Every finding on record at A Grace Sub Acute & Skilled Care

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of one of three sampled residents (Resident 1) when medications were not available to be administered as ordered. This failure had the potential to compromise the resident's health and safety.Findings:Review of Resident 1's medical record indicated he was readmitted to the facility on [DATE] and had diagnoses including traumatic brain injury and epilepsy (a brain disorder that causes seizures [bursts of electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness]).Review of Resident 1's physician's orders indicated he had the following medication orders, dated 7/1/25: 1.) Clobazam (medication used to treat seizures) oral suspension 2.5 milligrams per milliliter (mg/ml, unit of dose measurement) give 8 ml via gastrostomy tube (GT, a tube inserted through the abdomen and into the stomach) two times a day; and 2.) Lacosamide (medication used to treat seizures) oral solution 100 mg/ml give 20 ml via GT two times a day. Resident 1 also had an order, dated 7/2/25, for Zonisamide (medication used to treat seizures) oral suspension 100 mg/5 ml give 15 ml via GT one time a day.Review of Resident 1's medication administration record (MAR), dated 7/2025, indicated Clobazam and Lacosamide were not documented as administered on 7/1/25, 7/2/25, and 7/3/25. Further review of the MAR indicated Zonisamide was not documented as administered on 7/2/25 and 7/3/25.Review of Resident 1's progress notes, dated 7/1/25 to 7/3/25, indicated the above medications were not available and that the facility was waiting for the medications to be delivered from the pharmacy.During an interview with licensed nurse A (LN A) on 7/10/25, at 3:21 p.m., LN A verified the above medications were not administered to Resident 1 because they had not been delivered to the facility from the pharmacy.During an interview with the consultant pharmacist (CP) on 8/14/25, at 1:20 p.m., the CP explained there was a delay in the delivery of the above medications because Clobazam and Lacosamide were controlled medications (medications regulated by the government due to their potential for abuse and addiction) and the pharmacy was waiting for the required triplicates (signed prescriptions from the physician or other valid prescriber). The CP further explained that Lacosamide was a high-cost medication for which the pharmacy requested delivery authorization from the facility, but the facility had not replied.An email from the CP, dated 8/15/25, was reviewed. The email contained documentation that the pharmacy faxed a request for triplicates for Clobazam and Lacosamide to Resident 1's physician on 7/2/25 at 12:31 p.m., but did not receive these triplicates until after 7/3/25. The email also contained documentation that the pharmacy faxed a high-cost medication delivery authorization request for Zonisamide to the facility on 7/2/25 at 2:54 a.m., but did not receive authorization from the facility until after 7/3/25.The facility's policy titled Pharmacy Services Overview, revised 4/2019, indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.The facility's policy titled Medication Ordering and Receiving from Pharmacy Provider, dated 1/2025, indicated, Medications and related products are received from the provider pharmacy on a timely basis. The policy further indicated, The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances.

Based on observation, interviews, and record review, the facility failed to ensure professional standards of practice were followed for five out of 22 sampled residents (Residents 25, 35, 75, 93, and 98) when: For Residents 25, 35, 93, and 98, there were incomplete physicians orders, which had the potential for unsafe implementation of the orders and untimely treatment or intervention residents' medical conditions. For Resident 75, the staff took the blood pressure (BP) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access), did not monitor her intake and output (the measurement of the fluids that enter the body and the fluids that leave the body). The failures had the potential to cause injury and unmonitored medical condition. Findings: 1. A review of Resident 93's clinical record indicated an order for Admelog [insulin lispro, a short-acting insulin to lower blood sugar] Injection Solution 100 UNIT/ML [milliliter] . Inject 3 ml [milliliters] subcutaneously [injection under the skin] as needed for DM [diabetes mellitus], dated 7/19/2024. The order had a dose of 3 ml which would be equal to 300 units of insulin; and did not have a frequency and parameters, such as blood sugar (BS) above certain readings, when to give it. During a concurrent interview and record review with Registered Nurse B (RN B) on 10/15/24 at 10:29 a.m., he reviewed Resident 93's Admelog order and stated he would give it if the BS was above 130 milligrams/deciliter (mg/dL) as BS above 130 mg/dL would be considered high. RN B stated the 3 ml is a questionable dose and confirmed the order had no dosing frequency nor parameters for when to give it. During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/24 at 12:14 p.m., she reviewed Resident 93's Admelog order and stated, It is totally unclear, and the dose is wrong as 3 ml (or 300 units) would be too high. 2. A review of Resident 35's clinical record indicated he had the following orders for lorazepam (medication for agitation or anxiety): - Lorazepam 1 mg, Give 1 tablet by mouth as needed for Anxiety for 90 days, dated 4/20/24; it was discontinued on 5/17/24; - Lorazepam 1 mg, Give 1 tablet by mouth as needed for Anxiety for 90 days, dated 5/17/24; it was discontinued on 7/16/24. The above orders did not include the dosing frequency (how often to give it). A review of Resident 35's medication administration records (MARs) and the Controlled Drug Record for lorazepam indicated the nursing staff administered 28 lorazepam doses from 4/30/24 to 7/16/24 while the orders did not include a dosing frequency. There was no documented evidence the nursing staff clarified the order with the physician. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 10/15/24 at 4:16 p.m., she confirmed the above finding and acknowledged the nursing staff carried out the order and administered the medication while the order did not have the frequency. 3. A review of Resident 98's physician orders included the following insulin orders: - Insulin glargine (long-acting insulin), inject 17 units subcutaneously every 12 hours for DM, dated 9/19/2024 - Insulin lispro, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific BS readings) . If BS < 60 follow hypoglycemic [low blood sugar] protocol, dated 9/20/2024. There was no written hypoglycemic protocol in Resident 98's clinical record. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) C on 10/17/24 at 11:19 a.m., when asked what he would do if the resident had a BS reading below 60, he stated he would call the doctor and give the resident some juice if she could drink; and if not, he would given Glucagon (an injectable medication to treat low BS). When asked if there were prescribed orders for hypoglycemic protocol, LVN C stated he could not find any. During a concurrent interview and record review with the DON on 10/17/24 at 11:35 a.m., she reviewed Resident 98's clinical record and confirmed there were no prescribed or an established hypoglycemia protocol. She stated, There should be an order for the protocol for staff to carry out. 4. A review of Resident 25's physician's orders included the following: - Insulin Glargine, inject 5 unit subcutaneously at bedtime for DM, dated 10/11/2024 - Insulin Lispro, inject per sliding scale . FSBS [finger-stick BS] <70 Refer to hypoglycemia orders, dated 10/11/2024 There was no prescribed hypoglycemia orders in Resident 25's medical record. During a concurrent interview and record review with the MDSC on 10/17/24 at 3:20 p.m., she confirmed despite having 2 insulin orders, there were no prescribed or an established hypoglycemia protocol in place for the nursing staff to follow in case the resident had BS readings below 70. She stated she just had the order clarified with the doctor about an hour before this interview. A review of the facility's policy and procedures (P&P) titled, Medication Therapy, revised 4/2007, indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . All medication orders will be supported by appropriate care and practices . All decisions related to medications shall include appropriate elements of the care process, such as . Consideration of the clinical relevance of symptoms and abnormal diagnostic test results . Upon or shortly after admission, and periodically thereafter, the staff and practitioner . will review an individual's current medication regimen, to identify whether . b. The dosage is appropriate; c. The frequency of administration and duration of use are appropriate . A review of the facility's P&P titled Medication and Treatment Orders, revised 7/2016, indicated in part, Orders for medications must include . Dosage and frequency of administration . Clinical condition or symptoms for which the medication is prescribed . If clarification is necessary, the nurse shall contact the prescriber. 36623 5. During a review of Resident 75's face sheet (summary page of a patient's important information), printed 10/16/24 indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (treatment that helps body to remove extra fluid and waste products from blood). During a review of Resident 75's Physician order dated, 7/5/24 indicated monitor dialysis access AV (arteriovenous) fistula (connection made between an artery and a vein for dialysis access) left forearm for s/sx (signs and symptoms) of infection, swelling, redness, bleeding, or any drainage QS (every shift). Notify MD (medical doctor) as needed. During a review of Resident 75's Care Plan indicated an intervention, Do not draw blood or take B/P (blood pressure) on left arm shunt/fistula. During a Review of Resident 75's Blood Pressure Summary for 10/2024 indicated, Resident 75's BP was taken on the left arm from 10/1/14 to 10/15/24. During a concurrent interview and record review with Licensed Vocational Nurse D (LVN D) on 10/16/24 at 3:50 p.m., LVN D confirmed Resident 75's BP summary indicated the resident's blood pressures were taken on her left arm. LVN D stated Resident 75 has an AV shunt/fistula on the left arm and she cannot get her blood pressure taken on her left arm. LVN D stated taking blood pressures on the arm with AV fistula can cause injury to Resident 75. During a concurrent interview and record review with LVN E on 10/17/24 at 1:15 p.m., LVN E confirmed Resident 75's BP summary indicated his blood pressures were taken on the left arm. She stated licensed nurses are responsible for taking and recording the blood pressure. LVN E stated taking blood pressure on the arm with an AV fistula might cause bleeding. During a concurrent interview and record review with Director of Nursing (DON) on 10/17/24 at 4:43 p.m., the DON confirmed Resident 75's BP summary indicated the resident's blood pressure was taken on her left arm from 10/1/24 to 10/15/24. DON stated Resident 75 has an AV fistula on her left arm. She stated taking blood pressures to the left arm could put the resident at risk for bleeding. During a concurrent interview and record review with LVN L on 10/18/24 at 10:37 a.m., LVN L confirmed Resident 75's BP summary is correct and accurate. LVN L stated he worked with Resident 75 and when Resident 75 was eating using her right hand, he checked the blood pressure on her left arm. LVN L stated Resident 75 had AV fistula, but he cannot remember which arm. LVN L stated taking blood pressure to arm with AV fistula might cause bleeding. During a review of Resident 75's Physician order dated, 5/24/24 indicated, 1000 cc (cubic centimeter, unit of volume)/(per) day Fluid restriction AM (morning) = 180 cc, PM (evening) = 90 cc, NOC (night) = 0 cc, BF (breakfast) = 240 cc, L (lunch) = 240 cc, D (dinner) = 240 cc. During a concurrent interview and record review with Licensed Vocational Nurse D (LVN D) on 10/16/24 at 3:50 p.m., LVN D confirmed Resident 75 was on a fluid restriction, but there was no monitoring for Resident 75's fluid intake and output. LVN D stated there was no intake and output in Resident 75's records. During a concurrent interview and record review with LVN E on 10/17/24 at 1:15 p.m., LVN E confirmed there was no monitoring for intake and output for Resident 75. LVN E stated dialysis residents should have monitoring for intake and output. During a concurrent interview and record review with the Director of Nursing (DON) on 10/17/24 4:43 p.m., the DON confirmed there was no order to monitor intake and output for Resident 75. During a review of the facility's undated policy and procedures titled, Dialysis, Coordination of Care & Assessment, indicated do not perform blood pressures on arm with shunt. The policy also indicated to monitor fluid balance through recording and assessment of intake and output.

Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 18 of 22 sampled residents (Residents 66, 38, 75, 77, 13, 4, 9, 5, 73, 57, 29, 54, 98, 6, 99, 28, 82, and 16) and 77 nonsampled residents. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. During an observation in Resident 66's room on 10/14/24 at 8:41 a.m., Resident 66 was sitting in bed. Resident 66's bed had both upper half side rails. Review of Resident 66's physician order, dated 10/04/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 66's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 66's Side Rail Assessment, dated 10/07/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 66's Informed Consent for the Use of Bed Rails, dated 10/04/24 indicated alternatives were not attempted. 2. During an observation in Resident 38's room on 10/14/24 at 8:48 a.m., Resident 38 was in bed. Resident 38's bed had both upper half side rails. Review of Resident 38's physician order, dated 4/21/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 38's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 38's Side Rail Assessment, dated 9/11/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 38's Informed Consent for the Use of Bed Rails, dated 4/21/22 indicated alternatives were not attempted. 3. During an observation in Resident 75's room on 10/14/24 at 8:55 a.m., Resident 75 was in bed. Resident 75's bed had both upper half side rails. Review of Resident 75's physician order, dated 1/27/23 indicated she had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 75's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 75's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 75's Informed Consent for the Use of Bed Rails, dated 1/27/23 indicated alternatives were not attempted. 4. During an observation in Resident 77's room on 10/14/24 at 9:24 a.m., Resident 77 was in bed. Resident 77's bed had both upper half side rails. Review of Resident 77's physician order, dated 11/23/23 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 77's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 77's Side Rail Assessment, dated 8/20/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 77's Informed Consent for the Use of Bed Rails, dated 2/23/23 indicated alternatives were not attempted. 5. During an observation in Resident 13's room on 10/14/24 at 9:47 a.m., Resident 13 was in bed. Resident 13's bed had both upper half side rails. Review of Resident 13's physician order, dated 2/15/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 13's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 13's Side Rail Assessment, dated 8/12/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 13's Informed Consent for the Use of Bed Rails, dated 3/21/21 indicated alternatives were not attempted. 6. During an observation in Resident 4's room on 10/14/24 at 10:00 a.m., Resident 4 was in bed. Resident 4's bed had both upper half side rails. Review of Resident 4's physician order, dated 9/27/21 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 4's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 4's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 4's Informed Consent for the Use of Bed Rails, dated 9/27/21 indicated alternatives were not attempted. 7. During an observation in Resident 9's room on 10/14/24 at 10:04 a.m., Resident 9 was in bed. Resident 9's bed had both upper grab bars. Review of Resident 9's physician order, dated 10/11/23 indicated he had an order for grab bars/Side Rails up for positioning and easy bed mobility. Review of Resident 9's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 9's Side Rail Assessment, dated 7/26/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 9's Informed Consent for the Use of Bed Rails, dated 10/11/23 indicated alternatives were not attempted. 8. During an observation in Resident 5's room on 10/14/24 at 10:04 a.m., Resident 5 was in bed. Resident 5's bed had both upper grab bars. Review of Resident 5's physician order, dated 6/05/24 indicated he had an order for both upper grab bar/Rail up for positioning and easy bed mobility. Review of Resident 5's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 5's Side Rail Assessment, dated 8/23/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 5's Informed Consent for the Use of Bed Rails, dated 6/01/24 indicated alternatives were not attempted. 9. During an observation in Resident 73's room on 10/14/24 at 10:45 a.m., Resident 73 was lying in bed. Resident 73's bed had both upper half side rails. Review of Resident 73's physician order, dated 5/23/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 73's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 73's Side Rail Assessment, dated 8/27/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 73's Informed Consent for the Use of Bed Rails, dated 5/22/24 indicated alternatives were not appropriate due to use of LAL [low air loss mattress]. 10. During an observation in Resident 57's room on 10/14/24 at 12:42 p.m., Resident 57 was lying in bed. Resident 57's bed had both upper half side rails. Review of Resident 57's physician order, dated 11/04/23 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 57's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 57's Side Rail Assessment, dated 8/05/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 57's Informed Consent for the Use of Bed Rails, dated 11/02/23 indicated, Alternatives not appropriate due to use of LAL [low air loss mattress]. 11. During an observation in Resident 29's room on 10/14/24 at 1:55 p.m., Resident 29 was in bed. Resident 29's bed had bilateral half side rails. Review of Resident 29's physician order, dated 12/13/23 indicated she had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 29's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 29's Side Rail Assessment, dated 4/17/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 29's Informed Consent for the Use of Bed Rails, dated 11/13/23 indicated alternatives were not attempted. 12. During an observation in Resident 54's room on 10/14/24 at 1:55 p.m., Resident 54 was in bed. Resident 54's bed had bilateral half side rails. Review of Resident 54's physician order, dated 1/13/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support. Review of Resident 54's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 54's Side Rail Assessment, dated 8/20/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 54's Informed Consent for the Use of Bed Rails, dated 1/20/24 indicated alternatives were not appropriate. 13. During an observation in Resident 98's room on 10/14/24 1:55 p.m., Resident 98 was in bed. Resident 98's bed had bilateral half side rails. Review of Resident 98's physician order, dated 10/8/24 indicated she had an order for (1/2) Both Upper Side Rail up for postural support. Review of Resident 98's Side Rail Assessment, dated 9/18/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 98's Informed Consent for the Use of Bed Rails, dated 9/18/24 indicated alternatives were not attempted. 14. During an observation in Resident 6's room on 10/15/24 at 9:42 a.m., Resident 6 was in bed. Resident 6's bed had both upper (1/4) side rails. Review of Resident 6's physician order, dated 8/06/24 indicated he had an order for (1/4) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 6's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 6's Side Rail Assessment, dated 8/30/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 6's Informed Consent for the Use of Bed Rails, dated 8/06/24 indicated alternatives were not attempted. 15. During initial facility observations on 10/14/24, between 9:00 a.m. and 3:30 p.m., it was noted that Residents 99, 28, 82, and 16 each had bilateral half side rails raised. Review of Resident 99's physician order, dated 9/27/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 99's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 99's Side Rail Assessment, dated 8/14/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 99's Informed Consent for the Use of Bed Rails, dated 9/27/24 indicated alternatives were not attempted. 16. Review of Resident 28's physician order, dated 3/5/22 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 28's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 28's Side Rail Assessment, dated 8/26/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 28's Informed Consent for the Use of Bed Rails, dated 3/5/22 indicated alternatives were not attempted. 17. Review of Resident 82's physician order, dated 2/5/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 82's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 82's Side Rail Assessment, dated 9/3/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 82's Informed Consent for the Use of Bed Rails, dated 2/5/24 indicated alternatives were not attempted. 18. Review of Resident 16's physician order, dated 1/11/20 indicated he had an order for May have both 1/2 Upper Side Rails up for repositioning and easy bed mobility. Review of Resident 16's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 16's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 16's Informed Consent for the Use of Bed Rails, dated 4/7/19 indicated alternatives were not attempted. During an interview with the Director of Nursing (DON) on 10/16/24 at 2:00 p.m., the DON confirmed about the attempted alternatives prior to the use bed rails were findings. The DON stated that alternatives were not considered necessary, as the side rails were used for support, mobility, and positioning. The survey team expanded the sample and identified via observation and record review an additional 77 residents had side rails. Review of the Informed Consent for the Use of Bed Rails for the 77 residents indicated there was no documentation that the facility attempted alternatives prior to the use of side rails. During an interview on 10/18/24 at 11:55 a.m., the Director of Nursing (DON) confirmed most residents in the facility have side rails. She stated usually if they see that side rails will be beneficial for the resident, then they use the side rails. The DON stated if the facility determines alternatives are not appropriate for a resident, that is the reason why the facility did not attempt alternatives prior to the resident using side rails. Review of the facility's policy, Proper Use of Side Rails, revised 12/2016 indicated less restrictive interventions will be incorporated in care planning and documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for 3 out of 5 residents (Residents 35, 39, and 85). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally). Findings: During an interview with the Director of Nursing (DON) on 10/15/24 at 3:40 p.m., she explained that each time a resident requested an as-needed controlled medication, the nurse assesses the resident, reviews the physician's order, signs it out of the CDR, administers the medication to the resident, documents the medication administration on the MAR, and re-assesses the resident for effectiveness of the medication within one hour. 1. A review of Resident 39's clinical record indicated a physician's order, dated 12/11/23, for diazepam (a controlled medication to treat anxiety or other medical conditions) 5 milligrams (mg, unit of measurement), give 1 tablet every 4 hours as needed for intermittent jerking. On 10/15/24 at 3:50 p.m., in the presence of the DON, an interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). A review of Resident 39's CDR for diazepam 5 mg and the June, August, and September 2024 medication administration records (MARs) indicated the nursing staff signed out of the CDR but did not document on the MAR to show the medication was administered to the resident, on 5 occasions, as follows: - 6/23/24 at 4 a.m. - 6/27/24 at 8 p.m. - 6/27/24 at illegible time - 8/7/24 at 8 p.m. - 9/12/24 at 8:30 p.m. During the interview and record review above, the MDSC confirmed this finding. She reviewed the nursing progress notes and stated there was documentation showing diazepam was given one time on 6/27/24 and on 9/12/24. However, both the DON and MDSC stated the nursing staff is expected to document the medication administration on the MAR so the computer system would prompt the re-assessment in one hour, and also to prevent the medication from being given again too soon. 2. A review of Resident 35's clinical record indicated a physician's order for lorazepam (medication for agitation and anxiety) 1 mg, give 1 tablet by mouth as needed for Anxiety for 90 days, dated 4/20/24. The order did not specify how frequent it should be administered. During a concurrent interview and record review with the MDSC on 10/15/24 at 4:16 p.m., a review of Resident 35's CDR for lorazepam 1 mg and the May and July MARs indicated, on 9 occasions, the nursing staff signed out one tablet on the CDR but did not document their administration on the MAR, as follows: - 5/1/24 at 2 p.m. - 5/2/24 at 2 p.m. - 5/7/24 at 3 p.m. - 5/11/24 at 3 p.m. - 5/13/24 at 3 p.m. - 5/17/24 at 3 p.m. - 5/25/24 at 3 p.m. - 7/15/23 at 3 p.m. - 7/30/24 at 8 a.m. During the interview and record review above, the MDSC verified the finding, and confirmed 9 lorazepam was not accounted for. 3. A review of Resident 85's clinical record indicated a physician's order, dated 11/26/2023, for oxycodone (a potent controlled medication for pain) 5 mg, 1 tablet every 6 hours as needed for moderate to severe pain. During a concurrent interview and record review with the MDSC on 10/15/24 at 4:29 p.m., a review of Resident 85's oxycodone 5 mg CDR and the July and August 2024 MARs indicated the nursing staff removed one tablet on the following dates and times without documenting in the respective administration on the MAR: - 7/22/24 at 4:30 a.m.; - 7/23/24 at 10:00 p.m.; - 7/24/24 at 6:00 a.m.; - 8/1/24 at 6:00 a.m. During a concurrent interview and record review on 10/15/24 at 4:35 p.m., the MDSC verified: three tablets of diazepam 5 mg for Resident 39; nine tablets of lorazepam 1 mg for Resident 35; and four tablets of oxycodone 5 mg for Resident 85, were unaccounted. She stated the nurses didn't document medication administration when they are supposed to. A review of facility's P&P titled Medication Administration Controlled Substances, dated 1/2023, indicated in part, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose . Administer the controlled medication and document dose administration on the MAR.

Based on observation, interview, and policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their used by date, bananas with black spots, partially soft and ruined tomatoes, dry green onion were found in the refrigerator and on the shelves in the kitchen; 2. A tube of Auto-Chlor test strips (used to test the chemical concentration of cleaning solutions to ensure that sanitizers are used appropriately in dishwashers, sinks, and buckets) was expired; and 3. Dietary supervisor (DS) did not sanitize the contaminated thermometer before checking the temperature of the lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 44 residents eating at the facility. Findings: 1. On [DATE], at 9:15 a.m., during an observation of the kitchen's storage shelves and in the walk-in refrigerator, with the registered dietician (RD) and the dietary supervisor (DS), the following were observed: a. A sugar container, but there was no use by date; b. Six tomatoes were partially soft and had signs of rotting; c. Four bunches of green onion were dry; d. One gallon of premium sweet pickle relish with a use by date of [DATE]; e. Open bag of five pounds of raisins with no open date and no use by date; f. One brown rice container, one white rice container, and one barley container with no use by date; g. One imperial country style gravy mix received on [DATE]; h. Eight ounces of ground cloves with use by date [DATE]; i. Eighteen bananas with black spots; j. Open container of 20 ounces of whole sesame seed with no open date; k. Open container of 16 ounces of cayenne pepper with no open date; l. Open container of 16 ounces of whole Mediterranean oregano with no open date; m. Open container of five pounds of ground black pepper with no open date; n. Open container of five pounds of granulated onion with no open date; During a concurrent interview with the RD, the RD reviewed the facility's Dry Goods Storage Guidelines and confirmed that the sugar container should have a use by date on it. The RD stated the gravy mix was good for one year, and it was expired The RD also stated the above food should have open date and use by date. He stated the expired food should not be on the shelves and should have been discarded. Review of the facility's 2023 policy, Labeling and Dating of Foods, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines . Review of the facility's 2023 policy, Storing Produce, indicated 1. Check boxes of fruit and vegetables for rotten, spoiled items . Throw away all spoiled items. 2. During an observation with the DS at the dishwasher in the kitchen on [DATE], at 11:15 a.m., a tube of Auto-Chlor test strips had an expiration date of ,d+[DATE]. During a concurrent interview with the DS, she confirmed that the tube of Auto-Chlor test strips was expired in ,d+[DATE]. The DS stated the tube should be discarded. 3. During a tray line observation on [DATE], at 12:05 p.m., the glasses of the drinks were placed in a bin with ice on top of their lids. The DS was checking the temperature of the lemonade. The DS held the thermometer in her hand; she tossed the ice on top of the lid of the lemonade glass with her index finger of the same hand, and the tip of the thermometer touched the bin several times, then the DS dipped the thermometer into the lemonade to check its temperature without sanitizing the thermometer. During a concurrent interview, the DS stated she should sanitize the contaminated thermometer before dipping it into the lemonade to check its temperature. Review of the facility's 2023 policy, Thermometer Use and Calibration, indicated . Cleaning and Sanitizing: . Wipe the clean thermometer with the sanitizing solution using a clean cloth or paper towel. Let the thermometer air dry before use.

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention techniques were followed when: 1. two oxygen concentrators had dirty filters, 2. a nurse did not wear appropriate personal protective equipment (PPE), two times during medications pass, for one of six residents who was on enhanced barrier precautions (a set of infection control measures that use gowns and gloves during high-contact care activities to reduce the spread of multidrug-resistant organisms), and 3. during personal care, the urine collection bag for one of 17 residents with a urinary catheter (a tube which is used to allow urine to drain if you have an obstruction in the tube that carries urine out of your bladder), was placed on the mattress of the bed. These failures had the potential of spreading facility acquired infections to vulnerable residents who are already immunocompromised. Findings: 1. During an observation on 10/14/24 at 9 a.m., the oxygen concentrator filter, in room R2, had a layer of greyish dust on it. During an observation and subsequent interview with the ADON on 10/16/24 at 10:14 a.m., when asked about the oxygen concentrator filter in room R2, the ADON stated I will clean it. During an observation on 10/15/24 at 9:42 a.m., the oxygen concentrator filter, in Room R1, had a layer of whitish dust on the filter. During an observation and subsequent interview with the assistant director of nursing (ADON) on 10/16/24 at 10:17 a.m., the ADON looked at the oxygen concentrator filter in room R1 and stated the filter needed to be cleaned. She stated she needs to check the facility's policy to see how often the filters should have been cleaned. During an interview with the administrator (ADM) 10/17/24 at 10:45 a.m., the ADM stated that they had cleaned the filters. During a review of the facility's policy & procedure (P&P) titled, Oxygen Equipment Maintenance - Oxygen Concentrator Filter, revised 10/2010, the P&P indicated General Guidelines | Assigned EVS staff is responsible for the scheduled, weekly cleaning and/or changing of the oxygen concentrators' filters. 27000 2. During the medication administration observation with Registered Nurse (RN) J on 10/14/24 04:13 PM, RN J was observed donning on a pair of gloves at the medication cart and entering Resident 47's room to assess the resident's blood pressure (BP). She also wore a surgical mask, but did not wear a protective gown. Four large signs/posters were observed on Resident 47's room door. One of the large white posters read, PLEASE check-in with Charge Nurse before Entering Room. Wash hand BEFORE and AFTER Entering Room. The orange poster read, ENHANCE BARRIER PRECAUTIONS . PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use . feeding tube . Shortly after the BP assessment, on 10/14/24 at 4:17 p.m., RN J returned to the medication cart and started preparing four medications for the resident. On 10/14/24 at 4:32 p.m., RN J returned to the resident's room again without a gown. She changed into the new gloves and proceeded to administer the medications through the resident's gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). During the interview on 10/14/24 at 4:45 p.m., after being shown the posters on the resident's room, RN J stated she should have gowned up before entering the resident's room each time. A review of Resident 47's care plan, dated 2/6/24, for Enhanced Barrier/Standard Precautions indicated: [Patient 47] tested positive for CP-C.R.E (Carbapenemase-Producing Carbapenem-Resistant Enterobacterales, a type of bacteria that are resistant to antibiotics and can cause serious infections) - CDPH [California Department of Public Health] recommends the use of ESP [enhanced standard precautions], primarily the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO [multi-drug resistant organism] colonization and transmission; - Perform hand hygiene and don PPE before beginning activity; - Gloves to protect hands; - Gown to protect body, clothes; - Mask/goggles/shield to protect face, eyes; - Place appropriate sign at room entry - Remove, discard PPE, and perform hand hygiene in room when activity complete. During an interview with the Director of Nursing (DON) and the Assistant DON (ADON) on 10/15/24 at 3:35 p.m., they stated, for residents on EBP, the staff providing care, such as BP measurement and medication administration, need to wear a mask, gown, and gloves before entering the room. A review of the facility's P&P titled Categories of Transmission-Based Precautions - EBP, dated 9/2024, indicated the following under Enhanced Standard Precautions/Enhanced Barrier Precautions: Wear gowns and gloves when performing high-contact tasks . This includes . Device care, for example . feeding tube. 36623 3. During an observation in Resident 73's room on 10/16/2024 at 11:28 a.m., Certified Nursing Assistant (CNA F) placed Resident 73's urinary drainage bag on his bed. The urine from the tube was observed flowing back toward the resident when turning Resident 73. During an interview with Treatment Nurse H (TN H) on 10/16/2024 at 12:11 p.m., TN H confirmed CNA F placed the urinary drainage bag on the bed of Resident 73 while he was doing the wound treatment. TN H stated Resident 73 would be at risk to have infection if the urine from the urinary drainage bag flows back into the bladder. During an interview with CNA F on 10/16/2024 at 12:40 p.m., CNA F confirmed the above observation and stated she put the urinary drainage bag on the bed when performing care with Resident 73. CNA F stated placing the drainage bag on the bed has the potential for infection. During an interview with infection preventionist (IP I) on 10/16/2024 at 4:14 p.m., IP I stated the urinary drainage bag should always be placed below the bladder. IP I stated urine that back flows has the potential to cause infection. During an interview with Director of Nursing (DON) on 10/17/2024 at 4:43 p.m., the DON stated urinary drainage bags should always be placed below the level of bladder to prevent infection. During a review of the facility's policy and procedure titled, Catheter Care, Urinary, date revised September 2014, indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to provide accommodation of needs for one of 22 residents (Resident 81) when Resident 81 did not have the appropriate staff call device (call button) that she would be able to use if she needed to call for assistance. This failure had the potential to result in the resident not getting assistance timely and delay necessary care and services. Findings: Review of Resident 81's clinical record indicated she was admitted to the facility with diagnoses including respiratory failure and quadriplegia (complete or partial paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). Review of Resident 81's Nursing Admission Screening/History, dated 9/16/24 indicated the resident was alert x 4 (alert to person, place, time and event). Review of Resident 81's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/2/24 indicated her Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (cognitively intact). Review of Resident 81's physician order, dated 5/30/24 indicated she had an order for bilateral resting hand splints at all times except ADL's (activities of daily living) for contracture prevention. During an observation on 10/15/24 at 9:23 a.m., Resident 81 was in bed. Resident 81 had hand splints on her hands and arms. Resident 81's call button was on the bed next to her. During a concurrent interview with Registered Nurse K (RN K), he stated Resident 81 yells out when she needs help. During an interview on 10/16/24 at 1:59 p.m. the maintenance director (MD) stated the facility has other call devices available. He stated if a resident was not able to push on the call button using their fingers and the nusring staff could put a special call device if the resident needs it. During an interview with Resident 81 and an interpreter on 10/15/24 at 10:31 a.m., Resident 81 stated she calls out when she needs help. During an interview on 10/16/24 at 2:14 p.m., nurse supervisor M (NS M) stated Resident 81 has not been assessed for an appropriate call device. She stated there are other call devices available. NS M stated she thinks a call device that could be turned on by pressing it with her head would be good for Resident 81. During an observation on 10/17/24 at 11:10 a.m., Resident 81 was in bed. Resident 81 had hand splints on her hands and arms. Resident 81's call button was on the bed next to her. During a concurrent observation and interview on 10/17/24 at 2:03 p.m., when the Director of Nursing (DON) was asked if Resident 81's call button was appropriate for the resident and the DON asked if Resident 81 whether could move her thumbs. Resident 81 moved her arms slowly up and down and stated that she was not able to. The DON stated we have other call devices, including a padded call device or a call device that could be placed by her head. Review of the facility's policy, Assistive Devices and Equipment, revised 1/2020 indicated, Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include . Call light devices. The policy also indicated appropriateness for resident condition is one of the factors that are addressed.

Based on interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for two of 22 sampled Residents (Resident 66 and Resident 25). This failure had the potential for the residents and/or responsible party (RP) to be unaware of the plan of care. Findings: During a review of Resident 66's Baseline Care Plan (BCP), dated 10/04/2024, the BCP indicated Resident 66 was admitted on [DATE]. It also indicated the following were left blank: Therapy Services, BCP Completion Date, Date Reviewed With Resident/Representative, Staff Name and Signature, Resident signature, Representative Name and Signature. During a review of Resident 25's BCP, dated 10/10/2024, the BCP indicated Resident 25 was admitted on [DATE]. It also indicated the following were left blank: Safety, BCP Completion date, Date Reviewed With Resident/Representative, Resident signature, Representative Name and Signature. During an interview with Nurse Supervisor M (NS M) on 10/18/24 at 11:20 a.m., NS M stated the admission nurse would start the BCP upon admission and should have been completed within 72 hours. During a concurrent interview and record review with MDS Coordinator G (MDS G) on 10/18/24 at 11:58 a.m., MDS G confirmed the above findings and stated baseline care plans would be completed within 72 hours upon admission. During a concurrent interview and record review with Director of Nursing (DON) on 10/18/24 at 2:13 p.m., the DON confirmed the above findings. The DON stated all areas of the BCP should have been completed within 72 hours of admission for Resident 66 and Resident 25. During a review of the facility's policy and procedure titled (P&P), Care Plans - Baseline, dated December 2016, the P&P indicated, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within Seventy-Two (72) hours of the resident's admission. 2. The interdisciplinary team will review the healthcare practitioner's order (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care and needs including, but not limited to the following: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services . 4. The resident and their representative will be provided a summary of the baseline care plan .

Based on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities to the facility during the monthly regimen review (MRR) for two out of 20 sampled residents (Residents 5 and 93). The failure resulted in an unsafe order without being clarified for Resident 93, and Resident 5 not receiving the medication in accordance with the manufacturer's specifications to optimize drug therapy. Findings: 1. A review of Resident 93's clinical record indicated an order for Admelog [insulin lispro, a short-acting insulin to lower blood sugar] Injection Solution 100 UNIT/ML [milliliter] . Inject 3 ml [milliliters] subcutaneously [injection under the skin] as needed for DM [diabetes mellitus], dated 7/19/2024. The order had a dose of 3 ml which would be equal to 300 units of insulin; and did not have a frequency and parameters, such as blood sugar (BS} above certain readings, when to give it. During a concurrent interview and record review with Registered Nurse B (RN B) on 10/15/24 at 10:29 a.m., he reviewed Resident 93's Admelog order and stated he would give it if the BS was above 130 milligrams/deciLiter (mg/dL) as that would be considered high. RN B stated the 3 ml is a questionable dose and confirmed the order had no dosing frequency nor parameters when to give it. During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/24 at 12:14 p.m., she reviewed Resident 93's Admelog order and stated, It is totally unclear, and the dose is wrong as 3 ml (or 300 units) would be very high. When asked whether the CP identified this as an irregularity during the monthly MRR since July 2024, the DON stated she could not find any recommendation related to this. During a telephone interview with the CP on 10/17/24 at 3:35 p.m., when asked whether she had identified and reported to the facility the irregular Admelog order for Resident 93, the CP responded she did not. She stated, Looks like I did not see it. 2. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including chronic kidney disease (CKD, long-term condition where the kidneys are damaged and can not filter blood properly). Resident 5's physician's orders included an order for: - Calcium Acetate (Phoslo; a phosphate binder, medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease) 667 mg, give 2 tablets by mouth three times a day for CKD, dated 6/3/2024. It was scheduled to be administered at 9 a.m., 1 p.m., and 5 p.m. According to the Prescribing Information from the manufacturer for calcium acetate, dated 3/2011, it indicated, Calcium acetate . when taken with meals, combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration. It indicated to take the medication with each meal. The facility scheduled breakfast at 7 a.m.; lunch at 12 noon; and dinner at 5 p.m. Thus, the calcium acetate administration time was not scheduled at the same time with breakfast and lunch. During an interview and record review with RN B on 10/16/24 at 11:37 a.m., he stated the facility meal scheduled breakfast around 7:30 a.m., lunch at noon, and dinner is at 5 p.m. He stated Resident 5 had breakfast around 7 to 7:30 a.m. that morning, and he administered the calcium acetate to Resident 5 at 8:35 a.m. (about one hour after breakfast). On 10/16/24 at 11:18 a.m., an interview was conducted with Resident 5, who had a Brief Interview for Mental Status (BIMS, a scale to determine a patient's cognitive understanding) of 15, conducted on 8/23/24, indicating she had intact cognition. When asked whether she took her Phoslo with food or whenever the nursing staff gave it to her, she stated, Whenever they give it to me. She said she did not know it has to be given with food. During a concurrent interview and record review with the DON on 10/16/24 at 12:09 p.m., she acknowledged the calcium acetate should be given with meals. She reviewed Resident 5's calcium acetate administration schedule and confirmed they were not consistent with meal times. A review of the Resident Details (a document showing the actual medication administration time) with the DON showed Resident 5's calcium acetate doses were not given during meal times 35 times out of 39 administrations from 10/3/24 to 10/15/24. A review of Resident 5's laboratory test, dated 3/6/24, indicated her phosphorous level was at 5.8 (high; the normal range is 2.5 - 5.0). During a telephone interview with the CP on 10/17/24 at 3:59 p.m., when asked whether she made a recommendation for Phoslo to be administered with meals, she stated, There was no recommendations after June this year for the Phoslo to be taken with meals. A review of the facility policy and procedures titled Medication Regimen Reviews, dated 5/2019, indicated, The consultant pharmacist performs a medication regimen review (MRR) for every resident . The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . medications ordered in excessive doses . incorrect medications, administration times .

Based on observation, interview, and record review, the facility failed to ensure two out of 22 sampled residents (Residents 35 and 98) were free from unnecessary medications when Resident 35 received warfarin (a blood thinner to prevent blood clots) for a wrong indication; and Resident 98's lidocaine patch (a topical medication applied to the skin for pain) was not administered in accordance with the manufacturer's specifications. This deficient practice resulted inadequate indication for medication use; and the potential for adverse effects of medication. Findings: 1. A review of Resident 35's clinical record indicated he was admitted to the facility with diagnoses including chronic embolism and thrombosis of other specified veins (conditions that involve blood clots and can lead to serious complications) and saddle embolus of pulmonary artery with acute cor pulmonale (condition occurs when a large blood clot becomes lodged at the intersection where the main pulmonary artery divides and branches off into the left and right lungs). A review of Resident 35's physician's orders indicated the resident has been receiving warfarin, a blood thinner that required frequent blood testing and dosage adjustment based on the test results. He had the following orders: - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema (condition where too much fluid builds up in the lungs, making it difficult to breathe), dated 9/13/24; - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema, dated 9/20/24; - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema, dated 9/25/24; During an interview with Resident 35 on 10/16/24 at 4:09 p.m., he stated he had been receiving warfarin for a massive saddle PE (saddle pulmonary embolism, a rare, life-threatening condition that occurs when a large blood clot gets lodged in the pulmonary artery, blocking blood flow to both lungs) that required very long hospitalization . During a concurrent interview and record review with the Director of Nursing (DON) on 10/17/24 at 11:45 a.m., she reviewed Resident 35's warfarin orders and confirmed the diagnosis for warfarin should be pulmonary embolism, not pulmonary edema. 2. A review of Resident 98's clinical record indicated she was admitted to the facility with diagnoses including back pain. A review of her physician's orders indicated an order for lidocaine patch 4%, apply to back topically one time a day for pain management, dated 9/21/24. On 10/17/24 at 11:19 a.m., Licensed Vocational Nurse C (LVN C) was asked to show the lidocaine patch that was administered to Resident 98 earlier that morning. LVN C provided a lidocaine 4% patch box labeled Lidocaine Pain Relief Patch. The manufacturer's directions in the back of the box indicated to not use longer than a 12-hour period. A review of Resident 98's medication administration record (MAR) with LVN C indicated a new patch was scheduled to be administered at 9 a.m., and the removal of the used patch was scheduled at 0859 a.m. (same time as the new patch application). LVN C stated he applied a new patch this morning at around 9 a.m. and removed the previous day's patch at the same time. During a concurrent interview and record review with the DON on 10/17/24 at 11:35 a.m., she stated the facility had a template for lidocaine patch application: it is supposed to be on at 9 a.m. and off at 9 p.m. (12-hour period). She reviewed Resident 98's lidocaine order and stated, It wasn't used for this patient, and confirmed it should have been used. During a telephone interview with the Consultant Pharmacist (CP) on 10/17/24 at 3:35 p.m., she stated, Lidocaine is supposed to be 12 hours on, 12 hours off. A review of the facility's policy and procedures titled, Medication Therapy, revised 4/2007, indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . Medication use shall be consistent with an individual's condition . All medication orders will be supported by appropriate care and practices . All decisions related to medications shall include appropriate elements of the care process, such as . The frequency of administration and duration of use are appropriate .

Based on observation, interview, and record review, the facility had a medication error rate of 5.56% when two medication errors occurred out of 36 opportunities during the medication administration for 2 out of 6 residents (Residents 67 and 93). The failures resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the residents not receiving full therapeutic effects or complications of medications. Findings: 1. During the medication administration observation on 10/14/24 at 9:15 a.m., Licensed Vocational Nurse (LVN) A was observed preparing and administering 15 medications to Resident 67. Included in the medications was an oral inhaler called Alvesco (medication for asthma). After shaking the Alvesco inhaler, LVN A gave it to the resident and asked her to press on the inhaler and inhale deeply. After she finished, LVN A asked Resident 67 to repeat by giving herself another puff without allowing some time in between the inhalations. There was about 4 or 5-second time lapse between the 2 puffs. During an interview shortly after the observation, on 10/14/24 at 9:37 a.m., LVN A was asked whether he should have allowed time between the 2 puffs of inhaled medication, he stated, Not typically. He also stated he was not familiar with spacing out inhaled medications. A review of Resident 67's clinical record indicated a physician's order, dated 10/10/24, for Alvesco Inhalation 160 micrograms/actuation (unit of measurement), inhale 2 puffs orally two times a day for asthma prevention and control. During an interview with the Director of Nursing (DON) on 10/14/24 at 3:07 p.m., she stated, For patients with multiple inhalations, they [the nurses] should allow 1-2 minutes between inhalations. A review of the facility's P&P titled Administering Medications through a Metered Dose Inhaler, dated 10/2010, indicated, Repeat inhalation, if ordered. Allow at least (1) minute between inhalations of the same medication . 2. During the medication administration observation on 10/14/24 at 10:09 a.m., Registered Nurse (RN) B was observed preparing 10 medications, 1 liquid and 9 solid medications, for Resident 93. The resident was receiving medications via the gastrostomy tube (or G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). RN B crushed each solid medication separately and diluted each with about 10 milliliters (mL, unit of measurement) of water. He also added some water to the liquid medication to dilute it. On 10/14/24 at 11 a.m., after attaching a 60-mL syringe to the resident's G-tube, RN B was observed flushing the G-tube with about 50 mL of water. Then he poured each of the medication in the syringe, one by one, without flushing with water between the 10 medications. He flushed the tubing with about 60 mL of water after the last medication. Shortly after the observation, on 10/14/24 at 11:19 a.m., RN B confirmed he did not rinse or flush the tubing with water between the medications. He said he was supposed to. During an interview with the DON on 10/14/24 at 3:07 p.m., she stated the nursing staff was to flush the resident's enteral tube with about 50 mL of water before medication administration, 10 mL after each medication, and do a final flush with 50 mL of water. A review of the facility's P&P titled Administering Medications through an Enteral Tube, revised 11/2018, indicated at the beginning of administration, Stop feeding and flush tubing with at least 50 mL warm water . If administering more than one medication, flush with at least 10 mL warm water . between medications . When the last of the medication begins to drain from the tubing, flush the tubing with 50 mL of warm water .

Based on observation, interview, and record review, the facility failed to provide meals with food items according to preferences and dislikes for two of 44 residents (55 and 67). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents. Findings: Review of Resident 55's Admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 67's Admission Record indicated she was admitted to the facility on [DATE]. During a tray line observation with the dietary supervisor (DS) on 10/15/24, at 12:35 p.m., Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served for him. Resident 67's lunch ticket indicated she disliked rice, but rice was served for her. During a concurrent interview with the DS, she confirmed that Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served for him. Resident 67's lunch ticket indicated she disliked rice, but rice was served for her. The DS stated meals should have been served according to the residents' preferences and dislikes. Review of the facility's 2023 policy, Food preferences, indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.

Based on observation, interview, and record review, the facility failed to ensure one of 27 initial pool residents (Resident 1) had access to a staff call device (call button), in case of needing help or for an emergency. This failure had the potential of Resident 1 becoming seriously harmed or even lead to death. Findings: During an observation in Room R3 on 10/14/24 at 8:40 a.m., the call button for bed A was observed hanging on the wall above the head of the bed, not within reach of Resident 1. Resident 1 stated she can not reach the call button, and would want to call. During an observation in Room R3 on 10/14/24 at 12:28 p.m., the call button was still hanging on the wall. During an observation in Room R3 on 10/14/24 3:17 p.m., the call button was still on the wall, out of reach of Resident 1. During an observation and subsequent interview with registered B (RN B) on 10/14/24 at 3:19 p.m., RN B took the call button off of the wall and handed it to Resident 1. RN B stated Resident 1 should have had the call button within reach. During a review of the facility's policy & procedure (P&P) titled Assistive Devices and Equipment, revised 01/2020, the P&P indicated, 1. Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include (but are not limited to): . d. Call light devices.

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment for one of 22 sampled residents (Resident 28) due to cracked walls near Resident 28's bathroom door and at the bottom left side of the toilet in the bathroom. This deficient practice had the potential to adversely affect the health and safety of residents in the facility. Findings: During an observation and interview with Resident 28 on 10/14/24 at 3:30 p.m., in Resident 28's room, Resident 28 stated about the cracked walls near her bathroom door and at the bottom, left side of the toilet in the bathroom. Resident 28 also stated that the walls were damaged and needed to be repaired. Resident 28 further stated that the facility was aware of the cracked walls near the bathroom door and the bottom left side of the toilet since last year. During a concurrent interview and record review with the maintenance director (MD) on 10/16/24 at 2:00 p.m., upon review of the maintenance log with the MD, the maintenance log indicated it was reported to maintenance. The MD confirmed that maintenance staff had started the repairs but missed the areas near the bathroom door and the bottom of the toilet. The MD stated he would inform the maintenance staff to complete the repairs. Resident 28's quarterly minimum data set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 28's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognition impairment; 8 to 12 moderate impairment; 13 to 15 patient is cognitively intact). Review of facility's policy, Maintenance Service, revised 12/2009, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards .

Based on interview and record review, the facility failed to complete a Morse Fall Scale (an assessment used to determine a resident's risk for falls) after a fall for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify fall risk factors and implement interventions accordingly. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hemiplegia (one side of the body is paralyzed), disorientation (confusion), and muscle weakness. Review of Resident 1's Morse Fall Scale, dated 4/30/24, indicated Resident 1 was at moderate risk for falling. The instructions printed on the top of the Morse Fall Scale indicated, Complete on admission, quarterly, at change of condition, and after a fall. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/10/24 and written by licensed nurse A (LN A), indicated Resident 1 was seen scooting out of bed. The SBAR indicated LN A tried to control Resident 1, but he got out in bed in sitting/lying position next to bed. The SBAR further indicated, Let resident lie down on floor safely with pillow on head and LN call for help. During an interview with LN A on 7/8/24, at 3:13 p.m., LN A explained what happened during the incident described in the above SBAR, dated 5/10/24. LN A stated she and another staff member saw Resident 1 sliding off his bed. LN A stated she tried to help Resident 1, but by the time she got to him, he had already slid onto the ground. LN A stated this incident was a witnessed fall. Further review of Resident 1's medical record indicated there was no documentation that the facility completed a Morse Fall Scale after Resident 1's witnessed fall on 5/10/24. During an interview and concurrent record review with LN B on 7/9/24, at 11:26 a.m., LN B confirmed the facility was supposed to complete a Morse Fall Scale after each time a resident fell . LN B reviewed Resident 1's medical record and confirmed there was no documentation that the facility completed a Morse Fall Scale after the resident fell on [DATE]. The facility's policy titled Fall Risk Assessment, revised 3/2018, indicated the facility will seek to identify risk factors for falls and establish a falls prevention plan based on relevant assessment information. The facility's undated document titled FALL checklist was reviewed. The document listed the things that should be done if a resident fell . The third item listed on the document was, Morse assessment.

Based on interview and record review, the facility failed to ensure the Fall Morse Scale was completed accurately for one of two sampled residents (Resident 1). The failure to accurately assess residents ' fall risk has the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions for falls. Findings: Review of Resident 1 ' s medical record indicated he was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that may lead to personality changes). Review of Resident 1 ' s Interdisciplinary Team Progress Notes (IDT), dated 9/14/23 , indicated Resident 1 had an unwitnessed fall on 9/13/23. Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 9/8/23, indicated his brief interview for mental status (BIMS, a tool used to screen and identify a resident ' s cognition [thinking ability]) was 15 (13-15 means intact cognition). Review of Resident 1 ' s morse fall scale assessment, dated 9/3/23, indicated Resident 1 had a history of falls; and that, his fall score was 40 (a score of 25 -44 means a moderate risk for falls). Review of Resident 1 ' s morse fall scale assessment, dated 9/29/23, indicated, no history of fall, and his fall score was 25. Review of Resident 1 ' s morse fall scale assessment, dated 11/15/23, indicated, no history of fall, and his fall score was 25. During a concurrent interview and record review with the director of nursing (DON) on 11/21/23 at 12:53 p.m., she verified the morse fall scale assessments were done for all residents every quarter, and post fall and as needed. The DON confirmed staff did not complete Resident 1 ' s morse fall scale assessments accurately on 9/29/2023 and 11/15/2023. The DON stated staff should have completed these assessments accurately to capture Resident 1 ' s history of falls. During a concurrent interview and record review with the Minimum Data Set (MDS, resident ' s clinical and functional assessment tool) Nurse (MDSN) on 12/11/23 at 11:00 a.m., the MDSN reviewed Resident 1's medical record and confirmed he had a fall on 9/13/23. The MDSN confirmed Resident 1 ' s morse fall scale assessments were not accurately completed on 9/29/2023 and 11/15/2023, which did not account for Resident 1 ' s fall on 9/13/2023. The MDSN stated staff should have accurately completed both assessments to derive accurate fall score(s) for Resident 1, which would then be used to develop a fall risk care plan for implementation. Review of the facility ' s policy and procedure titled, Falls-Clinical Protocol, dated 8/2012, it indicated, The staff will evaluate, and documents falls that occurs while the individual is in the facility. Review of the facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017, indicated, All services provided for the resident towards the care plan goals or any changes in the resident ' s medical, physical, functional, or psychosocial shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary teams regarding the resident ' s condition and response to care.

Based on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. A physician order for the wearing of a hand splint was not followed; 2. A physician order for the wearing of a knee brace was not followed; 3. RNA (Restorative Nursing Assistant) services were not provided as ordered; These failures resulted in Resident 1 not receiving proper treatment and had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including subarachnoid hemorrhage (bleeding into the fluid space surrounding the brain), aneurysm of carotid artery (bulging in one of the arteries supplying blood to the brain, head, face, and neck), and obstructive hydrocephalus (fluid build-up in the brain). Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 8/21/23, indicated Resident 1 had severely impaired cognitive skills for daily decision making and required extensive assistance for activities of daily living (ADL). Review of Resident 1 ' s physician order, dated 11/8/23, indicated, may wear left resting hand splint at all times, except ADLs, to prevent contractures. Check for signs and symptoms of redness and edema and notify MD accordingly. Review of Resident 1 ' s medication administration record (MAR) indicated the order to wear the left hand splint was listed on the MAR but the daily entries had an X marked in each box for the month of November and December. There were no licensed nurse ' s initials on the MAR to document Resident 1 ' s wearing of the left hand splint or checking for redness and edema by the licensed nurses. During an interview with Licensed Vocational Nurse A (LVN A) on 12/19/23 at 12:15 p.m., he stated Resident 1 should always wear the left hand splint as tolerated. During a concurrent record review, LVN A acknowledged Resident 1 had a physician order to wear a left hand splint and to monitor for redness and edema. LVN A confirmed the nurses were not documenting anything on the MAR for this physician order and stated the order was transcribed incorrectly. LVN A further stated when the order is transcribed correctly the nurses would initial every shift that the splint was applied and would document a Y or a N ' indicating yes or no for the presence of redness or edema. LVN stated nurses should follow the physician order and document the application and monitoring of the left hand brace. 2. Review of Resident 1 ' s physician order, dated 11/8/23, indicated RNA services order: Donning and Doffing (practice of putting on and removing) of knee brace on the right starting at 7am to 3pm for 7 times a week. A review of Resident 1 ' s MAR, TAR (treatment administration record), and RNA Treatment records was conducted. There was no evidence of licensed nurses or RNA staff carrying out the physician order and documenting the application of Resident 1 ' s right knee brace. During an interview and concurrent record review with Licensed Vocational Nurse A (LVN A) on 12/19/23 at 12:15 p.m., he stated the physician order for donning and doffing of the right knee brace was transcribed incorrectly. LVN A stated the physician order did not appear in Resident 1 ' s administration record and he confirmed there was no documented evidence that facility staff was applying Resident 1 ' s right knee brace. He further stated if the physician order was transcribed correctly the facility staff would initial the application and removal of the right knee brace. LVN A stated nurses should follow the physician order and document the donning and doffing Resident 1 ' s right knee brace. 3. Review of Resident 1 ' s physician order, dated 10/26/23, indicated RNA services order: Passive range of motion to gentle passive stretching on (B)UE/LE (both upper and lower extremity) for 5 times per week. Focus on stretching the right knee towards extension and left ankle motions. Apply the PRAFO boot (Pressure Relief Ankle Foot Orthosis boot to prevent contractures and pressure ulcers) after stretching. A review of Resident 1 ' s RNA treatment records indicated missing entries for the performance of RNA services as ordered by Resident 1 ' s physician. The RNA treatment record for 11/1/23 through 11/30/23 indicated RNA services were documented as performed only 8 times. The RNA treatment record for 12/1/23 through 12/18/23 indicated RNA services were documented as performed only 3 times. During an interview and concurrent record review with RNA B, on 12/19/23 at 1:50 p.m., he confirmed he was providing RNA services to Resident 1. He reviewed the RNA treatment record for the month of November and December and acknowledged there were blank spaces on the monthly records. He confirmed the physician order was for Resident 1 to receive RNA services 5 times a week. When asked to explain the missing entries he stated the blanks were the days when Resident 1 did not receive RNA services and stated Resident 1 refuses the range of motion exercises frequently. RNA B stated Resident 1 will often scream and yell when RNA B attempts to do range of motion as prescribed, and he will not force Resident 1 to exercise. He further added I can usually only do it once or twice a week. When asked if he documents Resident 1 ' s refusals, RNA B stated he was not aware that he needed to document Resident 1 ' s refusals. During an observation on 12/19/23 at 10:50 a.m., Resident 1 was seated in her wheelchair in the main dining room of the facility. She was not wearing any hand splint on her left hand or a right knee brace. During a concurrent interview with the ADON on 12/19/23 at 10:50 a.m., she confirmed that Resident 1 was not wearing any left hand splint or right knee brace. The ADON stated she was unaware of why Resident 1 was not wearing these devices. During an interview and concurrent record review with the ADON, on 12/19/23 at 11:45 a.m., she confirmed Resident 1 had physician orders to wear a left hand splint and a right knee brace. Upon further review of these physician orders, the ADON stated both of these orders were not transcribed correctly, The ADON stated licensed nurses were not initialing the application of the left hand splint or documenting to check for redness and edema, and she confirmed they should be. The ADON further stated the order to apply the right knee brace did not appear on Resident 1 ' s administration record so staff were not documenting the donning and doffing of the right knee brace, and she confirmed they should be. The DON reviewed Resident 1 ' s physician order for RNA services 5 times a week. She reviewed Resident 1 ' s RNA treatment record for November and December and acknowledged there were blank spaces on the record. When asked about the missing entries she stated she was unaware of why the RNA did not document that services were provided 5 times a week as ordered. She confirmed if a resident refuses medications or treatments, the refusal should be documented. Review of the facility policy titled Charting and Documentation, revised July 2017, indicated all services provided to the resident shall be documented in the resident ' s medical record. Documentation of procedures and treatments will include care-specific details, including . e. Whether the resident refused the procedure/treatment . g. The signature and title of the individual documenting. Review of the facility ' s undated Job Description: RNA, indicated Duties and Responsibilities: . Adheres to department procedures regarding documentation of services.

Based on observation, interview, and record review, the facility failed to resolve the grievance for one of three residents (1) when Resident 1's complaint about missing her chips, sodas, and baby wipes was not acted on. This failure had the potential to cause frustration for the Resident 1. Findings: Review of Resident 1's Admission Record indicated she was admitted to the facility on [DATE]. During an interview with Resident 1 on 6/30/23 at 11:55 a.m., she stated her sodas were missing, and her baby wipes which were stored in the closet were also missing. Resident 1 stated she reported them to the staff. During a concurrent observation, Resident 1's soda pack was placed on the bed next to her bed, and her closet did not have a lock. Review of the facility's grievance binder indicated on 5/2/23 Resident 1 filed a grievance about her missing chips, sodas, and wipes with the recommendations to have Resident 1's items placed in a closet with a lock and Resident 1 had the key. However, the grievance did not indicate that the recommendations were acted on. During an interview with the business office clerk A (BOC A) on 6/30/23 at 2:25 p.m., he stated he worked in the social services office and just transferred to the business office on 6/20/23. The BOC A reviewed Resident 1's 5/2/23 grievance, and confirmed that nothing had been done for Resident 1's complaint on missing items. During an interview with Resident 1 on 6/30/23 at 3:45 p.m., she confirmed that her closet did not have a lock, and she did not have a key. Review of the facility's policy, Grievances/Complaints, Filing, dated 4/2017, indicated The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative . 7. The Administrator had delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is Social Services and Designee . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the action that will be taken to correct any identified problems: a. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

Based on observation, interview, and record review the facility failed to post a required infection control prevention sign in five of ten resident isolation rooms (rooms used to isolate residents with a suspected or confirmed infectious disease). This failure had the potential of staff, visitors and other residents not knowing what infection control precautions to take, and placed the facility at risk for the spread of infection. Findings: Review of the Carbapenem-Resistant Organisms (CRO, groups of chemical producing bacteria that destroy antibiotics) Line List form, updated 3/17/23, indicated the facility had ten resident isolation rooms. During an interview and tour of the isolation rooms with an infection control nurse (ICN) on 4/27/23 at 4 p.m., Rooms 1, 2, 3, 4, and 5 did not have a sign posted indicating to please check-in with charge nurse before entering room and to wash hands before and after entering room. During the concurrent interview, the ICN confirmed the sign should have been posted. Review of Isolation-Categories of Transmission-Based Precautions policy, revised January 2023, indicated when a resident was placed on transmission-based precautions, appropriate notifications were to be placed on the room entrance door for instructions.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards or practice when: 1. Licensed nurses (LN) did not check food trays for the correct diets before serving the residents in two of 4 stations (Station AA and Station BB); 2. Two of seven sampled residents' (Resident 64 and 84) medications were not clarified with the physician. Resident 64's vitamin D (to prevent [CONDITION(S)] or treat vitamin D insufficiency) order did not have a strength since 12/23/21. Resident 84's as-needed [MEDICATION(S)] (medication to treat anxiety disorder) order did not have a dosing frequency since 3/5/22. These failures had the potential to compromise the residents' health and well-being, and not meeting the residents' therapeutic needs or excessive use of medications for the residents Findings: 1. During an observation in the hallway of station BB on 5/12/22 at 7:41 a.m., two LNs were passing medications in the hallways of stations AA and BB. Certified nursing assistants (CNA) were passing trays in station BB. The LNs were not observed checking the food tray before the CNAs distributed the trays to the residents. During an observation on 5/9/22 at 12:44 p.m., CNAs were seen passing out the lunchtime meal trays to the residents. There were two food carts parked in the hallway of station three and station four which contained the lunch trays of the residents. Two LNs were seen in the hallways of station three and four, standing by their medication carts, and were not participating in the passing of the lunch trays to the residents. During an interview with licensed vocational nurse D (LVN D) on 5/9/22 at 12:44 p.m., he was asked if he checked the contents of the meal trays before the CNAs distributed lunch to the residents on station three and station four. LVN D stated No I did not, I do it if I have time. During an interview with the director of nursing (DON) on 05/12/22 at 8:50 a.m., she stated Our process is to have the licensed nurses check the meal trays and make sure the food matches the diet tray card before the CNAs start passing the trays. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 05/12/22 at 12:17 p.m., lunch trays were being passed to the residents. LVN E was reading the diet cards while inspecting the contents of the meal tray for each resident prior to giving it to the CNAs to deliver to the residents. LVN E stated she compares the type of diet listed on the diet slip with the actual food on the tray. LVN E stated licensed nurses do this at every meal and for every resident tray. Review of the facility policy Tray Identification, revised April 2007, indicated nursing staff shall check each food tray for the correct diet before serving the residents. 2a. During a medication administration observation on 5/10/22, at 08:47 a.m., LVN J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During medications reconciliation, Resident 64's vitamin D order was: Vitamin D tablet ([MEDICATION(S)]) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at 11:05 a.m., with DON, she verified there was no strength for vitamin D order. She stated the nursing staff should have clarified with the physician. During another interview with the DON on 5/12/22 at 9:31 a.m., she stated the physician wanted to get the lab work for the vitamin D first before ordering the correct dose for the resident. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Lexi-Comp, a nationally recognized drug information resource, indicated vitamin D comes in different dosage forms, such as: 1,000 International Units (IU, unit of potency for vitamins), 5,000IU, 25,000 IU, and 50,000 IU. 2b. A review of Resident 84's physician orders, dated 3/5/22, indicated: [MEDICATION(S)] 0.5 milligram (mg) give 1 tablet by mouth as needed for anxiety or S.O.B (shortness of breath) for 90 Days M/B (manifested by) verbalization of anxiousness. The order did not include a dosing frequency, such as how often it should be given. During a concurrent interview and record review on 05/12/22, at 11:13 a.m. with DON and LVN L, they verified there was no dosing frequency for as needed [MEDICATION(S)] order, and they stated all medications should have a dosing frequency. A review of the Medication Administration Records (MARs) indicated nursing staff administered 10 doses in March 2022, 14 doses in April 2022, and 2 doses in May 2022. A review of the facility's policy and procedures titled Medication and Treatment Order, revised July 2016, indicated, .Orders for medications must include: a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy (if applicable); c. Dosage and frequency of administration; .

Based on observation, interview and record review, the facility failed to ensure treatment was provided after a sacrococcyx (base of the spine and tailbone) wound was identified for one of three residents (Resident 1) when: 1. Failure to assess and document the sacrococcyx wound size and condition accurately. 2. Failure to implement timely treatment as ordered by the wound physician. 3. Failure to notify the physician in accordance with the facility's policy and procedures regarding Resident 1's worsening sacrococcyx wound during weekly assessments of the wound. 4. Failure to offload (remove weight or pressure) Resident 1's sacrococcyx wound by not turning and repositioning every two hours. These deficient practices caused Resident 1 to develop a sacrococcyx wound that progressed into a three-centimeter (cm, unit of measurement) x two cm decubitus ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Resident 1 was transferred to a general acute care hospital (GACH), on July 12, 2020, due to an increase in heart rate, decrease in blood pressure, and fluctuation in oxygen saturation. The GACH indicated that Resident 1 had experienced septic shock due to a bacterial infection likely from the pressure ulcer and noted a foul-smelling pressure ulcer with green-stained packing. The GACH also indicated a possible [CONDITION(S)] (inflammation of bone or bone marrow due to infection) around the sacral wound. As a result, Resident 1 was expected to continue to have infectious complications in the future. Resident 1 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's medical record indicated Resident 1 was hospitalized on [DATE] to 7/24/2020 due to [CONDITION(S)] (severe infection). Review of Resident 1's minimum data set (MDS, an assessment tool) dated 5/17/2020 indicated Resident 1 was in a persistent vegetative state and was at risk for developing a pressure ulcer. It also indicated Resident 1 was incontinent (no voluntary control) with urine and bowel movements. MDS also indicated Resident 1 had no pressure ulcer on her sacrococcyx. Review of Resident 1's Braden Scale (risk assessment for developing pressure ulcer) dated 5/16/2020 indicated Resident 1 had a score of 10 (a score of 10-12 represented a high risk for developing pressure ulcer). During a concurrent interview with licensed vocational nurse D (LVN D) and record review of Resident 1's SBAR (Situation, Background, Assessment, Response) Communication Form and Progress Note dated 5/26/2020, on 9/29/2020 at 2:58 p.m., LVN D stated she found the excoriation (scratch, a linear break in the skin surface) on Resident 1's sacrococcyx on 5/26/2020. It indicated in the SBAR on 5/26/2020 that the wound was superficial, round and was 1 centimeter (cm, unit of measurement for length) by 1cm. LVN D stated she did not speak with the physician to get a new order for wound dressing but notified Resident 1's physician via fax only. LVN D stated she did not put any dressing to cover or protect the wound and just applied a moisture barrier cream on the area. Review of Resident 1's Skin Observation Tool dated 5/26/2020 indicated 1 cm blanchable excoriation on sacrococcyx. No width, depth or description of wound bed was documented. Review of Resident 1's Skin Observation Tool dated 5/27/2020 indicated 1 cm skin excoriation on sacrococcyx. No width, depth or description of wound bed was documented. Review of Resident 1's Skin Observation Tool dated 5/28/2020 indicated 1.4 cm by 1.8 cm skin excoriation on the sacrococcyx. No depth was documented. Review of Resident 1's Skin Observation Tool dated 6/4/2020 indicated Resident 1 had a stage 1 pressure ulcer (intact skin with non-blanchable redness over a bony prominence) on the sacrococcyx. No wound measurement was documented. It also indicated the sacrococcyx wound was excoriated. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin). Review of Resident 1's Skin Observation Tool dated 6/16/2020 indicated Resident 1 had an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (dead tissue, usually cream or yellow in color) and/or eschar (dry, black and hard dead tissue) in the wound bed). It indicated the wound size as 1.4 cm by 1.8 cm. Depth was UTD (unable to determine). It also indicated that the skin at the sacrococcyx was excoriated and the wound remains unchanged. No wound bed description was documented. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was an unstageable pressure ulcer and the assessment that it was excoriated (open skin) and that there were no changes to the wound. The document did not indicate if a physician was notified. Review of Resident 1's Skin Observation Tool dated 6/23/2020 indicated Resident 1 had excoriated skin on the sacrococcyx and was also a stage 1 pressure ulcer. It indicated in the notes the wound was excoriated and granulated (granulation tissue, new connective tissue and tiny blood vessels that form on the surfaces of a wound). No wound length, width, depth or description of wound bed documented. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin) and had granulation. Review of Resident 1's Skin Observation Tool dated 6/24/2020 indicated Resident 1 had excoriated skin and a stage 1 pressure ulcer on the sacrococcyx. No wound length, width, depth or description of wound bed documented. It indicated the wound was deteriorating and has increased in size. It indicated Resident 1 will be referred to the wound physician. The document did not explain the apparent discrepancy between the assessment that Resident 1's injury was stage 1 (intact skin) and the assessment that it was excoriated (open skin). Review of Resident 1's initial Wound-Weekly Observation Tool on 6/26/2020 indicated Resident 1 had a trauma wound (a severe break or injury in the soft tissue of the skin, may include abrasions, lacerations, crush wounds, penetration and puncture wounds) on the sacrococcyx. It indicated the wound was 1.4 cm by 1.8 cm. No depth was documented. It indicated UTD for tunneling or undermining (erosion under the wound edges, resulting in a large wound with a small opening). It indicated the wound bed was 20 percent (%) covered with slough. It indicated the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Surgical Consult by the wound physician on 6/26/2020 indicated this was a new consult for Resident 1. It indicated the wound was 1.4 cm by 1.8 cm with a depth of UTD. It indicated the treatment plan was to apply [MEDICATION(S)] as a dressing for Resident 1's sacrococcyx wound. It indicated Resident 1 needed offloading (removing weight placed on the wound to help prevent and heal ulcers) of the wound. Review of Resident 1's Order Summary Report dated 9/28/2020 and Treatment Administration Record (TAR) dated 6/2020 indicated an order 6/29/2020 to cleanse Resident 1's trauma wound to the sacrococcyx with normal saline, pat dry, apply [MEDICATION(S)], and cover with dry dressing every day and as needed if soiled. The treatment order was initiated three days after the wound physician saw the wound on 6/26/2020. Review of Resident 1's Skin Observation Tool on 7/1/2020 indicated Resident 1 had a pressure ulcer at the sacrococcyx. It indicated the wound was 1.4 cm by 1.8 cm and the depth was UTD. It indicated the wound was being cared for by the wound physician due to slow healing and a new treatment order was received. Review of Resident 1's Wound-Weekly Observation Tool on 7/3/2020 indicated Resident 1 had a trauma wound on the sacrococcyx. It indicated the sacrococcyx wound was worsening. The wound bed was covered with 50 % slough. The wound size was 1.8 cm by 2 cm. There was no documentation regarding the wound's depth or the presence of absence of tunneling or undermining. It indicated the peri-wound (skin surrounding the wound) was unhealthy. It indicated a physician was notified on 7/3/2020 but also indicated the wound physician was on vacation and was not available. Review of Resident 1's Skilled Charting on 7/3/2020, at 3:47 am, 1:40 pm, and 5:56 pm, indicated Resident 1 had no new changes to skin integrity. It also indicated no changes were noted to wound. No documentation a physician was notified regarding Resident 1's worsening sacrococcyx wound. Review of Resident 1's Skin Observation Tool dated 7/8/2020 indicated Resident 1 had an excoriation on the sacrococcyx. No wound length, width, depth or description of wound bed was documented. During an interview and record review of the Skin Observation Tool dated with DON on 11/17/2020 at 10:15 a.m., DON confirmed there was no documentation of Resident 1's wound size on 7/8/2020. Review of Resident 1's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their patients) Notes on 7/8/2020 at 9:30 a.m., indicated Resident 1 had a sacrococcyx excoriation. Wound measurements documented were from 6/26/2020 at 1.4 cm by 1.8 cm with depth as UTD and 20 % slough and 60 % granulation. It indicated to continue current treatment as ordered and monitor for effectiveness, weekly wound observation and weekly referral to wound doctor. The IDT notes did not include the most recent assessment on 7/3/2020 that Resident 1's wound was worsening. Review of Resident 1's Wound-Weekly Observation Tool dated 7/10/2020 indicated Resident 1's trauma wound on the sacrococcyx was worsening. The wound bed was 70% covered with slough and had an odor. The wound size was 3 cm by 3cm. Depth was UTD. Resident 1's wound had undermining at 3 cm in length at 12 o'clock, 3 o'clock, 6, o'clock and 9 o'clock. It indicated a new treatment order to cleanse the wound the with Dakin's solution (sodium hypochlorite, bleach that has been diluted) 0.125%, then lightly pack the wound with gauze moistened with Dakin's solution and cover with non-adherent dressing. Review of Resident 1's SBAR Communication Form and Progress Notes on 7/12/2020 at 4:54 pm, indicated Resident 1 had a change in condition and was experiencing an increase in heart rate, decrease in blood pressure, and fluctuation in oxygen saturation (percentage of oxygen in the blood). Resident 1 was transferred to an acute hospital emergency room at 2:15 pm. Review of Resident 1's acute hospital Critical Care History and Physical dated 7/12/2020 indicated Resident 1 was transferred from the skilled nursing facility due to a blood pressure of 78/44 millimeter of mercury (mmHg, a unit of measure for pressure). In the emergency room , Resident 1's had a blood pressure of 70/31 (normal, 120/80), a heart rate of 143 beats per minute (normal heart rate 60-100 beats per minute) and a temperature of 38.3 degrees Celsius (100.9 degrees Fahrenheit, normal is 97.7 to 99.5 degrees F). Resident 1 also had a marked leukocytosis (increased white blood cell or WBC, cells that fight infection) with a WBC count of 28.16 (normal is 3.5-11). During the physical exam, Resident 1 was noted with a foul smelling, 3 cm by 2 cm sacral decubitus ulcer (pressure ulcer) with green-stained packing. Review of Resident 1's acute hospital Inpatient Medicine: Discharge Summary dated 7/23/2020 indicated Resident 1 was found to have septic shock due to strep intermedius (a bacteria) bacteremia (presence of bacteria in the blood) likely due to the pressure ulcer. It indicated a CT scan (X-ray using computerized axial tomography) on the abdomen was done due to strep intermedius being implicated in intra-abdominal abscesses (a swollen area within the body containing pus). It indicated Resident 1 had no signs of abscess but had a possible [CONDITION(S)] (inflammation of bone or bone marrow due to infection) around the sacral wound. It indicated that goals of care were discussed with Resident 1's responsible party and given the sacral [CONDITION(S)] and extensive wound Resident 1 was expected to continue to have infectious complications in the future. It indicated under wound care to turn Resident 1 every 2 hours side to side only. Review of the facility's Order Summary Report dated 9/28/2020 indicated an order on 7/26/2020 indicating Resident 1 may be turned and reposition every 2 hours and as needed on the back, left and right side. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/28/2020, it indicated Resident 1 was placed on her left side from 2:00 a.m. to 8:00 a.m., a total of six hours. On 7/28/2020, it indicated resident was on her right side from 8:00 a.m. to 12:00 p.m., a total of four hours. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .m , a total of four hours on 8/1/2020. On 8/5/2020, it indicated Resident 1 was positioned her left side from 2:00 a.m. until 6:00 a.m., a total of four hours. On 8/6/2020, it indicated Resident 1 was positioned her left side from 2:00 a.m. until 6:00 a.m., a total of four hours. On 8/22/2020, it indicated Resident 1 was positioned on her right side from 6:00 p.m. until 10:00 p.m., a total of four hours. On 8/27/2020, it indicated Resident 1 was positioned on her left side from 2:00 p.m. until 10:00 p.m., a total of eight hours. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/3/2020, it indicated Resident 1 was positioned on her left side from 4:00 p.m. until 8:00 p.m., a total of four hours. On 9/5/2020, it indicated Resident 1 was positioned on her right side from 4:00 a.m. until 8:00 a.m., a total of four hours. On 9/15/2020, it indicated Resident 1 was positioned on her right side from 12:00 a.m. until 4:00 a.m., a total of four hours. On 9/15/2020, it also indicated Resident 1 was positioned on her left side from 6:00 a.m. until 10:00 a.m., a total of four hours. On 9/16/2020, it also indicated Resident 1 was positioned on her left side from 6:00 a.m. until 10:00 a.m., a total of four hours. During an interview and observation with licensed vocational nurse B (LVN B) on 8/31/2020 at 11:00 a.m., Resident 1's sacrococcyx wound was measured at 3 cm by 3cm by 2 cm with undermining of 2 cm at 9 o'clock and 2.5 cm at 1 o'clock. Resident 1 had an indwelling urinary catheter (a thin tube inserted in the bladder to drain and collect urine). During another interview with the DON on 8/31/2020 at 3:30 p.m., DON stated the licensed nurses did not accurately document Resident 1's wound condition and measurement. DON stated the licensed nurses also did not obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and record review of the Skin Observation tools dated 6/16/2020, 6/23/2020, and 6/24/2020 with LVN C on 9/3/2020 at 2:55 p.m., LVN C stated Resident 1's sacrococcyx wound was initially a superficial (shallow) skin excoriation which became a small hole and gradually increased in size. LVN C stated she did not notify the physician about Resident 1's worsening sacrococcyx wound. LVN C stated did not document the wound size and documented the wrong staging for the pressure ulcer. LVN C performed Resident 1's Skin Observation Tool on 6/16/2020, 6/23/2020, and 6/24/2020. During an interview with LVN D on 9/29/2020 at 2:58 p.m., LVN D stated she initially observed Resident 1's sacrococcyx wound. LVN D stated she documented the wound was an excoriation and described the wound as a round open area on the sacrococcyx. LVN D stated she faxed the physician and notified the responsible party on 5/26/2020. LVN D stated they did not place a dressing on the wound and only applied a moisture barrier ointment. LVN D stated feces and urine could contaminate the wound because there was no dressing. LVN D stated she does not remember getting any wound care training or in-service regarding wound care in the facility. LVN D stated Resident 1 should be turned and repositioned every two hours. During an interview with LVN A on 10/1/2020 at 1:36 p.m., LVN A stated he was one of the treatment nurses in the facility. LVN A stated he did not know about Resident 1's sacrococcyx wound until 6/26/2020. LVN A stated one of the nurses approached the wound physician during the physician's rounds to look at Resident 1's wound on 6/26/2020. LVN A stated he does not recall putting the wound physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A was the treatment nurse who assessed and documented Resident 1's initial Wound-Weekly Observation Tool on 6/26/2020, 30 days after the wound was initially found. During an interview with registered nurse E on 10/5/2020 at 11:42 a.m., RN E stated the physician should be called when a resident has a new skin condition and ask for advice or order for the wound treatment. RN E stated if there is an open wound on the sacral area that a dry dressing should be placed to protect the wound from bowel movement or urine. RN E stated the licensed nurses perform skin assessments weekly pursuant to the facility's policies and procedures and if a wound was getting bigger or worse to talk to the treatment nurse to re-assess the wound and call the physician. RN E stated the treatment nurse should be notified from the start if a new wound appears on the residents. During another interview with LVN B on 10/5/2020 at 12:05 p.m., LVN B stated the charge nurses must report new skin conditions to the treatment nurse. LVN B stated, if a resident has a wound, the licensed nurses would get a new order because the preventative measures were not working. LVN B stated, if there were any changes and the wound was getting bigger or getting infected, the licensed nurses should call the primary physician or the wound physician to get a consultation. During an interview with LVN H on 10/5/2020 at 12:33 p.m., LVN H stated if the resident has a new wound the licensed nurses must do a new skin assessment and notify the physician and the treatment nurse. LVN H stated the licensed nurses must notify the physician again if the same wound becomes worse. LVN H stated Resident 1 was unable to move or reposition herself due to contractures. LVN H stated she and a certified nursing assistant (CNA) reposition Resident 1 every 2 hours on her back, left and right. During an interview with LVN F on 10/5/2020 at 2:53 p.m., LVN F stated if a resident's wound looked worse that he would coordinate with the charge nurse to notify the primary physician if the wound physician was not available. LVN F stated he did not notify any physician about Resident 1's worsening sacrococcyx wound on 7/3/2020. LVN F stated wound physician was on vacation on 7/3/2020. During an interview with LVN G on 10/7/2020 at 11:13 a.m., LVN G stated she does not remember the treatment nurse notifying her about Resident 1's worsening sacrococcyx wound on 7/3/2020. LVN G did not notify any physician about the wound because she did not know Resident 1's wound became worse. LVN G stated if the wound was getting worse that the treatment nurse would be the one to contact the doctor because they were the one to assess the wound. LVN G stated they turn and reposition Resident 1 every 2 hours. During a concurrent interview and record review with RN J on 10/19/2020 at 9:33 a.m., RN J stated the IDT should have seen the wound was worsening since 6/26/2020 based on the weekly wound assessment on 7/3/2020. RN J confirmed the IDT team discussed the initial wound assessment for Resident 1 on 6/26/2020 but not the most recent assessment on 7/3/2020. RN J stated the wound physician did not see the wound until 7/10/2020 and the wound was bigger. During an interview with the director of nursing on 11/17/2020 at 10:15 a.m., DON stated the wound was initially an excoriation found on 5/26/2020. DON stated multiple times the wound was an excoriation due to shearing forces (dragging force between the skin and another surface). The definition of a pressure ulcer is a localized injury to the skin and or underlying tissue over a bony prominence as a result of pressure, or pressure in combination with shear forces. During an interview and record review with the DON on 11/17/2020 at 10:15 a.m., DON confirmed there was a discrepancy with Skin Observation Tool dated 6/4/2020. DON stated the wound was documented as both stage I pressure ulcer and an excoriation by the nurse. DON also confirmed there were no wound measurements documented for Resident 1's wound on 6/4/2020. During an interview and record review of the Skin Observation tool dated 6/16/2020 with the DON on 11/17/2020 at 10:15 a.m., the DON confirmed the wound was documented as an unstageable pressure ulcer. DON confirmed the document also stated that there were no changes in the wound. DON stated Resident 1's physician should have been notified if Resident 1's excoriation turned into to a pressure ulcer. DON confirmed the document did not indicate if a physician was notified. During an interview and record review of the Skin observation Tool dated 6/23/2020 and 6/24/2020 with the DON on 11/17/2020 at 10:15 a.m., DON confirmed the discrepancy in the assessment documented on the Skin Observation Tool since the wound was described as both a stage I pressure ulcer (intact skin) and excoriated and granulated wound on the sacrococcyx. DON also confirmed there were no wound measurements documented for Resident 1's wound on 6/23/2020 and 6/24/2020. During an interview with the director of nursing (DON) and record review of Resident 1's Wound-Weekly Observation Tool dated 6/26/2020 on 11/17/2020 at 10:15 a.m., DON confirmed the wound was initially found on 5/26/2020. DON stated if there was an existing wound the treatment nurse would initiate a Wound-Weekly Observation tool and the charge nurses would do a weekly Skin Observation Tool. The first Wound-Weekly Observation tool for Resident 1 was created on 6/26/2020, 31 days after the wound was initially found. During an interview and record review with the DON on 11/17/2020 at 10:15 a.m., DON reviewed the Surgical Consult dated 6/26/2020 and confirmed the wound physician ordered for [MEDICATION(S)] dressing on Resident 1's sacrococcyx wound on 6/26/2020. DON also confirmed the order was not put in place in the electronic health record until 6/29/2020 based on the treatment administration record (TAR) dated 6/2020. During an interview with the DON and record review of Resident 1's Wound-Weekly Observation tool dated 7/3/2020 on 11/17/2020 at 10:15 a.m., DON stated it was the duty of both the charge nurses and the treatment nurse to notify the physician if a wound was worsening. DON confirmed Resident 1's sacrococcyx wound was documented as worsening and confirmed there was no documentation another physician was notified. DON stated that if the wound physician was not available then the treatment nurse or charge nurse can call the primary care physician or medical director of the facility. During an interview with DON and record review of Order Summary Report dated 9/28/2020 on 11/17/2020 at 10:15 a.m., DON stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During the review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review of Resident 1's care plan created on 7/15/2020 and interview with the DON on 11/17/2020 at 10:15 a.m., DON stated the care plan indicated Resident 1's sacrococcyx wound found on 5/26/2020. The care plan indicated to monitor and document the location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan was created 50 days after the wound was found and three days after Resident 1 was hospitalized for [CONDITION(S)]. During an interview with the wound physician (WP) on 12/2/2020 at 2:54 p.m., the WP stated he did not know about Resident 1's sacrococcyx wound until 6/26/2020. WP stated a staff member approached him during his facility rounds to look at Resident 1's wound on 6/26/2020. WP stated the wound was not a stage I pressure ulcer because the wound was open. WP stated it was also not a trauma wound because the facility would have to identify what kind of trauma like a fall or a stab. During an interview with WP on 12/2/2020 at 2:54 p.m., WP stated what he wrote in the treatment plan was the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . WP stated the [MEDICATION(S)] was readily available in the facility. WP stated that if the [MEDICATION(S)] was not available then the nursing staff could have easily placed an alternative order for a plain dry dressing to cover the wound. During an interview with WP on 12/2/2020 at 2:54 p.m., WP stated he did not do facility rounds on 7/3/2020. WP stated the nursing staff should have notified the primary physician if the wound was worsening. WP stated he was not notified anytime between 7/3/2020 to 7/10/2020 by the nursing staff that Resident 1's wound was getting worse. WP stated Resident 1's wound was bigger when he assessed it on 7/10/2020. During an interview with WP on 12/2/2020 at 2:54 p.m., WP stated Resident 1 should be turned and repositioned every two hours. WP stated irreparable (severe) damage to the skin can occur if a patient was lying on one side for more the 2-3 hours due to the pressure. Review of the facility's job description titled Treatment Nurse indicated would be responsible for all treatments ordered to be done on the assigned shift, assesses and evaluates treatments, and does the proper documentation. It indicated the treatment nurse would periodically assess the resident's condition and communicate with the other departments and physicians if a change of treatment is indicated. It indicated the treatment nurse would follow-up in the weekly progress notes, care plan and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It also indicated the treatment nurse would make skin rounds with the physician on a weekly basis to present those residents whose healing was not progressing. Review of the facility's policy Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 3/2014 indicated the nurse shall describe and document/report a full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Review of the facility's policy Prevention of Pressure Ulcers/Injuries, revised July 2017, indicated: 4. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., nonblanchable [CONDITION(S)]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Furthermore, it also indicates evaluate, report, and document potential changes in the skin.

Based on observation, interview, and record review, the facility failed to implement their prevention of pressure ulcers (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) policy for three of 24 sampled residents (1, 12, and 17). This deficiency resulted in the further development of pressure sores. Findings: 1. Resident 1's clinical record was reviewed and his [DIAGNOSES REDACTED]. His 10/2015 Minimum Data Set (MDS, an assessment tool) indicated he did not have a pressure ulcer, he was incontinent of urine and feces, and he was totally dependent on the staff for bed mobility and toileting. Resident 1's 2/10/16 Weekly Pressure Ulcer Documentation Sheet indicated he had a Stage II pressure ulcer (partial thickness skin loss) on the coccyx (tail bone). On 4/27/16, it developed into a Stage III pressure ulcer (full thickness skin loss presenting as a deep crater), measuring 1 centimeter (cm, unit of measurement) by 0.5 cm by 0.8 cm. Resident 1's 4/9/16 care plan indicated to turn and reposition at least every two hours. His 5/23/16 care plan indicated to change his alternating pressure pad (APP, alternately inflates and deflates to constantly change pressure points) mattress to a low air loss (LAL, provides air flow to help skin dry as well as to relieve pressure) mattress. There was no documentation on 5/2016 indicating the resident was repositioned every two hours. Resident 1's 5/4/16 treatment record indicated he had a closed blood blister on his left heel which measured 4.5 cm by 3 cm. He had an order to treat it with a skin preparation (skin protectant used on the heels at risk for irritation due to friction). His 5/4/16 care plan indicated to use a heel protector, elevate his heels at all times, and to monitor every shift. His 5/23/16 treatment record indicated his left heel became an opened blister and he had an order to treat it with ointment and cover it with a dry dressing. During an observation on 5/22/16, at 8 a.m. and 2 p.m., Resident 1's heels were touching the bed, had no heel protectors, and his left heel was covered with a dry dressing. During a wound dressing observation with licensed vocational nurse U (LVN U) on 5/24/16, at 11:30 a.m., she stated Resident 1's pressure ulcer on his coccyx measured 1.5 cm x 0.5 cm x 1.2 cm. His left heel had an opened blood blister area measuring 4.3 cm x 2.5 cm x 0.2 cm and adjacent to it was a deep tissue injury (DTI, pressure related injury to subcutaneous tissue under intact skin with the appearance of a deep bruise) measuring 3.5 cm x 2.5 cm. During an interview on 5/24/16, at 4 p.m., LVN T stated on 5/21/16, he saw the open area on the left heel and he did not apply a skin preparation. He stated he cleaned the left heel and covered it with a dry dressing. LVN T stated the left heel blood blister could have opened up before his shift. He informed his supervisor regarding the status of the wound. LVN T did not call a physician for a new order, did not revise the care plan, and did not do a wound assessment including a measurement until 5/23/16. He stated Resident 1 was incontinent of urine and feces and the urine contributed to the pressure ulcer on the coccyx. During an interview on 5/25/16, at 3:35 p.m., LVN U stated she worked on 5/23/16 and she did not assess Resident 1's left heel and did not apply the skin preparation. She thought it was still a closed blood blister, and she was not informed the left heel was opened until 5/24/16. During an interview on 5/26/16, at 1:15 p.m., the nurse supervisor (NS) stated the physician was notified on 5/23/16 and a new treatment was ordered for the open area on the left heel and the care plan was also revised. She stated the staff should have assessed the left heel every shift and, when there was change in the wound status, the staff should have notified the physician immediately for new wound treatment orders, the care plan should have been revised timely, and it should have been communicated to the staff. The NS also stated the LAL mattress should have been placed after 4/27/16 when Resident 1's pressure ulcer on the coccyx deteriorated from a Stage II to a Stage III. She acknowledged there was no documentation in 5/2016 indicating the resident was routinely turned every two hours. Review of the facility's 3/2005 policy, Prevention of Pressure Ulcer, indicated the facility should have a timely assessment. A change in condition of the pressure ulcer should be recognized, evaluated, reported to the physician, and addressed timely. Bedbound residents need to change position every two hours or more frequently, and the staff should assess the resident to determine if a special mattress was needed. 2. Resident 12 was admitted with [DIAGNOSES REDACTED]. Her MDS, dated [DATE], indicated she was unresponsive and totally dependent for the activities of daily living. The Braden Scale for Predicting Pressure Sore Risk (a tool used to help health professionals, especially nurses, assess a resident's risk of developing a pressure ulcer) was performed a week after her admission and indicated the resident was at a high risk for a pressure ulcer. On 4/27/16, Resident 12 had a Stage ll pressure ulcer on her coccyx measuring 2 cm x 2.5 cm. She also had a Stage II pressure ulcer measuring 1 cm x 1 cm on her right buttock. On 5/4/16, Resident 12's wounds combined and measured 4.5 cm x 6 cm. The depth was unstageable due to the presence of slough (dead skin). On 5/9/16, an indwelling catheter (a flexible tube passed through the urethra and into the bladder to drain urine) was inserted and Resident 12 was transferred and admitted to an acute hospital for evaluation for gross hematuria (blood in the urine). On 5/12/16, Resident 12 underwent wound debridement (a procedure used to remove dead tissue and contaminated substances from a wound) in the hospital and was started on antibiotics (drug used in the treatment and prevention of bacterial infection). On 5/17/16, Resident 12 was readmitted to the facility with [DIAGNOSES REDACTED]. The treatment log indicated the pressure sore measured 6.5 cm x 5.5 cm with a depth of 22 cm. The treatment log on 7/17/16 indicated to cleanse the wound with normal saline and apply a [MEDICATION NAME] pack (wound management; a [MEDICATION NAME] paste) with wet gauze to cover. During an interview on 5/23/16, at 2:30 p.m., with a family member (FM), she confirmed Resident 12 had no pressure ulcers during the month long hospitalization prior to her admission to the facility. She developed the sores in the facility in less than two weeks. During an interview on 5/24/16, at 3:20 p.m., with LVN S, who assessed the pressure ulcer when it was first noticed, she acknowledged there was no documentation the resident was routinely turned every two hours. She stated a physician order [REDACTED]. During an interview with registered nurse V (RN V), the evening nursing supervisor, on 5/25/16, at 3:25 p.m., she stated a care plan recommended an APP mattress but there was no evidence the use of the APP was implemented. She also acknowledged a physician order [REDACTED]. During an interview with the wound doctor on 5/26/16, at 11:04 a.m., he stated he had seen Resident 12 before the resident was transferred to the hospital on [DATE] and on 5/20/16. He said there was no change in the condition of the pressure ulcer. He stated the ulcer was a Stage IV (a full thickness of skin and subcutaneous tissue was lost, exposing muscle and/or bone; at this stage the sore may be covered with a slough, drainage, necrotic, reddened induration). A review of the facility's 2005 policy, Pressure Ulcer Risk Assessment, indicated a pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly, annually, and with significant changes. Because a resident at risk can develop a pressure ulcer within two to six hours of the onset of pressure, the at risk resident needed to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. 3. Resident 17's clinical record review indicated he was readmitted from the acute care hospital with [DIAGNOSES REDACTED]. vessels), hypertension (high blood pressure), and acute kidney failure (a condition in which the kidneys cannot filter waste from the blood). The discharge summary from the acute care hospital, dated 3/16/16, indicated Resident 17 was completely dependent on turning. The Braden Scale, dated 3/16/16, indicated he was at high risk for developing a pressure sore. The Nursing Admission and Assessment, dated 3/16/16, indicated Resident 17 did not have any skin issues on his heels. A risk for skin breakdown care plan was initiated for Resident 17 on 3/16/16 and under approach it indicated, Remind resident to turn and reposition at least every 2-3 hours and as needed. A DTI on the left heel care plan was initiated on 3/31/16 and under approach it indicated, Turn and reposition resident at least (left blank) hours and as needed. There was no evidence indicating Resident 17 turned himself, or was turned or repositioned by the staff. The MDS, dated [DATE], indicated Resident 17 had moderate cognitive impairment and was at risk for developing a pressure ulcer. A nurses note, dated 3/31/16, indicated a certified nurse assistant (CNA) informed the charge nurse the skin on Resident 17's left heel was intact, but fragile with a black, brownish color and Resident 17 was in pain when the heel was touched. The Weekly Pressure Ulcer Documentation Sheet, dated 3/31/16, indicated the left heel had a DTI. On 4/1/16, the surgical consultant (SC) from a wound care company saw Resident 17 for an evaluation of his left heel. He wrote Resident 17 had a 2.5 cm x 3.0 cm slightly ecchymotic (discoloration such as a bruise) area of intact epithelium (the thin tissue forming the outer layer of a body's surface) without drainage or odor. On a follow-up visit, dated 4/8/16, Resident 17 had a 2.0 cm x 3.0 cm previously ecchymotic wound which was now open with a small amount of slough and dark granulating (new connective tissue and microscopic blood vessels forming on the surface of a wound during the healing process) tissue with a moderate amount of serosanguinous (containing blood and the liquid part of blood) drainage without odor. There was no evidence indicating the SC staged the opened wound on 4/8/16. On 5/20/16, the SC ordered Santyl (an enzymatic [MEDICATION NAME] ointment) for Resident 17's left heel wound. Again the wound was not staged. In an interview on 5/25/16, at 11:20 a.m., RN V stated when Resident 17 was readmitted from the acute care hospital he had no skin issues on his heels. She stated he developed an in-house DTI which opened and was treated with Santyl, which was used for a Stage III or IV pressure ulcer. RN V stated there was no evidence Resident 17 turned himself or was turned every two hours by the staff. During an observation on 5/25/16, at 1:45 p.m., accompanied by LVN F, Resident 17's left heel had yellowish slough on a dark background with a size around 2 cm x 2 cm. Review of the facility's 3/2005 policy, Prevention of Pressure Ulcers, indicated under general preventative measures for person in bed to change position at least every two hours or more frequently if needed. Review of the facility's 12/2007 policy, Pressure Ulcer Treatment, indicated a Stage III pressure ulcer had full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle were not exposed. Slough may be present but does not obscure the depth of the tissue loss. A review of the website for the National Alliance of Wound Care and Ostomy (woundcareadvisor.com) indicated as a DTI evolves, clinicians may see a thin blister over a dark wound bed on the skin. Once the DTI has fully opened, exposing the level of tissue damage, it can then be accurately staged as III or IV pressure ulcer.

Based on multiple observations, interviews, and record review, the facility failed to ensure one of 24 sampled residents (5) was free from unnecessary drugs, when: 1. The staff failed to report to the primary care physician (PCP) and nurse practitioner A (NP A) Resident 5's signs and symptoms of abnormal body movement, a likely side effect from the use of [MEDICATION NAME] an antipsychotic medication (psychiatric medication regulates the functioning of brain circuits controlling thinking, mood, and perception) which the resident had been exhibiting for about a year while in the facility; 2. Nursing staff documented 0 (zero) numbers of side effects on the Medication Administration Record [REDACTED] 3. There was no attempted gradual dose reduction (GDR, tapering of the dose) on an annual basis, as required, and in the presence of side effects; 4. NP A, the medical provider for Resident 5 on a monthly basis, was not aware (or made aware) of the resident's abnormal involuntary body movement; 5. There was no documented evidence indicating NP A assessed Resident 5's behaviors, to rule out possible underlying causes such as pain, electrolyte imbalance, loneliness, etc. that may have caused the resident to yell out; 6. The facility failed to act timely on the consultant pharmacist's (CP) recommendations to check the laboratory blood levels and provide routine pain medication to rule out possible causes of the resident's behaviors; and, 7. There was no order for a staff assessment of the resident's pain on a daily basis. These failures resulted in Resident 5's continued exhibition of abnormal involuntary movement of his head and upper body, and tremors in the hands and legs, without being assessed and treated, and prolonged use of [MEDICATION NAME]. These failures may also have resulted in the resident's weight loss and functional decline. Findings: Resident 5's clinical record was reviewed and indicated he was over the age of 70, a non-English speaking resident who was admitted to the facility in 2012 with [DIAGNOSES REDACTED].). He did not have a [DIAGNOSES REDACTED]. (progressive breakdown of nerve cells in the brain). The 3/17/16 Minimum Data Set (MDS, an assessment tool) indicated his cognition was moderately impaired, and he was totally dependent on staff for activities of daily living (such as bathing, dressing, eating). Resident 5 was unable to make his needs known. Resident 5's Weight Progress Record revealed he had been losing weight. Upon re-admission in 6/2013, his weight was 166 pounds. In May 2014, he weighted 136 pounds. In May 2015, he weighted 31 pounds. The resident weighed 109 pounds the beginning of May 2016. Resident 5 was 5 feet, 2 inches tall. Resident 5 had a physician order for [REDACTED]. On 3/25/15, the dose was reduced to 37.5 mg twice daily (75 mg total) and remained so until the survey date of 5/24/16. Resident 5 also had a physician order, dated 2/12/14, for [MEDICATION NAME] (an anti-anxiety medication, which can be very sedating) 1 mg every 8 hours as needed for anxiety manifested by an inability to relax/restlessness. [MEDICATION NAME] is an atypical antipsychotic medication. Neurological (nervous system) side effects associated with antipsychotic medications are: [DIAGNOSES REDACTED] (involuntary muscle contractions causing repetitive or twisting movements), pseudoparkinsonism (symptoms like those of Parkinsonism, i.e., slow movement, stiffness, tremor, and drooling), akinesia (loss or impairment of the power of voluntary movement), and akathisia (movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion). They are referred to collectively as extrapyramidal symptoms, or EPS (The Evidence-based Guide to Antipsychotic Medications, Anthony Rothschild, M.D.; 2009; Page 28). According to the 2007 Medscape (a web resource for physicians and health professionals) Article entitled Detection, Prevention, and Management of Extrapyramidal Symptoms, the clinical manifestations of EPS include a number of atypical involuntary muscle contractions influencing gait, movement, and posture. The symptoms can develop acutely, be delayed, or overlap making diagnosing a challenge. The article indicated the symptoms can range from minimal discomfort to permanent involuntary movements. It indicated, Dyskinesia (abnormality or impairment of voluntary movement) is a late-appearing side effect that can emerge months to years after an APM (antipsychotic medication) has been administered, and it is identified as tardive dyskinesia (involuntary movements of the tongue, lips, face, trunk, and extremities). In some cases, about 6%, the symptoms are irreversible. Lexi-Comp online (www.lexi.com), a nationally recognized drug information resource, indicated [MEDICATION NAME] may cause extrapyramidal symptoms, including pseudoparkinsonism, acute dystonic reactions, akathisia, and tardive dyskinesia. The 2013 prescribing information (Package Insert) for [MEDICATION NAME] reported incidents of EPS in patients receiving doses of 75 mg or higher per day, even in short-term use. Resident 5's Antipsychotic Care Plan, dated 3/30/16, included the following as potential side effects: akathisia, Parkinsonism, and tardive dyskinesia. In the Neuropsychological (related to brain function and behavior) Assessment Report, dated 3/4/14, the neuropsychologist (a professional specializing in structure and function of the brain as they relate to specific psychological processes and behaviors) wrote, On the assumption that his (Resident 5's) anti-psychotic [MEDICATION NAME] is becoming unnecessary, let us consider with his Physician the gradual tapering and discontinuance of this medication. There was no evidence in the medical record indicating gradual tapering and discontinuance was considered after this assessment. Resident 5's clinical record showed an Initial-Psychiatric Evaluation, dated 3/25/15, in which the psychiatry nurse practitioner (NP B) wrote, This patient doesn't have hallucination/delusions; yelling, angry outburst, laughing/crying biting behaviors are not indicated for [MEDICATION NAME]. [MEDICATION NAME] is not effective in treating these behaviors. Unrelieved pain can contribute to yelling . biting, crying. NP B recommended reducing [MEDICATION NAME] to 37.5 mg twice daily and follow-up afterwards. The [MEDICATION NAME] dose was reduced to 37.5 mg twice daily on 3/25/15 (as recommended); no further reduction was conducted until 5/24/16. On 5/24/16, at 9:45 a.m., Resident 5 was observed sitting in a wheelchair, by himself, at a table in the Activity Room, with his eyes closed and his head constantly bobbing up and down as in a nodding motion. His upper body was jerking as his head continued to move up and down, and his hands and feet were noted to have a moderate level of constant tremors. His head, hands, and feet were constantly moving in a restless motion. Resident 5 did not respond when his name was called. Licensed vocational nurse C (LVN C), who regularly cared for Resident 5 during the day shift, was present in the Activity Room during this observation. He stated Resident 5 had not been always like this (referring to the constant body movement). On 5/24/16, at 9:55 a.m., activity staff D (AS D), who was present in the Activity Room with Resident 5, stated when she first arrived at the facility about two years ago, the resident was fine, more active, and able to drink coffee by himself during activity times. She said Resident 5 could no longer do that now. She said she had noticed the change in the resident for about a year. On 5/24/16, at 10:08 a.m., Resident 5 was observed in a wheelchair in his room. His hands and feet were constantly moving, eyes blinking occasionally, upper body jerking, and his head was constantly bobbing up and down. On 5/24/16, at 10:10 a.m., at Resident 5's bedside, certified nurse assistant E (CNA E) stated, When he (Resident 5) comes here he does not have this kind of movement before. On 5/24/16, at 10:35 a.m., Resident 5 was observed in a wheelchair in his room. He was exhibiting the same type of body movement as earlier observed in the Activity Room. His eyes remained closed, blinking once in a while. His mouth was also moving in a slow chewing motion. Occasionally the resident would yell out something in his language. Any movement by a roommate or staff would cause the resident to say something out loud. During a concurrent observation and interview on 5/24/16, at 10:40 a.m., LVN F, who regularly cared for Resident 5 during the afternoon shift, was called to Resident 5's bedside. She observed the resident and said the body movement was due to his medication, [MEDICATION NAME], which could cause EPS. She stated she had observed the body movement, which was on and off, for about a month. She said the resident did not have that kind of movement before. A physician order, dated 6/17/13, indicated to monitor the side effects of [MEDICATION NAME] for Resident 5, which included extrapyramidal symptoms, every shift. The nursing staff documented zero number of side effects of [MEDICATION NAME] on the April and May 2016 MARs. The Psychoactive Drug Summary Report (PDSR, document which summarized the total number of behavior episodes and side effects per month; used by clinical providers such as physician, NP, pharmacist, etc. to assess for effectiveness and side effects of medication) indicated the staff documented zero adverse reactions (or side effects) from [MEDICATION NAME] from April 2014 to April 2016. During another interview on 5/24/16, at 11 a.m., LVN C stated Resident 5 had exhibited involuntary movement before but not as severe as he has now. He said he had noticed Resident 5's body movement for more than a year, and thought it was reported to the physician. LVN C stated he thought the abnormal body movement was due to the side effect of [MEDICATION NAME], specifically EPS. When shown the current MARs and the PDSR (from April 2014 to April 2016) which showed zero side effects, LVN C said the nursing staff should have put hashmarks on the MAR, indicating the resident had EPS. On 5/24/16, at 11:13 a.m., Resident 5 was observed in his wheelchair while his head bobbed up and down constantly, and tremors/shaking in his hands. His mouth was also moving as if slowly chewing something with an open mouth. On 5/24/16, at 11:15 a.m., the nurse supervisor (NS) was asked to come to Resident 5's bedside to observe the resident while the resident was exhibiting the body movement (as described above). After a moment of observation, the NS stated, That movement is a side effect of [MEDICATION NAME], EPS. Shortly after this observation, on 5/24/16, at 11:25 a.m., the NS reviewed Resident 5's medical record. There was no documented evidence the nursing staff reported the EPS to the physician. The NS confirmed the staff documented zero number of side effects of [MEDICATION NAME] on the MAR, and said the staff should have put hashmarks on the MAR indicated [REDACTED]. The NS also confirmed the last dose reduction of [MEDICATION NAME] was conducted on 3/25/15, which was 14 months prior. There was no documented evidence the CP recommended a GDR of [MEDICATION NAME] for Resident 5 in the presence of adverse effects when it was due in March 2016 (annual GDR attempt required for residents on antipsychotic longer than a year, unless contraindicated). On 5/24/16, at 11:40 a.m., LVN F was interviewed again. When asked if she reported Resident 5's abnormal body movement to the PCP, she stated she reported to the day nurse (LVN C) only. During the observations on 5/24/16, at 12:10 p.m. and at 12:30 p.m., Resident 5 was observed again with the same body movement as described above. His mouth was in a slow chewing motion, and his eyes were closed but blinked once in a while. During a concurrent observation and interview on 5/24/16, at 12:45 p.m., Resident 5 was at his bedside being fed by CNA E. The resident was calm and did not exhibit the upper body movement, but there were slight tremors in his hands and feet. CNA E stated Resident 5's body movement was on and off, and happened sometimes during feeding, which made it difficult to feed him. CNA E said before the resident was able to hold a cup and drink while being assisted but now the resident was fully dependent on the staff to feed him. Resident 5's nurses note, dated 5/24/16, at 12 noon, read, Dr. (PCP's name) notified about pt (patient) having involuntary movt (movement) (EPS symptoms) . MD ordered to (down arrow, meaning decrease) dose of [MEDICATION NAME] (to) 37.5 mg 1 tablet QD (once daily). During an interview on 5/24/16, at 3:40 p.m., Resident 5's PCP said he was aware of Resident 5's abnormal body movement, and told the staff to monitor it. The PCP stated he did not remember when he was made aware. He stated one could not prove the body movement was 100 percent EPS. The PCP said he did not see any recommendations for the GDR of [MEDICATION NAME] from the CP and would normally leave the antipsychotic medication alone. When shown the initial psychiatry recommendation from NP B regarding [MEDICATION NAME] not effective for treating Resident 5's behaviors, the PCP said, I don't know about this. When asked about Resident 5's weight loss, the PCP stated it could be due to multiple things. He said the constant body movement could cause the resident to spend a lot of energy, leading to the weight loss. On 5/24/16, at 5 p.m., Resident 5 was observed in a wheelchair in front of the skilled nursing station. His head was noted with bobbing motion, eyes closed but blinked once in a while, and occasionally saying something in a loud voice. On 5/25/16, at 7:50 a.m., Resident 5 was observed in a wheelchair, talking to himself. Less body movement was noted. On 5/25/16, at 8:50 a.m., Resident 5 was observed in his room. He opened his eyes when greeted. His right leg was constantly shaking, and his hands were noted with slight tremor. His head was moderately bobbing up and down. During a concurrent observation and interview with CNA G on 5/25/16, at 8:55 a.m., the resident was laughing and mumbling some incomprehensible words, with noted movement of the head, left hand, and right foot. When CNA G spoke to him in his language, he responded and laughed. CNA G said he was saying things that happened long ago. Sometimes she could understand him, other times could not. She said the resident normally would not respond to her questions such as whether he had pain. CNA G said she used to assist him to eat as he was able to hold a cup and drink and he was more dependent now. There was no documented evidence the PCP documented he was aware of Resident 5's body movement, and there was no documented evidence the staff were monitoring for the abnormal involuntary body movement. There was no care plan developed for this condition. The quarterly Interdisciplinary (IDT, group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) Care Conference meetings minutes and the nurses notes, from January 2015 to May 2016, did not indicate the staff were monitoring the resident's involuntary body movement. On 5/25/16, at 9:50 a.m., the NS stated she could not find documentation indicating the staff was monitoring the abnormal involuntary body movement. During a telephone interview on 5/25/16, at 10 a.m., the CP said she did not make the GDR recommendation for Resident 5's [MEDICATION NAME] because he continued to have behaviors so she did not think it was appropriate. When asked whether she asked for a risk vs. benefit assessment from the physician to continue the [MEDICATION NAME], as required when it was due annually, the CP said she did not. The CP said she was not aware of Resident 5's abnormal involuntary body movement, as she relied solely on the MAR for documentation of side effects and the AIMS (Abnormal Involuntary Movement Scale, a tool used to assess abnormal body movement). The AIMS, conducted on 3/18/15 and 5/2/16, indicated 0 (zero) under each section of the assessment except a 1 (minimal/normal) for the assessment of the lips and mouth area, which indicated the resident did not exhibit any unusual signs and symptoms of body movement. The CP stated she had never been invited to the IDT Care Conference or the [MEDICAL CONDITION] Drug Review meetings (those held to discuss behavioral medications) to discuss her evaluation of the resident's [MEDICATION NAME] and had never been made aware of the resident's abnormal body movement. Resident 5 was observed again on 5/25/16, at 10:30 a.m. The resident continued to exhibit the movement of the head, upper body, hands, and feet as described above. On 5/25/16, at 10:30 a.m., LVN H stated she had known Resident 5 exhibited the body movement for about a year. She stated, It may be the side effect of one of his meds. The antipsychotic. When asked if she reported the abnormal body movement to the PCP, she responded, No, not that I remember. Registered nurse L (RN L) was asked to observe Resident 5 on 5/25/16, at 11:20 a.m. After observing the resident for a while, she said when she conducted the AIMS assessment on 5/2/16, she only saw the movement of the lips and mouth. She agreed the 5/2/16 AIMS did not reflect the body movement as she was now observing. She said the resident looked uncomfortable in such a state. During this interview with RN L, the director of nurses (DON), who had been in the facility for about 10 days, was asked to observe Resident 5. She said, I am aware of his tardive dyskinesia condition. On 5/25/16, at 11:50 a.m., Resident 5 was observed in his room with the slight nodding motion of the head. On 5/25/16, at 2:55 p.m., Resident 5 was observed in his bed sleeping. No body movement was observed. The published article in the Neurologic Clinic entitled Movement Disorders Induced by Antipsychotic Drugs: Implications of the CATIE [MEDICAL CONDITION] Trial, dated 2/2011, indicated, Dyskinesias increase with emotional arousal, activation or distraction, and diminish with relaxation, sleep, or volitional (act of making a choice or decision) effort. As a result, symptoms of TD (tardive dyskinesia) fluctuate over time, such that repeated measurements are necessary for reliable assessment of severity and persistence. (Neurol Clin. 2011 Feb; 29(1): 127-viii.) The PDSR for the use of [MEDICATION NAME], from 4/2014 to 4/2016, indicated the staff were monitoring for disruptive constant yelling every shift. The number of behavior episodes varied from month to month, but, on average, ranged from 30 to 60 episodes per month. Besides the [MEDICATION NAME], the March to May 2016 MARs showed the staff administered the as-needed [MEDICATION NAME] tablet on the daily basis, one or two times daily for restlessness. In April 2016, there were 50 doses given. No pain assessment for Resident 5 was conducted on a daily basis. There was a physician order, dated 2/27/14, for Tylenol 650 mg twice daily for generalized discomfort. On 5/25/16, at 3:40 p.m., LVN H confirmed there had been no assessment on a daily basis of the resident's pain. When asked how the staff ruled out the resident's yelling out behavior was not due to pain, LVN H responded, I don't know. She said there was no physician order for [REDACTED]. On 5/25/16, at 3:45 p.m., LVN F stated there was no pain assessment during the shift; however, she said she noticed Resident 5 was more calm after she gave a dose of Tylenol during her shift. When asked how she could know the resident's yelling behavior was not due to pain, as he could not verbalize his needs, LVN F answered, I don't know. During a telephone interview on 5/25/16, at 4:30 p.m., Resident 5's family member (FM), who had been visiting Resident 5 on a routine basis, said the resident's body movement started about eight to ten months ago. The FM said the resident was not like that before. He was more active and able to communicate with family members. The FM said Resident 5 was so skinny now. He's not himself anymore. NP A had been seeing Resident 5 on a monthly basis from 8/2015 to 5/2016. There was no documented evidence the NP assessed the resident's behaviors and assessed whether the behaviors were due to underlying conditions such as pain, electrolyte imbalance, loneliness, etc. During a telephone interview on 5/25/16, at 5:12 p.m., NP A said she was not aware of the resident's abnormal involuntary body movements, and the staff never reported this condition to her. She asked, The patient has abnormal movement? When reported to her the resident had about 30 to 60 episodes of yelling behavior per month, she said, What behavior? Patient yelling? When asked if she had assessed whether the behaviors could be due to some underlying condition such as pain, NP A said, You have to talk to the nurse. They would call me if the patient has pain . Why are you asking me all these questions? During a telephone interview on 5/25/16, at 5:25 p.m., the psychiatry nurse practitioner (NP B) said her plan was to gradually decrease the [MEDICATION NAME] dose for Resident 5, then reassess the resident for a response with the goal to discontinue it. She said the facility discontinued her service shortly after the last visit on 3/25/15, so she did not return to make further recommendations. A [MEDICAL CONDITION] Drug Review meeting document, dated 3/25/15, indicated the [MEDICATION NAME] was reduced. The recommendation from the team members was to review [MEDICATION NAME] every 3 months and psychiatrist will review medication in 2-3 mos (months). On 5/26/16, at 8:45 a.m., Resident 5 was observed sitting on a wheelchair in his room and occasionally yelling out something in his language. His eyes remained closed, head bobbing up and down, and his upper body jerking constantly in a restless motion. His hands and feet were shaking slightly. On 5/26/16, at 9:10 a.m., the CP presented the surveyor with her recommendations, dated 3/29/16, addressed to the PCP. The recommendations were to check TSH (a [MEDICAL CONDITION] test), vitamin B12 level, other laboratory tests, and routine pain medication coverage, to rule out possible causes of Resident 5's behavior. The response for these recommendations was conducted on 5/25/16 (the day of the survey, which was almost two months after the recommendations). The CP acknowledged they were not acted upon timely. During an interview on 5/26/16, at 10:20 a.m., restorative nurse assistant M (RNA M) stated Resident 5 used to wheel himself around in the facility. She said he could no longer do that. RNA M was uncertain when the change happened. During an interview on 5/26/16, at 11:50 a.m., the registered dietitian (RD) said he had noticed the resident's abnormal body movement for about a year. On 5/26/16, at 12 p.m., a review of Resident 5's medical record with the NS confirmed there was no pain assessment on the daily basis. The pain assessment was only documented on the Nursing Weekly Summary and the quarterly pain assessment, which was last conducted on 3/28/16. There was also no daily assessment of whether the daily Tylenol doses were effective for the resident. The NS stated a pain assessment should be done on a daily basis. During an interview on 5/26/16, at 12:45 p.m., the DON acknowledged the following related to the care of Resident 5: The CP's recommendations for laboratory tests and routine pain medication were not acted upon timely; no GDR for [MEDICATION NAME] when required and in the presence of side effects; there was no order for and documentation of pain assessment on the daily basis; no care plan was developed for the abnormal body movement and pain; the NP, who had evaluated the resident monthly, was not aware (or made aware) of the resident's continued exhibition of abnormal involuntary body movement; and there was no documented evidence of an assessment of the resident's behaviors by a medical provider since 3/2015. On 5/26/16, at 1:15 p.m., the social service director (SSD) confirmed the facility discontinued the psychiatry nurse practitioner's service sometime between March and May 2015, and Resident 5 had not been evaluated by any psychiatry service since then. The SSD said the IDT did not discuss and evaluate Resident 5's abnormal body movement during the IDT Care Conference meetings. The facility's revised 4/2007 policy, Pain-Clinical Protocol, indicated the staff and the physician will evaluate how pain is affecting mood (behaviors); establish goals of pain treatment; and staff will reassess the individual's pain at regular interval at least each shift for acute pain. The facility's 9/2010 policy, Medication Management, indicated, (T)he behavioral symptoms must be re-evaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. In regard to GDR, the policy indicated, After the first year, GDR must be attempted annually, unless clinically contraindicated. The policy indicated GDR may be considered contraindicated if the physician has documented the clinical rationale for why a GDR would likely impair the resident's function or cause psychiatric instability. The facility's revised 4/2007 policy, Guidelines for Notifying Physicians of Clinical Problems, indicated the staff were to notify the physician promptly when there was a sudden onset or a marked change in the resident's status compared to the baseline.

Based on observation, interview and record review, the facility failed to implement an effective infection control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for all the residents in the facility when: a. One of four housekeeping staff (HK A) assigned to clean thirteen resident rooms, including Resident Room B which was under contact isolation precautions (form of isolation used to prevent the spread of disease in which anyone entering the patient's room and having direct contact with the patient wears gloves and a gown), and Nursing Station A's restroom, kept the sponges used for cleaning of the restroom sinks and a toilet brush together in one container; b. personal care items, i.e., oxygen tubings and syringes were not changed or dated for two of 24 sampled residents (7 and 19) and three nonsampled residents (28, 29, and 32); c. food was not served under sanitary conditions; d. several staff members did not follow the gowning or handwashing procedures when a resident was in isolation; e. housekeeping staff used inaccurate concentrations of cleaning solutions for the housekeeping services and, f. multiple staff members did not implement proper handwashing technique and glove use. On 7/2/15 at 4:15 p.m., the facility was verbally informed the Department determined the existence of an Immediate Jeopardy to the residents in the facility due to the failure to conduct effective resident and public environmental sanitation. On 7/3/15 at 3:15 p.m., the Immediate Jeopardy was lifted due to the acceptance and implementation of the facility's plan of correction. Findings: 1. Resident 6's clinical record was reviewed. On 6/27/15, a laboratory test indicated she had proteus mirabilis [DIAGNOSES REDACTED] oxytoca (a bacterial urinary tract infection that can be easily spread by touch). On 6/29/15, she was placed on contact isolation (measurement to prevent the spread of infection; staff must wear protective equipment when entering the room). During an observation on 7/2/15 at 10:20 a.m., housekeeping staff A (HK A) entered Resident 6's isolation room wearing a pair of gloves and a mask. She cleaned the side table, touched the garbage can lid and threw the dirty items in the trash bin located outside of the room. Using the same pair of gloves, HK A sprayed, wiped the side table and organized the books and magazines on the table. She then sprayed and wiped a wheelchair and a light fixture. Using the same gloves, HK A cleaned the toilet bowl with a toilet brush and then cleaned the sink with sponges. After using the toilet brush and the sponges, she stored the used sponges and the toilet brush together with a bathroom cleaner (disinfectant cleaner for use on washable, hard, non-porous surfaces) in a white container and placed the container back in the housekeeping cart. Using the same gloves, HK A dipped her gloved hand in a blue bucket containing wet mop cloths. She was then observed mopping the floor and touching the hazardous material bin in the room. She then bagged the dirty towels and the mop cloths and placed them in a soiled bin in the housekeeping cart. Afterwards, using the same gloves, she touched various items on the cart. She then threw her used gloves in a trash bin and washed her hands in the nursing station across from Resident 6's room. During a second observation and an interview in Resident Room C on 7/2/15 at 10:35 a.m., HK A demonstrated how she cleaned the rooms and the restrooms. She stated she used only one pair of gloves to clean the room and she did not change her gloves between cleaning different areas in the room. She stated she kept the used sponges and the toilet brush together with a bathroom cleaner in a white container in the housekeeping cart. During a third observation in Resident Room D on 7/2/15 at 10:45 a.m., HK A cleaned the room with the same toilet brush, sponges and disinfectant cleaner she used in the isolation room. She then placed them together in a white container in the housekeeping cart. During a fourth observation at Nursing Station A on 7/2/15 at 11:40 a.m. HK A cleaned the sink and the toilet bowl with the same toilet brush and sponges used in the isolation room and placed them together in the white container. During an interview with HK A on 7/2/15 at 2:05 p.m., she stated she kept the sponges, the toilet brush and the bathroom cleaner in a white container. She stated she used the same items for the isolation rooms, the regular rooms and the restroom in Nursing Station A. During an interview with the housekeeping supervisor (HK S) on 7/2/15 at 2:15 p.m., she stated the sponges and the toilet brush should be stored separately. Review of a the facility's undated policy, Housekeeping Department Policy and Procedure, indicated cleaning equipment which has become contaminated in an isolation room will be decontaminated or replaced before moving to the next room. On 7/2/15 at 4:14 p.m., an Immediate Jeopardy (IJ) was called and the administrator and director of nursing were informed. On 7/2/15 at 5:15 p.m., the administrator (ADM) presented a plan of correction and the plan was accepted. The plan of correction consisted of the following elements: Immediate Measures a. In-service all housekeeping staff on 7/2/15 at 5:30 p.m. to be conducted by the director of staff development (DSD) and the director of nursing (DON). b. Disinfect all housekeeping carts prior to using after the incident and discard used sponges and toilet brush. c. Clean environmental surfaces in Station A and all 13 rooms assigned to HK A. d. Horizontal cleaning of surfaces will be done to ensure prevention of the spread of infection every 4 hours. e. STAT (immediately) culture toilet bowls, sinks and horizontal surfaces like the bedside tables and the side rails in all 13 rooms assigned to HK A and the Station A restroom. On 7/3/15 at 3:15 p.m., the Immediate Jeopardy was lifted due to the acceptance and implementation of the facility's plan of correction. 2. During an initial tour on 6/29/15 at 11:30 a.m., Resident 7's oxygen tubing (tubing used to deliver supplemental oxygen to an individual in need of respiratory help), aerosol mist tubing (large corrugated tubing used to moisten the oxygen breathed by an individual on oxygen therapy) and a drain bag (trap used in the middle of the large corrugated tubing to collect condensed water) were observed labeled and dated 6/28/15. During an observation on 7/7/15 at 2:45 p.m., the oxygen tubing, aerosol mist tubing and drain bag were noted to be undated. During a concurrent interview with respiratory therapist H (RT H), she stated the tubings and the drain bag should have been changed weekly on Sunday and as needed. She stated the tubing and bag needed to be labeled and dated and the staff forgot. In an interview with the director of nurses (DON) on 7/7/15 at 3:30 p.m., she stated the tubing should have been labeled and dated. 3. During an initial tour on 6/29/15 at 11:15 a.m. with licensed vocational nurse M (LVN M), Resident 19 was observed on portable oxygen with undated oxygen tubing. During a concurrent interview, LVN M stated Resident 19's oxygen tubing was undated and the licensed nurse should have dated the oxygen tubing. 4. Review of Resident 28's physician orders, dated 12/12/14 and 6/29/15, indicated to change the syringe for the gastric tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) every day. During the initial tour with registered nurse P (RN P) on 6/29/15 at 11:45 a.m., Resident 28's syringe for her GT was dated 6/27/15. 5. During the initial tour on 6/29/15 at 11:45 a.m. and accompanied by RN P, Resident 29's syringe for her GT was dated 6/25/15. During a concurrent interview with RN P, she stated the staff was expected to change the syringe for the gastric tube everyday. She stated the syringes were usually changed during the afternoon shift. During an interview with the director of staff development (DSD) on 7/7/15 at 12:30 p.m., she stated the syringes for the residents with gastric tubes should be changed every 24 hours. 6. During an initial tour on 6/29/15 at 11:55 a.m. with LVN Q, Resident 32 had an undated nebulizer treatment machine with tubing. During a concurrent interview, LVN Q stated Resident 32's nebulizer tubing was not dated and she was not sure when it was changed. During an interview with the DON on 7/6/15 at 3 p.m., she stated the licensed nurse should have dated the oxygen and nebulizer tubing. A review of the facility's 7/21/14 policy, Respiratory Care Services, indicated the respiratory care practitioners and the licensed nurses should date and replace nasal cannulas, oxygen tubings and aerosol set-ups weekly and as needed. 7. During a lunch observation on 6/29/15 at 12:45 p.m., while wearing gloves certified nurse assistant O (CNA O) fed Resident 5 and touched the food while feeding the resident. CNA then changed his gloves, but did not wash his hands prior to putting on new gloves. During a concurrent interview, he stated he wore gloves when he feeds a resident and he changes them as needed. During another interview on 6/30/15 at 8 a.m., he stated he did not wash his hands prior to changing his gloves. During an interview with the DSD on 7/6/15 at 2:53 p.m., she stated the staff should wash their hands when they take off dirty gloves and put on new gloves. The facility's 12/2007 policy, Handwashing/Hand Hygiene, indicated employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water after removing gloves. 8. During an observation on 6/30/2015 at 11:50 a.m., CNA S carried food trays with one hand. The trays were raised up to the level of her shoulder and as a result the trays were observed touching her hair. Although the plates on the trays had lids, the lids were not securely placed on the plates. During an interview with RN T on 6/30/15 at 12:45 p.m., she stated CNA S should not have held the tray close to her hair because some of the lids were not securely placed on the plates. During an interview with the DSD on 7/7/15 at 2:53 p.m., she stated the CNAs should not carry the trays close to their hair. She stated the trays should be carried using their two hands and positioned in front of them. During an interview with CNA S on 7/8/15 at 8:25 a.m., she stated she should not have carried the trays close to her hair. She stated she should have carried the trays with her two hands in front of her at waist level. A review of the 2013 Food Code, indicated employees who handle food should effectively keep their hair off exposed food. 9. During an observation on 6/30/15 at 12:45 p.m., CNA S placed trays refused by residents inside the cart which stored other trays waiting to be served. During an interview with LVN G on 6/30/15 at 12:55 p.m., she stated the CNAs should not have placed the refused trays back inside the cart which contained other trays which were to be served. During an interview with the DSD on 7/1/15 at 8:20 a.m., she stated the CNAs were not supposed to put used trays with the clean trays. The facility's 2012 policy, Menus and Resident Services In-room Meal Service, indicated employees should return trays to the delivery cart after making certain all of the trays have been served before adding returned trays to the cart. Clean and dirty trays should not be mixed together on the same cart. 10. Resident 18's clinical record was reviewed. A methicillin-resistant staphylococcus aureus (MRSA, contagious and difficult to treat infection) screen done on 5/7/15 indicated the resident had MRSA in the wounds on his coccyx (tailbone) and left buttock. During an observation on 6/30/15 at 4:25 p.m., CNA V touched the resident's arm while wearing gloves but no gown. In a concurrent interview, he stated he should have worn a gown when he took Resident 18's vital signs (blood pressure, pulse, heart rate and temperature). He stated since he was just getting the vital signs, he thought he did not need to wear a gown. During an interview with RN X on 7/1/15 at 4:05 p.m., she stated Resident 18 was on contact precautions (everyone who enters the patient's room must wear a gown and gloves as the patient has a type of infection that can be transmitted if the person touches the infected person, contaminated surfaces or equipment near the infected individual) for the MRSA infection. During an interview with the DSD on 7/6/15 at 2:53 p.m., she stated the CNAs should wear gowns when taking the vital signs of residents with MRSA. 11. During an observation on 7/1/5 at 8:45 a.m., activity assistant BB (AA BB) changed a monthly activity calendar in each resident's room. She entered Resident Room F, which was an isolation room. When she entered the room she did not wear any personal protective equipment (PPE) except a facial mask. After AA BB exited the isolation room, she entered other residents' rooms and touched other residents' belongings while changing the activity calendars. She did not wash her hands during the room-to-room visits. During a concurrent interview, AA BB stated she should have worn PPE when she entered the isolation room and washed her hands when she left the isolation room. 12. During an observation on 7/1/15 at 9 a.m., HK Z was cleaning Resident Room F which was an isolation room. HK Z wore a gown and four times entered and exited Resident Room F while wearing the same gown to reach her housekeeping cart which was placed across the hallway. During a concurrent interview, HK Z stated she should not have left the resident's room wearing the gown. Review of the facility's 2001 policy, Isolation-Categories of Transmission-Based Precautions, revised 10/10, indicated to wear a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident's environment. Remove the gown and perform hand hygiene before leaving the resident's environment. 13. During an interview with HK S on 7/2/15 at 2:05 p.m., she demonstrated the preparation of the cleaning solutions. HK S stated she used a gray bucket to dilute the bleach in the water. She was unaware there was a measurement on the bucket and she filled the water up to a number 5, which was equivalent to 5 quarts (1.25 gallons). HK S stated she should have diluted 1 and 2/3 cups of bleach in 2 gallons of water. To clean the floors, HK S stated she used one ounce (oz) of the floor cleaner in 1.5 gallons of water. She stated she used an empty bottle of floor cleaner to measure 1.5 gallons of water. Review of the label on the bottle indicated the bottle contained one gallon of fluid. HK S stated she was unaware the bottle only contained one gallon. Review of the manufacturer's directions for the use of bleach (Classic Bleach) indicated to use 1 and 2/3 cups of bleach with 2 gallons of water. Review of the manufacturer's directions for the use of the floor cleaner (Bright Solutions Reflection Neutral Floor Cleaner) indicated to use 2 ounces of the floor cleaner per one gallon of water. 14. During an observation on 7/1/15 at 9:20 a.m., CNA CC washed her hands for three seconds with soap then rinsed her hands under running water. During a concurrent interview, she stated she should have scrubbed her hands with soap for ten to fifteen seconds. 15. During a dressing change observation of Resident 14's wound care on 7/1/15 at 11:30 a.m., RN FF did not wash her hands before, during or after the dressing change. While wearing glvoes, CNA GG grabbed Resident 14 for positioning while RN FF changed the dressing. After the dressing change, CNA GG left the resident's room wearing the same gloves, opened the utility room across the hallway while touching the handle of the door. CNA GG removed his gloves inside the utility room and washed his hands without using soap. During concurrent interviews with RN FF and CNA GG, RN FF stated she should have washed her hands before, during and after the dressing changes. CNA GG stated he should have removed his used gloves prior to leaving the resident's room and washed his hands with soap. Review of the facility's 2001 policy Dressings, revised 4/2007, indicated to wash hands thoroughly before and after dressing changes. 16. During an isolation room cleaning observation of Resident Room B on 7/3/15 at 2:20 p.m. with the DSD, on three occasions between glove changes, HK K was observed performed hand hygiene at the bathroom sink with soap and water for durations of less than ten to fifteen seconds. At 2:25 p.m., after HK K wiped down the bed frame of a resident occupied bed, she washed her hands for seven seconds before drying them with paper towels. At 2:35 p.m., after HK K cleaned an IV (intravenous) infusion pump and wiped the bathroom door, she washed her hands for nine seconds. At 2:50 p.m., after HK K cleaned the toilet and mopped the floor, she washed her hands for eight seconds. The DSD verified the duration of the handwashing observations. During an interview on 7/3/15 at 3:05 p.m., HK K stated she was supposed to wash her hands for fifteen to twenty seconds. 17. During an observation of handwashing on 7/2/15 at 10:30 a.m. in a resident room, CNA N used her hands to pick up from the floor a towel used to wipe a wet part of the floor. She rolled the towel and put it on the foot of a resident bed. She then left the room to get the Hoyer lift (a device used to lift and transfer a patient who is physically impaired from one area to another). No handwashing was observed. CNA N then left the resident room to get help from CNA U who was in another resident's room across the hallway. CNA U went to assist CNA N without washing his hands. During a concurrent interview with CNA N, she stated she put the dirty rolled towel on the foot of the bed because she planned to later put it in the dirty hamper. She also stated she forgot to wash her hands and acknowledged she should have washed her hands before and after providing resident care. In a concurrent interview with CNA U, he also acknowledged he should have washed his hands before and after providing resident care. 18. During a wound dressing change observation on 7/1/15 at 10 a.m., LVN G removed a soiled dressing and disposed of it. Using the same gloves, she cleaned the wound with normal saline. She then changed her gloves and applied medication and a new bandage. During a concurrent interview with LVN G, she stated she only used hand sanitizer when she changed her gloves during the dressing change. She also stated the use of hand sanitizer was an acceptable practice. During an interview with the DSD on 7/6/15 at 2:53 p.m., she stated the staff members should wash their hands after taking off dirty gloves and prior to putting on new gloves. Review of the facility's 2001 policy, Handwashing/Hand Hygiene, revised 12/2007, indicated employees must wash their hands for ten to fifteen seconds using antimicrobial or non-antimicrobial soap and water before and after direct contact with residents, after contact with non-intact skin and after removing gloves.

Based on interview and record review, the facility failed to ensure one of three sampled residents (2) maintained acceptable parameters of nutritional status such as body weight and protein level. Resident 2 lost 32 pounds (lbs.) in seven months, a 16% weight loss, when required adequate calorie levels were not provided. Resident 2's nutritional care plan was not updated and revised as the weight loss progressed. Findings: The health record indicated Resident 2 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, also known as resident assessment instrument (RAI)) indicated Resident 2's cognition was intact, and he was totally dependent on staff for all his activities of daily living. Resident 2 received his nutrition through a surgically inserted feeding tube (gastrostomy tube) which introduced feeding formula into his stomach. He also had the capacity to eat some pureed food. A lab result dated 7/14/11 indicated his [MEDICATION NAME] level was 2.9 gram per deciliter (g/dL; a unit of measurement) which was below the normal reference range of 3.4 - 5.0 g/dL. [MEDICATION NAME] is a form of protein in the body. Low [MEDICATION NAME] levels can suggest undernutrition (weight loss). Undernutrition (weight loss) may be due to insufficient intake, increased loss, or a condition that decreases the body's ability to digest and absorb nutrients from available food (labtestsonline.org). Registered dietitian C (RD C) documented in her nutritional care assessment dated [DATE] Resident 2's weight was 199 lbs. and height was 5 feet and 11 inches. RD C documented the estimated calorie needs for Resident 2 was 2250 - 2520 kilocalories (kcal) per day for weight maintenance. The feeding formula order at this time was Crucial at 85 cc (unit of measurement) per hour for 20 hours to provide 2550 kcal per day. A weight of 197 lbs. was recorded for Resident 2 on 8/3/11. On 8/28/11 Resident 2 went to the acute care hospital for six days. Resident 2 had been gone for six days and was readmitted to the facility on [DATE] weighing 186 lbs. On 9/5/11 registered dietitian B (RD B) documented in her nutritional care assessment Resident 2's estimated calorie needs was 2113 - 2535 kcal per day and he was on Crucial feeding formula at 70 cc per hour for 18 hours to provide 1890 kcal per day. RD B recommended the feeding time increased to 20 hours to provide 2100 kcal per day, which was followed to potentially result in weight gain. However, on 9/6/11 licensed nurse E (LN E) wrote in her nurse's note Resident 2 had a weight loss of 11 lbs. from 197 (8/3/11) to 186 (9/3/11) and the physician was informed of the weight loss. During an interview on 2/22/12 at 2:00 p.m. LN E stated there were no physician orders or interventions from any member of the interdisciplinary team (IDT) to avert further weight loss. On 9/23/11 RD C documented the current feeding formula was Crucial at 70 cc per hour for 20 hours to provide 2100 kcal per day. The care plan was not revised to include the increased feeding time. RD C also mentioned Resident 2 was on puree, nectar thick, no concentrated sweets snacks twice a day, which was not included in the care plan. RD C recommended a feeding formula change to DiabetiSource AC (brand name) at 90 cc per hour for 20 hours to provide 2160 kcal per day. This recommendation was not followed. On 9/28/11 RD C documented the current feeding formula was DiabetiSource AC at 70 cc per hour for 20 hours to provide 1680 kcal per day. RD C's 9/23/11 recommendation of increased feeding rate (90 cc per hour) was not followed. This new feeding order meant a decrease of 420 kcal per day from the 9/23/11 Crucial at 70 cc per hour for 20 hours (2100 kcal per day). On 10/3/11 Resident 2 weighed 184 lbs. On 10/30/11 RD B documented the current feeding formula was the same DiabetiSource AC at 70 cc per hour for 20 hours to provide 1680 kcal per day. RD B mentioned Resident 2 was on soft sandwich with nectar thick liquid for lunch only. The care plan was not revised to include this intervention. RD B also mentioned the 10/28/11 [MEDICATION NAME] blood level test result of 2.3 g/dL, considered below the normal reference range of 3.4 to 5.0 g/dL. The [MEDICATION NAME] level decreased from a prior (7/14/11) value of 2.9 g/dL. On 11/3/11 Resident 2 weighed 187 lbs. On 11/6/11 RD B documented the current feeding formula was the same DiabetiSource AC at 70 cc per hour for 20 hours to provide 1680 kcal per day. On 12/4/11 Resident 2 weighed 172 lbs. On 12/8/11 RD C documented the current feeding formula was the same DiabetiSource AC at 70 cc per hour for 20 hours to provide 1680 kcal per day. During an interview on 2/22/12 at 2:00 p.m. LN E stated Resident 2 lost 15 lbs. (from 187 (11/3/11) to 172 (12/4/11)). LN E stated she could not find documented evidence the physician was notified and there were no further physician orders or interventions from any of the IDT staff to avert further weight loss. On 1/1/12 Resident 2 weighed 170 lbs. On 1/19/12 RD C documented the current feeding formula was the same DiabetiSource AC at 70 cc per hour for 20 hours to provide 1680 kcal per day. RD C documented the 170 lbs. in January 2012 meant an 8% weight loss in 90 days and 15% weight loss in 180 days. RD C recommended DiabetiSource AC at 80 cc per hour for 20 hours to provide 1920 kcal per day. The facility followed the recommendation with an order dated 1/19/12. During a telephone interview on 2/14/12 at 10:50 a.m. RD C stated she and RD B were not facility employees but provided registered dietitian contract services until 1/31/12. RD C stated she and RD B could not comment on Resident 2's weight loss because she and RD B no longer provided registered dietitian services. During an interview on 2/14/12 at 2:45 p.m. the administrator (ADM) stated RD B and RD C no longer provided contract registered dietitian services as of 2/1/12 and registered dietitian D (RD D) started as the employee RD on 2/6/12. During an interview on 2/22/12 at 1:00 p.m. RD D stated that prior to the 1/19/12 feeding formula order (DiabetiSource AC at 80 cc per hour for 20 hours) the previous order (DiabetiSource AC at 70 cc per hour for 20 hours) only provided about 1680 kcal per day. The other nutritional interventions Pro-Source (protein supplement) one ounce twice a day through the feeding tube, which was not included in the care plan, soft sandwich with nectar thick liquid at lunch, and pureed snacks twice a day only contributed about 300 kcal per day. Resident 2 was receiving about 1980 kcal per day from all nutritional sources. RD D stated RD C's estimated calorie needs dated 7/15/11 (2250 - 2520 kcal per day) and RD B's estimated calorie needs dated 9/5/11 (2113 - 2535 kcal per day) was not being met with the 1980 kcal per day Resident 2 was receiving even with 100% intake of the oral feeding (sandwich and snacks/nectar thick liquids). RD D stated the 1/19/12 feeding formula order would provide 1920 kcal per day, the Pro-Source would add another 120 kcal, and the oral feeding would add about 180 kcal per day for a total of 2220 kcal per day, which was still less than the initial 7/15/11 estimated calorie needs of 2250 - 2520 kcal per day. RD D stated even the 1/19/12 feeding formula order was not enough to avert the weight loss. The health record indicated Resident 2 weighed 167 lbs. on 2/3/12, a loss of another 3 lbs. from 170 lbs. (1/1/12). RD D stated his analysis led him to his new estimated calorie needs of 2657 - 2884 kcal per day and a recommendation of DiabetiSource AC at 90 cc per hour for 20 hours to provide 2160 kcal per day which was ordered on [DATE]. This was RD C's 9/23/11 recommendation which was not followed at that time. This feeding formula plus the other nutrition sources (Pro-Source, sandwich, puree snacks/nectar thick liquids = 300 kcal) would potentially provide 2460 kcal per day, which was still below RD D's estimated calorie needs. The health record indicated Resident 2 weighed 153 lbs. on 2/20/12. The facility's policy/procedure, "Weight assessment and intervention" dated April 2007, indicated the nursing staff and the dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for its residents. The facility defined weight loss of more than 10% within six months as significant. Interdisciplinary team members should consider possible interventions relevant to their discipline. During a telephone interview on 2/24/12 at 11:15 a.m. the attending physician stated Resident 2 had [MEDICAL CONDITION] (swelling) when he was initially admitted . This could partially explain the weight loss from initial admission up to readmitted . The physician stated Resident 2's clinical picture had not significantly changed from the time of readmission. The physician stated Resident 2 had no liver or kidney disorder that would explain the weight loss, and was receiving the same feeding formula.

Based on record review and staff interviews the facility failed to provide sufficient fluid to maintain proper hydration and prevent dehydration in one of 24 sampled residents (Resident 14) when: a. the facility failed to implement, in a timely manner, the registered dietitian's (RD's) recommendations to increase the resident's fluid intake on three occasions; b. the facility failed to inform the physician of the resident's severe weight loss; c. and the facility failed to follow a physician's orders [REDACTED]. This failure caused Resident 14 to experience significant weight loss from fluid loss and had to be hospitalized twice with acute [MEDICAL CONDITION] (kidneys suddenly stop working) and required IV (intravenous) hydration. It also had the potential to result in further negative effects of dehydration, up to and including death. Findings: The medical record for Resident 14 was reviewed on 1/12/11 to 1/14/11. The resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the weight record for Resident 14 showed her weight on admission was 172 pounds. Ten days later on 7/19/10 she weighed 173 pounds (plus one pound). On 7/26/10, she weighed 166 pounds (minus 7 pounds in 7 days). On 8/2/10, she again weighed 166 pounds. A review of the Nutritional Care assessment dated [DATE], completed by the RD, stated the resident was also admitted with a [DIAGNOSES REDACTED]. The estimated nutrition needs included fluid needs estimated to be 2346 - 2737 milliliters (ml) daily with the rationale for the increased needs stated as "Diagnosis: [REDACTED]. The assessment further indicated the nutritional needs were not being met with the tube feeding ordered at the time of the assessment. The tube feeding and water flushes ordered provided a total free water of 1374 ml daily, 972 - 1363 ml less than the estimated needs. The assessment listed a plan to increase the tube feeding and water flushes so that the resident would receive a total of 2259 ml of free water daily. The plan also included water flushes of 50 ml before and after medications were given. Review of the physician's orders [REDACTED]. The orders showed an order dated 7/14/11 for [MEDICATION NAME] (an antibiotic) for a urinary tract infection (UTI - which can develop with inadequate fluid intake). A Dietary Note dated 7/28/10 stated, "RD recommendations (from the assessment) were not communicated/honored. Current Tube Feeding...providing...1674 ml of free water...Weight loss secondary to tube feeding not meeting (resident's) enteral (tube feeding) nutrition needs." At this point, the tube feeding and water flush order had been providing between 672 and 1063 ml of fluid daily less than the original estimate of fluid needs for 19 days. Again the plan listed was to increase the tube feeding and the water flushes to provide a total of 2127 ml of free water daily. The physician's orders [REDACTED]. The results of lab work from blood drawn on 8/1/10 showed that Resident 14's urea nitrogen (BUN - a kidney function test) was 57 (normal values were 5 - 26) and creatinine (also a kidney function test) was 1.24 (normal values were 0.44 - 1.10). It also showed that the BUN to creatinine ratio was 46 (normal was 7 - 25). A lack of adequate hydration can cause an elevated BUN to creatinine ratio. A review of the Clinical Record History and Physical from the acute care hospital dated 8/6/10, revealed that Resident 14 was admitted to the hospital with [REDACTED]. It further stated that the BUN to creatinine ratio was elevated with a plan for IVF (intravenous fluids) for dehydration. The BUN was now 87 (normal 5 - 26) and the creatinine was 2.5 (normal 0.44 - 1.10). A further review of Resident 14's medical record indicated that she returned to the facility from the hospital on [DATE]. Review of the "Nutrition Care Assessment" completed by the RD on 8/20/10 indicated that the resident now weighed 160 pounds (12 pounds less than her admit weight on 7/9/10). The estimated nutrition needs included fluid needs at that time estimated to be 2200 - 2500 ml daily with the rationale for the increased needs again stated as "Diagnosis: [REDACTED]. The assessment further stated the resident's nutritional needs were being met with the current tube feeding and water flush orders which provided "about 2400 ml per 24 hours." The recommendations of the RD assessment was to continue the current feeding and water flushes and monitor weekly weights x (times) 4. A review of the "Weight Progress Record" showed weights on 8/21/10 of 160 pounds, on 9/4/10 of 162.6 pounds, on 9/11/10 of 163 pounds and on 9/18/10 of 163.6 pounds. Further review of the "Dietary Notes" dated 9/7/10, showed the RD noted a weight gain of 2.6 pounds in 2 - 3 weeks and a concurrent increase in blood glucose levels. The RD recommended to decrease the tube feeding for weight management (even though the current weight represented a 19.4 pound weight loss from admission 2 months earlier). Since a decrease in feeding also would decrease the amount of water provided daily, the RD also recommended to increase the water flushes from 250 ml three times a day to 250 ml six times a day to provide 2682 ml of free water daily. Without the increase in water flushes the tube feeding and water flushes would provide 1932 ml of free water daily. A review of the physician's orders [REDACTED]. A review of the facility's policy "Enteral Nutrition" revised April 2007, stated, "Fluids to be provided (beyond free fluid in the product) will be calculated by the Dietitian and referred to the physician for an order." Further review of the Weight Record for Resident 14 showed weights on 10/5/10 of 164 pounds, on 11/9/10 of 160 pounds. No weight for December 2010 was recorded on this form. A review of the facility's Monthly Weights log, dated 12/8/10 showed a weight for Resident 14 of 151 pounds and a reweight of 151.2 pounds. The 12/8/10 weight represented a 9 pound or 5.6% weight loss in one month and a 21 pound or 12.2% weight loss in 5 months. There was no documentation the physician had been informed of the weight loss. A review of the facility's policy, "Weight Assessment and Intervention" revised April 2007, stated, "Any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation. If weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will respond within 24 hours of receipt of written notification." It further states, "Significant Weight Changes are defined as: more or less than 5% within 30 days; and more or less than 10% within 6 months." A review of the the facility's Clinical Protocol, "Nutrition (Impaired)/Unplanned Weight Loss" revised April 2007, stated, "The staff will report to the physician significant weight gains or losses..." During an interview with the DON on 1/12/11 at 11:00 a.m., she confirmed that the physician was not informed of Resident 14's 9 pound weight loss in one month. She further could not explain why there had been no evaluation of the significant weight loss from 12/8/10 until 12/20/10. A review of the dietary notes showed no dietary follow-up note between 11/9/10 and 12/20/10, 12 days after Resident 14 showed a significant weight loss. On 12/20/10, the RD wrote the resident was receiving about 1900 ml (of free water) per day from the tube feeding and water flushes She further noted the resident's lab values showed an increase in the BUN to creatinine ratio. The RD recommended to increase the tube feeding to provide 2100 ml of water per day. During an interview with the RD on 1/12/11 at 10:30 a.m., she was unable to state why there had been a delay of 12 days from when the facility knew about the 9 pound weight loss and when she had evaluated the resident. She further confirmed that at least part of the 9 pound weight loss was likely related to fluid loss since the resident was on a tube feeding which provided consistent nutrition daily. She confirmed that when the tube feeding was decreased on 9/7/10, the water flushes were not increased. Therefore, the resident was not getting the increased amount of fluids that the nutritional assessment stated she needed because she had a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. They further showed there was an order for [REDACTED]. The results of lab work from blood drawn on 12/13/10 showed that Resident 14's urea nitrogen (or BUN) was 21 (normal values were 5 - 26) and creatinine was 0.77 (normal values were 0.44 - 1.10). It also showed that the BUN to creatinine ratio was 27 (normal was 7 - 25). A review of the acute hospital's "History and Physical" for Resident 14, dated 12/23/10, showed that the resident's BUN was now 88 and her creatinine was 4.8. Under "Assessment and Plan" the physician stated, "Acute [MEDICAL CONDITION] and [MEDICAL CONDITION] (elevated potassium level), could be due to dehydration [MEDICAL CONDITION]. We will give IV fluids." Resident 14 was readmitted back to the facility on [DATE] with the same tube feeding and water flush orders that were ordered before she left on 12/23/10. The RD recommendations from 12/20/10 were still not carried out. Review of the RD note dated 1/3/11 stated that, "Resident (was) readmitted from acute (hospital)...Admit weight 170 pounds; weight gain of 19 pounds from last month's weight probably related to IV therapy from the hospital and [MEDICAL CONDITION] (swelling cause by fluid in the body's tissue)." It further stated, "Last month's recommendations not carried out, will re-recommend....also recommend weekly weights." A review of the physician's orders [REDACTED]. A review of the resident's medical record showed that no weekly weights were recorded from 1/3/11 until 1/14/11. During an interview with RNA 1 on 1/12/11 at 4:30 p.m., he stated it was the standard of practice for the facility that orders for weekly weights were communicated to the RNAs who weigh the residents. He further stated that he did not know about the physician order [REDACTED]. No weekly weight had been done.