**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, observations, interviews with the resident and staff, and a review of the facility's policy and procedure, the facility failed to ensure that the resident's environment remained as free of accident hazards as was possible for one (Resident #17) of two residents reviewed for accident hazards, from a total survey sample of 33 residents. The findings include: An observation was made of Resident #17 on 9/30/2024 at 1:55 PM in his room. He was awake and lying in bed under the covers watching television. During the observation of the resident's room, one shaving razor was observed inside of a plastic container on the bedside table located over the resident's bed. No facility staff were present. (Photographic evidence obtained) On 10/1/2024 at 9:39 AM, Resident #17 was observed again, lying in bed under his covers and watching television. During observations of the surrounding area, one shaving razor (same razor observed the previous day), was still inside of a plastic container on the bedside table next to the resident's bed. No facility staff were present. (Photographic evidence obtained) A return visit and interview on 10/2/2024 at 9:40 AM found that Resident #17 was in his room lying in bed under his covers and watching television. During the observation of the surrounding area of the bed, one shaving razor (same razor observed on previous days) was observed inside of a plastic container on the bedside table next to the resident's bed, and one shaving razor (second shaving razor found) was observed on top of the nightstand behind the resident's oxygen concentrator equipment, next to the bed. (Photographic evidence obtained) When asked if the facility allowed residents to store shaving razors inside their rooms, Resident #17 stated the certified nursing assistants (CNAs) were supposed to remove the razors from the rooms after shaving the residents. No facility staff were present. A review of Resident #17's medical record found that he was admitted to the facility on [DATE] with a previous admission on [DATE]. He had diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting his left non-dominant side, anemia, chronic respiratory failure, diabetes mellitus with diabetic polyneuropathy, peripheral vascular disease, chronic kidney disease - stage 2, anxiety disorder, cervical disc disorder with myelopathy, and fusion of the spine - cervical region. There was no indication in the record that the resident could safely shave himself. There were no physician's orders permitting Resident #17 to independently engage in personal hygiene tasks such as shaving. A review of the resident's Annual Minimum Data Set (MDS) assessment, dated 9/20/2024, revealed that Resident #17 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 possible points, indicating intact cognition. There were no documented signs of psychosis, behavioral symptoms, or rejection of care. Impairments in both upper and lower extremities, limitations in Activities of Daily Living (ADLs), and a need for substantial to maximal assistance for oral hygiene, toileting, and personal hygiene were also documented. Resident #17's care plan was reviewed on 9/24/2024 (Photographic evidence obtained) and revealed that he was at risk for decreased mobility, skin integrity issues, visual deficits, and communication deficits due to a history of cerebrovascular accident (CVA) with left hemiplegia. The goal was to ensure that he remained free from injury and skin breakdown. Interventions included providing substantial to maximal assistance with bathing, personal hygiene, dressing, nail care, and grooming on a daily basis, and as needed. CNA D was interviewed on 10/03/2024 at 1:45 PM. When asked which supplies were maintained inside of the residents' rooms, CNA D replied, Soap, lotion, and basins are kept in the residents' rooms. When asked where shaving razors or nail clippers were kept, CNA D stated items such as razors and nail clippers were kept in the central supply room. CNA D also stated after the CNAs finished shaving the residents, the razors were removed from the residents' rooms and disposed of inside of a sharps container. An interview was conducted with CNA C on 10/3/2024 at 2:12 PM. She was assigned to Resident #17 on 10/3/2024. When asked which items were allowed to be kept inside of residents' rooms, CNA C stated, Hairbrushes, lotions, basins, blue barrier cream, and items brought by family members such as body wash are allowed to be stored in the rooms. When asked about the process of shaving a resident at bedside, CNA C stated, I bring a razor from the central supply room and assist the resident with the shave. Once finished, I remove the razor from the resident's room and dispose of the razor in the sharps container. CNA C also stated sharps containers were located in the medication administration carts and in the shower rooms. On 10/3/2024, at 2:22 PM, CNA C was accompanied to Resident #17's room and was advised of the observation of the razors. CNA C observed two shaving razors that were left inside of the room: One shaving razor was in a plastic container on the bedside table, and one shaving razor was located behind the oxygen concentrator equipment, next to the bed, on top of the nightstand. CNA C confirmed that the shaving razors should not have been left inside of the resident's room. She acknowledged the oversight and promptly removed both razors from the room for disposal in a sharps container. A review of the facility's policy and procedure titled Procedural Guidelines (effective 1/2023 and updated 9/2023), revealed the following: 18. Tidy environment, remove supplies and store appropriately. A review of the facility's procedural guidelines found no evidence that the facility had established procedures to address sharp objects such as shaving razors and the proper storage and handling of them. (Photographic evidence obtained) .

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors from 27 opportunities for error, resulting in an error rate of 11%, and impacting three (Residents #48, #259 and #33) of five residents observed for medication administration, from a total survey sample of 33 residents. Failure to administer medications appropriately as ordered, could result in side effects and/or potential harm to the residents. The findings include: 1. During medication administration observation on 10/2/24 at 8:35 a.m., Licensed Practical Nurse (LPN) A was preparing medication for Resident #48. After reviewing the medication administration record (MAR), she stated she did not have Vitamin D3 1.25 milligrams (mg) equivalent to 5000 international units (IU) that was ordered for the resident. She checked the medication cart and obtained an over the counter (OTC) container of Vitamin D3, stating it was the wrong dosage because it contained Vitamin D3 25 microgram (mcg)(1000IU) tablets (Note: 1000 mcg = 1 mg, therefore 1.25 mg = 1250 mcg or 5 tablets of 25 mcg). On 10/2/24 at 8:47 a.m., LPN A notified Resident #48 that she did not have the Vitamin D3 and she would bring them to him once it was available. She proceeded to the nurses' station and contacted the pharmacy to see when the medication would be delivered. She stated the pharmacy representative explained to her that the medication was an OTC, therefore the facility was responsible for providing it. She then contacted the facility's central supply room and was notified that only Vitamin D3 25 microgram (mcg) tablets were available. LPN A stated she would check with another nurse to see whether she had the medication in her cart. Shortly thereafter, she returned and stated that medication was not available, and she would have to notify the physician to see what he would like to do. A review of Resident #48's active physician's orders revealed an order dated 6/6/24 for Vitamin D3 (Cholecalciferol) 1.25 mg (5000IU) by mouth one time a day (QD) every two weeks on Wednesday as a supplement. 2. During medication administration observation on 10/2/24 at 9:20 a.m., Registered Nurse (RN) B was observed preparing medication for Resident #259. She obtained an Aspirin 81 mg enteric coated (EC) tablet, crushed it, and mixed it with applesauce. She proceeded to the resident's room and administered the medication to the resident. A review of Resident #259's active physician's orders revealed an order dated 9/21/24 for Aspirin EC delayed release 81 mg one time a day for analgesic (pain). In an interview on 10/2/24 at 11:03 a.m., RN B confirmed that the medication was enteric coated and should not have been crushed. 3. During medication administration observation 10/2/24 at 8:23 a.m., Licensed Practical Nurse (LPN) A was observed preparing medications for Resident #33. She obtained the resident's vital signs and reported a blood pressure (BP) of 114/73 millimeters of mercury (mmHg) and a pulse of 114 beats per minute. She reviewed the Medication Administration Record (MAR) and obtained Aspirin 81 milligrams (mg), one tablet of Probiotics, Magnesium 500 mg, Metformin 500 mg, Clopidogrel 75 mg, Lasix 20 mg, Potassium 10 milliequivalent (mEq), and Protonix 40 mg from the medication cart. She stated she would be holding the Nifedipine 60 mg and Atenolol 25 mg because of the low blood pressure reading. She went to the resident 's room, administered the medication and notified the resident that she was holding her blood pressure medication because her blood pressure was low. A review of Resident #33's active physician's orders revealed an order dated 7/16/24 for routine Atenolol 25 mg one time a day for hypertension (high blood pressure) and routine Nifedipine Extended Release (ER) 24 hours 60 mg one time a day for blood pressure. In an interview on 10/2/24 at 8:47 a.m., LPN A was asked if the medication she held included parameters for when it should be held. She replied, No. She was then asked if she had an order to hold the medication and again, she answered, No, I was just using nursing judgement. She added that she normally held the medication when the resident had a systolic blood pressure (SBP) of less than 120 mmHg. During an interview on 10/3/24 at 2:48 p.m., the Director of Nursing (DON) confirmed that medication should not be held unless there is an order to hold it. If there were concerns with a resident's vital signs and the resident had scheduled medication, the expectation was that the nurse should notify the resident's physician. A review of the facility's policy and procedure titled Medication Pass and Med Pass with Medication Cart (Effective 1/2023, Updated 8/14/2024), revealed: Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systemically distribute medications to residents in accordance with state and federal guidelines. Fundamental Information: Physicians' Orders: Medications are administered in accordance with the written orders of the attending physician. If the dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication. Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. .

Based on observations, staff interviews, and a review of policies and procedures, the facility failed to serve food in accordance with professional standards for food service safety, by failing to ensure staff served food in a sanitary manner during two of two dining observations (lunch meals on 11/14/22 and 11/16/22) affecting Residents #34 and #18. The findings include: An observation of the lunch meal was conducted in the main dining room on 11/14/22 beginning at 11:57 AM. Certified Nursing Assistant (CNA) B was observed placing butter on Resident #34's roll using her bare hands. At 12:12 PM, CNA B used her bare hand to remove bread from a package (touching the bread with her bare hand) for Resident #49. Another lunch meal observation was made on 11/16/22 at 12:02 PM on the 100 hallway. CNA B was observed serving Resident #18 her meal tray. CNA B touched the roll on the lunch tray with her bare hand to place butter on the roll. An interview was conducted with CNA B on 11/16/22 at 12:03 PM. She stated she had recent training regarding safe food handling, and she probably should not have touched the bread with her bare hand. An interview was conducted with the Director of Nursing (DON) on 11/16/22 at 12:08 PM. The DON stated it was not acceptable for staff to handle food with bare hands. A review of the facility's policy for Serving Foods (SHCO30001.13, revised 2/21/17) revealed the purpose was to serve foods at the proper temperatures, attractively, and under sanitary conditions. .

Based on observations, interviews and record reviews, the facility failed to implement an effective infection control program, by failing to 1) Ensure staff followed infection control guidelines for hand hygiene during wound care for one (Resident #26) of two residents sampled for pressure ulcers, 2) Prevent cross contamination during catheter care for one (Resident #17) of one resident sampled for catheter care, 3) Ensure that the infection control committee was fully involved in the infection control program by offering feedback on infection control concerns during monthly meetings, and 4) Investigate an increase in urinary tract infections for one of two months available for review (October 2022). The findings include: 1. On 11/16/22 at 11:28 AM, an observation was made of Licensed Practical Nurse (LPN) A performing wound care for Resident #26. LPN A performed hand hygiene, applied clean gloves, removed the soiled dressing, removed her gloves, washed her hands, applied clean gloves, and then cleaned the wound. LPN A then applied the clean dressing without changing gloves or washing hands. LPN A proceeded to apply barrier cream to the peri-area without changing gloves or washing hands. On 11/16/22 at 11:50 AM, an interview was conducted with LPN A. When asked if LPN A changed her gloves and washed her hands between cleaning the wound and applying the clean dressing, she stated, No, I did not. When asked if LPN A changed her gloves and washed her hands after applying the dressing and applying barrier cream to the peri-area, she replied, No, I did not. LPN A confirmed that this could be an infection control issue. On 11/16/22 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated her expectation of the nurses was that they should wash their hands, apply gloves and remove the soiled dressing, then wash their hands and apply gloves, clean the wound from the inside out, wash their hands, apply gloves, and apply a dressing as per the facility's policy. On 11/16/22, a review was conducted of the facility's policy titled Clean Dressing Change, last revised on 11/28/2017, which revealed under Purpose: To ensure the licensed nurse or therapist completes dressing change in accordance with State and Federal Regulations, and National Guidelines. Under Procedure: 23. Cleanse wound as ordered with single outward strokes and using separate gauze for each cleansing wipe. 24. Use dry gauze or other ordered supply to pat the wound dry, as needed. 25. Discard any used gauze for cleaning/drying in resident's trash, as needed. 26. Remove gloves. 27. Hand hygiene. 28. [NAME] gloves. 29. Apply clean dressing as ordered and ensure dressing is dated. 30. Remove gloves. 31. Hand hygiene. 32. Hand hygiene. etc. 2. On 11/16/22 at 4:00 PM, an observation was made of Certified Nursing Assistant (CNA) D providing catheter care to Resident #17 with the assistance of CNA E. At the start of the observation, Resident #17's brief was loosened and tucked under his left side. CNAs D and E assisted the resident onto his right side. The brief was noted to be slightly soiled with a dark brown substance. CNA D instructed CNA E to get a new brief for the resident. Upon returning to the bed, CNA E proceeded to place the new brief on top of the soiled brief without attempting to remove the old brief. CNA E then informed CNA D to remove the old brief. The old brief was removed, however the new brief was left under the resident. At this time, the resident was rolled onto his back and CNA D left to gather supplies, leaving the resident uncovered with his genitals exposed. CNA D returned to the bedside with a basin of soapy water, two wash cloths and a package of disposable wipes. He then dampened the first washcloth in the basin and began to clean the catheter tubing in a back-and-forth motion from the tip of the penis down the tubing then back up the tubing toward the penis. CNA D discarded the cloth, changed his gloves, dampened the second wash cloth in the basin and washed the resident's genital area starting at the pubic bone, down between his right thigh and the right testicle, across the pubic bone, down between the left thigh and the left testicle, and then down the penis shaft and over the head of this penis. CNA D then wiped down the catheter tubing away from the penis. At no point did CNA D change the cloth or use a different area of the cloth. On 11/16/22 at 4:20 PM, an interview was conducted with CNA D. He stated during catheter care, you wash the head of the penis and the shaft, and then down the tubing starting with the cleanest field possible. He further stated that you start at the top and work your way down the penis. He then verified that the new brief was placed on top of the soiled brief and should have been changed out. On 11/17/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON), who stated that it was her expectation that during catheter care the staff member would clean down the tubing away from the penis and use a new cloth or another area of the washcloth to clean the genitals. She stated it was never okay to start at the top and work your way down the penis. The DON provided a copy of an in-service dated 9/2/22 titled Peri Care/E-Coli/UTI Prevention. CNA D signed as having attended. Attached to the sign-in sheet was a copy of the Perineal and Catheter Care training offered in the facility's online education program. Under the section titled Catheter Care it stated, Start by cleansing around the urethral meatus, which is the catheter's point of insertion, using a downward motion. Repeat this process to clean the entire perineum as described above. Remember to use a clean part of the washcloth with each stroke. Using a clean washcloth, cleanse the catheter itself starting at the urethral meatus working your way down the catheter about four inches or further if visibly soiled. Under the section titled Cleansing the Genital Area for males it stated, Grasp the penis and clean the tip using a circular motion starting at the urethral opening and working outward. Repeat until the area is clean moving down the shaft of the penis to the scrotum and inner thighs. Remember to use a clean part of the washcloth for each stroke to prevent contamination. A review of the policy SHCRC20007.06, Indwelling Catheter Care, last revised on 3/26/2019, stated on page 2, item #11, Clean by wiping away from the urinary meatus and not towards the urinary meatus. 3. On 11/17/22 at 9:00 AM, an interview was conducted with the DON, during which she stated that the infection preventionist had been out for several weeks due to an injury, and that she had been working in the role until his return a few weeks ago. She stated she had identified an increase in urinary tract infections (UTI) for the Month of October and felt this was due to the Medical Director ordering Urinalysis (UA) on any resident noted to have confusion. She stated she spoke with him a few nights ago about the need to have more than confusion to order a UA. She was asked if she had done any staff education as a result of the increase or if the infection control committee had made other recommendations. She stated the infection control committee met monthly at the beginning of each month and was made up of the department heads and a nurse and a CNA she pulled off the floor. She stated she only reported the infection rates for the previous month, and that she did all the talking and they just listen to me. She stated she had conducted an in-service in September for UTI Prevention and felt that the increase in UTIs for October was skewed, because everyone would test positive for a UTI if they were to have a UA every time they got confused. She stated the issue was systemic and not the fault of staff or care concerns. She stated she had not conducted audits of staff performing catheter or perineal care. She also stated that she was behind in the documentation related to tracking and trending of infections in the facility and that the data was available but was not always mapped out. She handed the surveyor two maps of the facility for what she stated were September and November. The maps identified each resident room and any room with an identified infection was highlighted using a color system on a key in the bottom left-hand corner of the documents. UTIs were highlighted in pink. Neither document had a month written on it to identify what month was being mapped out. When asked how she could tell what month the maps represented, she stated she would compare the map to the Monthly Infection Prevention & Control Summary Report. It was then when she realized the map she reported for September was actually for October, and she then wrote the month on the bottom of the map. She reported that she did not have a map for September but could make one quickly if needed. At this time, the DON provided a copy of the Monthly Infection Prevention & Control Summary Report for October 2022, which stated that the UTI (Urinary Tract Infection) rate for the facility was 14.2% in October, up from 2.1% in September, 2.8% for August and 2% in July. A review of the facility floor map dated for October for Healthcare Acquired Infections (HAI) revealed that of the 9 UTIs identified in October, 7 were on the south hall where the observation of catheter care had been conducted the previous afternoon in which concerns had been identified. When shown the map that identified increased concerns on the south hall, she stated, I did not catch that and I take full responsibility for that. A review of the policy Infection Prevention and Control Program, last revised in October 2018, revealed it read that the Infection prevention and control committee is responsible for reviewing and providing feedback on the overall program. Surveillance data and reporting information is used to inform the committee of potential issues and trends. Under item 11. Prevention of Infection (3) educating staff and ensuring that they adhere to proper techniques and procedures. .

Based on record reviews and interviews, the facility failed to provide treatment in accordance with professional standards of practice for one (Resident #58) of 34 sampled residents, by failing to hold a medication for five days prior to a scheduled procedure, as ordered, requiring the procedure to be rescheduled for a later date. The delay resulted in the resident being transferred to the hospital for care prior to her rescheduled surgery date. The findings include: In an interview on 3/30/2021 at 11:29 AM with Resident #58's the niece (Health Care Proxy), she stated, My aunt was scheduled for a procedure about two weeks ago, but the facility forgot to hold her aspirin prior to the procedure, and this caused the procedure to be put off for another week. My aunt ended up having to go out to the ER (emergency room) because of the procedure being delayed, because she was vomiting coffee grounds. A review of Resident #58's electronic medical record (EMR), revealed nursing progress notes which stated: Progress note: 3/11/2021: Resident returned to facility from appt. at approx 1700 (5:00 PM). New appt. 3/19/21 10 AM for upper endoscopy. Resident to be there at 8:30. Hold aspirin 5 days prior to appt. NPO (nothing by mouth) after midnight on 3/19/21. Can have clear liquid diet 3 hours prior to appt. Follow up appt. 4/1/21 at 11:45 AM. Progress note: 3/17/2021: Cancel appt. upper GI (gastrointestinal) for 3/19 and change to 3/24, NPO after mn (midnight) and clear liq (liquids) up to 3 hours prior to arrival time at 8:30. Stop clear liq at 5:30 AM, only 1/2 insulin morn (morning) of procedure. Trans slip in and niece notified. See instructions in chart. Progress note: 3/22/2021: New orders per Doctor, send to ER for GI bleed. Resident has had no further vomit at this time. Family notified. A review of the medication orders in the EMR revealed only one order, dated 3/19/2021, to hold the resident's aspirin dose: 3/19/2021: Aspirin 81 mg (milligram) tablet (chewable): one time only: hold aspirin x 5 days for surgery procedure 3/24/2021. A review of the Medication Administration Record (MAR) revealed Resident #58's ordered aspirin 81 mg was signed off as given on March 1, 2021 through March 16, 2021. It was signed off as held on March 17, 2021. It was signed off as given on March 18 and 19, 2021. It was signed off as held on March 20, 21, 22 and 23, 2021. The dose was discontinued on March 24, 2021. On 4/1/2021 at 10:21 AM, in an interview with the ADON, she was asked if she had any grievances or medication variances for Resident #58 related to her not having her aspirin 81 mg held for five days in March per the March 11, 2021 progress note mentioned above. She replied, Let me go see what I can find on that. I'm not familiar with Resident #58's occurrence. On 4/1/2021 at 11:10 AM, the ADON returned and stated, Okay, I just looked into this. Resident #58 was supposed to have her aspirin held for five days prior to a GI procedure on March 19th. It wasn't held, so it had to be rescheduled for March 24th, but on March 22nd she had some GI bleed symptoms and she was sent to the ER. The aspirin was on hold at that point for the March 24th procedure. I just called her niece to make sure she was aware that this happened, and she was. When asked whether a medication variance report was generated, she replied, Yes, I'll print you a copy. (Copy obtained) A review of the Medication Variance Report for Resident #58, dated 3/17/2021, read: Nursing description: Omission of order to hold aspirin for GI procedure. Resident description: Resident unable to give description. Immediate action taken: MD and family notified. GI procedure rescheduled for 3/24/2021. Though the facility documented on 3/17/2021 that the aspirin 81 mg had not been ordered or held per the 3/11/2021 progess note/order, and the appointment was rescheduled for 3/24/2021 with an order written to hold the aspirin 81 mg for five days prior to the 3/24/2021 surgery, on 3/19/2021, the fifth day before the surgery was scheduled, the medication was documented as having been given. The surgery appointment was delayed due to the facility's failure to hold medication as ordered, and the resident had to be sent to the hospital for care prior to her rescheduled surgery date as a result. (Copies obtained of all documentation noted above.) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #63) resident in a total sample of 34 residents. The findings include: A review of Resident #63's medical record, revealed and admission date of 10/29/2018, with a primary diagnosis of hemiplegia and hemiparesis following CVA (cerebrovascular accident - stroke). The secondary diagnoses included visual loss in the right eye, spondylosis and right hand contracture. The resident's cognition was impaired and she required extensive assistance with activities of daily living, including toileting and transfers. During a tour of the facility on 3/31/2021 at 2:58 PM, Resident #63 was overheard from the hallway yelling for help. Upon entering the room, the resident was observed yelling for help while sitting on the toilet in her bathroom. The room's call light was then triggered by the resident's roommate. On 3/31/2021 at 3:05 PM, two employees, identified as certified nursing assistants (CNA), were observed walking down the hallway and entering each room while giving verbal report. Resident #63 continued to yell for help and her call light was on outside of her room. The employees did not acknowledge the call light or the resident's verbal pleas for assistance. On 3/31/2021 at 3:08 PM, Employee G, CNA, was asked to check on the resident, as she had been yelling for assistance for approximately ten minutes. The employee explained that the resident was able to use the call cord in the rest room. She then entered the room. The CNA exited the room and exclaimed, That wasn't the resident I thought it was! That resident is actually blind and she can't pull the call cord. She is blind and has half a skull. She should never be left unattended! On 3/31/2021 at 3:10 PM, Employee H, CNA, entered Resident #63's room. She was the resident's assigned CNA. Upon exiting the room, Employee H stated, I could do it if we had more staff. Then we wouldn't have to run around like chickens with our heads cut off. A review of the resident's comprehensive care plan revealed a focus area for bowel and bladder incontinence. The care plan indicated the resident's incontinence placed her at risk for falls. An intervention on the care plan directed staff to remain with the patient during toileting to ensure safety. (Photographic evidence obtained) On 4/1/2021 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing (ADON). She was asked to explain how staff accessed the care information specific to each resident. She explained that the facility's process was for direct-care staff to use the [NAME] for each resident, and that the staff were required to sign off on the care they provided each shift. The ADON confirmed that if a resident's care plan directed staff to remain with the patient during toileting, the resident should not be left alone while toileting. .

Based on observation, interviews and record review, the facility failed to maintain complete, documented medical records for two (Residents #13 and #40) of 34 sampled residents , by failing to document apical pulses for Digoxin and blood pressures and heart rates for Lisinopril and Carvediolol. The findings include: 1. A record review was conducted for Resident #13, which noted an admission date of 7/17/2021 with diagnoses including congestive heart failure and hypertension. Physician's orders were reviewed, which noted an order for Lisinopril 2.5 mg (milligrams) daily, dated 7/19/2020, with parameters (hold if systolic blood pressure is below 110, diastolic below 60 and heart rate below 60), and Carvedilol 6.25 mg daily with parameters (hold for heart rate below 50 or systolic below 100), dated 3/22/2021. A review of the current Medication Administration Record (MAR) revealed that Lisinopril and Carvedilol were given daily with no blood pressures or heart rates documented. (Photographic evidence obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 3/31/2021 at 2:11 PM. She was asked to review the current MAR. The ADON reviewed the current MAR and confirmed the Lisinopril and Carvedilol had parameters which were not documented on the MAR. She confirmed the heart rates and blood pressures were missing. 2. A record review was conducted for Resident #40, which noted an admission date of 8/11/2011 and a re-entry date of 11/17/2020, with the following diagnosis: atrial fibrillation. A review of the current MAR, noted Digoxin 125 mcg (micrograms) daily, dated 8/24/2018, for heart disease, with no apical pulses documented. An interview was conducted with Employee D, Registered Nurse (RN), at 8:40 AM on 3/31/2021, while observing medication administration. The RN reported that when physician's orders were added to the electronic medical record, there was a place to add documentation for blood pressure or apical pulses, if needed, for medications. An interview was conducted with the ADON on 3/31/2021 at 2:03 PM. She reviewed the current MAR, and confirmed that apical pulses were not documented for the Digoxin. The ADON confirmed apical pulses should be taken and documented before administering Digoxin. The ADON corrected the MAR and added apical pulse to the Digoxin order. She also reported the resident required monthly vital signs. An interview was conducted with the ADON on 3/31/2021 at 4:30 PM. She reported that the resident had not had apical pulses documented since July 2020. (Photographic evidence obtained) A review of the policy and procedure for Medication Pass Guideline (Revised on 4/25/2017), noted the following under physician's orders: Medications are administered in accordance with written orders of the attending physician. Under Procedure 6:If applicable and or prescribed, take vital signs or tests prior to administration of dose (pulse with digitalis, blood pressure with anit-hypertensive) use. .