Based on record review, resident interview and staff interview, the facility failed to adequately resolve a grievance. This was true for one (1) of two (2) residents reviewed for personal property. Resident identifier: #27. Facility census 59. Findings included: On 6/24/24 at 12:45 PM, Resident #27 reported that she had some clothing come up missing a couple of months ago and the facility told her family to replace the clothing and they would refund resident's family the money. She reported that the money had not yet been refunded, she can't remember if she had filed a grievance or complaint. On 06/24/24 at 3:44 PM, review of resident's grievance from 04/22/24 stated that resident had missing clothing. 8 (eight) items- green sweater, solid green shirt, denim pants, pjs, socks white, gray bra, solid red shirt, pink shirt. This grievance completed by Social Worker (SW) stated Have family replace missing items and reimburse family for money spent to replace items. On 06/25/24 at 2:25 PM, an interview with the Social Worker (SW) who reported that resident's family was reimbursed for the clothing that was missing in April and would look for a receipt. He also reported that the resident has a history of missing items that the facility had replaced. On 06/25/24 at 3:40 PM, an interview with the SW who reported that the resident's family was not reimbursed because the facility replaced the items in question. The resident's daughter also replaced the same items and requested to be reimbursed. The SW acknowledged that the grievance stated Have family replace missing items and reimburse family for money spent to replace items. The SW stated that they would make arrangements to refund the resident's family.

Based on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASSAR) for Resident #3, after being diagnosed with major depressive disorder. Resident #51's PASSAR was not updated after being diagnosed with Post Traumatic Stress Disorder (PTSD) and Unspecified Psychosis. This was true for two (2) of two (2) residents reviewed for PASSAR's during the survey process. Resident identifiers: #3, #51. Facility census: 69. Findings included: a) Resident #3 At approximately 12:30 PM on 06/25/2024, a review of the electronic health record of Resident #3 was conducted. During this review, it was revealed Resident #3 was diagnosed with major depressive disorder on 09/28/2022. However, the most recent PASSAR completed for Resident #3 was on 06/10/2022, and makes no mention of the diagnosis of major depressive disorder. At approximately 1:53 PM on 06/26/2024, an interview was conducted with the Minimum Data Set (MDS) Coordinator concerning the PASSAR for Resident #3. The MDS Coordinator acknowledged the diagnosis of major depressive disorder on 09/28/2022 and the most recent PASSAR being completed on 06/10/2022. The MDS Coordinator acknowledged a new PASSAR should have been completed after Resident #3 was diagnosed with major depressive disorder. b) Resident #51 At approximately 2:30 PM on 06/24/2024, a review of the electronic health record of Resident #51 was conducted. During this review, it was revealed Resident #51 was diagnosed with PTSD and a psychosis disorder on 11/25/2022. However, the most recent PASSAR completed for Resident #51 was on 11/14/2022, and makes no mention of the diagnoses of PTSD or the psychosis disorder. At approximately 1:53 PM on 06/26/2024, an interview was conducted with the MDS Coordinator concerning the PASSAR for Resident #51. The MDS Coordinator acknowledged the diagnoses of PTSD and psychosis on 11/25/2022 and the most recent PASSAR being completed on 11/14/2022. The MDS Coordinator acknowledged a new PASSAR should have been completed after Resident #51 was diagnosed with PTSD and the psychosis disorder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately develop care plans related to capacity and one on one supervision. This failed practice was found true for (2) two of 17 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: #50 and #273. Facility census: 69. Findings Included: a) Resident #50 A record review on 06/25/24 at 11:06 AM, of Resident #50's care plan revealed the following: Intervention revised on 03/06/24: The resident has a communication problem r/t vision deficit/lacks capacity to make medical decisions. Further record review revealed a capacity form completed on 01/05/24 that is marked as Resident #50 demonstrates capacity to make decisions. During an interview on 06/26/24 at 12:15 PM, The Director of Social Services (DSS) confirmed that Resident #50 does have capacity and the care plan was wrong. b) Resident #273 Resident #273 was admitted to the facility on [DATE] with a diagnosis of a nondisplaced fracture of base of neck of right femur. The resident did not have surgery performed on the fracture, instead, she had a brace on her right leg and was non weight bearing. At approximately 12:00 PM on 06/25/24, a review of Resident #273's electronic health record was conducted related to falls the resident suffered while at the facility. During the review, it was discovered Resident #273 suffered two (2) falls with major injury while at the facility. On 04/10/24, Resident #273 suffered an unwitnessed fall that resulted in a fracture of the right elbow. On 05/22/24, Resident #273 suffered an unwitnessed fall that resulted in a laceration on her forehead of approximately two (2) inches, a laceration between the eyes, laceration of the left elbow, and a fractured neck. A review of Resident #273's care plan revealed the facility stated the resident should be 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. This was listed as a fall intervention due to resident is at risk for falls r/t (related to) recent fall with fx (fracture)./rx (prescription) antidepressant. At approximately 1:00 PM on 06/25/24, a telephone interview was conducted with a family member of Resident #273. The family member stated the facility was very aware the resident was unable to bear weight on the right leg due to the recent fracture, and the brace, and was continuously attempting to stand and walk on her own. The family member states the facility was not providing one (1) on one (1) care for Resident #273 despite stating she needed it. As a result, the family member states the family requested alarms for when Resident #273 would attempt to stand and walk on her own, but the facility told them alarms were not allowed by the State Agency (SA). The family member states that on 04/10/22, Resident #273 suffered a fall and hurt her right arm, at which time the facility ordered mobile x-rays for the resident. The family member states the facility told the resident's family the results of the mobile x-rays revealed no fracture, however, the resident continued to complain of pain in her arm, until she attended an orthopedic appointment on 04/15/22, at which time an x-ray was completed in their office. This x-ray revealed a fracture of the right elbow. Family member states the orthopedic doctor placed a brace on the resident's right arm and she returned to the facility. The next day, the family member states that while visiting the resident, the brace on her arm was gone and could not be located. The facility notes reveal the brace was found in a trash can and alleges the resident removed it. This resulted in the resident returning to the orthopedic doctor and having a cast placed on her arm. Family member states that the resident's family received a call on the night of 05/22/24 informing them the resident suffered a fall and was being transferred to the hospital. Family member states emergency services were preparing to life flight Resident #273 due to her being lethargic and almost unresponsive after the fall. Family member states the fall was unwitnessed. At approximately 2:05 PM on 06/25/24 an interview was conducted with the Interim Director of Nursing (IDON) concerning the care plan and one (1) on one (1) interventions for Resident #273. However, the IDON stated You will need to speak with (First Name) the MDS Coordinator because she is the one that put that in and she is getting ready to take over the Director of Nursing (DON) position. I wasn't here at that time and she was, so she would know more than me. At approximately 2:14 PM on 06/25/24, an interview was conducted with the MDS Coordinator concerning the one (1) on one (1) intervention in the care plan for Resident #273. During the interview, the MDS Coordinator stated she entered the one (1) on one (1) intervention due to a physician's order stemming from Resident #273 continuously attempting to stand up out of her wheelchair and walk unassisted, while being non-weight bearing. The MDS coordinator stated Resident #273 was not under constant one (1) on one (1) supervision and acknowledged it would be difficult for staff at the facility to know when the resident attempted to stand up unassisted without her being under constant supervision, making it difficult for the staff to implement the intervention of 1:1 when resident tries to get up unassisted as she is non weight bearing at this time. The MDS Coordinator acknowledged there were multiple instances of Resident #273 attempting to stand and walk unassisted prior to both falls at the facility. The MDS Coordinator stated she believes the intervention for one (1) on one (1) supervision should have been removed from the care plan but acknowledged it was never removed, and still in place at the time of both falls, meaning the care plan was not being followed at the time of the falls. The MDS Coordinator states, however, they do not know if or when the intervention should have been removed, that the old DON would know, but they were no longer with the company. At approximately 2:50 PM on 06/25/24, an interview was conducted with a second family member of Resident #273. During this interview, the family member stated When we brought her into the facility, we were told she would need one (1) on one (1) supervision because she kept trying to stand up when she wasn't supposed to. She would try to get out of her chair, out of bed, all the time by herself and she wasn't supposed to because her leg was broken and she had the brace on it, and she was at risk of falling. The family member states the family were told both falls at the facility were unwitnessed and there was no supervision to prevent Resident #273 from getting up on her own. At approximately 3:15 PM on 06/25/24, an interview was conducted with Resident #7, a roommate of Resident #273 at the time of her falls. Concerning the fall on 05/22/2024, Resident #7 stated that Resident #273 was in her wheelchair, falling asleep, moving her head side to side. Resident #7 stated It looked like she was trying to get comfortable enough to sleep. I was watching TV and looked away for a minute. When I looked back, she was leaning forward in her chair, almost in the floor. I looked back at the TV again and that's when I heard the other lady in our room yell that (Resident's first name) Resident #273 had fallen. Resident #7 stated she saw Resident #273 lying in the floor, at which time facility staff came into the room to attend to her. Resident #7 confirmed there was no one (1) on one (1) supervision taking place at the time of the fall. Review of both facility reported incidents from 04/10/24 and 05/22/24 confirm both falls were unwitnessed and no supervision was taking place, per the care plan for Resident #273.

Based on record review and staff interview the facility failed to complete a discharge summary of Resident #72. This failed practice was found true for (1) one of (1) residents reviewed for unplanned discharge during the Long-Term Care Survey Process. Resident identifier #72. Facility census 69. Findings Include a) Resident #72 A record review on 06/26/24 at 12:54 PM, revealed that Resident #72 had an unplanned discharge from the facility. Further record review revealed that a discharge summary was not completed in its entirety. During an interview on 06/26/24 at 12:57 PM, the Director of Nursing (DON) stated, Her discharge was so confusing. It was planned in the fact that she was going home, but unplanned because we did not know when her son was coming to get her. The DON further stated, We do have a problem with our discharge process and we are working on it,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A multidose medication vial was not dated when opened. This was a random opportunity for discovery made during the medication storage task. Facility census: 69. Findings included: a) Medication Storage During investigation of the [NAME] and [NAME] hallways medication preparation room on 06/25/24 at 9:35 AM, a multidose vial of Tubersol tuberculin purified protein derivative was found to not have been dated when opened. Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis. According to the Tubersol package insert accompanying the vial and available on the Food and Drug Administration website, A vial of Tubersol which has been entered and in use for 30 days should be discarded. Because the vial had not been dated when opened, it could not be determined when the vial should be discarded. Licensed Practical Nurse (LPN) #59 verified the Tubersol vial was not dated when opened. No further information was provided through the completion of the survey.

Based on resident interview, staff interview and observation, the facility failed to ensure hot food were served at a temperature of at least 120 degrees Fahrenheit (F). This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #21, #50, #66, and #51. Facility Census 69. Findings included: a) Resident #21 During the initial interview on 06/24/24 at 1:30 PM, Resident #21 stated, Hell no my food isn't hot. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. Further observation showed that Resident #21 had refused the lunch tray and the lunch tray was tempt immediately after the last tray was delivered. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. b) Resident #50 During the initial interview on 06/24/24 at 2:00 PM, Resident #50 states, The Food is cold, to get a hot cup of coffee around here would be a miracle. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. c) Resident #66 During the initial interview on 06/25/24 at 2:17 PM, Resident #66 states with a giggle Are you kidding me the food is always cold. During an observation on 06/25/24 at 12:25 PM, the temperature of the lunch food at point of service was as follows: Ground chicken thigh: 115.5 degrees F. Spinach: 117 degrees F. The Corporate dietary manager confirmed that temperature at point of service should be at 120 degrees F. d) Resident #51 At approximately 2:10 PM on 06/24/24, an interview was conducted with Resident #51. During the interview, Resident #51 stated I'm really happy with this place except for when my food is cold. It is cold a good bit of the time. That's the only thing I don't really like about it here. Temperatures were taken at the point of service for the lunch meal at approximately 12:25 PM, at which point the temperature of the chicken served was 115.5 degrees F and the spinach was 117 degrees F.

Based on observation, facility policy, record review and staff interview, the facility failed to ensure foods were stored and prepared in a safe, clean, and sanitary environment. During the observation of the kitchen, unsanitary and unclean areas were discovered. This had the potential to affect all residents receiving nourishment from the kitchen. Facility Census: 63. Findings included: A review of the facility policy titled Equipment with a revision date of 09/2017 read as follows. Procedures: 1. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directors and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be clean and sanitized after every use. 4. All non food contact equipment will be clean and free of debris A review of the facility policy titled Environment with a revision date of 09/2017 reads as follows. Procedures: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting and ventilation. 2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces. 3. All food contact surfaces will be cleaned and sanitized after each use. 4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas and surfaces. a) Facility Kitchen An initial tour of the kitchen with the Culinary Director (CD) beginning on 09/06/23 at 8:49 AM revealed the follow: -On the floor behind the Stove were food particles, an empty butter container, an empty dirty storage bag and a flat adhesive bait pad which had several bugs attached including a few dead and 2 alive roaches. -The stove drip pan had a large amount of food particles, several grease spills and a large amount of build up. During an immediate interview the CD stated It looks like it has not been cleaned in several days. During an immediate interview [NAME] #18 stated I cleaned the burners yesterday but did not do the drip pan or the oven. -The stove temperature knobs had grease build up on and around them. The CD pulled off the stove temperature knob and under it was full of dust with grease build up. During an immediate interview [NAME] #18 stated I did not know the knobs came off to clean under them. -The oven had food particles build up and grease spillage. During an immediate interview the CD acknowledged the oven had not been clean. The CD was asked for a kitchen/equipment cleaning list. A dining services opening checklist was provided by the CD on 09/06/23 at 9:27 AM. The week on 17-22, no month was provided. The job duties included: all equipment clean inside and out was void documentation on the following dates: -08/17/23 -08/20/23 Floors swept and mopped from last night was void any documentation for the week provided During an immediate interview the CD stated This is all the documentation I could find on the cleaning, we have not been keeping up with it. The maintenance completes a cleaning monthly, pulls out everything and cleans the vents. During an interview on 09/06/23 at 9:13 Am The Director of Plant Maintenance stated the other Maintenance man (Maintenance Technician #23's name) comes in monthly after the kitchen is closed and does a detailed cleaning. The Director of Plant Maintenance was asked for the monthly kitchen cleaning log. The Dietary Maintenance Log was presented to this surveyor on 09/06/23 at 9:35 AM it was void cleaning for the month of 08/23. The Director of Plant Maintenance acknowledged it was void of cleaning in August.

Based on observation and staff interview the facility failed to maintain sanitary condition of the outside garbage receptacle to prevent the harborage and feeding of pests. This deficient practice has the potential to affect all the residents that reside in the facility. Facility Census:63 Findings included: a) Garbage Receptacle During several observations of the outside garbage receptacle lids not closed on the follow date and times: -09/06/23 at 8:30 AM -09/06/23 at 8:48 AM -09/06/23 at 9:11 AM -09/06/23 at 9:42 AM -09/06/23 at 10:30 AM -09/06/23 at 11:03 AM -09/06/23 at 12:08 AM During a tour of outside of the facility on 09/06/23 at 12:15 PM Laundry Staff #83 was pushing a cart labeled Trash I observed her with the trash removal into the garbage receptacle. Laundry Staff #83 was trying to close the lid to the garbage receptacle but was unsuccessful. Laundry Staff #83 stated it was too bent and too heavy for me to close, and left the garbage receptacle lid open. During an interview, on 09/06/23 at 12:38 PM, the Executive Director and the Director of Plant Maintenance, acknowledged the garbage receptacle lids were open, and needed to be closed at all times.

Based on observation,record review and staff interview the facility failed to ensure an environment for residents that was free of rodents. The practice had the potential to affect more than a limited number of residents receiving nourishment from the facility kitchen. Facility Census: 63 Findings Included: a) Kitchen During an initial tour of the kitchen with the Culinary Director (CD) beginning on 09/06/23 at 8:49 AM revealed the following pest control traps. On the floor under the steam table/serving table were the following pest control traps A round ant bait trap A white carbon bait box with large of amount of bugs inside, including roaches A white flat adhesive bait pad with large amount of bugs attached including 4 roaches During an immediate interview the Culinary Director (CD) and [NAME] #18 acknowledged the bugs inside and on the bait. On the floor behind the stove an observation revealed a flat adhesive bait pad which had a large amount of bugs attached including a few dead and 2 alive roaches During an immediate interview the Culinary Director (CD) and [NAME] #18 acknowledged the bugs on the bait. On the floor under the Juice and Coffee Station an observation revealed two (2) black bug trapper boxes both of the box containing bugs including roaches. During an immediate interview the Culinary Director (CD) and [NAME] #18 acknowledged the bugs inside the bait. On the floor under the three compartment (3) sink observationr revealed a black bug trapper boxes with several bugs containing bugs including roaches. Observation also revealed a flat adhesive bait pad with several bugs attached. During an immediate interview the Culinary Director (CD) and [NAME] #18 acknowledged the bugs inside and on the bait. On the floor under another serving table with the toaster on it A black bug trapper boxes with several bugs containing bugs including roaches A flat adhesive bait pad with several bugs attached During an immediate interview the Culinary Director (CD) and Director of Plant maintenance acknowledged the bugs inside and on the bait. Inside the Thermal plate warmer caddy contained a large amount of food particles and seven dead roaches. During an immediate interview the Culinary Director (CD) and Director of Plant maintenance acknowledged the bugs inside of the plate warmer. The CD stated, We are unable to clean it, we don't know how to take it apart to clean it. The Director of Plant Maintenance pulled the inside of the Thermal plate warmer plate holder out and stated you just lift it out, you can clean it. The Dry storage room revealed a loose white plastic lid sitting on a shelf with two (2) sealed packages of cake mixes. A large amount of small black ants were crawling on the lid around the cake mixes. During an immediate interview the CD stated we have an ant problem, but the roaches come on the boxes from the food truck, that's how we get those. b) Interviews During an interview on 09/06/23 at 9:13 AM the Director of Plant Maintenance stated that we have always had an ant problem, I have worked here almost 28 years. We have roaches also. The pest control comes out monthly and we also spray in the kitchen when needed. During an interview on 09/06/23 at 11:10 AM Maintenance Technician #23 stated, I do the dietary monthly cleaning on the last Thursday of the month. I pull out the stove and all the serving tables to mop and buff under everything. The roaches and ants are everywhere. I have worked here over a year and there has always been a problem with both. The white adhesive traps were put out by myself and the (The director of plant maintenance's name) about a week and half ago. And stated I am sure they were full when you looked at them. The dietary is always calling us to come and change the adhesive traps. c) Pest Control During a review of a (a name of local) pest control invoice revealed the following comments(typed as written). 08/21/23: Replaced monitors in kitchen. There were five (5) on trap I replaced. 07/17/23: Ants in Activities office around air conditioning unit. 05/15/23: Kitchen had a few roaches in one trap. 03/17/23: Complaining of roaches around plate warmer machine in kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Infection Prevention and Control Program (IPCP) policy and procedures were reviewed annually in accordance with the federal guidance and the facility assessment. This had a potential to affect all residents residing in the facility. Facility Census: 63 Findings included: a) IPCP policy and procedures During an record review on [DATE] at 9:00 AM the facility policies and procedures were not reviewed annually were as follows: -A facility policy and procedure titled Infection Prevention Program with a reviewed date of [DATE] -A facility policy and procedure titled CPR(Cardiopulmonary resuscitation) Guidance during the COVID-19 Pandemic with a reviewed date of [DATE]. During a review on [DATE] at 9:13 AM the facility assessment read as follows. .Part 3: Facility resources needed to provide competent support and care for our resident population every day and during emergencies. .Policies and Procedures for provision of care 3.5 .Policies and procedures are reviewed annually and revised as needed. During an interview on [DATE] at 9:24 AM the Executive Director (ED) stated the facility was bought out in May. She stated, I assumed we would have a year to review everything. The ED acknowledged the facility assessment stated the policy and procedure would be revised as needed, which would include the take over date.

Based on medical record review and staff interview the facility failed to develop a comprehensive care plan in the area of dialysis services. This was discovered for one (1) of one (1) residents reviewed for dialysis services. Resident #11's care plan interventions did not include the specified days hemodialysis services were being provided. Resident identifier: #11 Facility census: 63 Findings included: a) Resident #11 A medical record review for Resident #11 on 09/13/22, revealed the care plan interventions for dialysis services were incomplete. It did not specify on what days hemodialysis services were being provided for Resident #11. An interview with the Director of Nursing (DON) on 09/14/22 at 10:30 AM, verified the care plan interventions for dialysis services did not include the days of the week Resident #11 received hemodialysis.

Based on record review and staff interview, the facility failed to revise a care plan for the care area of risk for falls. This is true for one (1) of two (2) residents reviewed for the care area of accidents during the long-term survey. Resident #7. Facility Census: 63. Findings Included: a) Resident #7 On 09/13/22 at 2:00 PM, the care plan with the focus area of risk for falls was reviewed. An intervention of hourly rounds at night was found. A review of the record found no evidence of the hourly rounds at night being completed. An interview on 09/13/22 at 2:38 PM with Assistant Director of Nursing (ADON) #32 was held. The ADON #32 stated, the intervention of hourly rounds at night was discontinued in June. The ADON #32 confirmed the care plan had not been revised to discontinue the intervention. No further information was provided during the survey process.

Based on medical record review and staff interview, the facility failed to notify the residents physician when a change of condition occurred. This was a random opportunity for discovery. Resident identifier: 163. Facility census: 63. Findings include: a) Resident #163 Review of Resident #163's original discharge summary from the hospital dated 02/25/22, revealed the resident had a pacemaker with an ICD implanted due to manage his atrial fibrillation with rapid ventricular rhythm. A implantable cardioverter-defibrillator (ICD) is a device that detects any life-threatening, rapid heartbeat. This abnormal heartbeat is called an arrhythmia. If it occurs, the ICD quickly sends an electrical shock to the heart. The shock changes the rhythm back to normal. This is called defibrillation. Review of Resident #163's nurses note, written by Employee #12, a Licensed Practical Nurse (LPN), dated 05/20/22 at 11:49 am, found a note which read: Daughter called the facility and spoke to the Minimum Data Set (MDS) nurse. Daughter stated that the resident's cardiology office had called her and stated that the pacemaker readings were showing runs of ventricular tachycardia (fast heart rate) and the cardiologist wanted him to be sent to the emergency room . Additionally, a nurses note written by LPN #70, dated 05/20/22 at 12:20 PM, which read, Earlier this am around 8:00 am, the resident kept ringing his call light and saying that his pacemaker was shocking him. Resident did this approximately 4 times . Further review found no nurses notes concerning the notification of the physician when the pacemaker with ICD was shocking the resident until the daughter called several hours later and requested the resident be sent out to emergency room as recommended by the cardiologist. On 09/14/22 at 9:15 AM, the Director of Nursing (DON) confirmed the nurse failed to notify the attending physician of the resident receiving a shock from his pacemaker with an ICD at least four (4) times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to provide care and services to promote healing of a known pressure ulcer and to prevent further pressure ulcers from developing. The facility failed to accurately assess and/or correctly document the location of the coccyx/buttocks wound care site (incorrect measurements and staging were conducted on 04/28/22, 05/10/22 and 05/17/22. Resident identifier: #163. Facility census: 63. Findings include: a) Resident #163 Resident #163 was originally admitted to the facility on [DATE]. Admitting diagnosis included: atrial fibrillation, acute and chronic respiratory distress with hypoxia, and rheumatoid arthritis. Review of the admission assessment dated [DATE] at 2:39 PM, revealed the resident required extensive assistant with bed mobility, dressing, toilet use and personal hygiene; total dependence on staff for transfers; and independent with feeding after initial setup. No skin issues were noted on initial assessment. The Resident was alert to person, place, time, and situation. Review of the baseline care plan completed on 02/27/22 at 1:20 PM, noted the resident should be turned and reposition every two (2) hours, have a pressure reducing mattress and a cushion in chair. Review of Resident #163's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/03/22, reveals the resident was at risk of developing pressure ulcers/injuries and is coded to indicate he has a pressure reducing device for the bed. The Resident was hospitalized from [DATE] through 03/18/22 for the treatment of right lower lobe pneumonia, atrial fibrillation, congestive heart failure and hyperkalemia. re-admission nursing assessment dated [DATE] at 5:32 PM, reveals the resident has the following pressure ulcer/injuries by Employee #3, Licensed Practical Nurse (LPN) and verified by RN #9 on 03/19/22 at 1:06 PM: --Suspected deep tissue injury- coccyx measuring 3.3 centimeters (cm) in length and 0.5 cm in width. -- Suspected deep tissue injury- right heel measuring 3.0 (cm) in length and 6.0 cm in width. -- Suspected deep tissue injury- left heel measuring 4.0 (cm) in length and 5.0 cm in width. Deep tissue injury (DTI): intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, purple discoloration, or separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. --Stage II pressure ulcer on right buttocks measuring 0.5 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Treatment orders written on 03/18/22 were as follows: Cleanse areas on coccyx and buttocks with normal saline and apply skin prep to discoloration on coccyx and zinc to the open areas on buttocks daily. Skin prep to be applied to bilateral heels daily. No orders were found for pressure-relieving mattress or a pressure relieving device for the chair. Weekly pressure ulcer assessment dated [DATE] at 10:10 am by RN #46, reveals the resident has the following pressure ulcer/injuries by RN #46: --Suspected deep tissue injury- coccyx measuring 3.2 centimeters (cm) in length and 0.5 cm in width. -- Suspected deep tissue injury- right heel measuring 3.0 (cm) in length and 6.0 cm in width. -- Suspected deep tissue injury- left heel measuring 3.0 (cm) in length and 5.0 cm in width. --Stage II pressure ulcer on right buttocks measuring 0.5 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Weekly pressure ulcer assessment dated [DATE] at 4:06 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.0 centimeters (cm) in length and 1.5 cm in width with no depth. Unstageable: full thickness skin and tissue loss in which the extent of tissue damage within the ulcer, cannot be confirmed because it is obscured by slough or eschar. --Stage II pressure ulcer on right buttocks measuring 0.3 cm in length and 0.2 cm in width and less than 0.1 cm in depth. --Stage II pressure ulcer on left buttocks measuring 0.2 cm in length and 0.2 cm in width and less than 0.1 cm in depth. Pressure ulcers on left and right heels resolved. Weekly pressure ulcer assessment dated [DATE] at 3:56 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.5 centimeters (cm) in length and 1.5 cm in width with no depth. Comments/summary: Area on coccyx declining measures 3.5 cm in length and 1.5 cm in width, wound bed is covered with 90% yellow slough. --Stage II pressure ulcer on left buttocks measuring 0.2 cm in length and 0.4 cm in width and less than 0.1 cm in depth. Pressure ulcer on the right buttock healed. The Physician wrote an order for the air mattress on 04/04/22. No orders for chair cushion noted. Weekly pressure ulcer assessment dated [DATE] at 8:02 am by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.4 centimeters (cm) in length and 0.5 cm in width with no depth. Pressure ulcer on left buttocks healed. Weekly pressure ulcer assessment dated [DATE] at 3:46 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.4 centimeters (cm) in length and 0.5 cm in width with no depth. The Resident was hospitalized from [DATE] through 04/28/22 for the treatment of atrial fibrillation with a rapid ventricular rate, hypotension, acute respiratory failure, chronic obstructive pulmonary disease, and decubitus ulcer of buttocks. re-admission nursing assessment dated [DATE] at 5:20 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 4.0 centimeters (cm) in length and 3.2 cm in width with no depth. Details/comments: Resident had an unstageable wound to coccyx prior to admission, upon re-admission wound is covered 100% yellow slough with surrounding skin purple in color measuring 8 cm in length and 3.0 cm in width. Interview with the Director of Nursing (DON) on 09/13/22 at 11:10 am, found the measurements for the unstageable wound on the coccyx should include the entire area including the purple-colored skin. She verified the measurements should read: 12 cm in length and 6.2 cm in width; this includes the area with slough and the purple-colored skin surrounding the area. The Resident was hospitalized from [DATE] through 05/02/22 for the treatment of atrial fibrillation with a rapid ventricular rate, hypotension, acute respiratory failure secondary to Covid-19 pneumonia, chronic obstructive pulmonary disease, and decubitus ulcer of buttocks. Evaluation by Registered Nurse completed on 05/03/22 at 4:42 PM by RN #9, reveal the following pressure ulcers as follows: --Stage IV on coccyx area measuring 3.5 cm in length and 2.0 cm in width and no depth measured. Stage 4: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are exposed. Weekly pressure ulcer assessment dated [DATE] at 1:30 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 3.3 centimeters (cm) in length and 2.0 cm in width with no depth. --SDTI- coccyx 0.9 cm in length and 0.5 cm in width. Weekly pressure ulcer assessment dated [DATE] at 3:57 PM by RN #46, reveals the resident has the following pressure ulcer/injuries: --Unstageable- coccyx measuring 5.5 centimeters (cm) in length and 3.2 cm in width with no depth. --Unstageable- right buttock measuring 1.5 centimeters (cm) in length and 1.2 cm in width with no depth. Description for pain management with the wound/treatment: wound to coccyx has increased and now encompasses the sacrum and right buttock, area is 100% covered with yellow slough. Interview with the DON on 09/14/22 at 9:15 am, found the nurses had failed to accurately stage and measure the pressure area on the sacral/coccyx area and extending on to the entire right buttocks. She also confirmed a pressure-relieving cushion for his chair was never ordered.

Based on medical record review and staff interview the facility failed to provide a dialysis order to include the designated days of treatment. This was discovered for one (1) of one (1) residents reviewed for the care area of dialysis services. The dialysis order for Resident #11 did not indicate what days dialysis services were being received. Resident identifier: #11. Facility census: 63. Findings included: a) Resident #11 A medical record review for Resident #11 on 09/13/22, revealed the dialysis order did not specify what days Resident #11 received his dialysis services. An interview with the Director of Nursing (DON) on 09/14/22 at 10:45 AM, verified the dialysis order did not indicate which days of the week Resident #11 was to receive dialysis.

Based on observations during the kitchen tour and staff interview the facility failed to store food in a safe and sanitary manner in accordance with professional standards for food service safety. It was discovered during the kitchen tour that food items were not stored properly after opening and the walk-in cooler was very dirty. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 63. Findings included: a) Kitchen tour During the kitchen tour on 09/12/22 at 10:55 AM, it was discovered a five (5) pound bag of potato squares had been damaged and the contents were spilling onto the floor. A package of pancakes were not dated after opening. In addition, the walk-in cooler had a buildup of a black tarry substance on the floor. The platforms used to keep food off the floor had debris under them. An interview with the Dietary Manager on 09/12/22 at 11:00 AM, verified the package of potato squares was damaged and the pancakes were not dated after opening. Also the floor of the walk-in cooler was dirty and needed to be cleaned.

. Based on observation, record review, and staff interview, the facility failed to ensure Resident #7 was treated with dignity and respect. This was a random opportunity for discovery. Resident Identifier: #7. Facility Census: 60. Findings included: a) Resident #7 On 05/17/21 at 1:49 PM Nurse Aide (NA) #41 entered Resident #7's room and stated, (First Name of Resident #7 ) my little pretzel I am going to put some mustard on your legs. Resident #7 was observed sitting in her geri-chair with her legs curled up and twisted around each other. An additional interview with NA #41 at 8:45 AM on 05/18/21, confirmed Resident #7 does move some in the bed on her own. She stated, she can wiggle in the bed and likes to curl up in the bed. She stated, I call her my pretzel lady and she (meaning the resident) just laughs. An interview with the Director of nursing (DON) at 9:27 AM on 5/19/21 confirmed NA #41 should not have said that. A review of Resident #7's most recent Minimum Data Set with an assessment reference date (ARD) of 02/05/21 found he Brief Interview of Mental Status (BIMS) was an 8 indicating a moderate cognitive impairment. During the exit conference with the facility staff the Nursing Home Administrator stated, Shame on us for telling this NA that she can not have this relationship with the resident. She stated, the NA is one of the best NA's they have and she stated, That's how she makes Resident #7 smile. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the resident's responsible party in a timely manner of a fall with injury. This was true for one (1) of six (6) residents reviewed for falls. Resident Identifier: Resident # 5. Facility census 60. Findings included: a) Resident # 5 Review of resident #5's medical record on 05/18/21 11:10 AM, found the resident fell on [DATE], and injured the left elbow. Further review of the record found no nursing notes regarding notification of the residents representative until 05/12/21. On 05/18/21 at 12:32 PM, the assistant director of nursing (ADON) confirmed the responsible party should have been notified. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to follow the physician's order for restraint usage for one (1) of one (1) resident reviewed for the use of restraints during the long term care survey. Resident identifier: #3. Facility census: 60. Finding included: a) Resident #3 Observation of the resident on 05/17/21 at 12:52 PM, found the resident in a wheelchair with a lap buddy. (A lap buddy is a cushioned device that fits in a wheelchair and assists with reminding a person not to get up by himself/herself.) Review of the resident's current care plan found the resident had 16 falls since 01/01/21. Prior to this time period the resident had 59 falls between 12/22/19 and 12/29/20. On 01/15/21, the physician ordered a, Lap buddy while in wheelchair. Check for skin breakdown and toilet every 2 hours. Review of the nursing assistant documentation on the [NAME] found documentation should have been provided for, Toilet resident every 2 hours. From 04/27/21 through 05/18/21, nursing assistants coded the toileting tasks every 2 hours as not applicable. Review of a quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/21 found the resident can ambulate with the assistance of one staff member assisting with guiding, maneuvering or other non weight bearing assistance. 05/18/21 at 4:23 PM, Registered Nurse Manager (NM) #3 reviewed the documentation from 01/15/21 and confirmed NA's have not been documenting the resident was toileted every 2 hours as directed by the physician's order. Review of information from RegisteredNursing. org found the following: The Provision of Care to Restrained Clients The following aspects of care must be provided as needed to a restrained patient or resident and documented at least every two (2) hours when the person is restrained for non behavioral reasons, . On 05/19/21 at 9:03 AM, the Director of Nursing (DON) confirmed the resident needs to be repositioned at least every 2 hours, and that was why we have the order to toilet Q (every) 2 hours. I know we have no documentation the resident was released every 2 hours and the resident was repositioned every 2 hours. The DON said the nurse who put the order in the computer wrote the wrong thing. She stated the order should have said, Was the restraint released, Yes or No. The DON said we fixed the order this morning. .

. Based on observation, record review, and staff interview, the facility failed to investigate the cause of a skin tear occurred by the resident to rule out any possible abuse or neglect. This was found for one (1) of one (1) resident reviewed for skin conditions. Resident identifier: #3. Facility census: 60. Findings included: a) Resident #3 Observation on 05/17/21 at 12:52 PM, found a bandage on the resident's left arm above the wrist. Review of the resident's incident reports found an incident dated 05/09/21. The incident description: This nurse was alerted by CNA (certified nursing assistant) that resident had acquired a skin tear during morning care. The incident report failed to contain any detail as to how the incident occurred. The incident report noted the resident was confused and oriented to person only. The level of pain was a 2, and the facial expression by the resident was described as: Sad, frightened, frown. Review of the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/21 coded the resident as having a poor long and short term memory. Staff were unable to complete the brief interview for mental status (BIMS.) On 05/19/21 at 10:30 AM, the assistant director of nursing (ADON) #99 said she was unable to find any investigation related to the incident. She confirmed no statements were taken and there was no information in the nursing notes to explain how the incident occurred. .

. Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of activities of daily living (ADL) received bathing as directed. Resident identifier: #14. Facility census: 60. Findings included: a) Resident #14 On 05/17/21 at 1:40 PM, Resident #14 said I do not always get my showers, I usually receive a cold bed bath. Review of the resident's care plan on 05/18/21, found the resident is total assistance with bathing activities. Showers are scheduled on Monday and Thursday, day shift. Further review of the the resident's Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 02/24/21, revealed the resident was coded as being totally dependent upon staff for bathing. Review of the shower documentation survey report for April and May on 05/18/21, found nursing assistants are directed to provide a bed bath 5 days a week on day shift. Showers on Monday and Thursday, day shift. In April 2021, the resident should have received nine (9) showers. Only five (5) showers were provided. Showers should have been provided on the following Mondays and Thursdays: 04/01/21, 04/05/21, 04/08/21, 04/12/21, 04/15/21, 04/19/21, 04/22/21, 04/26/21, and 04/29/21. Documentation shows showers were provided on 04/05/21, 04/08/21, 04/12/21, 04/15/21, and 04/29/21. Between 04/15/21 and 04/29/21, the resident did not receive a shower for thirteen (13) days. In May 2021, the resident should have received five (5) showers, four (4) showers were provided on the following Mondays and Thursdays: 05/03/21, 05/06/21, 05/13/21, and 05/17/21. The resident should have received a shower on 05/10/21. There was no documentation indicating the resident refused any showers. On 05/18/21 at 1:01 PM, the assistant director or nursing (ADON) #99 and nurse manager (NM) #3 confirmed the resident did not receive showers as scheduled. ADON #99 reviewed the documentation and said, I have no explanation as to what happened. On 05/19/21 at 9:10 AM, the director of nursing (DON), confirmed the resident did not receive showers as directed and there was no evidence the resident refused any showers. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to perform catheter care according to professional standards of practice for one (1) of one (1) resident reviewed for catheter care. Resident identifier: Resident #6. Facility census: 60. Findings included: a) Resident #6 Observation of the residents catheter care on 05/18/21 at 8:30 AM, with nursing assistant (NA) #71 found the catheter had no anchor. NA #71 prepared a pan of water with [NAME] shampoo and body wash to perform catheter care. NA #71 did not rinse the area after cleaning as directed by the label on the shampoo bottle. The above issues were discussed with the director of nursing (DON) on the afternoon of 05/19/21. No further information was provided. .

. Based on medical record review and staff interview, the facility failed to ensure the provision of physician services 24 hours a day, in case of emergency. This failed practice affected one (1) of 19 residents reviewed during the long-term care survey process. Resident identifier: #17. Facility census: 60. Findings included: a) Resident #17 On 04/08/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. A nursing progress note written on 04/08/21 at 12:41 PM stated, Resident's blood sugar reading hi at this time. 10 units administered and to be re-assessed. On 04/08/21 at 4:00 PM, a nursing progress note stated, Resident's blood sugar still reading hi. Message left for [physician's name] via cell phone to return call to facility concerning blood sugar. Awaiting call back from MD. A nursing progress note written on 04/08/21 at 6:11 PM stated, Blood sugar 561 at this time. 12 units Humulin R administered per standing order for coverage. Still awaiting a call back from MD to notify of high blood sugar. A nursing progress note written on 04/08/21 at 7:41 PM stated his regularly scheduled insulin was given and blood sugar reading hi. Resident not showing s/s [signs/symptoms] of hyperglycemia at this time. Awaiting return call [from] physician. A nursing progress note written on 04/08/21 at 8:14 PM stated, rechecked residents [sic] sugar and it was 469. Resident #17's fingerstick blood glucose was next checked on 04/09/21 at 6:45 AM and was 252. On 05/20/21 at 9:40 AM, the Administrator confirmed the physician did not respond to the telephone calls on 04/08/21 regarding Resident #17's elevated blood glucose levels. She also confirmed this physician was the only medical provider who received calls regarding residents. No further information was provided regarding the matter. .

. Based on medical record review and staff interview, the pharmacist failed to identify and report irregularities in the resident's blood glucose monitoring and sliding scale insulin administration. This failed practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #17. Facility census: 60. Findings included: a) Resident #17 Review of Resident #17's medical records revealed from 02/27/21 to 05/7/21, the resident had the following order in place: Humulin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if [blood glucose level] 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units Call MD, subcutaneously three times a day related to type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #17's medical records for April and May 2021 found the following irregularities regarding the above order: - On 04/5/21 at 4:45 PM, the Medication Administration Record (MAR) recorded the resident's blood glucose was 424 and 10 units of insulin were administered as ordered by the sliding scale. There is no indication the physician was notified as ordered for blood glucose level 401-450. - On 04/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. NA does not correspond to a chart code on the MAR. The Weights and Vitals Summary tab recorded the blood glucose level as 530 on 04/07/21 at 1:37 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 530. A nursing progress note written on 04/07/21 at 1:40 PM stated, Blood sugar 530. Administered 10 units at this time of coverage. Will re-check and re-assess. The insulin administration was not documented on the MAR. There was no indication the physician was notified. - On 04/08/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. A nursing progress note written on 04/08/21 at 12:41 PM stated, Resident's blood sugar reading hi at this time. 10 units administered and to be re-assessed. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level too high for the glucometer to read. The insulin administration was not documented on the MAR. There was no indication the physician was notified at this time. - On 04/08/21 at 4:00 PM, a nursing progress note stated, Resident's blood sugar still reading hi. Message left for Dr. William's via cell phone to return call to facility concerning blood sugar. Awaiting call back from MD. - A nursing progress note written on 04/08/21 at 6:11 PM stated, Blood sugar 561 at this time. 12 units Humulin R administered per standing order for coverage. Still awaiting a call back from MD to notify of high blood sugar. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 561. The insulin administration was not documented on the MAR. - A nursing progress note written on 04/08/21 at 7:41 PM stated his regularly scheduled insulin was given and blood sugar reading hi. Resident not showing s/s [signs/symptoms] of hyperglycemia at this time. Awaiting return call physician. - A nursing progress note written on 04/08/21 at 8:14 PM stated, rechecked residents [sic] sugar and it was 469. Resident #17's fingerstick blood glucose was next checked on 04/09/21 at 6:45 AM and was 252. - On 04/10/21 at 6:45 AM, the MAR reported the resident's fingerstick blood glucose level was 430 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. - On 04/12/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 04/12/21 at 1:21 PM. A nursing progress note written on 04/12/21 at 1:19 PM stated, Blood sugar 471. 10 units administered and to be re-checked. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 471. The insulin administration was not documented on the MAR. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. - The next fingerstick blood glucose was obtained 04/12/21 at 4:45 PM and the result was 433. According to the MAR, 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. - On 04/12/21 at 8:24 PM, the Weights and Vitals Summary tab recorded the blood glucose level as 431. There was no indication the physician was notified. The blood glucose level was rechecked on 04/12/21 at 10:46 PM and was recorded as 366 on the Weights and Vitals Summary tab. - On 04/17/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. - On 04/20/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 459 on 04/20/21 at 1:00 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 459. A nursing progress note written on 04/12/21 at 12:34 PM stated, Blood sugar 459. 10 units administered. There was no indication the physician was notified. - On 04/21/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. - On 04/22/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 429 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. - On 04/22/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 450 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. - On 04/27/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 453 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 453. A progress note written on 04/27/21 at 12:45 PM stated, Blood sugar 453. 10 units administered at this time. There is no indication the physician was notified. - On 04/27/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 404 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. - On 04/30/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 475. A progress note written on 04/30/21 at 1:01 PM stated, Blood sugar 475 at this time. 10 units administered in upper right arm. There is no indication the physician was notified. - On 04/30/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 408. 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. - On 05/02/21 at 6:45 AM, Resident #17's Medication Administration Record was blank in the area to record the blood glucose level. No blood glucose level was recorded on the Weights and Vitals Summary tab or in the progress notes. - On 05/02/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 05/02/21 at 12:42 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 475. A nursing progress note written on 05/02/21 at 12:21 PM stated, Resident's blood sugar is 475. 10 units administered in left arm and to be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. - On 05/05/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 202 on 05/05/21 at 10:52 AM. According to the physician orders, the resident should have received 2 units of insulin for a blood glucose level of 202. There is no indication on the MAR that 2 units of insulin was administered. - On 05/05/21 at 4:45 PM, the MAR recorded the resident's blood glucose was 427 and 10 units of insulin was administered. There is no indication the physician was notified as ordered for blood glucose level 401-450. - On 05/06/21 at 4:45 PM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 05/06/21 at 6:21 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 471. A nursing progress note written on 05/06/21 at 6:15 PM stated, Blood sugar 471. 10 units administered and to be re-checked by night shift LN [licensed nurse]. The insulin administration was not documented on the MAR. There is no indication the physician was notified. - On 05/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 598 on 05/07/21 at 1:35 PM. A nursing progress note written on 05/07/21 at 1:32 PM stated, Resident's blood sugar is 598 at this time. 12 units administered in right arm, per standing order. Will re-check. The insulin administration was not documented on the MAR. Resident #17's finger stick blood glucose was next checked on 05/07/21 at 6:17 PM and was 499. - A nursing note written on 05/07/21 at 4:17 PM stated, [Physician's name] in facility and reviewed resident's recent blood sugars with noted increase. New order received and noted to change Humulin R coverage order at this time and to increase amount of units administered each time coverage is needed. On 05/07/21, the following new order was written: Humulin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 201 - 250 = 7 units ; 251 - 300 = 9 units ; 301 - 350 = 11 units ; 351 - 400 = 13 units; 401 - 450 = 15 units Re-check in 2 hours and if still above 400, contact MD., subcutaneously three times a day related to type 2 diabetes mellitus with diabetic neuropathy. Review of Resident #17's medical records for May 2021 found the following irregularities regarding the above order: - On 05/12/21 at 11:30 AM, the MAR recorded the resident's blood glucose finger stick was recorded as 450. The resident received 15 units of insulin. There is no indication the physician was notified as specified in the order. - The next fingerstick blood glucose level was obtained 05/12/21 at 4:45 PM and was 417. The resident was administered 15 units of insulin. There is no indication the physician was notified for the blood glucose level remaining over 400. Following this, there was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. - On 05/14/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 489 on 05/14/21 at 1:30 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 489. A progress note written on 05/14/21 at 1:29 PM stated, Blood sugar 489. 15 units administered at this time. To be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. There is no indication the blood glucose level was rechecked in 2 hours as ordered. - The resident's blood glucose was next checked on 05/14/21 at 4:45 PM. The MAR recorded the resident's blood glucose level as 402 and 15 units of insulin were administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. - On 05/15/21 at 11:30 AM, the MAR recorded the resident's fingerstick blood glucose level as 420 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. - On 05/17/21 at 11:30 AM the MAR recorded the resident's blood glucose level as 440 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The pharmacist's monthly medication regimen review dated 5/5/21 stated no irregularities were identified. The pharmacist did not identify the above-described instances during which insulin was administered when the resident's fingerstick blood glucose was higher than the parameters in the sliding scale coverage. The pharmacist also did not identify the above-described instances during which the facility did not follow physician's orders to notify the physician or repeat the fingerstick blood glucose. On 05/19/21 at 2:30 PM, the Director of Nursing (DON) was notified the pharmacist's monthly medication regimin report dated 05/05/21 did not identify the above-described irregularities regarding Resident #17's fingerstick blood glucose checks and insulin sliding scale coverage. The DON had no further information regarding the matter. No further information was provided through the completion of the survey process. .

. Based on observation and staff interview, the facility failed to store and label medications in accordance with currently accepted standards of practice. This was a random opportunity for discovery and had the potential to affect any resident being tested for tuberculosis. Facility census 60. Findings included: On 05/19/21 at 7:42 AM, a tour of the medication room with the assistant Director of Nursing, Registered Nurse (RN) # 99 found a vial of Tuberculin Purified Protein Derivative Diluted Aplisol 5/0.1 ml. The vial was opened but not dated. RN #99 confirmed the vial was not dated when first accessed. The vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. The above issue was discussed with the Director of Nursing (DON) on the afternoon of 05/19/21. No further information was provided. .

. Based on record review and staff interview the facility failed to ensure Resident #9's medical record was complete and accurate. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 60. Findings Included: A) Resident #9 A review of Resident #9's medical record at 8:38 AM on 05/19/21 found a Weight Focus Sheet which was signed by the physician on 01/15/21. The sheet contained recommendation from the Dietary Manager to increase Resident #9's med pass to three times a day. This would have been a total of 180 milliliters (ML) of med pass per day. During an interview with the Director of Nursing (DON) at approximately 9:30 AM on 05/19/21 she was asked if this recommendation was implemented. She stated I will look into this and let you know what I find out. During an additional interview with the DON at 10:15 a.m. on 05/19/21 she explained the Med Pass was not increased to three times a day because the registered dietician came in and recommended it be increased to 120 ml two a times a day for a total of 240 ml which was greater than the Dietary Mangers recommendation. The DON presented an order audit report for Resident #9's med pass order. This report showed the original order for Med Pass was initiated on 12/03/20 for 60 ml two times a day. The order audit report also showed that on 01/13/21 the med pass was changed to 90 ml two times a day. Then on 01/15/21 it was switched to 120 ml two times per day. A review of the medication administration record (MAR) from 12/03/20 through 01/12/21 found documentation indicating Resident #9 received 120 ml of med pass twice daily even though she should have only received the ordered 60 ml of med pass. The DON was asked to review the MAR and confirmed the MAR for 12/03/20 through 01/12/21 was now showing 120 ml of med pass administered which was inaccurate. She stated, They should have discontinued the order and not just altered the milliliters to be given. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing services. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #7, #3, #17 #43, #22, #6, and #14. Facility census: 60. Findings Included: a) Resident #7 Observations of Resident #7 in her room on 05/17/21 at 2:05 PM found the resident up in her Geri chair. Her legs were hanging off the side of her chair. Resident #7's bed was observed, and an obvious gap was present between the end of the Residents mattress and her foot board. Review of Resident #7's medical record found she had unwitnessed falls from her bed on 06/04/20, 08/02/20, 08/17/20, 12/13/20, 01/03/21, and 01/04/21. This is an indication Resident #7 was able to move about in her bed without help from staff. Review of Resident #7's physician orders found a physician order for a Concave Mattress to the bed. Which was entered into the medical record on 01/05/21. Review of Resident #7's Minimum Data Set (MDS) with the following Assessment Reference Dates (ARDs) 04/01/20, 07/01/20, 09/30/20, 12/30/20, 02/05/21, and 05/05/21 found Section G Functional Status A. Bed Mobility was coded to reflect Resident #7 was an extensive assist with bed mobility. Extensive assist is defined as resident is involved in activity, but staff provided weight bearing support. A review of Resident #7's care plan found an intervention dated 10/11/18 which indicated Resident #7 was an extensive assist with bed mobility. Review of Resident #7's therapy screens dated 03/20/20, 09/16/20, 12/22/20, and 04/23/21 found the resident had no decline in her bed mobility. An interview with Nurse Aide (NA) #41 at 8:45 AM on 05/18/21, confirmed Resident #7 does move some in the bed on her own. She stated, she can wiggle in the bed and likes to curl up in the bed. She stated, I call her my pretzel lady and she laughs. An interview with NA # 43 at 8:50 am on 05/18/21, confirmed Resident #7 does move some in the bed on her own. She stated, I have only been here two (2) weeks, but she does like to curl up in the bed and will move some. An interview with Licensed Practical Nurse (LPN) #82 at 8:55 a.m. on 05/18/21, confirmed Resident #7 does move some in the bed. She stated she can grab the handrail and help with her turning and she can reposition herself in the bed. On 05/18/21 at 9:29 a.m. the Maintenance Director with the Nursing Home Administrator (NHA) present, measured the gap between Resident #7's mattress and foot board. The gap was found to be 7 inches. An interview with the NHA at 9:37 a.m. on 05/18/21 confirmed the gap should not be there she stated we usually get spacers to put in the gap. An additional interview with the Maintenance Director at approximately 9:50 a.m. on 05/18/21 found he measured to the foot board but not to where the frame connected to the foot board. He remeasured and the gap was still found to be 6.5 inches. He stated, I know what the problem is. This is a 76-inch mattress (he pulled the tag on the mattress up and said it says so right here.) These beds take an 80-inch mattress. Review of the Guidance for Industry and FDA (Food Drug Administration) Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 03/10/06 found the following, The body part dimensions used to develop FDA's dimensional limit recommendations are summarized in Table 2 below. Table 2 Key Body Part Dimension Head 120 mm (4 ¾ inches) Neck 60 mm (2 3/8 inches) and an angle > 60 degree Chest 318 mm (12 ½ inches) This document also defines seven (7) zones for risk of entrapment. Zone 7 is defined in this document as the area Between the Head or Foot Board and the Mattress End. At 11:00 a.m. on 05/18/21 the NHA provided a policy titled, Bed Maintenance and Inspections which contained the following, Policy: It is the policy of this facility to conduct regular inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify and avoid areas of Possible entrapment. Definitions: Bed Rails also known as side rails are adjustable metal or rigid plastic bars that attach to the bed. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director or Designee is responsible for keeping records of bed inspections and maintenance. 2. A list of bed frames, mattresses, and bed rails will be maintained, including the manufacturer for each. The Maintenance Director shall be notified of any new equipment brought into the facility. 3. The Maintenance Director shall review each manufacturer's recommendations and requirements for Maintenance and bed inspections, and shall establish a Maintenance and inspections schedule accordingly. 4. Bed rails shall be securely and properly installed according to manufacturer's requirements. 5. When bed rails and mattresses are used and purchased separately from the bed frame, the facility will ensure that the bed rails, mattress, and bed frame are compatible. 6. Bed frame, mattress, and bed rail inspections will be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and Maintenance cycle according to the manufacturer's recommendations, to include manufacturer's time frame recommendations. 7. If bed equipment is found to be outside of the manufacturer's requirements for any reason, the facility will perform Maintenance to the bed equipment and remove from use. Please note: The Policy did not have an Implementation date or revision date. The NHA provided a form titled, Bed Rail Inspection which is what she stated the Maintenance director uses to monitor for areas of entrapment. This form was completed on 04/14/21 for 14 beds. On 04/14/21 Resident #7's bed was not reviewed for entrapment. The Maintenance director only reviews and measures Zone 1, Zone 2, Zone 3, and Zone 4. He does not measure Zone 7 which is the relevant zone to Resident #7's situation. An additional interview with the NHA and the Maintanance Director in the afternoon of 05/18/21 found they do not monitor Zone 7 becuase there is not a set recommendation from the FDA for Zone 7. They agreed Zone 7 was a risk for entrapment but indicated most entrapments occur in Zones 1-4 and that is why they do not monitor the other Zones. b-1) Resident #3 Review of the resident's care plan found the resident had fallen on the following dates in the past year: 05/10/20, 05/12/20, 05/15/20, 05/20/2020, 05/30/2020, 06/19/20, 07/6/20, 07/16/2020, 08/01/20, 08/09/2020, 08/12/2020, 08/14/20, 04/8/21/2020, 08/27/2020, 09/08/20, 09/11/20, 09/12/20, 09/14/20, 09/23/20, 09/24/20, 09/27/20, 09/28/20, 09/30/20, 10/01/2020,10/5/20, 10/7/20, 10/12/2020, 10/15/20, 10/19/2020, 10/26/2020, 10/27/2020, 11/8/20, 11/11/20, 11/17/2020, 11/21/20, 12/2/20, 12/5/20, 12/06/20, 12/15/20, 12/20/20, 12/24/20, 12/25/20,12/28/20, 12/29/20, 01/05/21, 01/08/21, 01/09/21, 01/10/21, 01/19/21, 01/22/21, 02/9/21, 03/18/21, 3/21/21, 03/23/2021, 04/4/21, 04/15/21, 04/20/21, and 05/4/21. On 05/10/21, the physician wrote an order for, Low bed at all times when in bed. On 05/18/21 at 7:25 AM, observation found the resident was asleep in her bed. Nursing assistant (NA) #53 verified the residents bed was not in the lowest position. NA #53 pushed a button on the foot board of the resident's bed and lowered the bed. Review of the resident's care plan, revised on 05/11/21 found a focus/problem: Resident is at risk for ongoing falls due to wandering, confusion, ambulating and transferring independently . The goal associated with the focus: Will attempt to prevent further serious injuries from falls thru review date. Interventions included: low bed while occupied On 05/19/21 at 9:00 AM, the Director of Nursing said she was aware of the observation, NA #53 had already told her. No further information was provided at the close of the survey. b-2) Resident #3 Observation on 05/17/21 at 12:52 PM, found a bandage on the resident's left arm above the wrist. Review of the resident's incident reports found an incident dated 05/09/21. The incident description: This nurse was alerted by CNA (certified nursing assistant) that resident had acquired a skin tear during morning care. The incident report failed to contain any detail as to how the incident occurred. The incident report noted the resident was confused and oriented to person only. The level of pain was a 2, and the facial expression by the resident was described as: Sad, frightened, frown. Review of the residents Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/21 coded the resident as having a poor long and short term memory. Staff were unable to complete the brief interview for mental status (BIMS.) On 05/19/21 at 10:30 AM, the assistant director of nursing (ADON) #99 said she was unable to find any investigation related to the incident. She confirmed no statements were taken and there was no information in the nursing notes to explain how the incident occurred. c) Resident #17 Review of Resident #17's medical records revealed from 02/27/21 to 05/7/21, the resident had the following order in place: Humulin R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if [blood glucose level] 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units Call MD, subcutaneously three times a day related to type 2 diabetes mellitus with diabetic neuropathy. The glucose level was to be obtained by fingerstick. Fingerstick blood glucose monitoring is a procedure performed by nurses utilizing a blood glucose monitor and a drop of blood obtained by sticking the resident's finger with a small lancet. The blood glucose fingerstick results were documented on the Medication Administration Record (MAR). Sometimes the blood glucose fingerstick results were documented on the Weights and Vitals Summary tab in the Electronic Medical Record (EMR). On 04/5/21 at 4:45 PM, the MAR recorded the resident's blood glucose was 424 and 10 units of insulin were administered as ordered by the sliding scale. There is no indication the physician was notified as ordered for blood glucose level 401-450. The next fingerstick blood glucose was obtained 05/06/21 at 6:45 AM, and the result was 262. On 04/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. NA does not correspond to a chart code on the MAR. The Weights and Vitals Summary tab recorded the blood glucose level as 530 on 04/07/21 at 1:37 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 530. A nursing progress note written on 04/07/21 at 1:40 PM stated, Blood sugar 530. Administered 10 units at this time of coverage. Will re-check and re-assess. The insulin administration was not documented on the MAR. There was no indication the physician was notified. The next fingerstick blood glucose was obtained 04/7/21 at 4:45 PM and the result was 254. On 04/08/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. A nursing progress note written on 04/08/21 at 12:41 PM stated, Resident's blood sugar reading hi at this time. 10 units administered and to be re-assessed. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level too high for the glucometer to read. The insulin administration was not documented on the MAR. There was no indication the physician was notified at this time. On 04/08/21 at 4:00 PM, a nursing progress note stated, Resident's blood sugar still reading hi. Message left for Dr. William's via cell phone to return call to facility concerning blood sugar. Awaiting call back from MD. A nursing progress note written on 04/08/21 at 6:11 PM stated, Blood sugar 561 at this time. 12 units Humulin R administered per standing order for coverage. Still awaiting a call back from MD to notify of high blood sugar. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 561. The insulin administration was not documented on the MAR. A nursing progress note written on 04/08/21 at 7:41 PM stated his regularly scheduled insulin was given and blood sugar reading hi. Resident not showing s/s [signs/symptoms] of hyperglycemia at this time. Awaiting return call physician. A nursing progress note written on 04/08/21 at 8:14 PM stated, rechecked residents [sic] sugar and it was 469. Resident #17's fingerstick blood glucose was next checked on 04/09/21 at 6:45 AM and was 252. On 04/10/21 at 6:45 AM, the MAR reported the resident's fingerstick blood glucose level was 430 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/08/21 at 11:30 AM and the result was 258. On 04/12/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 04/12/21 at 1:21 PM. A nursing progress note written on 04/12/21 at 1:19 PM stated, Blood sugar 471. 10 units administered and to be re-checked. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 471. The insulin administration was not documented on the MAR. There was no indication the physician was notified for blood glucose level between 401-450 as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/12/21 at 4:45 PM and the result was 433. According to the MAR, 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. On 04/12/21 at 8:24 PM, the Weights and Vitals Summary tab recorded the blood glucose level as 431. There was no indication the physician was notified. The blood glucose level was rechecked on 04/12/21 at 10:46 PM and was recorded as 366 on the Weights and Vitals Summary tab. On 04/17/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the sliding scale order. There was no indication the physician was notified as specified in the sliding scale order. The next fingerstick blood glucose was obtained 04/18/21 at 6:45 AM and the result was 102. On 04/20/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 459 on 04/20/21 at 1:00 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 459. A nursing progress note written on 04/12/21 at 12:34 PM stated, Blood sugar 459. 10 units administered. There was no indication the physician was notified. The next fingerstick blood glucose was obtained 04/20/21 at 4:45 PM and the result was 258. On 04/21/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 421 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next fingerstick blood glucose was obtained 04/21/21 at 4:45 PM and the result was 359. On 04/22/21 at 11:30 AM, the MAR recorded the resident's blood glucose level as 429 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. On 04/22/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 450 and 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next fingerstick blood glucose was obtained on 04/23/21 at 6:45 AM and the result was 214. On 04/27/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 453 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 453. A progress note written on 04/27/21 at 12:45 PM stated, Blood sugar 453. 10 units administered at this time. There is no indication the physician was notified. On 04/27/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 404. 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. On 04/30/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 04/27/21 at 12:49 PM. The resident's insulin coverage orders did not address the amount of insulin to be given for a blood glucose level of 475. A progress note written on 04/30/21 at 1:01 PM stated, Blood sugar 475 at this time. 10 units administered in upper right arm. There is no indication the physician was notified. On 04/30/21 at 4:45 PM, the MAR recorded the resident's blood glucose level as 408. 10 units of insulin was administered as specified in the order. There was no indication the physician was notified as specified in the order. The next blood glucose level was obtained on 05/01/21 at 6:45 AM and the result was 200. On 05/02/21 at 6:45 AM, Resident #17's Medication Administration Record was blank in the area to record the blood glucose level. No blood glucose level was recorded on the Weights and Vitals Summary tab or in the progress notes. On 05/02/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 475 on 05/02/21 at 12:42 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 475. A nursing progress note written on 05/02/21 at 12:21 PM stated, Resident's blood sugar is 475. 10 units administered in left arm and to be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. The resident's next fingerstick blood glucose was obtained on 05/02/21 at 4:45 PM and was 378. On 05/05/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 202 on 05/05/21 at 10:52 AM. According to the physician orders, the resident should have received 2 units of insulin for a blood glucose level of 202. There is no indication on the MAR that 2 units of insulin was administered. On 05/05/21 at 4:45 PM, the MAR recorded the resident's blood glucose was 427 and 10 units of insulin was administered. There is no indication the physician was notified as ordered for blood glucose level 401-450. On 05/06/21 at 4:45 PM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 471 on 05/06/21 at 6:21 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 471. A nursing progress note written on 05/06/21 at 6:15 PM stated, Blood sugar 471. 10 units administered and to be re-checked by night shift LN [licensed nurse]. The insulin administration was not documented on the MAR. There is no indication the physician was notified. Resident #17's finger stick blood glucose was next checked 05/07/21 at 6:07 AM and was 217. On 05/07/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 598 on 05/07/21 at 1:35 PM. A nursing progress note written on 05/07/21 at 1:32 PM stated, Resident's blood sugar is 598 at this time. 12 units administered in right arm, per standing order. Will re-check. The insulin administration was not documented on the MAR. Resident #17's finger stick blood glucose was next checked on 05/07/21 at 6:17 PM and was 499. A nursing note written on 05/07/21 at 4:17 PM stated, [Physician's name] in facility and reviewed resident's recent blood sugars with noted increase. New order received and noted to change Humulin R coverage order at this time and to increase amount of units administered each time coverage is needed. On 05/07/21, the following new order was written: HumuLIN R Solution 100 UNIT/ML (Insulin Regular Human) Inject as per sliding scale: if 201 - 250 = 7 units ; 251 - 300 = 9 units ; 301 - 350 = 11 units ; 351 - 400 = 13 units; 401 - 450 = 15 units Re-check in 2 hours and if still above 400, contact MD., subcutaneously three times a day related to type 2 diabetes mellitus with diabetic neuropathy. On 05/12/21 at 11:30 AM, the MAR recorded the resident's blood glucose finger stick was recorded as 450. The resident received 15 units of insulin. There is no indication the physician was notified as specified in the order. The next fingerstick blood glucose level was obtained 05/12/21 at 4:45 PM and was 417. The resident was administered 15 units of insulin. There is no indication the physician was notified for the blood glucose level remaining over 400. Following this, there was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's fingerstick blood glucose level was next checked on 05/13/21 at 6:45 AM and the result was 334. On 05/14/21 at 11:30 AM, the MAR recorded NA in the area to record the blood glucose level. The Weights and Vitals Summary tab recorded the blood glucose level as 489 on 05/14/21 at 1:30 PM. The orders do not address the amount of insulin to be given for a blood glucose level of 489. A progress note written on 05/14/21 at 1:29 PM stated, Blood sugar 489. 15 units administered at this time. To be re-checked. The insulin administration was not documented on the MAR. There was no indication the physician was notified. There is no indication the blood glucose level was rechecked in 2 hours as ordered. The resident's blood glucose was next checked on 05/14/21 at 4:45 PM. The MAR recorded the resident's blood glucose level as 402 and 15 units of insulin were administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 6:14 AM, and the result was 204. On 05/15/21 at 11:30 AM, the MAR recorded the resident's fingerstick blood glucose level as 420 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 4:45 PM, and the result was 185. On 05/17/21 at 11:30 AM the MAR recorded the resident's blood glucose level as 440 and 15 units of insulin was administered. There was no indication the blood glucose level was re-checked in 2 hours as ordered for a blood glucose level between 401-450. The resident's blood glucose level was next checked on 05/15/21 at 4:45 PM, and the result was recorded as 271. On 05/19/21 at 9:03 AM, the Director of Nursing (DON) was notified regarding the facility's failure to follow Resident #17's physician's orders for fingerstick blood glucose monitoring and insulin administration in May 2021 as described above. The DON confirmed Resident #17's insulin coverage was for blood glucose levels up to 450. She confirmed nurses were to call the physician for blood glucose levels between 401-450. On 05/19/21 at 11:20 AM, Registered Nurse #3 stated the facility had no further information regarding the matter. During an interview on 05/19/21 at 12:50 PM Registered Nurse (RN) #20 was asked what she would do if a resident's fingerstick blood glucose results were higher than addressed by the parameters for insulin coverage. RN # 20 stated, I would not give sliding scale coverage if above parameters. I would call the doctor and get further orders. If I call and get no answer from the doctor, I would call again. If I have an emergency and can't get him, then I would call my nurse manager. During an interview on 05/19/21 at 12:55 PM, RN #16 was asked the same question. RN #16 stated, If the blood sugar is over the parameters, I would not give any insulin; I would call the doctor. If I couldn't get a hold of the doctor and they are really symptomatic like sweating, dizzy, can't see, thirsty, then I would give the 15 units ordered for 400-450. During an interview on 05/19/21 at 1:00 PM, Licensed Practical Nurse #14 (LPN) was asked the same question. LPN #14 stated, I would give the amount of insulin ordered for 400-450. Then I would recheck in 2 hours. Then I would call the doctor if the blood sugar isn't down. If I can't get the doctor, then I would call the RN on call. On 05/19/21 at 2:30 PM, the Director of Nursing (DON) was notified regarding Resident #17's fingerstick blood glucose readings for April 2021 as described above. The DON confirmed the resident's order was to call the doctor for fingerstick blood glucose levels 401-450. Regarding the standing order mentioned in the progress notes on 04/08/21 and 05/07/21, the DON stated the facility has standing orders for insulin coverage for elevated blood glucose levels. However, the facility standing orders are superseded by specific orders written by the physician for a resident. On 05/19/21 at 3:05 PM, the DON stated she believed the nurses were following facility's usual standing order instead of the resident's specific standing order. The DON stated, That still doesn't make it right. d) Resident #43 Review of Resident #43's medical records revealed an order written on 12/11/20 for a hemoglobin A1-c laboratory test to be performed 12/17/20. Hemoglobin A1-c measures the average amount of glucose in the blood over a period of time. No hemoglobin A1-c result for 12/17/20 could be located in the resident's electronic medical record. On 05/18/21 at 2:14 PM, Assistant Director of Nursing confirmed Resident #43 had no results for a hemoglobin A1-c performed on 12/17/20. No further information was provided through the completion of the survey process. e) Resident #22 Review of Resident #22's medical records revealed the resident experienced an unwitnessed fall on 04/07/21. According to the progress notes, neurological examinations were initiated and documented on a flow sheet. Neurological examinations include monitoring the resident's level of consciousness, motor response, pupil response, and vital signs. Changes in these areas may indicate the resident received a head injury during the unwitnessed fall. Resident #22's neurological examinations flow sheet dated 04/07/21 documented Resident #22 was sleeping at 10:00 PM. No neurological examinations were performed at that time due to the resident being asleep. During an interview on 05/19/21 at 9:03 AM, Director of Nursing (DON) stated the purpose of neurological checks is to make sure nothing is going on. She stated a resident sleeping might indicate a problem with the resident's consciousness. The DON stated education had already been started with staff to ensure residents are awoken for neurological evaluations. f) Resident #6 Observation of the residents catheter care on 05/18/21 at 8:30 AM, with nursing assistant (NA) #71 found the catheter had no anchor. NA #71 prepared a pan of water with [NAME] shampoo and body wash to perform catheter care. NA #71 did not rinse the area after cleaning as directed by the label on the shampoo bottle. g) Resident #14 On 05/17/21 at 1:40 PM, Resident #14 said I do not always get my showers, I usually receive a cold bed bath. Review of the resident's care plan on 05/18/21, found the resident is total assistance with bathing activities. Showers are scheduled on Monday and Thursday, day shift. Further review of the the resident's Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 02/24/21, revealed the resident was coded as being totally dependent upon staff for bathing. Review of the shower documentation survey report for April and May on 05/18/21, found nursing assistants are directed to provide a bed bath 5 days a week on day shift. Showers on Monday and Thursday, day shift. In April 2021, the resident should have received nine (9) showers. Only five (5) showers were provided. Showers should have been provided on the following Mondays and Thursdays: 04/01/21, 04/05/21, 04/08/21, 04/12/21, 04/15/21, 04/19/21, 04/22/21, 04/26/21, and 04/29/21. Documentation shows showers were provided on 04/05/21, 04/08/21, 04/12/21, 04/15/21, and 04/29/21. Between 04/15/21 and 04/29/21, the resident did not receive a shower for thirteen (13) days. In May 2021, the resident should have received five (5) showers, four (4) showers were provided on the following Mondays and Thursdays: 05/03/21, 05/06/21, 05/13/21, and 05/17/21. The resident should have received a shower on 05/10/21. There was no documentation indicating the resident refused any showers. On 05/18/21 at 1:01 PM, the assistant director or nursing (ADON) #99 and nurse manager (NM) #3 confirmed the resident did not receive showers as scheduled. ADON #99 reviewed the documentation and said, I have no explanation as to what happened. On 05/19/21 at 9:10 AM, the director of nursing (DON), confirmed the resident did not receive showers as directed and there was no evidence the resident refused any showers. .

. Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice in the laundry room had the potential to affect all residents that currently reside at the facility. The failed practice in the care area of wound care was true for four (4) of four (4) residents observed for the care area of pressure ulcers. Resident Identifiers: #14, #17, #61, and #2. Facility census 60. Findings included: a) Laundry Room During observation on 05/18/21 at 1:24 PM, of the laundry rooms, with Housekeeping Supervisor # 36 it was noted there was a clothing rack with resident clothing stored in the soiled side of the laundry room. There was no type of covering over the clean clothing. On the folding table was a light blue lunch box and a soda. HS # 36 stated she would remove the personal items and the clothing after she rewashed them. On 05/18/21 at 1:35 PM, Maintenance staff (MS) #27 was asked about the exhaust fan in the soiled laundry room. The exhaust fan was not pulling air out of the room. MS #27 picked up a used glove out of the trash can and pressed it to the center of the fan and stated it was working fine. MS #27 was made aware the vents on the outside of the exhaust fan were closed and the air was being blown back into the room. This was proven by holding a clean glove up to the fan which vigorously blew the glove around. In addition, there was also an exhaust fan on the clean side of the laundry room. This fan was pulling the soiled air into the clean side of the laundry room. MS #27 stated, Well what do you want me to do about it? It's been that way for years. b) Resident #14 On 05/19/21 at 8:54 AM, Licensed Practical Nurse (LPN) #14 was observed performing wound care on the lateral right foot of Resident #14. LPN #14 put the cream inside of a clear bag and laid the bag with the cream on the night stand. LPN #14 donned gloves, rubbed the cream on the whole foot. LPN #14 put the cream back in the clear bag and returned the supplies to the clean storage room. LPN #14 was asked if her normal practice was to take the wound medication in the room and return it to the storage room after it was placed on the residents night stand? She indicated it was her normal practice to do so. c) Resident #17 Observation of wound care for Resident # 17 began on 05/19/21 at 8:22 AM, with LPN #14. LPN #14 placed a towel on the side table. LPN #14 put about a 1/2 inch of water in a wash basin and placed it on the towel. She also placed an opened package of Hydrofera Blue Classic (this is a sterile absorptive foam dressing) antibacterial foam dressing, which had many pieces already cut out. A pair of scissors with orange handles was already inside of the packaging. LPN #14 washed her hands (Hand Hygiene) and donned gloves. LPN #14 removed the old dressing and the old Hydrofera foam and dropped them in the trash. Without any hand hygiene, LPN #14 put the wash cloth in the basin of water and poured a small amount of soap on the wash cloth. LPN #14 used a separate wash cloth to rinse the wound. LPN #14 removed the small blue disc that was previously cut out of the package. LPN# 14 realized she did not have a dressing to cover the wound. She laid the Hydrofera foam on the towel she used the dry the wound and left to get a dressing. Hand hygiene was performed. She picked up the piece of the Hydrofera foam and stated, this has to be wet. LPN #14 turned on the tap water at the sink and held the Hydrofera under the water. LPN #14 turned the faucet off without completing hand hygiene and/or changing gloves. The cut piece of Hydrofera was placed on the wound and the dressing was placed over wound. d) Resident #61 Observation of wound care with LPN #14 began on 05/19/21 at 8:51 AM. LPN #14 washed her hands for 12 seconds before donning gloves. She removed the soiled dressing and changed her gloves without performing hand hygiene. She used a spray bottle of wound cleanser to spray on the wound bed. She wiped the wound from the skin inward instead of wiping outward. This has the potential to carry pathogens from the skin into the wound. LPN #14 failed to perform any hand hygiene. She picked up the box containing a tube of Santyl (a medication used of debridement of a pressure ulcer.) LPN #14 used a cotton swab with a stick and squeezed a small amount of Santyl on the wound bed and applied a new covering. LPN #14 removed the gloves and put the wound spray and the boxed Santyl inside of her pocket. LPN #14 returned the used wound spray to a shelve in the clean supply room. She then put the medication (Santyl) back in the treatment cart on top of other resident's medications. She was asked if the wound spray was used only for Resident # 61. She stated no, anyone that needs to use it can. The practice of co-mingling and removing the medications still in the box, which are taken into the residents rooms, than returned to the clean storage room has the potential for cross contamination. Using opened treatment supplies and medications that were used on multiple residents has the potential to cross contaminate between residents. e) Resident #2 On 05/19/21 at 12:28 PM, Registered Nurse (RN) #3 returned the Wound Cleanser (in a spray bottle) back to the clean storage room, after providing wound care for Resident # 2. The spray bottle was not labeled with any residents name. RN #3 was asked where she puts the Wound Cleanser after using it in the room of Resident # 2. She stated, she returns it to the storage room and puts it back on the shelf. She was asked if she would use the same spray bottle on multiple residents? She said, Yes, I have and I do. The above issues were discussed with the director of nursing (DON) on the afternoon of 05/19/21. No further information was provided. .