Avir At Jacksonville

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to report alleged abuse to the ADM and HHSC on 2/11/26 at approximately 2:54 p.m. when LVN A allegedly forcefully placed an oxygen mask on Resident #1 and told her to keep it on or she would die. This failure could place residents at risk of abuse, emotional distress, and loss of dignity.Findings included: 1. Record review of Resident #1's face-sheet dated 2/25/26 revealed a [AGE] year-old female, initially admitted to facility on 1/23/26. Resident's diagnoses included: unspecified dementia (altered cognition), dehiscence of closer of surgical wound (surgical incision reopened), and Bronchopneumonia. Record review of an admission MDS dated [DATE] indicated Resident #1 was rarely or never understood and a BIMS was not conducted. Resident #1 required continuous oxygen therapy on admission. Record review of a comprehensive care plan for Resident #1 dated 1/24/26 indicated Resident #1 had impaired gas exchange (difficulty breathing) and required redirecting several times daily to wear mask to maintain oxygen saturations up due to history of respiratory failure. Interventions were in place to administer oxygen as prescribed or per standing order, evaluate or anxiety/restlessness, and evaluate as needed for shortness of breath. Record review of a statement dated 2/11/26 written by Laundry Aide indicated I entered the residents (Resident #1) room to delivery laundry. A registered nurse - the charge nurse. [LVN A] was verbally abusing [Resident #1]. Another woman witnessed and heard the interaction, [Sitter], who works at the state hospital. [LVN A] roughly shoved the oxygen mask on Resident #1 yelling at the resident to keep the mask on. Review of facility Concern/Grievance form dated 2/11/26 indicated Sitter C communicated to ADON concern that LVN A when telling resident she needed to keep mask on or she would have low O2 sats and be sent to the hospital was said in a direct manner. Findings included a conversation with Sitter D, a regular sitter with Resident #1, regarding LVN A She always in here doing her job; we told her from the start you have to be blunt with [Resident #1]. She is never mean. Results of action plan included: No further complaints from any staff or outside visitors regarding this nurse bed side manner. The form indicated the incident was not reportable to the state. The form was signed by ADM on 2/16/26. Review of an In-Service Training Report dated 2/11/26 titled Customer Service indicated ADON completed 1 on 1 coaching with LVN A related to customer service skills. The summary of in-service indicated Counseled on customer service, even when being direct remember your tone and manner your[sic] saying it. Review of a skin assessment dated [DATE] at 10:37 a.m. indicated Resident #1 had skin issues related to known surgical wounds, no other acute skin abnormalities were reported. During an interview on 2/25/26 at 9:30 a.m., LVN A said Resident #1 had behaviors that made her care delivery difficult. LVN A said those behaviors included frequently removing her oxygen which caused her oxygen levels to desaturate (decrease from normal breathing range) due her diagnoses of COPD (chronic obstructive pulmonary disorder) and pneumonia. LVN A said she was Resident #1's nurse on 2/11/26. LVN A said resident had taken her oxygen mask off and she told her to put it back on or you'll have to go to the hospital. LVN A said she spoke matter of fact to the resident, but not in a mean way. LVN A said she was instructed to be blunt with Resident #1 from a staff member at the state hospital, where Resident #1 was a patient. LVN A denied ever forcefully placing an oxygen mask on Resident #1's face. During an interview on 2/25/26 at 9:35 a.m., RN B said she was working on 2/11/26, the day of the allegation, but was not a witness to it. RN B said she Resident # 1 frequently removed her oxygen but was generally redirectable to put it back on. RN B said she had never heard LVN A use abusive language toward residents or tell them they would die. During an interview on 2/25/26 at 10:00 a.m., the Maintenance Director said his employee, Laundry Aide, reported the allegation to him immediately upon witnessing it. He said he went to Resident #1's room and spoke to Sitter C and Sitter C wanted to file a grievance. The Maintenance Director said he went to the ADON and alerted her of the situation and then had Laundry Aide write a statement which he delivered to the ADON. The Maintenance Director said Laundry Aide told him LVN A forcefully placed an oxygen mask onto Resident #1's face and was verbally abusive. During an interview on 2/25/26 at 10:15 p.m., the Laundry Aide said she delivered laundry to room [ROOM NUMBER] on hall 100. The Laundry Aide said when she went into the room LVN A was yelling at Resident #1 to put her mask back on or she would go to the hospital. The Laundry Aide said LVN A forcefully pushed the oxygen mask back down on to Resident #1's face and pulled the straps into place. The Laundry Aide said she stayed in the room until LVN A left and immediately called her supervisor to alert him of the incident. The laundry aide said she had training in abuse and neglect and was to alert the ADM or her direct supervisor if the ADM was unavailable, and the ADM was out of the office on a facility related travel. The laundry aide said she was never interviewed by the ADON in regard to the incident, but she did write a statement and give it to her supervisor. During an interview on 2/25/26 at 10:35 a.m., the ADON said she first learned of the incident immediately after it happened from the Maintenance Director. The ADON said she went to Resident #1's room and spoke to Sitter C. The ADON said Sitter C reported LVN A had been blunt with resident about keeping her mask on and the risks of taking it off, but did not report LVN A forcefully placed an oxygen mask over Resident #1's face. The ADON said she investigated the incident and did not consider it reportable to the state because Sitter C did not mention LVN A forcefully placing an oxygen mask on Resident #1's face. The ADON said she had training in abuse and neglect and reporting requirements. The ADON said her investigation included interviews with other residents and sitters from the state hospital who sat with Resident #1. The ADON said she completed 1-on-1 coaching with LVN A regarding her customer service skills and tone of voice when speaking to residents. During a telephone interview on 2/25/26 at 10:55 a.m., Sitter C said she worked at the state hospital and was assigned to sit with Resident #1 on 2/11/26 on the evening shift (2pm-10pm). Sitter C said resident had taken off her oxygen mask to clean her mouth. Sitter C said LVN A came in and yelled at Resident #1 to put her mask back on. Sitter C said when Resident #1 did not put her mask on, LVN A walked to the bed and forcefully put her mask on her while yelling If you don't put this mask on you're going to die. Sitter C said the resident did not verbally respond to the incident, but that she looked frightened. Sitter C said she told the ADON the same information as she told this surveyor. Sitter C said she was always able to redirect Resident #1 and wasn't aware of any orders to speak to resident bluntly or matter of fact. During an interview on 2/25/26 at 1:45 p.m., the ADM said the incident occurred on 2/11/26 and she was not notified until 2/13/26. The ADM said she was notified by the ADON who told her the incident was handled. The ADM said she was not aware of Laundry Aide's written statement until that day, 2/25/26. The ADM said whether the incident was reportable was hard to answer in hindsight, but she planned to implement 1 on 1 training with all staff to ensure everyone understands abuse reporting requirements. During an interview on 2/25/26 at 2:00 p.m., the DON said she was first made aware of the details of the allegation, and that a written statement existed, that day 2/25/26. The DON said the policy said to report abuse allegations to the ADM or immediate supervisor in the ADM's absence. She said allegations should be reported immediately and the DON should have reported this incident to the ADM for review. The DON said the ADON did a thorough investigation and could not conclude there was an abuse allegation based on interviews with sitters who sat with Resident #1. The DON said risks to residents from unreported abuse could be continued abuse of a resident physically, verbally, or being neglected. The DON said going forward she planned to do 1-on-1's with all staff to make sure everyone understands who to report abuse to. The DON said she expected staff to ultimately report to the ADM, and report to their direct supervisor if the ADM is not reachable. Review of facility training record dated 1/16/26 revealed the ADON completed Abuse, Neglect, and Exploitation training. Review of In-service sign in sheet titled Abuse and Neglect and Exploitation dated 1/12/26 indicated the ADON was in attendance. Record review of facility policy Abuse, Neglect Exploitation or Misappropriation - Reporting and Investigating dated 2022 indicated .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents, (Resident #35) reviewed for Enhanced Barrier Precautions.
RN D failed to put on a gown prior to performing an aseptic procedure of draining the peritoneal cavity with a surgically inserted peritoneal catheter.
This failure could place residents under their care at risk for the transmission of communicable diseases and infections.
Findings included:
Record review of a face sheet dated 04/23/2025 indicated Resident #35 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had diagnoses which included, congestive heart failure, chronic kidney disease, ascites (a buildup of fluid in the abdomen), atrial fibrillation (an irregular and rapid heart rhythm), end stage heart failure, gastro-reflux disease, and anxiety disorder.
Record review of the quarterly MDS dated [DATE] noted Resident #35 had a BIMS score of 11 which indicated moderate cognitive impairment. He was receiving hospice services and had a peritoneal dialysis catheter inserted.
Record review of Resident #35's physician orders indicated an order dated 03/26/2025 1. Aseptic dressing change performed with each drainage of port by hospice nurse. 2. Hospice nurse to drain patient's port and report drainage amount to facility.
During an observation and interview on 04/22//2025 at 9:15AM, RN D (hospice nurse) was in the process of performing drainage of Resident #35's Aspira peritoneal drain. The peritoneal drainage process was observed. During the observation it was noted RN D had not donned a PPE gown and only had protective gloves on. After leaving the resident's room, the Enhanced Barrier Precautions (EBP) sign posted on Resident #35 door was noted and PPE supplies were stocked in hallway. During an interview after the procedure RN D said she did not don the PPE gown because she normally just wore gloves for the procedure. She said she had seen the EBP sign posted on Resident # 35 door but had not thought to don the PPE gown.
Record review of the progress notes for Resident #35 dated 04/22/2025 at 9:27AM indicated, hospice nurse drained 2000ml fluid from port, abdomen measurement is 47 ml., and changed dressing as ordered. Documented by LVN C.
Record review of the progress notes for Resident #35 dated 04/18/2025 at 12:15PM indicated, hospice nurse came and drained fluid using resident abdominal port, drained 2900ml. no complaint during fluid drainage or after completion.
Record review of the progress notes for Resident #35 dated 04/14/2025 at 10:26AM indicated, a hospice nurse came and drained 3075ml of fluid from abdominal port area.
During an interview on 04/22/2025 at 01:20 PM, LVN B said, she understood that EBP stood for Enhanced Barrier Precaution and had to do with infection control. She said EBP meant staff were supposed to wear a mask, gown, and gloves when handling catheters and wounds. LVN B reviewed the EBP sign on Resident #35's door and LVN B, said that a gown and gloves were to be used during high-contact resident care activities. LVN B said the staff had received in-services on infection control and EBP.
During an interview on 04/22/2025 at 01:40 PM, LVN C said, she understood that EBP stood for Enhanced Barrier Precaution, and it had to do with infection control. She said EBP meant staff were supposed to wear a mask, gown, and gloves when handling catheters and wounds. LVN C reviewed the EBP sign on Resident #35's door and LVN C verbalized understanding, saying that a gown and gloves were to be used during high-contact resident care activities. LVN C said the staff had received in-services on infection control and EBP.
During an interview on 04/22/2025 at 03:30 PM, the DON said she was the Infection Preventionist for the facility. She said she expected the nurses to follow the facility's policies on infection control and prevention including the policies on EBP. The DON said, the hospice agencies were responsible for educating the hospice nurses on Enhanced Barrier Precautions. She said, she expected the hospice' s nurses, and the staff members to follow the guidelines of EBPs to reduce the risk for transmission of infection. The DON said the Charge Nurses reports and post Enhanced Barrier Precaution signs on residents' doors that had met the EBP criteria for the facility's staff, and hospice staff providing direct care. The DON said the purpose of EBP was to reduce the risk of spreading infection. The DON said RN D should have put on a gown prior to performing drainage of Resident # 35 Aspira drainage system:(a tunneled long-term catheter used to drain fluid from the pleural or peritoneal cavity) peritoneal catheter.
A record review of the facility's policy dated 04/1/2024 and titled Enhanced Barrier Precautions indicated the following: The policy of this facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The initiation of Enhanced Barrier Precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers), and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes).
A record review of the facility's policy dated, July 2024, title Infection Prevention and Control Program indicated the following: The facility's infection control policies and practices are intended to facilitate, maintain a safe, sanitary, comfortable environment, help prevent, and manage transmission of diseases and infections. The objectives are to establish guidelines for implementing Isolation Precautions, availability and accessibility of supplies and equipment necessary for Standard and Transmission -Based Precautions.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen.
The facility failed to ensure thickened liquids and therapeutic beverage containers were dated when opened.
The facility failed to ensure the leftovers in the reach in cooler were discarded after 3 days.
These failures could place residents who ate food from the kitchen at risk of foodborne illness.
Findings included:
During observations and on 04/21/25 of the kitchen the following was noted:
at 9:50 AM in the 2 door reach in cooler there were the following:
one 46 oz. Honey Thick Sweet Tea had no open date. Packaging indicated After opening, may be kept up to 7 days under refrigeration.
one 32 oz. chocolate high protein, high calorie drink had no open date. Packaging indicated Refrigerate after opening and use within 3 days.
one 32 oz. chocolate high protein, high calorie drink had an open date of 04/17/25. Packaging indicated Refrigerate after opening and use within 3 days.
one plastic container of cole slaw dated 04/11/25 and covered with an unsecured piece of foil.
one plastic container of pork steak with gravy dated 04/16/25.
one plastic container of cheese sauce dated 04/16/25.
one plastic zip bag of bacon dated 04/11/25.
During an interview on 04/21/2025 at 9:55 AM [NAME] A said she and the other cook were responsible for the food items in the cooler. She said leftovers were to be discarded after 3 days. She said she did not realize the thickened tea and chocolate therapeutic drinks had expiration dates after opening. She said food items should be marked when opened. She removed the tea, chocolate drinks, cole slaw, pork steak, cheese sauce and bacon from the cooler and discarded them.
Record review of an undated facility policy on Food Storage indicated: .2. Refrigerators .d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.
The dietary manager was on sick leave and could not be interviewed regarding the oversight of the dietary kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident #1)
The facility failed to ensure CNA A did not go through Resident #1's personal posessions without his permission or remove items from his room without his permission.
This negative finding caused the resident to be distressed and could cause residents to feel disrespected.
Findings included:
Record review of Resident #1's face sheet, with no date, indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were depression and muscle wasting.
Record review of Resident #1's Annual MDS assessment dated [DATE] indicated his cognition was intact with a BIMS (brief interview for mental status) score of 13. His assessment for mood and behaviors did not indicate any concerns.
Record review of Resident #1's Care Plan dated 4/3/24 indicated a problem of General. The approaches were the resident preferred showers or baths once a day on Monday, Wednesday, and Friday on the 6 am to 2 pm shift.
During an interview on 5/1/24 at 9: 45 a.m., Resident #1 said on 4/30/24, CNA A came into his room and started opening his nightstand drawers and rummaging through them. He said she continued to go through his things, and he asked her what she was doing, and she ignored him. Resident # 1 said he got mad and started yelling at her and told her to get out and leave his things alone. He said to make things worse, when he left his room to talk to the DON about CNA A going through his things without permission, CNA A and CNA B had gone in his room and taken all his towels. He said some of the towels were his own personal towels and they had taken those as well.
During an interview on 5/1/24 at 10:14 a.m., CNA A said she was asked by the ADON to check resident rooms for towels. She was just doing what she was told. She was told to get the extra towels out of residents' rooms and that was what she was doing. She said Resident #1 took a shower every day and sometimes twice a day and felt he always needed extra towels. She said she did not have any problems with anyone else but Resident #1. CNA A said she had knocked on Resident #1's door and told him she was checking for towels. She told him she was going to check his dresser drawers and he appeared fine with that. However, when she had gone to his closet, he became upset and stated hollering, what are you doing? You have no business in there? She said she saw a bag in the closet that contained towels. She did not remove the bag because the resident was freaking out (hollering and upset.) She said she had told CNA B and they had gone back later to get the towels when the resident was not in the room. She said it was two large stacks of towels, and they had taken them to the Environmental Services Supervisor who said they were the facility's towel. CNA A said they were the facility's towels and he should not have had them. She said she was in-serviced on Resident Rights.
During an interview on 5/1/24 at 10:23 a.m. the ADON said the Environmental Specialist Supervisor was doing inventory on his linens. He asked her to see if she could get the aides to do room search for towels. She said in some cases, hospice aides put towels in the rooms, so they had them when they wanted to do showers. She said she asked CNA A and CNA B to search the rooms for towels. The ADON said she did not think she had to tell them to knock on doors and ask for permission before looking for towels. She said she thought staff understood when the resident says no, that means no.
During an interview on 5/1/24 at 10:44 a.m., the DON said the ADON asked CNA A to go to residents' rooms to see if they were hoarding towels. The DON said Resident #1 came to her and said CNA A had gone through his things without his permission. She said Resident #1 said he was upset that she went through his things. The DON said her interview with CNA A revealed she went to Resident #1's room and told him she was going to look for towels. The DON said that was not what they were supposed to do. The DON stated they were to ask for permission to go through the residents' things. She said she immediately started and an in-service on Resident rights.
During an interview on 5/1/24 at 11:25 a.m., CNA B said the ADON had asked her and CNA A to check resident rooms for towels. She had to take care of another resident and CNA A had gone into Resident #1's room alone. She said the aide told her she knocked on his door and told him what she was doing. She said CNA A said Resident #1 got upset when she went into his closet. CNA B said CNA A came and told her Resident #1 had a lot of towels in his closet. CNA B said they had gotten the towels while Resident #1 was not in the room.
During an interview on 5/1/24 at 12:30 p.m., the Administrator said they had started an in-service on yesterday regarding residents' rights and they had counseled CNA A. She said if things happened the way Resident #1 said, the aide should not have looked through his things without permission.
During an interview on 5/1/24 at 12:40 p.m., Resident #1 said his main concern was that girl (CNA A) violated his rights by going through his things and he felt something needed to be done.
Record review of an in-service dated 4/30/24 indicated Resident Rights and Privacy: You cannot go into a resident room and start looking through things without their permission. All staff must be mindful that this is their home, and we should respect that., at no point should they fell like they have no personal boundaries with staff, knock before you enter, let them know what you are in their room for, and ask permission before going forward with the task. The in service was signed by 8 staff. Attached to the in service was a copy of the facility Resident Rights policy.
Record review of the facility's policy on Resident Rights revised February 2021 indicated Employees should treat all residents with kindness, respect, and dignity. The resident had the right to a dignified existence, to be treated with respect, kindness, and dignity, be informed of, and participate in his or her care planning and treatment, privacy, and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen.
The dietary staff did not accurately test the dish machine for chlorine sanitizing with the correct test strips from 02/27/24 until 03/11/24.
This failure could place residents who ate food from the kitchen at risk of foodborne illness.
Findings included:
During an observation and interview in the kitchen on 03/11/2024 at 09:45 AM, DA A was going to demonstrate checking the sanitizing on the dish machine and she had a container of testing strips on top of the machine. She said she had not tested the machine yet this morning. She was finished with washing the breakfast dishes. She ran the machine and took a test strip from the container and tested the water containing the sanitizer. The test strip was a yellow color and had no reaction. Observation of the label on the container of strips indicated the strips were for use on QAC (quaternary ammonium compounds) sanitizer and not chlorine sanitizer. DA A said she had been using those strips to test the dish washing machine since the RD told them they could use the QAC strips. She said those were the only test strips she had to use and not the purple ones.
A review of a Facility Dish Machine Temperature and Sanitizing Log dated March 2024 and posted on the wall by the dish machine indicated the sanitizer had been tested every day from 03/01/24 to 03/11/24 three times a day and test results for sanitizing were noted at 50 ppm when using strips that were unable to test for the presence of chlorine.
During an observation and interview on 03/11/24 at 11:25 AM DA A said she found some chlorine test strips on a shelf in the kitchen. She demonstrated checking the sanitizer in the dish machine and it was sanitizing at 100 ppm.
During an interview on 03/12/24 at11:15 AM, DM said her RD told her she could use the quaternary test strips used at the 3 compartment sink on her chlorine sanitizing dish machine because her chlorine strips were out of date.
During an interview on 03/12/24 at 03:30 PM the DM said the RD came in on 02/27/24 and did a kitchen sanitation quality review and dining observations. She said she had been using the quaternary strips on the machine since that date. She said the machine should be tested 3 times a day, once for each meal where dishes would be washed. She said she had no written policy regarding when to test the machine other than the log sheet. She said the service vendor came to the facility on [DATE] and did a routine maintenance check and the machine was sanitizing properly on that day. She said the service vendor came on 03/11/24 at 3:45 PM to bring chlorine testing strips and did a full maintenance check at that time and the machine was sanitizing.
A review of information posted on Texas Health and Human Services website, viewed 03/14/24, indicated quaternary solution was used primarily for three compartment sinks and test strips for quaternary compounds indicated sanitizing was occurring when the solution was testing at 200-400 ppm.
FDA Food Code, dated 2013, viewed at FDA.gov indicated Low temperature machines using chlorine as a chemical sanitizer should have a concentration between 50 ppm and 100 ppm and be measured using the appropriate chemical test kits. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 1 of 7 residents (Resident #7) reviewed for medication administration
The facility gave Resident #7 medications belonging to another resident on 07/15/2023 at 5:15 PM.
The non-compliance was identified as past non-compliance. The noncompliance began on 7/15/23 and ended on 7/16/23. The facility had corrected the noncompliance before the investigation began.
This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.
The findings included:
A record review of Resident #7's admission record, dated 01/29/2024, revealed an admission date of 10/28/2022 and discharged home on [DATE] with diagnoses which included peripheral vascular disease (reduced blood flow to limbs), hyperkalemia (high potassium), and cerebral Infarction (stroke).
A record review of Resident #7's quarterly MDS, dated [DATE], revealed Resident #7 was a [AGE] year-old female admitted with peripheral vascular disease (reduced blood flow to limbs) and was assessed with a 13 out of 15 BIMS score, which indicated Resident #7 was cognitively intact.
A record review of Resident #7's care plan, dated 03/23/2023 revealed, resident has diagnosis of congestive heart failure, administer medication as evaluate/record/report effectiveness/adverse side effects.
Record review of Resident #7's progress note written by LVN B reflected the resident received the following medications in error at 5:15 PM on 07/15/2023: Allopurinol 100mg (medication to treat Gout), Colace 100mg (stool softener), Gabapentin 300mg (medication to treat Neuropathy), Lisinopril 10mg (medication to treat high blood pressure), Tramadol 50mg (medication to treat pain), Metoprolol 50mg (medication to treat high blood pressure), Sertraline 50mg (medication to treat depression), and Simvastatin 10mg (medication to treat high cholesterol).
Record review of Resident #7's progress note dated 07/15/2023 reflected a physician order dated 07/15/2023 at 5:22 pm to start neurological evaluation and monitor respirations and sat.
A phone call was attempted on 01/29/2024 at 3:10 pm to Resident #7, but there was no answer and surveyor was unable to leave a voicemail.
During an interview on 01/29/2024 at 3:33 PM the DON said she received a call 7/15/2023 from LVN B notifying her that MA A had given the wrong medication to Resident #7. The DON said that they notified the physician and received an order to start a neurological evaluation and to monitor respirations and oxygen saturation. She said MA A received a written disciplinary action and was suspended pending investigation. The DON said she in serviced staff on administering medications. The DON said Resident #7 had no adverse side effects from the medication error. The DON said she expects her staff to follow the facility policy of administering medications. The DON said that not following the facility policy could have a potential negative outcome for residents including significant clinical changes in condition.
During an interview on 01/29/2024 at 4:38 PM MA A said she had worked at the facility for about a year. She said Resident #7 and another resident were sitting in the dining room. She said she gave another resident her medication and Resident #7 grabbed the medication and took it. She said she sat the medication down in front of the other resident and turned her head and when she turned back around the other resident hollered out, she took my medication. MA A said she could have gotten the medications mixed up but is not sure what happened when she had her head turned. Said she had just become a certified medication aide and she could have made the medication error. MA A said the DON came to the facility to investigate the medication error and she was suspended pending investigation and received written disciplinary action. She said when she returned to the facility, she was in serviced on the facility policy of following the rights of administering medications, and she was observed during medication administration to ensure the rights of medication administration were being followed. MA A said she was observed during medication administration once a week for four weeks.
During an interview on 01/29/2024 at 4:55 PM the Administrator said she expected her staff to follow the policies and procedures of the facility. She said that not following the medication administration policy places residents at risk of significant clinical changes in condition related to medication errors.
Record review of a statement dated 07/15/2023 written by MA A revealed: While I was preparing their evening medication I went ahead and pulled them together because both residents were in the dining room and sit together during meal times. When I handed Resident #7 her meds she took them and when I handed the other resident her cup she realized they were not hers and upon inspection I found that Resident #7 had taken the other residents meds and I reported it to the nurse immediately. I am aware that I should not have prepared the 2 meds at the same time due to risk of med error and the risk of serious injury that I could have caused.
Record review of a statement undated written by Resident #7 revealed: MA A handed me a cup of pills, I cannot see that well so I took them and the lady at the table with me told MA A those were not her pills, she determined that I had took the other residents pills and not mine.
Record review of facility policy titled Administering Medications dated April 2019 revealed: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
Record review of employee inservice titled Med Pass Error dated 7/15/2023 revealed: CMA A was educated on medication pass error.
Record review of Employee Memorandum dated 7/15/2023 revealed: MA A had a medication error due to her preparing 2 residents' medications at the same time. CMA A was suspended on 07/15/2023.
Record review of QAPI notes dated 08/23/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Dietary Manager, Director of Rehab, and Medical Director. The interventions and plan for correction included:
1.
Inservice over administering medication policy and procedure. In-services dated 07/16/23.
2.
Random check performed on nursing/CMA staff to ensure the medication administration policy was being followed.
3.
Random checks performed to ensure no staff should be pre-setting up residents' medication that could lead to medication errors.
4. MA A to be observed weekly for four weeks to ensure medication administration policy was being followed.
Record review of sign in sheets for all in-services dated 07/16/2023 indicated that 13 staff members had signed the sign in sheet for the in-services on Medication.
During interviews on 01/29/2024 between 3:20PM and 5:00 PM MA A, LVN B, RN C, DON, LVN D, and LVN E were able to appropriately verbalize understanding of the facility medication administration policy and procedures. The staff were able to verbalize and demonstrate when administering the medication check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
On 01/29/2024 at 5:30 pm, the Administrator, DON and Corporate staff were notified the non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 10 residents (Residents #1) reviewed for medications.
The facility failed to administer medications as prescribed for Resident #1.
This failure could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status.
The findings included:
A record review of Resident #1's admission record, dated 06/20/2023, revealed an admission date of 02/03/2023 with diagnoses which included enterocolitis due to clostridium difficile (bacteria in the colon that causes diarrhea).
A record review of Resident #1's annual MDS, dated [DATE], revealed Resident #1 was a [AGE] year-old female assessed with a 12 out of 15 BIMS score, which indicated a moderate cognitive impairment.
A record review of Resident #1's care plan, dated 06/20/2023 revealed, resident has pain related to diagnosis of ulcerative pancolitis (lining in the colon becomes inflamed), administer pain medication as ordered by physician.
A record review of Resident #1's March 2023 physician's order summary revealed Resident #1 was to receive starting on 03/07/2023 dificid 200mg (antibiotic to kill bacteria in the colon) take one tablet twice a day for five days then skip day six and then take one tablet once every other day for twenty days, for a total of twenty tablets to be given in total for diagnosis of clostridium difficile (bacteria in the colon that causes diarrhea).
Record review of the medication administration record dated 03/01/2023-03/31/2023 and 04/01/2023-04/30/2023 revealed the medication was transcribed to the medication administration record as Dificid 200mg one tablet twice daily for 5 days, then one tablet once a day.
Record review of the medication administration record dated 03/01/2023-03/31/2023 and 04/01/2023-04/30/2023 revealed Resident #1 received dificid 200mg for 5.5 days and then once daily for twenty days for a total of 31 tablets.
During an interview on 06/20/2023 at 09:15 AM with Resident #1, said she was not given her medication correctly for clostridium difficile. She said the facility did not follow the physicians' orders and gave her the medication daily instead of every other day as it was ordered. Resident #1 said she told the facility how the physician wanted her to take it, but they would not listen to her.
Record review of Resident #1's care plan conference dated 06/06/2023 revealed, Resident #1 and Resident #1's sister notified the Administrator, DON, MDS Nurse, and Ombudsman of the medication error during the care plan conference meeting.
During an interview on 06/20/2023 at 09:59 AM, MA A said the charge nurse receives new orders from the physician and enters it into the computer system. She said the order is sent electronically to the pharmacy to be filled and is then delivered from the pharmacy on the next delivery. She said she administers medications that are on the resident's medication list.
During an interview on 6/20/2023 at 10:15 AM, LVN B said she had worked at the facility for 2 years. She said the charge nurse or the administration nurses receives new orders from the physician and enters them into the computer system. She said once the order is entered into the computer it is electronically ordered from the pharmacy and is delivered on the next pharmacy delivery. She said she is not sure of the process used to ensure the accuracy of the orders that have been entered. She said once the physician order in entered into to the computer the MA can then administer the medication.
During an interview on 06/20/2023 at 11:20 AM, LVN C said she had worked at the facility for 3 ½ years. She said the nurse, DON, or ADON enter new physician orders into the computer system. She said the orders are sent electronically to the pharmacy and the medication is delivered on the next pharmacy delivery. She said she thinks the DON and ADON check the orders to make sure they have been entered in the computer accurately but is unsure of that process. She said once the physician order in entered into to the computer the MA can then administer the medication.
During an interview on 06/20/2023 at 03:00 PM, MA D said she had worked at the facility for 6 months. She said the nurse enters new physician orders into the computer. She said she is not sure of a system to check the accuracy of orders entered except for the DON and ADON to check the orders.
During an interview on 06/20/2023 at 03:10 PM, the Regional Clinical Resource Nurse said the DON and ADON are not available for interview. She said the DON and ADON are to review all new orders received in the last 24 hours daily in the daily clinical meeting. She said on Mondays the DON and ADON review all new orders received in the 72 hours in the clinical daily meeting. She said she is not sure how the dificid medication for Resident #1 was entered incorrectly and not caught in the daily clinical meeting.
During an interview on 06/20/2023 at 4:00 PM, the Administrator said she had worked at the facility for three weeks and was not employed at the facility at the time of the medication error and is not sure how it happened. She said the interdisciplinary team is to go over new medication orders in the clinical meeting every morning to ensure all orders have been transcribed correctly. She said the resident could have adverse effects if medication orders are not followed correctly.
A record review of the facility's Medication Orders policy, dated November 2014, revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Recording Orders: 1. When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered.
A record review of the facility's Medication Errors policy, dated April 2014, revealed, Policy Statement: The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as medication errors. Adverse consequences shall be reported to the attending physician and pharmacist, and to federal agencies as appropriate. Policy interpretation and implementation: If a medication error is identified the resident will be assessed to ensure that any adverse consequences are identified . a medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physicians' orders, manufacturers specifications, or accepted professional standards and principles of the professionals' providing services. examples of medication errors include: . wrong time, wrong dose . failure to follow manufacturer's instructions and or accepted professional standards .
A record review of the National Library of Medicine, accessed 06/20/2023, Fidaxomicin (Dificid), a Novel Oral Macrocyclic Antibacterial Agent For the Treatment of Clostridium difficile-Associated Diarrhea in Adults - PMC (nih.gov) revealed: The recommended dosage of fidaxomicin for the treatment of adults with CDAD is 200 mg twice daily with or without food for 10 days. No dosage adjustment is required based on the patient's renal function, age, or sex.17 According to the drug's labeling, fidaxomicin should be used only for infections that are known or are strongly suspected to be caused by C. difficile to avoid the development of drug-resistant bacteria, which would lessen the effectiveness of fidaxomicin.17 To date, fidaxomicin and vancomycin are the only medications approved for the treatment of CDAD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 5 of 20 residents. (Resident # 17, Resident #28, Resident #4, Resident #14, and Resident #3).
The facility failed to ensure CNA W changed gloves or preformed hand hygiene while providing incontinent care for Resident #17.
The facility failed to ensure LVN B changed gloves or preformed hand hygiene while providing wound care for Resident #28.
The facility failed to ensure LVN B disinfected the glucometer prior to use for Resident #4.
The facility failed to ensure LVN G changed gloves or preformed hand hygiene between checking blood sugar and administering insulin to Resident #14 and Resident #3.
These deficient practices could place residents at risk for infection due to improper care practices.
Finding include:
Record review of Resident #17's electronic face sheet, dated 02/08/23, revealed a 59
year old male who was admitted to the facility on [DATE] with diagnoses which included high blood pressure, cardiomegaly (large heart), muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use), urinary incontinence and Stiff-person syndrome {SPS} (a rare, progressive neurological disorder).
Record review of Resident #17's annual MDS assessment, with an ARD of 12/26/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating he understands and was coded as a 1 indicating he was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 05 for cognitive severe impairment. Section G, Function Status, under section B indicated he needed extensive assistance with bed mobility, transfers, dressing, personal hygiene, total assist with, bathing, and supervision with eating. Section H, Bladder and Bowel, under section H0300 he was coded a 3 indicated he was always incontinent of bladder and under section H0400 he was coded as a 3 indicating he was always incontinent of bowel.
Review of Resident #17's comprehensive person-centered care plan dated 06/23/16 when it was initiated, and it was revised on 01/03/23. Focus indicted: Resident #17 was incontinent of bowel and bladder due to cognitive status. He was at risk for further skin breakdown, if not cleaned properly and regularity. Intervention indicated: Provide incontinent care every 2 hours and as his voiding patterns indicated.
During an observation and interview on 02/06/23 at 12:31 p.m., CNA W and CMA P was providing incontinent care for Resident #17 who had a bowel movement. CNA W turned Resident #17 on his right side and started cleaning the bowel movement first, then applied brief without hand sanitizing or changing gloves. CNA M proceeded with incontinent care and assisted Resident #17 to turn over with the same dirty gloves to provide peri care to the front. CNA W then went to assist Resident #17 up in his Geri-chair all while having on the same gloves. CNA W said she did not realize she did not change her glove or preform hand hygiene while preforming incontinent care for Resident #17. CNA W said she knew without proper hand hygiene or changing gloves could lead to cross contamination. CNA W said she had been checked off by the DON for incontinent care.
Record review of competencies skills revealed CNA W had been checked off on 01/09/23.
During an interview on 02/07/23 at 1:06 p.m., CMA P say CNA W preform incontinent care procedure incorrectly. CMA P said she tried to correct CNA W but she would not listen. CMA P said CNA W should have started the incontinent care process wiping from front to back and changing gloves in between. CMA P said CNA W did not change her gloves or hand sanitize during the incontinent care process. CMA P said failure to change gloves and or perform hand hygiene could lead to infection. CMA P said they have done incontinent care periodically in the facility with the DON.
Record review of competencies skills revealed CMA P had been checked off on 08/09/22.
During an interview on 02/09/23 at 3:16 p.m., RNC said infection preventionist (IP) was responsible for competencies on hire and annually. The RNC said failure to do proper incontinent care and hand hygiene could lead to infection.
During an interview on 02/09/23 at 3:45 p.m., the ADON said she expected the staff to preform hand hygiene and peri-care correctly. The ADON said she had a lead CNA who worked with the CNA'S with peri-care and she was the overseer. The ADON said failure to preform hand hygiene and peri-care correctly could lead to infection.
During an interview on 02/10/23 at 10:00 a.m., the DON said she expected staff to preform peri-care and hand hygiene correctly to prevent infection. The DON said she, the ADON and CNA J usually did peri-care check offs with staff on hire, annual and as needed. The DON said failure to preform incontinent care and hand hygiene properly could lead to infection issues.
Record review of Resident #28's electronic face sheet, dated 02/08/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety (what we feel when we are worried, tense or afraid), muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use), chronic obstructive pulmonary disease {COPD} (diseases that cause airflow blockage and breathing-related problems).
Record review of Resident #28's quarterly MDS assessment, with an ARD of 12/23/22, revealed under Section B, Hearing, Speech, and Vision, under sections B0700 was coded as a 0 indicating she understands and under section B0800 was coded a 1 indicating she was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 12 for cognitive intact cognition. Section G, Function Status, under section G0110 indicated she needed extensive assistance with bathing, supervision with eating and personal hygiene and independent with bed mobility, transfers, and toileting. Section M, Skin Condition, under section M0300 did not indicate any pressure ulcers during the look back period.
Review of Resident #28's comprehensive person-centered care plan dated 02/07/23. Focus indicted: Resident #28 was at risk for development of foot problems related to mobility while in wheelchair using feet to propel wheelchair instead of hands. Intervention indicated: wear shoes always to avoid trauma to feet and assess and record if resident's feet are desensitized to pain and /or pressure.
Review of Resident #28's physician's orders dated 02/07/23 indicated, clean ball of left heel with normal saline, apply collagen and cover with dressing.
During an observation and interview on 02/07/23 at 3:32 p.m., LVN B was preforming wound care on Resident #28's left heel. LVN B preformed hand hygiene and applied clean gloves to removed old dressing. LVN B then preformed hand hygiene and applied new gloves to clean wound but did not perform hand hygiene or apply clean gloves before applying clean dressing to the wound. LVN B when questioned said she thought she had changed her gloves from dirty to clean. LVN B said not properly preforming hand hygiene or changing gloves could lead to infection.
During an interview on 02/09/23 at 3:16 p.m., RNC said she expected the nurses to preform hand hygiene and change gloves between cleaning a dirty wound and applying a clean dressing. The RNC said failure to preform hand hygiene or change glove could lead to infection.
During an interview on 02/09/23 at 3:45 p.m., the ADON said she expected nurses to wash their hands and change their gloves from dirty to clean when preforming wound care. The ADON said she and the DON was the overseers of nurses on wound care. The ADON said failure to perform hand hygiene or change glove could lead to infection.
During an interview on 02/10/23 10:00 a.m., the DON said she expected nurses to discard their gloves and preform hand hygiene after cleaning a dirty wound and applying a dressing to a clean wound. The DON said she and the ADON was responsible to ensure nurses were preforming wound care correctly. The DON said they had performed skill check offs with the nurses on wound care.
Record review of Resident #4's electronic face sheet, dated 02/08/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Diabetic, high blood pressure, anxiety (what we feel when we are worried, tense, or afraid), and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use).
Record review of Resident #4's quarterly MDS assessment, with an ARD of 12/12/22, revealed under Section B, Hearing, Speech, and Vision, under section B0700 was coded as a 0 indicating he understands and under section B0800 indicating he was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10 for cognitive moderately. Section G, Function Status, under section G0110 indicated he needed supervision assistance with eating, personal hygiene, bathing, independent with bed mobility, transfers, and dressing. Section N, Medications, under section N0300 he received 7 days of injections, and under section N0350 he received 7 days of insulin during the look back period.
Record review of Resident #4's physicians orders dated 12/14/22 indicated, Humalog Kwik pen insulin, give 35 units subcutaneous before meals.
Record review of Resident #4's medication administration records revealed blood sugars are taken and recorded each time before meals.
Review of Resident #4's comprehensive person-centered care plan dated 10/02/19 when it was initiated, and it was revised on 12/13/22. Focus indicted: Resident #4 was at risk for hypo/hyperglycemia episode related to diabetes mellitus, complicated by risk of pressure ulcers. Intervention indicated: Monitor blood glucose before meals and at bedtime, administer insulin as ordered and monitor for signs and symptoms of hyper/hypoglycemia.
During an observation and interview on 02/07/23 at 11:01 a.m., LVN B was preparing to do a glucometer check on Resident #4. LVN B wiped the glucometer with an alcohol pad and preceded to his room to preform a blood finger stick. LVN B when questioned said she did not realize she was supposed to re-clean the glucometer between uses with facility provided cleaning solution. LVN B said failure to clean glucometer properly could lead to infection problems.
During an interview on 02/09/23 at 3:16 p.m., RNC said she expected nurses to provide a clean surface when cleaning glucometers. The RNC said nurses should have 2 glucometers on their carts to ensure they always had a clean glucometer. The RNC said the ADON/DON was responsible to ensure nurses knew the process for cleaning glucometers. The RNC said failure to properly clean glucometers could lead to infection
During an interview on 02/09/23 at 3:45 p.m., the ADON said she expected nurses to clean glucometers before using on any resident. The ADON said she expected nurses to follow policy with cleaning the glucometer. The ADON said she and the DON were responsible to ensure nurses properly cleaned the glucometers before use and failure to clean properly could lead to infection.
During an interview on 02/10/23 at 10:00a.m., the DON said she expeced nurses to know how to properly clean glucometers before attempting to check any residents blood sugar. The DON indicated nurses should apply a clean surface with wax paper, wipe glucometer with the purple top and allowed to dry for 2 minutes before using on any resident. The DON said she and the ADON were responsible to ensure nurses knew how to properly clean glucometers before preforming a finger stick. The DON said not properly cleaning glucometers could lead to infection.
Record review of Resident #3's electronic face sheet, dated 02/16/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Diabetic, Schizoaffective (a serious mental illness that affects how a person thinks, feels, and behaves), high blood pressure and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use).
Record review of Resident #3's quarterly MDS assessment, with an ARD of 11/15/22, revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating he understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 09 for cognitive moderately impaired. Section G, Function Status, under section B indicated he needed extensive assistance with bathing, limited assist with personal hygiene, supervision with bed mobility, transfers, dressing, and eating. Section N, Medications, under section N0300 he received 7 days of injections, and under section N0350 he received 7 days of insulin during the look back period.
Record review of Resident #3's physicians ordered dated 11/28/22 revealed an order for Novolin N per sliding scale subcutaneous before meals.
Record review of Resident #3's medication administration records (Mar)revealed blood sugars are taken and recorded each time before meals.
Review of Resident #3's comprehensive person-centered care plan dated 01/13/15 when it was initiated, and it was revised on 11/16/22. Focus indicted: Resident #3 was at risk for hypo/hyperglycemia related to diagnosis of diabetes. Intervention indicated: provide his medication and labs as ordered and provide diet as ordered.
During an observation on 02/07/23 at 11:29 a.m., LVN G was preforming a finger stick for Resident # 3. LVN G preformed hand hygiene and applied clean gloves. LVN G took Resident #3's blood sugar and came out of room into the hallway with the same gloves on. LVN G open medication cart searched for Resident #3's insulin then went back into his room and gave the insulin as ordered. LVN G came back into the hallway with the same gloves on open medication cart and documented in Resident #3's chart then removed gloves and preformed hand hygiene.
Record review of Resident #14's electronic face sheet dated /02/08/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Diabetic, Schizoaffective (a serious mental illness that affects how a person thinks, feels, and behaves), Dementia and muscle wasting (a weakening, shrinking, and loss of muscle caused by disease or lack of use).
Record review of Resident #14's quarterly MDS assessment, with an ARD of 12/02/22, revealed under Section B, Hearing, Speech, and Vision, under section B0700 was coded as a 0 indicating she understands and under section B0800 indicated she was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 2 for cognitive severely impaired. Section G, Function Status, under section G0110 indicated she needed extensive assistance with bed mobility, personal hygiene, transfers, dressing, bathing, and supervision with eating. Section N, Medications, under section N0300 he received 7 days of injections, and under section N0350 he received 7 days of insulin during the look back period.
Record review of Resident #14's physicians ordered dated 11/28/22 revealed an order for Novolog Flex pen, give 20 units subcutaneous before meals.
Record review of Resident #14's medication administration records revealed blood sugars are taken and recorded each time before meals.
Review of Resident #14's comprehensive person-centered care plan dated 03/10/21 when it was initiated, and it was revised on 12/06/22. Focus indicted: Resident #14 was at risk for diabetes. Intervention indicated: Diet as ordered, finger sticks every meal and at bedtime, medication as ordered and observe for signs and symptoms of hypo/hyperglycemia.
During an observation and interview on 02/07/23 at 11:33 a.m., LVN G was preforming a finger stick for Resident # 14. LVN G preformed hand hygiene and applied clean gloves. LVN G took Resident #14's blood sugar and came out of his room into hallway with the same gloves on. LVN G open medication cart searched for Resident #14's insulin then went back into her room and gave the insulin as ordered with same dirty gloves on. LVN G came back into the hallway with the same gloves on open medication cart and documented in Resident #14's chart then removed gloves and preformed hand hygiene. LVN G said she had always preformed finger sticks this way. LVN G said until questioned she did not realize she was doing the process incorrectly. LVN G said she had been trained on finger sticks. LVN G said she now realized without proper hand hygiene or changing gloves it could lead to the spread of infection.
Record review of competencies skills revealed LVN G had been checked off on skills 01/17/23.
During an interview on 02/09/23 at 3:16 p.m., RNC said she expected nurses to preform blood sugar checks in the privacy of each resident's room. The RNC said she expected the nurses to remove their gloves and hand sanitizer before going to the med cart.The RNC said she expected nurses to apply new gloves to give the insulin and then sanitized their hands when completed. The RNC said the ADON/DON was responsible to ensure nurses were preforming fingerstick and giving insulin correctly. The RNC said failure to clean hands and change gloves could lead to the spread of infection or disease. The RNC said they would do a skills fair for nurses and CNA's as soon as they could get it set up.
During an interview on 02/09/23 at 3:45 p.m., the ADON said she expected nurses to know clean from dirty. The ADON said she expected the nurses to remove their gloves from dirty to clean and handwash in between. The ADON said failure to properly clean hands and wear contaminated gloves could cause infection.
During an interview on 02/10/23 at 10:00a.m., the DON said she expected charge nurses to discard their gloves and hand hygiene once they completed checking the blood sugar and before they gave the insulin. The DON said they did skill check offs on hire, annually and as needed. The DON said all nurses had been trained on checking finger sticks and given insulin. The DON said she and the ADON were responsible to ensure the nurses knew how to properly do blood sugar checks and give insulin and failure to do them properly could cause infection.
During an interview on 02/10/23 at 11:14 a.m., the ADM said he expected the aides to preform peri care per policy. The ADM said he expected nurses to follow the policy and procedure when cleaning glucometers, checking blood sugars, and preforming wound care. The ADM said nurse management was responsible to ensure the aides and nurses were competent in their skill sets. The ADM said he was not a nurse but believes if the aides and or nurses are not following policy and procedure it could possibly lead to infection issues.
Record review of the hand washing, and hand hygiene policy dated January 2023 indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. #3 wash hands with soap and water, when hands are visibly sold and after contact with resident . #4 use an alcohol based hand rub containing at least 60% to 95% ethanol alcohol or isopropyl alcohol #5 hand hygiene must be performed prior to donning and after doffing gloves.
Record review of Perineal care policy dated January 2023, indicated, Perineal care was providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the residents skin condition.
Record review of Wound Care policy dated June 22 revealed, The purpose of this procedure was to provide guidelines for the care of wounds to promote healing. Perform hand hygiene put on clean gloves pull gloves overdressing and discard into appropriate receptacle perform hand hygiene put on clean glove's wash in a circular motion from inside out apply treatment and dress wound as ordered by physician.
Record review of Cleaning and Disinfecting of Resident Care Items and Equipment dated October 2018, indicated, Resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to the current CDC recommendations for disinfection and OSHA bloodborne pathogen standard. Reusable resident care equipment will be decontaminated and are sterilized between residents according to the manufacturers guide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Record review of Resident #18's face sheet dated 02/10/23 indicated that was Resident #18 a 66year old female who admitted to the facility on [DATE] with the diagnosis of anxiety.
Record review of Resident #18's admission MDS dated [DATE] indicated in Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 15 for cognitively intact. The MDS section I, Active diagnosis, under section I5700 indicated Resident #18 had a diagnosis of anxiety.
Record review of Resident #18's physician order report dated 01/01/23-02/10/23 indicated that resident had an order for alprazolam-schedule IV tablet; 1mg; oral [DX: anxiety disorder due to known physiological condition] Twice a day-PRN; PRN1, PRN2 dated to start on 12/26/2022 and end on 02/10/2023.
Record review of Resident #18's medication administration history dated 01/01/2023-01/31/2023 indicated that resident was administered alprazolam 1mg tablet oral on 1/15/23, 1/18/23, and 1/28/23
Record review of Resident #18's medication administration history dated 02/01/2023-02/10/2023 indicated that resident was administered alprazolam 1mg tablet oral on 2/7/23 and 2/8/23.
During an interview on 02/10/23 at 10:10 a.m. the DON said any PRN order for psychotropic medications had a 14-day time limit and the physician should have re-evaluated the medication use, or the medication should have been discontinued. She said that the risk to the resident if the evaluation was not completed would be the resident not being monitored for effectiveness, or it could have caused an increase in the side effects of the medications. The DON said that if the resident was taking the medication on a regular basis, the medication should have been changed to routine to help resident's anxiety by the 14-day time-period.
During an interview on 02/10/23 at 10:34 a.m. the administrator said his expectation for psychotropic medications was for them to be followed up with by the physician, pharmacist, the DON, and the ADON. He said he was not sure about the risks to the resident, but if the medications were needed it should have been followed up with by the ADON and DON. The administrator said if there was no need for medications, he expected them to be discontinued or residents could have had adverse side effects.
Record review of the facility policy
Medication Monitoring Medication Management dated 01/20 indicated
Policy
Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug
In excessive dose
For excessive duration .
Based on comprehensive assessment of a resident, the facility must insure:
Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record
Residents who use psychotropic drugs .
PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days .
Based on interview and record review the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 3 (Resident #31, #27, #18) of 7 residents reviewed for unnecessary medications.
The facility failed to ensure Resident #31's and Resident #27's PRN lorazepam (anti-anxiety medication) was discontinued after 14 days or a documented rationale for the continued provision of the medication was provided.
The facility failed to ensure Resident #18's PRN alprazolam (anti-anxiety medication) was discontinued after 14 days or a documented rationale for the continued provision of the medication was provided.
This failure could put residents at risk of possible psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.
Findings included:
1.
Record review of Resident #31's undated facesheet indicated Resident #31 was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses that included anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities), and depressive episodes (episodes of persistent sadness and loss of interest).
Record review of Resident #31's quarterly MDS dated [DATE] indicated Resident #31 did not have a BIMS score (a tool used to screen an identify the cognitive condition of residents upon admission into a long care facility). This indicated Resident #31 was rarely/never understood. Resident #31 was assessed to have anti-anxiety medication 7 of 7 days during the assessment window. Resident #31 required extensive assistance for eating and toileting. Resident #31 required total assistance for bed mobility, transfers, locomotion, dressing, and personal hygiene.
Record review of Resident #31's care plan dated 11/23/22 and revised on 01/03/23 indicated a care plan for psychotropic drug use. The goal was benefit without side effects. Interventions included Gradual dose reduction, monitor for side effects per psychotropic flowsheet, monitor target behaviors per psychotropic flowsheets, and refer to social services if needed.
Record review of Resident #31's physician's orders dated 02/08/23 reflected an order for lorazepam 0.5mg 1 tab, may have one PRN dose between doses, once a day - PRN. The order start date was 12/04/22. No end date was found.
Record review of Resident #31's MAR dated 12/31/22 for the month of December 2022 reflected an order for lorazepam 1 tablet 0.5mg, once a day - PRN. Further review of the MAR indicated Resident #31 was administered the PRN lorazepam on 12/19/22, and 12/22/22.
Record review of Resident #31's MAR dated 1/31/23 for the month of January 2023 reflected an order for lorazepam 1 tablet 0.5mg, once a day - PRN. Further review of the MAR indicated Resident #31 was administered the PRN lorazepam on 01/02/22.
Record review of Resident #31's MAR dated 02/08/23 for the month of February 2023 reflected an order for lorazepam 1 tablet 0.5mg, once a day - PRN.
2.
Record review of Resident #27's electronic face sheet, dated 02/10/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included depression, anxiety (what we feel when we are worried, tense or afraid), and chronic obstructive pulmonary disease {COPD} (diseases that cause airflow blockage and breathing-related problems).
Record review of Resident #27's significant change MDS assessment, with an ARD of 06/25/22, revealed under Section B, Hearing, Speech, and Vision, under sections B0700 was coded as a 0 indicating he understands and under section B0800 was coded a 1 indicating he was usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 07 for cognitive severely impaired. Section G, Function Status, under section G0110 indicated he needed extensive assistance with bathing, personal hygiene limited assist with toileting, dressing supervision with eating, bed mobility, and transfers.
Review of Resident #27's comprehensive person-centered care plan dated initially dated 11/12/21 and revised 02/09/23. Focus indicated: Resident #27 may need Ativan (lorazepam) as needed for anxiety episodes or behavior episodes. Intervention indicated: assess, monitor, and document his mood, give medication as ordered, be assuring and listen to his concerns.
Review of Resident #27's physician's orders dated 06/22/22 indicated Lorazepam 0.5mg, give 1 tablet by mouth every 4 hours as needed.
Record review from pharmacy recommendation dated 12/06/22 recommended facility get a stop date on Lorazepam for Resident #27.
3.
Record review of Resident #18's face sheet dated 02/10/23 indicated that Resident #18 a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of dialysis dependence, heart failure, stomach bleed, insomnia, mood disorder, anxiety, and high blood pressure.
Record review of Resident #18's admission MDS dated [DATE] indicated in Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 15 for cognitively intact. The MDS section I, Active diagnosis, under section I5700 indicated Resident #18 had a diagnosis of anxiety.
Record review of Resident #18's physician order report dated 01/01/23-02/10/23 indicated that resident had an order for alprazolam-schedule IV tablet; 1mg; oral [DX: anxiety disorder due to known physiological condition] Twice a day-PRN; PRN1, PRN2 dated to start on 12/26/2022 and end on 02/10/2023.
Record review of Resident #18's medication administration history dated 01/01/2023-01/31/2023 indicated that resident was administered alprazolam 1mg tablet oral on 1/15/23, 1/18/23, and 1/28/23
Record review of Resident #18's medication administration history dated 02/01/2023-02/10/2023 indicated that resident was administered alprazolam 1mg tablet oral on 2/7/23 and 2/8/23.
During an interview on 02/09/23 at 02:20 p.m. RN D said he gave Resident #31 her medications today. He said he had not given the PRN lorazepam to her. He was not sure if it should have an end date. He said in his experience generally it is up to the doctor to decide when the medication should have an end date. He said some doctors set the end date at 30 days and extend it if needed. He said that unnecessary medications could cause side effects such as over sedation or sleepiness.
During an interview on 02/09/23 at 02:28 p.m. RN T said she has given Resident #31 the PRN lorazepam before. She has not noticed if Resident #31 had any side effects. She said the order for the PRN lorazepam should have an end date after 14 days. She said unnecessary medications could cause side effects. She said that could include neurological or musculoskeletal side effects. she said this could include muscle twitching, over sedation, and sleepiness.
During a phone interview on 02/10/23 at 10:00 a.m. The DON said all psychotropic PRN medications should have an end date at 14 days and be reevaluated at the end date. She said the ADON and DON are responsible for checking orders for end dates, and nurses are supposed to check on end dates and make sure the medications are reevaluated by the doctor. She said the risk of unnecessary medications could be that the medications are not being monitored and could cause side effects. She said if order is present the staff should be monitoring for side effects and effectiveness. She said the PRN lorazepam for Resident #31 should be changed to routine or stopped instead of remaining PRN. She said the PRN lorazepam should have an end date.
During an interview on 02/10/23 at 10:10 a.m. the DON said any PRN order for psychotropic medications have a 14-day time limit and the physician should re-evaluate the medication use, or the medication should be discontinued. She said that the risk to the resident if the evaluation was not completed would be the resident not being monitored for effectiveness, or it could cause an increase in the side effects of the medications. The DON said that if the resident was taking the medication on a regular basis, the medication should have been changed to routine to help resident's anxiety by the 14-day time-period.
During an interview on 02/10/23 at 10:33 a.m. The ADON said lorazepam PRN should have an end date at 14 days. She said there should be documentation of a rationale for continuing the order if it is continued. She said the risk of unnecessary medications could be that the resident could have side effects. She said the nurse and nurse management are responsible for checking if the PRN lorazepam have an end date.
During an interview on 02/10/23 at 10:34 a.m. the administrator said his expectation for psychotropic medications was for them to be followed up with by the physician, pharmacist, the DON, and the ADON. He said he was not sure about the risks to the resident, but if the medications were needed it should have been followed up with by the ADON and DON. The administrator said if there was no need for medications, he expected them to be discontinued or residents could have adverse side effects.
During an interview on 02/10/23 at 10:36 a.m., the ADON said if a resident has a PRN order, the order should read to give for 14 days and then re-elevated. If the physician decides to keep the medication, they will need to document why. The charge nurses and nurse management were responsible to look to see if PRN medication has a stop date. The ADON said the risk for PRN medication could be the side effects. The ADON said she was now aware Resident #27 had a PRN order for Lorazepam, she did not see the recommendation made by the pharmacist in December.
During an interview on 02/10/23 at 11:02 a.m., LVN G said she was aware PRN medication should only be used for 14 days and if the resident needs the medication routine, she will notify the doctor for further orders. LVN G said she was not aware if a resident came to facility already on a PRN medication the rules of 14 days stilled applied. LVN G looked at Resident #27's physicians ordered and verified Resident #27 did have a PRN. LVN G said failure to monitor could lead to side effects.
Record review of the facility policy
Medication Monitoring Medication Management dated 01/20 indicated
Policy
Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug
In excessive dose
For excessive duration .
Based on comprehensive assessment of a resident, the facility must insure:
Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record
Residents who use psychotropic drugs .
PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and resident choices for 1 of 17 residents reviewed for treatment and services. (Resident #93)
The facility failed to follow MD orders to obtain a CT (Computed Tomography) for Resident #93 on 8/11/22 and on 8/17/22. Resident #93 did not have a CT while she was in the facility. She had to have surgery for an abscess on 8/26/22.
This failure could place residents at risk of not receiving care as required and could result in further decline of condition and possible death.
An IJ was identified on 2/9/23. The IJ template was provided to the facility on 2/9/23 at 12:07 p.m. While the IJ was removed on 2/10/23 at 12:44 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm because (e.g.) all staff had not been trained on Lab and Diagnostic Testing Protocol, and Laboratory Guidelines.
Findings included:
A record review of the undated face sheet indicated Resident #93 admitted [DATE], was [AGE] years old, and had diagnoses that included: Diverticulitis of large intestine with perforation and abscess without bleeding (severe inflammation of the bowel wall layers with necrosis and loss of intestinal wall integrity), unspecified open wound of abdominal wall (surgical opening in abdomen), pain, colostomy status (a piece of the colon is diverted to the abdominal wall to bypass a damaged part of the colon), and Peritonitis (inflammation of the peritoneum caused either by the blood or after rupture of an abdominal organ). (The peritoneum is the serous membrane lining the cavity of the abdomen and covering the abdominal organs.)
A record review of the MDS dated [DATE] indicated Resident #93 admitted [DATE], had clear speech, understood others and was understood by others. The MDS indicated she had was cognitively intact and required the limited assistance of 1 staff for bed mobility and supervision with set up help for transfer. The MDS indicated Resident #93 had occasional pain and received PRN (as needed) medication for pain. The MDS indicated she had surgical wound(s) and received surgical wound care. The MDS indicated she had received an opioid (pain medication) 5 of 7 days of the look back period. The MDS indicated she had an ostomy and had received IV medications.
A record review of the care plan dated 7/28/22 indicated Resident #93 would have care assist documented: breakfast, lunch, dinner, and percentages of her evening snack. The care plan indicated she preferred to have her bath/shower at 5:00 a.m. The care plan indicated she would receive nail care, oral care, and a weekly head to toe skin assessment. The care plan did not address her surgical wound, ostomy, pain, IV antibiotics, or physician's orders.
A record review of the physician's orders dated 7/1/22 indicated Resident #93 had orders indicating:
8/11/22 CT (Computed Tomography-a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body) of abdomen and pelvis with IV (intravenous) oral contrast ASAP. STAT - Immediately, ordered by her PCP.
8/17/22 CT of abdomen and pelvis with IV oral contrast ASAP, ordered by her PCP.
A record review of the physician's orders on 2/9/23 at 9:16 a.m. indicated LVN G documented on 8/17/22, Resident #93 had an order for:
8/17/22 CT of abdomen and pelvis with IV oral contrast ASAP.
A record review of a progress note indicated Resident #93 discharged from the facility 8/25/22 at 10:20 a.m. The note indicated she was ambulatory, left in a personal car with a friend with her medications. The note indicated she had discharged with a surgical wound.
During a phone interview on 2/6/23 at 11:39 a.m., Resident #93 said she stayed in the facility for 25 days. She said the MD ordered a stat CT and she never got it because the facility did not make the appointment. She said she had 3 surgeries before admitting to the facility on 7/27/22. She said one of those surgeries was due an abscess in her abdomen. She said she admitted to the hospital on [DATE] a few hours after discharging from the facility and had surgery on 8/26/22 for an abscess. She said when she left the facility she did not tell anyone she had fever and chills because she just wanted to leave. She said she went to the ER the same day she left the facility (8/25/22) because she felt bad.
During an interview on 2/7/23 at 9:32 a.m., LVN G said she remembered Resident #93. She said she was on an antibiotic the entire time she was in the facility. She said she went off of her antibiotic and they called the infection control MD and he put her right back on the antibiotic. She said Resident #93 had a wound vac and her abdomen had mesh or Vaseline gauze on it or something along with the wound vac. She said she would have to look in the notes to see when she got the CT of her abdomen. She said she remembered the order for the CT.
During an interview on 2/7/23 at 9:52 a.m., LVN G looked at the notes and said Resident #93 was on an antibiotic 7/27/22 to 8/1/22. She said that same day the same antibiotic was restarted on 8/1/22 until 8/6/22. She said she started antibiotics again on 8/11/22 through her day of discharge on [DATE]. She said she never complained of being sick or feeling bad. She said she wanted to leave and did not give them time to set up home health. She said Resident #93 was determined to leave earlier than her planned discharge date (on 8/26/22) and discharged on 8/25/22. She said Resident #93 was determined to discharge even though she did not have home health and could not take the wound vac (facility wound vac.)
During an interview on 2/7/23 at 11:18 a.m., the MDS nurse said Resident #93 had a planned discharge for 8/26/22 but she was determined to discharge on [DATE]. She said Resident #93 said she would do her own wound care and her friend that picked her up when she discharged with would help her with it. She said if she correctly remembered the surgical wound on her abdomen was almost healed.
During an interview on 2/8/23 at 9:10 a.m., the ADON said she was looking for the CT that was ordered 8/11/22 for Resident #93. She said she would continue to look.
During an interview on 2/8/23 at 9:17 a.m., the ADON said she had looked in the records and did not see that Resident #93 had gotten the CT. She said she would continue to check. She said she saw where the information was faxed to the hospital by LVN A to request the appointment. She said LVN A was out of the country and could not be reached.
During an interview on 2/8/23 at 9:22 a.m., the RNC said if a CT was ordered for Resident #93 she should have gotten it per the MD orders. She said she would call the hospital to see if they had one.
During an interview on 2/8/23 at 9:31 a.m., Resident #93 said she was in the hospital 8/25/22 through 9/6/22. She said she started feeling bad and had chills a couple of hours after she discharged from the facility on 8/25/22. She said she had surgery 8/26/22 to remove an abscess. She provided the names and numbers of her physician's. She said pain was not a problem while she was in the facility. She said she received medication and her pain was controlled. She said the issue was she did not get the CT the MD wanted her to have. She said she thought the infectious disease MD had wanted her to have it. She said she was released from wound care last Friday.
A record review on 2/8/23 indicated Resident #93's recorded vital signs on the day of discharge were: Temperature 97.9 and respirations 18. There were no other documented vital signs for 8/25/22. Vital signs for her stay at the facility were reviewed and were within normal limits. A review of the MAR for July and August 2022 indicated she received pain medication and her pain was controlled.
A record review on 2/8/23 of the (facility) Wound Care MD's notes for Resident #93 indicated:
7/29/22, post-surgical wound, 33 x 6 x 4 cm, light serous exudate, 5% slough, 90% granulation (healthy pink tissue), and 5% muscle. The treatment plan was negative pressure wound therapy applied twice a week for 30 days. The notes indicated the Wound Care MD had debrided the wound. (Removing the dead or necrotic tissue.)
8/5/22, post-surgical wound, 27 x 6 x 3 cm, light serous exudate, 5% slough, 90% granulation tissue, 5% muscle. The treatment plan was negative pressure wound therapy twice a week with a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved.
8/12/22, post-surgical wound, 24 x 5 x 3 cm, light serous exudate, 5% slough, 90% grandulation tissue, 5% muscle. The treatment plan changed as Resident #93 wanted a break from the wound vac, educated resident it would take longer to heal without it. Resident continued to want a break from the vac. Treatment was alginate calcium with an abdominal pad apply once daily for 30 days and a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved.
8/19/22, post-surgical wound, 20 x 5 x 2.5 cm, light serous exudate, 5% slough, 90% granulation tissue, 5% muscle. The treatment plan was alginate calcium with an abdominal pad apply once daily for 30 days and a peri would treatment of skin prep twice a week. The Wound Care MD had debrided the wound. Wound progress was shown to be improved.
During a phone interview on 2/8/23 at 2:19 p.m., the nurse for Resident #93's infectious disease MD said the MD for Resident #93 was no longer in the state. She said she would research and let this surveyor know why a ASAP CT was ordered 8/11/22.
A record review of the MD orders dated 7/1/22 for the facility on 2/8/23 at 3:08 p.m., indicated Resident #93's Primary Care Physician ordered a CT of abdomen and pelvis with IV oral contrast ASAP, STAT immediately for Resident #93 on 8/11/22.
A record review on 2/8/23 of Infectious Disease Skilled Nursing, Nursing Home Orders indicated on 8/11/22 the infectious disease MD ordered Resident #93 a CT with IV/oral contrast ASAP and restarted her IV antibiotic medication.
During a phone interview on 2/8/22 at 3:17 p.m., Resident #93's PCP said he could not find the reason for the order for a CT for Resident #1 on 8/11/22. He said he may had ordered it for the Infectious Disease MD, but he did not remember. He said based on the records he was looking at on 8/11/22 Resident #93's antibiotic was restarted after she saw her infectious control MD. He said an ASAP CT was ordered along with restarting her antibiotic. He said her diagnoses at that time were: Localized peritonitis, long term use of antibiotics, and the last diagnosis was dated 7/18/22 and was Perforated diverticulitis. He said on 8/22/22 Resident #93 saw her surgeon for an office visit and she had an abdominal exam that indicated she was healing slowly with no signs or symptoms of infection or hernia and granulation was present (on the wound). Resident #93's PCP said she had gone to the ER on [DATE] with abdominal pain. He said on 8/30/22 Resident #93 had a drainage catheter placed in the area of fluid in her wound. He said the fluid can be a complication of surgery. He said she had 70 cc of fluid aspirated and he could not tell if the wound was infected. He said he did not think her having a CT on 8/11/22 would have prevented the hospitalization or procedures.
During a phone interview on 2/8/22 at 5:05 p.m., Resident 93's PCP said if she had an abscess it could have shown on a CT scan but he was not sure. He said if a CT had been performed on 8/11/22 he did not know if it would have prevented the hospitalization on 8/25/22 because he did not believe abscess was a primary diagnosis and she was admitted to the hospital on [DATE] to remove fluid.
During an interview on 2/8/22 at 5:16 p.m., LVN B said she did not remember Resident #93 having nausea and vomiting but that was a long time ago. She said she tried to show her how to do wound care and she was very involved in her care. She said she did not remember anything about a CT being ordered. She said if you get an order for a CT you send the resident information by fax to [Lab/Hospital name]. She said if they did not respond then the nurse would have to call them. She said the nurse that had taken the order for the CT was responsible to make sure it was done. She said the risk of not getting a CT when one is ordered by the MD could be serious illness, infection, and death. She said she remembered Resident #93 always reminded them when it was time for her pain medication.
During an interview on 2/8/22 at 5:28 p.m., the ADON said when a nurse took an order for a CT it was up to that nurse to call the hospital to set the CT up. She said the nurse would have to fax information to the hospital. She said the nurse was responsible for the CT, but if she did not do it, it would be up to her (ADON), then the DON. She said the order for the CT for Resident #93 should have been on the 24-hour report and should have been noticed immediately during the morning meeting from the 24-hour report. She said they failed to ensure the nurse had taken care of the CT and made the appointment. She said the risk of Resident #93 not getting the CT done per the MD order was it could be very harmful to her and could have caused serious injury or death. She said they did not have a radiology book.
During an interview on 02/08/23 at 5:41 p.m., CNA R said she faintly remembered Resident #93. She said Resident #93 always felt bad and always wanted pain medication.
During a telephone interview on 02/8/2023 at 5:43 PM CNA V said that she worked nights, and she remembered taking care of Resident #93. CNA V said she seemed to be sad all the time. She said she always complained of being sick and not wanting to do things. She said she would refuse her wound vac at times and complain of pain, but the nurse was responsible for that.
During an interview on 02/08/23 at 5:45 p.m., CMA L said Resident #93 had complained of pain around her abdomen and she gave her pain medication that was ordered. She said the pain medication seemed to help her. She said the nurse would usually be the one that asked her to give Resident #93 something for pain. She said Resident #93 would say her stomach had discomfort. She said she had a wound vac. She said she never gave Resident #93 a shower and did not see the wound. She said Resident #93 transferred herself. She said she did not complain about her colostomy. She said she was cooperative with her care, a sweet lady.
During a telephone interview on 02/08/2023 6:00PM LVN C said that Resident #93 had an abdominal wound. She said Resident #93 did not like to have the wound vac in place and would at times refuse it, turn it off, and refuse wound care. LVN C said she did not recall an order for CT scan, but if there ever was an order, she would have called DON or ADON to notify of the order, place on the 24-hour report, and follow through to ensure it was completed. LVN C said an order for a CT scan was important and could result in issues or complications related to the reason for the order.
During an interview on 2/8/23 at 6:10 p.m., the ADON said LVN F took the order for the CT on 8/11/22 for Resident #93. She said she was a mobile nurse for their company and she will find her phone number.
A record review of the hospital records indicated Resident #93 admitted [DATE] (no time was documented) with chief complaints of nausea and vomiting. The records indicated she had a CT on 8/25/22 indicating she had loculated (localized failure of an area to drain fluid, resulting in an enlarged mass) 9.3 x 5.1 x 3.2 cm fluid collection in her left lateral abdomen at the level of the previous perforation. The CT also indicated she had fluid collection that was probably extraperitoneal (the portion of the abdomen and pelvis which does not lie within the peritoneum) which could represent post operative seroma (a pocket of fluid) fluid collection under the skin near the cut the doctor made during surgery), but suggested aspiration to rule out abscess. The aspiration procedure on 8/26/22 indicated Resident #93 had a peritoneal abscess and 70 ml of fluid was aspirated. The hospital records also indicated she had a chest X-ray on 8/26/22 to evaluate for infection, due to her running a fever. The results of the X-ray indicated no active chest process.
During an interview on 2/9/23 at 8:51 a.m., the RNC said the process for radiological orders was that once an order was received, if it was not something that could be done in-house the nurse that took the order would contact the hospital for scheduling. She said their process was not followed regarding Resident #93 and her CT. She said the process was not followed in the morning stand-up meeting because they are supposed to go over all new orders in the meeting and Resident #93's CT was missed. She said she was not sure they were having the morning clinical meeting. She said all orders should be discussed in the morning clinical meeting and the nursing administration, the ADON, and DON were responsible to make sure all new orders were double checked and to make sure orders had been scheduled. She said all new orders should be reviewed by the ADON and DON every day in the morning clinical stand-up meeting. She said on Monday's the meeting goes back for 72 hours to check all new orders during the weekend. She looked at her calendar and said 8/11/22 was a Thursday so it should have been noticed either then or on the following Monday (8/15/22). The RNC said she believed the new order for Resident #93 was missed somehow. She said a STAT or ASAP CT should have been completed in 24 to 48 hours. She said, As soon as possible means as soon as possible. She said she could not answer why Resident #93's CT was not done because there was no documentation as to why it was not done. She said to go over the process for taking orders for radiology it was: 1. Nurse takes the order and follows up that it was done. Discuss the new orders in the morning clinical meeting with the 24-hour report. 2. Follow-up that the order was scheduled or completed, ensuring a date and time for the procedure. 3. Schedule transportation for the resident to go to the appointment. She said no one person was responsible because it was the responsibility of the ADON and DON. 4. The charge nurse was responsible to make sure the resident went to the scheduled appointment. The RNC said the failure was that the new order for Resident #93 was not discussed in the morning clinical stand-up meeting. She said the information about Resident #93's CT ordered 8/11/22 was on the 24-hour report. She said they had checked all their orders for CT's and radiological services and nothing else had been missed from August 2022 to present.
During a phone interview on 2/9/23 at 9:20 a.m., Resident #93's PCP said he did not remember reordering the CT on 8/17/22. He said it may have been because the CT was not done when ordered on 8/11/22 but he did not remember. He said the abscess on 8/26/22 on Resident #93's left abdomen had nothing to do with her incision. He said it had to do with her initial perforation prior to going to the facility on 7/27/22. He said the surgeon indicated on 8/26/22 Resident #93 had base grandulation in her wound based on the records he was looking at. He said he did not know if Resident #93 getting a CT on 8/11/22 or 8/17/22 would have prevented her hospitalization on 8/25/22 because he did not know if the abscess was there at that time. He said it could have been fluid left over from her surgery (prior to admitting at the facility). Resident #93's PCP said somewhere between her surgery prior to admitting to the facility and 8/25/22 she developed an infection on her left side which was the original area of perforation that caused the initial problem (prior to admitting to the facility
A record review on 2/9/23 of the progress notes indicated:
On 8/8/22 LVN G documented Resident #93 complained of heartburn and indigestion and requested medication for acid reflux. LVN G notified the MD and received an order for Protonix 40 mg by mouth daily.
On 8/9/22 LVN C documented Resident #93 stated the Protonix was very effective.
On 8/11/22 LVN F documented: Face sheet, order, and last doctor's visit with infectious disease faxed to [name and hospital] to schedule CT of abdomen and pelvis per orders. Awaiting approval for testing.
On 8/16/22 the ADON documented Resident #93 had vomited sometime after her scheduled Zofran (a medication for nausea and vomiting). The ADON documented Resident #93 wanted Mylanta and the ADON was awaiting a call back from the MD. The ADON documented she asked Resident #93 to please call her if she vomited so she could see it and inform MD of amount, color, smell. The resident voiced understanding. The progress notes indicated Resident #93 saw her surgeon on 8/22/22 with a new order to restart the wound vac. The office visit from the surgeon dated 8/22/22 indicated her abdomen was healing slowly, with no signs or symptoms of infection and no signs or symptoms of a hernia with granulation active on the midline of her surgical wound.
On 8/23/22 the MDS nurse documented she spoke with the resident regarding the potential need to stay a little longer due to being on the wound vac and the continuation of her IV medication. The MDS nurse documented on 8/23/22 Resident #93 was adamant she was going home on 8/26/22. The MDS nurse documented she asked Resident #93 for the safety of a good discharge to see about setting up wound care visits locally where she lived and asked her if she had anyone that could get her there. The MDS nurse noted the resident said she could do her own IV antibiotic and wound care. The MDS nurse explained the difficulty of that and Resident #93 said she was okay and was still going home on 8/26/22.
On 8/24/22 the progress notes indicated the DON called Resident #93's surgeon about her planned discharge on [DATE], explained she had no Home Health that would accept her insurance and no would vac. Requested to change her orders to something she and her family could manage at home.
On 8/25/22 LVN A documented Resident #93 had no signs or symptoms of infection at 8:27 a.m. The progress notes dated 8/25/22 documented by the MDS nurse indicated Resident #93 was going to discharge today even though she had no Home Health and no wound care set up yet. Resident did not want to wait and had a friend that was picking her up. The MDS nurse indicated she signed her paperwork and left hurriedly. The progress notes indicated LVN A documented on 8/25/22 Resident #93 refused to have the wound vac put back on and LVN A applied a wet to dry dressing to her incision. The progress notes indicated she left the facility ambulatory in a personal car with her friend at 10:42 a.m.
A record review on 2/9/23 of the progress notes 8/16/22 through 8/25/22 indicated there were no further notes regarding Resident #93 having nausea, vomiting or requesting Mylanta. There was no documentation of an order for Mylanta. A review of the MAR dated August 2022 did not indicate she had ever been given Mylanta.
A record review of the Facility activity report dated 08/11/22-02/02/23 on 02/09/23 at 08:45 a.m. which included all orders of any type of radiology for 54 residents in the facility during the time indicated Resident #93 was resident in the facility from 07/27/22-08/25/22 had CT of abdomen ordered on 8/11/22 as well as 08/17/22 and was never completed. Every order for radiology ordered during the time period had an image that was viewed to correspond to the order.
During an interview on 2/9/22 at 9:45 a.m., the ADON said Resident #93 did not get the CT ordered on 8/11/22 or the CT ordered on 8/17/22. She said she thought the infectious disease MD had ordered them. She said the process for taking radiological orders was the same process she explained yesterday, but they should not have been missed in the morning stand-up clinical meeting. She said it was her responsibility to check new orders and make sure everything was completed that was ordered. The ADON said she did not know how she missed the CT's twice for Resident #93. She said she tried to look at all new orders daily but if she did not, it was also up to the DON to check new orders daily. She said she must have been focused somewhere else in the facility and that was why she missed the orders for Resident #93.
During an interview on 2/9/22 at 9:55 a.m., the RNC said the CT ordered for Resident #93 on 8/11/22 and the CT ordered on 8/17/22 was not done. She said they were missed because they were not followed up on. She said staff should have followed up. She said Resident #93's nurse's, the ADON, and the DON should have followed up on them to make sure they were done. She said it should have been noticed on the 24- hour report that they went over in the standup clinical meeting in the mornings. She said possible outcomes of missing the CT twice could be serious injury or death because she already had an infection and had been on IV antibiotics while in the facility.
During an interview on 02/09/23 at 10:01 a.m., LVN A said she worked 6:00 a.m. to 6:00 p.m. She said if she had an order for a CT she would give the information to the transportation person (CMA L) because she usually made all transportation appointments. She said if she was not available, the facility would make arrangements for transportation. She said if the order read ASAP she would get the CT done as soon as possible. She said they would notify the family and MD, then document the appointment was made. She said Resident #93 had pain when she came to facility but that was nothing unusual as she had major surgery. She said they gave her pain medication prior to wound care. She said Resident #93 did not like the wound vac and had refused it at times. She said the facility Wound Care MD saw her and changed her order because she did not want the wound vac, then Resident #93 saw her surgeon and he put her back on the wound vac. She said the doctor told her it was better for her to use the wound vac. She said there was a calendar in the system where they would document appointments that have been made, then the information was put on the 24-hour report. She said you would not normally tell the ADON or DON because they could see the order for the CT in the computer system.
During a phone interview on 2/9/22 at 10:10 a.m., the DON said the process for ordering a CT or radiological order was the MD would usually set it up with the hospital. She said if not, the facility nurse for the resident would call the hospital and fax the necessary information regarding the resident. She said the hospital would then determine insurance and any other requirements, then usually within a few days they would hear back from the hospital with the appointment. The DON said usually a STAT or ASAP order is set up by the MD that ordered it, then the hospital calls them with the appointment. She said she did not know what went wrong with Resident #93 missing two CT's. She said two different nurses put in for a CT for Resident #93 and neither ever followed up on them. She said LVN A took the order on 8/17/22. She said she was out of the country and could not be reached. She said LVN F took the order on 8/11/22. She said usually the new orders stay on the 24-hour report and she and the ADON review the 24-hour report daily. She said on Monday's they look at the weekend 24-hour reports. She said the failure was the new orders were not monitored by herself and the ADON. She said they (ADON and herself) did not see them and did not know what happened to cause them to miss the orders. She said the ASAP or STAT CT ordered for Resident #93 on 8/11/22 should have been done by 8/13/22 or 8/14/22 at the latest. She said the ASAP or STAT CT for Resident #93 should have been done by 8/19/22 or 8/20/22 at the latest. She said if the MD had not set up either of the CT's the nurse, ADON or she should have called the MD for assistance to set up the CT's. She said as the DON she was one hundred precent responsible for making sure the CTs were done. She said the process they were using slipped through this time and it one hundred percent failed with these CTs. She said the CTs being missed should not have happened. She said it was a follow up oversite. She said the CT's ordered were just follow-up's because Resident #93 was not having symptoms of an infection. She said the potential harm for missing the CTs was a chance of a complication. She said she did not know if the potential for complication could be serious.
During an interview and record review on 02/09/23 at 10:19 a.m., CMA P /transportation said she tried to make all appointments for CT and radiology as much as possible. She said she made CT and radiology appointments if she was given the information to make it. She said once the appointment was made, she would get with the nurse, who would then input the appointment into the computer. She said she looked daily at the calendar for appointments. This surveyor reviewed August 2022 for any appointments for Resident #93 and did not see any appointments for her. She said she did not remember anyone asking her to make an appointment for Resident #93. She said if she had been told about it she would have made the appointment. CMA P said she would call and call and if needed would go by the place to see if they could get the resident in. But, she said she did not remember doing that for Resident #93. She said during the time they had an active Covid outbreak they had shut down all appointments to keep from spreading Covid but she did not remember if that was during that time or not.
During an interview on 02/09/23 at 10:30 a.m., the ADON said they had a Covid outbreak and indicated it was in July. She stated during the outbreak, they did cancel all appointments for a week to prevent the spread of COVID.
During an interview on 2/9/23 at 10:31 a.m., the ADON said she could not find the 24-hour reports for 8/17/22 and 8/18/22. She provided the 24-hour report for 8/11/22 - 8/12/22.
A record review on 2/9/23 of the 24-hour report dated 8/11/22 - 8/12/22 indicated Resident #93 was ordered:
8/11/22, CT of abdomen and pelvis with IV oral contrast ASAP, STAT, immediately. The order was created by LVN F and signed by Resident #93's PCP.
During an interview on 2/9/23 at 10:32 a.m., LVN F said she was a mobile nurse for the company. She said on 8/11/22 she and the DON, or the ADON (she could not remember which one) faxed information to the hospital regarding the order for the CT for Resident #93. She said she did not work the next day (8/12/22) but if she had she would have made sure the CT was scheduled. She said she thought there was a person that followed up on the CT but she did not know who. She said she thought it might have had something to do with Resident #93's insurance, maybe needing a prior authorization but she was not sure. She said she thought the ADON or DON would follow up on the order for the CT. She said she passed the information on in the 24- hour report.
During an interview on 2/9/23 at 10:32 a.m., the RNC provided a Lab and Diagnostic Test Results Policy. She said this covered both the Radiological Policy and the Monitor Diagnostic Tests Policy.
During an interview on 02/09/23 at 10:34 a.m., RN D said he had worked at the facility since September of 2022, only PRN and only as a medication aide. He said he did not work as a charge nurse. He said as soon as possible meant as soon as possible, as soon as you could get it done. He said if you had an order for a CT, but it would take a while to get the appointment made he would call the MD to see what he wanted to do because of the lengthy time frame. He said if he was able to make the appointment he would put on 24-hour report so the next nurse would see it and follow up on it. He said the information on the 24-hour report usually rol[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 1 of 17 residents reviewed for care plans, (Resident #93).
Resident #93 did not have a care plan for her surgical wound, ostomy, pain, PICC line, IV medications, pressure ulcer risk, psychotropic and opioid drug use.
This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.
Findings included:
A record review of the undated face sheet indicated Resident #93 admitted on [DATE], was [AGE] years old, and had diagnoses that included: Diverticulitis of large intestine with perforation and abscess without bleeding (severe inflammation of the bowel wall layers with necrosis and loss of intestinal wall integrity), unspecified open wound of abdominal wall (surgical opening in abdomen), pain, colostomy status (a piece of the colon is diverted to the abdominal wall to bypass a damaged part of the colon), and Peritonitis (inflammation of the peritoneum caused either by via the blood or after rupture of an abdominal organ). (The peritoneum is the serous membrane lining the cavity of the abdomen and covering the abdominal organs.)
A record review of the MDS dated [DATE] indicated Resident #93 admitted [DATE], had clear speech, understood others and was understood by others. The MDS indicated she had was cognitively intact and required the limited assistance of 1 staff for bed mobility and supervision with set up help for transfer. The MDS indicated Resident #93 had occasional pain and received PRN (as needed) medication for pain. The MDS indicated she had surgical wound(s) and received surgical wound care. The MDS indicated she had an ostomy and had received IV medications. The MDS indicated she had received an opioid (pain medication) 5 of 7 days of the look back period.
A record review of the care plan dated 7/28/22 indicated Resident #93 would have care assist documented: breakfast, lunch, dinner, and percentages of her evening snack. The care plan indicated she preferred to have her bath/shower at 5:00 a.m. The care plan indicated she would receive nail care, oral care, and a weekly head to toe skin assessment. The care plan did not address her wound, PICC line, antibiotics,colostomy, pain, or physician's orders.
During an interview 2/9/23 at 2:42 p.m., the MDS nurse said she never finished the care plan for Resident #93. She said it was during a Covid outbreak and she was working on the floor, was busy, and never finished the care plan. She said Resident #93 should have been care planned for her surgical wound, ADL's, colostomy, IV antibiotics and PICC line, pain, labs, and her ordered CT's. She said there was not a risk to Resident #93 of not having her care plan complete. She said she was receiving all the care per the MD orders. She said she should have completed the care plan for Resident #93.
During an interview on 2/9/23 at 2:53 p.m., the RNC said the MDS nurse should have completed the comprehensive care plan for Resident #93. She said the comprehensive care plan should have been completed 7 days after the completion of the MDS. She said the failure was in the morning clinical meeting that discusses new admits, change of condition, and all that happened in the building. She said the morning clinical meeting discusses all things that happened in the last 24-hours in the facility. She said the DON would know about a new admit from the clinical morning meeting. She said the failure was the morning clinical meeting and she said it was questionable if they were even having morning meetings. The RNC said the risk of Resident #93 not being care planned for her surgical wound, ostomy, pain, PICC line with IV medications, pressure ulcer risk, psychotropic and opioid drug use was immediate harm because staff should know what is going on with the resident and staff should be educated on what interventions are for all of her care.
During a phone interview on 2/10/23 at 9:59 a.m., the DON said Resident #93 should have been care planned for her surgical wound, ostomy, pain, IV medications, pressure ulcer risk, psychotropic, opioid drug use, and anything else she had going on. She said the MDS nurse should have finished the comprehensive care plan. She said as the DON she should have checked the care plan when she signed off on the MDS but she did not. She said she had no explanation of how she missed the care plan was incomplete. She said the orders for Resident #93 were being followed and the resident was not missing care. She said the only risk or problem was the resident should have been aware of her care plan and it should have been completed. She said without a complete care plan there were no clear and concise records of what her care needs were while she was in the facility.
During an interview on 2/10/23 at 10:08 a.m., the administrator said a care plan should be done on every resident in an appropriate time frame per the policy. He said Resident #93 not having a care plan was a failure of the team in general. He said he did not know the risk of Resident #93 not having a care plan because she had orders and the orders were being followed. He said Resident #93 was being seen by an outside wound MD, an infectious disease MD, and he said he was not sure if she was being seen by her surgeon, but she was also being seen by her PCP.
A record review on 2/10/23 of a Policy and Procedure for Care Plans, Comprehensive Person-Centered, dated December 2020 provided by the RNC indicated:
Policy Statement
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally - competent and trauma informed.
1.The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.
2.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .
8.The comprehensive, person-centered care plan will:
a. Include measurable objectives and times frames;
b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .
g. Incorporate identified problem areas .
h. Incorporate risk factors associated with identified problems;
I .Build on the resident's strengths;
j. Reflect the resident's expressed wishes regarding care and treatment goals;
k. Reflect treatment goals, timetables and objectives in measurable outcomes;
l. Identify the professional services that are responsible for each element of care
m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;
n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and
o. Reflect currently recognized standards of practice for problem areas and conditions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement policies addressing resident admission to the facility for 2 of 12 residents (Resident #15 and Resident #18) reviewed for admission.
Resident #15 was not provided a signed admission packet or information upon admission to the facility upon admission on [DATE] and continued to reside in the facility without a completed admission agreement.
Resident #18 was not provided a signed admission packet or information upon admission to the facility upon admission on [DATE] and continued to reside in the facility without a completed admission agreement.
This deficient practice could place residents at risk of not being made aware of their rights, the facility characteristics and services provided by the facility or policies of the facility.
The findings included:
1.Record review of the face sheet dated 2/10/23 indicated Resident #15 was a [AGE] year-old female who originally admitted to the facility on [DATE] with the diagnosis of chronic kidney disease, anxiety, high blood pressure, cellulitis (bacterial infection of the skin), and muscle weakness.
Record review of Resident #15's admission MDS dated [DATE] indicated in Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 13 for cognitively intact.
Record review of the Resident #15's admission packet indicated it was completed and signed on 02/06/23.
During an interview with Resident #15's family member on 02/06/23 at 11:50 a.m. she said that Resident #15 was never given an admission packet when admitted . She said she received an admission packet from the social worker for Resident #15 on 12/29/22 to complete and Resident #15 wanted to complete the packet while discussing it with her. Resident #15's family member said that resident had been paying private pay and is now in the process of applying for long term care Medicaid. She also said the facility did not have Resident #15's social security number correct, and she did not understand why she could not use their pharmacy for medications.
2. Record review of the face sheet dated 2/10/23 indicated Resident #18 was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of dialysis dependence, heart failure, stomach bleed, insomnia, mood disorder, anxiety, and high blood pressure.
Record review of Resident #18's admission MDS dated [DATE] indicated in Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 15 for cognitively intact.
Record review of the Resident #15's admission packet indicated it was completed and signed on 02/06/23.
During an interview with Resident #18 on 02/07/23 at 2:15 p.m. Resident #18 said she did not know why she did not get an admission packet completed when she admitted to the facility, but her sister called her and told her to complete it for the facility on 02/06/23. She said the business office guy came and had her sign the paperwork for admission on [DATE].
During an interview on 02/06/23 at 09:48 a.m. the business office manager said he was responsible for ensuring the admission packets were completed upon admission of each resident, but he was out of the facility for several days in the year 2022. He said that when he was out, the administrator would have assigned someone else to the task of completing the admission packet paperwork.
During an interview on 02/09/23 at 03:08 p.m. with the administrator, the administrator said every time a resident is admitted to the facility the admission packet paperwork should have been completed. He said the business office manager was responsible for ensuring the admission packets were completed. The administrator said the business manager also had a regional person who was supposed to oversee him and ensure the packets were completed. The administrator said there were many things that are important included in an admission packet, but on a legal standpoint, there would have been no consent to treat. He said the admission packet also had included the electronic surveillance, the facility policies, and the resident rights to choose the medical doctor and the pharmacy.
During an interview on 02/09/23 at 03:15 p.m. with the RNC, the RNC said the business office manager is responsible for completing the admission packet. RNC said the admission packets are expected to be completed, but unsure of the time frame. She said the problems that could happen if the packet was not being completed would include payment, insurance verification, medication, and pharmacy choices.
During an interview on 02/09/23 at 03:32 p.m. the business office manager said Resident #18's admission packet was just missed because he was out of the facility, and Resident #15's admission packet he did not know why it was missed. He said he had given Resident #15's sister a copy of the packet but was unsure of the date. Business office manager said that he had Resident # 15's social security number input incorrectly, but it had been fixed on 02/06/23 when he had Resident #15 provide it to him when she signed the admission packet. He said she had admitted under a Medicare replacement plan, so it did not affect the billing. The business office manager said, him not getting the admission packet completed upon admission was important and could have caused problems with residents, but he had a verbal agreement about the choice of medical director. He said Resident #15 and Resident #18 were the only packets he had missed.
Record review of the facility's policy titled admission Agreement (Revised October 2021) indicated .Policy statement: All residents have a signed and dated admission Agreement on file. Policy interpretation and implementation: 1. At the time of admission, the resident (or his/her representative) must sign an admission agreement which is a contract for services with the center .