Rivercrest Post Acute

1.-á-á-á-á-á Resident 2 admitted to the facility in 2025 with diagnoses including depression and adjustment disorder.The 1/29/25 Care Plan indicated Resident 2 experienced pain due to a recent surgery and motor vehicle accident with multiple fractures. Interventions included to administer medications as ordered.A 4/8/25 physician order indicate Resident 2 was to receive oxycodone 5 mg every four hours as needed for pain and 10 mg every four hours as needed for pain. The medication was not to exceed more than 40 mg daily.A 4/24/25 progress note indicated Staff 5 (LPN) signed out a dose of oxycodone and noted Resident 2 received 50 mg of Oxycodone on 4/23/25. The medication was to not exceed 40 mg per day. Resident 2 was notified and the on call provider was notified. Resident 2 was placed on alert.A 4/24/25 Medication Error report indicated Staff 5 signed out a dose of oxycodone and noted Resident 2 received 50 mg on 4/23/25. The order indicated not to exceed 40 mg per day.On 11/13/25 at 12:41 PM Staff 5 stated she recalled Resident 2 had an GÇ£oddGÇ¥ order related to pain medication. Staff 5 stated she could not recall the identified medication error and was unable to provide additional information.On 11/14/25 at 11:55 AM Staff 2 (DNS) acknowledged the findings of the medication error related to Resident 2 receiving excessive oxycodone.2.-á-á-á-á-á Resident 22 admitted to the facility in 2023 with diagnoses including depression.A 12/20/24 progress note indicated Resident 22 was approached with medications. Staff 15 (LPN) said the incorrect name to the resident. Resident 22 did not hear the wrong name and took the medication. Resident 22 was administered the medication in error. The provider was notified, and the resident was placed on alert for adverse side effects.The 12/20/24 Medication Error report indicated Resident 22 received her/his roommateGÇÖs morning medication including 60 mg of duloxetine (antidepressant). Resident 22 indicated she/he felt fine.On 11/18/25 at 12:00 PM Staff 22 stated she was worked for a staffing agency and only worked in the facility for one or two shifts. Staff 22 stated on the day of the incident she asked Resident 22 if this was her/his name [roommateGÇÖs name], and she/he stated yes. Staff 22 stated she told the resident she had her/his medication and the resident stated ""okay"" and took the medication. Staff 22 stated when she went to give medication to the roommate, she realized she gave Resident 22 the wrong medication. Staff 22 stated if she was not familiar with a resident and a picture was not available; she asked other staff where she could find the resident. Staff 22 acknowledged the identified medication error.On 11/18/25 at 11:18 AM Staff 1 (Administrator) acknowledged the identified medication error that occurred related to Resident 22.-á

Based on interview and record review it was determined the facility failed to ensure falls were evaluated to ensure resident safety and to ensure care plan interventions were followed for 2 of 4 sampled residents (#s 3 and 7) reviewed for accidents. This placed residents at risk for continued accidents. Findings include:

1. Resident 3 admitted to the facility in 11/2024, with diagnoses including heart failure.

A 12/1/24 at 02:26 AM Progress Note indicated Resident 3 slid out of bed, landed on the floor and got a skin tear on her/his leg. The same progress note indicated Resident 3 was sent out to the hospital per her/his request, not due to injury. The resident did not return to the facility.

The progress note did indicate if Resident 3's fall was witness or unwitnessed.

Record review found no documented evidence to show the resident's fall was evaluated to ensure resident safety and care plan interventions were followed.

On 4/18/25 at 10:15 AM, Staff 2 (DNS) and Staff 3 (RN consultant) confirmed that a thorough and complete analysis was not done for Resident 3's fall incident.

2. Resident 7 admitted to the facility 3/2025, with diagnoses including failure to thrive.

Resident 7's 4/1/25 Un-witnessed Fall Investigation was incomplete. Resident 7 was unaware of any details of the incident. The analysis of the fall incident was not in the report and no evidence to show the resident's fall was evaluated to ensure resident safety and to ensure care plan interventions were followed.

Review of Resident 7's clinical record indicated the resident's fall on 4/1/25 was not her/his first fall in the facility.

On 4/18/25 at 10:15 AM, Staff 2 (DNS) and Staff 3 (RN consultant) confirmed that a thorough and complete analysis of the incident was not done for Resident 7's 4/1/25 fall.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed contact precautions for 1 of 3 sampled residents (#1) reviewed for infection control. This placed residents at risk for cross contaminations. Findings include:

Resident 1 was admitted to the facility on 5/2024, with diagnoses including a stage 4 and stage 3 pressure ulcer.

On 4/17/25 at 9:09 AM, Staff 4 (LPN) and Staff 5 (CNA) performed a dressing change for Resident 1. Staff 4 removed the old dressing and carefully cleaned Resident 1's wound. Staff then re-dressed the wound per physician order. Staff 4 did not change her gloves between handling soiled dressings and clean dressings.

On 4/17/25 at 9:18 AM, Staff 4 (LPN) removed her PPE gown improperly. Staff 4 came into contact with the exterior side of the gown when it was removed.

On 4/17/25 at 9:21 AM, Staff 4 (LPN) confirmed she was aware she should have changed her gloves between dirty and clean portions of the procedure. Staff 4 stated she understood the contamination risk related to how a PPE gown should be removed.

On 4/18/25 at 10:15 AM, Staff 3 (RN consultant) and Staff 2 (DNS) stated the expectation was gloves were changed between dirty and clean portions of a dressing change. Staff 2 and Staff 3 also confirmed a PPE gown should not be removed over a person's head.

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411-086-0140 - Nursing Services: Problem Resolution and Preventive Care

Refer to F689
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411-086-0330 - Infection Control and Universal Precautions

Refer to F880
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Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R)(R14) reviewed for medication at bedside was assessed and evaluated to safely self-administer medications. This placed the resident at risk for medication errors, adverse medication interactions, and complications.

Findings include

Facility policy Self-Administration of Medications, revised February 2021, documented each resident's cognitive and physical abilities will be assessed to determine whether self-administering medications are safe and clinically appropriate for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan. For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken.

Review of R14's record documented resident was admitted on 5/1/23 with diagnoses including end-stage renal disease (ESRD) and dependent on renal dialysis (a process for removing waste and excess water from the blood due to failing kidney function. In ESRD, managing calcium and magnesium levels is crucial as the failing kidneys can't effectively regulate these minutes often leading to a situation where calcium levels might be slightly elevated while magnesium levels can be low, and both require careful monitoring and dietary adjustments to prevent complications). R14's Minimum Data Set (MDS-assessment tool), dated 8/9/24, documented the resident was cognitively intact with a brief interview for mental status score of 15 out of 15.

Review of R14's physician's orders documented Rolaids oral tablet, chewable 550-110 mg (calcium carbonate/mag hydrox) give 2 tablet by mouth every 6 hours as needed for GERD (Gastroesophageal reflux disease), start date 5/2/23.

Observation on 11/18/24 at 12:38 PM showed R14 in bed with 2-3 rolls of Rolaids (antacid medication containing calcium and magnesium to treat symptoms of heartburn or indigestion) wrapped in cellophane packaging on his overbed table within the resident's arm reach.

During an observation and interview on 11/18/24 at 2:33 PM R14 pointed to package of Rolaids on his overbed table and stated that he takes Rolaids whenever he gets acid reflux and he can take them whenever he wants to. He stated that he doesn't or have to tell the nurse when he takes it.

During an observation and interview on 11/19/24 at 8:13 AM R14 was lying in bed with transport company transporting resident to offsite dialysis center. Pack of Rolaids were observed on resident's overbed table over his bed.

Review of R14's record on 11/19/24 including medication administration record, physician's orders, care plan, evaluation, and progress notes did not document any physician orders for self-administration of Rolaids, medication self-administration assessment or care plan for self-administration of medication.

During an interview on 11/20/24 at 12:32 PM Licensed Practical Nurse (LPN)2 stated that R14 does not administer any of his own medications and did not know that R14 had Rolaids at the bedside. LPN2 stated that she had not given resident any Rolaids and approached LPN6 stating that LPN6 has been here longer. LPN6 stated that she was not aware R14 had Rolaids at this bedside. LPN6 stated that R14 should not be self-administering any medications, and no medications should be at his bedside. LPN6 further stated that if R14 wanted to keep medications at his bedside, there should be a physician's order. LPN6 stated that since R14 goes to dialysis and Rolaids has calcium, having Rolaids at R14's bedside was a concern. LPN6 stated that Rolaids should be in the medication cart with R14 asking for them if he needed it, and it should be documented when Rolaids are taken.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that R14 should not have any medications at his bedside, when informed that R14 had Rolaids at his bedside. DON stated that that was a concern since Rolaids had calcium and magnesium and that could affect resident since he was on dialysis. When informed that after discussion with LPN2 and LPN6, R14 now has a physician order that allows R14 to keep Rolaids at the bedside, but a medication self-assessment evaluation was not found. DON reviewed R14's records and confirmed a medication self-assessment was not completed but should have been done. DON stated that it was their expectation that the process for residents' self-administration of medications included that a physician order was obtained, an assessment of resident's ability to self-administer medications was completed and a care plan was initiated before leaving medication at bedside.

Based on interviews, record review, and facility policies and procedures, the facility failed to notify two residents (Resident (R) 13 and R 27) in writing prior to a change in room, roommate, or the reason for the change. The deficient practice could result in psychosocial decline in health or resident rights not being honored within the facility.

Findings include:
-For R 13
Review of the "Admission Record" located in the profile tab of the Electronic Medical Record (EMR) revealed Resident (R) 13 was admitted to the facility on 05/02/19 and readmitted on 09/17/20 with diagnoses that included unspecified cord compression (a serious condition that occurs when pressure is applied to the spinal cord, which can cause nerve damage), other chronic pain, osteomyelitis of vertebra (a rare spinal infection that causes inflammation of the bones in the spine), major depressive disorder, single episode, severe without psychotic features, chronic viral hepatitis c, and chronic viral hepatitis b without delta-agent (a long-term liver infection caused by the hepatitis B virus (HBV) that remains in the body after the acute phase).

Review of a Quarterly Minimum Data Set (MDS, a standardized collection of information used to assess the health of residents in nursing homes) with an Assessment Reference Date (ARD) of 08/30/24, indicated R 13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. Resident 13 had impairment to both sides of the lower extremities and the resident used a wheelchair (manual or electric) for mobility.

Review of the "Census" located under the census tab revealed on 10/15/24 R 13 was moved from a semi-private room to a room with 3-4 other residents.
Review of the "Notification of Room Change/New Roommate" dated 10/23/24 located in the Documents tab revealed R 13 was "verbally notified by staff of incoming new roommate" by the Medical Records Director who was the Social Services Assistant at the time.

On 11/19/24 at 12:54 PM an interview with concurrent record review was conducted with R 13. R 13 stated they had not received the Notification of Room Change/New Roommate form, or any written notification of the room change prior to the staff moving the resident on 10/15/24. R 13 stated the move happened after new management took over and that the information was presented to them as if the resident did not comply with the room change, they would be given a fourteen day notice to relocate. R 13 stated they did not know what "relocate" meant but it felt like a threat.

-For R 27
Review of the "Admission Record" located in the profile tab of the EMR revealed R 27 was admitted to the facility on 03/19/24 and readmitted on 04/12/24 with diagnoses that included acute respiratory failure with hypoxia (a condition in which there is a decrease in the oxygen supply to a tissue.), pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, resulting in inflammation), dysphagia (difficulty swallowing), and diverticulum of esophagus (a rare condition where a pouch or sac forms in the lining of the esophagus, the muscular tube that connects the mouth to the stomach).

Review of a Quarterly MDS with an ARD of 09/26/24, indicated R 27 was cognitively intact with a BIMS score of 14.

Review of the "Census" located under the census tab revealed on 11/16/24 R 27 was moved from a semi-private room to a "4 Bed Room."

Review of the "Notification of Room Change/New Roommate" dated 11/14/24 located in the Documents tab revealed R 27 and a resident representative was "verbally notified of pending room change" by the Medical Records Director.

During an interview on 11/18/24 at 01:20 PM, Resident 27 stated that she was moved into room 9 three days ago. She stated that the room is under construction and the call light system does not work. R27 stated they gave her a bell, but the staff never answer the bell. R27 rang the bell while surveyor was in the room.

During an interview on 11/19/24 at 01:30 PM, the Restorative Aide stated The Medical Records Director and Admissions Director complete the notifications to residents when there needs to be a room change. The Restorative Aide stated after she is notified that there is to be a room change, she will assist with the move. The Restorative Aide stated that before a resident is moved, all notices have been completed.

On 11/19/24 at 01:39 PM an interview with concurrent record review was conducted with the Medical Records Director. The Medical Records Director stated that they gave the verbal notices to R 13 and R 27. The Medical Records Director stated that when a room change is needed in a non-emergent situation, a resident is informed of the change by herself or the admissions director. The Medical Records Director stated that if the resident refuses the move or roommate the facility provides the resident with a fourteen (14) day notice. The Medical Records Director stated the purpose of the notice to let the resident know that regardless, after the 14 days the resident will be relocated within the building. The Medical Records Director stated that this met the state requirement for notification of transfer. When asked if they provided written documentation of the move, the Medical Records Director said, "no. But if they wanted a copy the resident could ask for it." When asked if that process met the federal regulation for providing a written copy to the resident, The Medical Records Director said, "to my knowledge that (the current process) meets the regulation."

On 11/19/24 at 02:07 PM during an interview, the Director of Nursing (DON) stated social services will "spear head" the notification of room changes. The DON stated that most residents are agreeable with room changes and they (the facility) want room changes to be as positive as possible. The DON stated that the 14 day "thing" was "unfamiliar" to her when she first started at the facility but there "really wasn't a 14-day thing." When asked if it could be perceived by residents that a 14 day notice to move might be intimidating, the DON said, "it could be, but we have never forced someone to change rooms." When asked if the facility policy includes providing written notification to residents prior to room change, the DON said, "yes." The DON also stated that not providing written notification could result in roommates having challenges from differences of opinion and claims that they were not made aware of the room changes.

Review of the facility policy titled "Room Change/Roommate Assignment" revised March 2021 included "changes in room or roommate assignment(s) are made when the facility deems it necessary or when the resident requests the change." Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives) are given advance written notice of such change.

Based on record review, interviews, and facility policy review, the facility failed to ensure residents received information regarding how to formulate an advanced directive for one of one resident (Resident (R) 88) reviewed for advanced directives out of 16 sample residents. The failure had the potential to affect resident end of life decisions.

Findings include:

Review of the facility's policy titled, "Advance Directives," dated 08/01/24 revealed, "During the admission process, written information is given to the resident/ representative regarding the resident's rights to make decisions concerning medical care. Including the right to request, refuse, and/ or discontinue medical or surgical treatment . . . and the right to formulate an advance directive."

Review of R88's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted on 11/15/24 with diagnoses which included fracture of right lower leg, anxiety, conversion disorder, chronic pain, and fracture of left fibula.

Review of R88's entry "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 11/15/24, revealed a "Brief Interview for Mental Status (BIMS)" score had not yet been conducted.

Review of the "Social History Assessment," dated 11/18/24 and located under the "Evaluations" tab of the EMR, revealed a "BIMS" score of 12 out of 15, which indicated the resident had moderately impaired cognition. The responsible/ legal guardian was marked as self-responsible. Advanced directives were marked as none of the above.

Review of the "IDT [Interdisciplinary] Conference Notes," dated 11/18/24 and located under the "Evaluations" tab of the EMR, revealed the section for advanced directives was blank for reviewed advanced directive information, discussed current wishes, and POLST reviewed.

Review of R88's EMR revealed no documentation of receipt of advanced directive information.

During an interview on 11/21/24 at 8:14 AM, the Director of Nursing (DON) stated the Social Services Director (SSD) would provide advanced directives information, determine whether they had one in place, and if they wanted to initiate an advance directive and do the POLST. She confirmed she did not find anything documented for receipt of advanced directive information for this resident.

During an interview on 11/21/24 at 8:32 AM, R88 stated "no" when asked if she had received information regarding how to formulate an advanced directive. She stated they signed something for a full code but did not receive anything related to advanced directives. R88 stated she probably needed to complete an advanced directive.

During an interview on 11/21/24 at 8:47 AM, the SSD stated she was not in charge of advanced directives and had not completed anything this week regarding advanced directives.

Based on interview and record review the facility failed to provide required and complete liability notices for 2 of 3 sampled residents (R) (R3 and R28) reviewed for liability notices, who remained in the facility after skilled services ended and had skilled benefit days remaining. These failures increased the residents' risk for not having adequate information to make financial decisions.

Findings include

Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-10055, is issued by the facility if the beneficiary intends to continue services and the facility believes the services may not be covered under Medicare. It is the facility's responsibility to inform the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services. The ABN form allowed the facility to enter the date of notice, the item or service deemed no longer meeting coverage requirements, the reason the item or service was not meeting coverage requirements, the estimated cost of the item or service and then asked the resident to choose one of three options based on this information.

Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, is given by the facility to Medicare beneficiaries (residents) before the end of a Medicare covered Part A stay or when all of Part B therapies are ending to inform the beneficiary they may have to pay for any services the Medicare provider (facility) as determined that Medicare probably will not pay for. In addition, the NOMNC informs the beneficiaries of the right to an expedited review by a Quality Improvement Organization.

Review of Medicare Claims Processing Manual Chapter 30- Financial Liability Protections, dated 8/1/24, https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c30.pdf, documented for SNF ABN "In the situation in which a SNF believes Medicare will not pay for extended care items or services that a physician has ordered, the SNF must provide a SNF ABN to the beneficiary before it furnishes those non-covered extended care items or services to the beneficiary." Under section, 260.3.4 - Required Delivery Timeframes, it was documented "The NOMNC should be delivered to the beneficiary at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily."

R3

Review of R3's records showed ABN signed on 5/31/24. The effective date for when resident "may have to pay out of pocket for this care if you do not have other insurance that may cover these costs" was not entered. In addition, the care, estimated costs, and reason Medicare may not pay was not completed and left blank. There was no NOMNC found for R3. R3 was discharged from the facility on 10/1/24.

R28

Review of R28's records showed NOMNC "the effective date coverage of your OT/ST (occupational therapy/speech therapy) will end 5/10/24. The form was signed by the resident on 5/28/24 (20 days late). R28's ABN form showed effective date was 5/11/24 for OT/ST services and was signed by the resident on 5/28/24 (19 days late). R28 still remained in the facility.

During an interview on 11/19/24 at 12:27 PM with Social Services Director (SSD) and Medical Records Director (MRD) who used to work in SS, SSD stated that R3 should have also been issued a NOMNC and the ABN was incomplete because it did not have care, estimated costs, reason Medicare may not pay and effective date. SSD also stated that R28's NOMNC and ABN should have been issued 2 days before the effective date to allow resident time to decide.

During an interview on 11/19/24 at 12:45 PM with Business Office Manager (BOM) and SSD, BOM confirmed R3 had Medicare part A benefit days remaining when SNF ABN was issued on 5/31/24.

During a concurrent record review and interview on 11/22/24 at about 11AM Administrator reviewed R3 and R28's NOMNC and ABN forms and acknowledged forms did not have complete information and was not provided on a timely basis. Administrator stated that R28 NOMNC and SNF was signed after effective date and should have been signed before the effective date.

Review of email from Administrator on 11/25/24 at 11:51 AM documented the facility did not have a policy on ABN and NONMC notices. The facility followed the regulation. Request for facility policy on ABN and NONMC was made without documents received.

Based on record review, interviews, and facility policy review, the facility failed to protect the resident's right to be free from verbal and physical abuse for one of four sampled residents (Resident (R) 5) by a resident, R7, reviewed for abuse. This failure had the potential to affect resident safety.

Findings include:

Review of the facility's policy titled, "Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection," dated 08/24, revealed "It is the policy of this center to ...Protect our residents from abuse ...Abuse is the willful infliction of injury."

1.Review of R5's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted 09/17/20 with diagnoses of schizoaffective disorder, major depressive disorder, and malignant neoplasm of scapula.

Review of R5's quarterly "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 09/06/24 and located under the "MDS" tab of the EMR revealed the resident had a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15 which indicated the resident was cognitively intact.

During an interview on 11/18/24 at 12:36 PM, R5 stated that a "guy," while outside smoking, punched her in the chest. She stated this happened about a month ago. R5 did not indicate the name of the person who struck her.

2. Review of R7's "Admission Record," located under the "Profile" tab of the EMR, revealed the resident was admitted on 02/10/23 with diagnoses of vascular dementia, major depressive disorder, bipolar disease, and nicotine dependence.

Review of R7's quarterly "MDS," with an ARD of 08/09/24 and located under the "MDS" tab of the EMR, revealed the resident had a "BIMS" score of 10 out of 15 which indicated the resident had moderately impaired cognition.

Review of R5's "Alert Note," dated 10/05/24 and located under the "Progress Notes" tab of the EMR, revealed "This Ln [Licensed Nurse] was passing medication on top hall ...when observed resident outside in smoking area having a cigarette with another resident socializing ...[R7] continued to try to talk to her [R5] and she got upset stood up to walk away and he reached his right hand out and pushed her right in the center of the chest, she was holding onto her walker with her left hand and she stepped one step back with her right foot gathered her balance. This Ln went to pull resident wheelchair back to separate the residents ...Other resident [R7] proceeded to tell resident with his right fist clenched that he was going to kill her. This LN stated ...inappropriate verbal abuse and will not be tolerated in the building ...She refused skin check of any kind, refused to press charges, refused to have situation reported or provider notified of incident."

During an interview on 11/19/24 at 1:18 PM, the Director of Nursing (DON) stated when it happened, she got a message from nursing. She stated R7 had asked for a cigarette and there was physical contact. She stated the nurse on duty that witnessed the incident was currently on vacation. She stated they had just completed a gradual dose reduction (GDR) with R7, and it was unsuccessful. She stated there had been no other incidents with R7 since January.

During an interview on 11/21/24 at 8:14 AM, the DON stated R7 was having escalated behaviors since the GDR, and they were monitoring him. She stated staff were usually with him, but he went out there unsupervised.

Based on record review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were reported in a timely manner to the State Agency (SA) for two of four sampled residents (Resident (R) 5 and R9) reviewed for abuse. This failure had the potential to affect resident safety in the facility.

Findings include:

Review of the facility's policy titled, "Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection," dated 08/24 revealed, "Any suspicion of a crime requires notification of law enforcement and the state agency . . . If with the suspicion of crime, there is abuse or a serious injury the staff member must report the incident within 2 hours of forming the suspicion to the law enforcement and the state survey agency."

1.. Review of R5's "Admission Record" located under the "Profile" tab of the electronic medical record (EMR) revealed the resident was admitted 09/17/20 with diagnoses of schizoaffective disorder, major depressive disorder, and malignant neoplasm of scapula.

Review of R5's quarterly "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 09/06/24 and located under the "MDS" tab of the EMR, revealed the resident had a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15, which indicated the resident was cognitively intact.

During an interview on 11/18/24 at 12:36 PM, R5 stated a guy, while outside smoking, punched her in the chest. She stated this happened about a month ago.
       

Review of R7's "Admission Record" located under the "Profile" tab of the EMR revealed the resident was admitted on 02/10/23 with diagnoses of vascular dementia, major depressive disorder, bipolar disease, and nicotine dependence.

Review of R7's quarterly "MDS," with an ARD of 08/09/24 and located under the "MDS" tab of the EMR, revealed the resident had a "BIMS" score of 10 out of 15, which indicated the resident had moderately impaired cognition.

Review of R5's "Alert Note," dated 10/05/24 and located under the "Progress Notes" tab of the EMR, revealed, "This Ln [Licensed Nurse] was passing medication on top hall . . . when observed resident outside in smoking area having a cigarette with another resident socializing . . . [R7] continued to try to talk to her [R5] and she got upset stood up to walk away and he reached his right hand out and pushed her right in the center of the chest, she was holding onto her walker with her left hand and she stepped one step back with her right foot gathered her balance. This Ln went to pull resident wheelchair back to separate the residents . . . Other resident [R7] proceeded to tell resident with his right fist clenched that he was going to kill her. This LN stated . . . inappropriate verbal abuse and will not be tolerated in the building . . . She refused skin check of any kind, refused to press charges, refused to have situation reported or provider notified of incident . . ."

During an interview on 11/19/24 at 1:18 PM, the Director of Nursing (DON) stated the incident with R5 happened on 10/05/24 and confirmed it was not reported to the SA.

During an interview on 11/21/24 at 8:14 AM, the DON confirmed this incident had not been reported to the SA or the police. She stated she would have called the police if there had been physical contact and the resident felt fearful, but the resident was not fearful. She stated this incident occurred because R7 was having escalated behaviors with a gradual dose reduction (GDR). She stated abuse reporting was to be within two hours. She stated they did not substantiate abuse because at the time it did not seem significant. She stated it would have been reported if the resident had felt unsafe.

2. Review of R9's "Admission Record," located under the "Profile" tab of the EMR, revealed the resident was admitted 09/17/20 with diagnoses of morbid obesity, major depressive disorder, traumatic brain injury, and expressive language disorder.

Review of R9's quarterly "MDS," with an ARD of 07/18/24 and located under the "MDS" tab of the EMR, revealed the resident had a "BIMS" score of 15 out of 15, which indicated the resident was cognitively intact.

During an interview on 11/18/24 at 1:19 PM, R9 stated she developed a bruise from an agency nurse over the summer. She stated he grabbed her very hard, resulting in a bruise.

Review of the "Social Services Note," dated 07/18/24 and located under the "Progress Notes" tab of the EMR, revealed, ". . . [R9] made an allegation of abuse after the fact against . . . agency nurse, reporting that he squeezed her right lateral antecubital resulting in a delayed bruise with underlying swelling. She explained that she reported this to the various members of her . . . healthcare team, but that she did report the injury to . . . until this time. She had previously emailed about not wanting to receive care from this nurse but did not report any injuries . . ."

During an interview on 11/19/24 at 1:18 PM, the DON stated the agency nurse had touched her and made her feel uncomfortable. She confirmed this was not reported to the SA or the police.

Based on record review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were investigated for two of four sampled residents (Resident (R) 5 and R9) reviewed for abuse. In addition, the facility failed to have a Licensed Practical Nurse (LPN) complete a background check and have that nurse complete abuse and neglect training prior to working with residents for one (LPN2) of six staff background checks reviewed. The facility allowed Licensed Practical Nurse (LPN) 2 to work a total of 13 hours and 30 minutes prior to receiving a criminal background check.

This failure had the potential to affect resident safety in the facility.

Findings include

Review of the facility's policy titled, "Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection," dated 08/24 revealed, "All alleged incidents of abuse . . . must be thoroughly investigated. The investigation is done to determine, as far as possible: i. What occurred; and ii. To make necessary changes to the provision of care and services to prevent reoccurrence . . ."

1.a. Review of R5's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted 09/17/20 with diagnoses of schizoaffective disorder, major depressive disorder, and malignant neoplasm of scapula.

Review of R5's quarterly "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 09/06/24 and located under the "MDS" tab of the EMR, revealed the resident had a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15 which indicated the resident was cognitively intact.

During an interview on 11/18/24 at 12:36 PM, R5 stated a guy, while outside smoking, punched her in the chest. She stated this happened about a month ago.

b. Review of R7's "Admission Record," located under the "Profile" tab of the EMR, revealed the resident was admitted on 02/10/23 with diagnoses of vascular dementia, major depressive disorder, bipolar disease, and nicotine dependence.

Review of R7's quarterly "MDS," with an ARD of 08/09/24 and located under the "MDS" tab of the EMR, revealed the resident had a "BIMS" score of 10 out of 15 which indicated the resident had moderately impaired cognition.

Review of R5's "Alert Note," dated 10/05/24 and located under the "Progress Notes" tab of the EMR, revealed "This Ln [Licensed Nurse] was passing medication on top hall . . . when observed resident outside in smoking area having a cigarette with another resident socializing . . . [R7] continued to try to talk to her [R5] and she got upset stood up to walk away and he reached his right hand out and pushed her right in the center of the chest, she was holding onto her walker with her left hand and she stepped one step back with her right foot gathered her balance. This Ln went to pull resident wheelchair back to separate the residents . . . Other resident [R7] proceeded to tell resident with his right fist clenched that he was going to kill her. This LN stated . . . inappropriate verbal abuse and will not be tolerated in the building . . . She refused skin check of any kind, refused to press charges, refused to have situation reported or provider notified of incident."

During an interview on 11/19/24 at 1:18 PM, the Director of Nursing (DON) stated when social services completed the interviews, they were placed in a "soft" file. She stated the social worker left last week. She stated the incident with R5 happened on 10/05/24.

During an interview on 11/21/24 at 8:14 AM, the DON acknowledged she was unable to find any of the "soft" files that would have contained R5's investigation that was conducted.

2. Review of R9's "Admission Record," located under the "Profile" tab of the EMR, revealed the resident was admitted 09/17/20 with diagnoses of morbid obesity, major depressive disorder, traumatic brain injury, and expressive language disorder.

Review of R9's quarterly "MDS," with an ARD of 07/18/24 and located under the "MDS" tab of the EMR, revealed the resident had a "BIMS" score of 15 out of 15 which indicated the resident was cognitively intact.

During an interview on 11/18/24 at 1:19 PM, R9 stated she developed a bruise from an agency nurse over the summer. She stated he grabbed her very hard, resulting in a bruise.

Review of the "Social Services Note," dated 07/18/24 and located under the "Progress Notes" tab of the EMR, revealed ". . . [R9] made an allegation of abuse after the fact against . . . agency nurse, reporting that he squeezed her right lateral antecubital resulting in a delayed bruise with underlying swelling. She explained that she reported this to the various members of her . . . healthcare team, but that she did report the injury to . . . until this time. She had previously emailed about not wanting to receive care from this nurse but did not report any injuries . . ."

During an interview on 11/19/24 at 1:18 PM, the DON stated the agency nurse had touched her and made her feel uncomfortable. She stated the agency nurse had come back and he was assigned to another unit. She stated that about two to three weeks later, she had a bruise on her arm. She stated the resident's story about what happened changed several times. She stated they determined the bruise happened because of a lab draw.

During an interview on 11/21/24 at 8:14 AM, the DON confirmed they did not have any evidence of an investigation for either of the residents' allegation of abuse.




, Background screening

Review of a "Background Screening Report" revealed that the request for screening was submitted on 11/04/24 at 04:43 PM. The completed report was dated 11/07/24 at 01:10 AM.

Review of "Time Punches" for LPN 2 revealed a clock in on 11/05/24 at 11:00 AM and a clock out at 04:00 PM for a total time of 5 hours. Another punch dated 11/06/24 had LPN 2 clocking in at 06:00 AM and clocking out at 02:40 PM for a total of 8 hours and 40 minutes.
LPN 2 was unavailable for interview about the time punches on 11/05/24 and 11/06/24.

During an interview on 11/21/24 at 02:21 PM, the Human Resources (HR) Generalist stated they did not know for sure what the date of 11/07/24 on the background check signified but they would investigate.

On 11/22/24 at 11:49 AM during another interview with concurrent review of the background check report, the Human Resources Generalist confirmed that the facility did not receive the completed background check until 11/07/24.

On 11/22/24 at 11:59 AM, the Infection Control Nurse and acting Director of Staff Development (DSD) stated staff have to complete all of the pre-employment steps before being allowed to work. The DSD stated HR finishes verification of license and background checks prior to the nurse coming in for orientation and skills check offs.

During an interview on 11/22/24 at 12:32 PM, the Director of Nursing (DON) was asked if it was the expectation to have clinical staff screened for a criminal background check prior to working at the facility or with residents. The DON stated that all background checks should be completed through HR prior to the clinical staff providing care to the residents. The DON stated that in the past there have been clinical staff that started a position without direct contact with residents and those background checks came in later.

Based on interview and record review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were conducted timely for 2 of 9 sampled residents (Resident) (R14 and R7) reviewed for quarterly MDS assessments. The failure to ensure quarterly MDS assessments were completed timely as required placed the residents at risk for delayed and unmet care needs and a diminished quality of life.

Findings include

Review of Resident Assessment Instrument (RAI) Manual version 1.1.9.1, dated October 2024, documented a quarterly assessment must be completed at least every 92 days when a comprehensive assessment was not required. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Resident 7

Review of R7's record showed last quarterly MDS assessment was conducted on 8/9/24. There was no MDS assessment conducted on 11/9/24, as required. The quarterly MDS with ARD date of 11/9/24 showed status "In Progress" as of 11/20/24 (11 days late as of 11/20/24). Quarterly MDS assessment should have been completed 14 days after the Assessment Reference Date (ARD).

Resident 14

Review of R14's record showed last quarterly MDS assessment was conducted on 8/9/24. There was no MDS assessment conducted on 11/9/24, as required. The quarterly MDS with ARD date of 11/9/24 showed status "In Progress" as of 11/20/24 (11 days late as of 11/20/24). Quarterly MDS assessment should have been completed 14 days after the Assessment Reference Date (ARD).

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that her expectation is quarterly MDS should be completed within 3 days of ARD. DON stated that MDS coordinator quit in October and current MDS coordinator started 2-3 weeks ago, works 16 hours a week at night only, and is currently on leave and not available for interview. DON acknowledged that R7 and R14's quarterly MDS were late. ?

Based on record review, interviews, and facility policy review, the facility failed to ensure the comprehensive care plan (CP) was developed timely for one of 16 sampled residents (Resident (R) 136) reviewed for care plans. This failure had the potential to affect resident care.

Findings include:

Review of the facility's policy titled, "Care Planning-Interdisciplinary Team," revised 03/22 revealed, "Resident care plans are developed according to the timeframes established . . . Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) . . ."

Review of R136's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR) revealed the resident was admitted on 09/30/24 with diagnoses of dysphagia (difficulty swallowing), respiratory failure, chronic obstructive pulmonary disease, anemia, hypertension, tobacco use, rheumatoid arthritis, fibromyalgia, and gastro-esophageal reflux disease without esophagitis.

Review of R136's admission "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 10/11/24, revealed a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15, which indicated the resident was cognitively intact.

Review of R136's comprehensive "Care plan" located under the "Care Plan" of the EMR revealed the following:

Focus area of Cardiac with no goals or interventions, dated 10/06/24.
Focus area of Oxygen with no goals or interventions, dated 10/06/24.
Focus area of Anti-Anxiety medication with no goals or interventions, dated 10/06/24.
Focus area of Antidepressant medication with no goals or interventions, dated 10/06/24.
Focus area of Physical Therapy with no goals or interventions, dated 10/06/24.
Focus area of Occupational Therapy with no goals or interventions, dated 10/06/24.
Focus area of supervision with new diet with no goals or interventions, dated 11/18/24.
One area with focus of antidepressants related to having generalized anxiety disorder (dated 10/06/24) and one area with focus related to activities (dated 10/09/24) were complete.

During an interview on 11/20/24 at 9:58 AM, the Director of Nursing (DON) stated that the current MDS worked remotely and that they lost their in-house MDS person around September 2024- October 2024. She stated they followed the Resident Assessment Instrument (RAI), and the comprehensive CP needed to be completed within a week. The DON confirmed that R136's CP was "grossly outstanding." The DON confirmed R136's care plan should have been completed around 10/26/24.

Based on observation, interview and record review, the facility failed to ensure care plans were revised to reflect resident-centered care for 1 resident (R14) and developed with resident/representative involvement for 1 resident (R20) of 16 sampled residents reviewed for care planning. These failures placed residents at risk for unmet care needs.

Findings include

Resident 14

Review of R14's record documented resident was admitted on 5/1/23 with diagnoses including end-stage renal disease (ESRD) and dependent on renal dialysis (a process for removing waste and excess water from the blood due to failing kidney function). R14's Minimum Data Set (MDS-assessment tool), dated 8/9/24, documented the resident was cognitively intact with a brief interview for mental status score of 15 out of 15.

Review of R14's orders showed Oxygen continuous at 2 liters per minute when resting, with activity and when sleeping. Start date 8/9/23.

Review of R14's care plan documented R14 used oxygen therapy related to COPD (chronic obstructive pulmonary disease, lung disease making it difficult to breathe) and included monitoring for signs and symptoms of respiratory distress and report to physician, oxygen per physician order and position resident to facilitate ventilation/perfusing matching.

Observation on 11/18/24 at 12:38 PM showed R14 in bed asleep. Resident was not using oxygen. Oxygen tubing was not in resident's nostrils.

During an observation and interview on 11/18/24 at 2:33 PM R14 was not using oxygen. Oxygen tubing was not in resident's nostrils. R14 stated that he didn't need to use oxygen all the time and used it when he wanted.

Observation on 11/20/24 at 11:10 AM showed R14 was not using oxygen. Oxygen tubing was not in resident's nostrils.

During an interview on 11/20/24 at 12:32 PM Licensed Practical Nurse (LPN)2 reviewed R14's current physician order and stated that R14 should be using oxygen continuously and oxygen tubing should always be resident's nostrils. LPN2 further stated that R14 takes it off on his own, he removes oxygen tubing out of his nose.

During an interview on 11/20/24 at 1:20 PM Certified Nursing Assistant (CNA)9 stated that she knew R14 well and he constantly takes off his oxygen, he puts the tubing in his hairline and when you tell him to put on his oxygen, he puts it on and then in a few seconds, it's back in his hairline.

During an interview on 11/21/24 at 3:15 PM Resident Care Manager (RCM)2 stated that resident uses his oxygen when he wants, he self-directs his own care. RCM2 stated that MDS staff develops the care plans. RCM2 reviewed R14's care plan for oxygen and acknowledged that R14's care plan was not resident-centered as it did not reflect resident's preference for intermittent, not continuous, oxygen use. RCM2 confirmed only agency nurses were working on the evening shift who were not as familiar with the resident and relied on accuracy of care plans.

Review of email received from Administrator in Training dated 11/21/24 at 1:11 PM documented the number of agency staff scheduled for 11/18/24 was 11, 11/19/24 was 9, 11/20/24 was 7, 11/21/24 was 6 and 11/22/24 was 13. The facility census at the time of survey entrance was 46.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that resident care plans should be resident-centered reflecting resident's preferences and care needs. DON reviewed R14's oxygen care plan and acknowledged it didn't reflect R14 or was individualized for R14.

Resident 20

Review of R20's records documented resident was admitted on 6/8/24 with diagnoses including quadriplegia (partial or total loss of movement and sensation in all four limbs and body), diabetes, pressure ulcer of sacral region, stage 4, and neuromuscular dysfunction of bladder (condition in which a person lacks urinary bladder control due to brain, spinal cord or nerve problems).

During an interview on 11/18/24 at 2:26 PM R20 stated that he was not involved in decisions about his care and there was no care plan meeting that he could remember.

During a concurrent interview and record review on 11/20/24 at 7:59 AM Medical Records Director (MRD) who recently was the Social Services Director (SSD) stated that resident's and their families/representatives are invited to quarterly care plan meetings where their input is obtained and incorporated in the resident's care plans. MRD reviewed R20's chart and stated that the last quarterly care conference meeting was on 4/1/24 so it's overdue as a meeting should have occurred in July 2024, but there was no documented evidence that this happened.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that residents/representative's needs, preferences and participation in their care occurs via quarterly care plan meetings that social services arranges and sends out invitations to residents/representatives. DON confirmed R20's last care conference was on 4/1/24 and therefore was overdue.

Facility policy Care Planning-Interdisciplinary Team, revised March 2022, documented "comprehensive, person-centered care plans are based on resident assessments and developed by an Interdisciplinary Team (IDT). The IDT includes but is not limited to: ....e. to the extent practicable, the resident and/or the resident's representative ....4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan ...."

Based on observation, interview and record review the facility failed to ensure 1 of 6 sampled residents (R )(R137) observed for prefilled insulin pen administration met professional standards of practice when staff did not follow manufacturer's instructions for priming the insulin pen prior to administration. This placed resident at risk of not receiving correct insulin dose per physician's orders.

Findings include

Review of R137's Medication Administration Record, dated November 2024, documented staff were to check resident's CBG (capillary blood glucose) before meals and at bedtime related to diabetes. The start date was 10/7/24 and staff were to inject Humalog insulin Lispro per sliding scale based on blood glucose level.

During concurrent observation and interview on 11/20/24 at 11:49 AM LPN19 removed R137's insulin Lispro Injection KwikPen from medication drawer and placed on medication cart. LPN19 then removed needle from cart and removed and disposed of packaging covering needle. LPN19 then placed needle onto syringe and turned pen dial to 6 units and administered insulin to resident. LPN19 did not prime the pen before administering the insulin. When asked about priming insulin pen prior to administering medication, LPN19 stated that the insulin pens don't require priming, there is no air bubbles and even if there were air bubbles, it would be very small. LPN19 stated that needle is screwed onto pen and then the amount of insulin needed is dialed up and given.

Review of facility provided Humalog KwikPen Instructions for Use, dated 3/31/20, documented steps for preparing insulin pen. Step 5-6 provided instructions for attaching capped needle to pen and pulling off needle shield. After Step 6 the instructions documented "Priming your pen. Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin .... Step 7: To prime your pen, turn the dose knob to select 2 units. Step 8: Hold your Pen with the Needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Step 9: Continue holding your pen with needle pointing up. Push the Dose Knob in until it stops, and "0" is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle. Step 10: Turn the Dose Knob to select the number of units you need to inject."

During an interview on 11/20/24 at about 12:30 PM LPN19 was shown above Humalog KwikPen Instructions for Use and asked to review steps 7, 8, and 9 about priming pen. LPN19 acknowledged the pen was supposed to be primed each time it was used, and she did not do this.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that insulin pens should be primed before administration to ensure residents get the right dose of insulin. DON confirmed that this was the standard of practice.

Review of R137's care plan for diabetes, date initiated 11/11/24, documented resident had diabetes with the goal to minimize the risk for complications of diabetes. Interventions to achieve this goal was to administer medications as ordered and monitor for signs of hyper/hypoglycemia (too high or too low blood sugar levels) and intervene to manage hyper/hypoglycemic episodes.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R7) reviewed for thickened liquids and 1 of 5 sampled residents (R) (R20) reviewed for unnecessary medications received the necessary care and services to attain or maintain their highest practicable level of well-being. Specifically, R7 orders for thickened liquids and R20's bowel care orders were not followed. These failures placed residents at risk for a decline in their health status and quality of life due to unmet care needs.

Findings include

Resident 7

Review of R7's records documented resident was admitted on 2/10/23 with diagnoses including history of cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties), bipolar disease (extreme mood swings that includes emotional highs and lows) and vascular dementia (impaired ability to remember, think or make decisions).

Observation on 11/18/24 at 12:06 PM showed Certified Nursing Assistant (CNA)4 assisting resident to sit at the edge of his bed to transfer resident using sit to stand device (assistive device that helps residents to go from sitting to standing position by use of electrical or hydraulic power) from bed to wheelchair. R7 continued to state that he was thirsty and wanted coffee. A lunch tray with covered plate and multiple cups of liquids were on the resident's overbed table. CNA4 stated that the therapist wants to watch resident drink his liquids, so the plan was to get resident up in wheelchair and eat his lunch in the dining room with the therapist. Resident repeatedly stated that he was thirsty and CNA4 responded multiple times that therapist wants you to drink with her.

Review of the physician's order and diet card on the lunch tray showed regular No Added salt diet, CCHO (controlled carbohydrate) and mildly thick liquids IDDSI 2 (International Dysphagia Diet Standardisation Initiative, regular thin liquids made thicker to help people with swallowing difficulties drink safely, to prevent choking or aspiration, which occurs when liquid enters the lungs instead of the stomach; level 0 is thin liquids, level 1 is slightly thick, level 2 is mildly thick, level 3 is moderately thick, and level 4 is extremely thick).

Observation on 11/18/24 at 12:47 PM showed resident eating lunch with Speech Therapist (ST)1 next to him. Resident drank some of his liquids and then coughed several times repeatedly and a gurling sound could be heard. ST1 told resident his coughing after drinking liquids was a concern to her so she will make a request for swallow study. ST1 told resident she wanted him to drink only the mildly thickened liquids, but resident said he didn't like the taste, frowned and pushed ST1's hands away.

Observation on 11/19/24 at 2:04 PM showed R7 wheeling self in wheelchair in the hallway. CNA4 asked resident if he wanted to go back to bed. R7 nodded his head. CNA4 and CNA6 assisted resident back to bed. A red sign was posted above R7's bed that read "Aspiration risk...mildly thicken liquids only". After resident was settled into bed, CNA4 and CNA6 left the room.

Observation on 11/19/24 at 2:24 PM showed R7 in bed calling out for water. CNA8 raised resident's head of bed and lowered his bed and took blue insulated mug with straw from resident's overbed table and gave it to the resident. R7 took sucked in several long pulls from the straw and immediately started coughing multiple times. CNA8 took mug away from resident and walked towards the door exit while R7 yelled that he wanted it back. CNA8 took the mug to the kitchen. Surveyor asked for the mug and asked Dietary Director (DD) to pour liquid into the sink. About a cup of thin yellow liquid was observed in the cup and was poured into the sink. DD stated that it was thin consistency lemonade but R7 was supposed to only have mildly thickened liquids and not thin liquids.

During an interview on 11/19/24 at 2:40 PM CNA4 stated that R7 was only supposed to have slightly thickened liquids and not thin liquids. CNA4 stated that she was not sure how thin liquid lemonade was left at resident's bedside and stated that maybe it was left over from last night, and she should have checked and removed the thin liquid from resident's bedside table.

During an interview on 11/20/24 01:20 PM CNA9 stated that blue insulated mugs and lemonade are from the coffee station located in the dining room area that residents have direct access to. CNA9 further stated there are no thickened liquids at the coffee station and any liquids/beverages from the coffee station needs to be taken to the kitchen who thickens them. CNA9 stated that R7 chokes a lot on thin liquids, and it is important to give resident mildly thickened liquids because he is at risk for aspiration.

During an interview on 11/21/24 at 12:22 PM Director of Rehabilitation (DOR) stated that ST requested swallow study that physician ordered because there is suspicion that R7 is aspirating, he is coughing quite a bit when he drinks even thickened liquids. DOR reviewed R7's records and confirmed resident was evaluated on 11/7/24 with mildly thickened liquid diet change on 11/7/24. DOR stated the concern is R7 could aspirate and get aspiration pneumonia if he drank thin liquids.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that R7 is at risk for aspiration and needs to have mildly thickened liquids. When asked how staff access thickened liquids for residents, DON stated that staff get thickened liquids from the kitchen until 8pm when the kitchen closes, after 8pm, the staff get little cartons of thickened liquids from the fridge. DON also stated that even thickened liquids should not be left at R7's bedside because thickened liquids become not as thick or don't maintain their thickness when left or stored at room temperature after awhile.

Review of email received from Administrator, dated 11/21/24 at 9:18 AM, documented facility did not have policies for aspiration precautions or following doctor's orders.

Resident 20

Review of R20's records documented resident was admitted on 6/8/24 with diagnoses including quadriplegia (partial or total loss of movement and sensation in all four limbs and body), diabetes, pressure ulcer of sacral region, stage 4, and neuromuscular dysfunction of bladder (condition in which a person lacks urinary bladder control due to brain, spinal cord or nerve problems). R20's Minimum Data Set (MDS-assessment tool), dated 9/14/24, documented resident was cognitively intact with brief interview for mental status of 12 out of 15, dependent on staff for toileting hygiene, rolling from left and right, always incontinent of bowel and had an indwelling urinary catheter.

Review of R20's current physician orders showed:
-Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide). Give 30 ml by mouth as needed for for no BM in 3 days. Start date 6/8/24.
-Dulcolax Suppository 10 MG (Bisacodyl). Insert 1 suppository rectally as needed for No BM on shift following Milk of Magnesia dose. Start Date 6/8/24.
-Fleet Enema 7-19 GM/118ML (Sodium Phosphates). Insert 1 application rectally as needed for no BM on shift following Dulcolax suppository application. Start date 6/8/24.
-Polyethylene Glycol 3350 Powder Give 17 gram by mouth every 12 hours as needed for Constipation. Start date 6/8/24.
-Sodium Phosphates Rectal Enema (Sodium Phosphates). Insert 1 application rectally every 24 hours as needed for Constipation. Start date 6/8/24.
-Bisacodyl Rectal Suppository 10 MG (Bisacodyl). Insert 10 mg rectally every 24 hours as needed for Constipation. Start date 6/8/24.

Review of bowel records for past 30 days, 10/21/24 to 11/19/24, documented R20 did not have a bowel movement on:
-four consecutive days from 10/28, 10/29, 10/30, 10/31 (10/27 at 0007 last BM). On 10/30 at 0007 resident should have been offered Milk of Magnesium but wasn't.
-five consecutive days from 11/4, 11/5, 11/6, 11/7, 11/8 (11/3 at 2109 last BM). 11/6 at 2109 should have been offered Milk of Magnesium but wasn't.

Review of Medication Administration Records (MAR) for October and November 2024 and Progress Notes from 10/28/24 to 11/9/24 documented no bowel medications (MOM, suppository, enema) was offered to and/or declined by R7.

Observation on 11/19/24 at 8:54 AM during sacral wound care showed R20 was dependent on staff for positioning, turning and bowel care.

During an interview on 11/20/24 01:20 PM CNA9 stated that R20 can be challenging, and staff are aware if resident had a bowel movement or not as resident is dependent on staff for bowel care.
During concurrent interview and record review on 11/21/24 at 2:41 PM Resident Care Manager (RCM)2 reviewed resident's bowel records and confirmed resident did not have a bowel movement for more than 3 consecutive days for the time periods mentioned above and did not see any bowel medications offered in response. RCM2 stated that when resident did not have a bowel movement for 3 consecutive days, staff should have offered milk of magnesium, and if that didn't work, then offered resident a suppository and then an enema if there still weren't any results. RCM2 stated that if resident refused offered bowel medications, then the refusal should be documented. RCM2 stated that she didn't see anything that goes against what was pointed out.

During an interview on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that staff provides R20 with assistance with bowel care and resident has several bowel medications available as needed for constipation. DON confirmed that R20 did not have a bowel movement for 4 days and then 5 days in October and November and should have been offered bowel medications for constipation, but this was not done.

Review of email received from Administrator, dated 11/21/24 at 9:18 AM, documented facility did not have policies for bowel management or following doctor's orders.
?

Based on record reviews, interviews, and facility policy review, the facility failed to ensure residents received timely smoking evaluations and implemented interventions after a smoking incident for one of one sampled resident (Resident (R) 5) reviewed for smoking. This failure had the potential to affect resident safety.

Findings include:

Review of the facility's policy titled, "Smoking Policy," dated 01/2023 revealed, "Staff is responsible for ensuring that smoking by residents is done in a safe manner . . . All smoking residents will be reassessed on at least a quarterly basis ...This periodic review is to validate that each resident can smoke and use smoking materials without presenting a danger to themselves or others . . ."

Review of R5's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted 09/17/20 with diagnoses of schizoaffective disorder and major depressive disorder.

Review of R5's quarterly "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 09/06/24 and located under the "MDS" tab of the EMR, revealed the resident had a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15, which indicated the resident was cognitively intact.

Review of the "Care Plan," dated 11/26/19 and located under the "Care Plan" tab of the EMR, revealed a focus area of "The resident is a smoker." Interventions included the following:

Revised 09/14/24: "I will be assessed quarterly and at any significant decline to ensure that I can smoke independently in a safe manner."
Initiated 01/03/20: "Instruct resident about the facility policy on smoking: locations, times, safety concerns."
Initiated 01/03/20: "Notify charge nurse immediately if it is suspected resident has violated facility smoking policy."
Initiated 01/03/20: "The resident can smoke UNSUPERVISED."

During an interview on 11/19/24 at 9:32 AM, R5stated that she kept her smoking supplies in her dresser drawer and did not want a lock box. She denied any fires, but then stated there was a lit cigarette when she came back from the store. She stated she did not bring it into the facility.

Review of the "Alert Note," dated 07/30/24 and located under the "Progress Notes" tab of the EMR, revealed, ". . . This LPN [Licensed Practical Nurse] notified Resident that she will have to be supervised smoker tonight due to recent fire. This LPN asked for lighter and matches to be given to this LPN to store in lockers smoker's area. Resident adamantly refused to give LPN red lighter. Given verbal education on safety and fire earlier and Resident adamant that she will not give lighter or smoking materials to this LPN . . ."

Review of the "Alert Note," dated 07/31/24 and located under the "Progress Notes" tab of the EMR revealed, ". . . Smoking eval [evaluation] completed tonight . . . Resident did reiterate that earlier fire was an accident, and Resident has not had any previous accidents while smoking. Resident had said that the lit cigarette had slipped out of her fingers and fallen into bag . . ."

Review of the "Smoking Safety Evaluation," dated 07/31/24 and provided by the facility, revealed, "Does the resident have history of smoking related incidents? Yes . . . Resident had inadvertently started a small fire on 07/30/24 when accidentally dropped lit cigarette into bag on walker. Resident has no other history of burns or fires and stated that the lit cigarette had slipped out of her fingers before she realized what happened. Team Decision: Safe to smoke independently. Plan of care is used to assure resident is safe while smoking? Yes . . ." There was no current smoking evaluation completed per policy requirement. The policy stated at least quarterly evaluations, therefore the next evaluation should have been completed on 10/31/24 and it was not completed as of 11/21/24, when reviewed.

During an interview on 11/19/24 at 9:08 AM, Certified Nurse Aide (CNA)7 stated there had been no other accidents since the one with R5. He stated the independent residents kept their supplies in a lock box and they were supposed to keep them locked up. He stated during the incident, they smelled smoke and tracked it down to R5's room. He stated her cloth bag was smoking and they took it outside. He stated they were watching her after the incident. He stated she was on a lot of pain medications during that time and was falling asleep.

During an interview on 11/19/24 at 9:49 AM, CNA4 stated R5 had dropped something, and she was "smoldering." She stated R5 was supervised for a while but was not sure what happened.

During an interview on 11/19/24 at 1:18 PM, Director of Nursing (DON) stated they tried to enforce the lock boxes. She stated they did not complete an incident report of the incident and was unsure why. She stated she had received a message from nursing, and they were trying to take her lighter. She stated that R5 was coming inside, and her handbag appeared to be on fire. She stated they took her back outside. She stated it would have been psychologically insulting to take away her smoking independence. She stated they tried to enforce the smoking policy. She confirmed another smoking assessment should have been completed on 10/31/24. She stated the system did not have it scheduled and so the assessment did not show up as needing to be completed.

During an interview on 11/21/24 at 8:14 AM, the DON confirmed there were no care plan updates after the incident and there should have been.

Based on observation, interview and record review, the facility failed to ensure 1 of 1 sampled resident (R) (R14) reviewed for dialysis services received ongoing assessment/monitoring for complications after dialysis as evidenced by lack of documented post-dialysis assessment for 21 of 35 opportunities during September to November. This failure placed resident at risk for complications, delayed response to complications, and potential diminished quality of life.

Findings include

Review of R14's record documented resident was admitted on 5/1/23 with diagnoses including end-stage renal disease (ESRD) and dependent on renal dialysis (a process for removing waste and excess water from the blood due to failing kidney function). R14's Minimum Data Set (MDS-assessment tool), dated 8/9/24, documented the resident was cognitively intact with a brief interview for mental status score of 15 out of 15.

Facility policy Hemodialysis Care, dated 8/1/24, documented "It is the policy of this center to provide care to the hemodialysis in conjunction with standards of care to prevent complications .....a. The licensed nurse completes the Dialysis Center Communication Form prior to the resident leaving for dialysis. Weights are obtained from Dialysis Communication Form. b. Upon return, the post dialysis assessment portion of the form is completed and attached to the resident's medical record ....Note-Residents who require hemodialysis are provided ongoing assessment and monitoring of the resident's condition before and after dialysis treatments including monitoring for complications and interventions as part of nursing standard of practice. Issues are documented, as noted by the licensed nurse and medical providers are notified."

Review of resident's care plan documented that resident requires dialysis treatment related to end-stage renal disease with the goal that resident would have no signs and symptoms of complications related to dialysis. Interventions included: 1. Emergency procedure: contact the physician or dialysis nurse immediately if you notice any of the following: any drainage, redness, swelling or pain around the exit site, any visible changes in the exit site, if the resident experiences chills or fever. If you notice bleeding from the dialysis catheter: Stop the bleeding by pinching, clamping, or tying off the end of the catheter or apply pressure dressing to the shunt, call 911 and notify primary physician, start date 5/7/23. Complications with signs and symptoms and actions were documented for pneumothorax (air in the lungs) or air in the catheter which were emergency procedures. The care plan documented infection at the access site, septic shock, bacteremia as other complications and documented that resident had dialysis on Tuesday, Thursday and Saturday and had a right upper chest tunneled dialysis catheter placed 4/28/23.

During an observation and interview on 11/18/24 at 2:33 PM R14 was lying in bed with chest visible. On his right upper chest area was a clear dressing with two short tubes hanging from dressing. The dressing was clean and dry.

Observation on 11/19/24 at 8:13 AM showed R14 being transported to offsite dialysis center. On top of resident's gurney was blue binder labeled R14's dialysis binder with contained several documents labeled Dialysis Center Communication Form. The top portion of the form was to be completed by dialysis center and included weight before and after dialysis, if resident was seen by doctor, any new orders, any medications given at dialysis center, condition of dressing and shunt, if labs were drawn, and any dietary changes. The bottom portion of the form, titled Post Dialysis Nursing Assessment (Completed by Facility upon Resident Return) allowed user to enter date, time, vital signs, lung sounds, access site, signs and symptoms of post dialysis complications (increased lethargy, cramping, signs/symptoms of dehydration, pain). There were several forms that had the top portion of the form completed but the bottom portion was incomplete or completely blank.

During an interview on 11/21/24 at 3:15 PM Resident Care Manager (RCM)2 stated that R14 took a binder to dialysis each time with a communication form. The top of the Dialysis Center Communication Form was completed by the dialysis center with information about the session. The bottom half was completed by the facility licensed nurse (LN) when the resident returned or a post dialysis note was completed in Point Click Care, electronic medical record.

Observation on 11/21/24 at 5:19 PM showed R14 had returned from dialysis with Certified Nursing Assistant (CNA)30 setting up dinner tray.

During an interview on 11/21/24 at 5:21 PM CNA30 stated that he was assigned to care for R14. CNA30 stated that his shift started at 2PM and since his start time, he passed water, gave one shower and check vital signs for one resident as this is the only resident who needs vital signs taken. When asked what care was provided to R14 since his return from dialysis, CNA30 stated that he thinks R14 returned between 4:15 PM to 4:40 PM and he helped transport transfer him to his bed, got his oxygen on and just now helped him set up his dinner tray. When asked if he took R14's vital signs, CNA30 shook his head no and stated that no one asked him to take R14's vital signs or do anything specific for R14.

During a concurrent observation and interview on 11/21/24 at 5:23 PM R14 was wearing a dark colored tee shirt, and his central venous access site was not visible. R14 stated that he was tired and came back from dialysis about 45 minutes ago and staff had not checked his vital signs or his dialysis access site yet.

Continuous observation on 11/21/24 at 5:23 PM and 6:00 PM showed Licensed Practical Nurse (LPN)13 with LPN20 checking resident's blood glucose, walking into several resident rooms and taking a break. LPN13 would talk with resident and LPN20 would remain nearby or at the doorway.

During an interview on 11/21/24 at 6:01 PM LPN13 stated that she had not checked on R14 since he returned from dialysis almost 90 minutes ago but should have. LPN13 stated that she should have checked R14's fistula for bruit and make sure his wrap (dressing) was still on and not bleeding. When informed that R14 had a central line, LPN13 stated that ok, I really should have checked him to make sure he wasn't bleeding and check his vitals. LPN13 further stated that residents should be checked as soon as they came back from dialysis but she was checking all of her diabetics first.

During a concurrent interview and record review on 11/22/24 at 9:39 AM Director of Nursing (DON) stated that nursing should document in Point Click Care (PCC), electronic health record, the post dialysis form when residents come back from dialysis and the goal is as soon as possible when they return. When asked what as soon as possible meant, DON stated "within 2 hours". However, later DON stated that if resident came back at 1PM, the nurse should assess by 2PM (within an hour). When asked what is included in an assessment, DON stated that nurses assess for prolonged bleeding, alertness, check what dialysis access site looks like, check for pain and vitals. When asked if CNA or other staff could get the vitals if nurse was busy, DON said yes, that would be fine. DON stated that R14 had a central venous line as his dialysis access site and there could a risk for bleeding from site and if there is bleeding there is a clamp taped to his wall for those types of emergencies. When asked if resident returned to facility at 4:40 PM, should assessment for access site for bleeding and vital signs be completed by 6PM, DON stated "yes". When informed that resident was not accessed by 6PM, DON stated that did not meet her expectations. DON then reviewed R14's records and stated that she could not find post dialysis assessment form completed in PCC or progress note from LPN13 last night documenting resident's assessment upon return from dialysis. DON stated that the post dialysis form should be completed documenting nurses' assessment of the resident upon their return from dialysis.

Review of three different sources of documentation (PCC Nursing Hemodialysis Communication Observation/Assessment-Facility Post Dialysis V1.0, Dialysis Center Communication Form, PRST5-SNF Post Dialysis Evaluation) from 9/3/24 to 11/21/24 (35 opportunities) showed post assessment was not done or incomplete 21 times on the following days: 9/7/24, 9/10/24, 9/12/12, 9/14/24, 9/17/24, 9/21/24, 9/24/24, 9/26/24, 10/1/24, 10/3/24, 10/10/24, 10/19/24, 10/24/24, 10/26/24, 10/31/24, 11/2/24, 11/5/24, 11/7/24, 11/14/24, 11/19/24, 11/21/24.

Review of facility training, dated 12/19/23, showed "pre and post dialysis forms being filled out under forms tab" with handout detailing "Emergency Procedure for Dialysis Catheter Care Quick Reference Guide: the primary types of dialysis accesses used include temporary vascular catheter ...contact the physician or dialysis nurse immediately if you notice any of the following: any drainage, redness, swelling or pain around the exit site, any visible changes in the exit site, if the resident experiences chills or fever, Bleeding from the catheter (stop the bleeding by pinching, clamping, or tying off the end of the catheter or apply pressure dressing to the shunt, call 911 and notify primary physician), Signs/Symptoms of Pneumothorax (air in the lungs)(shortness of breath, chest discomfort, call 911 and notify physician if resident has any of these symptoms), Air in the catheter (if the catheter is accidently cut or removed accidentally the resident may experience shortness of breath, chest pain or pass out, check the catheter every shift to make sure the caps are in place and no sharp objects are around the catheter at all times, this is an emergency if this occurs; clamp the catheter at the exit site. Lay resident on left side, head down and feet elevated, call 911 for help and notify physician), notify the physician of swelling of the neck, arm or hand on the catheter side, call 911 immediately any time the resident has uncontrolled bleeding, shortness of breath or chest pain."

Based on interview and record review, the facility failed to ensure staff had mandatory training, appropriate competencies and skills set necessary to provide nursing services for one of three reviewed nursing staff (Licensed Practical Nurse (LPN) 2). This failure placed residents at risk of not receiving appropriate services to meet their needs.

Findings Include:
During an observation of medication administration on 11/20/24 from 08:28 AM to 08:52 AM, LPN 2 administered medications to two residents (Resident (R) 29 and R 32).

Review of Electronic Medical Records (EMR) revealed R 29 had diagnoses that included Coronary Artery Disease, Dementia, Psychotic disorder and Post Traumatic Stress Disorder. Resident 32 had diagnoses that included anemia, anxiety, and depression.

During an interview on 11/20/24 at 08:52 AM, LPN 2 stated that she started at the facility the first week of November 2024. LPN 2 stated that she had been left without supervision for about a week prior to the survey.

A request was made to review LPN 2's employee file for training (including dementia care) and nurse competencies.

During an interview on 11/21/24 at 12:35 PM, the Administrator stated that LPN 2 did not have an "employee file" or any "checkoffs" [competencies] and was sent home.

Review of "Licensed Nurse Orientation Checklist" located in the personnel file for LPN 2 revealed no one had signed off that LPN 2 was not checked by a preceptor for providing care in areas that included the Nursing Process, Protocols (including diabetic protocol), CNA supervision, and Infection Control/Precautions.

During an interview on 11/22/24 at 11:59 AM with concurrent personnel file review, the Infection Control Nurse and acting Director of Staff Development (DSD) stated she was responsible for competency oversight of the clinical staff. The DSD stated that nurses are provided training on hire and that competency check lists must be completed prior to a nurse caring for residents without supervision. The DSD stated that performance evaluations are done on hire, within six months, and as needed for some staff. When asked if LPN 2 had been signed off needed competencies to provide care for the residents, the DSD said, "no."

During an interview on 11/22/24 at 12:32 PM, the Director of Nursing (DON) stated that the expectation is all staff have the needed minimum competencies done during their orientation and annually to meet the care needs of the residents. The DON said that during this survey, the facility is learning some file issues have come up with identifying completed training requirements.

An email dated 11/22/24 at 05:47 PM from the Administrator included a different "Licensed Nurse Orientation Checklist" for LPN 2 which now included preceptor initials or check marks in preceptor column for the entire list.

This email was sent after survey exit so no interview was conducted to explain why there were two different "Licensed Nurse Orientation Checklists."

Based on record review, interviews, and facility policy review, the facility failed to ensure physician response for pharmacy recommendations related to antibiotic usage for one of two sampled residents (Resident (R) 9) reviewed for antibiotics. This failure had the potential for extended antibiotic usage.

Findings include:

Review of the facility's policy titled, "Medication Regimen Reviews," revised 05/2019 revealed, ". . . Within 24 hours of the MRR [Medication Regimen Review], the Consultant Pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity ...If the physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or . . . Administrator . . ."

Review of R9's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted on 09/17/20 with diagnoses of retention of urine and personal history of urinary tract infections (UTI).

Review of the quarterly "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 07/18/24, revealed a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15 which indicated the resident was cognitively intact.

Review of the pharmacy's "Note To Attending Physician/ Prescriber," dated 05/12/24 and provided by the facility, revealed, ". . . Is currently on a routine Methenamine Hippurate [antibiotic medication] 1gm [gram] bid [twice a day] for suppression therapy of UTI infections. This order has been active since 7/28/23 . . . Please consider updating the following for documentation: 1. Please verify if this antibiotic regimen needs to be continued indefinitely. 2. If so, please provide a brief risk vs [versus] benefit assessment below to justify its continuation . . ." There was no physician response documented.

During an interview on 11/22/24 at 11:22 AM, the Director of Nursing (DON) stated that resident was still taking the same antibiotics and she just got an email response from the pharmacist, and the pharmacist documented the recommendation as "no response from this provider." She stated this resident used an outside provider, and it was difficult to get a response.

During an interview on 11/22/24 at 11:48 AM with the DON and the Administrator, the DON stated the previous Medical Director was not engaged and she had not yet got the current Medical Director involved.

Based on observation, interview and record review, the facility failed to ensure resident's drug regimen was free from unnecessary drugs for 1 of 5 sampled resident (R) (R7) reviewed for unnecessary medication use. R7 received anti-hypertensive medications that did not meet physician's blood pressure parameters. This failure placed resident at risk for adverse side effects such as hypotension, dizziness, and falls.

Findings include

Review of R7's records documented resident was admitted on 2/10/23 with diagnoses including history of cerebral infarction (stroke, blood supply to part of the brain is blocked, causing parts of the brain to be damaged or die, can cause weakness in one side of the body and swallowing difficulties), bipolar disease (extreme mood swings that includes emotional highs and lows) and vascular dementia impaired ability to remember, think or make decisions).

Observation on 11/18/24 at 12:06 PM showed Certified Nursing Assistant (CNA)4 assisting resident to sit at the edge of his bed to transfer resident using sit to stand device (assistive device that helps residents to go from sitting to standing position by use of electrical or hydraulic power) from bed to wheelchair. R7 yelled "oowwww" loudly several times when standing and appeared unsteady and wobbly when standing. CNA4 held onto resident to help steady resident.

Review of R7's physician orders and November 2024 Medication Administration Record documented *Hydralazine 10 mg, give 10 mg by mouth three times a day related to hypertensive heart and chronic kidney disease. Hold for SBP (systolic blood pressure, top number of blood pressure) less than 110. Notify Optum (physician medical group) for SBP less than 100.

During the month of November, resident's SBP was less than 100 but Hydralazine was documented as given six times on 11/6/24 (BP 108/63), 11/8/24 (BP 102/66), 11/12/24 (BP 107/69), 11/13/24 (BP 102/62), 11/14/24 (109/74), 11/17/24 (BP 104/60).

*Lisinopril 40 mg one time a day related to hypertensive heart and chronic kidney disease. Hold if SBP is less than 110 and call Optum (physician medical group) for SBP less than 100.

During the month of November, resident's SBP was less than 100 but Lisinopril was documented as given five times on 11/6/24 (BP 108/63), 11/8/24 (BP 102/66), 11/12/24 (BP 107/69), 11/13/24 (BP 102/62), 11/14/24 (109/74).

R7 received both anti-hypertensive medications on the same days when his blood pressure were below physician ordered hold parameter, which could have exacerbated the hypotensive effects of these medications.

During a concurrent interview and record review on 11/21/24 at 4:16 PM Director of Nursing (DON) stated that R7's blood pressure medications should have been held if his blood pressure was too low and nurses need to be following physician's orders. DON stated that at the last staff meeting, she stressed the importance of following parameters because not following blood pressure parameters for R7 can cause hypotension, dizziness, and falls.

Review of email received from Administrator, dated 11/21/24 at 9:18 AM, documented facility did not have policies for following doctor's orders.

Based on record review, interviews, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications had 14-day stop date for one of five sampled residents (Resident (R) 136) reviewed for unnecessary medications. This failure had the potential to affect residents' excessive psychotropic medication administration.

Findings include:

Review of the facility's policy titled, "Psychoactive Medications," dated 08/01/24 revealed, ". . . New orders for PRN antipsychotic medication expire in 14-days and require an in-person assessment by the medical provider and documentation for the order to continue an additional 14-days to determine whether medication should be scheduled routinely or discontinued . . ."

Review of R136's "Admission Record," located under the "Profile" tab of the electronic medical record (EMR), revealed the resident was admitted on 09/30/24 with diagnoses which included dysphagia (difficulty swallowing), respiratory failure, chronic obstructive pulmonary disease, anemia, hypertension, tobacco use, rheumatoid arthritis, fibromyalgia, and gastro-esophageal reflux disease without esophagitis.

Review of the admission "Minimum Data Set (MDS)," with an Assessment Reference Date (ARD) of 10/11/24, revealed a "Brief Interview for Mental Status (BIMS)" score of 15 out of 15, which indicated the resident was cognitively intact.

Review of the "Clinical Physician Orders," located under the "Orders" tab of the EMR, revealed an order dated 10/05/24 for "hydroxyzine HCL [hydrochloride] Oral Tablet 10 MG [milligram]. Give 1 tablet by mouth every 6 hours as needed for Anxiety take 1-2 tablets every 6 hours as needed for anxiety." There was no stop date recorded.

Review of the "Note To Attending Physician/Prescriber," dated 10/23/24 and provided by the facility, revealed, "Please consider adding a duration to Hydroxyzine HCL 10mg to 20mg q6h [every 6 hours] PRN Anxiety . . . Please note: Duration greater than 14 days requires a Physician rationale documented in chart . . ." There was no physician response documented.

During an interview on 11/20/24 at 9:58 AM, the Director of Nursing (DON) stated she was aware of the 14-day requirement for psychotropic medications and confirmed that R136's Hydroxyzine HCL medication did not have a 14 day stop order. She stated that the pharmacy usually monitored this. She stated that sometimes the pharmacy would have to resend the recommendation to the physician.

Based on interview and record review the facility failed to develop a Quality Assessment and Assurance (QAA) program that identified quality deficiencies and developed and implemented action plans to correct identified quality deficiencies. The facility failed to conduct analysis of quality data, develop and implement plans of actions to correct identified quality deficiencies, develop and implement systemic approaches to determine the underlying causes of problems impacting larger systems and prevent quality of care, quality of life or safety problems, and monitor the effectiveness of its performance improvement activities to ensure that improvements were achieved or sustained. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes. The facility had a census of 46.

Findings include

QAPI (Quality Assurance and Performance Improvement Plan, received from facility on 11/19/24, dated 9/10/24, showed the scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions....Aspects of service and care are measured against established performance goals and key measures are monitored and trended on a quarterly and/or annual basis." Under the section titled, Defining and Measuring Goals, "the center will use internal and national benchmarks provided by national associations, clinical organizations, and federal and state provided databases (e.g. CMS Quality Measures, Five-Star Quality Rating System, survey data) to establish baselines for organizational practices and goal-setting. In addition, the organization will continue to monitor progress toward goal by comparing its results to these benchmarks and its historical performance." Under the section titled Governance and Leadership, "The QA&A Committee reports to leadership and Governing Body and is responsible for.....4. Regularly reviewing and analyzing data collected under the QAPI program and data resulting from drug regimen review and acting on available data to make improvements. 5. Determining areas for PIPs (Performance Improvement Projects) and Plan-Do-Study-Act (PDSA) rapid cycle improvement projects. 6. Analyzing the QAPI program performance to identify and follow up on areas of concern and/or opportunities for improvement." Under the section System Analysis and Systemic Action, "We will use a thorough and highly organized/structured root cause analysis approach....to determine if and how identified problems may have caused or exacerbated by the way care and services are organized or delivered. This systemic approach will help to detemine when in-depth analysis is needed to fully understand the problem, its causes, and its implications of a change. these systemic actions will look comprehensively across all involved systems to prevent future events and promote sustained improvement....."


Review of QAA meetings for 2024 showed May 30, 2024, QAA meeting documented a PIP for documentation and process for collecting funds from in-house residents. QAA also documented incidents for March included 11 falls without injury, skin tears, resident to resident altercations, and three medication errors) but a PIP was not developed for these or any other resident-centered concerns.

Review of QAA meetings for 2024 showed Quality Measures were discussed at May and January meetings and Five star rating was discussed at January meeting but there were no PIPs with data identifying quality deficiency, measurement of quality data against goals, target, or benchmark, no trending or monitoring of quality data, no analysis of quality data performance, no interventions implemented to improve quality data, or ongoing monitoring of effectiveness after interventions.

During a concurrent record review and interview on 11/22/24 at 1:08 PM when asked about facility's PIP, Administrator and DON stated that currently were working on staff recruitment, to eventually reduce and eliminate use of nursing agency staff, which then also impacts staff onboarding and orientation and also replacing carpet with flooring materials. When asked about PIPs focused on resident care such as falls, pressure injuries, medication errors which would include identifying quality measurement data and developing targets, analyzing data and implementing actions to improve, Administrator stated that new ownership changed in September and could not speak to what occurred prior to September. During joint review of binder filled with previous QAA meetings, Administrator acknowledged that PIPs should improve the care and services for the residents and confirmed he did not see evidence of this.

Based on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required participants for 2 of 4 quarters during 2024. This failed practice placed residents at risk for quality deficiencies, adverse events, and diminished quality of life.

Findings include

QAPI (Quality Assurance and Performance Improvement Plan, received from facility on 11/19/24, dated 9/10/24, showed QA&A Committee members were Medical Director/Designee, Director of Nursing Services (DON), Administrator/Owner/Board Member/Other Leader, Infection Prevention & Control Officer (IP), At least two additional members, and Pharmacist.

Review of QAA meetings for 2024 showed required participants were not present during the 2nd and 3rd quarters of 2024.

Two QAA meetings were held during the 2nd quarter. During the April 25, 2024 meeting, DON, Medical Director, and IP did not attend. During the May 30, 2024 meeting, Medical Director and IP did not attend.

Two QAA meetings were held during the 3rd quarter. During the July 25, 2024 meeting, Medical Director and IP did not attend. During the June 27, 2024 meeting, Medical Director, IP, DON, and at least one additional member did not attend.

During an interview on 11/22/24 at 1:08 PM Administrator and DON stated that they noticed there were several blanks in the previous QAA meetings and some peole didn't attend. Administrator stated that QAA required participants included Medical Director, DON, Administrator/Owner/Board Member, IP, and two additional members. In addition, usually all department heads attended meeting.

2.      
Infection Prevention and Control (IPC) Program

Facility policy Infection Control Policies and Practices, adopted 12/15/2021, documented the policy was to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The program's objectives included ...."e. Maintain records of incidents and corrective actions related to infections ...3. The Quality Assurance Performance Improvement (QAPI) Committee, through the Infection Control Committee, oversees implementation of the infection control policies and practices, and assists department heads and managers to validate that they are implemented and followed .....5. The Administrator or Governing Body, through the QAPI and Infection Control Committees, have adopted our infection control policies and practices, as outlined herein, to reflect the Center's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA (Omnibus Budget Reconciliation Act), OSHA (Occupational Safety and Health Administration), and CDC (Centers for Disease Control and Prevention) guidelines and recommendations."

Review of CDC Long-term Care Facilities Nursing Home Infection Preventionist Training, dated March 28, 2024, accessed 11/21/24, https://www.cdc.gov/long-term-care-facilities/hcp/training/index.html, outlined specialized training covered core activities of effective IPC programs. Surveillance is a core activity of a nursing home's infection prevention and control, or IPC, program. Surveillance was the ongoing, systematic collection, analysis, interpretation, and dissemination of data. The purpose of surveillance is to identify infections and to monitor adherence to recommended IPC practices in order to reduce infections and prevent the spread of pathogens among residents, staff, and visitors. An IPC program uses surveillance data to monitor trends in infections and pathogens, including detecting outbreaks in the facility ....and to identify performance improvement opportunities. Outcome measures identify specific infection events, for both infections and pathogens, to monitor among residents and staff. When conducting surveillance, each outcome or process measure that is being monitored should be clearly defined using standard criteria so that data elements are collected in a consistent way, which ensures accuracy and reproducibility regardless of who is performing the surveillance .....Using the same definitions and methods to track infections or adherence to IPC practices allows your program to compare these data over time."

Review of facility's last three Infection Surveillance Monthly Reports, dated August 2024, September 2024, and October 2024, showed each month's report included a line graph for the number of infections in the facility that month, Summary by Infection Category, and then table detailing each resident's infection with infection onset, infection type, signs and symptoms, status and pharmacy order, and comments. The table did not include pathogen or organism data collected for each infection. August showed zero infections but there were no details for Infection Category or resident details and appeared to be an incomplete report. September showed 2 Bone & Joint infections, 1 Ear, Nose, Mouth & Throat infection, and five Other infections. The details for the Other infections included an infection with comments about resident having an urinary tract infection without catheterization and another resident with abnormal lung examination, cough and fatigue. Two residents did not have any signs and symptoms entered and zero of the residents had a pathogen or organism identified or documented. The October 2024 report was very similar to September 2024 with four Other infections, two residents without any signs and symptoms of infections entered and zero of the residents had a pathogen or organism identified or documented. There was no documented evidence of facility mapping by infections or organisms.

During a concurrent joint record review and interview on 11/21/24 at 10:10 AM Infection Preventionist (IP) reviewed August, September, October monthly Infection Surveillance Monthly reports. When asked how infections were categorized by infection type and what criteria was used to determine infection type category, IP stated that McGeer's criteria was used. When asked to provide McGeer's criteria used, IP stated that she would provide at a later time. McGeer's or criteria used to categorize infection type was not provided. When asked why there were so many infections categorized under "Other", IP stated that sometimes "Other" is used because they don't have enough information initially, however when additional information becomes available the Other category is not changed to a more specific infection type such as Lower Respiratory Tract Infection, Skin Infection, or Urinary Tract Infection. When asked how analysis, trends or actions can be taken if the majority of infections are categorized or miscategorized under "Other", IP stated that she was not sure how to answer that. When asked to provide written Infection Control program's monthly data analysis, identification of trends, rates of health care associated infections showing trends over time and compared to baseline or regional or national trends, IP stated that she would look for that. When asked for monthly written reports shared at Infection Control committee meeting or QAPI meeting. IP stated that she had been in the IP role since 11/4/24 but had completed the CDC IP Nursing Home course and provided a copy of course completion certificate. IP stated that she would ask previous IP (Resident Care Manager, RCM2) and DON for written IPC reports and responses to questions.
During an interview on 11/22/24 at about 12:30 PM, IP stated that she could not find written IPC reports showing data analysis and actions based on analysis that was presented to IC or QAPI meetings and deferred to DON.

During a concurrent interview and joint record review on 11/22/24 at 1:35 PM with DON and Administrator Aug, Sept, Oct Infection surveillance monthly reports were reviewed. DON stated that some of the residents were miscategorized under OTHER and should have been categorized or identified with urinary, skin or lower respiratory infections instead. When asked about written IPC reports showing data analysis, trends over time, comparison to benchmarks, and reported to IC or QAPI committees, DON stated that there was no IPC written reports and more oversight was needed for the IPC program. DON stated that over the past year, there has been a different person in the IP role every couple of months. DON listed 5 different individuals who held IP role in the past year.

3.      
Not following disinfecting wipes manufacturer's instructions when cleaning glucometers

Observation on 11/20/24 at 11:20 AM showed LPN19 exit R6's room with Evencare Proview glucometer, place glucometer on treatment cart, remove one wipe from Microkill container and quickly wipe glucometer with brisk motions and then within seconds placed glucometer in cart drawer, close drawer and walked down the hallway. LPN19 then gathered glucometer supplies and stated she would be checking blood sugars for residents on that hall now.

During a concurrent observation and interview on 11/20/24 at 11:45 AM showed LPN19 pricking R137's finger with lancet with a bead of blood produced. LPN19 brought strip in glucometer to bead of blood with blood sugar reading obtained. LPN19 then exited room and placed glucometer on cart, removed one Microkill wipe from container and wiped glucometer's surfaces and then placed glucometer back on cart and discarded wipe. LPN19 then opened cart drawer and removed another glucometer. After 30 seconds, glucometer that LPN19 wiped was picked up and was observed to be dry to touch. When asked why glucometers were wiped after use on resident, LPN19 stated that we are trying to kill everything on it as we don't want to spread bacteria and infection since we are using these for everybody. When asked about the process for using wipes on glucometer, LPN19 stated that we wipe glucometer and then leave it there, there's a 1-2 minute drying period between uses. LPN19 stated that prior to use on R137, the glucometer was used on R8. When asked if when using wipes if the glucometers needed to be wet for a certain period of time, LPN19 shook her head and stated that glucometers are just wiped and don't need to be wet for a certain period of time. Joint review of the Microkill disinfecting wipes label documented that the treated surface needed to remain visibly wet for one minute to kill the organisms on the label. When asked if the glucometer remained visibly wet for one minute, LPN19 shook her head and said "no".

During an interview on 11/21/24 at 10:10 AM IP stated that manufacturer's instructions for wipes for cleaning and disinfecting glucometers should be followed. When asked about the process for cleaning/disinfecting glucometers, IP stated that the contact/dry/wet time is "the amount of time that the nurses have to allow device to dry and they can't use it, they either wrap the device in wipe or scrub it continuously." Joint review of Microkill wipe container's label showed the device needs to remain visibly wet for the time indicated to kill pathogens.

During an interview on 11/21/2024 at 12:33 PM IP stated that the contact time, dry time and wet time has been discussed with staff today and yesterday. She stated that she prefers if staff wrap glucometer with wipe and let glucometer sit there. IP nodded that facility policy focuses on dry time and not wet time, which may be confusing to staff.

Review of Micro-Kill One manufacturer's materials showed "Micro-Kill One contact time for a disinfectant is the amount of time a surface must remain wet with the product to achieve disinfection."

Facility policy Disinfection of Point-of-Care Devices/Instrument, dated 8/1/24, documented "all point-of-care devices i.e. Glucometers will be cleaned and disinfected according to manufacturer's recommendations using EPA (Environmental Protection Agency) approved disinfectants. a. Care will be taken to assure the cleaning product has been allowed to dry per manufacturer's recommendation (dwell time). b. When possible the facility will be equipped with two glucometers per area. Glucometers will be used alternately to allow for adequate dwell (dry) time after disinfecting." The facility's policy focused on dry time whereas the disinfecting wipe focused on wet time.

Review of R137's Medication Administration Record, dated November 2024, documented staff were to check resident's CBG (capillary blood glucose) before meals and at bedtime related to diabetes. Start date 10/7/24.

4.      
Not performing hand hygiene

Review of R20's records documented resident was admitted on 6/8/24 with diagnoses including quadriplegia (partial or total loss of movement and sensation in all four limbs and body), diabetes, pressure ulcer of sacral region, stage 4, and neuromuscular dysfunction of bladder (condition in which a person lacks urinary bladder control due to brain, spinal cord or nerve problems).
Review of R20's care plan documented resident had an indwelling urinary catheter (a flexible tube inserted to the bladder to drain urine).

Review of R20's current physician orders documented Sacrum Wound: Clean with wound cleanser. Apply skin prep to periwound (skin edges around wound) and allow to dry. Gently Pack with 1/4 strength dakins (wound care solution that is a diluted bleach solution with other ingredients) moistened gauze into wound and cover with bordered foam dressing every other day and back MASD (moisture associated skin damage, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents. MASD is characterized by inflammation of the skin) to cleanse with soap and water, pat dry and apply silvadene (topical cream to treat and prevent wound infections) cream.

Observation on 11/19/24 at 8:54 AM showed staff changing R20's sacral wound dressing. Certified Nursing Assistant (CNA)9, DON, RCM2, and Wound Care Nurse (WCN) were assisting with wound care. The following supplies were prepared in the resident's room, Optifoam gentle, silver sulfadiazine cream 1%, cotton swab sticks, 6x6 gauze dressing, Dakin's solution, cup with gauze in Dakin's solution and the resident's tv stand shelf had two basin containers filled with wound care supplies. WCN with headlamp and gown and gloves on removed resident's sacral and mid back dressings. Without performing hand hygiene after removing dirty dressings, WCN took pictures of wound and then placed measuring tape near sacral wound and placed cotton tipped sticked into wound. Using the same gloves, WCN then sprayed gauze with skin integrity wound cleanser and patted resident's back in several location with the gauze. DON packed sacral wound with gauze and applied Optifoam dressing and dated dressing. Immediately after wound observation, WCN left the facility for the rest of the week and was not available to be interviewed.

During an interview on 11/19/24 at 9:20 AM DON was informed of observation of WCN not performing hand hygiene between dirty and clean tasks when changing gloves but should have.

During an interview on 11/21/2024 at 12:33 PM IP stated that the facility policy when going from a dirty to clean task, is to remove gloves, wash hands or hand hygiene and then apply new gloves. When informed of observation of WCN, IP stated that WCN did not follow facility's policy for hand hygiene.

Facility policy Hand Hygiene, dated 8/1/24, documented "Hand hygiene is the primary means of preventing the transmission of infection ...." The following were situations that required hand hygiene ...."r. after handling soiled or used linens, dressings .....u. after removing gloves ...; and/or before applying ..." ..."
, Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases. In addition, the facility failed to develop and implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for its residents. The facility census was 46. Specifically:

1. The facility failed to disinfect glucometers between and/or prior to use for four of four residents (Resident (R) 8, R 10, R 11, and R 90) observed receiving blood glucose testing. The failure to disinfect glucometers between residents observed on 11/20/24 from 07:40 AM to 08:02 AM placed 13 residents (R4, R6, R8, R9, R10, R11, R19, R20, R26, R28, R86, R136, and R137) who required daily blood glucose testing, 1 resident (R32) who required PRN (as needed) blood glucose testing, and 1 resident (R90) requiring fasting blood glucose testing at risk for serious and potentially life-threatening blood-borne illness; this constituted immediate jeopardy. On 11/20/24 at 10:13 AM the facility's Administrator and Administrator in Training was notified of an Immediate Jeopardy (IJ) determination.

The facility provided an acceptable Removal Plan which included putting residents who may have been affected on alert for potential exposure to a blood-born pathogen, and retraining and ensuring competency of all Licensed Practical Nurses (LPN) and Registered Nurses (RN) on the use and sanitization of glucometers. Through interviews with facility staff, observations of glucose testing, and review of staff in-services, the survey team verified implementation and removed the Immediate Jeopardy on 11/21/24 at 05:54 PM. The deficient practice remained at a scope and severity of pattern, no actual harm with potential for more than minimal harm following the removal of the immediate jeopardy.

2. Failed to ensure infection surveillance outcome data was clearly defined using standard criteria to facilitate identifying, tracking, analyzing and preventing infections, and facility failed to analyze, interpret, develop and provide written reports to Infection Control and/or Quality Assessment and Assurance meetings.

3. Failed to follow disinfecting wipes manufacturer's instructions when cleaning glucometer for 1 of 13 resident (R137) observations.

4. Failed to ensure staff performed hand hygiene between dirty and clean tasks during 1 of 2 sampled resident (R20) wound care observation.

Findings include


1.      
Not cleaning and disinfecting glucometers

Review of CDC Viral Hepatitis Basics, dated 7/30/24, at https://www.cdc.gov/hepatitis/about/index.html documented "viral hepatitis is a disease of the liver caused by a virus. Untreated, viral hepatitis can lead to serious liver problems, like scarring or cancer. Even if you don't have symptoms, you can spread viral hepatitis .....with many people not even realizing they are infected ...Hepatitis B [HBV] is contagious and ...primarily spread when blood ...or certain other bodily fluids-even microscopic amounts-from a person infected with HBV enter the body of someone who is not infected .....Many people with hepatitis C [HCV] don't look or feel sick, so they might not know they have the virus ...Hepatitis C usually doesn't have symptoms ....Hepatitis C is spread when blood from a person infected with HCV-even microscopic amounts-enters the body of someone who is not infected." The CDC website provides information about viral hepatitis transmission risk and prevention approaches for specific high risk populations and settings, including people with human immunodeficiency virus, people who use or inject drugs, people who experience homelessness.

R19

Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/24, indicated R 19 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The assessment included that R 19 had active diagnoses of Diabetes Mellitus (a chronic disease that occurs when the body can't produce or use insulin properly) and Viral Hepatitis.

R26

The facility provided resident profile documentation that R 26, admitted to the facility in 2024, had a history of drug use. A provider note dated 11/12/24 included that R 26 used "meth" (Methamphetamine also known as meth or crystal meth is a very addictive drug which can be smoked, snorted or injected directly into the bloodstream Injecting meth is linked with diseases like HIV and hepatitis C.)

R11

Review of a Quarterly MDS in August 2024, indicated R 11 was cognitively intact with a BIMS score of 15. The assessment included that R 11 had active diagnoses of Diabetes Mellitus, hyperthyroidism (a medical condition that occurs when the thyroid gland produces too much thyroid hormone, which speeds up the body's metabolism), and cataracts (a clouding of the eye's lens that reduces vision). R11 was admitted to facility in 2024.

Review of a Progress Note dated 11/04/24 revealed R 11's past medical history included being homeless and imprisonment.

Review of resident profile data dated 11/22/24, collected by the facility, revealed that R 11 was homeless.

R8

Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/24, indicated R 8 was cognitively intact with a BIMS score of 15. The assessment included that R 8 had active diagnoses of Diabetes Mellitus, depression, and long-term or current use of insulin.

R10

Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/24, indicated R 10 had moderate cognitive impairment with a BIMS score of 11. The assessment included that R 10 had active diagnoses of Diabetes Mellitus, fatty liver, and long-term or current use of insulin.

During a medication administration observation on 11/20/24 at 07:40 AM, Licensed Practical Nurse (LPN) 1 had cleaned a glucometer with an alcohol wipe, donned (put on) a pair of gloves and then entered R 11's room. LPN 1 instructed the resident that she was going to test blood sugar and wiped the resident's finger with another alcohol pad. LPN 1 pricked resident's finger with the lancet and squeezed the finger to form a bead of blood. LPN 1 brought the glucometer with the strip in the glucometer to the bead of blood. The bead of blood ran down the strip and registered the blood sugar reading. After obtaining the blood sugar reading, LPN 1 removed (doffed) their gloves and returned to the medication cart. LPN 1 placed a tissue on the top of the cart and placed the glucometer on top of the tissue. LPN 1 accessed the electronic medical record (EMR) and documented the blood sugar result. After documenting, LPN 1 locked the cart and pushed it west down the hallway to R 8's room.

LPN 1 was not observed cleaning or disinfecting the contaminated glucometer from R 11's room to R 8's room.

During another medication administration observation with the same medication cart and LPN on 11/20/24 at 07:44 AM, LPN 1 completed hand hygiene, opened the top drawer to remove a new testing strip, 2 x 2 gauze, and alcohol pad. LPN 1 completed hand hygiene again, donned new gloves, collected the same glucometer from the tissue on top of the cart, and entered R 8's room. After completing the finger stick glucose monitoring (same steps as observed for previous resident), LPN 1 returned to the medication cart at 11/20/24 at 07:51 AM placed the same glucometer on the same tissue on top of the cart, doffed her gloves, and performed hand hygiene. LPN 1 moved the cart south towards R 10's room.

Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/30/24, indicated R 8 was cognitively intact with a BIMS score of 15. The assessment included that R 8 had active diagnoses of Diabetes Mellitus, depression, and long-term or current use of insulin.

Again, LPN 1 was not observed cleaning or disinfecting the glucometer from R 8's room to R 10's room.

During another medication administration observation with the same medication cart and LPN on 11/20/24 at 07:51 AM, LPN 1 performed hand hygiene, donned gloves, then doffed gloves, then donned gloves again to enter R 10's room at 07:53 AM. LPN 1 completed the blood glucose monitoring (same steps as observed for previous resident), blood sugar reading was 102 and gave 32 units of insulin. Returned to the cart at 07:55 AM, LPN 1 laid the same glucometer back on top of the cart, doffed gloves, and completed hand hygiene. At 07:56 AM, LPN 1 removed a bag from the cart that held the insulin pen for R10 and laid the bag on top of the glucometer. LPN 1 completed hand hygiene prior to placing the insulin pen in the bag and then returned the bag to the drawer. LPN 1 moved the medication cart south again to R 90's room.

Review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/24, indicated R 10 had moderate cognitive impairment with a BIMS score of 11. The assessment included that R 10 had active diagnoses of Diabetes Mellitus, fatty liver, and long-term or current use of insulin.

Again, LPN 1 was not observed cleaning or disinfecting the glucometer from R 10's room to R 90's room.

During another medication administration observation with the same medication cart and LPN on 11/20/24 at 07:56 AM, LPN 1 was observed performing hand hygiene again and donning new gloves. At 07:57 AM doffed gloves to get new glucometer strip for machine then donned new gloves. LPN 1 wiped R 90's finger with another alcohol pad. LPN 1 pricked resident's finger with the lancet and squeezed the finger to form a bead of blood. LPN 1 brought the glucometer with the strip in the glucometer to the bead of blood. LPN 1 stated that R 90 was only having a fasting blood sugar test. At 07:58 AM LPN 1 doffed gloves, completed hand hygiene, donned new gloves. At 08:00 AM LPN donned new gloves and cleaned glucometer with a "micro-kill one germicidal alcohol wipe." LPN 1 wrapped the glucometer in the wipe and placed it on the top of the cart. At that time, LPN 1 removed a second glucometer from the drawer, wiped it with another micro-kill one wipe, wrapped it, and placed it on top of the cart next to the other glucometer.

During the observation from 07:40 AM to 8:02 AM, LPN 1 only removed two wipes from the micro-kill one germicidal alcohol wipe container on the medication administration cart at the end of the glucometer checks when LPN 1 cleaned two glucometers at the same time.

During an interview conducted on 11/20/24 at 08:02 AM, LPN 1 stated the glucometers are to be cleaned in between each resident. When asked why she didn't disinfect in between each resident, LPN 1 said, "I didn't?" When asked what the potential complications would be of not disinfecting between residents, LPN 1 said it would be an infection control risk. LPN 1 stated she thought she had disinfected between each resident. When asked where the second glucometer had been LPN 1 stated, "in the drawer." When asked if she was cleaning them together at the same time, LPN 1 said, "yes." LPN 1stated it was a one-minute wet time when using the wipes [micro-kill one germicidal alcohol wipe].

During an interview on 11/20/24 at 08:52 AM, LPN 2 stated that she uses the microbial white cleaning wipe [micro-kill one germicidal alcohol wipe] after the last patient in a glucometer "run". LPN 2 described a run as being 5 residents. LPN 2 stated that in-between residents, she uses an alcohol wipe because the "microbial wipes" cause cancer and she doesn't want to expose herself or the residents to that any more than needed. LPN 2 identified the "microbial wipes" as the micro-kill one germicidal alcohol wipe.

On 11/20/24 at 10:30 AM an interview was conducted with the Director of Nursing (DON), Administrator, and Administrator in Training (AIT). The DON stated that the expectation is for staff to clean the glucometers following manufacturer's guidelines. When asked if the nursing staff should limit the amount of exposure to the micro-kill one germicidal alcohol wipe because the wipes "cause Cancer", the DON did not comment. The DON stated that LPN 1 stated they had "swapped out" [alternating between] the glucometers between each resident. The DON stated that the staff stated that they did disinfect between each resident but acknowledged that comments that using the micro-kill one germicidal alcohol wipe could expose the resident's to cancer were inaccurate.

On 11/21/24 at about 9:30 AM LPN2 asked surveyor why cleaning glucometers with only alcohol was not enough as this is what she was taught in school and has been her practice. Informed LPN2 that CDC recommends glucometers not to be shared between residents but if glucometers are shared then manufacturer's instructions for cleaning and disinfecting glucometers needed to be done to prevent the spread of blood borne infections.

Review of facility's immediate jeopardy removal plan, dated 11/20/24, and facility records documented that 13 residents (R4, R6, R8, R9, R10, R11, R19, R20, R26, R28, R86, R136, and R137) required daily blood glucose testing, 1 resident (R32) required PRN (as needed) blood glucose testing, and 1 resident (R90) required fasting blood glucose testing.

Review of the "Evencare Proview Blood Glucose Monitoring System User's Guide" [what is date of guide, or state undated] included that the healthcare professionals should "adhere to standard precautions when handling or using this device. All parts of the glucose monitoring system should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals ...Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients." The guide also included that only "one disinfectant should be used on the device for the life of the device, as the effect of using more than one disinfectant interchangeably has not been evaluated." The guide included the following:
Disinfection Instructions:
The meter must be disinfected between patient uses by wiping it with a [brand name] towelette or EPA-registered disinfecting wipe in between tests and be cleaned prior to disinfecting. The Disinfection process reduces the risk of transmitting infectious diseases if it is performed properly.

Review of a facility policy titled "Disinfection of Point-of-Care Devices/Instruments" adopted 08/01/24 included the facility's policy is to "protect residents from cross contamination of blood-borne pathogens and/or other potential infectious materials by assuring other instruments and point-of-care devices are properly cleaned and disinfected." The policy included that all "point-of-care devices i.e. Glucometers, Coagu-chek meters will be cleaned and disinfected according to manufacturer's recommendation using EPA approved disinfectants ... When possible, the facility will be equipped with two glucometers per area. Glucometers will be used alternately to allow for adequate dwell (dry) time after disinfecting."

Review of a facility policy titled "Infection Control Policies and Practices" adopted 12/15/21 included that policy's intention is to "facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections." The policy included objectives to prevent and control infections, and to provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. The facility has adopted infection control policies and practices to reflect preventing transmission of infections and communicable disease as set forth in current CDC (Centers for Disease Control and Prevention) guidelines and recommendations.

CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 2/6/13 at https://www.cdc.gov/cliac/docs/addenda/cliac0313/07B_CLIAC_2013March_Glucose_Monitoring.pdf, documented "The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: ....
*whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions .....An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV, hepatitis C virus, and HIV)[Human immunodeficiency virus] through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters ....) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes ..., where residents require assistance with monitoring of blood glucose levels ...In the last 10 years alone, there have been at least 15 outbreaks of HBV infection associated with providers failing to follow basic principles of infection control when assisting with blood glucose monitoring. Due to under-reporting and under recognition of acute infection, the number of outbreaks due to unsafe diabetes care practices identified to date are likely an underestimate ....Blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose metes should be assigned to an individual person and not be shared. If he blood glucose meter must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents ..."

CDC Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration, undated, at www.cdc.gov/injectionsafety/providers/blood-glucose-monitoring_faqs.html documented "Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is defined as the transfer of an infectious agent (e.g., HBV) from one patient to another through a contaminated intermediate object (e.g., blood glucose meter) or person (e.g., healthcare personnel hands). With some blood glucose meters that require pre-loading of the test strip, the device may come into direct or close contact with the patient's fingerstick wound. If blood is transferred from the patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them. Indirect contact transmission can also occur even if the patient never directly contacts the meter. Healthcare personnel hands can become contaminated with blood at various points while performing assisted blood glucose monitoring including pricking the patient's finger or handling the test strip. Blood can then be transferred to the meter when healthcare personnel handle the meter to obtain the reading. If the meter is not cleaned and disinfected after use, the blood remaining on the meter can be transferred to subsequent patients via healthcare personnel hands when they handle the meter and then assist with fingerstick procedures. Numerous outbreaks have implicated this mechanism in the spread of HBV infections ....A multi-hospital study of blood glucose meters found that 30% were contaminated with blood; contamination was identified at the test strip insertion site as well as on the outside surfaces of meters. Further, HBV has been demonstrated to remain infectious in dried blood on environmental surfaces for at least 7 days. For these reasons, blood glucose meters should be cleaned and disinfected after each use, unless they are dedicated to a single patient and appropriately stored to prevent inadvertent contamination."

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 2, CNA 4, CNA 5, CNA 9, and CNA 12 received the required Abuse, Neglect, and/or dementia care in-service training for five of five CNA staff reviewed. This failure placed residents with dementia at risk of not receiving appropriate care and services to attain or maintain their highest practicable self.

Findings Include:
Review of personnel files for CNA 2, CNA 4, CNA 5, CNA 9, and CNA 12 did not include evidence of Abuse, Neglect, or Dementia training in the last 12 months.

Review of a "Facility Compliance [facility name]" dated January 1, 2024, through July 31, 2024, included that Certified Nursing Assistant "Annual Federal Training Summary" was completed by 7 of 12 (58%) and only 83 of 137 (61%) of the total required trainings for CNAs.

Review of the "Matrix" (a form used by healthcare facilities to identify the care categories for their residents) dated 11/18/24 revealed 9 of 44 residents had Alzheimer's/Dementia.

An email dated 11/21/24 at 03:56 PM from the Administrator included that the educational software used for in-service training had changed in September 2024 when the facility changed systems. The Administrator said they were working on gaining those records but at this time did not have access to the in-service training for Abuse, Neglect, or Dementia provided to the CNAs.

During an interview on 11/22/24 at 11:59 AM with concurrent personnel file review, the Infection Control Nurse and acting Director of Staff Development (DSD) stated there is ongoing training online and once a month there is an in-person training. The DSD stated that upon hire there is a whole list of training that needs to be completed prior to caring for residents. The DSD confirmed that Abuse, Neglect, and Dementia training is included in the training provided to CNAs. When asked specifically about CNA 2, CNA 4, CNA 5, CNA 9, and CNA 12s lack of training for abuse, neglect, and dementia in the personnel files the DSD said she would need to go and find those trainings.

During an interview on 11/22/24 at 12:32 PM, the Director of Nursing (DON) stated that the expectation is all staff have the needed minimum competencies done during their orientation and annually to meet the care needs of the residents. The DON said that during this survey, the facility is learning some file issues have come up with identifying completed training requirements. The DON stated it is here understanding that CNA 2, CNA 4, CNA 5, CNA 9, and CNA 12s but there is difficulty in getting the supporting evidence at this time.

Another email dated 11/22/24 at 05:47 PM from the Administrator included an in-service attendance sign in sheet dated 11/22/24. The subject/top documented on the sign in sheet included "Abuse-Screening, training, identification, investigation, reporting, and prevention, Neglect + exploitation.

Review of the additional supplied evidence did not include training in the previous 12 months for Abuse, Neglect, or Dementia training for CNA 2, CNA 4, CNA 5, CNA 9, and CNA 12.

Based on observation, interview and record review it was determined the facility failed to promote self determination for 1 of 3 sampled residents (#5) reviewed for choices. This placed residents at risk for lack of honoring choices and room preferences. Findings include:

1. Resident 5 was admitted to the facility on 9/2020 with diagnoses including anxiety and schizoaffective (a condition that is marked by depression and mania) disorder.

The Quarterly MDS dated 9/6/24, revealed Resident 5 had a BIMS score of 15, which indicated the resident was cognitively intact.

Random observations from 10/7/24 through 10/10/24 revealed her/his room was cluttered with multiple items on the bedside table, bed, dresser and on the floor. Resident 5 was observed using a front wheel walker, frequently going out to smoke or walking up and down the halls.

On 10/7/24 at 10:44 AM, Resident 5 and Staff 8 (LPN) were present for an interview. Resident 5 stated she/he was told by management she/he would have to move out of her/his room, which she had been in for "two years", and be placed in a room with three other female residents. Resident 5 stated this was not right and she/he had not been sleeping well since the conversation. Staff 8 stated Resident 5 was very "upset" and Staff 8 had noticed an increase in Resident 5 "anxiousness." Staff 8 stated the resident was not sleeping well during the night since the information was communicated to Resident 5.

On 10/8/27 at 12:36 PM, Staff 16 (CNA) stated Resident 5 had an increase in her/his "anxiousness" because the resident was told she/he would be moving rooms and sharing with three other female residents. Staff 16 stated the resident felt "overwhelmed" about moving rooms and did not want to pack up her/his belongings.

On 10/9/24 at 11:21 AM, Staff 24 (CNA) and at 1:05 PM, Staff 25 (LPN) both stated Resident 5 was alert and oriented with baseline confusion. Staff 24 and Staff 25 stated Resident 5 was very "private," and her/his room was "cluttered." Staff 24 and Staff 25 stated the resident did not like her/his room touched. Staff 25 stated Resident 5 struggled with change and very closed off to new outside persons.

On 10/11/24 at 9:55 AM Staff 3 (Social Service Director) and Staff 4 (Social Services) stated Resident 5 had briefly mentioned being told she/he would be moving rooms and sharing with three other female residents. Resident 5 did not want to move from her/his current room and was easily anxious. Staff 3 stated there was not a set time line.

On 10/11/24 at 12:10 PM Staff 2 (DNS) stated they were "considering" moving four long term care female residents into the therapy room (converting to a four room space) and had discussed this with Resident 5. Staff 2 stated the resident was very suspicious of anything new, was a hoarder, and had been in her/his room since 2021. Staff 2 stated Resident 5 had asked other staff about the move and had perseverated on the subject.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of changes in financial coverage for 1 of 3 sampled residents (#3) reviewed for advance beneficiary notification. This placed residents at risk for unknown financial liabilities and lack of knowledge regarding the right to appeal the decision. Findings include:

Resident 3 admitted to the facility in 5/2024 with diagnoses including lower extremity paraplegia (the inability to move lower extremities).

A review of Resident 3's electronic health record revealed she/he was discharged from Medicare Part A services on 8/9/24 with 37 skilled days remaining. The resident remained in the facility. No evidence was found in the resident's record to indicate she/he received a Notice of Medicare Non-coverage form (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN).

In an interview on 10/9/2024 at 3:16 PM Staff 4 (Social Services Coordinator) stated she was unable to locate a NOMNC or a SNF ABN for Resident 3.

In an interview on 10/11/24 at 12:05 PM, Staff 3 (Social Services Director) stated the facility did not provide a NOMNC or SNF ABN to Resident 3.

Based on observation, interview, and record review it was determined the facility failed to ensure personal privacy was honored for 1 of 1 resident (#187) reviewed for privacy. This placed residents at risk for breaches of confidentiality. Findings include:

Resident 187 admitted to the facility in 9/2024 with diagnoses including intracranial (inside the skull) abscess.

On 10/10/24 from 1:00 PM through 2:00 PM, Resident 187 was observed meeting with Staff 27 (Physician's Assistant) in a corner of the main dining room. The survey team was meeting in the activity room adjacent to the main dining room and the two rooms were separated by a curtain. The survey team was able to hear the medical conversation. The resident and Staff 27 were discussing private health information including diagnoses, symptoms, medications and prognosis. Resident 187 was overheard telling Staff 27 about her/his discomfort with the lack of privacy associated with sharing a room with three roommates and stated she/he wanted to leave the facility due to the lack of privacy.

In an interview on 10/11/24 at 9:28 AM Staff 27 stated he had private conversations with residents in the facility in their rooms or in the dining room. Staff 27 stated the conversation he had with Resident 187 might have been more appropriate in a more private area. Staff 27 stated he was not aware of a private meeting area in the facility.

In an interview on 10/11/24 at 9:52 AM, Resident 187 stated she/he preferred to have a private area to meet with Staff 27. Resident 187 stated it was difficult to find a place to have a private phone call in the facility, and it was "impossible" to have privacy while sharing a room with three other residents.

In an interview on 10/11/24 at 11:32 AM Staff 3 (Social Services Director) stated she tried to have private meetings or conversations in the Social Services office but sometimes residents preferred their rooms. Staff 3 stated she frequently utilized the activity room and residents utilized the outdoor areas for privacy. Staff 3 stated she had concerns about proposed changes in the facility which would impact the residents' privacy due to a lack of dedicated meeting space in the facility.

In an interview on 10/11/24 at 1:16 PM Staff 1 (Administrator) stated residents had a right to privacy when receiving care and a place to meet in private. Staff 1 stated residents were informed they could request to use staff offices for private meetings. Staff 1 stated Resident 187 did not request to use a staff office for her/his meeting with Staff 27. When asked where Staff 1 would like to have a conversation regarding personal medical information, Staff 1 stated he would like the conversation to be held in a private location.

Based on observation and interview it was determined the facility failed to ensure carpet, flooring and doors were in good repair 1 of 1 facility and 3 of 19 resident rooms reviewed for homelike environment. This placed residents at risk for injury from damaged surfaces and lack of a homelike environment. Findings include:

Multiple observations between 10/7/24 and 10/11/24 revealed hall carpet throughout the facility was heavily stained and worn.

Observations on 10/9/24 at 9:36 AM revealed a metal floor latch socket was missing below the fire doors between rooms 12 and 14. This created a hole in the flooring 2.5 inches long, 1.5 inches wide and an inch deep; large enough for canes and walkers to catch on.

On 10/10/24 at 10:50 AM the floor covering surrounding the base of the toilet between rooms 8 and 10 was observed to be damaged with exposed under floor. The exposed surface was rough, brownish-gray and was not a cleanable surface. The rest of the bathroom floor was worn and had patches of gray discoloration.

On 10/10/24 at 10:15 AM the hinge side of the door to room 15 was observed to have an approximately 18 inch section of rough damaged surface. The door to room 11 also had rough damage to the hinge side of door. The door of room 10 had a deeply gouged and splintered surface from the door knob to the floor with sharp edges.

In an interview on 10/11/24 at 10:41 AM Staff 21 (Maintenance director) confirmed the facility carpet was heavily stained and worn. He stated it was regularly steam cleaned but the stains remained. He stated the hole in the floor at the fire door was for a latch no longer in use for the type of fire door and it needed to be filled. Staff 21 confirmed damage to room doors was on his list of needed repairs, however, he was not specifically aware of the damage to room 10. Staff 21 agreed the edge of the door was sharp. He was not aware of the damage to the bathroom floor between rooms 8 and 10 and confirmed the flooring needed to be replaced.

On 10/11/24 at 1:01 PM these findings were reviewed with Staff 1 (Facility Administrator) who stated the facility was working on a plan for the flooring and the doors.

Based on interview and record review it was determined the facility failed to develop a comprehensive person centered care plan for 1 of 3 recently admitted residents (#85) reviewed for incontinence and respiratory care. This placed residents at risk for unmet needs. Findings include:

Resident 85 was admitted in 9/2024 with diagnoses including diabetes, chronic obstructive pulmonary disease, history of lung cancer, heart failure and generalized weakness.

Resident 85's Admission MDS and CAAs dated 9/24/24 identified the resident was frequently incontinent of urine related to weakness and the use of diuretic medication, and the resident required staff assistance with toileting.

Current Physician orders for Resident 85 included an order for a 2000 ml per day fluid restriction.

Resident 85's care plan dated 9/21/24 identified bladder incontinence related to the use of diuretic medication, impaired mobility and the need for extensive assistance with transfers. Interventions directed staff to "check and change frequently throughout the shift and PRN." The care plan did not include interventions to reduce incontinent episodes.

The resident's Comprehensive Care Plan was last revised on 10/9/24. The care plan included a focus area that indicated the resident was at risk for dehydration or electrolyte imbalance related to diabetes and diuretic use. Interventions included "encourage increase PO [oral] fluids." The care plan did not address the prescribed fluid restriction.

The Care Plan indicated the resident had an Advance Directive (a written instruction, such as a living will or durable power of attorney ... to direct the provision of health care when the individual is incapacitated). Further review of the resident's record revealed she/he was offered a blank Advance Directive form upon admission but did not have an Advance Directive in place.

On 10/11/24 at 10:51 AM Staff 2 (DNS) stated care plans were reviewed quarterly and after input from care conferences. Staff 2 confirmed Resident 85's care plan was not completely accurate or individualized.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received appropriate ADL assistance for 1 of 3 sampled residents (#136) reviewed for activities of daily living. This placed residents at risk for lack of grooming and personal hygiene. Findings include:

Resident 136 was admitted to the facility in 10/2024 with diagnoses including stroke.

A review of Resident 136's Baseline Care plan dated 10/5/24 revealed the resident required substantial/maximal assistance from one person for showers.

A review of Resident 136's 10/2024 shower task form revealed the resident received a bed bath on 10/6/24.

An observation and interview on 10/7/24 at 2:36 PM revealed Resident 136 was in bed and her/his hair was greasy. Resident 136 stated she/he received one bed bath since admission, but her/his hair was not washed, which would have been "nice."

Random observations from 10/8/24 through 10/9/24 revealed Resident 136 was in her/his bed or up in her/his wheelchair, and the resident's hair was greasy.

On 10/9/24 at 11:56 AM Resident 136 stated she/he did not receive a shower and would "kill" to have her/his greasy hair washed.

On 10/9/24 at 1:40 PM, Staff 15 (CNA) and at 5:58 PM, Staff 13 (CNA) stated residents received a shower or a bed bath two times weekly. Staff 15 and Staff 13 stated they noticed Resident 136's hair was greasy and should have been washed as part of her/his bed bath.

On 10/11/24 at 10:59 AM, Staff 5 (Resident Care Manager LPN) stated residents were scheduled for a shower or bed bath twice weekly. Staff 5 stated staff were expected to use warm soapy water for a bed bath, including washing all body parts, including Resident 136's hair. Staff 5 acknowledged Resident 136's hair was not washed.

Based on interview and record review it was determined the facility failed to ensure residents received support to maintain continence for 1 of 2 residents (#85) reviewed for incontinence. This placed residents at increased risk for skin breakdown and loss of dignity. Findings include:

Resident 85 was admitted in 9/2024 with diagnoses including chronic obstructive pulmonary disease, heart failure and generalized weakness.

Resident 85's Admission MDS dated 9/24/24 identified the resident was frequently incontinent of urine and the resident required staff assistance with toileting.

The 9/24/24 Urinary Incontinence CAA identified the type of incontinence as a mixture of "urge," related to use of diuretic medication and "functional," due to weakness and impaired mobility. According to the CAA as the resident regained strength, it was anticipated the resident would be "more able to self-toilet and avoid incontinence issues."

Resident 85's care plan dated 9/21/24 indicated the presence of moisture associated skin breakdown to the resident's groin and perineum related to incontinence episodes. Interventions included a directive to keep the resident's skin clean and dry "to the extent possible." The care plan also identified bladder incontinence related to the use of diuretic medication, impaired mobility and the need for extensive assistance with transfers. Interventions directed staff to "check and change frequently throughout the shift and PRN." The care plan did not address the type of incontinence (urge or mixed) or a specific strategy to reduce the frequency of incontinent episodes.

In an interview on 10/7/24 at 10:31 AM Resident 85 reported slow call light response times that caused the resident to be incontinent of urine. Resident 85 was told by staff to "plan better" but the resident felt this was impossible due to use of diuretic medication and subsequent urgency to void. Resident 85 indicated five to 10 minutes was too long to wait to avoid an incontinent episode and voiding in a brief was undignified. Resident 85 reported a history of skin breakdown on the tailbone which was healed but Resident 85 was concerned that wearing a wet brief would cause the area to breakdown again.

On 10/9/24 at approximately 4:00 PM Staff 13 (CNA) stated she was familiar with Resident 85. Staff 13 stated the resident was able to call for assistance and was unable to toilet or use a urinal without staff assistance.

On 10/9/24 at 4:15 PM Staff 26 (CNA) indicated he was new to caring for the resident and stated Resident 85 needed assistance to the toilet and assistance to get cleaned up after using it. Toileting assistance was provided when the resident called for it. He did not know if the resident used a urinal independently.

On 10/10/24 at 9:47 AM Staff 18 (CNA) stated the resident called for assistance if she/he needed to toilet and needed assistance to use the urinal.

On 10/10/24 at 1:18 PM Staff 5 (Resident Care Manager-LPN) confirmed interventions were not in place to reduce the frequency of incontinent episodes or the resident's desire to not rely on the use of a brief.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders for continuous oxygen use for 1 of 1 (#85) sampled resident reviewed for respiratory care. This place residents at risk for complications related to chronic respiratory disease. Findings include:

Resident 85 was admitted to the facility in 9/2024 for rehabilitation with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and heart failure.

Resident 85's physician orders dated 9/17/24 and Comprehensive Care Plan dated 9/21/24 directed staff to administer continuous humidified oxygen at 6 liters per minute via nasal cannula to keep oxygen saturation (percentage of oxygen in the resident blood) between 89 and 92%.

Review of a published cylinder duration chart for medical oxygen indicated an E-cylinder, if full, would last 1.7 hours at a flow rate of 6 liters per minute. This information was not part of the resident's plan of care.

On 10/7/24 at 1:23 PM Resident 85 was observed to transfer from a wheelchair to bed. The resident had a portable E-sized oxygen cylinder on the back of the wheelchair and was wearing a nasal cannula. The resident's oxygen tank was observed to be empty. The resident was cued by the surveyor to activate her/his call light. A CNA responded after approximately five minutes, moved the resident's oxygen to the in-room oxygen concentrator and obtained a new tank for the resident's wheelchair.

On 10/7/24 at 3:28 PM Resident 85 described a recent incident when staff assisted her/him to the toilet without oxygen and Resident 85 had to call out for staff due to almost "passing out."

On 10/9/24 at 8:20 AM Resident 85 was seated in a wheelchair in the dining room. The resident's oxygen tank was observed to be set a 6 liters per minute and was nearly empty. At 8:26 AM staff changed out the oxygen tank for a full one. Resident 85 remained up in her/his wheelchair until 10:31 AM when the resident returned to bed and resumed using oxygen via the in-room concentrator.

On 10/9/24 at 11:19 AM Resident 85 stated her/his BiPap machine (bi-level positive airway pressure machine used for management of sleep apnea) was humidified at night but oxygen was not humidified at other times. Resident 85 stated her/his nose was dry.

On 10/9/24 at 4:23 PM Staff 19 (LPN) confirmed Resident 85 had an order for humidification of oxygen and there was no humidifier on the oxygen concentrator in the resident's room.

On 10/10/24 at 1:18 PM Staff 5 (Resident Care Manager-LPN) stated she was not aware Resident 85's oxygen was without humidification. Staff 5 confirmed a portable tank at the resident's ordered flow rate would not last very long.

On 10/11/24 at 10:02 AM Staff 17 (CNA) stated she thought Resident 85's tank lasted "about a shift to a half a shift" depending on how long the resident was up in a wheelchair. Staff 17 stated she recalled an incident when the resident was up in the bathroom without oxygen and felt faint. She stated she wasn't aware at the time the resident needed oxygen at all times. She reported that staff sometimes forgot to turn the tank off when they switched the resident to the concentrator and this depleted the oxygen in the tank.

Based on observation and interview it was determined the facility failed to ensure medication storage areas were free of expired medication and biologicals for 1 of 1 medication storage room and 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include:

On 10/10/24 at 11:08 AM observations within the medication storage room refrigerator revealed a vial of tuberculin used for tuberculosis screening labeled as opened on 8/21/24. Staff 2 (DNS) confirmed the tuberculin was to be discarded 30 days after opening. A bottle of acidophilus with an expiration date of 8/2024 was located in the door compartment of the refrigerator. Staff 2 confirmed it was expired.

Observations of one of three facility treatment carts on 10/10/24 at 11:20 AM revealed a vial of Bacitracin (antibacterial) ointment with an expiration date of 8/2024. Staff 2 (DNS) confirmed the used tube of Bacitracin was expired.

Based on interview and record review it was determined the facility failed to have the Medical Director attend the Quality Assessment and Assurance and Quality Assurance Performance Improvement (QAA/QAPI) committee meetings. This placed residents at risk for unidentified needs. Findings include:

Documentation of QAA/QAPI meeting minutes were requested from 4/2024 through 9/2024 which revealed Staff 23 (Former Medical Director) did not attend any of the QAA/QAPI meetings.

On 10/8/24 at 9:59 AM, and on 10/11/24 at 1:51 PM, Staff 1 (Administrator) stated Staff 23 the Former Medical Director refused to attend the QAA/QAPI meetings in person or via skype.

OAR-411-085-0310: Residents' Rights: Generally

Refer to F561 and F583
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OAR-411-085-0320: Residents' rights: Charges and Rates

Refer to F582
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OAR-411-087-0100: Physcial Environment: Generally: Housekeeping and Maintenance

Refer to F584
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OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F656
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OAR-411-086-0110: Nursing Services: Resident Care

Refer to F677 and F695
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OAR-411-086-0140: Nursing Services: Resloution and Preventive Care

Refer to F690
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OAR-411-086-0260: Pharmaceutical Services

Refer to F761
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OAR-411085-0220: Quality Assurance

Refer to F868
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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/25/2023 and 12/31/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for adverse medical consequences. Findings include:

1. Resident 17 was admitted to the facility in 2022 with diagnoses including Parkinson's Disease (a disorder that affects movement), end-stage renal disease with dialysis, astherosclerotic heart disease (disease of the heart's major blood vessels) and depression.

a. A 5/1/23 physician order indicated Resident 17 was prescribed carbidopa-levodopa (Parkinson's medication) three times a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's carbidopa-levodopa was not given according to physician orders on the following days:
-6/3 mid day and evening doses;
-6/5 morning and mid day doses;
-6/6 mid day dose;
-6/8 morning, mid day and evening doses;
-6/9 evening dose;
-6/10 morning dose;
-6/12 morning and mid day doses;
-6/13 morning and mid day doses;
-6/15 morning and mid day doses;
-6/16 mid day dose;
-6/17 morning and mid day doses;
-6/18 morning, mid day and evening doses;
-6/22 morning and mid day doses;
-6/27 morning and mid day doses;
-6/29 morning and mid day doses;
-7/1 morning and mid day doses;
-7/4 morning and mid day doses and
-7/6 morning and mid day doses.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's carbidopa-levodopa was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's carbidopa-levodopa MAR and stated the resident's carbidopa-levodopa should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

b. A 5/1/23 physician order indicated Resident 17 was prescribed sertraline (an anti-depressant) one time a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's sertraline was not given according to physician orders on the following days:
-6/3, 6/5, 6/8, 6/10, 6/12, 6/13, 6/15, 6/17, 6/18, 6/22, 6/27, 6/29, 7/1 and 7/6.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's sertraline was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's sertraline MAR and stated the resident's sertraline should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

c. A 5/10/23 physician order indicated Resident 17 was prescribed metoprolol (used to treat heart failure) in the morning and at bedtime every Monday, Wednesday, Friday and Sunday. Hold on dialysis days.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's metoprolol was not given according to physician orders on the following days:
-6/5 morning dose;
-6/9 evenings dose;
-6/12 morning dose and
-6/18 morning and evening doses.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's metoprolol was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's metopolol MAR and stated the resident's metropolol should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

d. A 5/2/23 physician order indicated Resident 17 was prescribed apixaban (a blood thinner) one time a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's apixaban was not given according to physician orders on the following days:
- 6/8, 6/10, 6/12, 6/15, 6/17, 6/18, 6/20, 6/22, 6/27, 6/29, 7/1, 7/4 and 7/6.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's apixaban was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's apixaban MAR and stated the resident's apixaban should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

e. A 5/1/23 physician order indicated Resident 17 was prescribed atorvastatin (a cholesterol lowering medication) one time a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's atorvastatin was not given according to physician orders on the following days:
- 6/3, 6/8, 6/9, 6/15, 6/17, and 6/18.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's atorvastatin was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's atorvastatin MAR and stated the resident's atorvastatin should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

f. A 5/1/23 physician order indicated Resident 17 was prescribed sevelamer carbonate (used to lower blood phosphate levels when on dialysis) three times a day with meals.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's sevelamer carbonate was not given according to physician orders on the following days:
-6/3 noon dose;
-6/4 evening dose;
-6/5 morning and noon doses;
-6/6 noon dose;
-6/8 noon and evening doses;
-6/10 morning dose;
-6/11 morning dose;
-6/12 morning and noon doses;
-6/13 noon dose;
-6/15 morning and noon doses;
-6/16 noon and evening doses;
-6/17 morning and noon doses;
-6/18 morning, noon and evening doses;
-6/20 morning dose;
-6/22 morning and noon doses;
-6/27 noon dose;
-6/29 noon dose;
-7/1 morning and noon doses;
-7/4 morning and noon doses;
-7/6 morning and noon doses;
-7/8 morning dose and
-7/11 morning dose.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's sevelamer carbonate was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's sevelamer carbonate MAR and stated the resident's sevelamer carbonate should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

g. A 5/2/23 physician order indicated Resident 17 was prescribed Nephro-Vite (used to treat vitamin deficiency) one time a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's Nephro-Vite was not given according to physician orders on the following days:
- 6/5, 6/8, 6/10, 6/12, 6/13, 6/15, 6/17, 6/18, 6/22, 6/27, 6/29, 7/1, 7/4 and 7/6.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's Nephro-Vite was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's Nephro-Vite MAR and stated the resident's Nephro-Vite should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

h. A 5/3/23 physician order indicated Resident 17 was prescribed Nepro drinks (a nutritional supplement for individuals on dialysis) three times a day.

A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's Nepro drink was not given according to physician orders on the following days:
-6/2 evening dose;
-6/3 mid day dose;
-6/5 morning and mid day doses;
-6/6 mid day dose;
-6/10 morning dose;
-6/12 morning and mid day doses;
-6/13 morning and mid day doses;
-6/15 morning and mid day doses;
-6/16 mid day and evening doses;
-6/17 morning and mid day doses;
-6/18 mid day dose;
-6/22 mid day and evening doses;
-6/27 mid day dose;
-6/28 morning, mid day and evening doses;
-6/29 morning and mid day doses;
-7/1 morning and mid day doses;
-7/2 morning and evening doses;
-7/3 morning, mid day and evening doses;
-7/4 morning and mid day doses;
-7/5 morning, mid day and evening doses and
-7/6 morning, mid day and evening doses.

A review of Resident 17's health care record revealed no evidence the resident's physician was contacted when the resident's Nepro drink was missed or refused.

On 7/14/23 at 9:15 AM Staff 2 (DNS) reviewed Resident 17's Nepro MAR and stated the resident's Nepro drink should have been given on the dates identified. Staff 2 stated she expected the nursing staff to call the provider for all missed and refused medications. Staff 2 stated if medications were consistently missed due to dialysis, she expected the nursing staff to work with the resident's physician or herself to determine a better time to administer prescribed medications.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy for 1 of 1 sampled resident (#17) reviewed for oxygen. This placed residents at risk for unmet respiratory needs. Findings include:

The facility's Respiratory Treatment Policy and Procedure last revised 6/22/22 indicated the following:
-When residents had continuous oxygen therapy, the licensed nurse was responsible for checking residents oxygen therapy each shift and validating the regulator was set for the appropriate liter flow.

Resident 17 was admitted to the facility in 2022 with diagnoses including end-stage renal disease, chronic respiratory failure and heart failure.

Resident 17's 5/1/23 physician order indicated she/he required continuous oxygen at four liters per minute when resting, with activity and when sleeping.

On 7/11/23 at 2:30 PM and 7/12/23 at 12:09 PM Resident 17 was observed with oxygen administration being provided via nasal cannula between 1.5 and two liters per minute.

A review of Resident 17's 7/2023 health care record revealed no evidence the resident complained of shortness of breath and the resident's oxygen saturation levels (level of oxygen in the blood) were 90% or above.

On 7/12/23 at 12:17 PM Staff 7 (LPN) reviewed Resident 17's oxygen administration and reported the resident's oxygen flow was set between 1.5 and two liters per minute. Staff 7 verified Resident 17's physician order instructed the resident to receive continuous oxygen at four liters per minute. Staff 7 reported she completed rounds of Resident 17 earlier in the morning and did not notice the resident's oxygen was being incorrectly administered.

On 7/14/23 at 9:52 AM Resident 17 was observed with oxygen administration being provided via nasal cannula between 1.5 and two liters per minute. Resident 17 reported she/he felt fine and was not short of breath.

On 7/14/23 at 9:57 AM Staff 2 (DNS) reviewed Resident 17's oxygen administration and confirmed the resident's oxygen flow was set between 1.5 and two liters per minute. Resident 17 was resting in bed and reported on 7/13/23 evening shift, she/he told the nurse on duty that her/his oxygen flow was supposed to be at four liters per minute but the nurse did not make adjustments to her/his oxygen. Staff 2 stated she expected Resident 17 to receive oxygen at four liters per minutes as instructed by the physician's order.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 8, 11 and 12) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include:

A review of personnel records on 7/13/23 indicated the following employees had not received their annual performance evaluations:

-Staff 8 (CNA), hire date 4/9/22: no annual performance reviews were provided.
-Staff 11 (CNA), hire date 10/2/01: last performance review was completed on 2/20/20.
-Staff 12 (CNA), hire date 2/27/17: last performance review was completed on 12/10/20.

On 7/13/23 at 10:56 AM PM Staff 13 (Human Resource Director) confirmed annual performance reviews were not completed for the identified staff.

Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 1 of 2 medication carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include:

The facility's Medication Administration Policy indicated:
"Unlock medication cart: Cart may remain unlocked only when in direct line of sight and control by the nurse or medication aide who is administering the medications".

On 7/11/23 at 1:11 PM a medication cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 5 (LPN) verified the cart was unlocked.

On 7/11/23 at 2:10 PM a medication cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 6 (LPN) verified the cart was unlocked.

On 7/12/23 at 2:58 PM Staff 1 (Administrator) stated it was her expectation the carts remained locked when staff were not using them.

Based on interview and record review it was determined the facility failed to ensure physician's visit notes were in the resident's clinical record for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for inaccurate or incomplete records. Findings include:

Resident 2 was re-admitted to the facility in 2023 with diagnoses including disorder of the colon.

A review of Resident 2's clinical record revealed no routine regulatory physician's visits from 1/1/23 through 7/14/23 were documented in the resident's record.

On 7/14/23 at 9:51 AM Staff 2 (DNS) verified there were no regulatory physician's visit notes in Resident 2's clinical record. Staff 2 stated she was trying to obtain copies of the notes from the physician's office.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 8, 9, 10 and 12) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include:

On 7/13/23 at 9:48 AM Staff 1 (Administrator) stated in-service trainings were provided according the facility's training calendar, monthly staff meetings and via online courses.

On 7/14/23 at 10:59 Staff 1 provided the following annual CNA training hours for the past year:
-Staff 8 received five hours of annual in-service training;
-Staff 9 received six hours of annual in-service training;
-Staff 10 received six hours of annual in-service training and
-Staff 12 received nine hours of annual in-service training.

On 7/14/23 at 10:59 AM Staff 1 stated she expected CNA staff to receive at least 12 hours of in-service training annually.

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained and the use of Nursing Assistants (NAs) did not exceed more than 25% of the CNA staffing ratios on eight of 32 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports (DCSDRs) from 6/10/23 through 7/11/23 revealed the following days when state minimum CNA staffing ratios were not met and NAs exceeded the 25% ratio:

-6/10, 6/19, 6/20, 6/21, 6/25, 6/28, 7/3 and 7/5.

On 7/13/23 at 1:11 PM Staff 1 (Administrator) acknowledged the lack of CNA coverage and exceeded NA ratios on the identified days.

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411-086-0110 Nursing Services: Resident Care

Refer to 684 and F695

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411-086-0310 Employee Orientation and In-Service Training

Refer to F730 and F947

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OAR 411-086-0260 Pharmacy Services: Pharmaceutical Services

Refer to F761

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OAR 411-086-0300 - Clinical Records

Refer to F842
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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 12/26/2022 and 01/01/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.