Sandstone Estates Rehab Centre

Based on observation it was determined the facility failed to properly fill penetrations in multiple areas of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made during a facility tour conducted on October 29, 2024, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas:

1. Drywall patches to the smoke barrier above the smoke doors and ceiling tiles near room 210 were not properly sealed. The ductwork in this area as well as conduit going through the smoke barrier not properly sealed.

The management team confirmed the fire/smoke wall penetrations during the facility tour and the exit conference on October 29, 2024.

Based on observation the facility failed to have the light switch 5 ft above the finished floor in the oxygen storage rooms. Failing to mount or protect the wall outlet receptacles from physical damage could cause harm to the patients and staff if an oxygen bottle accidentally hits the wall receptacle outlets.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 99 2012 Edition Standard for Health Care Facilities." Chapter 5 Section 5.1.3.3.2 Design and Construction. Section 5.1.3.3.2 "(5) They shall be in compliant with NFPA 70 National Electrical Code, for ordinary locations. Locations for central supply systems and the storage of positive -pressure gases shall meet the following requirements." Section 5-1.3.3.2 "(5) Electrical devices should be physically protected, such as by use of protective barrier around the electrical devices, or by location of the electrical device such that it will avoid causing damage to the cylinders or containers. The device could be located at or above finished floor 1.5 m (5 ft) or other location that will not allow the possibility of the cylinders or containers to come into contact with the electrical device required by this section." Section 5.1.3.3.2 "(10) They shall protect electrical devices from physical damage."

Findings include:

Observations made while on tour on October 29, 2024 revealed the light switchs in the oxygen supply room across from room 109 and the oxygen room across from room 209 were not a minimum of 5 ft above the finished floor.

During the facility tour and the exit conference on October 29, 2024, the management team confirmed that the light switchs in the oxygen supply room across from room 109 and the oxygen room across from room 209 were not a minimum of 5 ft above the finished floor.

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two of two sampled residents (#11 and #13).

-Regarding Resident #11:

Resident #11 was admitted to the facility on July 05, 2024, with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive.

The admission Minimum Data Set (MDS) assessment dated August 27, 2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.

Review of the facility's Visitor Sign In log revealed that a male and female visitor had signed into the facility on September 04, 2024 at 6:07 to visit room 224, with no sign out time.

A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a "terrible joke" while holding money in his hand that he was "paying for sexual intercourse", but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident.

Review of the state agency reporting system revealed no evidence that the facility submitted a Self-Report form for an allegation of sexual abuse for Resident #11.

A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male sitting in the resident's wheelchair and the female sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed he male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet.

A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) "spoke to resident regarding events from last night", that the resident denies any "wrong doings" and that the resident instructed the male visitor to take a shower because he was "filthy". The resident denied any physical contact, and has no concerns with visitors.

Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a "male visitor naked in resident room" on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with "N/A" (not applicable) handwritten across the section.

A formal request was made to the facility on October 22, 2024 at 10:45 AM for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed the mandated self-reporting of the incident of alleged sexual abuse for Resident #11.

A follow-up formal request dated October 22, 2024 at 2:22 PM for the facility to specify if the incident regarding Resident #11 was reported, in which the facility indicated that the incident was only investigated internally.

A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was "giving out sexual favors to the ladies". She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident.

An Interview was conducted with the ADON (Staff #640) on October 2, 2024 at 7:27 AM. The ADON stated that it was the facility's policy that staff are to report any allegation of abuse, including sexual abuse, to the abuse coordinator immediately, and that the abuse coordinator has 2 hours to report the allegation to the state department, and then an internal investigation is completed by the facility.

An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:00 AM. Regarding Resident #11's incident on September 04, 2024, the DON stated that "I did the investigation". The DON stated that the facility's policy on reporting allegations of abuse is that it is supposed to be reported to the abuse officer, who was the interim administrator at the time (Staff #72), and that he was notified of the incident when he read the investigation report on either September 05 or September 06, 2024, and that she was not sure exactly when he was notified. She stated that she did not know if he reported it to anyone. When asked if the DON reported the allegation to any of the state agencies or the police, the DON stated that "It's up to the abuse coordinator"". She also stated that she was not sure on the mandated reporting time requirement, and that she would have to "look at the policy". Further, the DON stated that if there is a potential for abuse for a resident, and the facility does not protect the resident, that there could be continued abuse or harm to that resident.

-Regarding Resident #13:

Resident #13 was admitted to the facility on August 15, 2024 with diagnoses that included hemiplegia affecting the left side, dementia, traumatic brain injury, and major depressive disorder.

A physician order for Resident #13 dated August 16, 2024, indicated for behavior tracking for physical aggression every shift.

Review of the progress notes revealed a Behavior Note dated September 11, 2024, indicating that Resident #13 was "wheeling down the hallway, as she passed by another resident, he stuck his foot out". Resident #13 yelled at the other resident "Hey dipshit, don't do that. I don't like you" and "I had a way to hurt you, I would". The note revealed that staff redirected Resident #13 back to her room".

A Behavior Note dated September 13, 2024 at 5:13 PM,

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure a thorough investigation for allegations of abuse were completed for two of two sampled residents (#11 and #13) and that the residents were protected from further abuse during an investigation.

-Regarding Resident #11:

Resident #11 was admitted to the facility on July 05, 2024, with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive.

The resident's admission Minimum Data Set (MDS) assessment dated August 27, 2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.

Review of the facility's Visitor Sign In log revealed that a male and a female visitor had signed into the facility on September 04, 2024 at 6:07 to visit room 224, with no sign out time.

A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a "terrible joke" while holding money in his hand that he was "paying for sexual intercourse", but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident.

Review of the resident's clinical record revealed no evidence of communication from the facility to the provider regarding the incident involving the naked male visitor in Resident #11's room on September 04, 2024.

A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male sitting in the resident's wheelchair and the female sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed he male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet.

A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) "spoke to resident regarding events from last night", that the resident denies any "wrong doings" and that the resident instructed the male visitor to take a shower because he was "filthy". The resident denied any physical contact, and has no concerns with visitors.

Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a "male visitor naked in resident room" on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with "N/A" (not applicable) handwritten across the section. The internal investigation revealed no evidence of notes of staff interviews. The investigation revealed no evidence of which two CNA's initially entered the resident's room. The investigation also revealed no evidence of interviews of residents surrounding Resident #11's room.

Review of the facility's Visitor Sign In log revealed that the male visitor had also signed in to visit the resident on the following dates after the incident:
-September 11, 2024
-September 18, 2024
-October 04, 2024
-October 14, 2024.

Review of the clinical record revealed no evidence of communication follow-up from the facility to the resident's daughter regarding whether the male visitor was permitted back to the facility between the timeframe of September 04, 2024, and when the male visitor signed in on the facility's Visitor Sign in log on September 11, 2024 to visit Resident #11.

Review of the resident's electronic medical record on October 23, 2024 at 2:12 PM, revealed no evidence that the Special Instructions banner at the top of the resident's chart had any information regarding visitation instructions for the male and female visitors. However, on October 24, 2024, the DON provided a copy of the Special Instructions banner that was now updated to indicate "(the male and female visitors) CANNOT visit per POA".

A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was "giving out sexual favors to the ladies". She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident.

An interview was conducted on October 24, 2024 at 8:28 AM with Social Services Director (SS Director / Staff #672). The SS Director stated "I have no knowledge of this incident". She stated that she is part of the daily stand-up meeting with facility leadership, and that she did not recall the incident being discussed. She stated that if she had been made aware of the incident, that she would have had started the grievance process for it.

An interview was conducted with the DON (Staff #618) on October 24, 2024 at 10:00 AM. Regarding Resident #11's incident on September 04, 2024, the DON stated that "I did the investigation". The DON stated that staff monitored the resident the rest of the evening, and that the next morning (September 05, 2024) the DON came into the facility and did the investigation. The interview with the DON continued, and she described her investigation process. She stated she interviewed Resident #11 on September 05, 2024, that she interviewed the staff, but could not remember who the CNA staff was who initially entered the resident's room and saw the naked male visitor. She also stated that she interviewed the residents across the hall from Resident #11, despite no evidence of staff or resident interviews within the Internal Investigation. The DON stated that the resident was kept safe, as the facility notified the front desk staff that the male visitor was not allowed back. She further stated that the male visitor has not been back to the facility since the incident, and that he still is not allowed back, de

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to implement written policies and procedures that prohibit and prevent abuse for two of two sampled residents (#11 and #13).

-Regarding Resident #11:

Resident #11 was admitted to the facility on July 05, 2024, with diagnoses that included dementia, psychotic disorder, major depressive disorder, anxiety, chronic obstructive pulmonary disease, and adult failure to thrive.

The admission Minimum Data Set (MDS) assessment dated August 27, 2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.

Review of the facility's Visitor Sign In log revealed that a male and female visitor had signed into the facility on September 04, 2024 at 6:07 to visit room 224, with no sign out time.

A nursing progress note dated September 04, 2024, revealed that at approximately 7:05 PM, certified nursing assistants (CNAs) made the writer aware that two CNAs had knocked on Resident #11's room door a couple of times with no answer. The two CNAs then entered the room, and stated that they saw a completely naked male in the room. The naked male then ran into the restroom. The licensed practical nurse (LPN) then knocked and opened the patient's room. The male had no shirt on, but had put on his pants, and his belt was still unbuckled. An additional female visitor was sitting at the foot of the bed, while the resident laid in the bed. The nurse asked what the situation was. The male visitor made a "terrible joke" while holding money in his hand that he was "paying for sexual intercourse", but then said it was a joke. He then stated that he was just trying to take a shower. The nurse noted that at that time there was no shower water running and there was no scent of soap. The nurse notified the visitor that showers are for residents only. Resident #11 stated that she was not aware of this, and the male visitor kept blaming the resident for the situation. The note indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were made aware. The resident's daughter/ power of attorney (POA) was called and made aware of the situation. The resident's daughter stated that the resident used to live with the visitors but the daughter does not know them well, and that she would like the visitors listed as (Do Not Return) for the current time and would like to speak to her mother about the incident.

Review of the resident's clinical record revealed no evidence of communication from the facility to the provider regarding the incident involving the naked male visitor in Resident #11's room on September 04, 2024.

Review of the state agency reporting system revealed no evidence that the facility submitted a Self-Report form for an allegation of sexual abuse for Resident #11.

A nursing Alert Note dated September 5, 2024 revealed that at 1:20 AM, an LPN (Staff #621) received a message from the DON and night ADON to have both visitors (the male and female) leave the facility. The LPN entered the patient's room and observed the male visitor sitting in the resident's wheelchair and the female visitor sitting at the foot of the bed. The writer informed the visitors that they needed to leave the facility. The LPN observed the male visitor grabbing items from the bathroom, and that the bathroom and shower floor were wet.

A Communication with Resident note dated September 05, 2024 at 9:25 AM, revealed that the DON (Staff # 618) "spoke to resident regarding events from last night", that the resident denies any "wrong doings" and that the resident instructed the male visitor to take a shower because he was "filthy". The resident denied any physical contact, and has no concerns with visitors.

A Weekly Skin Observation dated September 05, 2024, revealed that Resident #11 had no new skin issues.

Review of the facility's Internal Investigation dated September 05, 2024 indicated that the allegation was of a "male visitor naked in resident room" on September 04, 2024 at 7:05 PM. The portion of the investigation indicating notification to the state department, notification to adult protective services, and notification to police was crossed out manually, with "N/A" (not applicable) handwritten across the section. The internal investigation revealed no evidence of notes of staff interviews. The investigation revealed no evidence of which two CNA's initially entered the resident's room. The investigation also revealed no evidence of interviews of residents surrounding Resident #11's room.

Review of the facility's Visitor Sign In log revealed that the male visitor had also signed in to visit the resident on the following dates after the incident:

-September 11, 2024
-September 18, 2024
-October 04, 2024
-October 14, 2024.

A formal request was made to the facility on October 22, 2024 at 10:45 AM for a log of all facility Self-Reports, all incidents and accidents, and all reportable and non-reportable investigations for the timeframe of August through October 2024. Upon review of facility provided documents, there was no evidence that the facility completed the mandated self-reporting of the incident of alleged sexual abuse for Resident #11.

A follow-up formal request dated October 22, 2024 at 2:22 PM for the facility to specify if the incident regarding Resident #11 was reported, in which the facility indicated that the incident was only investigated internally.

Review of the resident's electronic medical record on October 23, 2024 at 2:12 PM, revealed no evidence that the Special Instructions banner at the top of the resident's chart had any information regarding the male and female visitors. However, on October 24, 2024, the DON provided a copy of the Special Instructions banner that was now updated to indicate "(the male and female visitors) CANNOT visit per POA".

A telephonic interview was conducted on October 22, 2024 at 10:57 AM with Resident #11's daughter and POA. The daughter recalled the incident events and stated that she got conflicting stories from her mother and from the facility staff. The daughter stated that her mother has known this man for approximately 10 years, as they used to live in the same apartments, although they were not roommates. The daughter stated that she was told by facility staff that the male visitor was in her mother's room and did not have any clothes on, and that he was taking a shower, and that he made some remarks that he was "giving out sexual favors to the ladies". She stated that her mother said the male visitor did not take a shower. The daughter stated that her mother would not have asked the male visitor to get undressed. The daughter stated that she instructed the facility that she did not want the male visitor back until she could talk to her mother about the incident. She said that in one instance, the facility called and tried to keep the male visitor from entering the facility, but she had let the facility know that she had talked to her mother and that it was "OK for him to be there". The daughter further stated that she had "no concerns about any further incidents", that he has been back to the facility, and he "has been behaving. He brings her food. He's the only one who visits her. I would not let him be there if I was worried about my mom's safety".

An interview was conducted on October 22, 2024 at 1:42 PM with Resident #11. The resident stated that it was the nurse who said her male visitor was naked in the room. The resident stated that he was wearing jeans and had no shirt on, and that he is a construction worker. Resident #11 stated that she told the visitor to take a shower because he was dirty. The resident stated that she did not feel uncomfortable or unsafe reg

Based on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident (#420) was free from misappropriation of resident medications.

-Findings Include:

Resident #420 was admitted to the facility on August 03, 2021 with diagnoses that included Parkinson's disease, major depressive disorder, post-traumatic stress disorder, and heart failure.

A physician order dated January 26, 2023, for Oxycodone HCl Oral Tablet 20 mg to give 1 tablet by mouth every 3 hours as needed for pain.

The order was placed by a licensed practical nurse (LPN/Staff #220) and discontinued the same day by the same LPN.

An additional order dated February 02, 2023 revealed Morphine Sulfate Oral Tablet 15 MG to give 1 tablet by mouth every 3 hours as needed by pain.

The order was placed by the LPN (Staff #220) and was also discontinued that same day by the same LPN.

Review of the personnel file for the LPN (Staff #220) revealed a Disciplinary Action document dated December 9, 2022, for a "probationary period" for "failure to follow departmental policy and procedure when dispensing narcotics. Employee signs out narcotics in narc book but fails to document in eMAR (electronic medical administration record)".

An additional 30-Day Performance Improvement Plan dated December 09, 2022 indicated, as a corrective action step, that the LPN (Staff #220) would be required to have the oversight of an LPN who must cosign the dispense of the narcotic and accompany the employee to administer the narcotic to the patient. The Improvement Plan also indicated to "follow up with employee every 7 days and record development below". However, the spaces provided by the form were left blank.

An additional Disciplinary Action document dated February 08, 2023, for the LPN (Staff #220), revealed that the type of action was "termination". The details indicated an "investigation for narcotic diversion", and that the supervisor "met with employee, she had no answers as to investigation outcome", and that the facility's investigation was "substantiated". The supervisor's name was listed as the DON at that time (Staff #55).

A review of the SA incident reporting system revealed a Reportable Event Record submitted by the facility dated February 06, 2023, revealed that on February 03, 2023, it was identified that a nurse was possibly diverting narcotics. The nurse in question was suspended pending investigation on February 03, 2023, and the investigation was initiated. The Reportable Event Record indicated that the interventions implemented after the incident were that the nurse was suspended and terminated, the pharmacy will no longer accept scripts printed from the electronic medical record, the physicians must E-prescribe, call the pharmacy themselves, or write the narcotic scripts on their own script pad, and that the DON or designee will obtain the daily narcotic logs and match them with what was ordered and delivered in the cart.

Review of the state reporting system revealed that the facility's Administrator at that time (Staff #82) filed a Self-Report form dated February 06, 2023 at 7:24 PM for an allegation of misappropriation (narcotic diversion) for Resident #420.

A Complaint Form dated February 08, 2023 to the state board of nursing revealed that the DON at that time (Staff #55) filed a complaint against the LPN (Staff #220). The complaint specified that during the facility's investigation of possible narcotic diversion by the LPN, that the facility identified "over 34 orders that had been started and discontinued in the same shift that she worked" and "that each prescription (was) the physical prescription with identical handwriting/DEA#/signature with different patient information in the middle. If you look at the top right if the prescription you will see a faint line where the new patient's information was overlaid on the existing signed prescription. Later during the same shift (Staff #220) would receive the medication from the pharmacy and discontinue the medication from the medical record so there was (no) evidence of it being ordered. We did verify with all physicians for attached and signed prescriptions that they did not sign or prescribe them". The complaint specified that no harm occurred to the patients involved, that the LPN was terminated, and that authorities were notified.

A telephonic interview was conducted on October 23, 2024 at 10:47 AM with the Director of Nursing (DON/Staff #55), who was no longer employed at the facility. When asked to describe the incident of the LPN (Staff #220) diverting narcotics, the DON stated that she suspended the nurse immediately when she knew about the missing medications. She stated that initially, her Assistant Director of Nursing (ADON) had identified that morphine was missing. According to the investigation, it was the DON's understanding that the LPN would order medications at the beginning of her shift, the medications would be delivered from the pharmacy, and then the LPN would discontinue the order from the computer. The LPN had an old prescription form from a patient that was printed and signed by one of the facility's providers. The LPN would then fold the new prescription with the new details over the old signed prescription paper, and there was a faint line on all of her orders that signified where she folded the paper. The DON stated that she verified with the provider that he did not write those prescriptions. The DON stated that after the incident, that the facility put in place interventions to prevent recurrence of narcotic diversion, including using strictly prescription pads or computer orders and daily cross checks with the pharmacy.

A telephonic interview was conducted on October 23, 2024 at 11:04 AM, with the Administrator (Staff #82), who was no longer employed by the facility. The Administrator stated that the incident was first noted by the ADON at the time, who noticed a missing bottle of morphine. An investigation started and it was discovered that the LPN (Staff #220) was printing orders, falsifying the signature, sending the script to the pharmacy, and getting medications delivered. The Administrator stated that is was hundreds of pills that were diverted, and that the employee was terminated.

The facility policy titled Freedom from Abuse, Neglect, and Exploitation: Preventing and Prohibiting Abuse, revised May 04, 2023, revealed that it is the facility's policy to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#24) of five sampled residents was not administered an unnecessary medication.

Findings include:

Resident (#24) was admitted to the facility on September 24, 2024 with diagnoses that included Type II Diabetes Mellitus with hyperglycemia.

The care plan for Diabetes Mellitus dated on September 24, 2024 included the intervention to administer medications as ordered and to refer to current orders and/or medication administration record. The care plan also included to monitor for potential side effects and to report changes or abnormalities to medical provider as applicable.

The minimum data set (MDS) dated September 30,2024 included a brief interview for mental status (BIMS) score of 15 indicating the resident was cognitively intact.

A review of the current order summary revealed an order for Lantus solution 100 Unit/Milliliter (ML) (insulin Glargine) Inject 20 unit subcutaneously at bedtime for manage hyperglycemia, hold for blood sugar (BS) less than 100; scheduled for 9:00 PM dated September 25, 2024.

However, There was no evidence of a current order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 units subcutaneously one time a day for diabetes mellitus, hold for BS less than 100.

A review of the October 2024 Medication Administration Record (MAR) revealed an order for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously one time a day for diabetes mellitus, hold for BS less than100; scheduled for 8:00 PM with a start date of September 27, 2024 and a discontinue date of October 20, 2024.

Further review of the October 2024 MAR revealed an order dated September 30, 2024 for Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for manage hyperglycemia, hold for BS less than 100; scheduled for 9:00 PM.

The MAR for October 2024 also revealed that resident (#24) received both orders of Insulin Glargine on the following dates:
- October 5, 2024
- October 6, 2024
- October 14, 2024

An interview was conducted with RN (Staff #644) on October 23, 2024 at 1:29 PM who stated the resident (#24) did have two separate orders for insulin glargine, one for 15 units and one for 20 units per night. She stated that she would clarify with the physician because both of the orders were scheduled close together. The RN (Staff #644) also stated that there was no evidence showing the two orders were clarified with the physician.

An interview was conducted on October 24, 2024 at 9:34 AM with Physician (Physician/Staff #700) who stated he was not aware of staff contacting him to clarify the two orders for Insulin Glargine. He also stated that staff usually contacts him to clarify orders. The physician stated that he did not know why there would be two orders unless there was a change in the dose. He further stated that he does not remember a conversation about discontinuing the first Insulin Glargine order.

In an interview conducted on October 24, 2024 at 10:39 AM with the Director of Nursing (DON/Staff #618), who stated that staff would contact the physician if they needed clarification on an order. The DON stated that the two separate orders for Insulin Glargine should have been clarified with the physician, and that there was no evidence that the physician was contacted to clarify the order. She further stated that the pharmacy should have caught the duplicate order for Insulin Glargine. The DON (Staff #618) stated the risks to the resident by not clarifying the orders would be that the resident (#24) could receive too much Insulin Glargine and become hypoglycemic. The DON also stated that this did not meet facility expectations by not clarifying the physician's orders.

The facility's policy, "Pharmacy Services, Medication Management" dated November 2017, indicated that the resident's medication regime will be evaluated and modified for efficacy and adverse consequences. The policy also revealed that the physician plays a key leadership role in medication management by developing, monitoring, and modifying the medication regimen in conjunction with residents, their families, and/or representatives, other professionals and direct care staff, the interdisciplinary team.

Based on observation, clinical record review, staff and resident interviews, and policy review, the facility failed to ensure one resident (#12) was provided shower and dressing in timely manner. This deficient practice could result in residents not being provided hygiene care and services.

Findings include:

Resident #12 was admitted to the facility on July 22, 2023 with diagnoses that included type 2 diabetes mellitus, chronic kidney diseases, anxiety, and depression.

Review of the care plan dated November 30, 2023 revealed the resident had activities of daily living (ADL) performance deficit related to general weakness.

Review of the admissions Minimum Data Set (MDS) assessment dated July 26, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident required two or more-person assistance with shower/bathing self.

Review of the resident bathing schedule showed that resident was schedule for bathing every Tuesday and Friday.

Review of progress note dated June 19, 2024 showed that resident was asked for shower at 2:45a.m. It further revealed that resident refused shower and stated she was too tired. Further review of progress note dated October 8, 2024 showed that resident was asked for shower at 12:27a.m. and resident refused shower and she stated that she got one on Monday.

Review of shower sheets for resident #12 from June-October, 2024 revealed that resident got showers on following days:

June: 4, 7, 18, 21, 25
July: 2, 9, 16, 19, 23
Aug: 5, 9, 18, 20, 27
September: 3, 10, 13, 16, 23, 27, 30
October: 4, 8, 11, 14, 21

An interview was conducted with resident #12 on October 21, 2024 at 12:43 pm in presence of daughter and daughter stated that one of the ongoing issues is bathing because my mother is not moveable, she is not getting schedule bath specially with agency staffs. There is one aid who makes sure she gets at least one in a week. She is scheduled to get bath on Tuesday and Friday and she rarely get Friday bath. I talk to administrator and director of nursing several times and they mention that they will change schedule but nothing happened so far. If there is agency staff person during night shift then they will come in morning around 1 am or 4 am for bath while I am sleeping.

An interview was conducted again with resident #12 on October 23, 2024 at 11:52 am and resident stated that I cannot walk and I need one-person assistance with changing, bathing and bathroom. I get bed bath every Tuesday but not Friday. If I refuse bath then they supposed to bring form for refusal but when I refuse they say "okay". Only time I refuse when they come middle of night when I am sleeping. I have to remine them every time that its Friday and I want bath. I have an issue with anxiety and there is time when I feel they are not taking me seriously and it happen mostly with agency staffs.

An interview was conducted with certified nursing assistance (CNA #684) on October 23, 2024 at 12:40 pm and she stated that I don't feel like there is enough staff because we have 3 CNA for whole 2nd floor and we are running around and there are not enough CNA for patient to get adequate care. I feel like I am over whelmed because of not having enough staff and specially 2nd floor has lot of incontinent residents and they are not getting adequate care. When we are under staff, it's hard to answer residents in timely manner. She further stated that shower is schedule for every resident twice a week. Resident #12 is scheduled for Tuesday and Friday shower. If resident refuse shower then they have to wait until next schedule date. She also stated shower supposed to be done by 10:30pm and as far as it done before 10:30pm then it's not too late. We have lot of agency staff specially at night and weekend and that's why shower get missed lot of time. She then stated that risk for not getting shower/bath would be skin/hair irritation, fungus growing under folds.

An interview was conducted with certified nursing assistance (CNA #622) on October 24, 2024 at 7:42 am and she stated that showers are provided by CNA. We have schedule shower for both day and night. Night shower has to be done before 10pm. If residents ask after 10pm then we provide and its usually not a problem. She further stated that risk for resident not getting schedule shower would be skin break down, dry skin, odor, itchiness. At night shift I usually ask for shower after vital and before going to bed and not at midnight.

An interview was conducted with certified nursing assistance (CNA #657) on October 24, 2024 at 8:03 am and she stated that night showers are provider before 10pm, that is after taking resident vitals and before going to bed. So far, I have just done bed bath and if resident refuses then we write in shower sheet that they refused and then CNA and nurse sign it, and let next shift know. She further stated that risk for not getting schedule shower would be getting infection.

An interview was conducted with director of nursing (DON #618) on October 24, 2024 at 11:01 am and she stated that we offer shower/bathing minimum twice a week and if resident wants then we try to accommodate every day. She further stated that we offer shower before 10pm so that we not walking them up residents' middle of night. She also stated that risk of not having shower/bath would be poor hygiene and shower helps to maintain general health of wellness. She further stated that resident #12 is scheduled for shower/bath every Tuesday and Friday and waking up resident middle of night shouldn't have happened.

Review of the facility policy titled, "Activities of Daily Living (ADLs/Maintain Abilities" revised on May 4, 2024 indicated that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, record review, and staff interviews, the facility failed to ensure that one resident (#43) was free from significant medication errors.

Findings include:

Resident #43 was originally admitted to the facility on August 13, 2023 with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension.

A care plan initiated on February 7, 2024 revealed the resident has potential for fluctuating blood glucose levels related to diabetes. Interventions included to give medication as ordered by the physician and monitor for signs and symptoms of hypoglycemia and hyperglycemia.

The quarterly Minimum Data Set assessment dated August 7, 2024 revealed the resident had cognitive skills for daily decision making as "0" indicating independence in decisions regarding tasks of daily life.

During a medication administration observation conducted on October 22, 2024 at approximately 8:24 am with a Registered Nurse (RN/staff #700), the RN was observed to administer.

- One Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 and one Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) with expiration date October, 2025, were given to resident #43.

However, review of the physician's order revealed that Jardiance (Empagliflozin) 10mg tablet, was discontinued on August 28, 2024. A new order Farxiga Oral Tablet 5 mg (Dapagliflozin Propanediol), give 1 tablet by mouth in the morning were active from August 28, 2024.

An Interview was conducted on October 23, 2024 at 9:04am with license practical nurse (LPN/ staff #685) and she stated that she looks at medication administration record (MAR) regarding what medication to be given to resident. Also, if medications are coming from hospital then staff verify from inhouse physician and then put in order list and on MAR. She further stated that resident #43 is a "veteran" and if medications come from VA hospital then we check from assistance director of nursing (ADON) and director of nursing (DON) whether medication from pharmacy or VA to continue and we don't give medication not listed in order. When asked staff #685 to pull out resident #43 blood sugar medication, she unlocked "north 2" cart and showed Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025. She then looked into point click care in her computer for Jardiance order and stated that Jardiance (Empagliflozin) was discontinued and replace with Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) and it was put on reorder by a nurse yesterday.

An interview was conducted on October 23, 2024 at 10:30 am with registered nurse and she stated that resident #43 Jardiance (Empagliflozin) 10mg tablet medication was discontinued on August 28, 2024 and was started on Farxiga Oral Tablet 5 mg from August 29, 2024. She further stated that staff supposed to take out Jardiance and discard in Rx destroyer.

An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that we administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. Regarding resident #43 she stated that resident was on Empagliflozin (generic is Jardiance) 10mg tablet starting September 14,2024 and ended September 28, 2024, and on Farxiga Oral Tablet 5 mg daily starting September 29, 2024 and medication is currently active. When asked during med pass, it was observed that staff #700 giving Jardiance (Empagliflozin) 10mg tablet to resident #43 then she stated that she has to go and pull out Jardiance (Empagliflozin) from medication cart and stated that staff are reading the box/cart instead of physician order.

Review of the facility provided policy titled, Medication Administration, reviewed and revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's order, manufacturer's specifications (not recommendations) and accepted professional standards and principles. It further revealed that the relative significance of medication errors is a matter of professional judgement. However, three general guidelines can be used in determining is a medication error is significant or not: resident condition, drug category and frequency of error.

-Regarding Resident #29:

Resident #29 was originally admitted to the facility on November 21, 2023 with diagnoses that included Type II Diabetes Mellitus, respiratory failure, and chronic kidney disease.

The resident's quarterly minimum data set (MDS) assessment dated August 27, 2024 included a brief interview for mental status (BIMS) score of 11, indicating moderately impaired cognition.

The resident's care plan for Diabetes Mellitus dated September 24, 2024, included an intervention to administer medications as ordered.

A physician order dated March 2, 2024 prescribed: Humalog Injection solution (Insulin Lispro), inject as per sliding scale: if 0 - 69 = 0 units Give glucose and notify physician; 70 - 149 = 0 units; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units; 350 > give 12 units and notify physician, subcutaneously before meals and at bedtime for diabetes.

An additional physician order dated August 30, 2024 prescribed: Humalog Injection solution (Insulin Lispro), inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units;150 - 199 = 2 Units; 200 - 249 = 4 Units; 250 - 299 = 7 Units; 300 - 349 = 10 Units; 350+ = 12 Units; 350 > give 12 units and notify physician, subcutaneously before meals and at bedtime for diabetes.

Review of the Medication Administration Record (MAR) dated August 2024 revealed:
-August 09, 2024 at 4:00 PM, that blood sugar of 408 and 12 units of insulin were administered.

The MAR dated September 2024 revealed:
-September 02, 2024 at 12:00 PM, that blood sugar of 410 and 12 units of insulin were administered.

Review of the clinical record revealed no evidence that the physician was notified as ordered when the resident's blood glucose was greater than 350 and 12 units of insulin were administered on August 09 and September 02, 2024.

An interview was conducted on October 24, 2024 at 8:52 AM, with the Assistant Director of Nursing (ADON/ Staff #640), who stated that it is his expectation that staff call the provider if a physician order indicates to call the physician if something such as a resident's vital sign or lab results was out of parameters. He further stated that it was his expectation that the staff would document in the electronic health record that the call to the provider was made. The ADON stated that staff can either document this provider communication through the MAR when administering medication or the nurse could enter a progress note. When Resident #29's MAR for August and September 2024 were reviewed together with the ADON, he stated that he could not find any evidence that the provider was notified as ordered on August 09 or September 02, 2024. He stated that the impact on a resident if the provider was not called would be that the facility staff may miss an order and that the physician would not know what was going on with the resident.

An interview was conducted with the Director of Nursing (DON / Staff #618) on October 24, 2024 at 9:43 AM, who stated it was her expectation that if a resident has something, for example vital signs or labs, outside parameters and if they have an order stating to notify the physician, that the nurse would call the physician. The DON stated that if the issue was critical, that the physician should be notified immediately, and if it is not critical, that the physician would still be communicated with. She stated that in both cases, the communication with the physician should be documented in the medical record. When reviewing Resident #29's clinical record together, the DON stated that the lack of documentation regarding physician communication would not meet her expectation, and that "the provider needs to be looped in".

The facility's policy, "Pharmacy services, Medication Administration", revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's orders and accepted professional standards and principles.

Based on observations, staff interviews, review of records, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for two residents (#43 and #21).

Findings include:

Resident #43 was admitted to the facility on April 1, 2024 with diagnoses that included chronic obstruction pulmonary disease, type 2 diabetes mellitus, insomnia and hypertension.

During a medication administration observation conducted on October 22, 2024 at approximately 8:24 am with a Registered Nurse (RN/staff #700), the RN was observed to administer.

- one Jardiance (Empagliflozin) 10mg tablet with expiration date August, 2025 and one Farxiga Oral Tablet 5 MG (Dapagliflozin Propanediol) with expiration date October, 2025, were given to resident #43.

However, review of the physician's order revealed that Jardiance (Empagliflozin) 10mg tablet, was discontinued on August 28, 2024. A new order Farxiga Oral Tablet 5 mg (Dapagliflozin Propanediol), give 1 tablet by mouth in the morning were active from August 28, 2024.

Resident #21 was admitted to the facility on October 10, 2024 with diagnoses that included type 2 diabetes mellitus, resistance to multiple antimicrobial drugs, and hypertension.

During a medication administration observation conducted on October 22, 2024 at approximately 9:30 am with a licensed practical nurse (LPN/staff # 710), the LPN were observed putting Amiodarone HCl Oral Tablet 200 MG 1 tablet that expired on September 30, 2024 in a small paper cup. When asked regarding expired medication, she stated that she haven't looked at the expiration date.

An Interview was conducted on October 22, 2024 at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication, who stated that we follow 5 rights during medication administrations including right patient, dose, route, medication and time. She also stated that we should dispense medication directly on cup and not on hand because our hands have bacteria, even if we sanitized and wash hand, we should not get into practice of touching medication while giving to patient, we should follow orders, rules, guidelines, protocol, and they are in place for reason. When asked regarding expiration medication then she stated that never give expired medication because medication has shelf-live and would be given according to shelf-life. An addition observation was conducted for medication cart "North 1" on October 22, 2024 at 1:01pm revealing that expired medication Amiodarone HCl Oral Tablet 200 MG remained on the medication cart and staff #710 stated that I am sorry, we missed this medication, it should be discarded to Rx destroyer.

An Interview was conducted on October 22, 2024 at 1:52 pm with a Registered Nurse (RN/staff #700), that was observed during the medication, who stated that we follow 7 rights during medication administrations including right patient name, medication, dose, reason, right documentation, time (med expiration), and route. She further stated that during medication administration, we use bubble method to dispense medication directly to cup from medication strip, where you don't touch medication, you pop up directly into cup without touching it because touching medication directly can cause cross contamination, cause infection and if you touch medication with hand then there is a chance of observing medication to your skin the effect of drug. Regarding expired medication, she stated that for blood pressure and over the counter medication, we use Rx destroyer and for narcotics, do two-person verification before destroying to Rx destroyer. She further stated that risk for giving expiration medication would be non-effectiveness, cause harm, cause rebound with BP, and mess with other medications.

An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that we administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. She further stated that during med pass, we dispense medication from bubble cart to medicine cup and it should go directly into cup and not from hand to cup else there will be potential for infection. She then stated that risk of using expiry medication would be efficacy of medication can't be effective by expiration dates. Regarding resident #43 she stated that resident was on Empagliflozin (generic is Jardiance) 10mg tablet starting September 14,2024 and ended September 28, 2024, and on Farxiga Oral Tablet 5 mg daily starting September 29, 2024 and medication is currently active. When asked during med pass, it was observed that staff #700 giving Jardiance (Empagliflozin) 10mg tablet to resident #43 then she stated that she has to go and pull out Jardiance (Empagliflozin) from medication cart and stated that staff are reading the box/cart instead of physician order.

Review of the facility provided policy titled, Medication Administration, reviewed and revised on May 4, 2023 revealed that medications will be prepared and administered in accordance with prescriber's order, manufacturer's specifications (not recommendations) and accepted professional standards and principles. It further revealed that the relative significance of medication errors is a matter of professional judgement. However, three general guidelines can be used in determining is a medication error is significant or not: resident condition, drug category and frequency of error.

Based on observations, staff interviews, facility documentation, policies and procedure, the facility failed to ensure expired medications were appropriately disposed of and not available for resident use.

Findings include:

During a medication administration observation conducted on October 22, 2024 at approximately 9:30 am with a licensed practical nurse (LPN/staff #710), the LPN were observed putting Amiodarone HCl Oral Tablet 200 MG in a small paper cup for administration. The medication was observed to be expired on on September 30, 2024. When asked regarding expired medication, she stated that she haven't looked at the expiration date and was observed taking out expired medication from cup and putting in biohazard bin. She then put medication strip bubble of Amiodarone HCl Oral Tablet with expired on September 30, 2024 back into "North 1" cart drawer.

An Interview was conducted on October 22, 2024 at 12:41pm with a licensed practical nurse (LPN/staff # 710), that was observed during the medication, who stated that we follow 5 rights during medication administrations including right patient, dose, route, medication and time. She also stated that we should dispense medication directly on cup and not on hand because our hands have bacteria, even if we sanitized and wash hand, we should not get into practice of touching medication while giving to patient, we should follow orders, rules, guidelines, protocol, and they are in place for reason. When asked regarding expiration medication then she stated that never give expired medication because medication has shelf-live and would be given according to shelf-life.

An addition observation was conducted for medication cart "North 1" on October 22, 2024 at 1:01pm revealing that expired medication Amiodarone HCl Oral Tablet 200 MG remained on the medication cart and staff #710 stated that I am sorry, we missed this medication, it should be discarded to Rx destroyer.

An Interview was conducted on October 22, 2024 at 1:52 pm with a Registered Nurse (RN/staff #700), that was observed during the medication, who stated that we follow 7 rights during medication administrations including right patient name, medication, dose, reason, right documentation, time (med expiration), and route. Regarding expired medication, she stated that for blood pressure and over the counter medication, we use Rx destroyer and for narcotics, do two-person verification before destroying to Rx destroyer. She then stated that risk for giving expiration medication would be non-effectiveness, cause harm, cause rebound with BP, and mess with other medications.

An Interview was conducted on October 23, 2024 with director of nursing (DON/ staff # 618) who stated that staff administration medication according to physician order and follow five rights including: right medication, route, patient, form (IV/oral/rectal/capsule/tablet), time (right time), and expiration. She further stated that during med pass, we dispense medication from bubble cart to medicine cup and it should go directly into cup and not from hand to cup else there will be potential for infection. She then stated that risk of using expiry medication would be efficacy of medication can't be effective beyond the expiration dates.

Review of the facility provided policy titled, Labeling and Storage of Drugs and Biologicals, reviewed and revised on May 4, 2023 revealed that medications labelling and biological dispensed by the pharmacy must be consistent with applicable federal and state requirements and currently accepted pharmaceutical principles and practices.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration.

Findings:

During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 7:56 a.m., for resident #426, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on "north 2" cart.

- metFORMIN HCl Oral Tablet 500 MG (Metformin HCl) Give 1 tablet by mouth two times a day for Diabetes management
- Cholecalciferol Tablet 1000 UNIT Give 1 tablet by mouth one time a day for Supplement

During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 8:08 a.m., for resident #49, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on "north 2" cart.

- Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 3 tablet by mouth one time a day for PTSD
- ARIPiprazole Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth two times a day for PTSD

During the Medication Administration observation with the registered nurse (RN/ staff #700) on October 22, 2024 at 8:24 a.m., for resident #43, the RN dispense following tablets from med strip bubble to her bare hand and then to the small plastic cup placed on "north 2" cart.

- busPIRone HCl Oral Tablet (Buspirone HCl) Give 10 mg by mouth three times a day for anxiety AEB restlessness
- Memantine HCl Oral Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth every 12 hours for dementia aeb confusion and impulsive behaviors
- Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for NUEROPATHY
- Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth three times a day for Parkinson
- Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet by mouth one time a day for DVT PPX
- Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 25 mg by mouth one time a day for HTN: hold for SBP

Based on resident and staff interviews, a food test tray, and policy review, the facility failed to ensure food was provided that was palatable and at a temperature that is safe for consumption.

Review of the lunch menu for October 22, 2024 revealed the following:
-Chili Cheese Dog
-Sweet Potato Fries
-Herb Green Beans
-Banana Pudding

An observation was conducted on October 22, 2024 at 12:50 PM of a test tray. The test tray temperatures were taken by staff as follows:
-Chili Cheese Dog-123 F
-Sweet Potato Fries-121 F
-Banana Pudding 63 F

The test tray sampled by surveyors who reported that the chili cheese dog cooked but served cold. Two of the seven surveyors noted that the sweet potato fries were cold but crunchy. Additionally, three out of seven surveyors indicated that the banana pudding was not chilled.

An interview conducted on October 21, 2024 at 9:06 a.m. with Resident # 32, with a BIMS Score of 11, stated that on October 20, 2024, he had to push his call light three times for because his lunch hasn't delivered yet. The resident stated that he to stepped out from his room to find staff regarding the lunch tray and it was not delivered until two-thirty p.m., and was cold.

An interview conducted on October 21, 2024 at 10:36 a.m. with Resident #15, with a BIMS Score of 15, stated that staff deliver food cold every time.

An interview conducted on October 21, 2024 at 2:16 p.m. with Resident #36, with a BIMS Score of 13, revealed that food always arrives cold and not looking appetizing.

An interview conducted on October 21, 2024 at 2:30 p.m. with Resident #7, with a BIMS Score of 13, stated that food is always cold, bland, and not appetizing.

An interview conducted on October 21, 2024 at 2:30 p.m. with Resident # 11, with a BIMS Score of 11, stated that food is horrible. The resident stated that she tries not to eat the food because it's nasty by the time she receives her meal.

An interview conducted on October 22, 2024 at 11:30 a.m. with Resident # 49, with a BIMS Score of 14, stated that food is terrible. The resident stated for the last two nights, the soup, mashed potatoes, and the meat are cold already when she received the tray.

An interview was conducted on October 23, 2024, with the Dietary Manager (Staff #669). She reported that a few residents had complained about cold food over the past three months. The Dietary Manager emphasized that whenever residents express concerns about food temperature, she promptly addresses the issue with her staff. This includes checking the food temperature before serving and ensuring that food is covered when presented to the residents. For room trays, the staff serves the food on plates, covers the plates, and places them in a warmer before delivering the trays to the residents' rooms.

Review of the Facility Policy titled "Food and Nutrition Services" revealed that facility will procure food from sources approved or considered satisfactory by federal, state or local authorities. Food items will be stored, prepared, distributed and served in accordance with professional standards for food safety.

Review of the Facility Guideline titled "Serving Temperatures for Hot and Cold Foods" revealed that staff will follow the guidelines when serving hot and cold beverages and food.

Review of the Facility Procedure titled "Serving Temperatures for Hot and Cold Foods" revealed that foods will be serve at the following temperature to ensure a safe and appetizing dining experience. The minimum serving temperatures do not reflect the required temperatures needed for preparation, cooking or cooling of foods.

Based on clinical record review, staff interviews, hospital record, facility documentation and policy review, the facility failed to ensure one resident (#55) was free from neglect, by failing to act in the presence of life-threatening signs and symptoms. This deficient practice could result in resident's not being provided necessary services

Findings include:

Resident #55 was admitted on April 5, 2023 with diagnoses of a wedge compression fracture of T7 (thoracic vertebrae 7)-T8, multiple rib fractures, COPD (chronic obstructive pulmonary disease), heart failure, hypothyroidism, peripheral vascular disease, and hypokalemia.

A review of a 5-day MDS assessment dated April 11, 2023 the resident had a BIMS (brief interview for mental status) score of 14 indicating the resident had intact cognition.

The nursing skin and wound note dated April 6, 2023 included that the resident was admitted with open wounds to her left knee, left upper ankle, left lower ankle, and right ankle, as well as several bruises, abrasions and scabbed areas.

The care plan dated April 5, 2023 revealed the resident was at risk for skin breakdown related to fragile skin and mobility. Interventions including monitoring skin during care and reporting changes.

The physician order dated April 7, 2023 revealed an order to cleanse left ankle, wound care every Monday, Wednesday, and Friday.

A wound note dated April 12, 2023 included there was no change in the resident's condition.

A physician progress note dated April 14, 2023 revealed the resident was still weak and frail and had no fever.

The blood pressure (BP) summary revealed the following information:
-April 15, 2023 at 7:24 a.m. the BP was 94/55
-April 15, 2023 at 2:32 p.m., the BP was 71/43. However, this record was struck out; per the documentation, there was "incomplete documentation."

Despite documentation of these low BP, the clinical record revealed no documentation that the physician was notified until April 15, 2023 at 9:22 p.m. (approximately 7 to 14 hours after the BP reading was taken).

A physician progress note dated April 15, 2023 at 9:22 p.m. revealed the physician was notified by a nurse that earlier that morning the resident was hypotensive at 71/43, was tachycardic all day at 108 and with increased oxygen requirement and was on 4 liters via nasal cannula with oxygen saturation of 92%. It also included that the resident's left lower extremity appeared warm and swollen. Per the documentation, the resident's family reported that the resident appeared lethargic and was shivering. Assessments included sepsis secondary to lower extremity cellulitis; and, acute hypoxic respiratory failure. The plan was to send the resident to the hospital STAT.

Review of the hospital record revealed the resident was seen on April 15, 2023 at 3:27 p.m.in the emergency room and had a chief complaint of sepsis. Per the documentation, upon arrival to the emergency room, the resident had an axillary temperature of 101.8, heart rate of 135, respiratory of rate of 24 and BP of 146/117. Impression included severe sepsis without septic shock.

Continued review of the hospital record included that history was obtained from the family at bedside. Per the documentation, the family reported that resident was admitted at the facility; and that, the staff removed her left lower extremity wound dressing for shower and did not replace the dressing for several hours. It also included that the family was told that the resident's BP in the morning was in the systolic 70s. It also included that the resident had been noted to be saturating less than 90% on her home 4 L/min, so she was placed on nonrebreather. Further, the record revealed the resident was admitted to the hospital for treatment of severe sepsis with septic shock and was treated with multiple antibiotics. Further, the hospital record included that the resident expired on April 16, 2023 at 3:23 p.m.

In an interview conducted with a certified nursing assistant (CNA/staff #104) on May 4, 2023 at 2:38 p.m., the CNA stated that if a resident's blood pressure were low, she would immediately tell the nurse and get the resident some water to drink. The CNA also stated that they put their vitals into the electronic record; and that, the nurses also document vitals.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on April 27, 2023 at 1:50 p.m. The LPN stated that on the morning of April 15, 2023 a CNA reported a low blood pressure at approximately 7:30 a.m.; and that, she asked the CNA to get a repeat blood pressure. However, the LPN stated that the agency CNA did not get back with her right away. The LPN said that at the time she was very busy passing meds; and, that was really not an excuse. Further, the LPN stated that the CNA gave her a new blood pressure about noon and she documented this in the eMAR (electronic Medication administration record) or progress notes. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no documentation of the assessment that she had conducted after the resident's blood pressure was reported low at 7:30 a.m. She also reported that the BP of 71/43 was done at approximately 6:00 a.m. on April 15, 2023; and that, she struck it out because the resident was lying flat and she had set the resident up to see if it will help. The LPN said that she asked a female agency CNA to get a new set of vitals but she did not get the new vitals until noon. The LPN stated that it was not normal for her to send out a resident without any documentation; and that, when there is a change of condition the resident is assessed first, then sent them out to the hospital/emergency room and then document in the clinical record all the assessments and change of condition. Regarding resident #55, the LPN said that on April 15, 2023 the family arrived at the facility at around 11:30 a.m., the doctor came in about 12:00 p.m., and the resident was sent out about 12:30 p.m.

An interview was conducted on May 4, 2023 at 3:30 p.m. with the director of nursing (DON/staff #98) who stated that in the event of a change of condition, her expectation was that the nurses would do an assessment, get vitals, and report any changes to the physician within one hour. The DON said that low blood pressure could be caused by sepsis, an infection, or medications; and that, she would definitely notify the physician. She stated that the CNAs documents their own vitals in the electronic record; but, they also give a copy to the nurses. The DON stated that if a nurse got a different result they could strike out the documentation of a CNA, because their scope of practice is higher. However, the DON said that she would expect a corrected entry or a progress note clarifying the difference. During the interview, a review of the clinical record was conducted with the DON who noted the resident's (#55) blood pressure of 71/42 and that it was struck out; and, the physician note that indicated the low blood pressure earlier that morning was communicated to the physician. The DON stated that there were no follow up blood pressure readings or progress notes found in the clinical record. Further, the DON said that neglect was defined as a resident not getting the care that the facility should be providing; or, withholding care to the resident. Regarding the incident with resident #55, the DON said the care was there but there was definitely a delay in notifying the physician of the resident's low BP.

The facility policy on Change in a Resident's Condition or Status, revised February 2021 included that the nurse will notify the resident's attending physician when there has been significant change in the resident's condition and that the nurse will record in the resident's medical

Based on staff interviews, hospital record, facility documentation and policy review, the facility failed to ensure one resident (#55) received treatment and care according to professional standards of care. This deficient practice could result in changes in condition being missed and timely interventions being implemented.

Findings include:

Resident #55 was admitted to the facility on April 5, 2023 with diagnoses of wedge compression fracture of T7-T8, multiple rib fractures, COPD (chronic obstructive pulmonary disease), heart failure, hypothyroidism, peripheral vascular disease, and hypokalemia.

A review of a 5-day MDS dated April 11, 2023 noted the resident had a BIMS of 14, indicating no cognitive impairment.

The blood pressure (BP) summary revealed the following information:
-April 15, 2023 at 7:24 a.m. the BP was 94/55
-April 15, 2023 at 2:32 p.m., the BP was 71/43. However, this record was struck out; per the documentation, there was "incomplete documentation."

There was no evidence found in the clinical record that interventions were put in place to address the resident's low BP reading.

Further review of the clinical record revealed no evidence that resident's BP was rechecked and monitored a low BP reading.

Despite documentation of these low BP, the clinical record revealed no documentation that the physician was notified until April 15, 2023 at 9:22 p.m. (approximately 7 to 14 hours after the BP reading was taken).

A physician progress note dated April 15, 2023 at 9:22 p.m. revealed the physician was notified by a nurse that earlier that morning the resident was hypotensive at 71/43, was tachycardic all day at 108 and with increased oxygen requirement and was on 4 liters via nasal cannula with oxygen saturation of 92%. It also included that the resident's left lower extremity appeared warm and swollen. Per the documentation, the resident's family reported that the resident appeared lethargic and was shivering. Assessments included sepsis secondary to lower extremity cellulitis; and, acute hypoxic respiratory failure. The plan was to send the resident to the hospital STAT.

Review of the hospital record revealed the resident was seen on April 15, 2023 at 3:27 p.m.in the emergency room and had a chief complaint of sepsis. Per the documentation, upon arrival to the emergency room, the resident had an axillary temperature of 101.8, heart rate of 135, respiratory of rate of 24 and BP of 146/117. Impression included severe sepsis without septic shock.

In an interview conducted with a certified nursing assistant (CNA/staff #104) on May 4, 2023 at 2:38 p.m., the CNA stated that if a resident's blood pressure were low, she would immediately tell the nurse and get the resident some water to drink.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on April 27, 2023 at 1:50 p.m. The LPN stated that on the morning of April 15, 2023 a CNA reported a low blood pressure at approximately 7:30 a.m.; and that, she asked the CNA to get a repeat blood pressure. The LPN stated that at the time she was very busy passing meds; and, that was really not an excuse. Further, the LPN stated that the CNA gave her a new blood pressure about noon and she documented this in the eMAR (electronic Medication administration record) or progress notes. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no documentation of the assessment that she had conducted after the resident's blood pressure was reported low at 7:30 a.m. She also reported that the BP of 71/43 was done at approximately 6:00 a.m. The LPN said that she asked the CNA to get a new set of vitals but she did not get the new vitals until noon. The LPN further stated that it was not normal for her to send out a resident without any documentation; and that, when there is a change of condition the resident is assessed first, then sent them out to the hospital/emergency room and then document in the clinical record. However, regarding resident #55 the LPN stated the resident was sent out around 12:30 p.m. Despite having symptoms at 6:00 a.m., no interventions were put in place and the resident was not admitted until 3:27 p.m. which is a gap of approximately 9 to 9.5 hours which could result in increased morbidity and mortality.

An interview was conducted on May 4, 2023 at 3:30 p.m. with the director of nursing (DON/staff #98) who stated that in the event of a change of condition, her expectation was that the nurses would do an assessment timely, get vitals, and report any changes to the physician within one hour. The DON said that low blood pressure could be caused by sepsis, an infection, or medications; and that, she would definitely notify the physician. She stated that the CNAs documents their own vitals in the electronic record; but, they also give a copy to the nurses. The DON stated that if a nurse got a different result they could strike out the documentation of a CNA, because their scope of practice is higher. However, the DON said that she would expect a corrected entry or a progress note clarifying the difference. During the interview, a review of the clinical record was conducted with the DON who noted the resident's (#55) blood pressure of 71/42 and that it was struck out; and, the physician note that indicated the low blood pressure earlier that morning was communicated to the physician. The DON stated that there were no follow up blood pressure readings or progress notes found in the clinical record. Regarding the incident with resident #55, the DON said the care was there but there was definitely a delay in notifying the physician of the resident's change in condition.

Review of facility policy titled 'Change in a Resident's condition or status' revealed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's condition. It also revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status.

Based on clinical record review, staff interviews, hospital record, facility documentation and policy review, the facility failed to ensure one resident (#55) was free from neglect, by failing to act in the presence of life-threatening signs and symptoms.

Findings include:

Resident #55 was admitted on April 5, 2023 with diagnoses of a wedge compression fracture of T7 (thoracic vertebrae 7)-T8, multiple rib fractures, COPD (chronic obstructive pulmonary disease), heart failure, hypothyroidism, peripheral vascular disease, and hypokalemia.

A review of a 5-day MDS assessment dated April 11, 2023 the resident had a BIMS (brief interview for mental status) score of 14 indicating the resident had intact cognition.

The nursing skin and wound note dated April 6, 2023 included that the resident was admitted with open wounds to her left knee, left upper ankle, left lower ankle, and right ankle, as well as several bruises, abrasions and scabbed areas.

The care plan dated April 5, 2023 revealed the resident was at risk for skin breakdown related to fragile skin and mobility. Interventions including monitoring skin during care and reporting changes.

The physician order dated April 7, 2023 revealed an order to cleanse left ankle, wound care every Monday, Wednesday, and Friday.

A wound note dated April 12, 2023 included there was no change in the resident's condition.

A physician progress note dated April 14, 2023 revealed the resident was still weak and frail and had no fever.

The blood pressure (BP) summary revealed the following information:
-April 15, 2023 at 7:24 a.m. the BP was 94/55
-April 15, 2023 at 2:32 p.m., the BP was 71/43. However, this record was struck out; per the documentation, there was "incomplete documentation."

Despite documentation of these low BP, the clinical record revealed no documentation that the physician was notified until April 15, 2023 at 9:22 p.m. (approximately 7 to 14 hours after the BP reading was taken).

A physician progress note dated April 15, 2023 at 9:22 p.m. revealed the physician was notified by a nurse that earlier that morning the resident was hypotensive at 71/43, was tachycardic all day at 108 and with increased oxygen requirement and was on 4 liters via nasal cannula with oxygen saturation of 92%. It also included that the resident's left lower extremity appeared warm and swollen. Per the documentation, the resident's family reported that the resident appeared lethargic and was shivering. Assessments included sepsis secondary to lower extremity cellulitis; and, acute hypoxic respiratory failure. The plan was to send the resident to the hospital STAT.

Review of the hospital record revealed the resident was seen on April 15, 2023 at 3:27 p.m.in the emergency room and had a chief complaint of sepsis. Per the documentation, upon arrival to the emergency room, the resident had an axillary temperature of 101.8, heart rate of 135, respiratory of rate of 24 and BP of 146/117. Impression included severe sepsis without septic shock.

Continued review of the hospital record included that history was obtained from the family at bedside. Per the documentation, the family reported that resident was admitted at the facility; and that, the staff removed her left lower extremity wound dressing for shower and did not replace the dressing for several hours. It also included that the family was told that the resident's BP in the morning was in the systolic 70s. It also included that the resident had been noted to be saturating less than 90% on her home 4 L/min, so she was placed on nonrebreather. Further, the record revealed the resident was admitted to the hospital for treatment of severe sepsis with septic shock and was treated with multiple antibiotics. Further, the hospital record included that the resident expired on April 16, 2023 at 3:23 p.m.

In an interview conducted with a certified nursing assistant (CNA/staff #104) on May 4, 2023 at 2:38 p.m., the CNA stated that if a resident's blood pressure were low, she would immediately tell the nurse and get the resident some water to drink. The CNA also stated that they put their vitals into the electronic record; and that, the nurses also document vitals.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on April 27, 2023 at 1:50 p.m. The LPN stated that on the morning of April 15, 2023 a CNA reported a low blood pressure at approximately 7:30 a.m.; and that, she asked the CNA to get a repeat blood pressure. However, the LPN stated that the agency CNA did not get back with her right away. The LPN said that at the time she was very busy passing meds; and, that was really not an excuse. Further, the LPN stated that the CNA gave her a new blood pressure about noon and she documented this in the eMAR (electronic Medication administration record) or progress notes. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no documentation of the assessment that she had conducted after the resident's blood pressure was reported low at 7:30 a.m. She also reported that the BP of 71/43 was done at approximately 6:00 a.m. on April 15, 2023; and that, she struck it out because the resident was lying flat and she had set the resident up to see if it will help. The LPN said that she asked a female agency CNA to get a new set of vitals but she did not get the new vitals until noon. The LPN stated that it was not normal for her to send out a resident without any documentation; and that, when there is a change of condition the resident is assessed first, then sent them out to the hospital/emergency room and then document in the clinical record all the assessments and change of condition. Regarding resident #55, the LPN said that on April 15, 2023 the family arrived at the facility at around 11:30 a.m., the doctor came in about 12:00 p.m., and the resident was sent out about 12:30 p.m.

An interview was conducted on May 4, 2023 at 3:30 p.m. with the director of nursing (DON/staff #98) who stated that in the event of a change of condition, her expectation was that the nurses would do an assessment, get vitals, and report any changes to the physician within one hour. The DON said that low blood pressure could be caused by sepsis, an infection, or medications; and that, she would definitely notify the physician. She stated that the CNAs documents their own vitals in the electronic record; but, they also give a copy to the nurses. The DON stated that if a nurse got a different result they could strike out the documentation of a CNA, because their scope of practice is higher. However, the DON said that she would expect a corrected entry or a progress note clarifying the difference. During the interview, a review of the clinical record was conducted with the DON who noted the resident's (#55) blood pressure of 71/42 and that it was struck out; and, the physician note that indicated the low blood pressure earlier that morning was communicated to the physician. The DON stated that there were no follow up blood pressure readings or progress notes found in the clinical record. Further, the DON said that neglect was defined as a resident not getting the care that the facility should be providing; or, withholding care to the resident. Regarding the incident with resident #55, the DON said the care was there but there was definitely a delay in notifying the physician of the resident's low BP.

The facility policy on Change in a Resident's Condition or Status, revised February 2021 included that the nurse will notify the resident's attending physician when there has been significant change in the resident's condition and that the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status.

Based on staff interviews, hospital record, facility documentation and policy review, the facility failed to ensure one resident (#55) received treatment and care according to professional standards of care.

Findings include:

Resident #55 was admitted to the facility on April 5, 2023 with diagnoses of wedge compression fracture of T7-T8, multiple rib fractures, COPD (chronic obstructive pulmonary disease), heart failure, hypothyroidism, peripheral vascular disease, and hypokalemia.

A review of a 5-day MDS dated April 11, 2023 noted the resident had a BIMS of 14, indicating no cognitive impairment.

The blood pressure (BP) summary revealed the following information:
-April 15, 2023 at 7:24 a.m. the BP was 94/55
-April 15, 2023 at 2:32 p.m., the BP was 71/43. However, this record was struck out; per the documentation, there was "incomplete documentation."

There was no evidence found in the clinical record that interventions were put in place to address the resident's low BP reading.

Further review of the clinical record revealed no evidence that resident's BP was rechecked and monitored a low BP reading.

Despite documentation of these low BP, the clinical record revealed no documentation that the physician was notified until April 15, 2023 at 9:22 p.m. (approximately 7 to 14 hours after the BP reading was taken).

A physician progress note dated April 15, 2023 at 9:22 p.m. revealed the physician was notified by a nurse that earlier that morning the resident was hypotensive at 71/43, was tachycardic all day at 108 and with increased oxygen requirement and was on 4 liters via nasal cannula with oxygen saturation of 92%. It also included that the resident's left lower extremity appeared warm and swollen. Per the documentation, the resident's family reported that the resident appeared lethargic and was shivering. Assessments included sepsis secondary to lower extremity cellulitis; and, acute hypoxic respiratory failure. The plan was to send the resident to the hospital STAT.

Review of the hospital record revealed the resident was seen on April 15, 2023 at 3:27 p.m.in the emergency room and had a chief complaint of sepsis. Per the documentation, upon arrival to the emergency room, the resident had an axillary temperature of 101.8, heart rate of 135, respiratory of rate of 24 and BP of 146/117. Impression included severe sepsis without septic shock.

In an interview conducted with a certified nursing assistant (CNA/staff #104) on May 4, 2023 at 2:38 p.m., the CNA stated that if a resident's blood pressure were low, she would immediately tell the nurse and get the resident some water to drink.

An interview with a licensed practical nurse (LPN/staff #23) was conducted on April 27, 2023 at 1:50 p.m. The LPN stated that on the morning of April 15, 2023 a CNA reported a low blood pressure at approximately 7:30 a.m.; and that, she asked the CNA to get a repeat blood pressure. The LPN stated that at the time she was very busy passing meds; and, that was really not an excuse. Further, the LPN stated that the CNA gave her a new blood pressure about noon and she documented this in the eMAR (electronic Medication administration record) or progress notes. During the interview, a review of the clinical record was conducted with the LPN who stated that there was no documentation of the assessment that she had conducted after the resident's blood pressure was reported low at 7:30 a.m. She also reported that the BP of 71/43 was done at approximately 6:00 a.m. The LPN said that she asked the CNA to get a new set of vitals but she did not get the new vitals until noon. The LPN further stated that it was not normal for her to send out a resident without any documentation; and that, when there is a change of condition the resident is assessed first, then sent them out to the hospital/emergency room and then document in the clinical record. However, regarding resident #55 the LPN stated the resident was sent out around 12:30 p.m. Despite having symptoms at 6:00 a.m., no interventions were put in place and the resident was not admitted until 3:27 p.m. which is a gap of approximately 9 to 9.5 hours which could result in increased morbidity and mortality.

An interview was conducted on May 4, 2023 at 3:30 p.m. with the director of nursing (DON/staff #98) who stated that in the event of a change of condition, her expectation was that the nurses would do an assessment timely, get vitals, and report any changes to the physician within one hour. The DON said that low blood pressure could be caused by sepsis, an infection, or medications; and that, she would definitely notify the physician. She stated that the CNAs documents their own vitals in the electronic record; but, they also give a copy to the nurses. The DON stated that if a nurse got a different result they could strike out the documentation of a CNA, because their scope of practice is higher. However, the DON said that she would expect a corrected entry or a progress note clarifying the difference. During the interview, a review of the clinical record was conducted with the DON who noted the resident's (#55) blood pressure of 71/42 and that it was struck out; and, the physician note that indicated the low blood pressure earlier that morning was communicated to the physician. The DON stated that there were no follow up blood pressure readings or progress notes found in the clinical record. Regarding the incident with resident #55, the DON said the care was there but there was definitely a delay in notifying the physician of the resident's change in condition.

Review of facility policy titled 'Change in a Resident's condition or status' revealed the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's condition. It also revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status.

Based on review of the facility Emergency plan, record review and staff interview, it was determined, the facility failed to develop and implement emergency preparedness policies and procedures, based on subsistence needs for staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies and alternate sources of energy are not planned for and available.


Finding include

During observations while on tour Febuary 1, 2023, it was revealed that the facilities did have the needed amounts of water needed to sustain the staff patients and visitor the three days as described in their plan.

The acting administrator confirmed during the exit interview conducted on Febuary 1, 2023, that the sustenance on hand was not nearly enough..

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to develop a facility based emergency planning, training and testing program. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation.

Finding include:

Observation while on Tour and reviewing the facility's Emergency Plan (EP) documentation on Febuary 1, 2023, revealed the documentation related specifically to the facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan. I addition staff was not able to demonstrait knowledge of emergency Preparedness training when questioned

The Acting Administrator confirmed during an interview the EP plan did not include facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan. Her plan was new and had now been shared with current staff.

Based on review of the facility's Emergency Preparedness Testing Requirements, record review and staff interview, it was determined the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency.


Findings include:

During document review on Febuary 1, 2023, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based or a facility-based exercise or table top drills for the last two cycles.

The Acting Administrator confirmed during the exit interview that the facility was not able to locate proof of participation in a full-scale exercise that was community-based or a facility based exercise in the last four years.

Based on observation and interviews with staff, it was determined that the facility failed to provide a safe means of egress out of the emergency exit doors. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress therefrom, or visibility thereof."

NFPA 101 Life Safety Code 2012 Edition, Section 19.2 Means of Egress Requirements Section 19.2.1 General. Every aisle, passageway, corridor, exit discharge , exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11. Section 7.2.1.15 Inspection of Door Openings, (2) Fire rated door assemblies shall be inspected and tested in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's" , Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, 2010 Edition, "Standard for Smoke Door Assemblies and Other Opening Protective's." Section 7.2.1.15.4 A written record of the inspections and testing shall be signed and kept for inspection by the authority having jurisdiction. Section 7.2.1.15.5 Functional testing of door assemblies shall be performed by individuals who can demonstrate knowledge and understanding of the operating components of the type of door being subject to testing.

During a facility tour conducted on February 1, 2023, the facility had the following doors blocked;
1. NE second-story stairwell door locked with a magnetic holder. The holder did not release after 15 seconds as designed and then did not release when the fire alarm was activated. The door was key released from the magnet and personnel staged to guard the door and the repairs were made three hours later
2. One of the two emergency exits in the rehabilitation area had the handle missing preventing exit during an emergency.

The acting Administrator confirmed during the exit conference that the emergency exit door on the second floor and pathways were blocked by a non-releasing magnetic door hold and one of the emergency exit doors in the rehabilitation area was missing the handle preventing exit.

Based on observation the facility failed to maintain the one hour fire rated doors. Failing to maintain fire barriers could allow a fire to spread more rapidly through the fire barrier and give residents less time to evacuate the building.

NFPA 101 Life Safety Code, 2012, Chapter 7, Sub-Section 7.2.2.5.1.1. All inside stairs serving as an exit or exit component shall be enclosed in accordance with Section 7.1.3.2 Exits, Sub-Section 7.1.3.2.1. Where this Code requires an exit to be separated from other parts of the building, the separating construction shall meet the requirements of Section 8.2 and the following:
(1)* The separation shall have a minimum 1-hour fire resistance rating where the exit connects three or fewer stories.
(2) The separation specified in 7.1.3.2.1(1), other than an existing separation, shall be supported by construction having not less than a 1-hour fire resistance rating.
(3)* The separation shall have a minimum 2-hour fire resistance rating where the exit connects four or more stories, unless one of the following conditions exists:
(a) In existing non-high-rise buildings, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(b) In existing buildings protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, existing exit stair enclosures shall have a minimum 1-hour fire resistance rating.
(c) The minimum 1-hour enclosures in accordance with 28.2.2.1.2, 29.2.2.1.2, 30.2.2.1.2, and 31.2.2.1.2 shall be permitted as an alternative to the requirement of 7.1.3.2.1(3).


Findings include:

Observations while on tour on February 1, 2023, revealed the two doors on the north side failed when released from the magnetic latching devices. Both of the doors were on the second-story north-side doors one in the middle and the one on the west end. In addition the pharmacy roll-up door was missing its annual fire door inspection the tag on the door showed it had not been tested since 2020,

During the exit interview on February 1, 2023, the acting Administrator acknowledged that both of the second-story fire/smoke barriers failed to close and latch when released from the holder and the pharmascy rool-up door had not had its annual inspection.

Based on a records review it was determined that the facility failed to perform the quarterly Testing of the facility's sprinklers systems. Failing to perform the required inspections may cause harm to patients and staff


NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly and annual testing of automatic sprinkler systems.

Findings Include:

Observations while on tour on February 1, 2023, revealed the facility failed to show proof of quarterly testing of the sprinkler systems in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.


The acting Administrator confirmed during the exit conference that the facility failed to conduct the required quarterly testing of the sprinkler systems.

Based on observation, interview, and record review it was determined the facility failed to inspect and maintain the facility's fire /smoke dampers or fusible links. Failing to inspect and maintain the facility's smoke dampers may cause harm to the patients and staff.

NFPA 101 Life Safety Code, 2012 Edition Chapter 19, Section 19.5.2, "Heating Ventilating and Air Conditioning." Section 19.5.2.1 "Heating, ventilating and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacture's specifications" Section 9.2.1 " Air Conditioning, Heating, Ventilating, Ductwork, and Related Equipment." Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90 A." "Standard for Installation of Air Conditioning and Ventilating Systems, NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 90 A 2012 Edition Section 5.4.8 Maintenance Section 5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80 Standard for Fire Doors and Other opening Protective's. Section 5.4.8.2 Smoke dampers shall be maintained in accordance with NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 80 Standard for Fire Doors and Other opening Protective's Chapter 19 Installation, Testing, and Maintenance of Fire Dampers, Section 19.4* Periodic Inspection and Testing The test and inspection frequency shall be every 4 years, except in hospitals, where the frequency shall be every six years.

Section 19.4.4 if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped. Section 19.4.5 The operational test of the fire damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts. Section 19.4.6 The damper frame shall not b penetrated by any foreign objects that would effect fire damper operations. Section 19.4.7 The fusible link shall be reinstalled after testing is complete. Section 19.4.8.1 if the link is damaged or painted, it shall be replaced with a link of the same size, temperature and rating. Section 19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 19.4.11 Periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's.

NFPA 105 Standard for Smoke Door Assemblies and Other Opening Protective's Chapter 6 Installation, Testing and Maintenance smoke dampers. Section 6.5.2 Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except hospitals, where the frequency shall be every 6 years.

Section 6.5 Periodic Inspection and Testing. Section 6.5.11 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered. Section 19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected. Section 6.5.11

Section 6.6 Maintenance.

Section 6.6.1 Any reports of abrupt changes in airflow or noise from the duct system shall be investigated to verify that it is not related to damper operation. Section 6.6.2* All exposed moving parts of the damper shall be dry lubricated as required by the manufacturer. Section 6.6.3 if the damper is not operable, repairs shall begin as soon a s possible. Section 6.6.4 Following any repairs, the damper shall be tested for proper operation in accordance with Section 6.6.5 Smoke damper actuation shall be initiated at a time interval recommended by the actuator manufacturer. Section 6.6.6 All maintenance shall be maintained and records shall be retained in accordance with 6..5.11 and 6.5.12.

Findings Include:

During the review of the facility documentation conducted on February 1, 2023, revealed the facility had fire or smoke dampers, but no documentation was found indicating that the smoke dampers were maintained in the past four years.

The acting Administrator confirmed during the exit conference that the facility failed to test the HVAC dampers every four years.

Based on Record Review and Interview the facility failed to properly document weekly generator testing of the generator battery. Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES" 2012 Edition, Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...

Findings Include:

Observations while on tour on February 1, 2023, revealed the facility failed to document the continuity or conductivity tests on the generator.

The acting Administrator acknowledged during the exit conference on February 1, 2023, that the facility was not documenting the continuity or conductivity tests on the generators at the facility.

Based on Observation it was determined the facility allowed the use of power strips and did not use the wall outlet receptacles for appliances. Failure to properly use power strips and outlets could lead to electrical overload or fire which could cause harm to the patients and staff.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings include:

Observations while on tour on February 1, 2023, revealed the following locations with power strips plugged into refrigerators, and microwaves.
1. Case management had a refrigerator plugged into a power strip.
2. The Director of Nursing had a refrigerator and microwave plugged into a power strip.

During the exit conference conducted on February 1, 2023, the acting Administrator confirmed the improper use of power strips.

Based on observation and staff interview the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the residents if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observation, record review, and staff interview on February 1, 2023, revealed the facility was unable to produce documentation to identify all electrical equipment tests, repairs, and modifications. The tour revealed numerous Blood Pressure monitors without a Preventive Maintenance (P.M.) sticker and the facility was not able to provide proof the P.M. was completed

The acting Administrator acknowledged during the exit conference on February 1, 2023, the facility failed to test some electrical equipment

Based on Observation the facility failed to properly store full oxygen (O2) cylinders five (5) ft. from combustible items and to label the door indicating the hazard. This could result in the combustible items becoming oxygen saturated and easily ignitable which could cause a fire to start prematurely. Failing to label the door could result in personnel entering the area unaware of the hazards inside

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.2.3 (11) Free standing cylinders shall be properly chained or supported in a proper cylinder stand or cart."

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.4.1 'A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING"

NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment Section 11.3.2.3 "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft)(2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. (3)Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1/ 2 hour

Findings include:

During a facility tour conducted on February 1, 2023, it was revealed the following items;
1. The facility was not storing oxygen (O2) properly. The O2 storage room on the first floor was being used to store combustibles as well as O2 bottles.
2. The facility was storing four Carbon Dioxide storage bottles in the janitor closet in the kitchen that was not secured to prevent falling.

During the exit conference conducted on February 1, 2023, the acting Administrator acknowledged the following discrepancies:
1. Combustibles being stored with oxygen bottles in the first floor O2 storage room
2. CO2 bottles not properly secured in the janitorial closet in the kitchen

Based on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#20) received treatment and services in accordance with professional standards of practice, and that policies and procedures for physical health services are documented and implementd to protect the health and safety of a resident.

Regarding Resident #20

Findings include:

-Resident #20 was admitted on December 17, 2022 with diagnoses that included chronic hypoxia, type 2 diabetes, morbid obesity, and spinal stenosis.

Review of weekly skin observation dated December 17, 2022 at 2:29 p.m., included the following:
-Redness underneath axilla area
-Redness in the groins
-Redness in the folds of stomach area
-Redness on coccyx

Further record review revealed no additional weekly skin observation.

A skin/wound note written on December 19, 2022 at 1:53 p.m., by the LPN/wound nurse (staff #33) included a clarification to admission skin assessment. Per the note, the resident has redness under both armpits.

Review of a physician progress note dated December 19, 2022 at 2:01 p.m., included a left axillary area with redness and discoloration. The physician's impression stated left axilla dermatitis/Nystatin powder.

However, record review revealed no order for the Nystatin powder and no treatment provided for the left axilla dermatitis.

Review of the physician orders dated December 19, 2022 at 5:00 p.m., revealed a treatment to cleanse folds redness with normal saline, then apply antifungal cream twice daily for wound care.

Review of care plan initiated on December 20, 2022 included a problem for at risk to skin breakdown related to infection. The interventions included to keep skin clean and dry, and apply barrier cream or ointment as ordered.

An admission MDS (Minimum Data Set) dated December 21, 2022 revealed a BIMS (Brief Interview of Mental Status) score of 11, indicating moderately impaired cognition. The assessment included skin treatment by applications of ointment/medication other than feet.

On December 23, 2022, the physician wrote the following orders for oral antibiotics:
-Doxycycline Hyclate tablet 100 milligrams by mouth every 12 hours for cellulitis for 10 days.
-Keflex Capsule 500 MG every 6 hours for cellulitis for the left under arm cellulitis for 10 days.

A physician order dated December 28, 2022 revealed a wound care and evaluation of left arm cellulitis due to wound is weeping with foul odor.

Review of the physician order dated January 10, 2023 included a dermatology consult and treatment as indicated for one month.

Review of physician order dated January 17, 2023, revealed an order for Triamcinolone Acetonide Cream 0.1%, apply to under left axilla topically three times a day for rash.

Review of a wound assessment detail report dated January 17, 2023 included a left armpit wound that was present on admission, classified as fungal, and that it was identified on December 19, 2022.

Review of the physician orders dated January 18, 2023 revealed an order for Nystatin External Cream 100,000 unit/grams, apply to left arm pit topically three times a day for fungal rash for 30 days.

However, further record review revealed no treatment order for the left arm pit wound from December 19, 2022 through January 9, 2023.

An interview was conducted on January 24, 2023 at 11:54 a.m., with a licensed practical nurse/wound nurse (LPN/staff #33). She stated the process when a new admission enters the facility included the admitting nurse to complete a body check. She stated the admitting nurse documents all skin alterations in the progress notes on point-click-care, under admission notes. She stated that if an admitting nurse identify any skin alteration, the general understanding is to start a treatment. Staff #33 stated that the facility has a standing order for skin protocol that all nurses knew and were trained to use. Further, she stated that she was always available via telephone for any questions and guidance for skin alteration treatment protocols.

A second interview was conducted on January 24, 2023 at 12:15 p.m., with a licensed practical nurse/wound nurse (LPN/staff #33). She accessed the treatment administration record for December 2022, and stated that the antifungal treatment that the physician ordered on December 19, 2022 was only to treat the reddened folds of the pannus, not for the left armpit wound. She stated when the resident arrived in the facility, the left armpit was already deeply red and odorous. She stated the resident is receiving antibiotic now for the left armpit infection/cellulitis. After staff #33 further reviewed the electronic record, she stated the order to treat the armpit was not obtained until January 9, 2023. Staff #33 stated she has no treatment order for the left armpit wound prior to January 9, 2023. She stated with regards to the weekly skin assessment, she did not know much about it because the nurses complete the required form, then the DON reviews the assessment. She accessed the weekly skin assessment records and stated, the skin assessment was not completed since December 24, 2022.

A resident interview was conducted on January 25, 2023 at 2:49 p.m. The resident stated he entered the facility with a rash under the left armpit present. He said the nurse knew about it because they check his entire body completely. He stated two days after the admission the string from the hospital gown got stuck under his left armpit and back because he is too heavy (obese). He stated about a few days after he was admitted, he had a burn-like cut in his left armpit and he told the nurse it was causing him a lot of pain. He stated he told the nursing staff but no one was providing treatment on it. He stated he was in so much pain, like his armpit was on fire, that he told the staff to send him to VA (Veterans Affair) ER (Emergency Room). He stated the left armpit wound was treated at the VA ER. The resident stated the wound became infected, but it is getting better now.

An interview was conducted with a licensed practical nurse (LPN/ staff #141). She stated she was familiar with the resident #20 and that the resident is alert, oriented, and is able to communicate his needs. She stated when a new resident enters the facility, she would complete a body check and will document any redness or open areas on the body including the armpits. She stated, if a resident is admitted with skin alteration, the standard of nursing practice is to call the physician and get a treatment order, and the skin nurse follows up the following day. If a resident is admitted on the weekend, the admitting nurse will call the physician to get a treatment order if a treatment order is not already included in the admission transfer orders. She stated the treatment, if ordered, is provided right away.

An interview was conducted on January 25, 2023 at 3:07 p.m. with a licensed practical nurse (LPN/ staff #55). She stated upon admission, a full body assessment is conducted looking for redness and alteration of the skin. The skin assessment is documented in the form, Weekly Skin Observation, indicating the date of admission, then the skin assessment is conducted weekly thereafter. If there is a wound or skin alteration, she would call the provider and obtain treatment order, then provide the treatment the same day as ordered.

An interview with the director of nursing (DON/ staff #8) was conducted on January 26, 2023 at 8:40 a.m. She stated it is her expectation with nursing staff when there is a skin alteration such as rash can be treated without doctor order if the medication is OTC (over the counter). She stated skin assessment on admission is checked by the wound nurse within 24-48 hours of admission. She stated that if the wound nu

Based on clinical record review, staff interviews, the RAI (Resident Assessment Instrument) Manual and policy review, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#4) within the required timeframe. The sample size was 23. The deficient practice could result in the resident not receiving continuity of care.

Findings include:

Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician's order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

On 01/01/23 at 12:49 p.m. the Weight Summary indicated the resident weighed 206.0 lbs, for a weight loss of 7.36% in a 2-week timeframe.

On 01/03/23 at 1:04 p.m. a dietary note included a meal intake/diet change. Per the note, the resident was receiving a carbohydrate consistent diet with no added salt with double portions (6000 kcals, 232 grams of protein) plus liquid protein twice daily (32 grams). The note stated the resident eats 100%, which would cause significant weight gain, pressure on the sacral wound, increased hyperglycemia, and excess protein for CKD. The note indicated that the estimated demands were 2795 - 3261 kcals and 140 - 186 grams of protein and that double portions would be discontinued.

However, review of the clinical record did not demonstrate that the weight loss had been identified or that the provider and/or the dietitian had been notified of the change in the resident ' s weight status. In addition, the resident did not trigger a significant change of condition assessment.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff #85). She stated that she did not get to see the resident's weight on the 22nd because she comes in on Tuesdays, which would have been the 24th. She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident's amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the resident had wounds, a wound vac, and fluid shifts. She stated that you have to take a weight with a grain of salt because they are speculative. She stated that the weight changes were expected, but that it was not stated in his record. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing. She stated that there were no Nutrition at Risk meetings, but that there are weekly meetings every Thursday where they look at weights. She stated that they have a morning meeting also, where they go around the room and discuss concerns with residents. She stated that resident #4 was just missed.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff #8). She stated that resident weights are obtained within 24-48 hours of their admission. She stated that weekly weights are obtained on Sundays by the Certified Nursing Assistants. She stated that the dietitian monitors the weights via a weekly report. She stated that when a resident loses weight, the doctor will be notified because the weight loss may be related to a diagnosis. She stated that it is nursing ' s role to notify, and that the conversation should be documented in the resident's clinical record. She stated that she would have to review the policy to identify what percentage of weight would be considered a significant weight loss. She stated that if that was the case, the Registered Dietician would trigger a significant change. She stated that if the weight loss was desirable or care planned, then it would not be considered a significant change.

The Change in a Resident's Condition or Status policy, revised February 2021, included that the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident ' s medical/mental condition and/or status. The nurse will notify the resident ' s attending physician or on call when there has been a significant change in the resident ' s physical/emotional/mental condition. A "significant change" of condition is a major decline or improvement in the resident ' s status that requires interdisciplinary review and/or revision to the care plan and is ultimately based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.

Based on clinical record review, staff interview, facility documentation and review of policies and procedures, the facility failed to ensure that a care plan for treatment and care of pressure ulcer was developed for one resident (#77).

Findings include:

-Resident #77 was admitted on December 23, 2022 with diagnoses that included unspecified protein-calorie malnutrition, pneumonia, respiratory failure, and unspecified with hypoxia.

Review of the facility assessment, Weekly Skin Observation, dated December 23, 2022 at 7:36 p.m., included a right antecubital bruise, and generalized bruising on both legs from previous injuries/falls.

A facility assessment, Wound Rounds, dated December 27, 2022 included a wound on the coccyx. Per the assessment, the type is pressure ulcer, and the clinical stage is unstageable. The assessment included a tissue type of bright beefy read, 50%, and loosely adherent slough of 50%.

Review of the facility assessment, Weekly Skin Observation, dated January 6, 2023 at 08:21 a.m., included an open area on the buttocks. Per the assessment note, the wound nurse was notified and that the wound nurse placed the treatment.

Review of the physician order dated January 9, 2023 at 6:00 a.m., revealed the following treatment order for the coccyx:
-Cleanse with normal saline, apply Santyl ointment to wound bed, and cover with dry dressing every day shift on Monday, Wednesday, and Friday.

A care plan initiated on December 23, 2023 included a problem that resident is at risk for skin breakdown or at risk for additional skin breakdown due to a stage 1 pressure ulcer that was present on admission. The interventions included keep skin clean and dry, avoid friction and sheering, and encourage nutrition.

However, the care plan did not include interventions for treatment and care of the current unstageable pressure ulcer on the resident's coccyx.

An interview was conducted on January 26, 2023 at 8:40 a.m. with the director of nursing (DON/staff #8). The DON accessed the resident's medical record and she reviewed the care plan. After record review, the DON stated the treatment and care for the coccyx pressure ulcer was not found in the care plan. The DON stated it is her expectation that care plan should include the treatment and interventions for the pressure ulcer if indicated. She stated failure to create a care plan may place the staff at risk of not following the best practice for the care of the resident's pressure ulcer.

Review of the facility policy, Care Planning, with a revision dated March 2022, stated the interdisciplinary team is responsible for the development of resident care plans. The implementation included a development of comprehensive, person-centered care plans that are based on resident assessments.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that one resident (#4) had care plan revisions to meet their needs. The sample size was 23. The deficient practice could result in a lack of care provided to meet the resident's needs.

Findings include:

-Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

On 01/01/23 at 12:49 p.m. the Weight Summary indicated the resident weighed 206.0 lbs, for a weight loss of 7.36% in a 2-week timeframe.

However, review of the clinical record did not demonstrate that the weight loss had been identified or that the provider and/or the dietitian had been notified of the change in the resident ' s weight status.

Review of the resident ' s care plan did not provide evidence of revision to the risk for compromised nutritional status care plan.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff #85). She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident ' s amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff #8). She stated that if the resident had an unanticipated weight loss, then yes, she would expect the Registered Dietician to update the care plan to address the weight loss.

A review of facility policies titled 'Goals, Objectives, and Care Plans' revised April 2009, #5 states "Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition or when the desired outcome has not been achieved."

A review of facility policies titled 'Care Plans, Comprehensive Person Centered' Revised March, 2022 #11 states "Assessments of the resident are ongoing and care plans are revised as information about the residents and the resident's condition change"

Based on clinical record review, staff interviews, and review of policy, revealed the facility failed to ensure one resident (#20) received treatment and services in accordance with professional standards of practice. The deficient practice could result in residents not receiving the treatment and care based on their assessed needs.

Regarding Resident #20

Findings include:

-Resident #20 was admitted on December 17, 2022 with diagnoses that included chronic hypoxia, type 2 diabetes, morbid obesity, and spinal stenosis.

Review of weekly skin observation dated December 17, 2022 at 2:29 p.m., included the following:
-Redness underneath axilla area
-Redness in the groins
-Redness in the folds of stomach area
-Redness on coccyx

Further record review revealed no additional weekly skin observation.

A skin/wound note written on December 19, 2022 at 1:53 p.m., by the LPN/wound nurse (staff #33) included a clarification to admission skin assessment. Per the note, the resident has redness under both armpits.

Review of a physician progress note dated December 19, 2022 at 2:01 p.m., included a left axillary area with redness and discoloration. The physician's impression stated left axilla dermatitis/Nystatin powder.

However, record review revealed no order for the Nystatin powder and no treatment provided for the left axilla dermatitis.

Review of the physician orders dated December 19, 2022 at 5:00 p.m., revealed a treatment to cleanse folds redness with normal saline, then apply antifungal cream twice daily for wound care.

Review of care plan initiated on December 20, 2022 included a problem for at risk to skin breakdown related to infection. The interventions included to keep skin clean and dry, and apply barrier cream or ointment as ordered.

An admission MDS (Minimum Data Set) dated December 21, 2022 revealed a BIMS (Brief Interview of Mental Status) score of 11, indicating moderately impaired cognition. The assessment included skin treatment by applications of ointment/medication other than feet.

On December 23, 2022, the physician wrote the following orders for oral antibiotics:
-Doxycycline Hyclate tablet 100 milligrams by mouth every 12 hours for cellulitis for 10 days.
-Keflex Capsule 500 MG every 6 hours for cellulitis for the left under arm cellulitis for 10 days.

A physician order dated December 28, 2022 revealed a wound care and evaluation of left arm cellulitis due to wound is weeping with foul odor.

Review of the physician order dated January 10, 2023 included a dermatology consult and treatment as indicated for one month.

Review of physician order dated January 17, 2023, revealed an order for Triamcinolone Acetonide Cream 0.1%, apply to under left axilla topically three times a day for rash.

Review of a wound assessment detail report dated January 17, 2023 included a left armpit wound that was present on admission, classified as fungal, and that it was identified on December 19, 2022.

Review of the physician orders dated January 18, 2023 revealed an order for Nystatin External Cream 100,000 unit/grams, apply to left arm pit topically three times a day for fungal rash for 30 days.

However, further record review revealed no treatment order for the left arm pit wound from December 19, 2022 through January 9, 2023.

An interview was conducted on January 24, 2023 at 11:54 a.m., with a licensed practical nurse/wound nurse (LPN/staff #33). She stated the process when a new admission enters the facility included the admitting nurse to complete a body check. She stated the admitting nurse documents all skin alterations in the progress notes on point-click-care, under admission notes. She stated that if an admitting nurse identify any skin alteration, the general understanding is to start a treatment. Staff #33 stated that the facility has a standing order for skin protocol that all nurses knew and were trained to use. Further, she stated that she was always available via telephone for any questions and guidance for skin alteration treatment protocols.

A second interview was conducted on January 24, 2023 at 12:15 p.m., with a licensed practical nurse/wound nurse (LPN/staff #33). She accessed the treatment administration record for December 2022, and stated that the antifungal treatment that the physician ordered on December 19, 2022 was only to treat the reddened folds of the pannus, not for the left armpit wound. She stated when the resident arrived in the facility, the left armpit was already deeply red and odorous. She stated the resident is receiving antibiotic now for the left armpit infection/cellulitis. After staff #33 further reviewed the electronic record, she stated the order to treat the armpit was not obtained until January 9, 2023. Staff #33 stated she has no treatment order for the left armpit wound prior to January 9, 2023. She stated with regards to the weekly skin assessment, she did not know much about it because the nurses complete the required form, then the DON reviews the assessment. She accessed the weekly skin assessment records and stated, the skin assessment was not completed since December 24, 2022.

A resident interview was conducted on January 25, 2023 at 2:49 p.m. The resident stated he entered the facility with a rash under the left armpit present. He said the nurse knew about it because they check his entire body completely. He stated two days after the admission the string from the hospital gown got stuck under his left armpit and back because he is too heavy (obese). He stated about a few days after he was admitted, he had a burn-like cut in his left armpit and he told the nurse it was causing him a lot of pain. He stated he told the nursing staff but no one was providing treatment on it. He stated he was in so much pain, like his armpit was on fire, that he told the staff to send him to VA (Veterans Affair) ER (Emergency Room). He stated the left armpit wound was treated at the VA ER. The resident stated the wound became infected, but it is getting better now.

An interview was conducted with a licensed practical nurse (LPN/ staff #141). She stated she was familiar with the resident #20 and that the resident is alert, oriented, and is able to communicate his needs. She stated when a new resident enters the facility, she would complete a body check and will document any redness or open areas on the body including the armpits. She stated, if a resident is admitted with skin alteration, the standard of nursing practice is to call the physician and get a treatment order, and the skin nurse follows up the following day. If a resident is admitted on the weekend, the admitting nurse will call the physician to get a treatment order if a treatment order is not already included in the admission transfer orders. She stated the treatment, if ordered, is provided right away.

An interview was conducted on January 25, 2023 at 3:07 p.m. with a licensed practical nurse (LPN/ staff #55). She stated upon admission, a full body assessment is conducted looking for redness and alteration of the skin. The skin assessment is documented in the form, Weekly Skin Observation, indicating the date of admission, then the skin assessment is conducted weekly thereafter. If there is a wound or skin alteration, she would call the provider and obtain treatment order, then provide the treatment the same day as ordered.

An interview with the director of nursing (DON/ staff #8) was conducted on January 26, 2023 at 8:40 a.m. She stated it is her expectation with nursing staff when there is a skin alteration such as rash can be treated without doctor order if the medication is OTC (over the counter). She stated skin assessment on admission is checked by the wound nurse within 24-48 hours of admission. She stated that if the wound nurse identifies a skil

Based on clinical record review, staff interviews, and the facility's policies and procedures, the facility failed to prevent a pressure ulcer from developing in accordance with professional standards by failing to provide consistent preventative treatment for one resident (#77).

Findings include:

Resident #77 was admitted on December 23, 2022 with diagnoses that included unspecified protein-calorie malnutrition, pneumonia, and respiratory failure, unspecified with hypoxia.

Review the facility assessment, Weekly Skin Observation, dated December 23, 2022 at 7:36 p.m., included the following:
-A right antecubital bruise
-A generalized bruising on both legs

A care plan initiated on December 23, 2023, included a skin breakdown due to stage 1 pressure ulcer present on admission. The following interventions were included:
-Keep skin clean and dry.
-Avoid friction and sheering.
-Encourage nutrition.

Review of skin/wound nursing note dated December 27, 2022 at 4:28 p.m., stated a clarification to admission skin assessment, and that resident has no open area.
The note included the following:
-Bilateral bruises on upper extremities
-Redness on sacral area

Review of the physician order dated December 27, 2022 at 6:00 p.m. included the following:
-Apply barrier cream on sacral area at every brief change, every 2 hours for skin integrity protection.

However, review of treatment administration records (TARs) dated December 2022 and January 2023 revealed multiple gaps. Further record review revealed the barrier cream was ordered on the same day the pressure ulcer was identified from Stage 1 into unstageable on December 27, 2022.

A facility assessment, Wound Rounds, dated December 27, 2022 revealed a wound on the coccyx. The assessment included the following:
-The type of wound is pressure ulcer
-The clinical stage is unstageable
-The tissue type is 50% beefy red, and 50% loosely adherent slough.

Further record review revealed no documentation that additional wound rounds/assessments was conducted, and no revision of care plan to prevent the worsening of pressure sore.

Review of the physician order dated January 9, 2023 at 6:00 a.m., revealed the following treatment order for the coccyx:
-Cleanse with normal saline, apply Santyl ointment to wound bed, and cover with dry dressing every day shift on Monday, Wednesday, and Friday.

A wound treatment observation was conducted on January 25, 2023 at 10:30 a.m., with the wound nurse (staff #33). The wound nurse described the coccyx wound as present on admission as follows:
-The type of wound is pressure ulcer
-The length is 1.7 centimeter by 0.8-centimeter-wide, UTD (undetermined depth).
-The tissue is 65% slough, 35% pale/pink granulation.

A follow up interview with the wound nurse was conducted immediately after the treatment observation. She stated the wound was present on admission but it was not opened, it was only a reddened area. She accessed the electronic record of her assessment dated December 27, 2022. She stated on December 27, 2022, she documented a stage 1 on the coccyx, and it was described as blanchable erythema. The wound nurse accessed the record and stated the pressure ulcer was not present on admission, and that she has to document a clarification to change the pressure ulcer to facility acquired. She stated the gaps in the treatment administration records means the treatment was not provided. She stated the treatment to prevent the pressure ulcer on the coccyx was not consistently provided as evidenced by the gaps on the treatment records.

An interview was conducted on January 26, 2023 at 8:33 a.m. with the director of nursing (DON/staff #8). She stated if the treatment is not charted is not provided. She stated it is her expectation that treatment must be completed on the assigned time. She stated if the treatment for pressure ulcer prevention is not done, there must be a documentation why. She stated the risk for the resident if the treatment is not done included a potential deterioration of the pressure ulcer.

A facility policy titled, Prevention of Pressure injuries, revised on April 2020, stated the purpose of the policy is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The preparation section included review of the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The skin assessment section included inspection of the skin on a daily basis when performing personal care. The section also included identifying any signs and symptoms of developing pressure injuries (like non-blanchable erythema). The prevention section included keeping the skin clean and hydrated, use barrier product to protect skin from moisture, and use incontinence products with high absorbency. The monitoring section stated to evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis.

Based on observations, resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#238) environment was free from accidents/hazards, and that one resident (#74) received adequate supervision to prevent medication accidents. The sample size was 23. The deficient practice could lead to residents sustaining accident-related injuries.

Findings include:

-Regarding Resident #238:

Resident #238 admitted to the facility on 08/31/22 with diagnoses including chronic systolic (congestive) heart failure, orthostatic hypotension and history of falling.

A nurses progress note dated 09/09/22 at 9:31 a.m. included that the writer heard a loud bang from the nurses station. The note included that the writer went to assess the situation and found the resident sitting in his bed with the headboard on his bed as well as glass from the picture that had fallen on him. Per the note, the glass was cleaned off the resident and he was assisted to the chair and further assessed for injuries. The resident complained of right shoulder pain, and redness to the shoulder was noted. The resident's family and the provider were notified. The provider ordered an x-ray for the shoulder and the resident was switched to a different room.

On 01/24/23 at 12:06 p.m. an interview was conducted with resident #238. He stated that on the morning of the incident, he was repositioning his bed to sit up. He stated he heard a loud pop and somehow the picture that had been over his bed had fallen onto his head. He stated that the glass shattered all over him, but that he was not cut. He stated that he called out for assistance. He stated that a Certified Nursing Assistant (CNA) came into his room and turned on the light and said, "Oh, my God". He stated that they immediately called maintenance and picked the glass off him. He stated that he was transferred into a different room.

An observation was conducted on 01/25/23 at 9:51 a.m. with a CNA (staff #12) in the first floor resident rooms. In room #136, bed A, it was noted that a headboard was no longer afixed to the wall. Upon further inspection, 2 nickle-sized holes were identified in the wall approximately 2 feet from the floor, on either side of the bed. Drywall was noted to be protruding from the holes. Markings on the wall above the bed, at approximately 4 \'bd feet from the floor, bore resemblance to the area on the wall where other fixed headboards had been secured. Picture hardware was identified above both beds A and B. However, the pictures had been removed. In room #143, which was unoccupied, it was noted that the headboard of the beds in the room were bolted to the wall behind the heads of the beds. The bottom of the headboards were approximately 2 feet from the floor. The tops of the headboards were approximately 4 \'bd feet from the floor. Above the headboards, pictures were hung on the wall over the beds which measured approximately 3 feet long by 2 feet wide. The pictures were observed to have glass covering them.

An interview was conducted on 01/25/23at 9:52 a.m. with staff #12. She stated that the headboards are bolted into the wall. She stated that she thinks the pictures are screwed into the wall above them. She stated that she thought she had heard about a resident who had a picture fall on his head. She stated that if the bed was lowered all the way into the low position, and the resident had adjusted his bed to sit up, the bed frame would have hooked under the headboard and could have popped the bed frame up, hitting the picture and releasing it from the wall. The CNA demonstrated by raising and lowering the bed. She stated that sometimes when she is working, the bed frame gets caught under the headboard.

On 01/26/23 at 11:26 a.m. an interview was conducted with a CNA (staff #141). He stated that sometimes the beds will get stuck under the headboard. He stated that he has to pull the bed out from the wall for the bed to go up. He stated that he last talked to maintenance about it about 2 weeks ago when one of the beds got stuck on the second floor. He stated that he did not remember what maintenance did because he was working after that.

An interview was conducted on 01/26/23 at 3:10 p.m. with the Director of Nursing (DON/staff #8). She stated that her expectation is that they meet the needs for each resident specifically and that they maintain a safe environment. She stated that if a CNA or nurse identifies a safety issue, they will notify maintenance to correct it within a timely manner. She stated that she thought maintenance went through the building and re-anchored the bed frames.

However, evidence of completion of the work orders was not provided to the State survey team.

The Safety and Supervision of Residents - Accidents/Hazards policy, revised July, 2017, included the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, QAPI reviews of safety and incident/accident data and a facility-wide commitment to safety at all levels of the organization. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.

Based on the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident ' s (#4) weight was obtained as ordered and/or that he maintained acceptable parameters of nutritional status. The sample size was 23. The deficient practice could result in residents with unplanned weight loss.

Findings include:

Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident ' s weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

Review of the clinical record did not provide evidence that the resident was weighed again
until 01/01/23 when the resident ' s weight was documented at 206.0 lbs, for a weight loss of 7.36%. However, review of the clinical record did not demonstrate that the provider and/or the dietitian had been notified of the change in the resident ' s weight status.

On 01/03/23 at 1:04 p.m. a dietary note included a meal intake/diet change. Per the note, the resident was receiving a carbohydrate consistent diet with no added salt with double portions (6000 kcals, 232 grams of protein) plus liquid protein twice daily (32 grams). The note stated the resident eats 100%, which would cause significant weight gain, pressure on the sacral wound, increased hyperglycemia, and excess protein for CKD. The note indicated that the estimated demands were 2795 - 3261 kcals and 140 - 186 grams of protein and that double portions would be discontinued.

Per the Weight Summary, the resident ' s ensuing weight was not obtained until 01/15/23. According to the record, the resident ' s weight was 214.0 lbs.

The Weight Summary revealed a subsequent weight was not obtained until 01/22/23, at which time the resident ' s weight was documented at 178.3 lbs, for an additional weight loss of 17.07%.

However, further review of the resident ' s clinical record did not demonstrate the weight loss had been identified or that the provider had been notified.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff # ). She stated that she did not get to see the resident ' s weight on the 22nd because she comes in on Tuesdays, which would have been the 24th. She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident ' s amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the resident had wounds, a wound vac, and fluid shifts. She stated that you have to take a weight with a grain of salt because they are speculative. She stated that the weight changes were expected, but that it was not stated in his record. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that she could not say why the weekly weights were not completed as ordered. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing. She stated that there were no Nutrition at Risk meetings, but that there are weekly meetings every Thursday where they look at weights. She stated that it was like an at risk meeting. She stated that they have a morning meeting also, where they go around the room and discuss concerns with residents. She stated that he was just missed.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff # ). She stated that resident weights are obtained within 24-48 hours of their admission. She stated that weekly weights are obtained on Sundays by the Certified Nursing Assistants. She stated that the dietitian monitors the weights via a weekly report. She stated that her expectation is that weekly weights are done as ordered. She stated that all the staff have been trained on accurately obtaining weights. She stated that when a resident loses weight, the doctor will be notified because the weight loss may be related to a diagnosis. She stated that it is nursing ' s role to notify, and that the conversation should be documented in the resident ' s clinical record.

The Nutrition (Impaired) Unplanned Weight Loss - Clinical Protocol policy, revised September 2017, included the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions.

The Weight Assessment and Intervention policy, revised March 2022, included that resident weights are monitored for undesirable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will notify the dietician in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria:
1 month - 5% weight loss is significant; greater than 5% is severe.
3 months - 7.5% weight loss is significant; greater than 7.5% is severe.
6 months - 10% weight loss is significant; greater than 10% is severe.

Based on review of facility documentation, staff interviews, review of the Payroll Based Journal (PBJ) and policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 82. The deficient practice has the potential to affect resident care.

Findings include:

Review of the PBJ revealed on dates in the second quarter 2022, the facility failed to ensure an RN was on duty for 8 consecutive hours for dates including: March 19, 20, 26 and 27, 2022.

Review of the punch detail for nursing staff for the month of March 2022 provided no evidence that an RN was on duty for those dates.

On 01/26/23 at 1:49 p.m. an interview was conducted with the staffing coordinator (staff #16). She stated that there is an RN on duty 8 hours per day, 7 days per week. She stated that they have to have an RN on duty. She stated that she could not recall whether or not there were times when an RN was not on duty in the building.

An interview was conducted on 01/26/23 at 2:40 p.m. with the Director of Nursing (DON/staff #8). She stated she expects that there will be an RN in the building at least 8 hours a day, 7 days per week. She stated that she always expects to supply enough staff to meet the needs of the residents.

The Staffing policy, revised October 2017, included that the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment.

Based on observations, staff interviews, review of the policy and procedures, the facility failed to discard expired medications and failed to ensure expired medications were not available for administration.

Findings include:

A medication pass observation was conducted on January 24, 2023 at 8:09 a.m. with a licensed practical nurse (LPN/staff #45) in the loop unit. During the observation, staff #45 placed one tablet of zinc sulfate 50 milligrams in the medication cup to be administered to a resident.

However, upon inspection of the zinc sulfate, it revealed an expiration date of June 2022.

An immediate interview with staff #45 was conducted in which she inspected the bottle of the zinc sulfate. After inspecting the medication bottle, she stated the medication had expired on June 2022. She stated she usually look at the expiration of the medications but not today. She stated she would have administered the expired medication to the resident if it was not caught during the observation. She stated she would dispose the medications and she would get a new bottle from the storage.

Following the medication pass observation on January 24, 2023 at about 8:14 a.m. an inspection of the medication cart was conducted in the loop unit with staff #45. During the inspection, the following expired medications were found in the medication cart:
-Vitamin E 200 units with an expiration date of January 2022
-loperamide 2 milligrams with an expiration date of February 2022
-Vitamin B Complex with an expiration date of March 2022
-Benadryl 25 milligrams with an expiration April 2022
-Bisacodyl 5 milligrams with an expiration date of May 2022
-ferrous gluconate 240 milligrams with an expiration date of July 2022.
-folic acid 400 micrograms with an expiration date of August 2022
-omeprazole 20 milligrams with an expiration date of September 2022
-Zyrtec 10 milligrams with an expiration date of September 2022

An immediate interview was conducted on January 24, 2023 at approximately 8:30 a.m. with staff #45. She stated the process of maintaining the OTC (over the counter) medications included the nurse who has the cart is responsible to check the expiration date of the medications. She stated the risk if the resident received expired medication is decreased efficacy of the medications.

Continued observation of medication storage was conducted on January 24, 2023 at 8:32 a.m. with a licensed practical nurse (LPN/ staff #109). A medication cart inspection on the South unit, 100 hallways contained the following expired medications:
-Melatonin 1 milligrams with an expiration date of March 2022
-Melatonin 3 milligrams with an expiration date of May 2022
--Bisacodyl 10 milligrams with an expiration date of September 2022.
-cetirizine 10 milligrams with an expiration date of December 2022
-famotidine 10 milligrams with an expiration date of December 2020
-Rena-vite with an expiration date of December 2022

Following the observation, an immediate record review was conducted with staff #109 who stated two of the expired medications were administered to two residents on January 22, 2023.

An interview was conducted on January 24, 2022 at 8:41 a.m. with staff #109. She stated the night shift is responsible for maintaining the medication carts including checking the expiration dates of OTCs (over the counter) medications and re-stocking the medication carts.

An interview was conducted on January 26, 2023 at 8:26 a.m. with the director of nursing (DON/staff #8). She stated it is her expectation that the nurses verify the expiration dates of the medications prior to administration. She stated that medication carts are checked on the night shift verifying what needs to removed or replaced. She stated the risk for the resident who receives expired medications included decreased efficacy and possible side effects.

A policy and procedure titled, Storage of Medications, with a revision date of November 2020, stated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The implementation included the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Per the policy, discontinued, outdated medications are returned to the dispensing pharmacy or destroyed.

Based on closed clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident's (#4) clinical record was accurately documented in accordance with accepted professional standards of practices. The deficient practice could result in the resident's clinical record not being accurate and complete.

Findings include:

Resident #4 was admitted December 17, 2022 with pertinent diagnosis that include stage 4 sacrum pressure ulcer, type 2 diabetes, malnutrition, chronic obstructive pulmonary disease, and heart failure.
The record review of the MDS (Minimum Data Set), revealed an MDS dated December 21, 2022 noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident has no cognitive impairment.

Review of the care plan dated December 19, 2022 the resident is at risk for impaired skin integrity related to a current wound and poor nutrition. Noted interventions include 'Evaluate skin', 'monitor for redness, especially over bony prominences', and 'provide wound care per treatment order'

Review of physician orders dated December 17, 2022 revealed the following orders:
- Wound care / Podiatry consult and treat as indicated
- Cleanse lower back wound with NS, Pat dry, Apply wound vac @ 125MMHG

A review of the COM (Clinical Admission Evaluation) dated December 17, 2022 revealed an incomplete admission assessment. Sections titled 'Body System Baselines' and 'Clinical evaluation' had no documentation present. The pertinent skin assessment also had no documentation present.

An interview was conducted on January 25, 2023 at 1058 with a licensed practical nurse (LPN #33). The LPN stated that she is the wound nurse, but does not have her wound certification. The LPN states this facility uses Athena for assessing wounds, which is a contract nurse practitioner. The LPN states that her expectation if a wound or skin issue is identified that treatment is provided. The LPN further states that she does a second skin assessment on every resident when they are admitted. The LPN states that she didn't see any skin assessments in the computer for this resident (#4). The LPN stated that if assessments weren't done the resident could see a worsening of wound conditions.

A review of the facilities policy titled 'Prevention of Pressure Injuries' dated April 2020 under the section 'Skin Assessment' stated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and to inspect the skin on a daily basis when performing or assisting with personal care or ADL's (Activities of Daily Living).

Based on closed clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident's (#4) clinical record was accurately documented in accordance with accepted professional standards of practices.

Findings include:

Resident #4 was admitted December 17, 2022 with pertinent diagnosis that include stage 4 sacrum pressure ulcer, type 2 diabetes, malnutrition, chronic obstructive pulmonary disease, and heart failure.
The record review of the MDS (Minimum Data Set), revealed an MDS dated December 21, 2022 noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident has no cognitive impairment.

Review of the care plan dated December 19, 2022 the resident is at risk for impaired skin integrity related to a current wound and poor nutrition. Noted interventions include 'Evaluate skin', 'monitor for redness, especially over bony prominences', and 'provide wound care per treatment order'

Review of physician orders dated December 17, 2022 revealed the following orders:
- Wound care / Podiatry consult and treat as indicated
- Cleanse lower back wound with NS, Pat dry, Apply wound vac @ 125MMHG

A review of the COM (Clinical Admission Evaluation) dated December 17, 2022 revealed an incomplete admission assessment. Sections titled 'Body System Baselines' and 'Clinical evaluation' had no documentation present. The pertinent skin assessment also had no documentation present.

An interview was conducted on January 25, 2023 at 1058 with a licensed practical nurse (LPN #33). The LPN stated that she is the wound nurse, but does not have her wound certification. The LPN states this facility uses Athena for assessing wounds, which is a contract nurse practitioner. The LPN states that her expectation if a wound or skin issue is identified that treatment is provided. The LPN further states that she does a second skin assessment on every resident when they are admitted. The LPN states that she didn't see any skin assessments in the computer for this resident (#4). The LPN stated that if assessments weren't done the resident could see a worsening of wound conditions.

A review of the facilities policy titled 'Prevention of Pressure Injuries' dated April 2020 under the section 'Skin Assessment' stated to conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and to inspect the skin on a daily basis when performing or assisting with personal care or ADL's (Activities of Daily Living).

Based on review of facility documentation, staff interviews, review of the Payroll Based Journal (PBJ) and policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.

Findings include:

Review of the PBJ revealed on dates in the second quarter 2022, the facility failed to ensure an RN was on duty for 8 consecutive hours for dates including: March 19, 20, 26 and 27, 2022.

Review of the punch detail for nursing staff for the month of March 2022 provided no evidence that an RN was on duty for those dates.

On 01/26/23 at 1:49 p.m. an interview was conducted with the staffing coordinator (staff #16). She stated that there is an RN on duty 8 hours per day, 7 days per week. She stated that they have to have an RN on duty. She stated that she could not recall whether or not there were times when an RN was not on duty in the building.

An interview was conducted on 01/26/23 at 2:40 p.m. with the Director of Nursing (DON/staff #8). She stated she expects that there will be an RN in the building at least 8 hours a day, 7 days per week. She stated that she always expects to supply enough staff to meet the needs of the residents.

The Staffing policy, revised October 2017, included that the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with the resident care plans and the facility assessment.

Based on clinical record review, staff interviews, the RAI (Resident Assessment Instrument) Manual and policy review, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#4) within the required timeframe.

Findings include:

Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician's order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

On 01/01/23 at 12:49 p.m. the Weight Summary indicated the resident weighed 206.0 lbs, for a weight loss of 7.36% in a 2-week timeframe.

On 01/03/23 at 1:04 p.m. a dietary note included a meal intake/diet change. Per the note, the resident was receiving a carbohydrate consistent diet with no added salt with double portions (6000 kcals, 232 grams of protein) plus liquid protein twice daily (32 grams). The note stated the resident eats 100%, which would cause significant weight gain, pressure on the sacral wound, increased hyperglycemia, and excess protein for CKD. The note indicated that the estimated demands were 2795 - 3261 kcals and 140 - 186 grams of protein and that double portions would be discontinued.

However, review of the clinical record did not demonstrate that the weight loss had been identified or that the provider and/or the dietitian had been notified of the change in the resident ' s weight status. In addition, the resident did not trigger a significant change of condition assessment.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff #85). She stated that she did not get to see the resident's weight on the 22nd because she comes in on Tuesdays, which would have been the 24th. She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident's amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the resident had wounds, a wound vac, and fluid shifts. She stated that you have to take a weight with a grain of salt because they are speculative. She stated that the weight changes were expected, but that it was not stated in his record. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing. She stated that there were no Nutrition at Risk meetings, but that there are weekly meetings every Thursday where they look at weights. She stated that they have a morning meeting also, where they go around the room and discuss concerns with residents. She stated that resident #4 was just missed.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff #8). She stated that resident weights are obtained within 24-48 hours of their admission. She stated that weekly weights are obtained on Sundays by the Certified Nursing Assistants. She stated that the dietitian monitors the weights via a weekly report. She stated that when a resident loses weight, the doctor will be notified because the weight loss may be related to a diagnosis. She stated that it is nursing ' s role to notify, and that the conversation should be documented in the resident's clinical record. She stated that she would have to review the policy to identify what percentage of weight would be considered a significant weight loss. She stated that if that was the case, the Registered Dietician would trigger a significant change. She stated that if the weight loss was desirable or care planned, then it would not be considered a significant change.

The Change in a Resident's Condition or Status policy, revised February 2021, included that the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident ' s medical/mental condition and/or status. The nurse will notify the resident ' s attending physician or on call when there has been a significant change in the resident ' s physical/emotional/mental condition. A "significant change" of condition is a major decline or improvement in the resident ' s status that requires interdisciplinary review and/or revision to the care plan and is ultimately based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument.

Based on clinical record review, staff interview, facility documentation and review of policies and procedures, the facility failed to ensure that a care plan for treatment and care of pressure ulcer was developed for one resident (#77).

Findings include:

-Resident #77 was admitted on December 23, 2022 with diagnoses that included unspecified protein-calorie malnutrition, pneumonia, respiratory failure, and unspecified with hypoxia.

Review of the facility assessment, Weekly Skin Observation, dated December 23, 2022 at 7:36 p.m., included a right antecubital bruise, and generalized bruising on both legs from previous injuries/falls.

A facility assessment, Wound Rounds, dated December 27, 2022 included a wound on the coccyx. Per the assessment, the type is pressure ulcer, and the clinical stage is unstageable. The assessment included a tissue type of bright beefy read, 50%, and loosely adherent slough of 50%.

Review of the facility assessment, Weekly Skin Observation, dated January 6, 2023 at 08:21 a.m., included an open area on the buttocks. Per the assessment note, the wound nurse was notified and that the wound nurse placed the treatment.

Review of the physician order dated January 9, 2023 at 6:00 a.m., revealed the following treatment order for the coccyx:
-Cleanse with normal saline, apply Santyl ointment to wound bed, and cover with dry dressing every day shift on Monday, Wednesday, and Friday.

A care plan initiated on December 23, 2023 included a problem that resident is at risk for skin breakdown or at risk for additional skin breakdown due to a stage 1 pressure ulcer that was present on admission. The interventions included keep skin clean and dry, avoid friction and sheering, and encourage nutrition.

However, the care plan did not include interventions for treatment and care of the current unstageable pressure ulcer on the resident's coccyx.

An interview was conducted on January 26, 2023 at 8:40 a.m. with the director of nursing (DON/staff #8). The DON accessed the resident's medical record and she reviewed the care plan. After record review, the DON stated the treatment and care for the coccyx pressure ulcer was not found in the care plan. The DON stated it is her expectation that care plan should include the treatment and interventions for the pressure ulcer if indicated. She stated failure to create a care plan may place the staff at risk of not following the best practice for the care of the resident's pressure ulcer.

Review of the facility policy, Care Planning, with a revision dated March 2022, stated the interdisciplinary team is responsible for the development of resident care plans. The implementation included a development of comprehensive, person-centered care plans that are based on resident assessments.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure that one resident (#4) had care plan revisions reviewed and revised to meet their needs.

Findings include:

-Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident's weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

On 01/01/23 at 12:49 p.m. the Weight Summary indicated the resident weighed 206.0 lbs, for a weight loss of 7.36% in a 2-week timeframe.

However, review of the clinical record did not demonstrate that the weight loss had been identified or that the provider and/or the dietitian had been notified of the change in the resident ' s weight status.

Review of the resident ' s care plan did not provide evidence of revision to the risk for compromised nutritional status care plan.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff #85). She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident ' s amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff #8). She stated that if the resident had an unanticipated weight loss, then yes, she would expect the Registered Dietician to update the care plan to address the weight loss.

A review of facility policies titled 'Goals, Objectives, and Care Plans' revised April 2009, #5 states "Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition or when the desired outcome has not been achieved."

A review of facility policies titled 'Care Plans, Comprehensive Person Centered' Revised March, 2022 #11 states "Assessments of the resident are ongoing and care plans are revised as information about the residents and the resident's condition change"

Based on the clinical record review, staff interviews and policy reviews, the facility failed to ensure one resident ' s (#4) weight was obtained as ordered and/or that he maintained acceptable parameters of nutritional status.

Findings include:

Resident #4 admitted to the facility 12/17/22 with diagnoses including pressure ulcer of sacral region, stage 4, type 2 diabetes mellitus with diabetic chronic kidney disease (CKD) and quadriplegia.

A physician ' s order dated 12/17/22 included weekly weight monitoring every day shift, every Sunday.

On 12/17/22 at 6:41 p.m. the Weight Summary indicated the resident ' s weight at 231.0 pounds (lbs).

The admission Minimum Data Set (MDS) assessment dated 12/21/22 revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. He required extensive 1-2 person physical assistance for most activities of daily living.

A risk for compromised nutritional status care plan initiated on 12/28/22 related to excessive carbohydrate intake, inactivity and body mass index greater than 23 had a goal to remain at +/- 5% of admission weight. Interventions included a consistent carbohydrate diet.

Review of the clinical record did not provide evidence that the resident was weighed again
until 01/01/23 when the resident ' s weight was documented at 206.0 lbs, for a weight loss of 7.36%. However, review of the clinical record did not demonstrate that the provider and/or the dietitian had been notified of the change in the resident ' s weight status.

On 01/03/23 at 1:04 p.m. a dietary note included a meal intake/diet change. Per the note, the resident was receiving a carbohydrate consistent diet with no added salt with double portions (6000 kcals, 232 grams of protein) plus liquid protein twice daily (32 grams). The note stated the resident eats 100%, which would cause significant weight gain, pressure on the sacral wound, increased hyperglycemia, and excess protein for CKD. The note indicated that the estimated demands were 2795 - 3261 kcals and 140 - 186 grams of protein and that double portions would be discontinued.

Per the Weight Summary, the resident ' s ensuing weight was not obtained until 01/15/23. According to the record, the resident ' s weight was 214.0 lbs.

The Weight Summary revealed a subsequent weight was not obtained until 01/22/23, at which time the resident ' s weight was documented at 178.3 lbs, for an additional weight loss of 17.07%.

However, further review of the resident ' s clinical record did not demonstrate the weight loss had been identified or that the provider had been notified.

On 01/26/23 at 8:19 a.m. an interview was conducted with the Registered Dietician Nutritionist (staff # ). She stated that she did not get to see the resident ' s weight on the 22nd because she comes in on Tuesdays, which would have been the 24th. She reviewed the initial weight loss and stated that it might have been related to swelling associated with the resident ' s amputation. She stated that it was not identified, documented and that the provider was not notified. She stated that she failed to document and notify the provider. She stated that the resident had wounds, a wound vac, and fluid shifts. She stated that you have to take a weight with a grain of salt because they are speculative. She stated that the weight changes were expected, but that it was not stated in his record. She stated that the appropriate course of action would be to re-weigh the resident to ensure the weights were accurate, and of course to notify the provider. She stated that she had just dropped the ball. She stated that she could not say why the weekly weights were not completed as ordered. She stated that to monitor weights, she checks the weight report. She stated that the resident did not show up on the weight report and that she did not notice the resident was missing. She stated that there were no Nutrition at Risk meetings, but that there are weekly meetings every Thursday where they look at weights. She stated that it was like an at risk meeting. She stated that they have a morning meeting also, where they go around the room and discuss concerns with residents. She stated that he was just missed.

An interview was conducted on 01/26/23 at 9:30 a.m. with the Director of Nursing (DON/staff # ). She stated that resident weights are obtained within 24-48 hours of their admission. She stated that weekly weights are obtained on Sundays by the Certified Nursing Assistants. She stated that the dietitian monitors the weights via a weekly report. She stated that her expectation is that weekly weights are done as ordered. She stated that all the staff have been trained on accurately obtaining weights. She stated that when a resident loses weight, the doctor will be notified because the weight loss may be related to a diagnosis. She stated that it is nursing ' s role to notify, and that the conversation should be documented in the resident ' s clinical record.

The Nutrition (Impaired) Unplanned Weight Loss - Clinical Protocol policy, revised September 2017, included the nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. The staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions.

The Weight Assessment and Intervention policy, revised March 2022, included that resident weights are monitored for undesirable or unintended weight loss or gain. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will notify the dietician in writing. The threshold for significant unplanned and undesired weight loss will be based on the following criteria:
1 month - 5% weight loss is significant; greater than 5% is severe.
3 months - 7.5% weight loss is significant; greater than 7.5% is severe.
6 months - 10% weight loss is significant; greater than 10% is severe.

Based on observations, staff interviews, review of the policy and procedures, the facility failed to discard expired medications and failed to ensure expired medications were not available for administration.

Findings include:

A medication pass observation was conducted on January 24, 2023 at 8:09 a.m. with a licensed practical nurse (LPN/staff #45) in the loop unit. During the observation, staff #45 placed one tablet of zinc sulfate 50 milligrams in the medication cup to be administered to a resident.

However, upon inspection of the zinc sulfate, it revealed an expiration date of June 2022.

An immediate interview with staff #45 was conducted in which she inspected the bottle of the zinc sulfate. After inspecting the medication bottle, she stated the medication had expired on June 2022. She stated she usually look at the expiration of the medications but not today. She stated she would have administered the expired medication to the resident if it was not caught during the observation. She stated she would dispose the medications and she would get a new bottle from the storage.

Following the medication pass observation on January 24, 2023 at about 8:14 a.m. an inspection of the medication cart was conducted in the loop unit with staff #45. During the inspection, the following expired medications were found in the medication cart:
-Vitamin E 200 units with an expiration date of January 2022
-loperamide 2 milligrams with an expiration date of February 2022
-Vitamin B Complex with an expiration date of March 2022
-Benadryl 25 milligrams with an expiration April 2022
-Bisacodyl 5 milligrams with an expiration date of May 2022
-ferrous gluconate 240 milligrams with an expiration date of July 2022.
-folic acid 400 micrograms with an expiration date of August 2022
-omeprazole 20 milligrams with an expiration date of September 2022
-Zyrtec 10 milligrams with an expiration date of September 2022

An immediate interview was conducted on January 24, 2023 at approximately 8:30 a.m. with staff #45. She stated the process of maintaining the OTC (over the counter) medications included the nurse who has the cart is responsible to check the expiration date of the medications. She stated the risk if the resident received expired medication is decreased efficacy of the medications.

Continued observation of medication storage was conducted on January 24, 2023 at 8:32 a.m. with a licensed practical nurse (LPN/ staff #109). A medication cart inspection on the South unit, 100 hallways contained the following expired medications:
-Melatonin 1 milligrams with an expiration date of March 2022
-Melatonin 3 milligrams with an expiration date of May 2022
--Bisacodyl 10 milligrams with an expiration date of September 2022.
-cetirizine 10 milligrams with an expiration date of December 2022
-famotidine 10 milligrams with an expiration date of December 2020
-Rena-vite with an expiration date of December 2022

Following the observation, an immediate record review was conducted with staff #109 who stated two of the expired medications were administered to two residents on January 22, 2023.

An interview was conducted on January 24, 2022 at 8:41 a.m. with staff #109. She stated the night shift is responsible for maintaining the medication carts including checking the expiration dates of OTCs (over the counter) medications and re-stocking the medication carts.

An interview was conducted on January 26, 2023 at 8:26 a.m. with the director of nursing (DON/staff #8). She stated it is her expectation that the nurses verify the expiration dates of the medications prior to administration. She stated that medication carts are checked on the night shift verifying what needs to removed or replaced. She stated the risk for the resident who receives expired medications included decreased efficacy and possible side effects.

A policy and procedure titled, Storage of Medications, with a revision date of November 2020, stated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. The implementation included the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Per the policy, discontinued, outdated medications are returned to the dispensing pharmacy or destroyed.

Based on observations, resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident's (#238) environment was free from accidents/hazards and that the institution's premises and equipment are free from a condition or situation that may cause a resident to suffer physical injury.

Findings include:

-Regarding Resident #238:

Resident #238 admitted to the facility on 08/31/22 with diagnoses including chronic systolic (congestive) heart failure, orthostatic hypotension and history of falling.

A nurses progress note dated 09/09/22 at 9:31 a.m. included that the writer heard a loud bang from the nurses station. The note included that the writer went to assess the situation and found the resident sitting in his bed with the headboard on his bed as well as glass from the picture that had fallen on him. Per the note, the glass was cleaned off the resident and he was assisted to the chair and further assessed for injuries. The resident complained of right shoulder pain, and redness to the shoulder was noted. The resident's family and the provider were notified. The provider ordered an x-ray for the shoulder and the resident was switched to a different room.

On 01/24/23 at 12:06 p.m. an interview was conducted with resident #238. He stated that on the morning of the incident, he was repositioning his bed to sit up. He stated he heard a loud pop and somehow the picture that had been over his bed had fallen onto his head. He stated that the glass shattered all over him, but that he was not cut. He stated that he called out for assistance. He stated that a Certified Nursing Assistant (CNA) came into his room and turned on the light and said, "Oh, my God". He stated that they immediately called maintenance and picked the glass off him. He stated that he was transferred into a different room.

An observation was conducted on 01/25/23 at 9:51 a.m. with a CNA (staff #12) in the first floor resident rooms. In room #136, bed A, it was noted that a headboard was no longer afixed to the wall. Upon further inspection, 2 nickle-sized holes were identified in the wall approximately 2 feet from the floor, on either side of the bed. Drywall was noted to be protruding from the holes. Markings on the wall above the bed, at approximately 4 \'bd feet from the floor, bore resemblance to the area on the wall where other fixed headboards had been secured. Picture hardware was identified above both beds A and B. However, the pictures had been removed. In room #143, which was unoccupied, it was noted that the headboard of the beds in the room were bolted to the wall behind the heads of the beds. The bottom of the headboards were approximately 2 feet from the floor. The tops of the headboards were approximately 4 \'bd feet from the floor. Above the headboards, pictures were hung on the wall over the beds which measured approximately 3 feet long by 2 feet wide. The pictures were observed to have glass covering them.

An interview was conducted on 01/25/23at 9:52 a.m. with staff #12. She stated that the headboards are bolted into the wall. She stated that she thinks the pictures are screwed into the wall above them. She stated that she thought she had heard about a resident who had a picture fall on his head. She stated that if the bed was lowered all the way into the low position, and the resident had adjusted his bed to sit up, the bed frame would have hooked under the headboard and could have popped the bed frame up, hitting the picture and releasing it from the wall. The CNA demonstrated by raising and lowering the bed. She stated that sometimes when she is working, the bed frame gets caught under the headboard.

On 01/26/23 at 11:26 a.m. an interview was conducted with a CNA (staff #141). He stated that sometimes the beds will get stuck under the headboard. He stated that he has to pull the bed out from the wall for the bed to go up. He stated that he last talked to maintenance about it about 2 weeks ago when one of the beds got stuck on the second floor. He stated that he did not remember what maintenance did because he was working after that.

An interview was conducted on 01/26/23 at 3:10 p.m. with the Director of Nursing (DON/staff #8). She stated that her expectation is that they meet the needs for each resident specifically and that they maintain a safe environment. She stated that if a CNA or nurse identifies a safety issue, they will notify maintenance to correct it within a timely manner. She stated that she thought maintenance went through the building and re-anchored the bed frames.

However, evidence of completion of the work orders was not provided to the State survey team.

The Safety and Supervision of Residents - Accidents/Hazards policy, revised July, 2017, included the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, QAPI reviews of safety and incident/accident data and a facility-wide commitment to safety at all levels of the organization. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary

Based on observations, resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#74) received adequate supervision to prevent medication accidents, and that medications are inaccessible to residents.

Regarding Resident #74

Resident #74 was admitted December 13, 2022 with pertinent diagnosis that include a left femur fracture, type 2 diabetes, heart disease and end stage renal disease.

Record review of an Admission MDS (Minimum Data Set), dated December 19, 2022 noted a BIMS (Brief Interview for Mental Status) of 12, indicating that the resident has mild cognitive impairment.

On January 23, 2023 A bottle of nitroglycerine sublingual tablets were noted on the bedside table in the resident's room. This bottle was noted to be within arms reach of the resident. This writer alerted staff to the observation and the Licensed Practical Nurse (LPN #45) on the floor removed the medication from the room and secured it in medication cart.

Review of the care plan dated December 12, 2022 revealed the resident is at risk for poor medication management. Resident will be prescribed the minimum amount of medications necessary, with a noted intervention of 'consult pharmacist to review medications'.

However, no care plan measure for self-administration was noted in this review.

Review of physician orders dated December 17, 2022 revealed no orders for nitroglycerine. No order for self-administration was noted in this review.

An interview was conducted on January 24, 2023 at 0900 with a Licensed Practical Nurse (LPN #45). The LPN stated that it is not a facility policy to leave medications at bedside. The LPN states she is not sure if they do resident self-administration assessments and hasn't seen that in this facility. The LPN stated that if medications are found at bedside they would be secured in the medication cart. The LPN was unable to identify why this medication was left at bedside.

An interview was conducted on January 24, 2023 at 0913 with resident #74. The resident reports she was never asked about self-administration. She reports the facility doesn't allow her to take her own medications and that the nursing staff watch her when she takes her pills. She also reports that the pill bottle was there so she didn't forget to ask for a new one from her heart doctor.

An interview was conducted on January 26, 2023 at 1230 with a Licensed Practical Nurse (LPN #55). The LPN stated there should never be medications left at bedside. The LPN Stated she has found medications at bedside during admissions and that the medications are secured and explained to the resident why this is necessary. The LPN States the risks of medications at bedside could cause side effects or a bad disposition for the resident. The LPN States she is not aware of any self-administration policy or medication at bedside policy in this facility. When asked about what the outcome could be if nitroglycerine is used at bedside, The LPN states the resident could pass out and fall as a result of having low blood pressure. The LPN also reports she would notify her supervisor in the event medications are found at bedside.

A review of the facilities policy titled 'Self-Administration of medications' dated February 2021 revealed the IDT can evaluate factors when determining whether self-administration of medications is safe and appropriate for the resident based on a variety of criteria.

However, since the resident was not identified as appropriate for self-administration, and also had no physician's order for this medication, resident was at risk for a medication related injury.