bleeding and bruising as indicated in the facility's policy and procedure titled, Anticoagulation Therapy Fact Sheet and the residents plan of care.
This deficient practice had the potential to result in Resident 6, Resident 88, and Resident 7's to have undetected bruising and bleeding which could result in blood loss and bleeding in the brain and other major organs to bleed without immediate interventions and lead to a decline in the resident's wellbeing.
Findings:
1. During a review of Resident 6's admission Record, indicated the facility admitted Resident 6 on 4/30/2023 with diagnoses that included paroxysmal atrial fibrillation (irregular and often faster heartbeat) and type 2 diabetes mellitus (DM - a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/18/2023, the MDS indicated, Resident 6's cognition for daily decision making was intact. The MDS indicated, Resident 6 required moderated assistance (resident participate in the care) with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene.
During a review of Resident 6's Physician Order, dated 4/30/2023, indicated to administer Eliquis (an anticoagulant) 5 milligrams (mg) one tablet by oral (by mouth), twice daily for paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days).
During a concurrent interview and record review on 12/16/2023 at 12:19 pm, the facility's Director of Nursing (DON) Resident 6's medical record was reviewed. The DON stated there was no other clinical documentation that Resident 6 was assessed or monitored for side effects of anticoagulant use. The DON stated residents who were receiving anticoagulants should be assessed and monitored for signs and symptoms of bleeding because the residents could easily get skin discoloration or bleed easily.
2. During a review of Resident 88's admission Record, indicated the facility admitted Resident 88 on 12/13/2023 with diagnoses that included unspecified systolic heart failure (a condition that develops when heart doesn't pump enough blood for your body's needs) and hypertension (high blood pressure).
During a review of Resident 88's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/17/2023, the MDS indicated, Resident 88's cognition for daily decision making was intact. Resident 88 required moderated assistance with oral hygiene, toileting hygiene, upper and lower body dressing, and personal hygiene.
During a review of Resident 88's Physician Order, dated 12/13/2023, indicated to administer Eliquis oral tablet 5 mg one tablet by mouth, twice daily to the resident for unspecified systolic heart failure.
During a review of Resident 88's Care Plan titled, Anticoagulant Therapy, initiated on 12/13/2023, indicated Resident 88 was receiving anticoagulant therapy. The interventions indicated the nursing staff will monitor/document/report as needed adverse reactions (undesired effect) of anticoagulant therapy: blood tinged or red blood urine, black tarry stools, dark or bright red stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (sleepiness or deep unresponsiveness), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs and daily skin inspection and report abnormalities.
During a concurrent interview and record review on 12/16/2023 at 12:28 pm, the facility's Director of Nursing (DON) Resident 88's medical record was reviewed. The DON stated there was no clinical documentations that indicated Resident 8 was assessed or monitored for side effects of anticoagulant use. The DON stated, Residents 88 was on anticoagulant and resident should be assessed and monitored for signs and symptoms of bleeding because the residents could easily get skin discoloration or bleed easily.
A review of the facility's policy and procedure titled, Anticoagulant Therapy Fact Sheet, revised June 2018, the P&P indicated, the licensed nurse should regularly inspect the patient or resident receiving oral anticoagulants and regularly inspect the patient from bleeding gums, bruises, melena (presence of blood in the stool), tarry stools. hematuria (presence of blood in the urine), and hematemesis (presence of blood in the emesis or vomit).
3. A review of Resident 7's Face sheet indicated an admission to the facility on 6/29/2023 with diagnoses that included cerebral infarction (stroke or interruption of blood flow to the brain due to blood clot or bleeding), surgical aftercare following surgery on the digestive system and type 2 diabetes mellitus (chronic condition that happens when one has persistently high blood sugar levels) without complications.
A review of Resident 7's History and Physical assessment dated [DATE] indicated Resident 7 did not have the capacity to make her own decisions.
A review of Resident 7's Order Summary Report, dated 12/14/2023, indicated the physician ordered Resident 7 to receive Eliquis (also known as Apixaban- a medication that prevent or delays blood clot formation or blood thinner) one 5 milligrams (mg, unit of measure) tablet given by oral (by mouth) by mouth two times a day for bilateral (both sides) DVT and to monitor Resident 7 for signs and symptoms of bruising/bleeding, and thromboembolism (obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation).
During a concurrent interview and record review of Resident 7's Medication Administration Record (MAR) with the Director of Nursing (DON) on 12/17/2023 at 11:22 AM, the DON stated she could not find documented evidence in the MAR for 12/14/2023 and 12/15/2023, that licensed nurses monitored the resident for adverse reaction of Eliquis such as bleeding/bruising. The DON stated the use of Eliquis should be monitored for Resident 7 for any discoloration, bruising, and bleeding.

Based on observation, interview, and record review, during the medication administration, the facility staff failed to ensure the opened (in-use) Basaglar KwikPen insulin (Insulin Glargine - long-acting insulin- a hormone that works by lowering levels of sugar in the blood) was marked with the date opened for one of four resident (Resident 13) as indicated in the facility policy.
This deficient practice had the potential for Resident 13 to receive Basaglar KwikPen insulin (insulin pen) with less efficacy or adverse reaction (not desired effect) of insulin.
Findings:
A review of Resident 13 ' s admission record, indicated the facility admitted Resident 13 on 4/14/2023, with diagnoses that included Type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning).
During a review of Resident 13 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13 ' s cognition for daily decision making was intact.
A review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar KwikPen, 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for Type 2 diabetes mellitus.
During a concurrent medication pass observation and interview on 12/17/2023, at 9:50 am, together with License Vocational Nurse (LVN) 2, upon inspection one Basalgar KwikPen was opened but not dated as to when it was first opened and used. LVN 2 stated it was important to label the insulin pen with an open date to know the medication was still effective. LVN 2 stated that based on the facility ' s
policy, every insulin should be labeled with an open date and should be discarded after 28 days.
During an interview on 12/17/2023 at 10:07 am, the facility ' s Director of Nursing (DON), stated that medications should be labeled with the open date. The DON stated that the efficacy and potency of the medication will be affected because Insulin will expire in 28 to 30 days based on the insulin storage guide from the pharmacy.
During a review of the facility's policy and procedure (P&P) titled, Specific Medication Administration Procedures, dated 8/2008, indicated to check expiration date on package/container. The P&P indicated when opening a multi-dose container, place the date on the container.
During a review of the pharmacy guide for Insulin storage, dated 8/25/2023, indicated Insulin Glargine 100 units/ml Pen, once in use discard unused portion after 28 days.
During a review of the Humalog KwikPen's manufacturer's literature revised in 11/2023, indicated Do not use your Pen past the expiration date printed on the Label or for more than 28 days after you first start using the Pen. https://uspl.lilly.com/basaglar/basaglar.html#ug0

Based on observation, interview and record review, the facility failed to follow it's policy and procedure on storing, preparing, distributing and serving food in accordance with professional standards for food service safety, proper sanitation and food handling practices by failing to ensure the Kitchen Aide (KA 1) 1 was wearing a hair net while cleaning the food preparation area.
These deficient practices had the potential for residents to be at risk for contracting food borne illnesses (infections or irritations of the gastrointestinal tract caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals).
Findings:
During an initial tour of the kitchen on 12/15/2023 at 7:19 pm, KA 1 was observed not wearing a hairnet or hair cover while cleaning the food preparation area. KA 1 stated, he forgot to wear the hairnet while in the kitchen. KA 1 stated it was important to wear a hairnet to prevent hair from falling into the kitchen utensils in the food preparation area.
During an interview on 12/16/2023 at 11:49 am, the Head [NAME] (HC) stated, before entering the kitchen the staff should wear a hair net or cap because hair might fall in the food or kitchen utensils.
During an interview on 12/16/2023 at 11:50 am, the Dietary Supervisor (DS) stated hairnet should be always worn by staff while inside the kitchen. The DS stated, the staff's hair could fall or drop in the food, or kitchen utensils if staff were not wearing hairnet or hair covered when preparing food and contaminate the food and cause food borne illnesses.
During a review of the facility's P&P titled, Dietary Department, General, revised on 10/24/2023, the P&P indicated, food service staff must wear hairnets when cooking, preparing, or assembling food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide safe, and sanitary environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of six sampled residents (Resident 19, 4, 13, 86 and 87) as indicated int facility's policy and procedure, titled Cleaning and disinfection (process of removing disease causing organism) of Resident Care Equipment.
The facility failed to:
1. Sanitize (disinfect something with a chemical, in order to destroy bacteria) the sphygmomanometer (BP [blood pressure] cuff-equipment used to measure blood pressure) cuff and the stethoscope (a medical device use for listening to the internal sounds of the human body) before and after used, between Resident 19 and Resident 4 as indicated in the facility's policy,
2. Sanitize the glucometer (a small, portable device that lets you check your blood sugars (glucose levels) for Resident 13 before and after each use.
3. Ensure Resident 86 and Resident 87's Nasal Cannula (NC) tubing (a plastic tubing used to deliver oxygen to the nares [opening in the nose]) was labeled with the date as indicated in the facility's policy and procedure Oxygen Administration.
These deficient practices had the potential to result in cross contamination of disease-causing organisms (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and result in a widespread infection in the facility.
Findings:
1. During a review of Resident 4's admission Record, indicated the facility admitted Resident 4 on 9/8/2022 with diagnoses that included hypertension (high blood pressure).
During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/1/2023, the MDS indicated Resident 4 required supervision with bed mobility (how resident moves to and from lying position), transfer, oral hygiene, toilet use and personal hygiene.
During a medication pass observation, on 12/17/2023 at 8:16 am, the Licensed Vocational Nurse 2 (LVN 2) did not sanitize the BP cuff and the stethoscope (a device used to listen to the heartbeat or pulse and lung sounds) after using to check Resident 4's BP and pulse.
During a medication pass observation, on 12/17/2023 at 8:52 am, the LVN 2 did not sanitize the BP cuff and the stethoscope before using for Resident 19.
During a review of Resident 19's admission Record, indicated the facility admitted Resident 19 on 4/15/2022 with diagnoses that included hypertensive heart disease (a range of conditions that affect the heart) with heart failure (heart disease that affects pumping action of the heart muscle).
During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 required extensive assistance with one person assist with bed mobility (how resident moves to and from lying position), transfer, oral hygiene, toilet use and personal hygiene.
During an interview on 12/17/2023 at 8:53 am with the LVN 2, the LVN 2 stated all equipment should be sanitized before and after each residents use. The LVN 2 stated, it was important to sanitize equipment before and after using between residents to prevent the spread of infection.
During an interview on 12/17/2023 at 10:07 am with the facility's Director of Nurses (DON), the DON stated the staff should disinfect or sanitize (clean something with a chemical to destroy bacteria) all equipment used in between residents. The DON stated, staff needed to disinfect or clean equipment before and after use to prevent cross contamination.
2. During a review of Resident 13's admission record indicated, the facility admitted Resident 13 on 4/14/2023 with diagnoses that included type 2 DM Diabetes Mellitus (a condition of having high blood sugar) and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning).
During a review of Resident 13's Physician order, dated 10/19/2023, indicated to inject Basaglar Kwik Pen insulin (Insulin Glargine - long-acting insulin [a hormone that works by lowering levels of sugar in the blood]) 28 units subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) one time a day for type 2 DM.
During a review of Resident 13's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/10/2023, the MDS indicated, Resident 13's cognition for daily decision making was intact. Resident 13 required moderated assistance with toileting, shower, and lower body dressing.
During a medication pass observation on 12/17/2023 at 9:46 am, LVN 2 did not sanitize the glucometer prior to testing Resident 13's blood sugar level. LVN 2 stated, the glucometer should have been disinfected before and after use, to make sure it was clean, because there might be a splash of blood in the glucometer.
During an interview on 12/17/2023 at 10:09 am with the facility's DON, the DON stated there might be a splash of blood in the glucometer if it was not disinfected before using. The DON stated, the staff needed to disinfect or clean equipment before and after use to prevent cross contamination.
During a review of the facility's P&P titled, Cleaning and disinfection of Resident Care Equipment, revised on 5/1/2017, indicated reusable items (equipment that is designated reusable by more than one resident) are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment).
3a. During a review of Resident 86's admission Record, indicated the facility admitted Resident 86 on 12/13/2023 with diagnoses that included acute respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in the body tissues).
A review of Resident 86's Physician Order's, dated 12/13/2023, indicated to administer oxygen at two (2) liters per minute (L/min) via nasal cannula (a device with two prongs that sit below the nose used to deliver supplemental oxygen directly into the nostrils) to keep oxygen saturation (a percent of blood cells carrying oxygen in the body) 90% and above every eight hours as needed.
During a concurrent observation and interview on 12/15/2023, at 8:22 pm, with LVN 3, Resident 86 lying in bed with oxygen in use delivered at 2 LPM via nasal cannula with the tubing unlabeled without date of when it was last changed. LVN 3 stated the nasal cannula should be labeled when first used and if not in used the NC tubing should be placed in a bag with date labeled. LVN 3 stated, NC tubing should be dated for infection control.
During an interview on 12/16/2023, at 12:50 pm, with the facility's DON, the DON stated, NC tubing should be labeled when first used and it should be placed inside the bag when not in used for infection control.
During a review of the facility's policy and procedure titled, Oxygen Administration, revised on 8/1/2014, indicated, all oxygen tubing, humidifiers (a device used to make supplemental oxygen moist), masks and cannulas used to deliver oxygen will be changed weekly.
3b. During a review of Resident 87's admission record indicated, the facility admitted Resident 13 on 12/8/2023 with diagnoses that included type 2 DM and long-term use of insulin (a hormone that helps control your body's blood sugar level) use.
During a review of Resident 87's History and Physical (H&P), dated 12/11/2023, indicated Resident 87 did not have the capacity to understand and make decisions.
During a concurrent observation and interview on 12/15/2023, at 8:12 pm, with Director of Staff and Development (DSD), Resident 87 lying in bed with oxygen concentrator (a medical device that concentrates oxygen from environmental air and delivers it to the resident in need of supplemental oxygen) with a humidifier (a bottle connected to the oxygen concentrator used to moisten the air before breathing in via NC) that had no label of the date the humidifier was first used or when to be changed. The NC and the storage bag for the NC at the bedside did not have a label of the time it was first used and when to be change.
During a concurrent observation and interview on 12/15/2023, at 8:31 pm, with the DSD, the DSD stated Resident 87's nasal cannula tubing should be labeled with date to know when it was replaced and first used for infection control. The DSD stated, the storage bag should be labeled with resident name and date to know that nasal cannula belonged to Resident 87.
During an interview on 12/17/2023, at 10:30 am, with the facility's DON, the DON stated the nasal cannula tubing and the storage bag should be labeled to identify the equipment for infection control.
During an interview on 12/17/2023, at 10:39 am, with the facility's Infection Prevention Nurse (IPN), the IPN stated the nasal cannula tubing and the storage bag belonged to Resident 87. The IPN stated she forgot to label the date in the nasal cannula and label the storage bag of Resident 87's name. IPN stated, nasal cannula tubing and storage bag should be dated and labeled with Resident 87's name for infection control.
During a review of the facility's policy and procedure titled,Oxygen Administration), revised on 8/1/2014, indicated, for infection control all oxygen tubing, humidifiers, masks and cannulas used to deliver oxygen are for single resident used only.