**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide care consistent with professional standards of practice to prevent a facility-acquired pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence which will often present as an open ulcer because of intense and/or prolonged pressure. Soft tissue damage related to pressure may also be affected by skin temperature and moisture) for one Resident (#65) out five applicable residents, in a total sample of 22 residents. Specifically, the facility staff failed to assess the Resident's skin based on facility policy and professional standards, resulting in the development of a Stage 3 pressure injury (Full-thickness skin and tissue loss in which subcutaneous (beneath the skin) fat may be visible in the ulcer and granulation tissue (new connective tissue) and epibole (rolled edges) are often present), and subsequent wound infections, requiring multiple hospitalizations and surgical interventions. Findings include: Review of the facility policy titled, Skin Check, undated, indicated the following: - It is the policy of the facility to perform skin checks on all residents who reside at the facility. Skin checks are to be performed by a Licensed Nurse on admission and weekly thereafter. Skin checks may also be performed as needed, such as per Physician's order, upon resident/family request, or any other circumstances that require a skin check. The plan of care begins at admission. - In response to the completed skin check, the facility shall activate skin interventions promptly . Skin checks may be scheduled on the resident's preferred day schedule or per Physician's order. Resident #65 was admitted to the facility in February 2023 with diagnoses including Cervical Disc Disorder with radiculopathy (compressed nerve in the neck resulting in pain, muscle weakness and numbness), urinary tract infection, low back pain, other specified Spondylopathies (inflammation in the spine) and a Neurogenic Bladder (lack of bladder control due to a brain, spinal cord or nerve problem), requiring use of a suprapubic catheter (a hollow flexible tube inserted into the bladder through the abdomen, used to drain urine). Review of the Clinical admission assessment dated [DATE], indicated the Resident did not have any skin issues. Review of the admission Norton Scale (an assessment tool widely used to assess the risk for pressure ulcer in adult patients. The five subscale scores of the Norton Scale are added together for a total score that ranges from 5-20) dated 2/21/23 indicated a score of 14 (A lower Norton Score indicates higher levels of risk for pressure ulcer development. Generally, a score of 14 or less indicates at-risk status). Review of Resident #65's Physician's orders indicated the following: - Weekly skin check - complete weekly skin check documentation on weekly skin assessment UDA in the evaluation section of Point-Click-Care (the facility's electronic health record system), initiated 2/21/23. - Hydrocortisone External Cream 2.5% (Hydrocortisone Topical, a steroid cream used to reduce swelling, itching and redness), apply to rectal area topically three times a day, 14 days on (use) and 7 days off (do not use) for hemorrhoids, initiated 2/21/23. Review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], indicated: -the Resident was at risk of developing pressure injuries, -did not currently have any pressure injuries -and interventions included a pressure reducing device for the Resident's bed and application of ointments/medications other than to his/her feet. Further review of the MDS assessment indicated the Resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of the Resident's Skin Care Plan dated 3/5/23 indicated the following: - The Resident was at risk for skin breakdown due to pain, impaired mobility, and suprapubic catheter use (a tube inserted through the abdomen into the bladder to drain urine). - A Licensed Nurse should check my skin weekly. - I need a pressure relief mattress on my bed. - I need to be reminded to turn and position myself. - I need the help of staff to turn/reposition me every two hours to prevent me from getting skin breakdown as needed. - Please apply house barrier cream to my bony prominences each shift. - Please perform a Norton Plus assessment quarterly. Review of the Weekly Skin Check Assessments indicated the following: - 3/14/23 - Skin clean and intact - 3/21/23 - Skin clean and intact - 3/28/23 - Skin clean and intact - 4/4/23 - Skin clean and intact - completed by Unit Manager (UM) #4 - 4/11/23 - Skin clean and intact - completed by UM #4 - 4/18/23 - Skin clean and intact - completed by UM #4 Review of the Weekly Pressure Injury Evaluations, dated 4/20/23, indicated the following: -Stage 3 pressure injury to the sacrum (area below the lumbar spine and above the tailbone) measuring 11 centimeters (cm) long by (x) 3.5 cm wide x 1.5 cm deep. -The wound bed contained yellow slough, firm wound edges, moderate amount of serous (clear fluid) drainage. -The peri-wound (area surrounding wound) had hardened skin and was painful. During an interview on 6/23/23 at 2:25 P.M., UM #4 said on 4/20/23, Resident #65 told her that his/her hemorrhoids have been bothering him/her and asked the UM to assess the area. UM #4 said she observed the area and discovered Resident #65 had a very large wound to his/her sacral area (area below the lumbar spine and above the tailbone). UM #4 said she had been completing the weekly skin checks prior to 4/20/23, but she never assessed the Resident's sacral area during that time. During an interview on 6/27/23 at 9:44 A.M., CNA (Certified Nurses Aide) #1 said the Resident usually did all his/her own personal care, including showering without the assistance of the CNAs, therefore they were not aware of the Resident's wound prior to it being discovered on 4/20/23. During an interview on 6/27/23 at 10:33 A.M., Nurse #7 said it is the responsibility of the nursing staff to complete weekly skin checks on all residents. She further said this is often done on shower days and that the CNAs were also good about letting Nurses know when there was a concern with a resident's skin. Nurse #7 said it is the responsibility of the Nurses to ask all residents, including those who are independent with care to assess their skin, and if the resident should refuse assessment, it should be documented in the medical record. Nurse #7 further said that skin checks should include the entire body, head to toe, front and back. Review of the Initial Progress Note, dated 4/20/23 by the facility's Wound Care Physician indicated the following: -Patient seen today for a Stage 3 coccyx (small triangular bone at the base of the spine) pressure injury measuring 11 cm x 3.5 cm x 1.5 cm. -Noted to have moderate serosanguineous drainage (drainage consisting of blood and clear fluid). -Tissue containing 80% slough and 20% epithelial tissue (a type of body tissue that forms covering on all internal and external surfaces of the body). Review of Resident 65's medical record indicated the Resident was transferred to the hospital on 4/24/23. Review of the Emergency Medicine Note, dated 4/24/23 indicated the following: -Resident said he/she was sent to the hospital for further evaluation as to why he/she had been feeling so unwell for the past few months, feeling generally weak, with decreased appetite. Notes a sacral wound which has been treated at the facility but stated over the past week the wound started to become very foul-smelling and during this time he/she experienced worsening nausea, increasing fatigue and feeling more unwell. -Examination: large foul-smelling and necrotic (dead tissue) appearing sacral wound tracking into intergluteal cleft (groove between buttocks below the sacrum to the perineum (area between the anus and vulva or scrotum). - Laboratory work showing leukocytosis (high WBCs-white blood cell count), computerized tomography (CT) scan concerning for possible cellulitis (skin infection)/soft tissue infection/abscess (pocket of pus) formation. -Surgery contacted for possible debridement (the removal of dead, damaged, or infected tissue to improve the healing potential of remaining healthy tissue). Review of the Hospital Operative Note, dated 4/25/23 indicated the following: - Resident brought to operating room, intubated (breathing tube placed into the trachea/windpipe) and sedated by Anesthesia. -Using a surgical blade, the eschar (dead, devitalized tissue) overlying the wound were sharply incised (cut) down to the subcutaneous tissue down to the muscle layer. -Using a combination of electrocautery (instrument that is electrically heated) and sharp dissection we debrided to the best of our ability. -At the superior (top) pole of the wound, there was a pocket of purulent (pus) fluid noted. -Over 20 square cm of tissue was removed, and we deemed the sacral decubitus ulcer (pressure injury) to be a Stage 4, down to the muscle layer overlying the sacrum. Review of the Hospital Discharge summary, dated [DATE] indicated the following: - Resident admitted for treatment of necrotic sacral wound infection with left gluteal crease abscess and surrounding soft tissue infection. Review of the facility's Physician Assistant (PA) post-hospitalization progress note dated 5/2/23 indicated the following: -Resident was admitted to the hospital with necrotic sacral wound infection with left gluteal crease abscess and was treated with intravenous (medicines/fluids given through a tube or needle inserted into a person ' s veins) antibiotics and seen by surgery for debridement. -He/she was discharged from the hospital and was to continue with a ten day course of Augmentin (an oral antibiotic) to end on 5/9/23 and has been referred to the wound clinic. -Plan to continue with daily wound care, turn and reposition every two hours and as needed, off-load (reduce pressure/weight on a body part) bony prominences, monitor for incontinence (lack of control of bowel and/or bladder) and moisture control and optimize nutrition. Review of the facility's Physician Assistant (PA) progress note dated 5/17/23 indicated the following: - Wound with strong odor and serosanguineous drainage, peri-wound with erythema (redness). Needs debridement therefore will send to the emergency department. Review of a Nursing progress note dated 5/17/23 indicated the following: - PA in to visit Resident and notified this author the Resident would need to be sent to the emergency department for debridement of wound as well as concern over the odor from the wound. Review of the Hospital Discharge summary dated [DATE] indicated the following: - Large decubitus ulcer (bedsore) evaluated by the medicine team, plastic surgery team and general surgery team. -He/she went to the operating room and had a debridement. -We have been using a wound-vac (a type of therapy that utilizes negative pressure using a suction pump, tubing, and a wound covering/dressing to remove excess wound drainage and to promote healing in chronic wounds) since the surgery. -We discussed the potential for a diverting colostomy (a surgical procedure that [NAME] the colon and diverts the upper part to an artificial opening within the abdomen) and possible reconstruction with plastic surgery. -The wound cultures grew Enterococcus (a type of bacteria) and Methicillin-Resistant Staphylococcus Aureus (MRSA, a bacteria resistant to certain antibiotics) and he/she is being discharged on antibiotics. Review of a Wound Clinic progress note dated 6/8/23 indicated the following: - Pre-procedure diagnosis of Wound #1 is a pressure injury. There was an excisional skin/subcutaneous/muscle debridement with a total area of 75 square centimeters. -Post-debridement measurements: 12.5 cm length x 6 cm width x 4 cm depth. During an observation and interview on 6/21/23 at 11:37 A.M., the surveyor observed Resident #65 to be seated in a wheelchair with a wound-vac being used to treat the pressure injury. The Resident said he/she did not have a wound when he/she entered the facility. During an interview on 6/23/23 at 8:40 A.M., Resident #65 said prior to the wound, he/she slept in a recliner chair with no pressure relief. The Resident said he/she began having pain in his/her backside, and thought it was hemorrhoids. Resident #65 said the Nurses provided medication for hemorrhoids for him/her to self-administer without checking the area that was causing pain. Resident #65 said when the pain did not improve after using the hemorrhoid cream, he/she asked the Nurse to look at the area and the wound was identified. The Resident reiterated that staff did not look at his/her skin routinely until he/she asked. They never asked to check my skin and I would have never refused. Review of Resident 65's care plan failed to indicate a care plan for the self-administration of Hydrocortisone cream and failed to indicate the Resident, who was at risk for skin breakdown did not sleep on a pressure relieving mattress, but instead slept in his/her recliner chair full-time. Review of the Nursing 2022 Drug Handbook, 42nd Edition by Wolters Kluwer, copyright 2022, pg. 729 indicated the following: - Hydrocortisone (topical), adverse reactions: skin - impaired wound healing, fragile skin, petechiae (small red or purple spots that can appear on the skin), erythema (redness), sweating. During an observation and interview on 6/27/23 at 10:55 A.M., the surveyor observed Nurse #3 perform wound care for the Resident. The surveyor observed the Resident lying in his/her bed on an air mattress. The surveyor also observed a fitted sheet, a folded sheet and a soaker pad underneath the Resident, who was also wearing an incontinence brief. After observing Nurse #3 remove the wound-vac and the associated dressings from the wound, the surveyor observed a wound measuring approximately 11 cm long x 7 cm wide with the wound bed containing approximately 75% tan slough with scattered dark brown areas and 25% granulation tissue. The wound was surrounded by blanchable erythema (reddened skin that turns white when pressed). Nurse #3 stated that when a Nurse performs a skin check, it is head to toe as well as front and back. Nurse #3 further said that the Resident should not be laying on multiple layers of linens as the increased heat and moisture caused by the layers are not good for wound healing.

Based on observations, interviews and record reviews, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence and occurs as a result of intense and/or prolonged pressure or pressure in combination with shear: force pushing down such as between patient and bed) through use of A.) an air mattress and special booties to relieve pressure and shear, and B.) provide the necessary treatment and services to promote healing and prevent infection of the wounds when they developed such as providing daily dressing changes, and responding to presence of infection for one sampled Resident (#70), out of a total sample of 30 residents. Findings include: Resident #70 was admitted to the facility in February 2022 with a diagnosis of Diabetes Mellitus (a chronic condition that affects the body's ability to process glucose: blood sugar). On 6/21/22 at 9:56 A.M., the surveyor observed Resident #70 lying in a regular bed with dressings present on his/her bilateral heels which were not dated/timed or initialed. During an interview, Resident #70 said the wounds were painful. The surveyor observed dressing supplies on the windowsill and bedside table in the room. There was no evidence that the resident was on a specialty mattress. On 6/22/22 at 12:32 P.M., the surveyor observed Resident #70 seated in a wheelchair at the bedside, fully dressed and eating lunch. He/she was wearing non-skid socks with sandals and did not have booties on. On 6/27/22 at 10:13 A.M., the surveyor observed the Resident #70 lying in bed and he/she moved his/her feet out from under the covers. The Surveyor observed the Resident's feet were dry, the toenails were very long, and extended over the end of his/her toes and were discolored and thick. There was a gauze dressing on the right foot, and a border dressing on the left heel, both which were peeling off the feet around the edges. The dressing on the right foot was dated 6/24/22. The dating of the left foot dressing was not visible in the Residents position. The bottom sheet on the bed had dried brown stains on lower portion of sheet by the Resident's feet. The left heel dressing was noted to be stained with old serosanguinous (a mixture of blood and serum: thin watery body fluid) drainage. On 6/28/22 at 11:08 A.M., the surveyor observed Resident #70 seated in a wheelchair at the bedside wearing non-skid slipper socks. There were no protective booties on his/her feet. On 6/29/22 at 11:18 A.M., the surveyor observed Resident #70 lying in bed on a regular mattress and had on slipper socks. His/her right heel was elevated on a pillow. The Surveyor observed protective booties were lying on the floor next to the side of the Resident's bed. On 6/30/22 at 9:01 A.M., the Surveyor observed Resident #70 lying in bed, head elevated, eating breakfast. The outlines of the resident's feet were visible under sheet and the Surveyor noted there were no protective booties on. Review of the Minimum Data Set (MDS) Assessment, dated 2/14/22, indicated Resident #70 was at risk for pressure ulcer development and had no pressure areas on admission. Review of a Progress Note, dated 2/22/22, indicated the Resident had large blisters on bilateral heels and an open area on upper coccyx. Review of a Progress Note, dated 2/26/22, indicated the Resident had a necrotic (dead skin/tissue) left heel wound. Review of the MDS Assessment, dated 2/28/22, indicated: there were pressure ulcers present: two stage 2 pressure ulcers and one unstageable pressure ulcer. Review of the Physician's Orders for June 2022 indicated the following active orders: -Air mattress to bed, set to weight/resident comfort; monitor setting and function every shift (3/25/22) -Heel protectors for a Deep Tissue Injury (DTI) Left heel (2/10/22) -Order Z boots (a type of padded protective booties to relieve pressure) to keep patient's heels elevated every shift (4/28/22) -sacral area: inspect skin daily, apply foam dressing to area every day (4/2/22) -Weekly skin check (2/8/22) -Wound documentation Left heel every day (2/28/22) -Wound documentation Right heel every day (3/10/22) -Wound documentation sacrum every day (5/19/22) -Cleanse bilateral heels with Normal Saline, pat dry, apply Medihoney (a product used to prevent infection and promote the healing of pressure wounds) pad to wound bed, skin prep to wound edge, apply ABD and kerlix every day for wound care (6/27/22) Review of the June 2022 Treatment Administration Record (TAR) indicated: -all wound assessments and treatments were signed off as being completed, with the exception of when the Resident was in the hospital -Vancomycin Resistant Enterococci (VRE: bacteria, normally present in the intestines that are resistant to Vancomycin, a powerful antibiotic) precautions were documented as being maintained every shift -Air mattress was signed off as being checked every shift Review of the June 2022 Medication Administration Record (MAR) indicated: -Z boots to keep heels elevated were signed off on all shifts as done with the exception of when the resident was hospitalized . During an interview on 6/23/22 at 12:37 P.M., Nurse Practitioner #1 said the Resident developed wounds while at the facility, and subsequently developed an infection and was put on Vancomycin. During an interview on 6/27/22 at 10:20 A.M., Nurse #9 said the dressings are the ones she put on Friday 6/24/22. She said the wound care is supposed to be done daily and had not been completed as ordered. During an interview on 6/27/22 at 10:52 A.M., Certified Nurse's Aide (CNA) #5 said if a resident wears protective boots, the nurses usually tell the aides. She was not aware that boots were ordered for Resident #70. She further said the Resident had a regular mattress. During an interview on 6/27/22 at 11:05 A.M., Nurse #9 said Resident #70 had an air mattress but did not have it anymore. On 6/27/22 at 11:24 A.M., the surveyor observed Nurse #9 looking for protective booties and found them in the closet. Nurse #9 said that nursing had to sign them off as being applied so the nurses should apply them, not the CNAs. On 6/27/22 at 11:38 A.M., the surveyor reviewed the June 2022 MAR and TAR with Unit Manager (UM) #2 who said that that the VRE precautions were being signed off as being done and they are no longer in effect. She also said the air mattress was being signed off on the TAR and there was no air mattress in use for this Resident. During an interview on 6/28/22 at 12:33 P.M., UM #2 said Resident #70 had a regular mattress on his/her bed and was not on an air mattress. She said the Resident was at risk for skin breakdown, had pressure wounds, and there was a doctor's order for an air mattress and the order was not followed as required.

Based on observation, interview and record review, the facility failed to ensure that it's staff managed pain, consistent with professional standards, during a dressing change for one sampled Resident (#70) out of a total sample of 30 residents. Findings include: Review of the facility policy titled: Administering Pain Medications, revised March 2020, indicated the following: -The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice the comprehensive care plan, and the resident's choices related to pain management. -Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals and includes assessing the potential for pain. Resident #70 was admitted to the facility in February 2022 with a diagnosis of Opioid dependency in remission. Review of the Physician's Orders for June 2022 included the following orders: -Acetaminophen (Tylenol: a mild pain reliever) 325 milligrams (mg) tablets: give two tablets every 4 hours as needed for pain (2/8/22) -Diclofenac Sodium Gel 1% (a topical pain reliever): Apply to legs topically every eight hours as needed for leg pain (2/10/22) -Gabapentin (a pain medication used to treat neuropathic pain: pain caused by nerve damage or dysfunction) 400 mg by mouth three times a day for pain (2/16/22) -Methadone Hydrochloride (a synthetic drug used in the treatment of morphine and heroin addiction) concentrate 10 mg/milliliter(ml): Give 10 ml by mouth one time a day for pain (2/15/22) Review of the Clinical admission Evaluation, dated 2/8/22, indicated that the Resident had a history of chronic pain, complained of pain during the evaluation, and that facial grimacing was an indicator of pain. On 6/27/22 at 11:06 A.M., the surveyor observed Nurse #9 in Resident #70's room as she prepared to provide wound care. The surveyor observed the left heel dressing was peeling off around the periphery (edges) of the dressing and had old blood-tinged drainage on it and the center of the dressing was adhered to the wound. The old dressing on the right heel was removed easily but the left heel dressing was stuck to the Resident's foot. Nurse #9 repeatedly sprayed wound cleanser to the old dressing on the left heel, to moisten the dressing and help remove it from the wound bed. Resident #70 was observed with facial grimacing and tensing the left leg, and drawing the left foot away from Nurse#9 as she attempted to peel the old dressing off the wound on the left foot. At 11:13 A.M., during the procedure, Unit Manager (UM) #2 came into the room and stood at the Resident's side. The Resident reached out and grabbed UM #2's hand and told her that he/she was in pain. UM #2 provided reassurance to the Resident and instructed Nurse #9 to medicate the Resident with pain medication, as the old dressing was being removed. The old left heel dressing was noted to be saturated with serosanguinous (a mixture of old blood and body fluid) and purulent (pus containing) drainage. Wound care was provided as ordered and the remainder of the procedure was uneventful. At 11:24 A.M., the surveyor observed Nurse #9 as she assessed the Residents pain by asking the Resident to rate the pain on a scale of 1-10, and Resident indicated it was number 6 on the 1-10 scale and was medicated at this time. During an interview at the time of the observation, Nurse #9 said that the dressing was stuck to the Resident's wound and she should have medicated the Resident prior to the dressing change. During an interview on 6/27/22 at 11:47 A.M., U.M. #2 said the Resident should have been assessed for pain prior to the dressing change and pre-medicated. She said it had been several days since the dressing was last changed and was stuck to the wound which increased the Resident's pain during the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. For Resident #117, the facility failed to ensure that the air mattress used to prevent skin conditions was set appropriately. Resident #117 admitted to the facility on [DATE] with diagnoses including epilepsy, hemiplegia (partial paralysis) and Dementia with behavioral disturbance. Review of MDS Assessment, dated 5/26/22, indicate that Resident #117 was at risk for developing pressure ulcers and used a pressure reducing device for the bed. Review of Resident #117's Skin Care Plan, revised 3/28/22, included an intervention for the air mattress to be set at 4 BARS (setting on the mattress which indicated firmness/softness)/comfort, and to check the setting/function every shift. Review of Resident #117's June 2022 Physicians Orders, revised 3/28/22, indicated the air mattress was to be set at 4 BARS/comfort, and to check the setting/function every shift to promote positive skin integrity. On 6/21/22 at 9:46 A.M., Resident #117 was observed lying on his/her air mattress set at 5 BARS. The setting box to the air mattress had a label that indicated for the mattress to be set at 4 BARS. On 6/22/22 at 11:40 A.M., Resident #117 was observed lying on his/her air mattress set at 5 BARS. On 6/23/22 at 8:11 A.M., Resident #117 was observed lying on his/her air mattress set to 5 BARS. On 6/23/22 at 8:33 A.M., Nurse #1 said that she looked at the TAR or the Physician's Orders for instructions on the Resident's air mattress and said that it was not set appropriately. Based on observations, interviews and record reviews the facility failed to ensure staff provided care in accordance with professional standards of practice for five Residents (#28, #70, #43, #95 and #117), out of the 30 residents sampled specifically when they 1) Failed to properly store medications, 2) Allowed unlicensed staff to apply prescription medications, 3) Failed to obtain specialty consults as ordered by the physician, 4) Failed to administer medication in a timely manner, 5) Failed to follow medication and treatment orders prescribed by the physician and 6) Failed to collaborate with hospice for the Patient's plan of care. Findings include: 1. For Resident #28, the facility failed to provide care consistent with professional standards for a skin condition by: A) improperly storing prescription creams, B) application of prescription treatments by unlicensed personnel, C) failing to obtain a psychiatric consult, and D) administering medications beyond the two-hour medication administration window which resulted in increased physical and emotional discomfort for the Resident. Resident #28 was admitted to the facility in September 2021 with Psoriasis (a long-lasting skin disease characterized by raised, red, dry and itchy patches) and anxiety disorder. Review of the Minimum Data Set (MDS) Assessment, dated 3/23/22, indicated the Resident scored 15 out of 15 on the Brief Interview of Mental Status (BIMS) and was cognitively intact. On 6/21/22 at 11:46 A.M., the surveyor observed a large container of prescription cream in Resident #28's room. The Resident stated he/she has had Psoriasis for a long time, but this was the worst the Psoriasis had been. Resident #28 also said that a Dermatologist had seen and ordered medications for the rash. On 6/22/22 at 11:55 A.M., the surveyor observed Resident #28 lying in bed and observed a reddened rash on his/her bilateral lower arms, face and lower legs. There was a large container of prescription cream on the top of the dresser and the pharmacy label indicated it was to be applied twice daily. Resident #28 said the rash was all over his/her body, he/she had always had it, and the Dermatologist thought the rash had worsened due to stress and ordered a Psychiatric consult. On 6/23/22 at 10:24 A.M., the surveyor observed Resident #28 in his/her room. There were patches of redness and scabbed areas over his/her back, abdomen, groin, arms, and legs with several small superficial open areas. Resident #28 said the rash was a little less itchy, but he/she had scratched it a lot. The Certified Nurse's Aide (CNA) #6 arrived to provide care and showed the surveyor the prescription cream that was in the top drawer of the dresser. During an interview at the time of the observation, CNA #6 said that the CNAs put the cream on when Resident #28 asked for it and said that the Nurses also applied the cream. He said when he was in the room providing care, he had applied the cream himself, rather than get the Nurse who is all the way up the hallway. During an interview on 6/28/22 at 9:23 A.M., Resident #28 said he/she was concerned about the staffing on weekends and nights, and that medications were not given on time; one day morning medications were not given until 2:30 P.M. Resident #28 said that he/she knows which medicines he/she gets and when he/she was supposed to get them, it was upsetting to get the medications so late and when he/she gets upset the rash and itch worsens. Review of Resident's record indicated Resident #28 declined to self-administer medications and preferred the Nurse to administer medications. Review of the June 2022 Physician's Orders indicated the following active orders: -Hydroxyzine hydrochloride (a medication used to treat itching) tablets give 10 milligrams (mg: measurement denoting strength) by mouth three times a day -Clobetasol Propionate Cream 0.05% (a topical skin treatment to decrease inflammation and irritation) apply to generalized skin rash every day and evening shift, and as needed for psoriasis (6/9/22). -Triamcinolone Acetonide Cream 0.1% (a treatment applied directly to the skin to reduce redness, swelling and itching) apply to skin rash/lesions topically two times a day for psoriasis 5/18/22. -Escitalopram (a medication used to treat anxiety disorder) tablet 20 mg by mouth once a day (9/16/21) Review of the Medication Administration Audit Report for June 2022 indicated the following: -Escitalopram was documented as given outside the two-hour medication window five times out of 28 opportunities during the month of June. -Hydroxyzine was documented as given outside the two-hour medication window on the day shift four times out of 56 opportunities during the month with medication given at 2:24 P.M. on 6/10/22 and 1:33 P.M. on 6/25/22. On the evening shift, Hydroxyzine was documented as administered beyond the two-hour window nine times out of 28 opportunities during the month of June. -Triamcinolone was documented as administered outside the two-hour medication window eight times on the day shift and eight times on the evening shift during the month of June. -Clobetasol was documented as administered outside the two-hour administration window five times on the day shift and four times on the evening shift in the month of June. Review of the Resident's record indicated an order for Psychiatric consult dated 5/27/22. There was no evidence in the record that the Psychiatric consult had been completed. Review of the Nursing Care Plan indicated a Skin Rash Care Plan was initiated 6/24/22, during the survey. During an interview on 6/28/22 at 12:41 P.M., Unit Manager (UM) #2 said she was not aware of late administration of medications. She said there were times when the Nurses were not available to administer resident medications at 7:00 A.M., but should definitely be on the medication cart by 8:00 A.M. to dispense Resident medications. She said there was supposed to be a medication error report completed if medications are given outside the administration time (one hour before/after the scheduled administration time). During an observation on 6/23/22 at 11:32 A.M., UM #2 accompanied the surveyor to Resident #28's room and together observed the Triamcinolone cream and Clobetasol cream, both with pharmacy labels, which were in the Resident's top dresser drawer. The Clobetasol cream was uncapped. There was also a tube of hydrocortisone cream, unlabeled, in the Resident's dresser drawer. During an interview at the time of observation, UM #2 said that prescription creams were to be locked up in the treatment cart at all times, and prescription treatments should only be applied by Licensed Nurses as ordered, after an assessment of the rash. She said the prescription creams were improperly stored and not locked up as required and were being applied by unlicensed personnel which was against the facility policy. During an interview on 6/30/22 at 2:08 P.M., the Regional Nurse Assistant confirmed that there was an order written for a Psychiatric consult on 5/27/22 and said that the consult had not been done as ordered. 2. For Resident #70, the facility failed to provide diabetic care in accordance with professional standards of practice by failing to: A) routinely administer insulin on a timely basis, B) implement an order for an outpatient endocrinologist consult, C) obtain and document fingerstick blood sugars as ordered, D) accurately document meal and snack intakes, and E) administer glucagon during an episode of hypoglycemia which resulted in the Resident being sent to the emergency room. Review of the facility policy titled Nursing Care of the Older Adult with Diabetes Mellitus, revised November 2020 indicated the purpose of the policy was to provide an overview of diabetes in the older adult including symptoms, complications, and the principles of glucose monitoring and refers the reader to Standards of Medical Care in Diabetes by the American Diabetes Association for further education and guidelines. In addition, the policy included the following: -complications from diabetes can be contributed to uncontrolled hyperglycemia and subsequent damage to the vasculature and overtreatment of diabetes resulting in hypoglycemia. -glycemic targets (goals for blood sugars) are 90-130 milligrams per deciliter (mg/dl) for a fingerstick blood sugar done prior to meals for a healthy older adult and can be less stringent for adults with chronic illnesses. Resident #70 was admitted to the facility in February 2022 with Diabetes Mellitus (a chronic condition that affects the body's ability to process glucose: blood sugar). Review of the Physician's Orders for June 2022 included the following: -If blood sugar is greater than 400 mg/dl, recheck and notify Physician. Once the patient is treated for hyperglycemia, recheck blood sugar in one hour (initiated 2/8/22). -Trulicity solution (a medication used to increase insulin secretion and delay emptying of the stomach in an effort to lower blood sugar elevations after meals) pen injector 0.75 mg/0.5 milliliter (ml): one application subcutaneously (SC: under the skin) one time every Monday for diabetes, initiated 6/20/22. -Humalog (Insulin Lispro: a type of short acting insulin administered around mealtime used to control blood sugar) solution 100 unit/ml inject subcutaneously as per sliding scale (dosage of medication based on the blood sugar at the time of administration), initiated 4/2/22 -Insulin Lispro solution 100 units/milliliter inject 3 units SQ before meals for diabetes management (initiated 6/23/22) -Insulin Glargine (Lantus: a long acting insulin used in the management of diabetes to reduce blood sugar) solution 20 units SQ for glycemic control at bedtime ordered 6/16/22 and discontinued on 6/22/22. A new order for Lantus 5 units daily was ordered on 6/22/22 and a new order for insulin glargine 18 units SQ daily written at 10:45 A.M. on 6/23/22 and discontinued on the same day, and Insulin glargine 5 units SC daily at 1:30 P.M. initiated on 6/23/22 -Insulin glargine solution, inject 5 international units SQ at bedtime for glycemic control (initiated 6/23/22) -Decrease Lantus to 5 units daily, check FBS at 4:00 A.M. and 6:00 A.M. daily (initiated 6/22/22) -Insulin Lispro solution 100 units/ml, inject 3 units SQ before meals for diabetes (initiated 6/23/22) A) Review of the Medication Administration Audit Report for June 2022 indicated: -the Humulin Insulin ordered to be administered prior to the breakfast meal was administered late three times out of 12 opportunities -the Humulin Insulin ordered to be administered prior to the lunch meal was administered late twice out of 16 opportunities -the Lispro insulin ordered to be administered prior to lunch was administered late twice out of five opportunities -the Lispro insulin ordered to be administered prior to breakfast was administered late once out of five opportunities -the Humulin Insulin administration ordered to be administered prior to supper meal was documented as given late one time on the 3:00 P.M. to 11:00 P.M. shift out of five opportunities -the bedtime dose of Lispro insulin was documented as administered late on six out of 20 opportunities -the Lispro Insulin ordered to be administered prior to the supper meal was documented as administered late twice out of five opportunities During an interview and review of the 6/2022 Medication Administration Audit Reports on 6/30/22 at 9:46 A.M. with the surveyor, UM #2 said the medication pass process was pouring the medications for the resident, administering the medications to the resident, and then returning to the medication cart to document that the medications were administered. If the medication administration was not charted at the time of administration, she said that was a medication error and an error report needed to be completed. She said further that the late administration had to be reported to the on-call physician or practitioner because other medications may have to be adjusted as a result. UM #2 said she was not able to provide the medication error reports to the surveyor as none were completed for this Resident. B) Review of the 6/2022 Physician's Orders indicated Endocrinology consults ordered on 4/4/22 and 6/2/22. Review of the Resident's clinical record indicated no documented evidence that outpatient endocrinology consults were scheduled and/or completed for Resident #70, as ordered by the Physician. C) The facility failed to ensure staff obtained and documented results of fingerstick blood sugars as ordered. Review of the June 2022 Physician's Orders indicated an order to add an additional fingerstick blood sugar daily at 4:00 A.M. (initiated on 6/20/22). Further review of the Physician's Orders indicated an additional order, initiated 6/22/22, to check the Resident's fingerstick blood sugar daily at 4:00 A.M. and 6:00 A.M. Review of the June 2022 Medication Administration Record (MAR) indicated the 4:00 A.M. fingerstick blood sugar was documented as completed on 6/21/22, 6/22/22 and 6/23/22, but there was no documented evidence of the results in the Resident's clinical record. Further review June 2022 MAR indicated no documented evidence that the order to check the Resident's blood sugar at 6:00 A.M. was transcribed into the MAR and was completed as ordered. During an interview on 6/23/22 at 12:32 P.M., Nurse Practitioner (NP) #1 said she had ordered additional blood sugar testing during the night because the Resident's blood sugar was very labile (likely to change), had bottomed out at night resulting in Resident #70 being transferred to the hospital. NP #1 reviewed the June 2022 MAR with the surveyor, and said the 4:00 A.M. blood sugars had been charted as done but the results were not evident within the clinical record. She further said she was very frustrated because orders for Resident #70 were not implemented. D. and E.) The facility failed to ensure staff provided the necessary monitoring and treatment to prevent and treat an episode of hypoglycemia which resulted in the Resident being sent to the emergency room. Review of the facility policy titled Management of Hypoglycemia (a low blood sugar, as defined by the American Diabetes Association as less than 70 milligrams per deciliter: blood concentration), revised 11/2020, indicated the following: -signs and symptoms of hypoglycemia have a sudden onset and may include weakness, moist skin, excessive perspiration, stupor, and unconsciousness -hypoglycemia may be classified as: Level 1: blood glucose less than 70 mg/dl but greater than 54 mg/dl, Level 2: Blood glucose less than 54 mg/dl, Level 3: altered mental and or physical status requiring assistance for the treatment of hypoglycemia -if a Resident has Level 3 hypoglycemia and is unresponsive: call 911, administer glucagon, notify the provider, remain with the resident, place the resident in a safe place and monitor the resident's vital signs. Review of the clinical record indicated Resident #70 was sent to the hospital on seven occasions since his/her admission. Review of Hospital Progress Notes, dated 3/31/22, indicated that Resident #70 was a brittle diabetic, had been discharged from the hospital for hypoglycemia earlier that day, and was re-presenting to the hospital via emergency medical services with a concern for hypoglycemia. The note further indicated that the hypoglycemia was suspected to be medication induced as the dosage of insulin Lispro was capped (not to be administered more then) 4 units by the endocrine team (composed of specialists in the treatment of hormone related disorders such as diabetes) at the hospital, but that Resident #70 was given 7 units of insulin Lispro the morning prior to his/her hospital admission, which was 3 units more then previously prescribed by the hospital. Review of the clinical record indicated that Resident #70 was transferred to the emergency room on 6/19/22 for hypoglycemia and unresponsiveness. Review of the June 2022 Physician's Orders indicated the following: -Glucerna (a dietary supplement drink for diabetics) ordered 4/28/22 -Carbohydrate Controlled diet, regular texture, thin liquids consistency ordered 2/14/22. -Glucagen Hypokit (Glucagon: a rapid acting injectable form of glucose used to reverse low blood sugars in an unresponsive resident): inject 1 milligram subcutaneously every four hours as needed for hypoglycemic protocol. Special instructions: if fingerstick blood sugar is below 60 mg/dl and unable to swallow, recheck fingerstick in 10 minutes and update provider (initiated 2/8/22) -Glucose 45 Gel 40% (a rapid acting form of sugar given orally) give one dose by mouth every 4 hours as needed for hypoglycemic protocol (initiated 2/8/22) -Monitor for signs and symptoms of hypo/hyperglycemia every shift (initiated 2/8/22) Review of a Nurse's Progress Note, dated 6/19/22 at 9:24 P.M., indicated the Resident was found unresponsive and diaphoretic (sweating) with a fingerstick blood sugar of 60 mg/dl. Emergency Medical Services (EMS) was called and when they arrived, they rechecked the Resident's blood sugar and it was 36 mg/dl. Review of the June 2022 MAR indicated no documented evidence that Resident #70 had received Glucagon, as ordered by the Physician. Review of hospital records Emergency Medicine Note, dated 6/19/22 at 8:24 P.M., indicated Resident #70 presented with hypoglycemia, the symptoms had resolved, and that EMS had administered glucagon along with an intravenous infusion of dextrose (sugar) and water. The note indicated the Resident was responsive and felt well at the time of the hospital admission, was diagnosed was hypoglycemia and acute insulin reaction, and discharged back to the facility on the same day at 9:35 P.M. During an interview on 6/29/22 at 5:10 P.M., Nurse #6 said she administered Resident #70's insulin via sliding scale per his/her Fingerstick Blood Sugar reading and when she went to administer the evening medications she noted that the Resident was drowsy, diaphoretic, and awake but not responding. Nurse #6 said a Fingerstick Blood Sugar was checked and it was 60 mg/dl. She said she called the EMS, who arrived shortly after as she passed by them when going downstairs to print up transfer forms. Nurse #6 said she left Resident #70 with a Certified Nurses Aide during this time. Nurse #6 further said there was no glucagon available in the building, so she was not able to administer the dosage of glucagon as ordered and that she was unsure what the Resident's meal consumption was at supper that night. Nurse #6 said that Residents with diabetes usually get a snack at bedtime, and that the Certified Nurses Aides give them whatever was available. Review of the Meal Percentage Intake Sheets, dated 6/19/22, indicated Resident #70 was documented as consuming 76-100% of his/her supper meal at 4:05 P.M. Review of the Evening Snack documentation for 6/19/22, indicated Resident #70 consumed 100% of an evening snack at 3:50 P.M. During an interview on 6/29/22 at 9:03 A.M., the Corporate Food Service Director (FSD) said that Resident #70 was diabetic and was on a Carbohydrate Controlled Diet. He said the evening tray line starts around 4:30 P.M., and that Resident #70's tray was on the last cart delivered in the building. The Corporate FSD said the kitchen staff deliver a tray of snacks to the units twice daily at 7:00 A.M. and 7: 00 P.M. and that it was the responsibility of the Nursing staff to provide the diabetic residents with a snacks from the snack trays provided. During an interview on 6/29/22 at 3:27 P.M., CNA #5 said she didn't think Resident #70 ate dinner the night of 6/19/22. She said there was supposed to be five CNAs on the unit, but on that day there were only two CNAs on that evening because it was Father's Day weekend. She said resident charting was difficult when the unit was short staffed. CNA #5 said that supper trays arrive to the unit between 4:30 P.M. and 5:30 P.M., and that she usually documented Resident intake of meals at the end of the shift. During a review of the CNA documentation for 6/19/22, CNA #5 said the documentation indicated Resident #70 consumed the supper meal prior to when it would have been delivered. She further said that the documentation indicated Resident #70 consumed his/her evening snack prior to when it would have been delivered at 7:00 P.M., and that she was unsure if the documentation was accurate. She further said she should have documented the amount consumed by Resident #70 after the meal/evening snack was provided and not prior to ensure the documentation was correct. During an interview on 6/30/22 at 9:46 A.M., UM #2 said the CNAs were responsible for documenting the percentage of a meal or snack taken by Residents, and that the documentation should be completed after the meal or snack was consumed. UM #2 said Resident #70's documented intake prior to the meal/evening snack served on 6/19/22 was inaccurate and made it impossible to know how much he/she actually consumed, if any, on the evening shift (3:00 P.M. to 11:00 P.M.). She further said Residents with diabetes should receive an evening snack, and that Resident #70 currently did not have a Physician's Order to provide one. UM #2 further said that the Nurse should be monitoring and documenting intake every shift for diabetic resident and if a nurse administered insulin prior to a meal, and then the meal was not consumed by the Resident, that this could result in a low blood sugar level. UM #2 said the facility staff cannot safely provide care for 48-53 residents with only two Nurses and two CNAs. During an interview on 6/30/22 at 12:52 P.M., the Regional Nurse Assistant said that there were only two CNAs on the A2 Unit on the evening of 6/19/22. She said that there was glucagon in the building and the hypoglycemia protocol should have been followed and was not for Resident #70. 3. For Resident #43, the facility failed to ensure the air mattress was set at the appropriate setting. The resident has a history of skin impairment requiring preventative measures to maintain skin integrity. Resident #43 was admitted to the facility in August 2021 with diagnoses including dementia and pressure ulcer of the right heel. Review of the June 2022 Physician's Orders, initiated on 3/30/22, indicated for an air mattress to be applied to the Resident #43's bed which was to be set to weight/comfort, set the air mattress at 180 (pounds/lbs) and to monitor the setting/function every shift. Further review of the June 2022 Physician's Orders indicated additional orders to float the Resident's heels and numerous treatments to be administered to his/her right foot and toes. In addition, there was an order for Resident #43 to be weighed monthly. Review of the Resident #43's clinical record indicated the following weights: -161.2 (6/14/22) -160.9 (5/9/22) -167.7 (4/4/22) -167.7 (3/31/22) On 6/21/22 at 1:24 P.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. On 6/24/22 at 8:20 A.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. There was a sticker on the air mattress box which indicated to set the air mattress to 200 lbs. On 6/29/22 at 1:51 P.M., the surveyor observed Resident #43 lying in bed with the air mattress set to 200 lbs. Review of the 6/2022 Treatment Administration Record (TAR) indicated the Resident's air mattress was monitored on most shifts (some missing documentation was noted), and indicated that the air mattress setting was at 180 lbs on the dates observed by the surveyor (6/21/22, 6/24/22 and 6/29/22). During an observation and interview on 6/30/22 at 1:15 P.M., the surveyor who was accompanied by the Regional Nurse Assistant, observed Resident #43's air mattress which was set between 180 and 200 lbs. The sticker on the air mattress box indicated for it to be set at 200 lbs. When the surveyor asked what the air mattress should be set at, Regional Nurse Assistant said that it should be set to the Resident's weight. She further said that resident weights are obtained monthly and that the air mattress settings should be updated based on the newly obtained weight. The Regional Nurse Assistant said that Resident #43's air mattress was not set appropriately, was not based on his/her most recent weights, and the Physician's Order needed be updated. 4. For Resident #95, the facility failed to provide evidence of ongoing collaboration with Hospice services relative to the development, implementation and revision of the coordinated plan of care. Review of the facility policy entitled Hospice Program, updated 2017, indicated when a resident participated in a hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. Resident #95 was admitted to the facility in December 2021 with a diagnosis of Alzheimer's disease. Review of the June 2022 Physician's Orders indicated an order, dated 4/29/22, for a Hospice referral and for admission Hospice services if indicated. Review of the Change of Status Minimum Data Set (MDS) Assessment, dated 5/11/22, indicated Resident #95 was receiving Hospice services while in the facility. On 6/21/22 at 11:35 A.M., the surveyor observed the door to Resident #95's room was closed. During an interview at this time, Nurse #8 said that Resident #95 was on Hospice services and was receiving care from facility staff at that time. On 6/24/22 at 8:10 A.M., the surveyor observed Resident #95 lying in bed with his/her eyes open, dressed in a hospital gown. Review of the Resident #95's Comprehensive Plan of Care did not indicate a Hospice Plan nor any indication of services and frequency of services provided by the Hospice entity. During a review of the clinical record with Nurse #8, Nurse #2 and the Regional Nurse Assistant on 6/30/22 at 3:00 P.M. indicated weekly progress notes from the Hospice Nurses regarding medication recommendations only. There was no documented evidence of Hospice services provided to Resident #95 nor a Hospice plan of care. Nurse #2 and Nurse #8 said that an older lady visited Resident #95 and checked in with facility staff once in a while and would ask if they want the Resident's vital signs (blood pressure, respiratory rate, temperature, pulse), but they were unclear if she was a Nurse or another discipline. Both Nurse #2 and Nurse #8 said that they were not aware of how frequently the Hospice Nurses or other Hospice interdisciplinary staff members including Social Work or Chaplin visit Resident #95, and that the facility and Hospice should be collaborating regarding the Resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that its staff provided adequate supervision, and reduce the risk of accidents/ hazards for three Residents (#178, # 175 and #104) out of a total sample of 30 residents. Specifically the facility failed to provide supervision for: 1) Resident #178 who eloped from the facility, was found off the facility premises in an altered medical status and was transported to the hospital for evaluation, and 2) Resident #175 and #104, during smoking and access to smoking materials. 3) Reduce the risk of accidents/hazards relative to ensuring laundry dryer lint filters were properly cleaned as required, hazardous smoking materials were stored properly on one Unit (B1), and medications and treatments were stored properly on one Unit (A2). Findings include: 1. For Resident #178 the facility failed to provide adequate supervision to prevent elopement which resulted in a hospitalization. Review of the facility policy titled Discharging a Resident without a Physician's Approval, dated October 2012, indicated, but is not limited to the following: - Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending Physician will be promptly notified. - If the resident or representative (sponsor) insists upon being discharged without the approval of the attending Physician, the Resident and/or Representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the Resident's medical record and witnessed by two staff members. Review of the facility policy titled Wandering and Elopements, dated March 2019, indicated the following: -If a resident is missing, initiate the elopement/missing resident emergency procedure: a. Determine if the resident is out on an authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; and c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the Resident's legal Representative, the attending Physician, law enforcement official, and (as necessary) volunteer agencies (i.e., emergency management rescue squads, etc.). Resident #178 was admitted to the facility in May 2022 with the following diagnoses: muscle weakness and abnormalities of gait and mobility. Review of the Minimum Data Set (MDS) Assessment, dated 6/6/22, indicated Resident #178 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15 indicating moderate cognitive impairment. Review of the progress notes indicated Resident #178 was on a MLOA (medical leave of absence) on 6/25/22, 6/26/22, and 6/27/22. The progress notes did not indicate the date, time or reason Resident #178 was on the MLOA. Review of the clinical record did not indicate Physician Orders for Resident #178 to be transferred or discharged from the facility. Review of the clinical record did not indicate any documented evidence that Resident #178 had signed a Release from Responsibility for Discharge (Against Medical Advice or AMA) form. Review of the hospital Emergency Medicine Note, dated 6/24/22 at 7:16 P.M., indicated the following: -Resident #178 currently resided at a skilled nursing/rehab facility, a bystander called 911, after finding Resident #178 lying on the ground. The Resident was found to be hypotensive (low blood pressure), mildly tachycardic (rapid heart rate) which improved with one liter of Intravenous (IV) fluids, hypomagnesemic (low magnesium in the blood) and to have Pneumonia on x-ray. Resident #178 reported to hospital staff that he/she felt lightheaded and dizzy and was unsure if he/she had passed out or not. Review of the hospital History and Physical Note, dated 6/24/22 at 10:57 P.M., indicated the following: -Resident #178 was found lying on the side of the road, a bystander called 911, and Resident #178 complained of lower back pain and was Spanish speaking only. Staff at the nursing home facility reported that Resident #178 had eloped. Resident #178 indicated in the hospital note that he/she had walked for about one and a half hours in the heat until he/she could not walk anymore and collapsed by the roadside. Hospitalization of Resident #178 was requested for continued care. Review of the hospital Social Service Form, dated 6/27/22 at 12:39 A.M., indicated Resident #178 eloped from the nursing home facility and was brought to Emergency Department via ambulance after he/she was found lying on the side of the road. When asked why the resident left the nursing home facility, he/she reported that he/she just wanted to go home. During an interview, on 6/28/22 at 11:42 A.M., the Director of Nursing (DON) said Resident #178 went home and that the facility did not complete an investigation of the incident. She further said there should have been documentation in the chart as to how Resident #178 was discharged from the facility but there was not. During an interview on 6/28/22, at 12:32 P.M., the DON said she had been notified the evening of 6/24/22, by Nurse #15, that Resident #178 had left the facility against medical advice (AMA). The DON said that she had called Nurse #15 today for more details, but he had not responded. She said that she had called Unit Manager (UM) #1 today, 6/28/22, and was waiting for her to update the progress notes for Resident #178. Review of the Nurses Progress Note, dated 6/28/22, at 12:54 P.M., indicated UM #1 spoke to Nurse #15 on 6/24/22, at 10:07 P.M. who informed her that he had received a call from the hospital reporting that Resident #178 had been transported to the hospital by ambulance. The note indicated Nurse #15 told UM #1 that the Resident had packed his/her belongings and had signed out at some point during the 3:00 P.M. to 11:00 P.M. shift. The note indicated Nurse #15 told UM #1, that Resident #178 had left the facility and walked off the premises, must have passed out, and that someone called 911 to help him/her. During an interview on 6/28/22 at 2:29 P.M., UM #1 said that she received a telephone call from Nurse #15 on 6/24/22 at approximately 6:50 P.M. She said Nurse #15 informed her that he had received a call from the hospital reporting that Resident #178 had been taken there and he/she had signed out of the building at the front desk. UM #1 said that she informed the DON via text message. In addition, UM#1 said that the following morning (on 6/25/22), she received a call from the day shift (7:00 A.M. to 3:00 P.M.) Nurse reporting Resident #178 missing. She further said that Resident #178 received a Notice of Medicare Non-Coverage (NOMNC-a form which must be delivered at least two days before covered services end) on 6/24/22. During an interview on 6/28/22 at 3:51 P.M., Certified Nurse Aide (CNA) #9 said she saw Resident #178 standing in the doorway of his/her room with a bag in his/her hand on 6/24/22 at 3:00 P.M. She said she asked the day shift Nurse if the Resident was going home and was told that he/she was not scheduled to be discharged . CNA #9 said sometime after 4 :00 P.M., she asked Nurse#15 if he had seen Resident #178 and Nurse #15 said that he had not seen him/her. CNA #9 said she then went outside and saw Resident #178 standing outside in the front of the facility where other Residents were sitting. She said she did not notice any belonging with him/her. She said when she returned to the nursing unit, she informed Nurse #15 that the Resident was outside. CNA #9 said that this was the only time she checked for the Resident outside and that when she delivered Resident #178's dinner tray to his/her room between 5:30-6:00 P.M., the Resident was not there. CNA #9 said at approximately 6:30-7:00 P.M., she was at the desk, and Nurse #15 received a telephone call from the hospital. CNA #9 said that Nurse #15 left the unit, went to the reception desk, and returned and told her that he had looked at the Leave of Absence sign-out sheet and Resident #178 had signed out of the facility. Review of the facility Release of Responsibility or Leave of Absence form, located at the reception desk, indicated Resident #178 did not sign out of the facility. During an interview on 6/29/22 at 9:41 A.M., Receptionist #2 said she was at the reception area on 6/24/22 from 4:15 P.M. to 6:30 P.M. and did not see Resident #178 outside of the building. She further said she did not see anyone in the driveway or walking on the road. Receptionist #2 said that there was a group of regulars that go outside, and that they were the only residents that she saw leave the building. Receptionist #2 said if a resident she does not know approaches the front doors, she will ask them to wait while she calls the Nurse and asks the Nurse if they can go outside. She said that she was not aware of a system to identify which residents can go outside unsupervised. During an interview on 6/29/22 at 10:25 A.M., Medical Records Staff said that she was at the reception area on 6/24/22 at 4:00 P.M., and gave report to Receptionist #2 when she came in. Medical Records Staff said that she did not see any Residents other than the regulars leave the building. She said that there was an Elopement book at the reception desk that identifies Residents that are at risk for elopement. She said that the doors are always locked from the outside, but people can leave at any time unless they are wearing an alarm at which point a staff member would need to enter a code. Review of Resident #178 Baseline Care Plan, dated 5/31/22, indicated no documented evidence that the Resident was assessed for elopement risk. During an interview on 6/28/22, at 3:00 P.M., Social Worker (SW) #1 said that she had learned today, about ten minutes previously, that Resident #178 had left the building on 6/24/22 and was admitted to the hospital. She said the Resident had been given a NOMNC on 6/24/22, that he/she wanted to go home on 6/24/22 after receiving the NOMNC letter, but she informed the Resident that he/she would need to stay at the facility until the next week when services could be arranged. SW #1 said that the Resident had agreed to stay at the facility. During an interview on 6/29/22 at 10:40 A.M., Nurse Practitioner (NP) #1 said she worked in the facility on 6/25/22 and was informed on that morning that Resident #178 had eloped the evening before and was brought to the hospital. During an interview on 6/29/22 at 12:16 P.M., the Administrator said the incident involving Resident #178 was reported to him as a discharge AMA, and that the Resident had a right to leave the facility. The Administrator said Resident #178 did not sign an AMA Release of Responsibility for Discharge form nor did Resident #178 sign a Release of Responsibility Leave of Absence form indicating he/she was leaving the facility. During an interview on 6/29/22 at 12:16 P.M., the DON said that she received a text message from Nurse #15 on 6/24/22 after 10:00 P.M. indicating that Resident #178 had signed out AMA. The DON said that she could not investigate the incident without a statement from Nurse #15 and that he had not returned her calls. On 6/28/22 at 2:25 P.M.,. the surveyor called and text messaged Nurse #15. Nurse #15 called back on 7/8/22 at 9:23 A.M. During an interview on 7/8/22, at 9:23 A.M., Nurse #15 said he reported to work on 6/24/22 at 3:00 P.M. and did not see Resident #178 in his/her room or on the unit. He further said that the Resident could have been gone before he reported to work. He said that he was very busy and there was only one CNA working on the unit at 3:00 P.M. He said that he had not been notified that the Resident was outside. Nurse #15 said at approximately 6:30 P.M., he received a call from the hospital telling him that Resident #178 was in the Emergency room. 5. The facility staff failed to ensure one medication cart out of three units and one treatment cart (a cart containing various medical supplies and topical ointments and liquids) out of three units were secured as required. Review of the facility policy titled, Storage of Medications, dated 2017, included the following: - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. On the Unit B1 on 6/24/22 at 8:07 A.M., the surveyor observed an unlocked, unattended medication cart next to the Nurse's station. There was no facility staff observed anywhere in the immediate vicinity, and residents and a visitor were in the immediate area of the medication cart. At 8:10 A.M., a facility staff member came out of a Resident's room to tend to an employee of a transportation company who had arrived to transport a Resident to an appointment. The entire duration of the employee's interaction was with the transportation employee, her back was turned away from the unlocked medication cart. At 8:12 A.M., Nurse #16, who was behind closed doors in room [ROOM NUMBER], located behind the Nurse's station, opened the door to the room, poked her head out, went back in and closed the door. At 8:14 A.M., Nurse #16 then exited room [ROOM NUMBER] to look for assistance with the Resident in room [ROOM NUMBER], observed the surveyor at the Nurse's station and observed the medication cart was not locked and subsequently secured the cart. She said the cart should have been locked and it was not as required. On Unit A2 on 6/30/22 at 10:50 A.M., the surveyor observed an unlocked, unattended treatment cart in a hallway around the corner from the Nurse's station. There were Residents in the immediate area. At this time, Nurse #4 and Nurse #9 were seated at the Nurse's station around the corner conversing. The surveyor alerted both Nurses of the unsecured treatment cart around the corner. They nodded acknowledgment and went back to their conversation. On 6/30/22 at 11:20 A.M., the surveyor observed the treatment cart remained unlocked, still with Residents in the immediate vicinity and Nurse #4 and Nurse #9 at the Nurse's station around the corner. The surveyor again brought their attention to the unlocked treatment cart. Nurse #4 apologized and said she thought the surveyor secured it for them when it was mentioned at 10:50 A.M., got up from the Nurse's station, went around the corner and locked the cart. 3. The facility failed to ensure smoking materials were stored securely when not being used on the B1 Unit. During an interview on 6/23/22 at 1:12 P.M., Resident #104 said he/she kept his/her cigarettes and lighter in his/her room. During an observation on 6/27/22 at 10:12 A.M., the surveyor observed a lighter in the open in Resident #104's room, on the bedside table, while the Resident was not in his/her room. During an interview on 6/27/22 at 10:14 A.M., the surveyor and Nurse #5 observed the lighter in Resident #104's room. At the time of observation Nurse #5 said the lighter should not be in the Resident's room, as it is a hazard, and it should be locked up in the Nurse's cart. She proceeded to remove the lighter and notified the Resident that it was being put in the Nurse's cart. 4. The facility failed to ensure staff cleaned the lint filter for one of three dryers in the laundry room. On 6/21/22 at 2:58 P.M., while touring the laundry room with the Housekeeping Director, the surveyor observed that one of three dryers had a thick coating of lint in the filter. Review of the Dryer Lint Trap Log for June 2022 indicated the dryer had not been cleaned since 10:00 A.M Further review of the sheet indicated no documentation that the lint filters had been cleaned from 1:00 P.M. on 6/14/22 till 1:00 P.M. on 6/15/22. During an interview following the observation the House Keeping Director said the lint filter should be cleaned every hour and the lint build up that was observed in the dryer was more than an hours' worth of lint. He further said he was unable to tell if the lint filters have been cleaned during the times in question on 6/14/22 and 6/15/22, and the hours that were not signed off on, for 6/21/22. He said that the lint filter cleaning log should be signed off on directly after the lint filters are cleaned and this had not been done on the days in question as required. 6. The facility failed to ensure that a medication cart was locked when unattended on the A2 Unit. On 6/27/22 at 4:56 P.M., the surveyor observed one of the medication carts on the A2 Unit unattended and unlocked. There were Residents and staff in the hallway by the cart. During an interview on 6/27/22 at 4:59 P.M., Nurse #6 said the medication cart should be locked and she said she did not do that as required. During an interview on 6/27/22 at 5:01 P.M., Unit Manager (UM) #2 said the medication cart should be locked when unattended and this was not done as required. 2. For Resident #175, the facility staff failed to implement their Smoking Policy/Procedure relative to supervision provided and location of smoking materials. Review of the facility Smoking Policy and Procedure, undated, indicated the purpose of the policy was to protect residents' rights while ensuring the highest level of safety for both residents and staff from the serious consequences that may result from fire and and/or smoking activities. The policy also indicated: -for safety reasons, residents may not possess smoking paraphernalia including but not limited to tobacco products, lighters, matches or other smoking materials. These items must be turned over to facility staff so they may store them. -during designated smoking times, these items will be provided to residents to use in the designated smoking area under supervision -facility staff are responsible for igniting/lighting all resident smoking materials -designated smoking times are 10:30 A.M., 1:30 P.M., 4:00 P.M. and 8:30 P.M. -the facility reserves the right to conduct random, routine and for suspicion room searches for smoking materials not surrendered by the resident/resident agent. The facility will endeavor to conduct searches within the presence of the resident/agent and always maintain resident dignity. If the resident/agent is not present, two senior facility staff members must conduct the search, with the consent of the Administrator. All smoking contraband will be removed and properly stored. Resident #175 was admitted to the facility in June 2022. Review of the Resident Smoking List, provided to the survey team upon entrance, indicated Resident #175 was listed as an active smoker. Review of the Smoking Evaluation, dated 6/16/22, indicated Resident #175 was a smoker and required constant supervision when smoking. Review of Resident #175's Comprehensive Plan of Care did not indicate he/she smoked. During an observation and interview on 6/28/22 at 8:26 A.M., Resident #175 who was dressed and seated at the edge of the bed in his/her room, said that he/she was an independent smoker and was able to go outside to smoke whenever he/she wanted. Resident # 175 said that smoking materials including his/her cigarettes and lighter were kept in his/her unlocked bedside drawer and that he/she was able to keep them because he/she was an independent smoker. During an interview on 6/29/22 at 9:14 A.M., Nurse #13 said that residents who smoke were supposed to be supervised by facility staff and adhere to a smoking schedule. She further said that smoking materials should be locked up by the facility staff and a process should be in place for distributing smoking materials during the resident smoking breaks, but there was not one in place. Nurse #13 said that she has worked at the facility for over a year, had attempted to talk to facility administration about these safety concerns and nothing has been done. On 6/29/22 at 5:45 P.M., the surveyor observed Resident #175 seated outside in a stationary chair smoking a cigarette. There was no staff present with Resident #175 during the observation. During an interview on 6/29/22 at 12:09 P.M., the Administrator said that the facility had independent and supervised smokers. He said that residents who smoke have been assessed by facility staff and if they are determined to require supervision then a facility staff member had to be outside with them during the scheduled smoking times. The Administrator said that smoking materials must be kept at the Nurses medication cart for all residents who smoke and are returned to the Nurse after the smoking break concluded. The Administrator was informed by the surveyor during the interview regarding the concerns about unsecured smoking materials in Resident #175's room and the determination per the smoking assessment that Resident #175 was to be supervised.