Haven Of Tucson

Based on observations, staff interviews, and policy review, the facility failed to ensure medications were disposed of according to accepted professional standards. The deficient practice of erroneous medication disposal may result in undesirable medication- induced harm.

Findings include:

During a medication administration observation conducted on December 17, 2024 at 7:32 A.M. the Licensed Practical Nurse (LPN/Staff #242) was observed to split a medication tablet (Mirapex) in half and proceed to place one half of the medication tablet into a clear unlabeled medication cup and place it back into the medication cart stating to "save for the afternoon". The LPN also disposed of a medication (Geri-Kot) in the resident's room trashcan after the resident refused the medication.

An interview was conducted on December 17, 2024 at 8:07 A.M. with the LPN (staff #242) who stated that he was not sure what the facility policy was regarding saving half of the Mirapex medication. He further stated that he could waste the other half of the medication and then in the afternoon do the same thing. The LPN stated that he would dispose of the medication by throwing it in the sharps container. The LPN also stated that he should have asked the resident to retrieve the medication the resident refused from the medication container and then disposed of it in the sharps container. The LPN stated that placing the unused half of the Mirapex into an unlabeled container for later use and disposing of a medication in the resident's room trash did not meet facility expectations.

An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated that the facility expectation would be to follow the state guidelines and regulations regarding the disposal of medications. The DON stated that the process for cutting a medication in half would include to dispose of the unused half of the medication and not save it for later use. The DON also stated that if it was a single pill then it should go into either the sharps container or the drug buster, and to not dispose of medications in the trash. She further stated that not disposing of the unused half of the Mirapex and disposing of the Geri-Kot in the resident's room trash did not meet facility expectations.

Review of the facility policy titled, Medications: Discarding Medications, version 051123 revealed that non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding the disposition of non-hazardous medications.

Based on observation, record review, interviews, and facility policy, the facility failed to ensure that monitoring and evaluation of physical restraints are completed for the continued use of physical restraints for one resident (Resident #62).

Findings include:

Resident #62 was initially admitted into the facility on April 16, 2024, and then re-admitted on August 8, 2024 with the diagnosis of metabolic encephalopathy, pneumonitis due to inhalation of food and vomit.

A review of a care plan focus initiated on August 13, 2024 revealed that Resident #62 used a form of physical restraints, bilateral soft mitts. The focus also revealed interventions to ensure the resident is positioned correctly with proper body alignment while restrained, and, as well as monitoring and assistance every 2 hours for daily care.

An order dated August 13, 2024 revealed that staff will ensure proper placement of bilateral soft mitts are released every two hours for ten to fifteen minutes.

An order dated August 19, 2024 revealed that staff will provide frequent checks for safety and positioning of mitts, and to notify the provider for any skin breakdown.

A review of a quarterly Minimum Data Set (MDS) assessment dated November 14, 2024 revealed no evidence of a Brief Interview for Mental Status (BIMS) score. The MDS also revealed that the resident is completely dependent on staff assistance. The MDS also revealed that the resident had a limb restraint for daily use in bed.

On December 16, 2024 at 12:00 P.M. an observation was done on Resident #62, where Resident #62 was observed in bed with bilateral soft mitts on.

In an interview conducted on December 16, 2024 at 12:25 P.M. with the power of attorney (POA) for Resident #62, the POA stated their approval of the restraint and the communication received, regarding the bilateral soft mittens. The POA also stated that they were provided the education and the expectations regarding the restraints and shared that they believe the facility had not provided regulation accordingly, and properly, as it was discussed with them.

An interview conducted on December 16, 2024 at 12:46 P.M. with a Certified Nursing Assistant (CNA/Staff #206), where Staff #206 stated they had been provided training on the usage of restraint devices, including bilateral mitts, and to remove the restraint every two hours. Staff #206 stated that specifically for Resident $62, the were to observe the resident's hands for any skin tares and skin abnormalities, and as well as if the resident states of any itchiness and sweating in the mitts. Staff #206 stated that any CNA and nurse has the capability to assist the resident with the removal of the restraint and that the restraint had been ordered for the resident as Resident #62 had a history of pulling out their tracheostomy tube and their peripherally inserted central catheter (PICC) line. Staff #206 stated that their role in this process is to document their checks on the Resident #62's tasks chart on the facility's electronic health record platform.

An interview conducted on December 16, 2024 at roughly 12:50 P.M. with a Care Coordinator (Staff #72), were Staff #72 stated that the expectation with physical restraints is to complete skin observations and provide the resident with supervised time with the restraints off every two hours. Staff #72 also stated that the time spent monitoring the resident with restraints off can be between 10-15 minutes.

An interview conducted on December 16, 2024 at 1:05 P.M. with a Licensed Practical Nurse (LPN/Staff #196) where Staff #196 stated they had been provided training on the usage of restraint devices, which included bilateral mitts, and that they were trained to remove the restraint every two hours, providing monitored time of 10 to 15 minutes with the restraints off, and then to ensure that there is at least a two finger gap around the closure of the restraint. Staff #196 also stated that Resident #62 had been ordered the usage of restraints due to their history of behavioral episodes where the resident had tried to remove their tracheostomy tube and their peripherally inserted central catheter (PICC) line. Staff #196 stated that their role is to complete their checks on the Resident #62's treatment administration record and to complete assessments such as a restraint assessment and a skin assessment, on the facility's electronic health record platform. Staff #196 had also stated that there were times where the completion of charting the checks are not completed, and that they are missed.

An interview conducted on December 16, 2024 at 1:39 P.M. with the POA for Resident #62, and the POA shared that they had been with Resident #62 since approximately 9:00 A.M. that day, and that the expectations provided to them regarding the restraint, had not been completed.

On December 16, 2024 at 1:45 P.M. an observation was done on Resident #62, where Resident #62 was observed in bed with bilateral soft mitts on.

An interview was completed with the Director of Nursing (DON/Staff #94) on December 16, 2024 at 2:14 P.M., where Staff #94 stated that the expectations of restraint usage is that all staff, CNA's, nurses, and as well as respiratory nurses, are to be trained to aid with restraints, including soft bilateral mitts. That CNA's are to complete their hourly checks in any resident's task chart, regardless of what changes or conditions are observed. During this interview, Resident #62's tasks charts were reviewed up to 14 days prior to the investigation, and it revealed that the only date, out of the previous 14 days, where the charting tasks were completed accurately was December 8, 2024. Staff #94 stated that the incompletion of the expected monitoring of restraints did not meet the facilities expectations and the professional standards of the facility, as the harm to incorrect restraint monitoring for Resident #62 can lead to break down of the skin.

A review of the facility's policy titled "Use of Restraints" revealed that the opportunity for motion and exercise were to be provided for a period of not less than ten minutes during each two hours, in which restraints are employed. The policy also revealed that the resident should be repositioned at least every two hours on all shifts.

Based on observations, interviews, review of clinical records, and review of facility policy, the facility failed to ensure one resident (#46) received assistance to maintain hearing ability.

Findings Include,
Resident # 46 was admitted to the facility on November 27, 2024, with diagnoses of a right pelvic fracture, atrial fibrillation, anticoagulant therapy, anxiety, depression, and lack of coordination.

The resident's inventory dated November 27, 2024 failed to list hearing aids under the resident's personal property.

The resident's order dated November 27, 2024 revealed the resident could be seen by an audiologist.

The care plan dated November 27, 2024 with the download date of December 16, 2024, revealed no focus, goals, or interventions for resident's hearing.

The admission Minimum Data Set (MDS) dated December 3, 2024 revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS also revealed the resident had minimal difficulty in the ability to hear. The MDS did not reveal the resident use of hearing aids as an assistive device.

A psychological evaluation note dated December 10, 2024 revealed the resident's cognitive functioning and fund of knowledge were intact and age appropriate.

A progress note dated December 10, 2024 revealed the resident required multiple verbal cues for redirection, after revealing resident demonstrated compromised cognition.

A progress note dated December 13, 2024 revealed the resident was alert and oriented, but needed redirection during the day, and exhibited some signs confusion in the evening.

A progress note dated December 16, 2024 revealed resident did not have dementia or any other neurological concerns at the time
.
Review of the clinical record revealed no other information about the resident's hearing aid, such as when the hearing aid should be used, how much assistance the resident needed with the hearing aid, or that the resident had used the hearing aid while in the facility.

Review of the clinical record revealed no information regarding the escalation of any concerns regarding resident confusion.

A resident observation was conducted on December 15, 2024 at 2:40 p.m. Resident laying in bed. No writing materials, sensory boards, or any other hearing assistive device in resident's area with the exception of the left ear hearing aid.

The resident was observed on December 16, 2024 at approximately 9:30 a.m. during breakfast. No writing materials, sensory boards, or any other hearing assistive device in resident's area, with the exception of the left ear hearing aid.

The resident was observed speaking with a Certified Nurse Assistant (CNA) and the unit manager regarding her hearing aid. The CNA stated to the resident and unit manager that she charged the resident's hearing aid for her every night. No writing materials, sensory boards, or any other hearing assistive device in resident's area, with the exception of the resident's hearing aid charging by the television set.

An interview with the resident was conducted on December 15, 2024 at 2:40 p.m. The resident vocalized anxiety and frustration over the malfunction of her hearing aid. The resident further elaborated that it is very difficult to communicate with the staff, and tells them to slow down and please be patient with her. The resident stated that she has told the nurses about her hearing aid but they have not done anything about it. The resident denied the ability to communicate with sign language.

An interview conducted with a CNA (CNA/Staff #28) on December 16, 2024 at 8:50 a.m. The CNA stated that when a resident is hard of hearing they try to accommodate the resident by slowing down and speaking clearer. The also will write things down for the resident for increased understanding.

A revisit interview was conducted on December 16, 2024 at 9:30 a.m. with resident #46 whom revealed that the staff does not write messages down for her, but they do their best to speak loud enough and repeat for her. The resident stated that writing messages on a pad would be a "great idea". The resident further elaborated that sometimes when she still cannot understand what some staff members say, she will tell them to "just be patient with me". On the subject of forgetfulness, the resident stated she is a little forgetful at times, but a lot of times, she does not understand what is being said. The resident further stated sometimes when she does not understand she just "goes along with what I think they are saying".

An interview was conducted on December 17, 2024 with Social Services Director (SS/Staff #126) at 2:51 p.m. The director stated that the facility works closely with the resident, and refers to the clinical record in order to determine if any communication sensory needs are present. The director further elaborated that the facility provides communication boards, google, and writing pads to assist with resident communication. In regards to scheduling the appointment, the order is received by the primary care provider, and communicated to the staff who will schedule the appointment, and assist with transportation.

An interview was conducted with the MDS Coordinator (MDS/Staff #72) on December 18, 2024 at approximately 11:00 a.m. The coordinator was unable to locate in the MDS, the need for assistive devices for hearing. The coordinator stated the MDS is based on admission assessments, resident observations, and any other credible/approved clinical source. The coordinator explained that the MDS does assist in resident care planning. In addition, there is a likelihood that if the need for a hearing assistive device is missed on the MDS, it may also not immediately reflect in the care plan.

A written interview/correspondence conducted with the MDS Coordinator (Staff # 72) on December 18, 2024 at 1:21 p.m., revealed the coordinator submitted a correction for the MDS. In addition, the coordinator noted hearing difficulty was already care planned in the clinical record.

An interview was conducted with the Director of Nursing (DON/Staff #94) on December 18, 2024 at approximately 11:43 a.m. stated the process for residents with hearing impairments are identified and care planned for. The DON voiced that the hearing aid should have been included on the inventory sheet, the MDS, and the care plan of resident # 46. The director also further explained that staff are expected to communicate with all residents in a way that gives the greatest clarity and understanding. Staff # 94 agreed that the resident will benefit greatly from hearing assistance follow-up.

The facility's "Accommodation of Needs" policy revealed the resident's need for adaptive devices and modifications to the physical environment are evaluated upon admission, and reviewed on an ongoing basis.

The facility's "Care of the Hearing-Impaired Resident" policy revealed that the staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors.

The facility's "Resident Examination and Assessment" policy revealed the assessment process shall be systematic, comprehensive and multidisciplinary based on the individual's needs, acuity, and priorities in accordance with physician orders.

Based on staff interviews, clinical record review, and facility policy, the facility failed to ensure that one resident (#149) was not discharged with an unnecessary device.

Resident #149 was admitted on December 7, 2023 with diagnoses of urinary tract infection, Klebsiella pneumoniae and type 2 diabetes. This resident was discharged to an assisted living facility on February 6, 2024.

A care plan initiated on January 16, 2024 included that the resident was on Antibiotic Therapy including Meropenem for a urinary tract infection. Interventions included to observe for possible infection every shift.

A physician's order dated January 16, 2024 included Meropenem (antibiotic) Intravenous Solution Reconstituted 1 gram Use 1 gram intravenously every 8 hours for urinary tract infection for 3 Days was discontinued on January 19, 2024. A review of the clinical record did not find any medications administered intravenously after January 19, 2024.

A physician's order dated January 16, 2024 included to flush PICC Line with 10ml of NS
Q Shift, PRN and Pre and Post Medication every shift for PICC Line Usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 30, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024.

A physician's order dated January 16, 2024 included monitor PICC Line insertion site every shift for signs/symptoms of infection including redness, warmth, swelling, drainage every shift for PICC line usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 30, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024.

A physician's order dated January 16, 2024 included to change PICC line dressing every 7 days and as needed using sterile technique every day shift every Thursday for PICC Line Usage. This order was discontinued on January 30, 2024. Review of the clinical record included that the last notation of this cap being changed was on January 25, 2024. However, review of the record indicated that this resident had the PICC line until February 7, 2024.

A physician's order dated January 16, 2024 included discontinue intravenous (IV)/PICC line after completion of IV antibiotics, however review of the clinical record did not reveal documentation that the IV/PICC line had been removed.

A medication administration note dated January 25, 2024 included that the resident was no longer on IV antibiotics and that a message was sent to the MD to remove the PICC line and that the writer was awaiting a response. However, no further record of the PICC line was included until February 7, 2024.

A progress note dated February 6, 2024 included "Patient was discharged today at 1800 hours. patient unable to sign paperwork. Personal belongings and leftover meds were taken with. Picked up by transportation company"

A progress note dated February 7, 2024 included "Went to patients care home and removed midline no bleeding noted tip intact patient tolerated well pressure dressing applied"

An interview was conducted on December 17, 2024 at 1:08 P.M. with a Licensed Practical Nurse (LPN/staff #242) who said that they perform multiple discharges and that usually when a resident is finished with antibiotics, there is an order to remove the PICC line. This nurse said that the only reason the resident would keep a PICC line is if they are going to continue the IV meds. This nurse reviewed the medical records and said that they saw that the resident was on Meropenum and said that they saw were the medication was discontinued and that the PICC line should have been discontinued at that time. This Nurse checked the medical record and was unable to find where the PICC had been discontinued and said that they would not have been able to discontinue it as only a Registered Nurse (RN) could do so. This nurse said that there were multiple RN's to ask including the admissions, wound or managers.

An interview was conducted on December 17, 2024 at 2:02 P.M. with the owner of the assisted living facility that resident #149 discharged to. This person stated that the assisted living does not provide infusion and that he believed that the Skilled nursing facility sent a nurse out to remove the PICC line.

An interview was conducted on December 17, 2024 at 2:40 P.M. with the Manager of the assisted living facility that this resident discharged to from the skilled nursing facility. This person said that resident #149 arrived at her facility around 7pm, and in the morning when the staff were getting her dressed they informed her that the resident had an IV. This staff said that she sent a picture of the IV site to the assisted living facility's Medical Director who stated that the IV was a PICC line and that the assisted living staff should not remove it. This staff then reached out to the DON (staff #352) who asked if they could remove the PICC. This staff informed staff #352 that the Medical Director was not comfortable removing the PICC and that staff #352 would need to send someone to remove it. This staff said that a person from the skilled nursing facility came and took it out.

An interview was conducted on December 18, 2024 at 10:47 A.M. with a Registered Nurse (RN/staff #57 who said that a PICC line should be pulled by an RN after getting an order from a provider. They said that the PICC line should be flushed and the dressing on it maintained until it can be removed. This staff said that a patient should absolutely not be discharged with a PICC. This staff reviewed the clinical record and said that the last time the dressing was changed was on January 25, 2024 and that this PICC line was not discontinued prior to the resident's discharge. This staff said that the dangers of a resident discharged with a PICC line would be the use of illegal drugs and sepsis.

An interview was conducted on December 18, 2024 at 11:09 A.M. with the Director of Nursing (DON/staff #94) who said that the staff should flush PICC's every shift and change the dressing once a week. This staff said that residents are not discharged with a PICC line unless they are going home with IV antibiotics and going to an infusion clinic. This DON reviewed the clinical record and said that this resident did not receive IV antibiotics in February and that the order to discontinue the PICC line was on January 31. This DON stated that the last time the dressing was changed was on January 25 and the last time the PICC line was monitored was on January 30 on the day shift. This DON stated that the PICC should have been monitored and flushed, and the dressing changed. This DON said that this resident should not have been discharged with a PICC and that the resident "could have gotten a hell of an infection, could have bled, she could have been shooting up" from the PICC line left in. This DON stated that she would check if there was a policy for not discharging a resident with a PICC line and provide it if there was, however such a policy was not provided.

A policy titled Intravenous Therapy: Central Venous Catheter Care and Dressing Changes noted to be in effect January 1, 2024, included that the purpose of this procedure is to prevent complications associated with intravenous therapy, including catheter- related infections that are associated with contaminated, loosened, soiled, or wet dressings. This document included that staff should change the dressing if it becomes damp, loosened or visibly soiled and at least every 7 days for a transparent semi-permeable membrane (TSM) dressing, at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the s

Based on observations, staff interviews, and policy review, the facility failed to ensure medications were disposed of according to accepted professional standards.

Findings include:

During a medication administration observation conducted on December 17, 2024 at 7:32 A.M. the Licensed Practical Nurse (LPN/Staff #242) was observed to split a medication tablet (Mirapex) in half and proceed to place one half of the medication tablet into a clear unlabeled medication cup and place it back into the medication cart stating to "save for the afternoon". The LPN also disposed of a medication (Geri-Kot) in the resident's room trashcan after the resident refused the medication.

An interview was conducted on December 17, 2024 at 8:07 A.M. with the LPN (staff #242) who stated that he was not sure what the facility policy was regarding saving half of the Mirapex medication. He further stated that he could waste the other half of the medication and then in the afternoon do the same thing. The LPN stated that he would dispose of the medication by throwing it in the sharps container. The LPN also stated that he should have asked the resident to retrieve the medication the resident refused from the medication container and then disposed of it in the sharps container. The LPN stated that placing the unused half of the Mirapex into an unlabeled container for later use and disposing of a medication in the resident's room trash did not meet facility expectations.

An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated that the facility expectation would be to follow the state guidelines and regulations regarding the disposal of medications. The DON stated that the process for cutting a medication in half would include to dispose of the unused half of the medication and not save it for later use. The DON also stated that if it was a single pill then it should go into either the sharps container or the drug buster, and to not dispose of medications in the trash. She further stated that not disposing of the unused half of the Mirapex and disposing of the Geri-Kot in the resident's room trash did not meet facility expectations.

Review of the facility policy titled, Medications: Discarding Medications, version 051123 revealed that non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding the disposition of non-hazardous medications.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure appropriate infection control practices were followed during medication administration.

Findings include:

A medication administration observation was conducted on December 17, 2024 at 7:32 A.M. with Licensed Practical Nurse (LPN/Staff #242). The LPN was observed to dispense a Mirapex tablet into his ungloved hand, split the medication with ungloved hands, and then place the medication into a clear medication cup. The LPN was also observed to reach into a medication cup with ungloved hands and retrieve a medication that the resident refused and then give the medication cup back to the resident with other medications for administration.

An interview was conducted on December 17, 2024 at 8:07 A.M. with LPN (staff #242) who stated that he should have asked the resident to retrieve the medication she refused from the medication cup and then dispose of it in the sharps container. He also stated that it did not follow facility expectations to dispense and split the medication with his ungloved hands. The LPN further stated that the risk to the resident could result in contamination of the medications.

An interview was conducted on December 17, 2024 at 2:05 P.M. with the Director of Nursing (DON/Staff #94) who stated the process for cutting a medication in half would include making sure to wear gloves and to use a pill cutter. She also stated that dispensing medications, splitting medications, and retrieving medications from a medication cup using ungloved hands did not meet facility expectations. She further stated that the risk to the residents could include the medications becoming contaminated by the nurse not wearing gloves.

Review of the facility policy titled, Medications: Administering Oral Medications, version 051123, revealed that tablets or capsules from a bottle, to not touch the medication with your hands. The policy also indicated that for unit dose tablets or capsules to place packaged medications directly into the medication cup.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#74) was weighed on admission.

Findings include:

Resident was admitted to the facility on November 27, 2024, with diagnoses that included quadriplegia, protein-calorie malnutrition, feeding tube, and difficulty swallowing.

A care plan with the initiate date of November 27, 2024 had a noted goal of experience no significant weight changes (i.e. 5% x 1 month, 7.5% x 3 months, and 10% x 6 months).

An order dated November 27, 2024, with a start date of December 1, 2024, revealed the resident was to be weighed on admission, and then to follow facility protocol. In addition, the resident was to be weighed every day shift on Sundays.

A care plan with the initiate date of December 1, 2024 had a noted goal of to maintain the resident's weight without significant weight variance.

The admission Minimum Data Set (MDS) dated December 3, 2024 revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. The MDS in addition revealed the resident weighed 117 pounds, and experienced a weight loss (either 5% or more over the last month, or a 10% loss over the last 6 months). It clarifies that at the time of weight change the resident was not on a physician-prescribed weight-loss regimen.

A progress note for December 12, 2024 revealed the resident weight on December 3, 2024 was used to help determine the resident need for nutritional adequacy and weight management. The note in addition recorded the Ideal Body Weight Range (IBWR) as 126-154 pounds.

A Treatment Administration Record (TAR) for December 2024, with the download date of December 16, 2024, revealed a resident weight of 117 pounds on both December 8, 2024, and December 15, 2024.

Further review of the clinical record revealed no evidence the resident was weighed on date of admission.

An interview was conducted with a Certified Nursing Assistant (CNA/Staff #28) on December 16, 2024 at 8:50 a.m. Staff #28 revealed a job responsibility is to obtain new residents' weights upon admission. The type of scale and frequency of weights depends on the ability of the resident, and the physician order. The CNA further explained that the resident weights are recorded in the clinical record. Staff #28 stated that if the CNA's have any concerns about the weight and resident, they immediately report to the nurse.

An interview was conducted with the Dietary Manager (Staff #168) on December 17, 2024 at approximately 1:33 p.m. The dietary manager verified all residents are to be weighed on admission and then weekly for four weeks. The manager reviewed the resident's clinical record and verified the initial weight was not recorded until December 3, 2024. The manager stated that not obtaining the weight upon admission is not facility policy or following physician order. The manager further stated that resident weights, especially the initial weights, are of great importance in determining weight variance and improving clinical outcomes.

A written interview/correspondence from the Executive Director (ED/Staff #421) on December 17, 2024 at 12:30, verified that the resident was not weighed on admission, but rather the initial weight was obtained on December 3, 2024.

An interview was conducted on December 18, with the Director of Nursing (DON/Staff # 94) revealed that all residents are to be weighed upon admission, and as ordered. The DON stated she was only able to locate the resident weight on December 3, 2024 in the clinical record. The DON voiced this did not meet facility standards, or physican orders. The director recognized the resident has a low Body Mass Index (BMI) and weight monitoring is vital for the resident's well-being.

The facility's "Nutrition Management Program " revealed that all residents are weighed within 24 hours of admission and then for the following four weeks or until stable. Residents that demonstrate a significant weight loss will be placed on weekly weights until weight is stabilized. All other residents will be weight monthly.

The facility's "Weight Assessment and Intervention" policy revealed residents are to be weighed upon admission and at intervals established by the interdisciplinary team.

Based on staff interviews, review of records and facility policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#1) regarding fall risk assessments.

Findings include:

Resident #1 had a most recent admission on June 24, 2024 with diagnosis including metabolic encephalopathy, cerebral infarction, acute respiratory failure, Alzheimer's disease, hypertensive heart disease, dysarthria, anarthria, asthma, protein-calorie malnutrition and major depressive disorder-recurrent.

A review of the quarterly MDS (minimum data set) assessment dated April 6, 2024 revealed a BIMS (brief interview of mental status) score of 8, suggesting moderate cognitive impairment. Section J of the MDS revealed that the resident had one noted fall with injury since admission or reentry.

A review of the resident's care plan revealed a focus area noting that the resident is at risk for falls and injury post actual falls.

A review of the progress notes dated for June 23, 2024 at 7:09 P.M. revealed that the resident was discovered by his roommate post fall with 'copious' amounts of blood on the floor and lacerations to the right upper eyebrow, as well as bruising to the bilateral knees and elbow. Notes further revealed that the resident was stabilized prior to hospital transfer.

The progress notes further revealed an entry dated June 24, 2023 at 6:29 A.M. notating that the resident had returned to the facility. Change of condition charting was observed on June 24 and 25, 2024 referencing the fall.

A review of the hospital discharge documentation dated June 24, 2024 revealed resident #1's discharge diagnosis included an elbow contusion, fall and head injury.

A review of the admission fall risk evaluation dated June 24, 2024 revealed that the assessment scored the resident as having had "no falls" during the past 90-days; however, the resident had been transferred from the facility to the hospital as a result of a fall.

An interview was conducted on September 3, 2024 at 9:48 A.M. with staff #14, CNA (certified nursing assistant). Staff #14 stated that fall risk assessments are completed for residents and once a concern had been identified based on the assessment, interventions may include falling leaf program, mobility assist bars, fall mats on both sides of the bed and more frequent monitoring.

An interview was conducted on September 3, 2024 at 12:12 P.M. with the MDS nurse (staff #31). Staff #31 stated that the fall should have been documented on the fall risk evaluation, but stated that he felt it wouldn't have made a change in the implementation of services but would have made a change in the scoring, resulting in an inaccurate assessment.

An interview was conducted on September 3, 2024 at 12:43 P.M. with the DON (director of nursing/ staff #52). Staff #52 stated that the expectation is that an accurate fall risk evaluation is completed for each resident. After the DON reviewed the fall risk evaluation dated June 24, 2024, she stated that the fall should have been documented as it was noted in the facility progress notes and the hospital discharge documentation. The DON stated that the risk could include inaccurate documentation and potential for miscommunication among staff.

A review of the facility policy entitled Fall Prevention Program dated 2014 version 0414 revealed that all new admissions are to have a thorough review of history as well as a fall risk evaluation completed with assistns a risk level, it further stated that if there is a history of falls, the causative factors should be identified and care plan interventions should be implemented; however, the most recent fall, which had occurred in the facility, was not documented on the fall risk evaluation.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that physician orders were in place for fall preventative measures, regarding fall mats for one resident (#1).

Findings include:

Resident #1 had a most recent admission on June 24, 2024 with diagnosis including metabolic encephalopathy, cerebral infarction, acute respiratory failure, Alzheimer's disease, hypertensive heart disease, dysarthria, anarthria, asthma, protein-calorie malnutrition, and major depressive disorder-recurrent.

A review of the quarterly MDS (minimum data set) assessment dated April 6, 2024 revealed a BIMS (brief interview of mental status) score of 8, suggesting moderate cognitive impairment. Section J of the MDS revealed that the resident had one noted fall with injury since admission or reentry.

A review of the resident's care plan revealed a focus area noting that the resident is at risk for falls and injury post actual falls and that the interventions include bilateral landing strips placed on both sides of the bed.

A review of the physician orders in the resident's medical record, revealed no evidence of a current order for fall mats/ landing strips.

An observation was conducted on September 3, 2024 at 11:20 A.M. Resident #1 was observed to have bilateral fall mats next to his bedside.

An interview was conducted on September 3, 2024 at 10:02 A.M with staff #65, LPN (licensed Practical Nurse). Staff #65 stated that when a resident has a known history of falls, they will often have the bed lowered, have a fall risk bracelet, fall mats, and or bolsters. Staff #65 stated that fall mats require orders prior to implementation and that these would also be documented in the care plan.

An interview was conducted on September 3, 2024 at 11:52 A.M. with staff #22 (LPN). Staff #22 stated that orders are required for landing strips/ fall mats. Staff #22 reviewed the record for resident #1 and stated that the care plan did call for landing strips, but confirmed that no physician orders were in the record for the landing strips/ fall mats.

An interview was conducted on September 3, 2024 at 12:43 P.M. with staff #52 (DON-director of nursing). Staff #52 stated that fall mats require an order. Staff #52 reviewed the medical record for resident #1 and stated that the need for fall mats was documented in the care plan but that there was no order for the fall mats observed in the record. Staff #52 stated as long as the fall mats were in the resident's room that there was no direct risk to the resident but that the risk would include a lack of communication among staff members.

A review of the facility policy entitled Assessments/ Care Planning: Physician Services dated January 1, 2024 revealed that physician orders and progress notes are to be maintained in accordance with current OBRA regulations and facility policy; however, the electronic health record for resident #1 revealed no evidence of an order for fall mats/ landing strips.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#2). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Findings include:

Resident #2 was admitted February 9, 2023 with diagnosis that include type 2 diabetes, end stage renal disease, dependence on renal dialysis, seizures, chronic obstructive pulmonary disease, and Parkinson's disease.

Review of the care plan dated February 10, 2023 revealed that the resident is at risk for seizures related to a seizure disorder, with a noted intervention of 'Give medications as ordered. Monitor document for effectiveness and side effects'

Record review of an admission MDS (Minimum Data Set) dated February 15, 2023 noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident had no cognitive impairment.

A physician's order dated February 17th 2023 revealed an order for Sodium Zirconium Cyclosilicate Oral Packet 5GM (grams), with instructions indicating 10GM(grams) (two packets) be given by mouth one time a day for supplementation.

Review of the MAR (Medication Administration Record) dated February 2023 revealed from February 17, 19, and February 21 through 27, 2023 revealed the medication were documented as code 9 on the MAR, indicating other/see nursing notes.

Review of progress notes regarding Sodium Zirconium Cyclosilicate revealed the following:

February 17, 2023 at 0749 - "on order"
February 18, 2023 at 1347 - No documentation given
February 19, 2023 at 0855 - "Awaiting medication from pharmacy, med not available in Cubex"
February 20, 2023 at 0855 - "Pending Pharmacy"
February 21, 2023 at 1214 - No documentation given
February 22, 2023 at 0924 - "unavailable"
February 23, 2023 at 0854 - No documentation given
February 24, 2023 at 1005 - No documentation given
February 25, 2023 at 0943 - No documentation given
February 27, 2023 at 0746 - "Medication not in cart, awaiting from pharmacy."

The Resident discharged from the facility on February 28, 2023.

Further record review revealed no evidence that the physician or pharmacy were notified that the medication was not available.

An Interview was conducted on March 2, 2023 at 0935 with a Licensed Practical nurse, (LPN/staff #92) The LPN stated that if a medication was not available she would check the medication room and pyxis, then see if she could get it delivered. The LPN also stated she would call the physician to see if the medication could be held in the meantime. The LPN stated that reordering the medication is done in the MAR (Medication Administration Record) and shows every time the medication is delivered. The LPN demonstrated to this writer that process on the facilities MAR (Medication Administration Record) to verify the procedure. The LPN stated that if documenting using a code 9 (Other / See Nursing notes) that she stated she would not document that, and instead the staff should be finding ways to make sure that medication was available. The LPN stated that the risks of residents not having timely medications could result in side effects such as high blood pressure, stroke, or heart attack. The LPN also stated that for supplements we should be looking at other medications, such as diuretics and monitoring labs related to these medications, and that the physician should be notified for a replacement if the medication is unavailable.

An interview was conducted on March 2, 2023 at 1030 with the DON (Staff #52), The DON stated that their process for reordering medications when not available is a 3-fold process. 1. to use the previously mentioned process in the facilities MAR (Medication Administration Record), 2. to call the pharmacy, and 3. to fax over the order to the pharmacy. The DON also stated that the physician should be notified, asked for a substitution, or that the medication be held. The DON stated that the risks associated with not having timely medication administration of physician ordered medications could be cardiac issues, arrythmias, and other issues such as irregular bowel movements. The DON stated that her expectation of the staff when a medication is not available is that they should have called the pharmacy and notified to doctor to address the issue.

The Facilities policy titled "Medication Administration General Guidelines" dated May 2016 stated that Medications are administered in accordance with written orders of the prescriber. It further stated If a regularly scheduled medication is withheld, refused or given at other than the scheduled time, an explanatory note is entered in the medical record. If two consecutive doses of a vital medication are withheld or refused, the physician is to be notified.

Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring.

Findings include:

On February 27, 2023 at 8:00 a.m. the survey team entered the facility. At 8:36 a.m., an entrance conference was conducted with the facility administrator (staff # 124). During the conference, staff #124 stated he has a full-time infection preventionist (IP), staff #100. Staff #124 stated the IP is responsible for the facility's Infection surveillance, antibiotic stewardship, and NHSN line list and the DON (Director of Nursing), staff # 52, is responsible for vaccination efforts with residents and staff.

A record review of antibiotic stewardship was conducted on March 1, 2023 at 11:38 a.m. with the IP (staff # 100) and DON (Staff # 52). During the record review, staff #100 and staff #52 provided documents pertaining to antibiotic stewardship. Facility surveillance mapping was observed in the infection control log book, designating residents with active infections. However, mapping surveillance data included both facility acquired as well as non-facility acquired infections. The DON stated that they are just watching for specific organisms and not separating the data between facility and non-facility acquired infections. The DON further stated that mapping is currently utilized for trending only. A further review of the infection control log book, revealed the absence of laboratory data to determine the nature of the infection and support accurate treatment of any identified organisms. The DON stated that she was aware that the antibiotic stewardship surveillance data tracking currently did not meet the standard.

The McGreer guidelines were evident in the infection log book; however, there was no evidence of implementation of the guidelines regarding antibiotic stewardship surveillance.

Three months of antibiotic order listing data was requested to include November 2022, December 2022 and January 2023. However, per observation, the date on the order listing for November 2022 was not reviewed timely, as evidence by a print date of December 5, 2022.

Review of the Infection Control Program, revealed that the policy encompasses prevention, surveillance, containment, education and reporting.

Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#127) received care and services to restore and/or maintain continence. The sample size was 18. The deficient practice could adversely impact the resident's dignity and result in bowel and bladder continence not being maintained.

Findings include:

Resident #127 admitted to the facility on 02/14/23 with diagnoses including fracture of sacrum, subsequent encounter for fracture with routine healing, intervertebral disc degeneration, lumbar region and retention of urine.

An indwelling catheter care plan dated 02/14/23 related to acute neurogenic bladder had a goal to be/remain free from catheter-related trauma. Interventions included to monitor/document for pain/discomfort due to catheter.

The 5-day Minimum Data Set assessment dated 02/20/23 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. She required extensive 2+ person physical assistance for most activities of daily living and she had an indwelling catheter.

A physician's order dated 02/22/23 at 2:52 p.m. included for removal of Foley catheter for voiding trial. Instructions indicated that if the resident did not void in 6 hours, to have a bladder scan. If the residual urine was more than 350 milliliters (mL), [utilize] a straight catheter. After two straight catheterizations, call the MD to verify possible replacement. One time a day for 1 day.

However, review of the resident's indwelling catheter care plan did not include evidence that that the care plan was revised or updated to reflect the Foley removal, voiding trial, bladder scan or straight catheterization.

The Medication Administration Record (MAR) documentation dated 02/22/23 revealed a code "2" in the space provided for Foley removal. Per the Chart Codes key on the last page of the MAR, code "2" indicated the resident had refused.

Review of an electronic MAR (eMAR) administration note dated 02/23/23 at 12:01 p.m. included that the Foley had been removed for a voiding trial the previous day and that the resident had been unable to void. The note indicated [the Foley] had been reinserted.

However, review of the clinical record provided no evidence of documentation to indicate whether or not the resident had received bladder scans and/or straight catheterization. In addition, the nursing documentation did not include the amount of residual urine visualized on the bladder scan and/or the amount of urine that had been removed. Further review of the clinical record did not include documentation to evidence that the provider had been notified that the resident had been unable to urinate.

On 2/25/23 at 7:30 p.m. an alert progress note included that the Foley had been discontinued per the resident's request at 12:30 p.m. to trial prior to discharge. According to the note, the resident had not voided at (sic) 7:00 p.m., so the resident was bladder scanned, 100 cc (mL) [was visualized]. The resident had no discomfort at that time.

However, review of the physician's orders did not indicate that an order to discontinue the Foley had been obtained. Further review did not include bladder scanning, residual monitoring and/or straight catheterization.

Review of the Point of Care (POC) Certified Nursing Assistants (CNA) tasks dated 02/25/23 at 11:19 p.m. indicated that the resident was provided limited assistance to the toilet.

However, review of the clinical record did not include nursing documentation to indicate whether or not the resident was able to void and/or approximately how much.

A physician's order dated 02/26/23 at 6:00 p.m. revealed for bladder scanning every 6 hours. If more than 300 mL, [administer] straight catheterization. Every 6 hours for monitoring. The order was discontinued on 02/27/23.

Review of the February 2023 MAR bladder scanning documentation included:

-02/26/23 at 6:00 p.m. 500 mL was visualized on a bladder scan.
-02/27/23 at 0000 [midnight] 650 mL of urine was visualized.
-02/27/23 at 6:00 a.m. 0 mL was noted.

However, further review of the clinical record did not indicate whether or not the resident had received straight catheterization. In addition, there was no documentation to indicate that the provider had been notified.

On 02/27/23 at 10:45 a.m. an interview was conducted with resident #127. She stated that her Foley had been removed for bladder retraining. She stated that on Saturday (02/25/23) evening she had complained about bladder pain/feeling of urgency. She stated that she complained about increasing bladder pain to her night nurse (Licensed Practical Nurse/staff #112). She stated that staff #112 told her around 2:00 a.m. that someone would replace the Foley in the morning. She stated that she was given oxycodone (opioid analgesic) for the pain. She stated that the following morning (02/26/23) she received straight catheterization. She stated that on the night of 02/26/23, she woke up around 2:30 - 3:30 a.m. with back and bladder pain. She stated that she told her CNA (staff #32) that she needed her bladder drained again. She said however, the nurse did not come in and that no one drained her bladder. She stated that around 4:15 a.m. she was assisted to the commode by staff #32 to have a bowel movement. She said that when she sat on the commode, she actually urinated on her own.

An interview was conducted on 02/28/23 at 7:46 a.m. with a CNA (staff #32). She stated that on 02/25/23 the resident was bladder scanned at 7:00 p.m. and about 100 mL was viewed. She stated that the resident asked for pain medication around midnight and that she reported it to the nurse. She stated that she was told the resident could not have pain meds at that time because she had received them around 9:00 o'clock. She stated that the nurse told her to just let him know when the resident asked again. She stated that the resident used her call light again about 2:00 a.m. She stated that she went into the resident's room with staff #112 to speak with the resident and give her the pain medication. She stated that she did not hear the nurse ask the resident where her pain was. She stated that the resident told the nurse that she had not peed yet, but that she did not complain of bladder pain. She stated that she and the nurse encouraged the resident to continue drinking water and if she still wasn't urinating to call again and let them know. She stated that staff #112 did not bladder scan the resident at 2:00 a.m. because the resident did not ask for it. She stated that she did not know whether nurses usually asked residents if they would like to have a bladder scan. She stated that around 6:30 - 7:00 a.m., staff #112 scanned the resident's bladder and that 600 mL (more or less) was visualized. She stated that staff #112 asked her to go into the resident's room with him after the morning report to straight catheterize the resident. She stated that about 1,000 mLs were removed.

On 03/01/23 at 10:12 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #112). He stated that he thought the resident's Foley catheter had been discontinued on the 25th. He stated that the day shift told him. He stated that he told the resident/encouraged her to remember to drink water and that she had said she would try. He stated that the resident was able to use a commode with assistance. He stated that the CNA told him that the resident was peeing. He stated that no amount of urine was measured or monitored. He stated that he told the resident that he would provide bladder scanning/straight catheterization if needed. He stated that the resident asked for pain medication at 10:00 p.m., but did not say where her pain was. He stated that he completed a bladder scan at 2:00 a.m. and that he thought

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#2). The deficient practice could result in not receiving medications that are physician ordered and necessary.

Findings include:

Resident #2 was admitted February 9, 2023 with diagnosis that include type 2 diabetes, end stage renal disease, dependence on renal dialysis, seizures, chronic obstructive pulmonary disease, and Parkinson's disease.

Review of the care plan dated February 10, 2023 revealed that the resident is at risk for seizures related to a seizure disorder, with a noted intervention of 'Give medications as ordered. Monitor document for effectiveness and side effects'

Record review of an admission MDS (Minimum Data Set) dated February 15, 2023 noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident had no cognitive impairment.

A physician's order dated February 17th 2023 revealed an order for Sodium Zirconium Cyclosilicate Oral Packet 5GM (grams), with instructions indicating 10GM(grams) (two packets) be given by mouth one time a day for supplementation.

Review of the MAR (Medication Administration Record) dated February 2023 revealed from February 17, 19, and February 21 through 27, 2023 revealed the medication were documented as code 9 on the MAR, indicating other/see nursing notes.

Review of progress notes regarding Sodium Zirconium Cyclosilicate revealed the following:

February 17, 2023 at 0749 - "on order"
February 18, 2023 at 1347 - No documentation given
February 19, 2023 at 0855 - "Awaiting medication from pharmacy, med not available in Cubex"
February 20, 2023 at 0855 - "Pending Pharmacy"
February 21, 2023 at 1214 - No documentation given
February 22, 2023 at 0924 - "unavailable"
February 23, 2023 at 0854 - No documentation given
February 24, 2023 at 1005 - No documentation given
February 25, 2023 at 0943 - No documentation given
February 27, 2023 at 0746 - "Medication not in cart, awaiting from pharmacy."

The Resident discharged from the facility on February 28, 2023.

Further record review revealed no evidence that the physician or pharmacy were notified that the medication was not available.

An Interview was conducted on March 2, 2023 at 0935 with a Licensed Practical nurse, (LPN/staff #92) The LPN stated that if a medication was not available she would check the medication room and pyxis, then see if she could get it delivered. The LPN also stated she would call the physician to see if the medication could be held in the meantime. The LPN stated that reordering the medication is done in the MAR (Medication Administration Record) and shows every time the medication is delivered. The LPN demonstrated to this writer that process on the facilities MAR (Medication Administration Record) to verify the procedure. The LPN stated that if documenting using a code 9 (Other / See Nursing notes) that she stated she would not document that, and instead the staff should be finding ways to make sure that medication was available. The LPN stated that the risks of residents not having timely medications could result in side effects such as high blood pressure, stroke, or heart attack. The LPN also stated that for supplements we should be looking at other medications, such as diuretics and monitoring labs related to these medications, and that the physician should be notified for a replacement if the medication is unavailable.

An interview was conducted on March 2, 2023 at 1030 with the DON (Staff #52), The DON stated that their process for reordering medications when not available is a 3-fold process. 1. to use the previously mentioned process in the facilities MAR (Medication Administration Record), 2. to call the pharmacy, and 3. to fax over the order to the pharmacy. The DON also stated that the physician should be notified, asked for a substitution, or that the medication be held. The DON stated that the risks associated with not having timely medication administration of physician ordered medications could be cardiac issues, arrythmias, and other issues such as irregular bowel movements. The DON stated that her expectation of the staff when a medication is not available is that they should have called the pharmacy and notified to doctor to address the issue.

The Facilities policy titled "Medication Administration General Guidelines" dated May 2016 stated that Medications are administered in accordance with written orders of the prescriber. It further stated If a regularly scheduled medication is withheld, refused or given at other than the scheduled time, an explanatory note is entered in the medical record. If two consecutive doses of a vital medication are withheld or refused, the physician is to be notified.

Based on clinical record review, staff interviews, observation, facility documentation and policies and procedures, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for two residents (#125, #126).

Findings include:

Regarding Resident #125
-Resident was admitted to the facility on February 14, 2023 with diagnoses that included aftercare following joint replacement, infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter and presence of other orthopedic joint implants.

Review of a physician order dated February 15, 2023 included regular diet, thin liquids consistency.

Review of facility form, Nutritional Data Collection and Assessment, dated February 19, 2023 at 10:35 a.m., included a comprehensive nutritional admission assessment. Per the assessment, the diet order for the resident is regular diet, regular texture, and thin liquids.

Review of 5-day assessment Minimum Data Set dated February 20, 2023 revealed a brief interview of mental status score of 15, indicating intact cognition. The assessment included the resident required supervision with eating. The assessment revealed the resident has no swallowing disorder and no therapeutic diet required.

An interview was conducted on February 27, 2023 at 11:20 a.m. with resident #125. During the interview, resident #125 stated the facility offered food choices on the menu and from the menu a meal slip was created. She stated she thinks the facility just throws the meal slip away because she never gets the right food items she had chosen from the menu.

An interview was conducted on March 2, 2023 at 9:00 a.m. with a licensed practical nurse (LPN/ staff #12). She stated resident #125 is alert and oriented to name, time and place, very pleasant, and does not complain. She said the residents have the menu and alternates that are always available. She said the resident reviews the menus ahead of time and orders alternative food items if desired.

A follow up interview was conducted on March 2, 2023 at 8:00 a.m., with resident #125. She stated she was given the menu when she came in and was explained how to use it. The staff asked her what she wanted for two days, then it stopped. She was told to use the slip for daily choices, it was submitted to the kitchen, but when she received her meals she did not get anything that was circled on the diet slip. She stated no one has spoken with her about her dietary preferences because she does not eat a lot of carbohydrates, fried food, white bread, and processed meat. She stated no dietary personnel met with her about her dietary preferences. She stated this morning she got 1 piece of fried sausage, a coffee cake, and oatmeal. She said she ate the oatmeal and her friends brought her some food from home to meet her dietary preferences.

An interview was conducted on March 2, 2023 at 8:49 a.m., with a licensed practical nurse (LPN/ staff #12). She stated if a resident has food preferences she would tell the dietician and manager and it should be honored as choices.

An interview was conducted on March 2, 2023 at 8:56 a.m., with a certified nursing assistant (CNA/ staff #124.) She stated when serving a meal tray, she would read the diet slip and look at the food items on the tray to make sure it was correct. She stated it is important to read the diet slip to ensure the resident is getting what the physician ordered and to ensure the resident's food preferences were followed. She stated if a resident preferred a low carbohydrate diet, no fried food, special bread or gluten free diet she would notify the dietary department and the charge nurse. She stated if a resident is unable to tolerate carbohydrates, fried food, or gluten, the resident may experience an allergic reaction, high blood sugar, stomach aches or diarrhea.

Regarding Resident #126
-Resident was admitted on February 17, 2023 with diagnoses that included other specified disorders of bone, contusion of left hip, unspecified fall, and mild protein-calorie malnutrition.

Review of a physician order dated February 18, 2023 revealed an order for regular diet, regular texture, thin liquids consistency.

A facility assessment, Nutritional Data Collection and Assessment, dated February 20, 2023 at 12:12 p.m., included food preferences/likes/dislikes. The assessment for dislike included grain, and all fats. The assessment's comment section included the following allergies: gluten, peanut, will not gluten free bread, has a lot of food restrictions.

Review of admission minimum data set dated February 23, 2023 included a brief interview of mental status score of 12, indicating intact cognition. The assessment included no swallowing disorder and no therapeutic diet. The assessment stated the resident required supervision/setup help only for eating.

An interview was conducted on February 27 at 10:33 a.m., with resident #126. She stated her children bring her food from home because she can't eat the food the facility serves. She stated upon admission, she had notified the dietician that her food preferences included sugar-free and gluten-free and the facility did not accommodate these preferences.

A dining observation was conducted on March 2, 2023 at 8:44 a.m. during breakfast. Resident #126 was observed having breakfast in her room. The resident's meal tray included a bowl of oatmeal, scrambled eggs, and a cup of hot tea. Review of the breakfast diet slip indicated the resident is allergic to peanuts and gluten.

An immediate follow up interview was conducted with resident #126 who stated she was not happy this morning because the kitchen gave her oatmeal again and she does not eat grain because it hurts her stomach. She stated she told the staff many times about the grain and oatmeal, but they keep bringing her oatmeal almost every day. She stated a staff member talked to her about food before and she told them her food preferences but it's not being honored. She stated she is not tolerating gluten and that it was written on the diet slip.

An interview was conducted on March 2, 2023 at 8:49 a.m., with a licensed practical nurse (LPN/ staff #12). She stated if a resident has food preferences she would tell the dietician and manager and it should be honored as choices.

An interview was conducted on March 2, 2023 at 8:56 a.m., with a certified nursing assistant (CNA/ staff #124. She stated when serving a meal tray, she would read the diet slip and look at the food items on the tray to make sure it was correct. She stated it is important to read the diet slip to ensure the resident is getting what the physician ordered and to ensure the resident's food preferences were followed. She stated if a resident preferred a low carbohydrate diet, no fried food, special bread or gluten free diet she would notify the dietary department and the charge nurse. She stated if a resident is unable to tolerate carbohydrates, fried food, or gluten, the resident may experience an allergic reaction, high blood sugar, stomach aches or diarrhea.

The facility policy, Resident Nutrition Services, with a revision date of November 2015, stated each resident shall receive meals, with preferences accommodated. The policy interpretation/implementation included the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits. Per the policy implementation, nursing personnel will ensure that residents are served the correct food tray.

Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to conduct an ongoing review for antibiotic stewardship as required by Center for Medicare and Medicaid Services (CMS) guidelines, and failed to review clinical signs and symptoms and laboratory reports to determine if antibiotics are indicated. The deficient practice could have the potential for residents to have adverse effects due to the lack of protocols and monitoring.

Findings include:

On February 27, 2023 at 8:00 a.m. the survey team entered the facility. At 8:36 a.m., an entrance conference was conducted with the facility administrator (staff # 124). During the conference, staff #124 stated he has a full-time infection preventionist (IP), staff #100. Staff #124 stated the IP is responsible for the facility's Infection surveillance, antibiotic stewardship, and NHSN line list and the DON (Director of Nursing), staff # 52, is responsible for vaccination efforts with residents and staff.

A record review of antibiotic stewardship was conducted on March 1, 2023 at 11:38 a.m. with the IP (staff # 100) and DON (Staff # 52). During the record review, staff #100 and staff #52 provided documents pertaining to antibiotic stewardship. Facility surveillance mapping was observed in the infection control log book, designating residents with active infections. However, mapping surveillance data included both facility acquired as well as non-facility acquired infections. The DON stated that they are just watching for specific organisms and not separating the data between facility and non-facility acquired infections. The DON further stated that mapping is currently utilized for trending only. A further review of the infection control log book, revealed the absence of laboratory data to determine the nature of the infection and support accurate treatment of any identified organisms. The DON stated that she was aware that the antibiotic stewardship surveillance data tracking currently did not meet the standard.

The McGreer guidelines were evident in the infection log book; however, there was no evidence of implementation of the guidelines regarding antibiotic stewardship surveillance.

Three months of antibiotic order listing data was requested to include November 2022, December 2022 and January 2023. However, per observation, the date on the order listing for November 2022 was not reviewed timely, as evidence by a print date of December 5, 2022.

Review of the Infection Control Program, revealed that the policy encompasses prevention, surveillance, containment, education and reporting.

Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#127) received care and services to restore and/or maintain continence. The sample size was 18. The deficient practice could adversely impact the resident's dignity and result in bowel and bladder continence not being maintained.

Findings include:

Resident #127 admitted to the facility on 02/14/23 with diagnoses including fracture of sacrum, subsequent encounter for fracture with routine healing, intervertebral disc degeneration, lumbar region and retention of urine.

An indwelling catheter care plan dated 02/14/23 related to acute neurogenic bladder had a goal to be/remain free from catheter-related trauma. Interventions included to monitor/document for pain/discomfort due to catheter.

The 5-day Minimum Data Set assessment dated 02/20/23 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. She required extensive 2+ person physical assistance for most activities of daily living and she had an indwelling catheter.

A physician's order dated 02/22/23 at 2:52 p.m. included for removal of Foley catheter for voiding trial. Instructions indicated that if the resident did not void in 6 hours, to have a bladder scan. If the residual urine was more than 350 milliliters (mL), [utilize] a straight catheter. After two straight catheterizations, call the MD to verify possible replacement. One time a day for 1 day.

However, review of the resident's indwelling catheter care plan did not include evidence that that the care plan was revised or updated to reflect the Foley removal, voiding trial, bladder scan or straight catheterization.

The Medication Administration Record (MAR) documentation dated 02/22/23 revealed a code "2" in the space provided for Foley removal. Per the Chart Codes key on the last page of the MAR, code "2" indicated the resident had refused.

Review of an electronic MAR (eMAR) administration note dated 02/23/23 at 12:01 p.m. included that the Foley had been removed for a voiding trial the previous day and that the resident had been unable to void. The note indicated [the Foley] had been reinserted.

However, review of the clinical record provided no evidence of documentation to indicate whether or not the resident had received bladder scans and/or straight catheterization. In addition, the nursing documentation did not include the amount of residual urine visualized on the bladder scan and/or the amount of urine that had been removed. Further review of the clinical record did not include documentation to evidence that the provider had been notified that the resident had been unable to urinate.

On 2/25/23 at 7:30 p.m. an alert progress note included that the Foley had been discontinued per the resident's request at 12:30 p.m. to trial prior to discharge. According to the note, the resident had not voided at (sic) 7:00 p.m., so the resident was bladder scanned, 100 cc (mL) [was visualized]. The resident had no discomfort at that time.

However, review of the physician's orders did not indicate that an order to discontinue the Foley had been obtained. Further review did not include bladder scanning, residual monitoring and/or straight catheterization.

Review of the Point of Care (POC) Certified Nursing Assistants (CNA) tasks dated 02/25/23 at 11:19 p.m. indicated that the resident was provided limited assistance to the toilet.

However, review of the clinical record did not include nursing documentation to indicate whether or not the resident was able to void and/or approximately how much.

A physician's order dated 02/26/23 at 6:00 p.m. revealed for bladder scanning every 6 hours. If more than 300 mL, [administer] straight catheterization. Every 6 hours for monitoring. The order was discontinued on 02/27/23.

Review of the February 2023 MAR bladder scanning documentation included:

-02/26/23 at 6:00 p.m. 500 mL was visualized on a bladder scan.
-02/27/23 at 0000 [midnight] 650 mL of urine was visualized.
-02/27/23 at 6:00 a.m. 0 mL was noted.

However, further review of the clinical record did not indicate whether or not the resident had received straight catheterization. In addition, there was no documentation to indicate that the provider had been notified.

On 02/27/23 at 10:45 a.m. an interview was conducted with resident #127. She stated that her Foley had been removed for bladder retraining. She stated that on Saturday (02/25/23) evening she had complained about bladder pain/feeling of urgency. She stated that she complained about increasing bladder pain to her night nurse (Licensed Practical Nurse/staff #112). She stated that staff #112 told her around 2:00 a.m. that someone would replace the Foley in the morning. She stated that she was given oxycodone (opioid analgesic) for the pain. She stated that the following morning (02/26/23) she received straight catheterization. She stated that on the night of 02/26/23, she woke up around 2:30 - 3:30 a.m. with back and bladder pain. She stated that she told her CNA (staff #32) that she needed her bladder drained again. She said however, the nurse did not come in and that no one drained her bladder. She stated that around 4:15 a.m. she was assisted to the commode by staff #32 to have a bowel movement. She said that when she sat on the commode, she actually urinated on her own.

An interview was conducted on 02/28/23 at 7:46 a.m. with a CNA (staff #32). She stated that on 02/25/23 the resident was bladder scanned at 7:00 p.m. and about 100 mL was viewed. She stated that the resident asked for pain medication around midnight and that she reported it to the nurse. She stated that she was told the resident could not have pain meds at that time because she had received them around 9:00 o'clock. She stated that the nurse told her to just let him know when the resident asked again. She stated that the resident used her call light again about 2:00 a.m. She stated that she went into the resident's room with staff #112 to speak with the resident and give her the pain medication. She stated that she did not hear the nurse ask the resident where her pain was. She stated that the resident told the nurse that she had not peed yet, but that she did not complain of bladder pain. She stated that she and the nurse encouraged the resident to continue drinking water and if she still wasn't urinating to call again and let them know. She stated that staff #112 did not bladder scan the resident at 2:00 a.m. because the resident did not ask for it. She stated that she did not know whether nurses usually asked residents if they would like to have a bladder scan. She stated that around 6:30 - 7:00 a.m., staff #112 scanned the resident's bladder and that 600 mL (more or less) was visualized. She stated that staff #112 asked her to go into the resident's room with him after the morning report to straight catheterize the resident. She stated that about 1,000 mLs were removed.

On 03/01/23 at 10:12 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #112). He stated that he thought the resident's Foley catheter had been discontinued on the 25th. He stated that the day shift told him. He stated that he told the resident/encouraged her to remember to drink water and that she had said she would try. He stated that the resident was able to use a commode with assistance. He stated that the CNA told him that the resident was peeing. He stated that no amount of urine was measured or monitored. He stated that he told the resident that he would provide bladder scanning/straight catheterization if needed. He stated that the resident asked for pain medication at 10:00 p.m., but did not say where her pain was. He stated that he completed a bladder scan at 2:00 a.m. and that he thought

Based on clinical record review, staff interviews, observation, facility documentation and policies and procedures, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for two residents (#125, #126).

Findings include:

Regarding Resident #125
-Resident was admitted to the facility on February 14, 2023 with diagnoses that included aftercare following joint replacement, infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter and presence of other orthopedic joint implants.

Review of a physician order dated February 15, 2023 included regular diet, thin liquids consistency.

Review of facility form, Nutritional Data Collection and Assessment, dated February 19, 2023 at 10:35 a.m., included a comprehensive nutritional admission assessment. Per the assessment, the diet order for the resident is regular diet, regular texture, and thin liquids.

Review of 5-day assessment Minimum Data Set dated February 20, 2023 revealed a brief interview of mental status score of 15, indicating intact cognition. The assessment included the resident required supervision with eating. The assessment revealed the resident has no swallowing disorder and no therapeutic diet required.

An interview was conducted on February 27, 2023 at 11:20 a.m. with resident #125. During the interview, resident #125 stated the facility offered food choices on the menu and from the menu a meal slip was created. She stated she thinks the facility just throws the meal slip away because she never gets the right food items she had chosen from the menu.

An interview was conducted on March 2, 2023 at 9:00 a.m. with a licensed practical nurse (LPN/ staff #12). She stated resident #125 is alert and oriented to name, time and place, very pleasant, and does not complain. She said the residents have the menu and alternates that are always available. She said the resident reviews the menus ahead of time and orders alternative food items if desired.

A follow up interview was conducted on March 2, 2023 at 8:00 a.m., with resident #125. She stated she was given the menu when she came in and was explained how to use it. The staff asked her what she wanted for two days, then it stopped. She was told to use the slip for daily choices, it was submitted to the kitchen, but when she received her meals she did not get anything that was circled on the diet slip. She stated no one has spoken with her about her dietary preferences because she does not eat a lot of carbohydrates, fried food, white bread, and processed meat. She stated no dietary personnel met with her about her dietary preferences. She stated this morning she got 1 piece of fried sausage, a coffee cake, and oatmeal. She said she ate the oatmeal and her friends brought her some food from home to meet her dietary preferences.

An interview was conducted on March 2, 2023 at 8:49 a.m., with a licensed practical nurse (LPN/ staff #12). She stated if a resident has food preferences she would tell the dietician and manager and it should be honored as choices.

An interview was conducted on March 2, 2023 at 8:56 a.m., with a certified nursing assistant (CNA/ staff #124.) She stated when serving a meal tray, she would read the diet slip and look at the food items on the tray to make sure it was correct. She stated it is important to read the diet slip to ensure the resident is getting what the physician ordered and to ensure the resident's food preferences were followed. She stated if a resident preferred a low carbohydrate diet, no fried food, special bread or gluten free diet she would notify the dietary department and the charge nurse. She stated if a resident is unable to tolerate carbohydrates, fried food, or gluten, the resident may experience an allergic reaction, high blood sugar, stomach aches or diarrhea.

Regarding Resident #126
-Resident was admitted on February 17, 2023 with diagnoses that included other specified disorders of bone, contusion of left hip, unspecified fall, and mild protein-calorie malnutrition.

Review of a physician order dated February 18, 2023 revealed an order for regular diet, regular texture, thin liquids consistency.

A facility assessment, Nutritional Data Collection and Assessment, dated February 20, 2023 at 12:12 p.m., included food preferences/likes/dislikes. The assessment for dislike included grain, and all fats. The assessment's comment section included the following allergies: gluten, peanut, will not gluten free bread, has a lot of food restrictions.

Review of admission minimum data set dated February 23, 2023 included a brief interview of mental status score of 12, indicating intact cognition. The assessment included no swallowing disorder and no therapeutic diet. The assessment stated the resident required supervision/setup help only for eating.

An interview was conducted on February 27 at 10:33 a.m., with resident #126. She stated her children bring her food from home because she can't eat the food the facility serves. She stated upon admission, she had notified the dietician that her food preferences included sugar-free and gluten-free and the facility did not accommodate these preferences.

A dining observation was conducted on March 2, 2023 at 8:44 a.m. during breakfast. Resident #126 was observed having breakfast in her room. The resident's meal tray included a bowl of oatmeal, scrambled eggs, and a cup of hot tea. Review of the breakfast diet slip indicated the resident is allergic to peanuts and gluten.

An immediate follow up interview was conducted with resident #126 who stated she was not happy this morning because the kitchen gave her oatmeal again and she does not eat grain because it hurts her stomach. She stated she told the staff many times about the grain and oatmeal, but they keep bringing her oatmeal almost every day. She stated a staff member talked to her about food before and she told them her food preferences but it's not being honored. She stated she is not tolerating gluten and that it was written on the diet slip.

An interview was conducted on March 2, 2023 at 8:49 a.m., with a licensed practical nurse (LPN/ staff #12). She stated if a resident has food preferences she would tell the dietician and manager and it should be honored as choices.

An interview was conducted on March 2, 2023 at 8:56 a.m., with a certified nursing assistant (CNA/ staff #124. She stated when serving a meal tray, she would read the diet slip and look at the food items on the tray to make sure it was correct. She stated it is important to read the diet slip to ensure the resident is getting what the physician ordered and to ensure the resident's food preferences were followed. She stated if a resident preferred a low carbohydrate diet, no fried food, special bread or gluten free diet she would notify the dietary department and the charge nurse. She stated if a resident is unable to tolerate carbohydrates, fried food, or gluten, the resident may experience an allergic reaction, high blood sugar, stomach aches or diarrhea.

The facility policy, Resident Nutrition Services, with a revision date of November 2015, stated each resident shall receive meals, with preferences accommodated. The policy interpretation/implementation included the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes, and eating habits. Per the policy implementation, nursing personnel will ensure that residents are served the correct food tray.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on March 1, 2023, revealed the following;

1) the double doors near the first floor nurses station failed to latch secure when tested 3 of 3 times.
2) the double doors on the second floor "U 1" hall failed to latch secure when tested 3 of 3 times. The smoke seal on the lower portion of the frame was not secure and dangling
3) the rated door at the soiled wash side of the laundry room to corridor failed to close and latch secure when tested 3 of 3 times.

During the exit conference conducted on March 1, 2023, the above findings were again acknowledged by the management team.