Every finding on record at Aegis Health and Rehabilitation

Based on interview and record review, the facility failed to follow the facility's policy and acceptable standards of practice when staff failed to accurately complete a post (after) fall observation report for 72 hours by not obtaining current vital signs for two residents sampled (Resident #1 and #3) and failed to complete post fall observations for 72 hours for one resident (Resident #2). The facility failed to notify the physician and emergency contact when one resident (Resident #1) had a fall. The facility failed to update the residents' care plans timely after falls for two residents (Resident #1 and #3) and failed to update the care plan for one resident (Resident #2). The facility failed to document Resident #2 had a fall in the nurse progress notes. The sample was 3. The census was 62.Review of the facility's Incident and Accident policy, revised 9/1/22, showed:-Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident;-Definitions: -Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident; -An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member;-Policy Explanation: The purpose of incident reporting can include: -Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care; -Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences; -Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements; -Meeting regulatory requirements for analysis and reporting of incidents and accidents;-Compliance Guidelines: -1. Incident/accident reports are part of the facility's performance improvement process and are confidential quality assurance information; -2. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root causes; -5. The following incidents/accidents require an incident/accident report but are not limited to: -Falls; -Observed accidents/incidents; -6. In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm; -7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions; -8. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events; -9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury; -10. In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner; -11. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital; -12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information; -13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions; -15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing (DON) and/or Administrator. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/28/25, showed:-Cognitively intact;-Always continent of bowel and bladder;-Falls since admission/entry or reentry or the prior assessment, No;-Diagnoses included inflammatory bowel disease, diabetes, malnutrition, syncope (temporary loss of consciousness) and collapse. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident had an actual fall, date initiated 8/14/25;-Goal: The resident will resume usual activities without further incident, date initiated 8/14/25;-Interventions: -If fall is unwitnessed or Resident hits head during fall: begin Neuro-checks x per facility protocol, date initiated 8/14/25; -On 8/5/25 resident had an unwitnessed fall in room. Encourage resident to use call light and call for assistance for transfer assist; date initiated 8/14/25; -For no apparent acute injury, determine and address causative factors of the fall, date initiated 8/14/25. Review of the risk management incident report (not part of the medical record) dated 8/5/25 at 5:45 P.M., showed:-Nursing description: Unwitnessed, resident reported fall;-Resident description: Resident reports falling in her room while trying to transfer to her wheelchair and got herself up and back into her wheelchair. Resident rolled up to nurses station to report fall. Resident reports some pain in right hip;-Immediate action taken: -Description: Nurse Practitioner (NP) notified. New order for x ray; -Resident taken to hospital: No;-Injury type: No injuries observed at time of incident;-Level of consciousness: Alert and Oriented times (x) 4 (person, place, time and situation);-Level of pain: No documentation;-Predisposing environmental factors: Clutter;-People notified: Physician on 8/5/25 at 5:55 P.M., DON on 8/5/25 at 5:55 P.M.;-Notes: -On 8/8/25, reviewed resident's fall documentation, resident reported to staff that he/she fell in his/her room and got himself/herself up. Resident complained of hip pain. Xray done: No fracture noted. Intervention: Resident reminded to call for assistance if she is feeling weak or light headed prior to attempting to ambulate. Review of the resident's progress notes, showed no nursing progress notes the resident had a fall on 8/5/25. Review of the resident's pain evaluation, showed:-Effective date: 8/5/25 at 8:00 P.M.;-Should a pain interview be conducted: Yes;-Ask resident: Have you had pain or hurting at any time in the last 5 days?: Yes;-Ask resident: How much of the time have you experienced pain or hurting over the last 5 days?: Almost constantly;-Ask resident: Over the past 5 days, has pain made it hard for you to sleep at night?: No;-Ask resident: Over the past 5 days, have you limited your day-to-day activities because of pain?: No;-Most Recent Pain Level (pain scale 0 - 10, 0 = No pain, 1 - 3 mild pain, 4 - 7 moderate pain, 8 - 9 is severe pain, 10 = worst pain possible): Pain level: Zero, Pain scale: Numerical, Date: 8/5/25 at 8:39 A.M.;-Frequency with which resident complains or shows evidence of pain or possible pain: Indicators of pain daily;-Received as needed (PRN) pain medications? Yes;-Describe administration patterns, any side effects and effectiveness: Hydrocodone (pain medication that treats moderate to severe pain);-Signed date: 8/13/25. Review of the resident's post fall observation, showed:-Effective date: 8/6/25 at 2:54 A.M.;-Vital Signs: -Temperature (T, normal 98.6 degrees Fahrenheit (F)) 97.7 F, date 7/8/25 at 10:09 A.M.; -Pulse, (P, heart beats per minute (BPM), normal range 60 - 100) 78, date 7/8/25 at 10:09 A.M.; -Respiratory rate (R, breaths per minute, normal range is 12-18) 16, date 7/8/25 at 10:09 A.M.; -Most recent blood pressure, (BP, normal 120/80) 82/58, 7/24/25 at 5:29 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 3; -Date: 8/6/25 at 12:21 A.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No changes in pain reported;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Additional Comments/Notes: Additional Comments or notes: Bruising to right thigh;-Date signed: 8/9/25;-Vital signs documented T, P, R, and BP were not for the current day or shift. Review of the resident's post fall observation, showed:-Effective date: 8/6/25 at 10:56 A.M.;-Vital Signs: -T, 97.7 degrees F, date 7/8/25 at 10:09 A.M.; -P, 78, date 7/8/25 at 10:09 A.M.; -R, 16, date 7/8/25 at 10:09 A.M.; -Most recent BP 85/58, 7/24/25 at 5:29 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 0, Date: 8/6/25 at 9:17 A.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No changes in pain reported;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs documented T, P, R, and BP were not for the current day or shift. Review of the resident's progress notes, showed:-Physician Assistant (PA) note on 8/6/25 at 1:11 P.M., no acute fractures. The mentioned pubic ramus (forms the lower and anterior (front) part of each side of the hip bone) fracture has been noted on prior imaging in 2023, so this is not a new finding;-PA visit note on 8/6/25 at 4:27 P.M., Resident fell yesterday. Resident said that he/she was sitting in bed when he/she became dizzy and lightheaded and he/she ended up on the floor. He/She believes this may be from low blood pressure. X-ray of pelvis and right hip was negative for acute fracture or dislocation. There was mention of age indeterminate (unknown) pubic ramus fracture. Records show prior history of this; therefore this is not a new fracture. Resident denies pain in hip/pelvis today. Review of the resident's post fall observation, showed:-Effective date: 8/6/25 at 6:57 P.M.;-Vital Signs: -T, 97.7 F, date 7/8/25 at 10:09 A.M.; -P, 78, date 7/8/25 at 10:09 A.M.; -R, 16, date 7/8/25 at 10:09 A.M.; -Most recent Blood pressure, BP 85/58, 7/24/25 at 5:29 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 0, Date: 8/6/25 at 9:17 A.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: Blank;-If resident has pain, what is the current pain management regimen? No changes in pain reported;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs documented T, P, R, and BP were not for the current day or shift. Review of the resident's post fall observation, showed:-Effective date: 8/7/25 at 2:58 A.M.;-Vital Signs: -T, 97.7 degrees F, date 7/8/25 at 10:09 A.M.; -P, 78, date 7/8/25 at 10:09 A.M.; -R, 16, date 7/8/25 at 10:09 A.M.; -Most recent BP 85/58, 7/24/25 at 5:29 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 0, Date: 8/6/25 at 7:43 P.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No changes in pain reported;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs documented T, P, R, BP and pain were not for the current day or shift. Review of the resident's post fall observation, showed:-Effective date: 8/8/25 at 11:19 A.M.;-Vital Signs: -T, 97.7 F, date 7/8/25 at 10:09 A.M.; -P, 78, date 7/8/25 at 10:09 A.M.; -R, 16, date 7/8/25 at 10:09 A.M.; -Most recent BP 85/58, 7/24/25 at 5:29 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 2, Date: 8/8/25 at 9:10 A.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No changes in pain reported;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs that were documented T, P, R, and BP were not for the current day or shift. Review of the resident's medical record, showed no neuro checks completed for fall on 8/5/25 (unwitnessed fall). 2. Review of Resident #1's MDS, dated [DATE], showed:-Cognitively intact;-Frequently incontinent of bowel and bladder;-Falls since admission/entry or reentry or the prior assessment, No;-Diagnoses included diabetes, malnutrition, anxiety, depression, cognitive communication deficit and need for assistance with personal care. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident is at risk for falls, revised 5/8/25;-Goal: Resident will be free of falls through the review date, revised 5/28/25;-Interventions: -Anticipate and meet the resident's needs, date Initiated 4/11/24; -Be sure the resident's call light is within reach and encourage the resident to use itfor assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 4/11/24; -The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide rails as ordered, handrails on walls, personal items within reach, revised 5/7/25; -No interventions listed for fall on 8/15/25. Review of the resident's progress notes showed:-On 8/15/25 at 8:39 P.M., Resident stated that he/she was trying to put himself/herself in bed from his/her wheelchair on his/her own, but with Certified Nurse Aide (CNA) staff as a stand by assist (SBA, the presence of another person within arm's reach required to prevent injury) as the resident attempted to transfer himself/herself CNA noticed the resident was struggling, so the CNA grabbed resident and guided him/her to the floor preventing a fall. The nurse was called in after episode was over and resident stated that CNA helped him/her to regain his/her balance by guiding him/her to the floor. The nurse got resident in bed with no other issues to report;-No notifications to the physician or emergency contact documented. Review of the resident's medical record, showed:-No pain evaluation completed;-Post fall observations completed for the 72 hours after the fall. During an interview on 9/16/25 at 8:22 A.M., the Administrator said if a resident lost his/her balance and needed to be lowered to the floor by a CNA, that would be considered a fall. He said if something happened that caused the resident to lose balance, he would want that documented and followed up on. He said the care plan may need to be updated and the resident may need to be evaluated by therapy. Interventions need to be looked at to make sure it doesn't happen again. During an interview on 9/16/25 at 11:30 A.M., the Regional Nurse Consultant (RNC) said a fall is considered an unintentional change in plane. She said if a resident loses his/her balance during a transfer and the CNA has to lower the resident to the floor, that is considered a fall. 3. Review of Resident #3's MDS, dated [DATE], showed:-Cognitively intact;-Occasionally incontinent bladder;-Frequently incontinent of bowel;-Falls since admission/entry or reentry or the prior assessment, No;-Diagnoses included high blood pressure, diabetes, depression, muscle weakness and need for assistance with personal care. Review of the resident's care plan, in use during the survey, showed:-Focus: Resident is at risk for falls, revised 5/28/25;-Goal: Resident will have reduced risk of falls and falls with major injury through the review date, revised 5/28/25;-Interventions: -Dycem (brand of non-slip material used to enhance grip and prevent sliding) to wheelchair, date initiated 1/24/25; -Anticipate and meet the resident's needs, date Initiated: 1/24/25; -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, date initiated 1/24/25; - Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, date initiated 1/24/25;-Focus: Resident had an actual fall with minor injury, date initiated 4/27/25;-Goal: Resident will resume usual activities without further incident through the review date, revision date 5/28/25;-Interventions: -If fall is unwitnessed or Resident hits head during fall: begin Neuro-checks per facility protocol, revision 4/28/25; -Reeducate resident in wheelchair positioning for safety, date initiated 4/27/25; -Check range of motion per facility protocol and PRN, revision 4/28/25; -Monitor/document /report PRN for 72 hours to physician for signs and symptoms of pain, bruises, change in mental status, any new onset: confusion, sleepiness, inability to maintain posture, agitation, date initiated 4/27/25; -On 8/3/25, Resident was in electric wheelchair outside leaning over to pick up cell phone from ground, minor injury. Advised resident to ask for help even when sitting outside, date initiated: 8/22/25;-Intervention for fall on 8/3/25 not implemented timely. Review of the risk management incident report (not part of the medical record), dated 8/3/25 at 3:10 P.M., showed:Incident description: Resident checked out at the front desk to go outside at 2:20 P.M. Resident was told to stay under the awning by this nurse. Vehicle was emitting exhaust fumes while the resident was outside. The resident stated he/she was going across to the sidewalk because of the exhaust fumes. Resident was checked on by staff throughout his/her break outside. Resident dropped his/her cell phone on the concrete. Resident bent over to pick up his/her cell phone, lost his/her balance and fell face forward out of the wheelchair onto the concrete; witnessed fall (by another resident). Staff responded immediately. Resident was found face down on the concrete with his/her right foot underneath his/her wheelchair. Staff manually lifted the chair off the resident's leg. Resident was rolled supine (lying on back) while supporting c-spine (the top seven vertebrae (C1-C7) located in your neck, just below your skull). Resident insisted on sitting up right, resident was alert and oriented (A&O) times (x) 4 (Level of awareness of (1) self, (2) place, (3) time, and (4) situation. The higher the number, the better oriented a person is considered. Healthcare providers score a person's orientation on a scale of 1 to 4.) baseline. 911 was called and Emergency Medical Services (EMS) was dispatched. Staff remained at resident's side until EMS arrived. Resident was found to have a laceration to the left eyelid and an abrasion to the left forehead, and a bump on the right side of his/her forehead/hairline that measured approximately 2 inches ( ) by 2, from the fall. EMS transported the resident to the hospital emergency room. Paperwork provided, DON, PA, and Administrator made aware of fall and resident being sent to hospital. Resident stated, I bent over to pick up my cell phone and fell face first out of my chair and hit the concrete.-Was this incident witnessed: Yes;-Immediate action taken: Resident transferred to hospital by EMS;-Resident taken to hospital: Yes;-Injury observed at time of incident: -Abrasion to top of scalp; -Laceration to top of scalp; -Other: Top of scalp;-Level of pain: 7;-Level of consciousness: No change from baseline;-Mobility: Wheelchair bound;-Mental status: Orientated to time, place, person, and situation;-Injury report post incident: No injuries observed post incident;-Predisposing environmental factors: Other (Describe) blank;-Predisposing physiological factors: None;-Predisposing situation factors: None;-Other information: Outside sidewalk;-Statements: No statements found;-People notified: Emergency contact #3, PA and DON;-Notes: On 8/8/25 fall documentation reviewed, resident was outside in his/her electric wheelchair when he/she dropped his/her phone and attempted to pick it up. Resident leaned forward and his/her wheelchair flipped over on him/her. Resident sustained bruising to his/her face and a laceration to his/her left eyelid. Intervention: Resident instructed to notify staff for assistance when he/she drops something on the floor due to the risk of this occurring again. Review of the resident's progress notes, dated 8/3/25 at 3:47 P.M., showed the nurses note: resident fell outside and was lying face down on concrete. EMS arrived and transported resident to hospital for evaluation and treatment. Review of the resident's post fall observation, showed:-Effective date: 8/3/25 at 4:46 P.M.;-Vital Signs: -T, 97.6 F, date 8/1/25 at 9:22 A.M.; -P, 66, date 8/3/25 at 8:24 A.M.; -R, 20, date 8/1/25 at 8:27 A.M.; -Most recent BP 140/82, 8/3/25 at 8:24 P.M.;-Pain:-Most Recent Pain Level: -Pain level: 7, Date: 8/3/25 at 4:25 P.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: Yes;-If yes, describe area of pain: -Top of scalp 2 x 2 bump on right side of forehead/hairline; -Top of scalp abrasion to left forehead; -Top of scalp laceration to left eyelid;-If resident has pain, what is the current pain management regimen? Morphine (Pain medication used to treat moderate to severe pain) extended release (ER) 10 milligrams (mg);-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Additional comments or notes: Resident sent to hospital for evaluation and treatment;-Date signed: 8/3/25;-Vital signs that were documented T, and R were not for the current day or shift;-Vital signs that were documented P and BP were taken prior to the fall. Review of the resident's progress notes, showed:-On 8/3/25 at 5:30 P.M., ER nurse called report on resident. Resident will be returning to facility. Computed tomography (CT, imaging that uses x-ray techniques to create detailed images of the body) was negative and resident had a hematoma (pool of mostly clotted blood that forms usually caused by a broken blood vessel that was damaged by surgery or an injury) on right side of his/her forehead. Resident may have ice packs as needed for pain and swelling, residents left eyelid has been sutured up with dissolvable sutures, keep area clean and dry. Monitor hematoma. DON aware of resident's return, emergency contacts called and made aware;-On 8/4/25 at 12:26 P.M., PA noted: Fall on 8/3/25;-Event: Patient (wheelchair user) dropped cell phone, bent over to retrieve it, lost balance, and fell face-forward out of chair onto concrete (witnessed);-Injuries: Laceration to left eyelid (sutured with dissolvable sutures) Abrasion to left forehead 2 x 2 inch hematoma on right forehead/hairline;-Immediate Care: C-spine supported, EMS called, transported to emergency room;-CT head: Negative; laceration repair;-Returned to facility; ice packs for pain/swelling, wound care instructions;-Current Orders: Monitor hematoma. Keep left eyelid wound clean/dry. Review of the resident's post fall observation, showed:-Effective date: 8/4/25 at 1:06 P.M.;-Vital Signs: -T, 97.6 F, date 8/1/25 at 9:22 A.M.; -P, 66, date 8/3/25 at 8:24 A.M.; -R, 20, date 8/1/25 at 8:27 A.M.; -Most recent BP 146/82, 8/4/25 at 10:16 A.M.;-Pain:-Most Recent Pain Level: -Pain level: 5, Date: 8/4/25 at 1:06 P.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? Morphine routine;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? No;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/4/25;-Vital signs that were documented T, P and R were not for the current day or shift. Review of the resident's post fall observation, showed:-Effective date: 8/4/25 at 9:10 P.M.;-Vital Signs: -T, 97.6 F, date 8/1/25 at 9:22 A.M.; -P, 66, date 8/3/25 at 8:24 A.M.; -R, 20, date 8/1/25 at 8:27 A.M.; -Most recent Blood pressure, BP 153/96, 8/8/25 at 7:59 A.M.;-Pain:-Most Recent Pain Level: -Pain level: 8, Date: 8/4/25 at 5:00 P.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No change in pain;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs that were documented T, P and R were not for the current day or shift;-Vital signs that were documented pain was from previous shift not current shift;-Vital signs that were documented BP was listed as a future date and time from the date the assessment was completed. Review of the resident's post fall observation, showed:-Effective date: 8/5/25 at 5:12 A.M.;-Vital Signs: -T, 97.6 F, date 8/1/25 at 9:22 A.M.; -P, 66, date 8/3/25 at 8:24 A.M.; -R, 20, date 8/1/25 at 8:27 A.M.; -Most recent BP 153/96, 8/8/25 at 7:59 A.M.;-Pain:-Most Recent Pain Level: -Pain level: 8, Date: 8/4/25 at 5:00 P.M.;-Does the resident or caregiver report a change in pain level (new or worsened)?: No;-If resident has pain, what is the current pain management regimen? No change in pain;-Post fall observation:-Injury: Has there been any reports of swelling, bruising or other signs/symptoms of injury since the event? Yes;-Cognition: Does the resident or caregiver report a change in mental status or cognition? No;-Function: Does the resident or caregiver report a change in ADL ability or mobility? No;-Orders: Has there been any change in physician orders related to this event? No;-Sleep Patterns: Has the resident or care giver reported any change in sleep pattern such as inability to stay asleep or frequent waking? No;-Date signed: 8/9/25;-Vital signs that were documented T, P, R and pain were not for the current day or shift;-Vital signs that were documented BP was listed as a future date and time from the date the assessment was completed. During an interview on 9/16/25 at 10:01 A.M., the resident said he/she had a fall on 8/3/25 outside. The resident said he/she dropped his/her cell phone on the ground and when he/she bent over to pick up the cell phone, the sleeve of his/her shirt caught the controller for his/her electric wheelchair, and he/she had not powered down the chair. The sleeve caused the wheelchair to go backwards, and he/she fell forward. The resident said staff called 911 and he/she went to the hospital. The resident said after he/she returned to the facility the same day, the staff did not come in and take his/her vital signs to monitor him/her. The resident said the staff did not monitor his/her vital signs for three days after the fall. 4. During an interview on 9/16/25 at 8:22 A.M., the Administrator said when a resident falls, he expected the nurse to assess the resident. He expected the nurse to complete a risk management incident report, complete the post fall assessment for 72 hours. He preferred that falls were documented in a nurses note but if a nurses note was not completed regarding the fall, the information would be in risk management. Neuros are to be completed if a resident has an unwitnessed fall or if the resident hit their head. During an interview on 9/16/25 at 11:13 A.M., the RNC said when a resident has a fall, she expected the nurse to assess the resident, complete a risk management incident report, make notifications to the physician, and family, transcribe and new orders the physician may give. If there is not a nurse progress note regarding the fall, the information can be found in the risk management incident report. After a fall

Based on interview and record review, the facility failed to offer and vaccinate, as desired, eligible residents with the pneumococcal (pneumonia) and influenza (flu) vaccine for 4 out of 4 residents sampled for immunizations (Residents #40, #32, #21 and #44). The census was 60. Review of the facility's influenza vaccination policy, showed: -Policy: minimize the risk of acquiring, transmitting or experiencing complications for influenza by offering residents annual immunization against influenza; -Explanation and guidelines: -Influenza vaccinations will be routinely offered annually from October through March unless the vaccination is contraindicated or the immunization is refused; -Additionally, influenza vaccination will be offered to residents upon availability of the seasonal vaccine until influenza is no longer circulating in the facility's geographic area; -Following assessment for potential medical contraindication, influenza vaccinations may be administered in accordance with physician-approved standing orders; -Prior to administration of the influenza vaccination, the person receiving the immunization or his/her representative will be provided a copy of the Center for Disease Control (CDC) current vaccine information statement relative to the vaccination; -Individuals receiving the influenza vaccination, or the legal representative will be required to sign a consent form prior to the administration of the vaccine. The completed, signed and dated record will be filed in the individual's medical record; -The medical record will include documentation that the resident and/or representative was provided information regarding the benefits and potential side effects of the immunization, and that the resident received or did not receive the immunization due to contraindication of refusal. Review of the facility's Pneumococcal Vaccine policy, showed: -Policy: the facility will offer immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations; -Explanation and guidelines: -Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization will be acceptable; -Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident had been immunized; -Prior to offering the immunization, each resident or the representative will receive education regarding the benefits and potential side effects of the immunization. The individual receiving the immunization or the representative will be provided a copy of the CDC's current vaccine information statement; -The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the medical record; -Usually only one pneumococcal vaccination is needed in a lifetime. However, based on an assessment and practitioner recommendations, additional vaccines maybe provided; -The resident's medical record shall include documentation that indicates at the minimum, the following: -The resident/representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; -The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal. 1. Review of Resident #40's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/23/25, showed: -Cognitively intact; -Diagnoses included diabetes and high blood pressure; -Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state the reason: not offered; -Is the resident's Pneumococcal vaccine up to date: no; -If Pneumococcal vaccine not received, state reason: not offered. Review of the medical record, showed no documented influenza or pneumococcal vaccination administration or declination. During an interview on 5/30/25 at 10:15 A.M., the resident said he/she would like to receive the flu and pneumococcal vaccine. He/She had not been offered the vaccinations. 2. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included anemia, malnutrition and lung disease; -Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state the reason: not offered; -Is the resident's Pneumococcal vaccine up to date: no; -If Pneumococcal vaccine not received, state reason: not offered. Review of the medical record, showed no documented influenza or pneumococcal vaccination administration or declination. During an interview on 5/29/25 at 11:09 A.M., the resident said he/she was not offered the flu or the pneumococcal vaccines. He/She would like to receive the vaccinations. 3. Review of Resident #21's quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included anemia, malnutrition and kidney failure; -Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state the reason: not offered; -Is the resident's Pneumococcal vaccine up to date: no; -If Pneumococcal vaccine not received, state reason: not offered. Review of the medical record, showed no documented influenza or pneumococcal vaccination administration or declination. 4. Review of Resident #44's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included kidney failure, stroke, difficulty speaking, and lung disease; -Did the resident receive the influenza vaccine in the facility for this year's influenza season: no; -If influenza vaccine not received, state the reason: not offered; -Is the resident's Pneumococcal vaccine up to date: no; -If Pneumococcal vaccine not received, state reason: not offered. Review of the medical record, showed no documented influenza or pneumococcal vaccination administration or declination. 5. During an interview on 5/29/25 at 9:22 A.M., the Director of Nursing said she began to offer influenza and pneumococcal vaccinations to residents in September and October 2024. She was unable to offer or administer the vaccinations to residents due to facility duties. No consents or vaccination declinations had been scanned into resident medical records.

Based on observation, interview and record review, the facility staff used the incorrect insulin pen during the administration (Residents #45 and #13). Staff failed to apply personal protective equipment (PPE, equipment worn to protect individuals from various hazards) in rooms identified as requiring enhanced barrier precautions (EBP) (Residents #33 and #32). In addition, staff failed to ensure appropriate hand hygiene and glove changes during perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) (Resident #21). The sample was 14. The census was 60. Review of the facility's infection prevention and control program, showed: -Policy: to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -Explanation and guidelines: -Staff are responsible for following all policies and procedures; -All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing care services; -All staff shall use personal protective equipment (PPE) according to established facility policies; -Staff shall adhere to safe injection and medication administration practices; -Isolation protocol (TBP, transmission-based precautions): -A resident with an infection of communicable disease shall be placed on TBP as recommended by current Centers for Disease Control and Prevention (CDC) guidelines. 1. Review of Resident #45's medical record, showed: -Diagnoses included diabetes and cognitive communications deficit (inability to effectively communicate); -An order dated 4/7/25, for Humalog (insulin lispro, short acting insulin) administer before meals and at bedtime for glucose (blood sugar) control. For blood sugars between 150-200, administer 2 units (U). Review of Resident #13 medical record, showed: -Diagnoses included diabetes; -An order dated 2/17/25, for Novolog (insulin aspart, short acting insulin) subcutaneously (under the skin) before meals. Observation on 5/28/25 at 11:22 A.M., showed Licensed Practical Nurse (LPN) A performed a blood sugar check on Resident #45 and obtained a result of 188. LPN A obtained a Novolog insulin pen labeled with Resident #13's name and dialed the prefilled insulin pen to 2 units of Novolog. LPN A used Resident #13's insulin pen and administered the insulin to Resident #45. During an interview on 5/28/25 at 11:22 A.M., LPN A said he/she misread the names on the container and insulin pen. The residents had the identical alphabet letters for their first and last names. He/She admitted to failing to double check the name on the insulin pen prior to administering the medication. 2. Review of Residents #33's medical record, showed an order, dated 11/06/24, for Enhance Barrier Precaution (EBP, used to reduce the risk of transmission (spread) of unknown multidrug resistant organism (MDRO). Review of the resident's care plan, dated 11/6/24, showed: -EBP included the use of gowns and gloves during high-contact residents care; -EBP will be utilized during high-contact resident care activities including, but not limited to, dressing, bathing, transfers, linen changes, incontinent care, wound and/or indwelling devices care; -EBP signage and supply bin outside of the resident's room indicating that PPE (gloves/ gowns) are required for high-contact resident activities. During an observation and interview on 5/28/25 at 7:49 A.M., the resident said he/she remained in bed until staff could find a second person to assist with a Hoyer (full body mechanical lift) transfer. At 7:53 A.M., Certified Nursing Assistant (CNA) A and CNA B entered the room to assist the resident with care. CNA A and B assisted in care that included removal of dirty linens and cloths, perineal care, and transferring the resident from the bed to the wheelchair by Hoyer lift. Both CNAs wore gloves. No gown was worn by either CNA. During an interview on 5/28/25 at 10:23 A.M., CNA B said he/she was not aware the resident required EBP during care. He/She thought the EBP was required if care for wounds was involved and not for general care. He/She was re-educated by the Director of Nursing (DON) who informed staff that any care for Resident #33 required PPE. 3. Review of Residents #32 medical record, showed an order dated 11/6/24, for EBP. Review of the resident's care plan, dated 11/6/24, showed: -EBP included the use of gowns and gloves during high-contact resident care; -EBP will be utilized during high-contact resident care activities including, but not limited to, dressing, bathing, transfers, linen changes, incontinent care, wound and/or indwelling devices care; -EBP signage and supply bin outside of the resident's room indicating that PPE (gloves/ gowns) are required for high-contact resident activities. Observations on 5/27/25 at 2:39 P.M., showed CNA C entered the resident's room. CNA C did not don any PPE. The resident had bladder and bowel incontinence, and a large brown ring was noted on the linens and a strong urine odor noted in the room. CNA C exited the room. At 2:53 P.M., CNA C walked back into the resident's room and no PPE was worn. CNA C walked back to the hallway for a trash bag. Flies landed on/near the resident. CNA C provided perineal care and at 3:04 P.M., CNA D entered and assisted in providing care, he/she wore no PPE. CNA D and C completed care and repositioned the resident. CNA D and CNA C exited the room. During an interview on 5/28/25 at 9:50 A.M., CNA D said the DON discussed with him/her wearing PPE when there are EBP signs on the door. During an interview on 5/28/25 at 11:02 A.M., CNA C said EBP was used for Resident #32, for chronic wounds to the lower portion of the legs. 4. During an interview on 5/30/25 at 11:31 A.M., the DON said staff should wear the required PPE when a resident is identified as needing EBP. 5. Review of the facility's hand hygiene policy, showed: -Policy: staff will perform hand hygiene procedures to prevent the spread of infection to residents; -Definitions: hand hygiene is a general term for hand cleansing with soap and water or the use of antiseptic hand rub (ABHR, alcohol-based hand rub); -Explanation and compliance guidelines: -Staff will perform hand hygiene with either soap and water or ABHR before, during and after resident care; -The use of gloves does not replace hand hygiene. If gloves are required to perform the task, hand should be applied before donning (applying) and after removing gloves. 6. Review of Resident #21's quarterly Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/3/25, showed: -Severe cognitive impairment; -Moderate staff assistance needed for toileting and showering; -Frequently incontinent of bowel and bladder; -Diagnoses included: cognitive impairment, kidney insufficiency, and depression. Review of the resident's care plan, in used during the survey, showed: -Focus: self-care deficit; -Goal: improve level of function; -Interventions: the resident required partial assistance by staff for toileting including hygiene. During an observation and interview on 5/27/25 at 1:40 P.M., CNA F obtained washcloths and with gloved hands, wet the washcloths in the bathroom sink. CNA F used his/her gloved hands, wrung the washcloths and carried the washcloths to the resident's bedside. CNA F unfastened and lowered the urine saturated brief, obtained a washcloth and wiped down the front right thigh folds and used the same washcloth and wiped down the left thigh fold. CNA F used the same gloved hands and assisted the resident to turn onto his/her side. CNA F used the same gloved hands to obtain a wet washcloth and wiped between the resident's buttocks. CNA F used the same gloved hands and placed a clean brief under the resident, assisted the resident onto his/her back and secured the brief in place. CNA F removed his/her gloves and disposed of the gloves and the brief. CNA F said he/she did not wash or sanitize his/her hands prior to beginning care. He/She did not change gloves or sanitize his/her hands during care. He/She had been hurried to provide care. During an interview on 5/30/25 at 11:31 A.M., the DON said she expected staff to perform hand hygiene prior, during and after providing resident care. Gloves should be changed when moving from a dirty to a clean task. Appropriate hand hygiene and glove changes help prevent the spread of infection.

Based on observation, interview and record review, the facility failed to provide staff with appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain the highest practicable physical, mental, and psychosocial well-being for residents with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental health condition that can develop after a person has experienced or witnessed a traumatic event). The facility identified seven residents with a diagnosis of PTSD. Two residents with a diagnosis of PTSD were sampled and issues were found with one (Resident #4). This deficient practice had the potential to affect all seven residents with PTSD identified by the facility. The sample was 14. The facility's census was 60. During an interview on 5/30/25 at 9:25 A.M., the Director of Nursing (DON) said the facility does not have a trauma informed care policy. During an interview on 5/30/25 at 11:58 A.M., Regional Nurse said confirmed the facility does have a trauma informed care policy and will provide the policy. Review of the facility's Trauma Informed Care policy, revised 1/3/25, showed: -Policy Explanation and Compliance: The facility will work to facilitate the principles of trauma informed care which include: -Safety - Ensuring residents have a sense of emotional and physical safety; -Trustworthiness and transparency - Efforts to establish a relationship based on trust, and clear and open communication between the staff and the resident; -Peer support and mutual self-help - If practicable, assist the resident in locating and arranging to attend support groups (potentially hosted by the facility) which are organized by qualified professionals; -Collaboration: an emphasis on partnering between residents and/or his or her representative, and all staff and disciplines involved in the resident's care in developing the plan of care; -Empowerment, voice and choice - Ensuring that resident's choice and preferences are honored and that residents are empowered to be active participants in their care and decision-making, including recognition of, and building on resident's strengths; -The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others; -If the resident is non-English speaking, the facility will identify how communication will occur with the resident. If indicated, language assistance services will be arranged for the resident. The care plan will identify the language spoken and tools used to communicate; -The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals) to develop and implement individualized care plan interventions; -The facility will identify triggers which may re-traumatize residents with a history of trauma. While most triggers are highly individualized, some common triggers may include, but are not limited to: -Experiencing a lack of privacy or confinement in a crowded or small space; -Exposure to loud noises, or bright/flashing lights; -Certain sights, such as objects that are associated with their abuser; -Sounds, smells, and physical touch; -Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety; -The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included when possible and appropriate in this evaluation to ensure clear and open discussion and better understand if interventions must be modified; -The facility will engage the services of an interpreter to monitor or evaluate the effect of cultural interventions for non-English speaking residents; -In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Review of the facility's Social Services policy, dated 9/1/21, showed: -The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The social worker, or social service designee, will complete an initial and quarterly assessment of each resident, identifying any need for medically-related social services of the resident. Any need for medically-related social services will be documented in the medical record; -Providing or arranging for needed mental and psychosocial counseling services; -Identifying and seeking ways to support residents' individual needs through the assessment and care planning process; -Encouraging staff to maintain or enhance each resident's dignity in full recognition of each resident's individuality; -Assisting residents with advance care planning, including but not limited to completion of advance directives; -Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident; -Meeting the needs of residents who are grieving from losses and coping with stressful events; -The facility should provide social services or obtain needed services from outside entities during situations that include but not limited to the following: -Lack of an effective family or community support system or legal representative; -Expressions or indications of distress that affect the resident's mental and psychosocial wellbeing, resulting from depression, chronic diseases, difficulty with personal interaction and socialization skills, and resident to resident altercations; -Abuse of any kind (alcohol or other drugs, physical, psychological, sexual, neglect, exploitation); -Difficulty coping with change or loss (change in living arrangement, change in condition or functional ability, loss of meaningful employment or activities, loss of a loved one); -Need for emotional support; -The resident's plan of care will reflect any ongoing medically-related social service needs, and how these needs are being addressed; -The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning. Review of the facility's Facility Assessment, dated 3/14/25, showed: -Psychiatric/Mood Disorders: Impaired cognition, mental disorder, depression, bipolar disorder (mania/depression), schizophrenia, Post-Traumatic Stress Disorder, anxiety disorder, behavioral health, and history of substance use disorder; -Mental Health: Behavioral Health needs: 10-20 residents; -History of substance use disorders: 10-20 residents; -Provide person-centered directed care including psycho/social/spiritual support: The facility staff strives to develop a rapport with the residents and families to get to know their preferences. This allows the facility staff to determine preferences and routines, triggers, and recovery methods. This information is then incorporated into the care plan to ensure staff caring for the resident/representative understand and are aware of necessary treatment and care preferences; -The staff will support the resident's emotional and mental well-being and assist with coping mechanisms that are personalized. The staff will support and encourage the resident and responsible party (RP)/family to provide familiar belongings if designed; -The staff will ensure the safety of the residents by identifying hazards and risks. The staff will offer and assist resident and family caregivers to be involved in person-centered care planning and advance care planning. The staff will provide family/representative support. Review of the facility's Matrix, showed the facility identified seven residents with a diagnosis of PTSD. Review of the facility's Licensed Nurse Annual Competency and Education Record, showed: -Trauma Informed Care; -Abuse and Resident rights; -Dementia and Behavior Management; -No documentation of PTSD competency and education. Review of the facility's Ancillary Staff Annual Competency and Education Record, showed: -Trauma Informed Care; -Abuse and Resident Rights; -Dementia and Behavior Management; -No documentation of PTSD competency and education. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/19/24, showed: -Moderately Impaired Cognition; -Mood: Scored a 12: Moderate depression symptoms. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Mood: Scored a 17: Moderately Severe Depression Symptoms; -Little interest or pleasure in doing things; -Feeling down, depressed and hopeless; -Diagnoses included PTSD, depression, hemiplegia and hemiparesis (weakness and/or paralysis affecting one side of the body) on left side. Review of the resident's care plan, undated and in use at the time of the survey, showed: -Focus: had prior trauma related to PTSD; -Goal: Will have physical and emotional needs met without increased emotional distress through next review; -Interventions: Notify physician if increased or prolonged emotional symptoms occur; Offer physical items that provide resident comfort as possible; Referral to in house psychological services; When resident shows emotional need contact residents support person. Review of the resident's medical record, showed: -On 4/10/25, the resident's psychiatry progress notes, showed the resident felt depressed and anxious due to PTSD related to family deaths, including requesting to see a therapist; -On 4/30/25, the resident's primary care physician (PCP) progress note, showed the resident voiced concerns regarding his/her mental health related to family trauma. This time of year is the anniversary of several major deaths in his/her family, causing the resident to struggle with feeling depressed and compounded by his/her current health issues; -On 5/19/25, the resident's nurse progress note, showed the resident said I don't want to be here anymore. I just want to die. The resident said he/she was not going to harm himself/herself, he/she just did not want to be in pain anymore; -On 5/20/25, the resident's PCP progress note, showed the resident is feeling down and depressed. Resident looking at old photos of himself/herself and does not know how he/she got to the place where he/she is today. He/She has had a lot of body aches. Review of the facility's Activity Participation Binder residents' individual Activity Participation Log sheets, showed no entries for the resident. During an interview on 5/29/25 at 11:50 A.M., the resident said he/she experiences PTSD related to past sexual assault, family trauma, and loss of both his/her daughter and mother. This time of year is always particularly difficult, as May marks his/her mother's birthday and the anniversary of his/her daughter's death. The past few months have been especially challenging due to ongoing health issues and his/her brother's serious illness on top of the PTSD. The resident said that increased physical pain worsens his/her depression. He/She requested to see a therapist back in April and again more recently, stating that speaking with someone would help him/her cope during this difficult period. During an interview on 5/30/25 at 9:10 A.M., the social worker said she is currently working on getting a therapist group to come to the facility but is still waiting on the company to respond. She was unaware that the resident had requested to see a therapist and May was a trigger for the PTSD. If she would have known the urgency, she would have attempted to find an outside therapist that would see the resident. She was not sure of who was on 1:1 activities, but the resident would benefit from the activities 1:1 program. During an interview on 5/30/25 at 9:35 A.M. the activity supervisor said the 1:1 activities are done as a team approach. The receptionist, the activity aid, and certified nursing assistants (CNAs) will all do 1:1 activities with the residents. During an interview on 5/29/25 at 2:40 P.M., the Social Services designee said he/she is involved in the care plan meetings and oversees admissions and discharges of residents. The social history is completed by Social Services upon admission. Psychosocial assessments are completed upon admission, within the first three days in the building. It is updated quarterly and yearly. He/She also completes the Brief Interview of Mental Status (BIMS) and PHQ-9 (a 9-item depression screening tool used to assess the presence and severity of major depressive disorder). He/She reviews the referral and looks at the resident's background for any diagnoses of depression or PTSD. He/She meets with the resident and completes a trauma informed care form and the PHQ-9. If nursing staff is not aware of the resident reporting anxiety or reports of traumatic memories, the nursing staff will be informed. They touch base on the plan of care. They figure out the trigger and attack that as a team. They will notify the Physician Assistant and Medical Director. Post-admission, he/she personally checks on the resident. There are residents that like to meet with him/her. If the resident needs anything, he/she recommends it to the team that the resident needs to see psych or followed up with psychotherapy. He/She touches base with activities to see what type of activity would be good for them. The care plans are revised annually if there is a behavior issue. In order to know if an intervention is working or needs adjustment, he/she would do continuous interventions to see if they need to do something else. He/She does not give training or education to staff regarding PTSD. He/She completed in-services, and staff have a skills day. There is information on dementia and how to treat people with dementia. There is no training on mental health. He/She did not have formal training with behavioral health but completed a designee course. He/she had a lot of information under the belt about behavior health from personal experience. There is no supervision or licensed Social Worker in the facility. He/She completed trauma informed care education. There is no education on PTSD. If they go, he/she was not aware of it. Some non-pharmacological interventions used to support residents with history of trauma is being pleasant to resident, re-directing, and not trying the pharmaceuticals first unless there is a physician's order. He/She was unaware of type of behaviors to expect from someone with untreated PTSD. There are three residents that reside in the facility with a diagnosis of PTSD. Social Services does not touch base with psych. They round more with nursing or talk to the Director of Nursing (DON). During an interview on 5/30/25 at 11:29 A.M. the Administrator said the social history might be divided, but he would expect the interviews to be completed. Activities would complete the social history. The psychosocial assessment is expected to be completed upon admission and quarterly. Nursing and admission staff review the referrals and resident diagnoses. If it is in the medical record in the previous facility, it should be in the medical record unless the physician makes changes. If the resident is unable to give personal information, he would expect staff to reach out to a family member for information if the resident has a family member. It is helpful to get a a well rounded picture. He would expect staff to notify nursing services if a resident reported anxiety, depression, or behavior triggers. If a resident exhibits new symptoms or has a new diagnosis, he would expect the care plan to be updated. If a resident has a diagnosis of PTSD, he expects documentation of all known triggers and symptoms. It is important for staff to be aware of trauma and PTSD when working with residents, so they are aware of the best way to approach because they have to navigate certain aspects of trauma to get the best continuity of care. The completion of the social history is important as it relates from sharing from the resident. The Administrator agreed that knowing a resident's PTSD diagnosis and triggers can influence the way staff approach them such as changing tone, pace, and being more mindful of abrupt waking or alarms. If there's a pattern of behavior such as not getting out of bed, he would expect staff to document and notify management, the aides are expected to document any type of medical change in condition.

Based on observation, interview and record review, the facility failed to ensure residents who were trauma survivors received trauma-informed care in accordance with professional standards of practice, when the facility failed to clearly identify the resident's past trauma, identify triggers or individualized interventions to prevent traumatization or treat symptoms for (Resident #4), who had a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by a terrifying event/either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event). On 4/10/25, 4/30/25 and 5/20/25 Resident #4 verbalized increase depression due to PTSD - family trauma. On 5/19/25, he/she expressed wanting to die. The facility failed to identify triggers and incorporate the knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. This resulted in the resident having increased depression and end of life thoughts. The sample was 14. The census was 60. Review of the facility's Trauma Informed Care policy, revised 1/2025, showed: -Trauma-Informed Care: is an approach to deliver care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization; -The facility will identify triggers which may re-traumatize residents with a history of trauma; -The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools; -Trauma-specific care plan interventions will recognize the inter-relation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/19/24, showed: -Moderately Impaired Cognition; -Mood: Scored a 12: Moderate depression symptoms. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Mood: Scored a 17: Moderately Severe Depression Symptoms; -Little interest or pleasure in doing things; -Feeling down, depressed and hopeless; -Diagnoses included PTSD, Depression, Hemiplegia and Hemiparesis (weakness and/or paralysis affecting one side of the body) on left side. Review of the resident's care plan, undated and in use at the time of the survey, showed: -Focus: Had prior trauma related to PTSD; -Goal: Will have physical and emotional needs met without increased emotional distress through next review; -Interventions: Notify physician if increased or prolonged emotional symptoms occur; Offer physical items that provide resident comfort as possible; Referral to in house psychological services; When resident shows emotional need contact residents support person; -Focus: Uses psychotropic medications; -Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date; -Interventions: Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift; bupropion HCL extended release (anti-depressant) Black Box Warning (In patients of all ages who are started on antidepressant therapy, monitor closely for worsening and for emergence of suicidal thoughts and behaviors.) Review of the resident's psychiatry progress notes, dated 4/10/25, showed the resident felt depressed and anxious due to PTSD related to family deaths, including requesting to see a therapist. Review of the resident's primary care physician (PCP) Progress note, dated 4/30/25, showed the resident voiced concerns regarding his/her mental health related to family trauma. This time of year is the anniversary of several major deaths in his/her family, causing the resident to struggle with feeling depressed and compounded by his/her current health issues. Review of the resident's nurse progress note, dated 5/19/25, showed the resident said I don't want to be here anymore. I just want to die. The resident said he/she was not going to harm himself/herself, he/she just did not want to be in pain anymore. Review of the resident's PCP progress note, dated 5/20/25, showed the resident is feeling down and depressed. Resident looking at old photos of himself/herself and does not know how he/she got to the place where he/she is today. He/She has had a lot of body aches. Observations on 5/27/25 at 11:25 A.M., showed resident in lay in bed with a strong urine order in the room and said he/she would like to get up but most of the time there is not enough staff. At 3:25 P.M., the resident remained in bed and watched television (TV). On 5/28/25 at 12:15 P.M., the resident lay in bed and watched TV. On 5/29/25 at 11:50 A.M., the resident sat in a wheelchair and watched TV. During an interview on 5/29/25 at 11:50 A.M., the resident said he/she experiences PTSD related to past sexual assault, family trauma, and loss of both his/her daughter and mother. This time of year is always particularly difficult, as May marks his/her mother's birthday and the anniversary of his/her daughter's death. The past few months have been especially challenging due to ongoing health issues and his/her brother's serious illness on top of the PTSD. The resident said that increased physical pain worsens his/her depression. He/She requested to see a therapist back in April and again more recently, stating that speaking with someone would help him/her cope during this difficult period. During an interview on 5/30/25 at 9:10 A.M., the social worker said she was unaware that the resident had requested to see a therapist and May was a trigger for the PTSD. If she would have known the urgency, she would have attempted to find an outside therapist that would see the resident. She was not sure of who was on 1:1 activities, but the resident would benefit from the activities 1:1 program. During an interview on 5/30/25 at 9:35 A.M. the activity supervisor said she is unaware which residents have PTSD. During an interview on 5/30/25 at 9:45 A.M. the Director of Nursing (DON) said she would expect the resident's care plan to incorporate the knowledge about the trauma triggers and interventions.

Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents with Post-Traumatic Stress Disorder (PTSD) in their choice of activities to meet the interests and well-being for two residents when staff failed to provide one on one (1:1) visits for two residents who preferred to stay in their room and had a history of depression and PTSD (Resident #4 and Resident #25). The sample was 14. The census was 60. Review of the facility's Activity Policy, showed: -Activities may be conducted in different ways: One-to-One (1:1) Programs. -Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs; residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day. 1. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/19/24, showed: -Moderately Impaired Cognition; -Mood: Scored a 12: Moderate depression symptoms; -Activity Preferences: -How important is it to you to have a place to lock your things to keep them safe: Very Important; -How important is it to you to do things with groups of people: Very important; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very Important; -How important is it to you to have books, newspaper, and magazines to read: Somewhat important. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Mood: -Scored a 17: Moderately Severe Depression Symptoms; -Little interest or pleasure in doing things; -Feeling down, depressed and hopeless; -Diagnoses included PTSD, Depression, Hemiplegia and Hemiparesis (weakness and/or paralysis affecting one side of the body) on left side. Review of the resident's care plan, undated and in use at the time of the survey, showed: -Focus: had prior trauma related to PTSD; -Goal: Will have physical and emotional needs met without increased emotional distress through next review; -Interventions: Notify physician if increased or prolonged emotional symptoms occur; Offer physical items that provide resident comfort as possible; Referral to in house psychological services; When resident shows emotional need contact residents support person. -Focus: Uses psychotropic medications; -Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date; -Interventions: Administer Psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift; bupropion HCL extended release (anti-depressant) Black Box Warning (In patients of all ages who are started on antidepressant therapy, monitor closely for worsening and for emergence of suicidal thoughts and behaviors.) Review of the resident's psychiatry progress notes, dated 4/10/25, showed the resident felt depressed and anxious due to PTSD related to family deaths, including requesting to see a therapist. Review of the resident's primary care physician (PCP) Progress note, dated 4/30/25, showed the resident voiced concerns regarding his/her mental health related to family trauma. This time of year is the anniversary of several major deaths in his/her family causing the resident to struggle with feeling depressed and compounded by his/her current health issues. Review of the resident's nurse progress note, dated 5/19/25, showed the resident said I don't want to be here anymore. I just want to die. The resident said he/she was not going to harm himself/herself, he/she just did not want to be in pain anymore. Review of the resident's PCP progress note, dated 5/20/25, showed the resident felt down and depressed. Resident looking at old photos of himself/herself and does not know how he/she got to the place where he/she is today. He/She has had a lot of body aches. Review of the facility's Activity Department's 1:1 binder, showed the following for the resident: -A tab marked 1:1, in this section a sheet of paper titled Room to room [ROOM NUMBER] on 1's Schedule; -Resident #4 not listed as receiving 1:1 visits from staff. Review of the facility's Activity Participation Binder residents' individual Activity Participation Log sheets, showed no entries for Resident #4. Observations on 5/27/25 at 11:25 A.M., showed resident in lay in bed with a strong urine order in the room and said he/she would like to get up but most of the time there is not enough staff. At 3:25 P.M., the resident remained in bed and watched television (TV). On 5/28/25 at 12:15 P.M. the resident lay in bed and watched TV. On 5/29/25 at 11:50 A.M., the resident sat in wheelchair and watched TV. During an interview on 5/29/25 at 11:50 A.M., the resident said he/she experiences PTSD related to past sexual assault, family trauma, and loss of both his/her daughter and mother. This time of year is always particularly difficult, as May marks his/her mother's birthday and the anniversary of his/her daughter's death. The past few months have been especially challenging due to ongoing health issues and his/her brother's serious illness on top of the PTSD. The resident said that increased physical pain worsens his/her depression. He/She requested to see a therapist back in April and again more recently, stating that speaking with someone would help him/her cope during this difficult period. During an interview on 5/30/25 at 9:10 A.M., the social worker said she is currently working on getting a therapist group to come to the facility but is still waiting on the company to respond. She was unaware that the resident had requested to see a therapist and May was a trigger for the PTSD. If she would have known the urgency, she would have attempted to find an outside therapist that would see the resident. She was not sure of who was on 1:1 activities, but the resident would benefit from the activities 1:1 program. 2. Review of Resident #25's medical record, showed: -A quarterly MDS, dated [DATE], showed: -Diagnosis of bipolar disorder (mood disorder characterized by manic and depressive episodes), PTSD, and depression; -A care pan dated 5/27/25, showed: -Impaired cognitive function/dementia or impaired thought processes due to diagnoses of PTSD, and bipolar disorder; -Communication problem due to dementia and requires assistance for meeting emotional, intellectual, physical, and social needs; -Goal: Resident to participate in activities of choice daily to meet their interests and support mental, physical, and psychosocial wellbeing; -Interventions included staff to ensure the resident attends activities that are compatible with their physical and mental capacities and with known interests and preferences. Staff should adapt activities as needed (such as large print, holders if resident lacks hand strength, task segmentation). Staff should modify daily schedule and treatment plan to accommodate activity participation as indicated or expressed by residents' participation. Review of the facilities activity participation binder showed Resident #25 was not listed as participating in any group activities. Review of the facility's Activity Department's 1:1 binder, showed the following for the resident: -A tab marked 1:1, in this section a sheet of paper titled Room to room [ROOM NUMBER] on 1's Schedule; -Resident #25 not listed as receiving 1:1 visits from staff. Review of the facility's Activity Participation Binder residents' individual Activity Participation Log sheets, showed no entries for Resident #25. 3. During an interview on 5/30/25 at 9:35 A.M. the activity supervisor said she tries to have all the residents on the activities 1:1 program and they are tracked in the facility's 1:1 binder. The 1:1 activities are based on how a resident interacts with the activity supervisor. The 1:1's are done as a team approach. The receptionist, the activity aid, and certified nursing assistants (CNAs) will all do 1:1 activities with the residents. She would expect everyone to document in 1:1 activities in the 1:1 binder. She recently took over the department, which was previously unorganized, and she is still in the process of reorganizing it. 4. During an interview on 5/30/25 at 9:45 A.M. the Director of Nursing (DON) said she would expect 1:1's to be completed and documented for any resident that would benefit from the 1:1 program.

Based on observation, interview and record review, the facility failed to maintain a clean and organized medication cart within the facility, for two out of two carts checked. Both medication carts had several concerns which failed to ensure proper storage and labels on medications on one certified medical technician (CMT) medication cart and one registered nurse (RN) medication cart. The census was 60. Review of the facility's Medication Storage Policy, dated 2021, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturers' recommendations and sufficient to ensure proper temperature, light, ventilation, moisture control, segregation, and security; -Unused medications: The pharmacy, and all medications rooms are routine inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with medications with worn, illegible, or missing labels. These medications are destroyed. 1. Observation of the 200 hall medication CMT cart on 05/30/25 at 09:52 A.M., showed: -Top drawer 1st column, anti-diarrhea bubble pack without a resident's name listed; -Top drawer 2nd column, ½ cut blue pill in a clear bag stapled with residents' name listed on the outside of the packaging, no name or dose of the medication listed; -Top drawer, five loose pills, variety of shapes and colors, one peach, one large white marking of GC422, two small white pills marked with 439, one medium size pill no markings; -Top drawer 3rd column, four light/pale yellow pills loose; -3rd drawer, anti-itch cream without a resident's name; -3rd drawer, four loose white pills, one long blue, several small pieces of crushed, broken pills found in the far back 3rd column, behind medication cards; -Last small drawer on the right side, a dried liquid on the bottom; -Last draw 1st column, a long green pill with markings of G75. During an interview on 05/30/25 at 09:52 A.M., CMT A said he/she spilled a bottle of medications earlier and did not have a chance to clean the cart. He/She followed up with the night shift CMT who was unaware of the precut ½ sized medications and left the unused portion to be discard later. Staff usually clean the cart every Monday and Friday on their shift. 2. observation on the 100, 200 and 300 hall RN cart on 05/30/25 at 10:08 A.M., showed the top drawer 4th column, several broken hardened medications stuck to the cart. During an interview on 05/30/25 at 10:08 A.M., RN A said the cart should not have any medications loose in it. He/She did not understand why the pills were there. 3. During an interview on 05/30/25 at 10:06 A.M., the Regional Nurse said medication carts should be cleaned on a weekly bases, or as needed. There should not be any loose medications on the cart, if loose medications are seen, they should be discarded immediately. During an interview on 05/30/25 at 10:31 A.M., the Director of Nursing said it is up to the CMT, Licensed Practical Nurses (LPN), and RNs to clean the carts as needed.

Based on observation, interview and record review, the facility failed to ensure appropriate perineal care (cleansing from the front of the hips, between the legs and buttocks, to the back of the hips) for one perineal care observation (Resident #21). The sample was 14. The census was 60. Review of the facility perineal care policy, showed: -Policy: provide perineal care to incontinent residents to promote cleanliness and comfort, prevent infection to the extent possible, and to prevent and assess for skin breakdown; -Policy explanation and compliance guidelines: -Use bath basin with warm water or disposable cleaning cloth method; -If bath basin is used, use perineal cleanser; -Perform hand hygiene and apply gloves; -Cleanse buttocks and in between the buttocks, front to back, use a separate washcloth or wipe; -Apply skin protectant as needed. Review of Resident #21's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 4/3/25, showed: -Severe cognitive impairment; -Moderate staff assistance needed for toileting and showering; -Frequently incontinent of bowel and bladder; -Diagnoses included: cognitive impairment, kidney insufficiency, and depression. Review of the resident's care plan, in use during the survey, showed: -Focus: self-care deficit; -Goal: improve level of function; -Interventions: the resident required partial assistance by staff for toileting including hygiene. During an observation and interview on 5/27/25 at 1:40 P.M., Certified Nurse Aide (CNA) F obtained approximately four wash clothes and with gloved hands, wet the washcloths in the bathroom sink. CNA F used his/her gloved hands, wrung the washcloths and placed the wet washcloths on the bed and unfastened the resident's urine saturated brief. CNA F lowered the brief, obtained a washcloth and wiped down the right front thigh fold. CNA F used the same washcloth and wiped down the front of the left thigh fold and placed the used washcloth in between the resident's front legs. CNA F obtained a wet washcloth and cleansed parts of the resident's genital folds. CNA F did not cleanse the entirety of the resident's genitals. CNA F placed the used washcloth in between the resident's front legs. CNA F assisted the resident onto his/her side. CNA obtained a wet washcloth and wiped between the resident's buttocks. The resident loudly said oh, that is cold. CNA F did not cleanse the buttocks or hips. CNA F placed the used washcloth on the saturated brief and removed the soiled brief and disposed of the brief. CNA F placed a clean brief under the resident, assisted the resident onto his/her back and secured the brief in place. CNA F said the resident's brief was urine saturated. He/She had been rushed and forgot to apply cleanser to the washcloth or the resident's skin. Perineal care should be provided with soap or cleanser and all areas of the groin and buttocks should be cleaned. During an interview on 5/30/25 at 11:31 A.M., the Director of Nursing (DON) said staff should use a bath basin with warm soapy water or wipes to provide perineal care. A fresh washcloth or wipe should be used for each area of the groin. All areas that contacted a saturated brief should be cleaned. Thorough perineal care should be provided to prevent skin breakdown, odors or infection. MO00254370 MO00254851 MO00254094

See deficiency cited at event ID 4PUY12 This deficiency is uncorrected. For previous examples, refer to the statement of deficiencies dated 4/9/24. Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 47 opportunities observed, 7 errors occurred resulting in a 14.89% error rate (Resident #1, #9, and #503). The census was 47.

35394 Based on observation, interview and record review, the facility failed to provide each resident with a variety of food, in an appropriate quantity, to meet the needs for 2 of 14 sampled residents (Residents #9 and #19). The facility also failed to have enough food to provide for residents who asked for seconds and failed to provide an alternate upon request. The facility also failed to ensure residents had access to a menu prior to meal service. The census was 41. Review of the facility's Nursing Home Residents' Rights, provided upon admission to the residents showed: -Right to a dignified existence: -Be treated with consideration, respect, and dignity, recognizing each resident's individuality; -Quality of life is maintained or improved; -Exercise rights without interference, coercion, discrimination, or reprisal; -Right to self-determination: -Choice of activities, schedules, health care, and providers; -Reasonable accommodation of needs. Review of the facility's Menu Alternates policy, revised 5/31/21, showed: -Policy: Nutritionally comparable menu items shall be available to accommodate resident food preferences; -Procedure: Alternate menu items are planned during the menu planning process for protein source, grains, fruits, and vegetables; -Alternate menu items may be included on the cycle menu and/or included with the always available menu; -A By request or Always available menu will be written and available in all resident service areas; -Various dining areas may have slightly different versions of the By request menu designed to meet resident needs. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/6/24, showed: -Moderately impaired cognition; -Diagnoses included dementia and depression; -Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency: Supervision or touching assistance-helper provides verbal cues and touching/steadying assistance as resident completes activity. Review of the posted lunch menu for 4/5/24, showed Polish sausage, sauerkraut, diced potato and crushed pineapple. Observation of the lunch meal service in the main dining room, on 4/5/24 at 12:30 P.M., showed the resident sat at a table near the door to the kitchen and had chicken noodle soup, and mechanically chopped Polish sausage, sauerkraut and potatoes. Staff talked to the resident and then went to the kitchen door and said the resident wanted a grilled cheese sandwich. The staff person in the kitchen said very loudly and in an angry tone it's too late. He/She just made him/her soup and he/she got it already. The staff person standing at the door said the resident is not happy with the soup. The staff in the kitchen said that is too bad. He/She already made him/her something. The staff person in the kitchen spoke very loudly and could easily be heard by the surveyor who sat approximately 20 feet further away from the kitchen than the resident. The staff person at the door entered the kitchen and whispered, then looked in the direction of the state surveyor, and said I am sorry to the staff person in the kitchen. The staff person at the doorway then returned to the resident and said the kitchen staff is making the sandwich for him/her. During the group interview on 4/5/24 at 1:05 P.M., one resident said he/she did not know everyone else was served sauerkraut. He/She ate in their room, but he/she was served diced potatoes, peas and carrots with the Polish sausage. During an interview on 4/9/24 at 8:50 A.M., the Director of Nursing (DON) said residents should be treated with dignity and respect. If a resident requests an alternate, it is not appropriate for staff to complain about it loud enough for residents to hear. 2. Review of Resident #19's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Has physical behaviors; -Diagnoses included coronary artery disease, high blood pressure, renal failure, diabetes, anxiety, depression, and respiratory failure; -Coughing or choking during meals or when swallowing medications; -Has therapeutic diet. Review of the resident's physician's order sheets (POS), dated April 2024, showed: -An order, dated 11/27/23, for regular diet, diabetic, sodium precautions diet. Regular/thin consistency. Observation and interview on 4/5/24, showed: -At 8:17 A.M., the resident was served breakfast in his/her room. The resident said he/she was served quiche, but he/she did not like it. The resident pressed his/her call light. The resident told staff he/she did not like the quiche. Staff told the resident that quiche was really good. The resident said he/she did not like quiche. Staff said he/she would be able to get the resident some toast. A second staff person entered the resident's room. The two staff spoke quietly before exiting the room. The second staff was overheard saying he/she would see if the resident could receive fried eggs; -At 8:35 A.M., the resident said he/she was served cold cereal, but he/she continued to spill it on him/herself. The resident said he/she has trouble eating and swallowing. The resident said he/she coughs during meals. The resident was observed coughing and had cereal and milk spilled on his/her shirt. The resident said he/she was supposed to receive fried eggs instead. During an interview on 4/9/24 at 11:47 A.M., the Administrator said toast is not an appropriate alternate to the spinach quiche. 3. During the group interview on 4/5/24 at 1:05 P.M., all 11 residents said the meals have been very carb heavy. They are served noodles all the time. All 11 residents said they ate fettuccine last night. It was good, but it was carb heavy. All 11 residents said they had other pasta dishes this week. When they are served tacos, the tortillas are small and they only receive one. The portions have become child size. They can eat more than a 5th grader. They are probably trying to make due, but it is hard eating only one soft taco. The residents complained about the turkey salad that was served this week. All it had were little pieces of turkey and a slice of tomato. Nine out of 11 residents shared they still felt hungry after their meals. They run out of yogurt because everyone likes it. The residents have to ask for it. A resident said he/she was supposed to have yogurt, fruit and vegetables. It is on their meal ticket, but they do not receive it. Since dinner meals are small, they are hungry by 8:00 P.M., so they would like a snack. The snacks are kept behind the nurse's station. They cannot get the snacks until 9:00 P.M. or 10:00 P.M. Staff or other residents will take the snacks and there is nothing left. The residents said they would like to be served soup. If they are sick, they will still receive what was on the menu. The flu was going around in the facility and it would be nice to receive chicken noodle soup. Sometimes a heavy meal does not look good if they are sick and soup is something sick people eat. They residents said ordering meals can get expensive, so they would like to have meals they can have, such as salads and soup. If it were available regularly, they would not fuss. Review of the facility's weekly menu, showed: -On 4/2/24, dinner showed turkey salad platter, lettuce, and tomato. One each was written next to each item; -On 4/3/24, lunch showed eight ounces of beef mostaccioli; -On 4/4/24, lunch showed eight ounces of beef mac casserole. Dinner showed chicken fettuccine alfredo. Observation of the kitchen on 4/05/24 at 3:50 P.M., showed: -A large box of eggs that held a quantity of 15 dozen, approximately 3/4 full; -One large box with several yogurt containers inside; -12 cans of cream of mushroom soup. Each can was 50 ounce (oz); -Eight cans of tomato soup. Each can was 50 oz; -Seven cans of chicken noodle soup. Each can was 50 oz; -One can of chicken and dumpling. The can was 48 oz; -24 cans of tomato soup. Each can was 7.25 oz. 4. Review of the Resident Council minutes, dated 2/20/24, showed: -Issue: Kitchen; -Action Taken: Wants menus. Most places have menus; -Person responsible: Dietary Manager. During the group interview on 4/5/24 at 1:05 P.M., the residents said they used to get their menu for the day with breakfast. If they did not want fish or whatever that was on the menu, they could cross out what they did not want. They do not receive menus and when it was discussed in Resident Council, they received feedback that it would contaminate the kitchen. The residents do not have a way of informing dietary staff they do not want what is on the menu prior to being served. If they are served a meal and want something else, they get a hot dog or grilled cheese. During an interview on 4/5/24 at 8:31 A.M., the Dietary Manager said this is not a short order diner. They have to stick to the menu. They do not have the budget, and the menu is all budget based. If they are making scrambled eggs for one resident, then all of them would want them. The Dietary Manager said he prepared eggs for a couple of residents today and he would usually make it for them, but if one resident wanted something, the rest of the residents will want it. 5. During an interview on 4/9/24 at 11:47 A.M., the Administrator said the alternate meals include grilled cheese and hot dogs. If it is breakfast, the alternates are oatmeal, cereal and fried eggs. The alternate items were decided prior to the Administrator starting in early 2024, but the residents enjoy them as alternates. The residents can receive alternate meals upon request, before and during meal times. If the resident was already served the meal on the menu, but did not like it, the resident should still receive an alternate. They cannot make a completely different menu. They plan to implement resident's choice. The Resident Council will vote on a meal choice. The residents should receive seconds if requested. He was unsure if there was enough food for the residents to receive seconds. The Dietary Manager has to order food, but the Administrator was not sure the number that is ordered. There is also dietician input, budgeting, and making sure there's enough food at all times. There had not been issues with running out of food. He had no idea what budget based menu meant, but it may refer to operating the needs of the residents for meals. The residents have access to the menu. The residents wanted to choose three options for their alternate meal on the menu. They wanted it to be like a restaurant where they can order. The Administrator was aware the residents order food, but he was not aware if they did not like the food or if there was not enough. He was unsure if soup could be prepared for the residents. MO00233990

Based on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents' antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 41. On 4/9/24 at 2:10 P.M., the facility's Antibiotic Stewardship policy was requested from the Director of Nursing (DON) who is the facility's Infection Preventionist. The policy was never provided. Review of the facility's Infection Prevention and Control Program policy, revised 9/1/23, included the following: Antibiotic Stewardship: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; Antibiotic Stewardship: -An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program; -Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program; -The Infection Preventionist, with oversight from the DON, serves as the leader of the antibiotic stewardship program; -The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program. During an interview on 04/09/24 at 12:07 P.M., the DON, who is the Infection Preventionist, said they have not done an antibiotic stewardship program. She provided an infection log for December, January, and February but reported she did not have an antibiotic stewardship program set up. The infection log she provided is the one the facility had been using. She adapted to this facility and used the infection log she was provided when she started working at the facility but realized that log does not cover the antibiotic tracking. She said she finds things they should have done but were not. During an interview on 4/9/24 at 12:37 P.M., Regional Nurse M said he/she expected the facility to have an antibiotic stewardship program in place.

44950 50366 Based on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection prevention and control when staff hung medication through a single lumen (internal channel) peripherally inserted central catheter (PICC, intravenous (IV) access site) without cleaning the cap of the lumen, for one resident (Resident #337). Staff failed to ensure proper placement of indwelling urinary catheter (tube inserted into the bladder to drain urine) drainage bags when the bags lay directly on the floor and a catheter bag was not positioned to prevent reflux of urine. The facility identified four residents as having indwelling urinary catheters. Of those four, three were included in the sample and issues were identified with two (Residents #337 and #18). Staff failed to change gloves and sanitize their hands in accordance with the facility's policy and acceptable standards of practice. for one of three observations of personal care (Resident #23). In addition, staff failed to follow the facility's policy and acceptable standards of practice for infection control during wound dressing changes for three of three observations of wound care completed on two residents (Residents #3 and #20). The sample was 14. The census was 41. Review of the facility's Hand Hygiene policy, dated 9/1/21, showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors This applies to all staff working in all locations within the facility; -Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); -Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice; -Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table; -Alcohol-based hand rub with 60 to 95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom; -Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves; -Bar soap is approved for a resident's personal use only. Keep bar soap clean and dry in protective containers (i.e. plastic case or bag); -Liquid soap reservoirs must be discarded when empty. If refillable, dispensers must be emptied and cleaned, rinsed and dried according to manufacturer instructions; -Use lotions and creams to prevent and decrease skin dryness. Use only hand lotions approved by the facility because they won't interfere with ABHRs. Review of the facility's Hand Hygiene Table, showed: -Soap and water indicated when: Hands are visibly dirty, hands are visibly soiled with blood or other body fluids; -Either soap and water or ABHR indicated: Between resident contacts. After handling contaminated objects. Before performing invasive procedures. Before applying and after removing personal protective equipment (PPE), including gloves. Before and after handling clean or soiled dressings, linens, etc. Before performing resident care procedures. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving form a contaminated body site to a clean body site. After assistance with personal body functions (e.g., elimination, hair grooming, smoking). Review of the facility's Indwelling catheter use and removal policy: Compliance guidelines, dated 9/2021, showed: -Keeping the urinary catheter anchored to prevent excessive tension on the urinary catheter, which can lead to urethral tears or dislodgement of the urinary catheter and; -Securement of the urinary catheter to facilitate flow of urine, prevention no kinks in the tubing and positioning below the level of the bladder. Review of the facility's Wound Treatment Management Policy, dated 9/1/21, showed to promote wound healing of various types of wounds it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Review of Resident #337's Physician Order Sheet (POS), showed: -An order dated 3/25/24, for Vancomycin hydrochloride (antibiotic) IV solution 1000 milligrams (mg)/10 milliliters (ml), use 1 gram (1000 mg) every 12 hours for sepsis (presence of bacteria and infectious organisms in the blood stream) treatment; -An order dated 3/26/24, for every 8 hours perform urinary catheter care. Notify nurse if no urine or minimal urine output; -An order dated 3/26/24, indwelling urinary catheter, check urinary catheter anchor placement to prevent excessive tension on the urinary catheter. Keep tubing free of kinks and positioned below level of bladder every shift and as needed; -An order dated 3/26/24 IV PICC 1 lumen, location left upper arm; -Diagnoses included sepsis, urinary tract infection (UTI), diabetes, paraplegia, chronic buttock wound, and bipolar disorder (a mental health condition that affects your moods, which can swing from 1 extreme to another). Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has a urinary catheter; -Goal: The resident will show no signs or symptoms of urinary infection -Interventions: Position urinary catheter bag and tubing below the level of the bladder. Provide urinary catheter care every shift; -Focus: The resident is on antibiotic therapy; -Goal: The resident will be free of any discomfort or adverse side effects of antibiotic therapy; -Interventions; Administer antibiotic medications as ordered by physician. Observation on 4/3/24 at 11:08 A.M., showed the resident's urinary drainage bag on the floor, full of urine. The urine backed up into the tubing, as far as observation allowed due to the bed covers. Observation on 4/5/24 at 8:37 A.M., showed Licensed Practical Nurse (LPN) K entered the resident's room. The resident's urinary drainage bag rested directly on the floor and was full to the maximum. The urine filled the drainage tubing. LPN K walked to the resident's left side of the bed and stepped on the edge of the bag, then looked down and kicked the urinary drainage bag with his/her foot out of his/her path. LPN K prepared the PICC line for IV antibiotics without cleaning lumen with alcohol prior to flushing the PICC line with 10 ml of normal saline. LPN K then hung the resident's antibiotic. During an interview on 4/9/24 at 8:50 A.M., the Director of Nursing (DON) said urine drainage bags should not lay on the floor. They should be hung below the level of the bladder with no kinks in the tubing. Also, urine drainage bags should never be full of urine backing up into the tubing. They should be emptied a minimum of every 8 hours and as needed when full. The PICC line lumen should be cleaned with alcohol prior to flushing the IV and attaching the IV antibiotic. 2. Review of Resident #18's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/15/23, showed: -Severe cognitive impairment; -Diagnoses included heart failure, pneumonia, aphasia (language disorder), stroke, quadriplegia and seizure disorder; -Dependent with toileting hygiene; -Range of motion impairment to both sides of the upper and lower extremities; -Indwelling catheter. Review of the resident's care plan, in use during survey, showed: -Focus: Resident has indwelling catheter; -Goal: Resident will be/remain free from catheter-related trauma through review date; -Interventions: Change catheter as ordered by physician and as needed (PRN) for obstruction, soiled tubing and damage; -Change Foley tubing securement device weekly and PRN if loose or soiled. Apply and remove per package instructions; -Check tubing for kinks each shift; -Cleanse catheter with soap and water, rinse, pat dry every shift and PRN if soiling occurs; -Monitor and document catheter output each shift. Document milliliters (ml) on Medication Administration Record (MAR); -Monitor/document for pain/discomfort due to catheter. Review of the resident's POS, dated April 2024, showed: -An order, dated 12/18/23, for indwelling catheter 16 French (Fr) 10 ml balloon. Indwelling catheter indication: (obstructive uropathy, neurogenic bladder, Stage 3 or 4 pressure injury on peri-area, medical need for accurate output). No indication documented. -An order, dated 12/18/23, for catheter output. Monitor for changes and/or signs and symptoms of infection (decreased output, dark urine, foul odor, red tinged, lower abdominal discomfort/swelling) record amount every shift; -An order, dated 12/18/23, to change catheter and/or drainage bag when clinically indicated such as infection, obstruction, or when closed system is compromised as needed for catheter; -An order, dated 12/18/23, for indwelling catheter care and check catheter anchor placement to prevent excessive tension on the catheter. Keep tubing free of kinks and positioned below level of bladder every shift and as needed. Observation on 4/3/24, 4/4/24 and 4/5/24, showed: -On 4/03/24 at 9:45 A.M., the resident lay in bed, and his/her catheter hung on the right side of bed. The drainage bag was on the floor. The catheter tube was looped/kinked with approximately three feet of dark yellow urine in the tube that failed to drain into the bag. There was approximately 300 cubic centimeters (cc) of urine in the drainage bag; -On 4/3/24 at 11:56 A.M., the resident lay in bed, and his/her catheter hung on the right side of bed. The drainage bag was on the floor. The catheter tube was looped/kinked with approximately three feet of dark yellow urine in the tube that failed to drain into the bag. There was approximately 1000 cc of urine in the drainage bag; -On 4/4/24 at 5:38 A.M., the resident lay in bed, and his/her catheter hung on the right side of the bed. The drainage bag was on the floor. The catheter tube was looped with dried urine that was reddish in color inside the tube. There was approximately 250 cc of similar color urine in the bag; -On 4/4/24 at 8:01 A.M., the resident lay in bed, and his/her catheter hung on the right side of bed. The catheter tube was looped upward with approximately two feet of dark amber colored urine in the tube that failed to drain into the bag. There was approximately 200 cc of amber colored urine in the drainage bag. -On 4/5/24 at 12:11 P.M., the resident lay in bed, and his/her catheter hung on the right side of the bed. The catheter tube was looped upward with approximately 15 inches of urine in the tube that failed to drain into the drainage bag. The drainage bag was on the floor with a privacy cover. During an interview on 4/9/24 at 9:01 A.M., the DON said she expected the resident's catheter tubing to be straight so urine can fully drain into the bag. The catheter tube should not have any loops and should not be on the floor. The drainage bag should not be on the floor. The drainage bag is expected to be emptied every eight hours or as needed. She expected staff to notify the nurse with any changes in the urine. 3. Review of Resident #23's admission MDS, dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine), always incontinent of bowel; -Diagnoses included end stage renal disease (ESRD), atrial fibrillation (a-fib, irregular heart rhythm), pneumonia, asthma, hip fracture, and UTI; The resident's urinary catheter removed on 3/12/24. Observation on 4/5/24 at approximately 9:35 A.M., showed Certified Nursing Assistant (CNA) W and CNA I entered the resident's room with supplies to provide perineal care. CNA W and CNA I donned gloves. CNA W unfastened the resident's brief and wiped the resident's front area. CNA W rolled the resident to his/her right side and wiped the resident's buttock area from front to back. CNA W asked CNA I for a plastic trash bag. CNA W removed his/her gloves and grabbed a bag from CNA I's pocket. CNA W did not perform hand hygiene and donned new gloves, then placed the soiled brief in the plastic trash bag. With the same gloves, CNA W tucked a clean brief under the resident. CNA W and CNA I rolled the resident to his/her back and fastened the resident's brief. Both CNAs removed gloves and washed their hands, picked up the trash and left the resident's room. Observation on 04/05/24 at 12:00 P.M., showed LPN H and CNA J entered the resident's room. CNA J gathered supplies to provide perineal care for the resident. LPN H and CNA J donned gloves. The resident was transferred into bed. LPN H unfastened the resident's brief and assisted the resident to his/her left side. LPN H told the resident they figured out the resident had a urinary tract infection (UTI) and will start antibiotics soon. The resident was rolled to his/her left side. CNA J wiped the resident from front to back and tucked the soiled brief under the resident. CNA J took the new brief and placed it under the resident, then rolled the resident to his/her back and wiped the resident front to back. CNA J did not remove gloves or perform hand hygiene. The new brief has a brown smudge of stool. LPN H removed his/her gloves and left the room. He/She did not perform hand hygiene. LPN H returned with a clean brief. He/She donned gloves and assisted the resident to his/her left side. CNA J wiped the resident's buttock area again as LPN H placed a new brief under resident while wearing the same gloves. The resident was turned to the right and then to his/her back and positioned. LPN H and CNA J secured the resident's brief. CNA J adjusted the resident's blanket to cover the resident with the same gloves. CNA J repositioned the resident. CNA J grabbed the trash with one gloved hand and then adjusted the resident's bed control with the other gloved hand. CNA J set the trash bag down on the floor and went into the bathroom. He/She removed his/her gloves and washed his/her hands. LPN H removed his/her gloves, took the trash and left the room. 4. Review of Resident #3's POS showed an order, dated 12/21/23, for hidradenitis suppurative wounds (a chronic wound cause by inflammation and infection of the sweat glands), cleanse wounds with hypochlorous acid (skin cleanser commonly used for acne), do not rinse, protect peri-wound (skin sounding the wound) with skin protectant, apply self-adherent super absorbent dressing, change dressing daily and as needed when soiled. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: The resident has actual impairment to skin integrity related to diagnosis of hidradenitis suppurativa; -Goal: The resident will have no complications related to the alteration of the skin integrity; -Interventions: follow facility protocols for treatment of injury. Observation on 4/4/24 at 11:45 A.M., showed LPN O cleaned and applied medication to the resident's wound and then with the same gloved hands, went to the dressing cart to retrieve a different dressing. LPN O returned to the resident to complete the dressing change with the same gloved hands. During an interview on 4/9/24 at approximately 12:00 P.M., the DON said nurses should remove gloves prior to retrieving a dressing from the dressing cart. Nurses should follow the policy and procedure to remove gloves, retrieve dressings, sanitize their hands, and apply new gloves prior to completing dressing changes. 5. Review of Resident #20's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Occasionally incontinent of bowel and bladder; -Is resident at risk of developing pressure ulcers: Yes; -Does resident have 1 or more unhealed pressure ulcer at stage 1 or higher: No -Foot Problems: None; -Skin and ulcer treatments: Pressure reducing device for chair and pressure reducing device for bed; -Diagnoses included anemia (body does not have enough healthy red blood cells), diabetes, depression and respiratory failure. Review of the resident's electronic Physician Order sheet (ePOS) showed: -An order, revised 4/4/24, Cleanse left heel with vashe (wound cleanser that contains pure Hypochlorous Acid). Apply Santyl (ointment used in the healing of burns and skin ulcers), calcium alginate (highly absorptive dressing) and border gauze every day for wound care; -An order, revision date 4/6/24 and start date 4/7/24, Cleanse left heel with vashe. Apply Santyl, calcium alginate and border gauze every day for wound care. Observation on 4/4/24 at 4:00 P.M., showed LPN O entered the resident's room. He/She donned gloves and removed the resident's sock to assess the resident's left heel wound. The dressing was soiled with brown/red drainage. LPN O removed the dressing, removed his/her gloves and left the room. LPN O went to the treatment cart that sat outside the resident's room. He/She did not perform hand hygiene or wash his/her hands. LPN O donned gloves at the cart. He/She opened the treatment cart and grabbed supplies. LPN O entered the resident's room and moved a chair next to the side of the resident's bed while wearing the same gloves. He/She went to the resident's bathroom and grabbed a paper towel from the bathroom dispenser and placed the paper towel on the resident's bedside table. He/She then placed the supplies on the paper towel. LPN O did not change his/her gloves. LPN O sat down and had the resident place his/her foot on the LPN's knee. LPN O cleaned the wound and removed his/her gloves. LPN O donned new gloves. He/She did not perform hand hygiene. He/She took the tube of Santyl and a cotton tipped applicator off the paper towel. LPN O pushed up the cream with one hand while he/she held a cotton tip applicator in his/her other hand. LPN O put Santyl on the cotton tip applicator then placed it on the resident's wound. He/She picked up the scissors on the paper towel, grabbed and cut a piece of calcium alginate, then it placed on the resident's heel. LPN O secured with it bordered gauze. He/She cleaned up his/her trash and removed his/her gloves. LPN O did not perform hand hygiene. He/She took the Santyl and put it in the treatment cart. LPN O did not perform hand hygiene after he/she put the Santyl ointment in the treatment cart. Observation on 4/5/24 at 9:59 A.M., showed LPN H donned gloves and entered the resident's room with the treatment cart. LPN H said he/she needed assistance. LPN H walked to the hall and returned to the resident's room when no staff member was available. LPN H did not change his/her gloves. LPN H removed his/her gloves and left the room again. LPN H returned to the room with CNA J and donned gloves. He/She did not wash his/her hands or use hand sanitizer. The dressing appeared to be soiled with a brown and red substance. LPN H said this is treatment was changed daily. LPN H cleaned the wound. LPN H did not remove his/her gloves before he/she applied Santyl, covered it with calcium alginate, and secured it with a bordered gauze. During an interview on 4/9/24 at 12:37 P.M., Regional Nurse M said staff should change their gloves when going from dirty to clean when they provide wound care or perineal care. Hand hygiene should also be performed in between glove changes.

Based on observation, interview and record review, the facility failed to ensure medications are stored in accordance with currently accepted professional principles when the medication room refrigerator temperature was out of range and staff were not checking the temperature per policy, medications were not labeled with resident names, medication carts were left unlocked and not supervised, and schedule II medications were not stored behind two locks for one of one medication room and three of three medication carts reviewed. The facility had one medication room and four medication carts. The census was 41. Review of the facility's Medication Storage policy, dated 9/1/21, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security; -All drugs and biologicals will be stored in locked compartments; -Only authorized personnel will have access to the keys to locked compartments; -During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart; -Schedule II drugs are stored under double-lock and key; -All medications requiring refrigeration are stored in refrigerators. Temperatures are maintained within 36-46 degrees Fahrenheit (F). Charts are kept on each refrigerator and temperature levels are recorded daily by the charge nurse or other designee; -The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed. 1. Observation on 4/5/24 at 6:17 A.M., of the medication room refrigerator, showed the thermometer inside the refrigerator measured 50 degrees F. The medication refrigerator contained insulin and a variety of medications in vials. The Assistant Director of Nursing (ADON) said she is not sure who checks or logs the medication room refrigerator temperatures. Review of the medication room refrigerator temperature log book, located at the nurse's station, dated 4/2024 and reviewed on 4/5/24 at 6:20 A.M., showed: -Monitor temperatures closely; -Record temps twice each workday; -Take action if temp is out of range-too warm (above 46 degrees F) or too cold (below 35 degrees F); -The temperature taken once on the 1st, 2nd, and 3rd and documented as 40 degrees F. Observation on 4/8/24 at 8:34 A.M., of the medication room refrigerator, showed the thermometer inside the refrigerator measured 48 degrees F. 2. Observation of the nurse medication cart on 4/5/24 at 6:07 A.M., with the ADON, showed: -A vial of Lantus, opened with no resident name labeled on the vial; -The ADON said this insulin is shared and not for one resident; -A tube of diclofenac sodium 1% (used to treat arthritis pain topically); -The ADON said she knows which resident the ointment belongs to but is not sure where the bag went. The name is on the bag that is missing. 3. Observation on 4/5/24 at 6:22 A.M., showed the Certified Medication Technician (CMT) medication cart #1 sat at the nurse's station. No staff were present at the nurse's station or in view of the medication cart. The medication cart sat unlocked and contained prescription liquid medications, stock over the counter medications, individual resident prescribed oral medications and a narcotic locked box under one lock. During this time the ADON, CMT D, Certified Nursing Assistant (CNA) F, CMT A, came and went from nurse's station and cart #1 remained unlocked through 6:44 A.M. During an observation and interview on 4/5/24 at 9:01 A.M., CMT A pulled medications from the medication cart for a resident. At 9:06 A.M., CMT A left cart unlocked and went to the medication storage room. At 9:08 A.M., CMT A returned to the medication cart. At 9:15 A.M., CMT A entered a resident's room. The medication cart remained outside the room, unlocked. At 9:18 A.M., one resident walked past the unlocked medication cart. Observation on 4/5/24 at 11:58 A.M., showed no nurses at the nurse's station. Medication cart #1 and medication cart #2, both sat unlocked and contained prescription liquid medications, stock over the counter medications, individual resident prescribed oral medications and a narcotic locked box under one lock. At 12:01 P.M., CMT A returned to nurse's station, medication cart #1 and medication cart #2 remained unlocked in front of nurse's station. At 12:03 P.M., a resident self-propelled in a wheelchair to the vending machines and passed the unlocked cart #2. At 12:06 P.M., medication cart #2 remained unlocked with three residents passing by. No staff were present at the nurse's station. At 12:08 P.M., Regional Nurse M locked the medication cart #2. Observation on 4/8/24 at 8:45 A.M., showed a nurse medication cart locked with the top draw open with insulin pens visible in the top drawer. No staff were present. 4. During an interview 4/9/24 at 8:50 A.M., the Director of Nursing (DON) said it is not acceptable for insulin to be used on more than one resident. If insulin is pulled from stock, it should be labeled with the resident's name. Prescribed creams and ointments should be labeled with the resident's name. She is not sure who is responsible to check the medication room refrigerator temperatures, but it should be per policy. If the temperature is out of range, staff should adjust the temperature and follow up to see if it is an issue that requires maintenance. Medication carts should be locked when not in use and schedule II narcotic medications should be behind a double lock. 50366

Based on interview and record review, the facility failed to ensure each nurse aide had no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date rather than the calendar year, for 4 of 4 sampled Certified Nursing Assistants (CNAs) sampled. The facility identified four CNAs employed for more than a year. The census was 41. Review of the Facility Assessment Tool, updated 3/24/24, completed by the facility, showed: -Total number needed or average: 5-10 Nurse aides; -Staff training/education and competencies: Staff training/education is conducted by in-services; -1 on 1 training education packets with post-tests; -Clinical staff is monitored for 1 on 1 competencies for resident care, resident's rights, abuse prevention and reporting, person centered care, medication pass, transfers, perineal care, intravenous (lV) therapy, wound care, repositioning, restorative, trach care, gastrostomy (G-tube, feeding tube) care, behavioral interventions, physical assessment, documentation, dementia care, COVID-19 care, infection control, mandatory 12 hour for nurse aide training, etc. Review of CNA R's employee file, showed date of hire 11/30/22. No In-service tracking provided based on hire date, to show 12 hours of in-service training provided. Review of CNA F's employee file, showed date of hire 12/10/20. No In-service tracking provided based on hire date, to show 12 hours of in-service training provided. Review of CNA S's employee file, showed date of hire 3/3/06. No In-service tracking provided based on hire date, to show 12 hours of in-service training provided. Review of CNA T's employee file, showed date of hire 7/29/16. No In-service tracking provided based on hire date, to show 12 hours of in-service training provided. During an interview on 4/9/24 at 10:38 A.M., the Director of Nursing (DON) said she was responsible for the in-service and training of the CNAs. Regional Nurse M said nursing and Human Resources are responsible as well. The DON said she was behind on training for March 2024 and had not started April 2024. During an interview on 4/9/24 at 12:06 P.M., the DON said she was looking for the binder that held the training; however, she had a binder with sign in sheets for every month. Review on 4/9/24 at 12:06 P.M., showed a binder of in-service training provided by the facility. No documented number of hours for each in-service provided, no individualized tracking record for individual CNAs. During an interview on 4/9/24 at 12:33 P.M., Regional Nurse M said she would expect the CNA 12-hour training to be documented and reflect at least twelve hours of in-service training per year. She would expect nursing to have a system in place to provide evidence the facility can produce that demonstrates the in-service education.

Based on observation, interview, and record review, the facility failed to ensure resident care plans were comprehensive, person-centered and were developed based on the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) care area assessment summary (CAAS), for four of 14 sampled residents (Residents #33, #23, #188, and #187). The census was 41. Review of the facility's Comprehensive Care Plans policy, dated 9/1/21, showed: -It is the policy of this facility to develop and implement a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment; -The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed; -The compressive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All CAAS triggered by the MDS will be considered in developing the plan of care; -The comprehensive care plan will describe, at a minimum the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. 1. Review of Resident #33's Hospital Discharge Summary, dated 2/15/24, showed: -Diagnoses included acute on chronic respiratory failure, pneumonia, end-stage chronic obstructive pulmonary disease (COPD, lung disease) with acute exacerbation, recent facial burns, difficulty swallowing, and high blood pressure; -History significant for end-stage COPD, on 3 liters of home oxygen, recent facial burns that occurred smoking while using oxygen requiring admission to a burn center. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -Used a wheelchair; -Supervision or touch assistance required for eating, oral hygiene, toileting hygiene, and upper body dressing; -Substantial/maximal assistance required for lower body dressing, putting on/taking off footwear, and personal hygiene; -Partial/moderate assistance required to roll left and right and sit to lying; -Substantial/maximal assistance (helper does more than half of the effort) required for lying to sitting, sit to stand, and chair/bed-to-chair transfer; -Partial/moderate assistance required for toilet transfer and tub/shower transfer; -Walking not attempted due to medical condition or safety concerns; -Frequently incontinent of bowel and bladder; -Diagnoses included heart failure, high blood pressure, pneumonia, asthma or other lung disease, respiratory failure. cataracts, glaucoma, or macular degeneration; -On a scheduled pain medication regimen, received as needed pain medications, received non-medication interventions for pain; -Presence of pain: Yes, occasionally. Occasionally effects sleep. Occasionally interferes with therapy activities and day to day activities; -Pain rating: 6 (0 indicates no pain and 10 indicates the worse pain imaginable); -Received oxygen therapy; -CAAS: visual function, activity of daily living (ADL) functional/rehabilitation potential, urinary incontinence, psychosocial well-being, nutritional status, dehydration/fluid maintenance, pressure ulcer, and pain triggered and indicated by the facility as incorporated into the comprehensive care plan. During an observation and interview on 4/4/24 at 1:03 P.M., the resident lay in his/her room in bed. Oxygen on at 2.5 liters per simple face mask. The resident said he/she had a dry nose and he/she used the mask because of it. When he/she eats, he/she cannot breath because he/she cannot breath from his/her nose. Observation at this time showed the resident's right nasal opening with significant scar tissue and the nasal opening very small. The resident said he/she gets very short of breath. He/She has constant left hip pain due to arthritis and gets ibuprofen. He/She has anxiety and wishes someone would just sit and listen to his/her concerns. He/She always wears oxygen per mask due to shortness of breath and COPD. He/She is incontinent and staff have to clean him/her. He/She is also blind in one eye. During an interview on 4/4/24 at 2:14 P.M., Licensed Practical Nurse (LPN) B said the resident uses oxygen at 2-3 liters per mask. He/She cannot find an order, but there should be an order. The resident has difficulty breathing from his/her nose. He/She was a smoker but quit after he/she got burnt. He/She is blind in the right eye per the progress notes. The resident does have shortness of breath. The right nostril has issues, and it causes shortness of breath. That is why the resident wears an oxygen mask. When having shortness of breath, raising his/her head of bed helps. He/She does have anxiety because he/she thinks he/she is not breathing and feels his/her nostril is tight. He/She only has occasional pain. Staff to have to assist with care but he/she is not sure how much assistance he/she needs to do things, such as transfer. During an interview on 4/4/24 at 2:31 P.M., Certified Medication Technician (CMT) C said staff assist the resident with assist of one, but the resident can do stuff on his/her own. His/Her preference is to not get out of bed. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: Activity intolerance due to refuses participation: -Goal: Resident will maintain optimum activity level; -Interventions: Encourage resident to set small obtainable activity goals. Encourage times of rest and relaxation between care activities; -Focus: Potential for impairment to skin integrity: -Goal: Maintain or develop clean and intact skin; -Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Provide preventative skin care; -The resident's respiratory issues, need for a simple face mask for oxygen, shortness of breath, and history of facial burns were not included in the care plan with goals and interventions; -The resident's incontinence of bowel and bladder and need for assistance with ADL care were not included in the care plan; -The triggered CAAS for ADL care, urinary incontinence, vision and pain were not on the care plan. During an interview on 4/4/24 at 3:02 P.M., the MDS Coordinator said the care plan is updated by the Director of Nursing, herself, and other department heads, such as activities and social services. She would expect respiratory concerns such as those the resident has to be on the care plan. It should include goals for care and interventions to address the problems. Any CAAS triggered and identified as incorporated into the care plan should be on there. 2. Review of Resident #23's admission MDS, dated [DATE], showed: -Cognitively intact; -Indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine), always incontinent of bowel; -Diagnoses included end stage renal disease (ESRD), atrial fibrillation (a-fib, irregular heart rhythm), pneumonia, asthma, hip fracture, and urinary tract infection (UTI). Review of the resident's electronic medical record (EMR), showed a progress note dated 3/9/24 at 3:09 P.M., resident arrived at facility via ambulance with two attendants. Resident with a recent fall at home. He/She was hospitalized with diagnosis of femur fracture. The resident can make his/her needs known. The resident has a 16 French (F, catheter size)/10 milliliter (ml, the amount of ml used to inflate the balloon inside the urinary catheter) catheter in place. The catheter draining to gravity with yellow urine. The physician notified and medications verified. The pharmacy notified of new admit. Review of the resident's electronic Physician Order Sheet (ePOS) showed: -An order start date 3/11/24 and end date 3/18/24, voiding trial to begin after catheter is discontinued on 3/12/24 for 24 hours. Document urine output every shift. If unable to void (urinate), notify physician for orders to reinsert indwelling catheter every shift for voiding trial after discontinue of catheter; -An order start date 3/12/24, indwelling catheter to be discontinued on 3/12/24 and begin voiding trial. One time only for catheter removal for one day. Review of the resident's care plan, initiated and revised on 4/3/24, showed: -Problem: The resident has a catheter; -Goal: The resident will show no signs/symptoms of urinary infection through the review date; -Intervention: The resident has a catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door; Monitor/document for pain/discomfort due to catheter. Provide catheter care every shift. Observations of the resident in his/her room on 4/3/24 at 9:00 A.M. and 4/4/24 at 11:15 A.M., showed no urinary catheter tubing or bag. During an interview on 4/4/24 at 11:25 A.M. , the resident said he/she does not have a urinary catheter. He/She has not had one since he/she was in the hospital. During an interview on 4/5/24 at 8:50 A.M., LPN K said the resident does not have a catheter. The resident used to when he/she first came to the facility. During an interview on 4/5/24 at 9:10 A.M., LPN H said the resident does not have a catheter. 3. Review of Resident #188's admission MDS, dated [DATE], showed: -Cognitively intact; -Little Interest or pleasure in doing things: Yes, Frequency: 2-6 days (several days); -Feeling down, depressed, or hopeless: Yes, Frequency: 7-11 days (half or more the days); -Trouble falling or staying asleep, or sleeping too much: Yes, Frequency: 12-14 days (nearly every day); -Feeling tired or having little energy: Yes, Frequency: : 7-11 days (half or more the days); -Feeling bad about yourself: Yes, 7-11 days (half or more the days); -Frequently incontinent of bowel and bladder; -Diagnoses include anemia (condition in which the body does not have enough healthy red blood cells), diabetes, asthma, respiratory failure, ESRD, and heart failure; -CAA area triggered and indicated as addressed on care plan: Psychosocial well-being and mood state. Review of the resident's quarterly MDS, dated [DATE], showed: -Mild cognitive impairment; -Mood: Should Resident Mood Interview be Conducted: Yes; -Little Interest or pleasure in doing things: Yes, Frequency: 12-14 days (nearly every day); -Feeling down, depressed, or hopeless: Yes, Frequency: 12-14 days (nearly every day); -Trouble falling or staying asleep, or sleeping too much: Yes, Frequency: 12-14 days (nearly every day); -Feeling tired or having little energy: Yes, Frequency: 12-14 days (nearly every day); -Trouble concentrating on things: Yes, 7-11 days (half or more the days); -Occasionally incontinent of bladder, Frequently incontinent of bowel; -Diagnoses include heart failure, ESRD, diabetes, and respiratory failure. Review of the resident's EMR, showed: -A note at the top banner that said the resident's spouse is not allowed to have any information; -A progress note, dated 2/29/24 at 4:50 A.M., resident returned from emergency department (ED) via Emergency Medical Services (EMS). Resident stated, he/she did not want his/her spouse to be told anything about him/her. Staff asked the resident is this really what he/she wants or is this because he/she and his/her spouse were arguing in the ED. Resident stated they go back and forth a lot, sometimes he/she does not want his/her spouse to know anything and other times it is okay to tell him/her. Staff made the resident aware that staff will not be going back and forth on yes we can talk to him/her and no we cannot talk with him/her. Staff informed the resident that the decision needs to be consistent. Resident then stated, do not tell him/her anything. Nurse made aware; -A progress note, dated 2/29/24 at 1:29 P.M., spouse came to facility to see resident and asked this nurse how he/she was doing and did staff know about his/her behavior in the ER. This nurse stated he/she could not discuss his/her care with him/her. He/She asked if this was the resident's choice. Staff stated he/she could not discuss his/her care with him/her. He/She then handed staff his/her amazon packages and stated to tell him/her that he/she could perform sexual things on himself/herself. Staff asked him/her to leave. He/She has left and returned two times at this point. The first time a staff from human resources was in the room and the resident asked him/her to leave. The spouse found this nurse and stated he/she was going to call his/her lawyer because this marriage was over. Then continued to ask questions about his/her care which staff told him/her staff could not answer and asked him/her to leave. He/She just returned with his/her lawyers name to contact if he/she kicks the bucket. Then he/she is dead; -A progress note, dated 3/6/24 at 10:58 A.M., Resident resided alone in a house, his/her spouse in another home. Resident home is unkept and per spouse resident is a hoarder at baseline; -A progress note, dated 3/30/24 at 12:00 A.M., Resident demanding to be up in the recliner. Resident assisted to his/her recliner. After in recliner, he/she had all of his/her clothes off and thrown on the floor. [NAME] and trash thrown everywhere. Resident's feet were hanging down and noted some edema (swelling) starting. Resident encouraged to keep his/her feet up for one hour. Resident started yelling and waking other residents up, was put back to bed. Resident was becoming hostile but encouraged him/her to sleep; -A progress note, dated 4/4/24 at 1:53 P.M., Resident has requested to change his/her request to allow his/her wife to receive any information about this resident. This writer edited his/her face sheet. During an interview on 4/3/24 at 11:20 A.M., the resident said he/she did not want his/her spouse to be given information because he/she worries and has obsessive compulsive disorder (OCD). The resident said they have been married since 1996 and he/she did not talk to the resident for two months over that decision to not provide information. During an interview on 4/4/24 at 3:36 P.M., LPN O said the resident's mood/mental status goes up and down. Sometimes he/she is very ok. Sometimes he/she is upset over his/her spouse. LPN O said the resident told him/her that his/her spouse used to beat him/her up. The resident has some memory loss and can be in left field sometimes where you do not what he/she is talking about. He/She is aware most of the time. The resident also likes to be naked even when he/she is out of his/her room. During an interview on 4/5/24 at 915 A.M., LPN H said the resident does not really have specific behaviors, but he/she will get frustrated sometimes on how staff do things for him/her. He/She will want to do things a different way. Overall, he/she is cooperative. When staff tried to assist him/her out of bed, staff could tell he/she got frustrated. Staff just stopped and asked him/her how he/she wants to be helped. Review of the resident's care plan, initiated and revised on 4/3/24, showed: -Focus: The resident has depression; -Goal: The resident will remain free of signs/symptoms of distress, symptoms of depression, anxiety or sad mood by/through the review date; -Interventions: Administer medications as ordered. Arrange for psychiatric consult, follow up as indicated. Monitor/document/report PRN (as needed) any risk for harm to self. Monitor/document report PRN any signs/symptoms of depression. Monitor/record/report to physician PRN risk for harming other. Pharmacy review monthly or per protocol; - The care plan did not address the resident's behaviors or interventions for care when the resident has behaviors, such stopping and asking the resident how he/she wanted to be helped; -No psychosocial well-being, mood state listed on the resident's care plan, as triggered in the CAAs. 4. Review of Resident #187's admission MDS, dated [DATE], showed: -Cognitive assessment not completed with the resident; -Signs and Symptoms of Delirium: -Inattention: Behavior present, fluctuates (comes and goes, changes in severity); -Disorganized thinking: Behavior present, fluctuates (comes and goes, changes in severity); -Should resident mood interview be conducted: Yes; -Resident Mood Interview: Only first two answered below; -Little interest or pleasure in doing things: No response; -Feeling down, depressed, or hopeless: No response; -Verbal behavioral symptoms directed towards others: Behavior of this type occurred 4 to 6 days but less than daily; -Significantly interfere with the resident's care: Yes; -Significantly disrupt care of living environment: Yes; -Rejection of Care-Presence and Frequency: Behavior of this type occurred 4 to 6 days , but less than daily; -Diagnoses include ESRD, UTI (last 30 days), and low sodium; -Care areas checked as triggered and indicated as addressed in care plan: Delerium, cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence, psychosocial well-being, behavioral symptoms, nutritional status, dehydration/fluid maintenance, pressure ulcer; Review of the resident's All-Inclusive Admission and Readmission Assessment, showed: -Admission 3/21/24; -Adjustment Concerns/Behaviors include: Current smoker, alcohol regularly-daily or most days, history of alcohol dependence, drug use-rarely; -Mood/Behavior: Behavior concerns angry and anxiety. Review of the resident's Psychosocial Admission Assessment, dated 3/26/24, included: Resident verbally aggressive toward staff trying to give care. Resident verbalizes just wanting to be left alone. During an interview on 4/4/24 at 3:36 P.M., LPN O said the resident refuses care and cusses everyone out. LPN O said oh my God, yes when asked if the resident has behaviors. Sometimes talking to the resident will help to calm him/her down but not really if he/she is demanding something. When the resident wants something, he/she wants something. The resident can be high strung and anxious. LPN O said he/she was told the resident is a recovering addict and just seems angry. The resident has pain but due to history of drug abuse, the physician does not want to give anything stronger than Tylenol. As far as bothering the residents, some of them get tired of the resident's cussing. LPN O said he/she was told the resident's parents dropped him/her off and put a restraining order on the resident. The cops dropped off the papers last week. The resident is supposed to be discharged to an alcohol rehabilitation soon. The resident is very narcissistic to nurses. During an interview on 4/5/24 at 9:00 A.M., LPN K said the resident does have behaviors. He/She just tries not to argue with the resident. Earlier this morning the resident was ranting about the quality of the food. Then staff agreed with the resident, and he/she started laughing. Better to agree with the resident if you can. The resident seems to like it when someone argues with him/her and gives him/her a reason to argue and keep going with the argument. The resident seems angry, so staff pick their battles. He/She cannot always agree with what the resident says. The resident does seem to react better to men. He/She also loves whoever takes him/her out to smoke. During an interview on 4/5/24 at 9:15 A.M., LPN H said as far as behaviors for the resident, the answer is yes and no. It is more cussing. The resident does not usually bother other residents. Once he/she said something to him/her when he/she came out of his/her room and the resident told him/her to shut up. For the most part, if you remain calm and do not say anything he/she will calm down. During an interview on 4/9/24 at 12:37 P.M., Regional Nurse M said if a resident has a history of calling out or yelling those behaviors should be care planned. However, this resident was not at the facility long enough to do a comprehensive care plan. That would play a part in behaviors not on the care plan. When we do the admission, the things we know generate the baseline care plan. The facility knew about the drugs but not about the behaviors. Review of the resident's care plan, in use at the time of the survey, showed: -The comprehensive care plan not developed within 7 days after completion of the comprehensive assessment; -The care plan did not show focus for alcohol abuse or behaviors as mentioned in the baseline care plan upon admission. 5. During an interview on 4/9/24 at 12:37 P.M., Regional Nurse M said the care plans are updated quarterly with the MDS. He/She would expect the care plan to be accurate. 44950

Based on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in a sufficient detail to enable accurate reconciliation. The facility failed to ensure accuracy and monitoring for controlled substances for 2 of 2 narcotic count books reviewed. The census was 41. Review of the facility's Controlled Substance Administration & Accountability policy, dated 9/1/21, showed: -It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure; -Policy Explanation and Compliance Guidelines: Inventory Verification: For areas without automated dispensing systems, two licensed nurse or per state regulation account for all controlled substances and access keys at the end of each shift. Review of the facility's Narcotics Book #1 and Narcotics Book #2, reviewed on 4/5/24 at 6:22 A.M., showed: -The sheet contains eight columns: Shift, Date, Starting Count, Cards In, Cards Out, Ending Count, Off Going Nurse, On Coming Nurse; -The sheet prompted for a day/night and night/day count for each shift change. 1. Review of the Narcotics Book #1, on 4/5/24 at 6:22 A.M., showed a controlled substance shift change count sheet, starting date 2/26/24 and ending date 3/10/24: -No day/night count completed for four of 28 opportunities; -No night/day count completed for three of 28 opportunities; -Only one nurse signature for the count for eight of 28 opportunities. 2. Review of the binder labeled Narcotics Book #2, on 4/4/24 at 6:22 A.M., showed a controlled substance shift change count sheet, starting 3/17/24 and ending date 4/3/24: -No day/night count completed for eight of 26 opportunities; -No night/day count completed for eight of 26 opportunities; -Only one nurse signature for the count for 16 of 26 opportunities. -The off going nurse pre-signed the narcotic count sheet for off going with no date listed. 3. During an interview on 4/5/24 at 7:01 A.M., the Assistant Director of Nursing (ADON) said she worked the night shift. The narcotic count process is confusing. There are times she must count narcotics by herself. Last night when she came on duty, the day shift nurse left before they counted narcotics, so she had to count by herself. The process is, the oncoming and off going count together. The off going marks the book, the oncoming nurse physically counts. First count the number of cards in the cart total, then we count the number of pills in each card. 4. During an interview on 4/9/24 at 8:02 A.M., Licensed Practical Nurse (LPN) B said that nurses are expected to count narcotics at the beginning and end of their shifts. Nurses should not pre-sign the narcotic book before the end of their shift. 5. During an interview on 4/9/24 at 8:50 A.M., the Director of Nursing (DON) said she would expect the nurses to follow the policy and procedures for counting narcotics, not pre-sign before the oncoming shift, there is always someone to count with.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 38 opportunities observed, 11 errors occurred resulting in a 28.94% error rate (Residents #27, #6 and #28). The census was 41. Review of the facility's Medical Provider Orders policy, dated 9/1/21, showed: -This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of the facility's Medication Administration policy, dated 9/1/21, showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs out of the physician's prescribed parameters; -Verify the resident's name, medication name, form, dose, route, and time; -Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician; -Administer medication as ordered in accordance with manufacturer specifications; -Provide appropriate amount of food and fluid; -Medication requiring vital signs prior to administration: Anti-hypertensives (used to treat high blood pressure). 1. Review of Resident #27's medical record, showed: -Diagnoses included diabetes, peripheral vascular disease (reduced circulation of blood), and iron deficiency anemia (insufficient iron in the blood); -An order, dated 9/18/23, for blood sugar checks before meals and at bedtime. Notify medical doctor (MD) if lower than 60 or over 400; -An order, dated 1/28/24, for Insulin Glargine (long acting insulin) subcutaneous (under the skin) solution Pen-injector 100 units/milliliter (ml). Inject 28 unit subcutaneously in the morning; -An order for Lispro (short acting insulin) subcutaneous solution Pen-injector 100 unit/ml. Inject 5 unit subcutaneously before meals; -An order for Insulin Lispro subcutaneous solution Pen-injector 100 unit/ml. Inject as per sliding scale: if 0-200 = 0 No sliding scale indicated for blood sugar less than 200; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; BS 401 or above call MD. Subcutaneously before meals. -No nursing documentation in the progress notes on 4/5/24, 4/6/24, and 4/7/24 that the resident had refused the ordered dose of insulin; -The Assistant Director of Nursing (ADON) documented in the Medication Administration Record (MAR) that the resident refused the Lispro sliding scale insulin. During a medication administration observation on 4/5/24 at 6:46 A.M., the resident obtained his/her blood sugar level using an implanted electronic device and reported to the ADON that his/her blood sugar was 327. The ADON told the resident that she was going to administer the insulin as ordered and the resident refused. The resident told the ADON to give only 18 units of the Glargine and the ordered 5 units of Lispro. The ADON administered the insulin per the resident request to the left lower quadrant of his/her abdomen. During an interview on 4/5/24 at approximately 6:50 A.M., the ADON said that she did administer the resident's requested amount of insulin and would make the Director of Nursing (DON) aware. During an interview on 4/9/24 at 8:02 A.M., Licensed Practical Nurse (LPN) B said that insulin should be administered as ordered by the physician, not as requested by the resident. If the ordered amount is refused the physician should be notified. The nurse should document in the medical record the refusal and physician notification. During an interview on 4/9/24 at 8:50 A.M., the DON said that nurses should follow the policy and procedure for insulin administration. The nurses should not allow the residents to dictate the amount of insulin to be administered, the nurse should notify the physician, and the nurse should document in the resident's progress notes the resident's refusal and physician notification. 2. Review of Resident #6's medical record, showed: -An order start date 2/28/24, for aspirin enteric coated delayed release, 81 milligram (mg) one time a day for prevention of cardiac event, scheduled administration time 10:00 A.M.; -An order start date 2/28/24, for fluticasone propionate suspension (an inhaled steroid) 50 micrograms (mcg), two sprays in each nostril one time a day for sinus, scheduled administration time 10:00 A.M.; -An order start date 2/28/24, for GlycoLax powder (stool softener). Give 17 grams by mouth one time a day for constipation; -An order start date 2/28/24, for cyanocobalamin (vitamin B12) 1000 mcg. One tablet by mouth one time a day for supplement; -An order start date 2/28/24, for clonazepam (used to treat anxiety or seizure disorders), 0.5 mg. Give one tablet by mouth two times a day, scheduled administration times of 10:00 A.M. and 6:00 P.M.; -An order start date 2/28/24, for sennosides-docusate sodium (stool softener) 8.6-50 mg. Give one tablet by mouth tow times a day for constipation; -An order start date 3/18/24, for Lidocaine patch (pain medication) 4%. Apply to right shoulder topically one time a day for pain and remove per schedule. Scheduled removal time, 9:59 A.M. Scheduled application time 10:00 A.M.; -No order for vitamin D3. Observation on 4/5/24 at 8:55 A.M., showed CMT A administered medications to the resident. CMT A said the facility does not have open medication pass. Medications are to be administered up to one hour before or one hour after the scheduled administration time. The resident's clonazepam was not available for administration, so the resident would not receive it and he/she would need to call the pharmacy. CMT A administered aspirin 81 mg chew and said the resident is ordered aspirin enteric coated but the facility only had the chewable tablets. CMT A administered vitamin D3 400 iu orally and applied a lidocaine patch 4% to the resident's lower back. Vitamin B12, fluticasone propionate, GlycoLax powder, and sennosides-docusate sodium not administered. During an interview on 4/5/24 at 12:01 P.M., CMT A said he/she had not gone back to administer the resident any other medications after the observed medication pass and the only medication administered prior to the observation was the resident's 6:00 A.M. scheduled medication. He/She usually removes the prior lidocaine patch prior to administering the new patch. He/She removed the prior lidocaine patch from the resident's shoulder just prior to the medication administration observation. During an interview on 4/9/24 at 8:50 A.M., the DON said if a resident is ordered a certain form of a medication, such as enteric coated or chewable, the correct form should be administered. If a topical patch is ordered, it should be applied in the correct location. There should be an order for any medication administered. Staff should follow the order for lidocaine patches as far as how long they can stay on. She did not know what recommendations are per acceptable standards of practice but would expect the physician order to follow acceptable standards of practice. Review of the National Library of Medicine- Medline Plus website, last revised 6/15/21, showed: -Prescription lidocaine transdermal is applied only once a day as needed for pain. Never wear them for more than 12 hours per day (12 hours on and 12 hours off); -If you wear too many lidocaine transdermal patches or topical systems or wear them for too long, too much lidocaine may be absorbed into your blood. In that case, you may experience symptoms of an overdose; -In case of overdose, call the poison control helpline; -Symptoms of overdose may include: lightheadedness, nervousness, inappropriate happiness, confusion, dizziness, drowsiness, ringing in the ears, blurred or double vision vomiting, feeling hot, cold, or numb, twitching or shaking that you cannot control Seizures, , loss of consciousness, and slow heartbeat. 3. Review of Resident #28's medical record, showed: -Diagnoses included, chronic obstructive pulmonary disease (COPD, lung disease), high blood pressure, depression, and pain; -An order dated 8/31/23, for Losartan Potassium (treats high blood pressure) 100 mg, one time a day, staff to document blood pressure; -An order dated 3/18/24, for polyethylene glycol powder (stool softener), house stock, 17 grams daily. During a medication administration observation on 4/5/24 at 9:19 A.M., CMT A: -Administered Losartan Potassium 100 mg to the resident prior to obtaining the residents blood pressure; -Poured the polyethylene glycol powder in to a clear 30 ml medication cup at eye level. Then poured water into a clear 5-ounce (oz) cup, poured the powder into the water and stirred, then administered to the resident. While preparing the medication CMT A said I know this goes into 8 oz of water, but they only supply us with the small cups; -After administration of all the medication, CMT A went back into the room to obtain the blood pressure, which resulted in 147/93 (indicates high blood pressure). During an interview on 4/5/24 at 10:12 A.M., with LPN K, he/she was able to produce a bottle of the polyethylene glycol powder but was not able to find the directions regarding the amount of liquid that must be used to reconstitute the powder. During an interview on 4/9/24 at 8:50 A.M., the DON said the nurses should follow the policy and procedures for medication administration. When preparing the polyethylene glycol powder the staff should follow the directions, using the correct size measuring device and the correct amount of fluid. For those residents who receive medications for high blood pressure, that indicate a blood pressure to be taken, she would expect the staff to obtain the blood pressure prior to administering the medication. During a phone interview on 4/8/24 at 11:31 A.M., Pharmacist U, a pharmacist with the pharmacy that supplies the facility's medications, said polyethylene glycol powder is a house stock medication and is typically mixed with 8 oz of water or juice. 4. During an interview on 4/9/24 at 8:50 A.M., the DON said medications should be administered as ordered. This includes the correct medication, dose, route and time, per facility policy. 49992

Based on observation, interview, and record review, the facility dietary staff failed to follow proper hand hygiene while preparing food for the steam table when staff did not remove his/her gloves after he/she touched/rubbed/adjusted his/her clothing, touched their face mask, and the inside of the kitchen door frame using both gloved hands, and wiped off counter tops with a stained wet dish rag. Additionally, the facility dietary staff failed to maintain cold fruit at a temperature of 41 degrees Fahrenheit (F) or less on two separate days of observation, to prevent foodborne illness, prior to it being served to the residents in the facility. The sample size was 14. The census was 41. Review of the facility's Hand Hygiene Policy, dated 9/1/21, showed: -Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility; -Hand hygiene: is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR); -Policy Explanation and Compliance Guidelines: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Review of the Centers for Medicare and Medicaid Services State Operations Manual (SOM): Appendix PP Guidance to Surveyors for Long-Term Care Facilities Food Procurement, Store/Prepare/Serve-Sanitary, revised 11/2017, showed: -Definitions: --Critical Control Point: a specific point, procedure, or step in food preparation and serving process at which control can be executed to reduce, eliminate, or prevent the possibility of a food safety hazard; --Cross-contamination: the transfer of harmful substances or disease-causing microorganisms to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils; --Water percentage of the food. Foods that have a high level of water (e. g., fruits and vegetables) encourage bacterial growth; -Time and temperature control of the food: --The longer food remains in the danger zone, the greater the risks for growth of harmful pathogens. Bacteria multiply rapidly in a moist environment in the danger zone; --Danger Zone: temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness; --Refrigerated Storage: Potentially Hazardous Foods (PHF)/Time/Temperature Control for Safety (TCS) foods must be maintained at or below 41 degrees F, unless otherwise specified by law. Refrigeration prevents food from becoming a hazard by significantly slowing the growth of most microorganisms. Inadequate temperature control during refrigeration can promote bacterial growth. 1. Observation on 4/4/24 at 11:45 A.M., showed Dietary Cook Q put his/her gloves on, adjusted the bill on his/her cap, slid his/her hands down the side of his/her pants, walked to the doorway leading to the dining room, and leaned onto the door frame with gloved hands. He/She came back into the kitchen near the stove and opened a bottle of water, with the same gloved hands. He/She was cued by the Registered Dietician to wash his/her hands and change gloves. During the same observation, Dietary Cook Q changed his/her gloves, touched the trash can lid under the sink nearest the steam table, touched his/her face mask, and then picked up an empty water pitcher, placed two fingers inside of the water pitcher, and then placed it upside down on a metal storage rack located against the wall. With the same gloved hands, he/she picked up a white wet wash rag and cleaned off the metal table countertop, after which, he/she grabbed a cutting board, large knife, and began chopping up cauliflower with the same gloved hands. He/She scrapped the cauliflower into a metal container and placed the container onto the steam table using the same gloved hands. During an interview on 4/9/24 at 8:50 A.M., the Director of Nursing said staff should follow the hand hygiene policy. 2. Observation on 4/3/24 at 11:57 A.M., showed mandarin oranges for the lunch meal on the countertop covered with a food tray. They had been left out of the refrigerator. Approximately seven cups of mandarin oranges were served to residents. After the mandarin oranges went out to the residents, the Dietary Manager took the temperature of the mandarin oranges. The temperature measured 66.9 degrees F; During an interview on 4/3/24 at 11:57 A.M., the Dietary Manager told a kitchen helper to put the mandarin oranges back into the refrigerator to chill. He said he told staff a million times to keep the fruit and other cold items cold. Observation that time, showed the dietary aide put the mandarin oranges back into the refrigerator. 3. Observation on 4/4/24 at 11:55 A.M., showed the Registered Dietitian measured the temperature of the lunch time tropical fruit. The temperature measured 51 degrees F. During an interview on 4/4/24 at 11:55 A.M., the Registered Dietitian said the fruit had been in the refrigerator all morning, but staff should probably put it in at nighttime to be sure it was chilled.

Based on observation, interview and record review, the facility failed to ensure residents allowed to self-administer medications had been assessed by the interdisciplinary team to ensure the residents were knowledgeable and safe to self-administer medications and ensure there was a physician order for medication self-administration for two residents observed with medications left at the bedside (Residents #4 and #7). The census was 41. Review of the facility's undated Self-Administration of Medications policy, showed: -To maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if they facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer; -If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual abilities to carryout this responsibility during the care planning process; -For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition; -If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. Review of the facility's Admission Packet, showed Resident rights. No medication will be kept in the Resident's room or possession unless in accordance with the Plan of Care. 1. Review of Resident #4's medical record, reviewed on 4/3/24, showed: -An order dated 9/30/21, for Proventil hydrofluoroalkane (HFA) aerosol solution 90 microgram (McG)/puff (albuterol sulfate HFA, used to treat asthma) 2 inhalation inhale orally every 6 hours as needed for shortness of breath; -An order dated 8/4/23, for albuterol sulfate (used to treat lung disease and asthma) nebulization solution (2.5 milligram (mg)/3 milliliter (ml)) 0.083% 3 ml inhale orally via nebulizer every 4 hours as needed for shortness of breath; -An order dated 8/14/23, for Trelegy Ellipta (used to treat lung disease) inhalation aerosol powder breath activated 100-2.5-25 McG/puff 1 puff inhale orally one time a day related to chronic obstructive pulmonary disease (COPD, lung disease); -An order dated 9/7/23, for ipratropium-albuterol solution 0.5-25, 3 mg/3 ml per 1 vial, inhale orally every 6 hours related to COPD every 6 hours; -No order to self-administer medications; -No assessment to self-administer medications. Observation and interview on 4/3/24 at 9:35 A.M., showed the resident in his/her room. Three inhalers in a zip lock bag sat on the resident's bed and 4 vials of nebulizer medications sat on the nebulizer machine and bedside table. Liquid noted in the nebulizer medication chamber. The Resident said he/she is waiting on staff to fix his/her nebulizer so he/she can use it. He/She has requested the new part. He/She uses the nebulizer every 6 hours but has not used it this morning because a piece is missing. At approximately 10:00 A.M., the resident said the breathing machine part is still missing. Observation showed the resident had a fluticasone propionate inhaler, Trelegy inhaler and Proventil inhaler at the bedside. At 10:28 A.M., the Director of Nursing (DON) came into the room to check on the resident and the resident reported the missing nebulizer part. The DON left the room and brought in a new nebulizer chamber and tubing and applied it to the machine. During an observation and interview on 4/4/24 12:05 P.M., the resident said he/she has had his/her medications at bedside since he/she came to the facility. Nurses leave a couple nebulizer vials of medication, and he/she self-administers the vials with the nebulizer machine. Observation at this time showed 4 nebulizer vials of medication at the bedside. Observation and interview at 1:23 P.M., showed the resident picked up the Proventil and said he/she takes it when necessary, he/she does not know how often, probably two times a day when he/she coughs. He/She cannot read the label. He/She does not use very much of it but is needing it more and more. The Trelegy is very important, he/she takes it one time a day in the morning. The Resident held the fluticasone propionate and attempted to read the label and said he/she takes this medication in the afternoon and it's very hard to use it really as he/she attempted to open the medication. Observation showed the resident now had 5 nebulizer vials at the bedside. The Resident said he/she takes them every 6 hours/four times a day. He/She watches the clock to know when to take it. The staff wash the cup to the nebulizer out once a week. He/She does rinse his/her mouth out after the nebulizer because it tastes bad. During an interview with the DON and Regional Nurse L on 4/4/24 at 12:28 P.M., they said there are no orders for self-administration and no assessment for self-administration of medications completed for the resident. During an interview on 4/4/24 at 1:13 P.M., the DON said she reached out to Physician N and received an order for the resident's self-administration assessment to be completed and if the resident passes the test, Physician N gave an order for self-administration. 2. Review of Resident #7's medical record, showed: -An order start date 4/26/22, for daily-vitamin one tablet one time a day related to vitamin deficiency, scheduled administration time 10:00 A.M.; -An order start date 4/26/22, for oxybutynin 5 mg extended release. One tablet one time a day related to overactive bladder, scheduled administration time 10:00 A.M.; -An order start date 3/9/24, for sertraline HLC 150 mg one tablet daily for depression; -No assessment to self-administer medications. Observation on 4/4/24 at 12:46 P.M., showed the resident not in his/her room, a medication cup sat on the resident's bedside table and contained one yellowish colored round pill and one blue oval pill. At 3:07 P.M., the resident sat in his/her room and said he/she took his/her pills when he/she returned to his/her room after lunch. He/She does not know what the pills were. During an interview on 4/4/24 at 4:40 P.M., the DON said medications should not be left at the bedside. She is not sure if the resident had been assessed safe to self-administer medication. To qualify for self-administration of medications, the resident would need to know what the medications were and know that they could not be left at the bedside unattended. During an interview on 4/9/24 at 8:34 A.M., Certified Medication Technician (CMT) C said the only oval blue pill the resident takes is his/her sertraline HLC. His/Her yellowish round pill is his/her oxybutynin. 50366

Based on interview and record review, the facility failed to ensure the resident assessment was accurately coded for one of three closed resident records reviewed for accuracy of resident assessments (Resident #35). The census was 41. Review of Resident #35's medical record, showed: -discharged [DATE]; -A nursing note, dated 3/18/24 at 6:57 A.M., non-emergent transport was called to arrange transportation to the hospital. Review of the resident's discharge MDS, dated [DATE], showed: -admitted [DATE]; -discharged [DATE]; -Discharge status: Inpatient Rehabilitation Facility (IRF, free standing facility or unit). During an interview on 4/5/24 at 1:41 P.M., the MDS Coordinator said she was aware that the resident was sent to the hospital and she anticipated a return. She did select the incorrect coding for the resident's discharge.

Based on interview and record review, the facility failed to provide sufficient staffing to meet the needs of the residents. On [DATE] from approximately 8:17 P.M. until [DATE] at approximately 5:27 A.M., only one staff person, the Director of Nurses (DON), was present and working in the facility. The DON contacted the Acting Administrator (Administrator #1) and Administrator in Training (AIT) for assistance. The AIT called sister facilities for assistance with staffing. Administrator #1 and the AIT did not come into the facility. One of the facilities could not provide any staff, and the other two did not respond. The census on [DATE] was 50 residents. Thirty eight residents were designated as full code, two residents required total parenteral nutrition (TPN, the intravenous administration of nutrition outside of the gastrointestinal tract), two residents received tube feedings through a gastrostomy tube (g-tube, a tube inserted through the abdomen that brings nutrition directly to the stomach), two residents required intravenous (IV) antibiotics, six residents required assistance of one person for transfers, and 15 residents required two-person assistance for transfers. All residents did not receive routinely scheduled medications, a 10:00 P.M. IV antibiotic for wounds was not administered as ordered (Resident #1), and evening blood glucose checks (sugar found in blood) were not completed for four diabetic residents (Residents #2, #3, #4 and #5). The census was 51. The Regional Director of Operations (RDO) was notified on [DATE] at 3:25 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Facility Assessment Tool, last reviewed on [DATE], showed: -Number of residents licensed to provide care for: 66; -Average daily census: 35; -Number (enter average or range) of persons admitted : -Weekday: ,d+[DATE]; -Weekend: ,d+[DATE]; -Number (enter average or range) of persons discharged : -Weekday: ,d+[DATE]; -Weekend: ,d+[DATE]; -Acuity: -Special treatments and conditions: number/average or range of residents: -IV medications: 0; -Injections: 12; -TPN: not listed; -Tube feedings: not listed; -Assistance with activities of daily living (ADL): -Transfer: -Independent: 6; -Assist of ,d+[DATE] staff: 24; -Dependent: 5; -Toilet use: -Independent: 4; -Assist of ,d+[DATE] staff: 27; -Dependent: 4; -Staff type, included: -Administration (e.g., Administrator, Administrative Assistant, Staff Development, Quality Assurance and Performance Improvement (QAPI), Infection Control and Prevention, Environmental Services, Social Services (SS), Discharge Planning, Business Office, Finance, Human Resources, Compliance and Ethics); -Nursing Services (e.g., DON, Registered Nurse (RN), LPN, CNA, Certified Medication Technician (CMT), Minimum Data Set (MDS) nurse); -Staffing plan: Total number needed, average, or range: -Licensed Nurses providing direct care: ,d+[DATE]; -Nurse Aides: ,d+[DATE]; -Certified Medication Technician: ,d+[DATE]; -Other nursing personnel (e.g., those with administrative duties): 1 DON, 1 Assistant Director of Nursing (ADON), 1 MDS nurse; -Individual staff assignment: -Nurse management makes frequent rounds to evaluate resident needs and review in weekly clinical meeting to determine staffing needs; -Policies and procedures for provision of care: -Policies are reviewed at least yearly and with any change in regulation or according to facility needs. This is done through the QAPI process. Review of the facility's emergency staffing policy, located in the facility emergency preparedness binder, last reviewed on [DATE], showed: -Policy: It is the policy of this facility to establish procedures for handling staffing challenges in the case of an emergency or disaster. Emergency staff may include volunteers with varying levels of skill and training, to include medical and non-medical expertise; -Policy explanation and compliance guidelines: -1. The number of staff required for meeting resident needs on a daily basis are determined through the facility assessment. Schedules shall reflect sufficient staff; -2. The facility shall communicate with federally designated emergency health care professional organizations and other entities, including the state board of nursing, during the emergency plan review process to verify contact information and processes; -3. In an emergency situation, the Administrator and key staff shall meet for briefing on staffing needs and develop an action plan; -4. Staffing needs will be fulfilled in a step-wise fashion: -a. On duty staff and scheduled staff; -b. Off duty staff and on call staff, including department managers; -c. Staff from sister facilities (i.e. owned by same company), and non-medical volunteers who are already on file with the facility; -d. Staff from other facilities with which the facility has a memorandum of understanding on file to provide staff in the event of an emergency or disaster; -e. Staff from receiving facilities who intend to stay and assist with providing care; -f. Volunteers from medical reserve corps (or similar agency available to facility) in which credentialing has been pre-verified; -g. Healthcare professional volunteers who present to the facility to provide assistance; 5. Facility staff are expected to adhere to the emergency staffing plan when there is an identified emergency or disaster in the facility or community: -a. During an emergency, staff currently on duty will be required to stay on duty until they are relieved by other staff. Staff may not leave during an emergency to attend to personal needs; -b. All staff are advised to develop an emergency plan with their family in the event they are required to remain at work during emergency; -c. Staff are expected to make every effort to arrive to work for their regularly scheduled shift. Staff will contact his/her supervisor prior their scheduled shift to inform of their current location and status. Transportation may be arranged, if possible, to assist with getting the staff to work; -d. Staff not on duty may be recalled as dictated by staffing needs. Staff may or may not be recalled to their usual unit. Staff may be assigned to an alternate unit as needed to ensure the safety and welfare of the residents; -e. Every effort shall be made to ensure that no staff work greater than 16 consecutive hours. Staff may be required by the immediate supervisors to remain on-site at the facility after completing their assigned shift to be on-call and immediately available; -6. The RDO or designee shall be responsible for notifying sister facilities and/or other facilities of any staffing needs (as determined by meeting with the Administrator and key staff regarding staffing); -7. The Administrator, or designee, shall notify the authority having jurisdiction of any staffing or assistance needs; -8. Emergency staff and volunteers will report to a single person for allocation of roles and duties based on their credentials and expertise. Security measures will be taken to verify the credentials of healthcare professional volunteers; -9. Non-medical staff and volunteers will only be assigned to and perform non-medical tasks. Review of the facility's Medical Provider Orders policy, last review/revised date of [DATE], showed: -Policy: This facility shall use uniform guidelines for the ordering and following of medical provider orders; -Policy explanation and compliance guidelines: -1. Medications and/or treatments should be administered only upon the signed order of a person lawfully authorized to prescribe; -2. Verbal orders should be received only by licensed nurses, or pharmacists, and confirmed in writing by the medical provider, on the next visit to the facility; -3. Elements of the medication and/or treatment order: -a. Date and time the order is written; -b. Resident's full name; -c. Name of medication and/or treatment; -d. Dosage-strength of medication is included; -e. Time or frequency of administration; -f. Route of administration; -g. Type/Formulation (if applicable); -h. Hour of administration (if applicable); -i. Diagnosis or indication for use; -J. PRN (as needed) orders should also specify the condition, for which they are being administered, (e.g., as needed for sleep); -4. Documentation of Medication and/or Treatment Orders: -a. Each medication and/or treatment order should be documented with the date, time, and signature of the person receiving the order; -b. If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -c. Call, fax, or electronically transmit the medication and/or treatment order to the provider pharmacy; -d. Validate newly prescribed medications and/or treatment is in the electronic MAR/TAR; -e. When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -f. Validate the new order is in the electronic MAR/TAR; -g. Notify resident's sponsor/family of new medication order; -5. Following of Medication and/or Treatment Orders: -a. Medical provider orders should be reviewed prior to administration of medication and/or treatment to validate the orders contains all required elements; -b. Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order; -c. If an order does not contain all the required elements, staff should contact the ordering provider for clarification of the order prior to implementation of the order; -6. Specific Procedures for Medication Orders: -a. Handwritten order signed by the medical provider -The charge nurse on duty at the time the order is received should note the order and enter it on the medical provider order sheet or electronic order format, if not written by the medical provider. If necessary, the order should be clarified before the medical provider leaves the nursing station, whenever possible; -b. Verbal orders - The nurse should document an order by telephone or in person on the medical provider's order sheet or input into electronic record as per facility policy, transmit the appropriate copy to the pharmacy for dispensing, and place the signed copy on the designated page in the resident's medical records. Medical provider orders should be signed per state specific guidelines; -c. Written transfer orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending medical provider, unless the order is unclear or incomplete, or the date signed is different from the date of admission. If the order is unsigned, or signed by another medical provider, or the date is other than the date of admission, the receiving nurse should verify the order with the current attending medical provider before medications are administered. The nurse should document verification on the admission order record, by entering the time, date, and signature. Example: Order verified by the phone with Dr. [NAME]/M. [NAME], R.N.; 1. During an interview on [DATE] at 12:05 P.M., the Staffing Coordinator (SC) said WNBI stands for will not be in and indicates a scheduled staff person will not be reporting for work. Night shift works 7:00 P.M. to 7:00 A.M. and should be staffed daily including weekends with ,d+[DATE] floor nurses, and if the facility has two nurses, one nurse will pass the medications. If one nurse is scheduled, a CMT will be scheduled to pass mediations. If there are two nurses and a CMT scheduled, the CMT will be placed to work as a CNA for that night. Two CNAs are scheduled each night. Day shift works 7:00 A.M. to 7:00 P.M. and should be staffed daily including weekends with 2 nurses and 1 wound nurse, 1 CMT, and 2 CNAs. Monday through Friday, the facility has a swing shift for one CNA to work 3:00 P.M. to 10:00 P.M. and that CNA helps with showers, passing hall trays, assists residents with eating, and will also help the other CNAs with anything else they need assistance with. If staff do not show up for a shift, the protocol is to call the SC or the DON and try to figure out how to cover it with management's help and reach out to sister facilities for help. The SC said he/she is on call ,d+[DATE] for staffing. If the SC and DON were not able to find staff to come to the facility, the SC would go into the facility to work as a CNA and the DON would go into work as a nurse or CMT. The SC said he/she was on sick leave from [DATE] through [DATE]. While the SC was out sick, the staff were to contact the DON with any staffing issues. Two CNAs were scheduled to work night shift and called out on [DATE]. They said they cannot work every weekend any more without receiving pay for the Baylor program (a program to work every weekend on Saturday and Sunday 12 hour shifts and receive an additional 8 hours of pay for working every weekend) on Friday's paycheck [DATE]. The DON was scheduled to work [DATE]'s night shift and worked by herself because of the two CNAs calling in. Review of the facility's Daily Assignment Sheet, dated [DATE], showed: -One nurse, one CMT, and three CNAs scheduled for the day shift 7:00 A.M. through 7:00 P.M.: -Swing shift 3:00 P.M. through 10:00 P.M.: blank; -DON scheduled for nurse, CNA A with a line through the name and WNBI written next to the name, CNA B with no line through his/her name scheduled for night shift 7:00 P.M. through 7:00 A.M. Review of the facility's All punches detailed report, dated [DATE], showed: -Day shift nursing staff: -LPN C, clocked in at 7:29 A.M. and clocked out at 7:17 P.M.; -CMT D, clocked in at 7:34 A.M. and clocked out at 7:41 P.M.; -CNA F, clocked in at 8:20 A.M. and clocked out at 8:17 P.M.; -Night shift nursing staff: no time punches. During an interview on [DATE] at 9:30 A.M., the Regional Nurse Consultant (RNC) said there is nobody listed on the facility's All punches detailed report for [DATE] on the night shift because the DON is salaried and she does not clock in. Review of the facility's All punches detailed report, dated [DATE], showed: -Day shift non-nursing staff: -Dietary Aide (DA) G clocked in at 5:27 A.M.; -DA H clocked in at 5:28 A.M.; -Day shift nursing staff: -CNA F, clocked in at 6:32 A.M.; -LPN C, clocked in at 7:02 A.M.; -CMT D, clocked in at 7:29 A.M. During an interview on [DATE] at 1:43 P.M., the DON said she was the only staff in the building on Saturday night, [DATE]. CNA A called out Friday night and CNA B called out on Saturday. The DON said she sent messages to all the nurses, including nursing management in the building and nobody could come in. The DON also sent messages to Administrator #1 and the Administrator in Training (AIT). The DON said Administrator #1 did not respond, but the AIT did. The AIT reached out to sister facilities and requested help with staffing and was unsuccessful in finding additional staff. The DON said she did not have a list of everyone's phone numbers. The DON was in the facility by herself from approximately 8:00 P.M. until around 6:00 A.M. The DON thought that was when the kitchen staff came in. The DON was unable to answer call lights timely, pass medications timely, and some medications were not administered because it was too late to administer them when she got to them. The DON said she was passing the 8:00 P.M. medications until 2:00 A.M. to 3:00 A.M. The DON answered call lights as she was passing medication and changing residents. She was unable to give showers to residents who were scheduled that evening. Staff should stay until relief comes but staff cannot stay over 16 hours and the staff she relieved was staff who were going to come in to relieve her in the morning, so she had to let them leave. During an interview on [DATE] at 3:36 P.M., the AIT said the DON informed her and Administrator #1 that she was at the facility with no other staff the night of [DATE]. The AIT reached out to three sister facilities and only one responded. One facility responded saying they were very short staffed. Administrator #1 did not respond over the weekend when the facility was having issues. During an interview on [DATE] at 9:32 A.M., the AIT said she emailed sister facilities to try and get help with Saturday night [DATE], when the DON reached out to her and Administrator #1. The AIT said she responded to the DON at 3:48 P.M. and told her the other facility could not help. The AIT said she did not refer to the emergency preparedness plan with the staffing problem. The AIT said Administrator #1 did not respond and she wished she would have responded and offered a bonus to offer to staff to come in and work. The AIT said she cannot offer bonuses to staff. She and the DON worked hard on trying to find staff to come in and exhausted all resources and could not find anyone. The AIT said she did not reach out to the Regional Director of Operations (RDO) about the staffing issue. During an interview on [DATE] at 9:55 A.M., the DON said the SC texted her at 1:00 P.M. [DATE] to inform her the two CNAs scheduled for [DATE] night shift called in. The DON said she sent a message on a group text to CNAs and CMTs, asking if anyone could work the night shift and only one staff member responded and could not come in. The DON said if a resident would have become unresponsive, she would have started CPR by herself, she would not have been able to get the crash cart because that would delay compressions. The DON then said to check the code status, she would have needed to go to the nurses station to look in the binder that the code status are kept in to see what code status the resident is, then return to the resident. The DON did not refer to the emergency preparedness binder on Saturday. The residents in rooms 212 through 220 did not receive their 8:00 P.M. medications or 10:00 P.M. medications because it was between 2:00 A.M. and 3:00 A.M. before she got to their rooms. She did not administer the 10:00 P.M. IV antibiotic for wounds to Resident #1. The DON was unable to administer insulin and provide blood glucose checks to four residents, Resident #2,#3, #4 and #5 at 8:00 P.M. and 10:00 P.M. The DON did not have time to contact the physician or residents' responsible parties the night of [DATE] for any orders that she was unable to follow due to being in the facility by herself. During an interview on [DATE] at 3:28 P.M., the RNC said she comes to the facility and gives clinical advice to the DON. If a facility is having issues with staffing, she would assist with calling staff to ask them to come into the facility. The RNC said she would not come into the facility to assist by working on the floor because she has other facilities. The RNC said she was not aware the DON was the only staff member in the facility on the night shift of [DATE]. If she would have been made aware, she would have assisted in trying to find people to come into the facility and would find out who else was notified of the staffing issues. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Admission [DATE]; -Clear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Functional limitation in range of motion to the lower extremities on both sides; -Total dependence for toilet use; -Always incontinent of bladder; -Bowel not rated, resident has an colostomy (a piece of the colon is diverted through an artificial opening in the abdominal wall and stool passes through the colon through the abdominal wall into a bag located on the outside of the body to collect stool); -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain presence, yes; -Pain frequency: Occasionally; -Pain interference with day to day activities: Occasionally; -Pain intensity: Severe; -Prognosis: Does the resident have a condition or chronic disease that may result in a life expectancy of less than six months: no; -Skin conditions: -Determination of pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) risk: -Resident has a stage I (an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness) or greater, a scar over bony prominence, or a non-removable dressing device; -Formal assessment instrument/too (e.g., Braden (assessment used for predicting pressure sore risk), [NAME] (used to assess the risk for pressure ulcer), or other); -Risk of pressure ulcers: yes; -Unhealed pressure ulcers: yes; -Current number of unhealed pressure ulcers at each stage: -A. 1. Number of Stage I pressure ulcer: 0; -B. 1. Number of Stage II pressure ulcer (Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister): 0; -C. 1. Number of Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound): 0; -D. 1. Number of Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling): 1; -D. 2. Number of these Stage IV pressure ulcers that were present upon admission: 1; -E. 1. Number of unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined) due to non-removable dressing/device: 0; -F. 1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 0; -G. 1. Number of unstageable deep tissue injury (DTI) (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue): Suspected deep tissue injury in evolution: 2; -G. 2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry: 2; -Other ulcers, wounds and skin problems: Surgical wounds: none; -Skin and ulcer treatments: -Pressure reducing device for bed; -Pressure ulcer care; -Application of nonsurgical dressings (with or without topical medications) other than to feet; -Diagnoses included pressure ulcer of sacral (the triangular-shaped bone at the base of the back) region, Stage IV, elevated white blood cell count (indicates infection), acquired absence of right leg above knee, acquired absence of left leg above the knee. Review of the resident's EMR on [DATE], showed; -admitted [DATE]; -Discharge to hospital on [DATE]; -Readmitted [DATE]; -Cognitively intact; -No active care plan or base line care plan; -No all-inclusive admission or readmission assessment completed; -No Braden scale assessment completed; -One weekly skin check dated for [DATE]: -No site, no type, or measurements of any wounds documented; -Where there any new wounds identified during this skin check: no. Review of the resident's electronic Physician Order Sheet (ePOS), electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR), for [DATE] night shift 7:00 P.M. through 7:00 A.M., showed: -An order dated [DATE], for cyproheptadine HCL (used to relieve allergy symptoms) 4 milligram (mg) three times a day for allergies; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for gabapentin (used to relieve nerve pain) 100 mg three times a day for nerve pain; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for meropenem (antibiotic) solution reconstituted (the process of adding a liquid to a dry ingredient to make a specific concentration of liquid) 1 gram (gm) intravenously (IV) every eight hours for bacterial infection until [DATE]; -Documented as code 9, other see progress notes, indicating the medication was not administered at 10:00 P.M.: -EMAR administration progress note on [DATE] at 5:23 A.M., missed, caught after 2:00 A.M. next dose due at 6:00 A.M. During an interview on [DATE] at 10:41 A.M. the resident said he/she does not always get the IV antibiotics and medication like he/she is supposed to. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Clear speech, understood, understands, clear comprehension; -Cognitive status not assessed; -Behavior: Rejection of care: Behavior not exhibited; -Independent with toileting and transfers; -Always continent of bladder and bowel: -Insulin: -A. Insulin injections-Record the number of days that insulin injections were received during the last 7 days or since admission/reentry if less than 7 days: 7; -B. Orders for insulin-Number of days that injections of any type were received during the last 7 days or since admission/reentry if less than 7 days: 7; -Diagnoses included anemia (decrease in the number of red blood cells), peripheral vascular disease (PVD, poor circulation), diabetes mellitus (DM, metabolic disease), and Huntington's disease (a rare, inherited disease that causes the progressive breakdown of nerve cells in the brain) and emphysema (lung disease). Review of the resident's care plan, in use at the time of survey, showed; -The resident has DM: -Goal: The resident will have no complications related to diabetes through the review date; -Interventions: Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness; -The resident uses insulin: -Goal: The resident will be free from and signs or symptoms of hyperglycemia or hypoglycemia through the next review date; -Interventions: Administer insulin as ordered by physician. Monitor/document for side effects and effectiveness; Blood glucose monitoring per physician orders. Review of the resident's ePOS, eMAR and eTAR, for [DATE] night shift 7:00 P.M. through 7:00 A.M., showed: -An order dated [DATE], for acetaminophen PM (night time pain reliever and sleep aid) ,d+[DATE] mg give daily at bedtime for pain at 8:00 P.M.; -Documented as code 7, sleeping indicating the medication was not administered; -An order dated [DATE], for insulin glargine solution (long-acting insulin) 100 unit/ml, inject 10 unit subcutaneously (the injection is given in the fatty tissue, just under the skin) at bedtime for diabetes; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for buspirone HCL (used to treat anxiety) 5 mg give one tablet three times a day for anxiety; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for artificial tears ophthalmic solution ((eye drops used to relieve dryness) instill one drop in both eyes three times a day for dry eyes; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for blood glucose checks before meals and at bedtime related to type one DM with hyperglycemia (high blood glucose), notify physician if lower than 60 mg/deciliter (dl) or over 400 mg/dl; -Documented as code 9, other see progress note, indicating blood glucose was not checked at 9:00 P.M.; -EMAR progress note, dated [DATE] at 5:41 A.M., no progress note entered; -An order dated [DATE], for insulin lispro (fast-acting insulin) injection solution subcutaneously before meals and at bedtime for DM, inject per sliding scale if 151 mg/dl to 200 mg/dl give 2 units, 201 mg/dl to 250 mg/dl give 4 units, 251 mg/dl to 300 mg/dl give 6 units, 301 mg/dl to 350 mg/dl give 8 units, 351 mg/dl to 400 mg/dl give 10 units call physician greater than 400 mg/dl; -No documentation on eMAR at 9:00 P.M., indicating the medication was not administered. During an interview on [DATE] at 10:39 A.M., the resident said he/she does not always get his/her medications and insulin as ordered. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed: -Clear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Partial/Moderate (Helper does less than half the effort) assistance with toileting and transfers; -Occasionally incontinent of bladder and frequently incontinent of bowel; -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain intensity: Numeric rating scale (,d+[DATE]), 8; -Other health conditions: Shortness of breath: -A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring); -C. Shortness of breath or trouble breathing when lying flat; -Insulin: -A. Insulin injections-Record the number of days that insulin injections were received during the last 7 days or since admission/reentry if less than 7 days: 7; -B. Orders for insulin-Number of days that injections of any type were received during the last 7 days or since admission/reentry if less than 7 days: 7; -Diagnoses included heart failure, high blood pressure, wound infection (other than foot), other fracture, DM, chronic obstructive pulmonary disease (COPD, lung disease), and respiratory failure. Review of the resident's care plan, in use at the time of survey, showed; -The resident has DM: -Goal: The resident will have no complications related to diabetes through the review date; -Interventions: Blood glucose checks and insulin as ordered; Diabetes medication as ordered by physician. Monitor/document for side effects and effectiveness. Review of the resident's ePOS, eMAR and eTAR, for [DATE] night shift 7:00 P.M. through 7:00 A.M., showed: -An order dated [DATE], for montelukast sodium (used to control and prevent symptoms caused by asthma) 10 mg, one tablet at bedtime for bronchodilator; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for rosuvastatin calcium (used to treat high cholesterol) 5 mg at bedtime for lipid (fatty acid) control; -Documented as code 7, sleeping, at 8:00 P.M., indicating the medication was not administered; -An order dated [DATE], for trazodone HCL (used to treat d

Based on interview and record review, the facility failed to ensure five residents (Residents #9, #8, #7, #11 and #10) had a code status in their medical record and had a code status recorded in the code status book, which staff would refer to in the event their heart stopped. Residents #9 and #8, both alert and oriented residents, did not want Cardiopulmonary Resuscitation (CPR, an emergency procedure consisting of chest compressions often combined with artificial ventilation, or mouth to mouth in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest) administered in the event of cardiac arrest, however staff said they would perform CPR on them in accordance with the facility's policy. Additionally, the facility failed to provide CPR qualified staff for 28, 12-hour shifts between [DATE] and [DATE]. The Staffing Coordinator did not know he/she was responsible to ensure at least one CPR certified staff person was available on each shift. Thirty-eight residents were listed as full code (would want CPR administered). The census was 51. The Regional Director of Operations (RDO) was notified on [DATE] at 4:27 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's communication of code status policy, dated ,d+[DATE], showed: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information; -Policy explanation and compliance guidelines: -1. The facility will follow facility policy regarding a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an Advance Directive; -2. When an order is written pertaining to a resident's presence or absence of an advance directive, the directions will be clearly documented in designated sections of the medical record. Examples of directions to be documented include, but are not limited to: -a. Full Code; -b. Do not resuscitate, (DNR); -c. Do not intubate; -d. Do not hospitalize; -3. The nurse who notates the physician order is responsible for documenting the directions in all relevant sections of the medical record; -4. The designated sections of the medical record are: (hand written) physician order sheet (POS), care plan, resident information code status book; -5. Additional means of communication of code status include: (hand written) discussed in morning and clinical meeting for admission and readmission; -6. In the absence of an Advance Directive or further direction from the physician, the default direction will be Full Code; -7. The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services; -8. The Social Services Director shall maintain a list of residents who have an Advance Directive on file; -9. The resident's code status will be reviewed at least quarterly and documented in the medical record. Review of the facility's CPR policy, dated [DATE], showed: -Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR; -Policy explanation and compliance guidelines: -1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR; -2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: -a. In accordance with the resident's advance directives, or; -b. In the absence of advance directives or a Do Not Resuscitate order; and; -3. CPR certified staff will be available at all times; -4. Staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification which includes an online knowledge component yet still requires in-person skills demonstrations to obtain certification or recertification is also acceptable. 1. Review of Resident #9's electronic Physician Order Sheet (ePOS), reviewed on [DATE], showed: -No ordered code status. Review of the resident's electronic medical record (EMR), showed the resident admitted to the facility on [DATE]. Review of the code status binder, located at the nurse's station, showed no signed code status. During an interview on [DATE] at 9:40 A.M., the resident said he/she did not want to be resuscitated if his/her heart stopped beating. 2. Review of Resident #8's ePOS, reviewed on [DATE], showed: -No ordered code status. Review of the resident's EMR, showed: -The resident admitted to the facility on [DATE]; -A signed code status was uploaded into the electronic medical record under the misc tab on [DATE], and DNR was checked with the resident's signature. Review of the code status binder, located at the nurse's station, showed no signed code status. During an interview on [DATE] at 10:00 A.M., the resident said he/she did not want CPR if his/her heart stopped. 3. Review of Resident #7's ePOS, reviewed on [DATE], showed: -No ordered code status. Review of the resident's EMR, showed the resident admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Review of the code status binder, located at the nurse's station, showed no signed code status. During an interview on [DATE] at 2:42 P.M., the Director of Nurses (DON) said the resident came in before the DON starting working on the floor at 3:00 P.M. on [DATE]. The DON did not obtain a code status from the resident. Her expectation was for the night shift to obtain the resident's code status. The resident's code status should have been obtained at the time the resident arrived at the facility and she was unaware a code status was not obtained when the resident arrived. The DON expected the nurse giving report to notify her the resident did not have a code status obtained at the time report was given. The DON said when she gave report to the night shift, she told the night shift the admission needed to be completed and gave the night shift nurse the resident's discharge orders from the hospital to enter. The DON expected the night shift nurse to look at the whole admission and make sure everything was completed. The DON is responsible for doing the chart audit on new admissions the day after a resident admits to the facility and she did not have the opportunity to do the chart audit on the resident before he/she was sent out to the hospital. If a resident wants to be a DNR, the nurse will have the resident sign the purple DNR sheet and have the physician sign that purple DNR sheet. The DON was unsure if the DNR order should be entered if the physician has not signed the purple DNR sheet. The DON said even if the physician is called and notified of the resident's wishes of wanting to be a DNR, she was not sure if the order should be entered. If the order was not entered and the resident became unresponsive, staff would then have to treat the resident as a full code and the resident's wishes would not be followed, so the verbal order would need to be entered so the resident's wishes were followed. During an interview on [DATE] at 7:00 A.M., Licensed Practical Nurse (LPN) M said he/she was the night shift nurse who came in on [DATE] and the DON said when she entered the resident's orders, they did not all save and she would finish it the next day. LPN M said the DON did not say the resident's code status was not obtained and did not ask LPN M to complete the admission. LPN M was not CPR certified on [DATE]. During an interview on [DATE] at 7:26 A.M., LPN L said he/she noticed there was a problem with not all residents having a code status around two months ago. LPN L said he/she made sure all the residents had a code status at that time because if a resident were to become unresponsive, he/she would have not known the resident's wishes. LPN L said he/she believes it used to be Social Services responsibility to obtain code status, but he/she believes now it is whoever is doing the admission or readmission. The nurse doing the admission should obtain the code status and enter the code status into the orders. Code status should be obtained and the order should be entered with the resident's medication orders when the resident enters the building. It should be a top priority when residents enter the building. Resident #7 was admitted to the facility on [DATE] and on [DATE], LPN L was the nurse. There was nothing in the resident's medical record except bare minimum orders. LPN L said on [DATE], he/she looked for the resident's code status and there was not one, there was no admission note, and no assessments completed. LPN L then went to the miscellaneous tab and searched for the hospital paperwork and it was not uploaded into the resident's chart. If a resident does not have a code status they are considered a full code. LPN L said to locate a code status, he/she would first look in the resident code status binder at the nurse's station, next he/she would look in the EMR. When pulling up a resident's EMR, the code status is listed under the resident's name if an order has been entered. If the code status is not located under the resident's name, the last place to look is in the misc tab where documents for that resident have been uploaded. If there were a lot of documents uploaded, and he/she could not see the code status right away, he/she would treat the resident as a full code. 4. Review of Resident #11's ePOS, reviewed on [DATE], showed: -No ordered code status. Review of the resident's EMR, showed the resident admitted to the facility on [DATE]. Review of the code status binder, located at the nurse's station, showed no signed code status. Observation of the resident on [DATE] at 12:25 P.M., showed he/she lay in bed facing the wall. When his/her name was called, he/she turned his/her head but did not speak. He/She did not respond to any questions asked. 5. Review of Resident #10's ePOS, reviewed on [DATE], showed: -No ordered code status. Review of the resident's EMR, showed: -Initial admitted [DATE]; -discharged to the hospital on [DATE]; -readmitted on [DATE]; -discharged to the hospital on [DATE]; -readmitted on [DATE]; -discharged to the hospital on [DATE]; -readmitted on [DATE]; -discharged to the hospital on [DATE]; -readmitted on [DATE]. Review of the code status binder, located at the nurse's station, showed a copy of a full code document signed on [DATE]. No updated code status was in the record after his/her readmission. During an interview on [DATE] at 12:30 P.M., at the resident confirmed he/she wanted to be a full code. 6. During an interview on [DATE] at 7:15 A.M., CNA J said if he/she found a resident unresponsive (without signs of life), he/she would get the nurse. He/She does not know where to locate code status at the facility. During an interview on [DATE] at 7:19 A.M., Certified Medication Technician (CMT) K if he/she found a resident unresponsive, he/she would get the nurse. He/She said the only place to look for a code status would be in the resident's EMR on the front page. He/She said computers can take a while to pull up information. If there was no code status on the front page of the medical record, he/she would report the resident did not have a code status to the nurse. During an interview on [DATE] at 8:11 A.M., CMT D said if he/she found a resident unresponsive, he/she would get the nurse. He/She said the code status would be in the resident's EMR on the front page. If the code status was not on the resident's EMR, he/she would notify the nurse the resident did not have a code status. During an interview on [DATE] at 8:20 A.M., CMT E said if he/she found a resident unresponsive, he/she would get the nurse. He/She said the code status would be in the resident's EMR on the front page. If the code status was not on the resident's EMR, he/she would notify the nurse the resident did not have a code status. CMT E said the residents do not have paper charts so the EMR is the only place he/she would be able to look for a code status. During an interview on [DATE] at 10:31 A.M., the DON said the nurse doing the resident's admission is responsible for obtaining and entering the order for code status. Code status should be obtained as soon as possible and on the shift the resident arrives to the facility. Code status is obtained on admission and readmission because the resident could decide they want to change the code status on readmission. A resident should never go over 24 hours without a code status. Code status can be located at the nurse's station in the resident code status binder and in the SW's office. The SW's office is not open 24 hours a day and is locked at the end of business days and over the weekend. The SW is responsible for keeping the code status books updated. Code status can also be located in the resident's EMR; it shows the code status under the resident's name. If a resident is unresponsive and the code status cannot be located, the DON expected staff to treat the resident as a full code and initiate CPR. During an interview on [DATE] at 9:18 A.M., the Social Worker (SW) said he/she just started in this position last Monday [DATE], and he/she believes it is the SW's responsibility to obtain the code status from residents when they admit from the hospital the same day they admit or the next day, depending on what time they come to the facility. The SW said he/she would go in and have the resident sign the facility code status sheet and the SW would update the resident code status books, one at the nurses station and one located in the SW office. The SW said if the resident chooses to be a DNR, he/she would have it signed by the physician. The SW said he/she would enter a progress note and also enter the code status order. The code status is updated on admission, readmission, and annually. During an interview on [DATE] at 7:59 A.M., LPN C said the nurse completing the admission is responsible for obtaining the resident's code status and entering the order. A new code status should be entered for residents on every admission and readmission. The code status should be entered into the orders and obtained within the shift the resident is admitted . Code status can be located in the EMR under the resident's name, and in the resident code status binder at the nurse's station. If LPN C was unable to locate a code status for a resident and the resident was unresponsive, LPN C would initiate CPR. During an interview on [DATE] at 10:53 A.M., the Administrator in Training (AIT) said the admitting nurse is responsible for obtaining a resident code status on admission and readmission and entering the code status order into the resident's EMR. The AIT said the code status should be obtained and entered on admission as soon as possible. It is not appropriate for the code status to be obtained the day after admission, weeks or months later. The code status can be located on the front page of the resident's EMR and code status binder at the nurse's station. If a resident became unresponsive and staff were unable to locate the resident's code status, she expected staff to treat the resident as a full code and initiate CPR. During an interview on [DATE] at 4:10 P.M., Administrator #2 said she expected the SW to obtain code status on admission and readmission. She also expected the SW to talk about code status during care plan meetings and update the code status as needed. The SW gets the resident's signature on what code status the resident wants and places the up to date code status in the resident code status books at the nurse's station and in the SW office. If the SW is not in the facility, it is the nurse's responsibility to obtain the code status for the admission or readmission. The admitting nurse is responsible for entering the resident's code status into the orders. If the SW obtains the code status, the SW will inform the admitting nurse what code status the resident decided on, so the admitting nurse can enter the order into the resident's EMR. The code status should be obtained and entered within two to three hours of the resident admitting into the facility. If a resident became unresponsive and the staff were unable to locate a code status, the expectation is the staff initiate CPR. Administrator #2 expected all residents to have a current code status in the EMR and in the resident code status binders at the nurses station and SW office. During an interview on [DATE] at 6:18 P.M., the Regional Director of Operations (RDO) said the SW and nurses are responsible for obtaining code status from residents on admission and readmission. If the admission arrives in the evening hours, it is the admitting nurse's responsibility to obtain the resident's code status and enter the order. The code status should be obtained when the resident arrives. The facility needs to have the code status as soon as possible by the end of the shift the resident arrived to ensure the resident's wishes are verified. Residents should not go more than 12 hours without a code status after admitting to the facility. Code status can be located in the resident's EMR and in the resident code status binder located at the nurse's station. If a resident was unresponsive and staff were unable to locate a code status, he expected staff to treat the resident as a full code and initiate CPR. The RDO expected all residents to have a current code status. If a resident did not have a code status and CPR was performed because a current code status was not obtained, it could be going against the resident's wishes. During an interview on [DATE] at 1:21 P.M., the Medical Director (MD) said he expected all residents to have a current code status. If a resident were to become unresponsive and a code status could not be located, he expected the resident to be treated as a full code and CPR to be initiated. 7. Review of the facility's CPR certifications binder on [DATE], showed five current employees for the entire facility with active American Heart Association (AHA) CPR certifications. The facility staff AHA CPR certified included the DON, Staffing Coordinator (SC), Wound Nurse (WN), the facility's Transportation/Certified Nurse Aide (CNA), and LPN I. Review of the facility's time clock information for all staff titled All punches detailed report, dated [DATE] through [DATE], showed: -No CPR certified staff worked on the following shifts and dates: -On [DATE], day shift, (7:00 A.M. through 7:00 P.M.); -On [DATE], night shift, (7:00 P.M. through 7:00 A.M.); -On [DATE]; day shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], day shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], night shift -On [DATE], night shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], night shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], day shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], day shift; -On [DATE], day shift; -On [DATE], night shift; -On [DATE], night shift. During an interview on [DATE] at 10:31 A.M., the DON said Human Resources (HR) was responsible for obtaining CPR cards from staff on hire, but the facility currently does not have HR. The DON used to have an Infection Preventionist (IP) nurse and that nurse kept the staff CPR binder updated. The IP nurse resigned from the position, and it had been two weeks. She is now the person responsible for tracking staff who are CPR certified. She expected nursing staff who are working on the floor taking care of residents to be CPR certified including nurses, CMTs and CNAs. During an interview on [DATE] at 3:00 P.M. the SC said she is responsible for scheduling the nursing staff and ensuring there is one CPR certified staff member per shift. The SC said she was just informed on [DATE], that she was responsible for ensuring there was one CPR certified staff member per shift by the DON. The DON texted the SC on [DATE] at 4:35 P.M., asking if the night shift nurse scheduled on [DATE] was CPR certified. The SC told the DON that she did not know who was CPR certified and she did not have a list of CPR certified staff and did not know who was CPR certified. The SC said the RDO told her today he will give her a list of current CPR certified staff. During an interview on [DATE] at 7:19 A.M., CNA J said he/she would not provide CPR to a resident because he/she is not CPR certified. CNA J said he/she wanted to attend the CPR class but he/she was working the day the class was offered and he/she had to stay on the hall to take care of the residents. During an interview on [DATE] at 10:21 A.M., LPN N said he/she would not perform CPR on a resident if he/she was not CPR certified. LPN N was not CPR certified. LPN N said she would not do chest compressions or actively participate in the code while she did not have an active CPR certification. She said she would do other things to help like call 911 and gather paperwork for EMS. During an interview on [DATE] at 10:23 A.M., CMT D said he/she would not perform CPR on a resident if he/she was not CPR certified. CMT D was not CPR certified. During an interview on [DATE] at 10:53 A.M., the AIT said HR is responsible for obtaining CPR cards from staff when hired and during employment. The facility has a new HR person starting on Monday [DATE]. The regional HR has been assisting the facility until the new HR person starts. The DON and HR are responsible for tracking staff who are CPR certified. She expected at least one staff member to be certified per shift. During an interview on [DATE] at 6:18 P.M., the RDO said HR is responsible for obtaining CPR cards from staff on hire and during employment. HR and the SC are responsible for tracking certified CPR staff. He expected all nursing staff and housekeeping, and even dietary, to be CPR certified. He expected a CPR certified staff member to work each shift. He expected the facility staff CPR book to be current and up to date with current CPR certified staff. During an interview on [DATE] at 1:21 P.M., the MD said he expected at least one person per shift to be CPR certified. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

46104 Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, for one resident (Resident #25) who received a kidney transplant, when staff failed to obtain labs and administer anti-rejection medication as ordered by the physician. The resident was admitted to the facility on [DATE] and taken to the emergency room by family on [DATE] when the resident's blood work taken on the date of discharge showed critical. The resident was admitted to the hospital on [DATE] and passed away on [DATE]. The facility also failed to administer medication to one resident as ordered by his/her physician who was diagnosed with depression (Resident #27). The facility also failed to complete wound treatment as ordered by the resident's physician (Resident #21). The sample size was 28. The census was 51. The Administrator was notified on [DATE] at 3:00 P.M. of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Review of the facility's Admission Order's dated [DATE], showed: -Policy: A physician, physician assistant, nurse practioner or clinical nurse specialist must provide written and/or verbal orders for the resident's immediate care and needs: -Policy explanation and compliance guidelines: *The written and/or verbal orders should include at a minimum: a. Dietary; b. Medication or testing orders if indicated; c. Routine care orders; *The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission; *The orders should provide information to maintain or improve the resident's functional abilities until staff can conduct a comprehensive assessment and develop a interdisciplinary care plan. Review of the facility's Admission of a Resident policy dated [DATE], showed: -Policy: The admission process is intended to obtain all the information possible about the resident, for the development of comprehensive plans of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician; -The admission process has several phases: *Pre-admission preparation: The social service designee or other designated staff member may be needed to assist the admission process, in the gathering of information such as screening forms, mental health diagnoses and background information, etc. Review of the facility's Laboratory Services and Reporting policy, dated [DATE], showed: -The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practioner, or clinical nurse specialist in accordance with state law; -Policy Explanation and Compliance Guidelines: *The facility must provide or obtain laboratory services to meet the needs of its residents; *The facility is responsible for the timeliness of the services; *Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 1. Review of Resident #25's entry tracking Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated [DATE], showed: -admitted [DATE]; -Cognitively intact; -Diagnoses included non-Hodgkin's lymphoma (a disease in which malignant (cancer) cells form in the lymph system), acute kidney failure, seizures, severe sepsis with septic shock (Septic shock is the last and most severe stage of sepsis. Sepsis occurs when your immune system has an extreme reaction to an infection), chronic congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and Type 2 diabetes. Review of the resident's hospital discharge summary paperwork dated [DATE], showed: -The resident received a kidney transplant on [DATE]. He/She was released from the hospital on [DATE] and rehospitalized on [DATE] for abnormal labs; -While hospitalized , he/she developed sepsis and clostridioides difficile (C. diff is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) for which he/she was treated; -Active issues requiring follow up: -Bi weekly labs (every two weeks); -Discharge summary medications included: -Prednisone 5 milligram (mg) tablet. Take 1 tablet by mouth daily. This medication is very important. It prevents organ rejection; -Tacrolimus XR (extended release) 0.75 mg 24 hour. This is commonly known as Envarus XR. Take one tablet by mouth daily for a reduction in the body's resistance to infection. This medication is very important. It prevents organ rejection; -Letermovir 480 mg tablet, take one tablet by mouth daily, -Acyclovir 200 mg capsule. Take one capsule by mouth two times a day. This medication is very important. It prevents dangerous infection. Review of the resident's progress notes, showed on [DATE] at 3:54 P.M., the resident arrived via private vehicle with a diagnosis of sepsis. He/She is alert and oriented x 4 (person, place, time and situation). Recent renal transplant. Review of the resident's electronic Physician Order Sheet (ePOS), showed: -Order, dated [DATE], for Ayclovir capsule 200 mg. Give one capsule two times a day for viral infection; -Order, dated [DATE], for Lyumjev KwikPen Subcutaneous Solution Pen-Injector 100 Unit/Milliliter. Inject per sliding scale; -Order, dated [DATE], for Letemovir Oral Tablet 480 mg, Give one tablet one time a day for kidney transplant (this is generic of Prevymus); -Order, dated [DATE], for Envarus XR oral tablet Extended Release 0.75 mg, give one tablet by mouth one time a day for kidney transplant; -Order, dated [DATE], for Prednisone, 5 mg, give one capsule by mouth one time a day for kidney transplant. Review of the resident's electronic Medication Administration Record (eMAR), showed: -On [DATE] at 8:00 A.M., Envarsus, Prednisone, and Acyclovir not administered. At 4:00 P.M., Acyclovir not administered; -On [DATE] at 8:00 A.M., Envarsus, Prednisone, and Acyclovir not administered. At 4:00 P.M., Acyclovir not administered; -On [DATE] at 8:00 A.M., Envarsus not administered. A 9 recorded. (Chart Codes: 9 = See progress notes/other.) Review of the resident's progress notes, showed: -On [DATE] at 11:35 A.M., eMAR note Envarsus XR oral tablet extended release. Med was changed to prevymis. Review of the resident's electronic Medication Administration Record (eMAR), showed: -On [DATE], at 8:00 P.M., blood sugar not recorded, insulin not administered; -On [DATE] at 8:00 A.M., Envarsus not administered. A 9 recorded. Review of the resident's progress notes, showed: -On [DATE] at 9:15 A.M., eMAR note, Envarsus XR oral tablet not available. Review of the resident's electronic Medication Administration Record (eMAR), showed: -On [DATE] at 8:00 A.M., Envarsus not administered. A 9 recorded. Review of the resident's progress notes, showed: -On [DATE] at 3:57 P.M., eMAR note, Envarsus XR oral tablet not available. Review of the resident's electronic Medication Administration Record (eMAR), showed: -On [DATE] at 4:00 P.M., blood sugar not recorded insulin not administered. At 8:00 P.M., blood sugar not recorded insulin not administered; -On [DATE] at 2:00 P.M., blood sugar not recorded, insulin not administered; -On [DATE] at 8:00 A.M., Envarsus not administered. A 9 recorded. At 2:00 P.M., blood sugar recorded as N/A. No insulin administered; -On [DATE], Envarsus discontinued (does not show on ePOS). During an interview with the pharmacist on [DATE] at 8:00 A.M., he/she said they received the order for the Envasus on [DATE]. It was a specialty order and had to come from a different distributer so it would take at least a week to be delivered. They notified the facility of this. The letermovir was also a specialty drug but was very expensive. It would also take a week to arrive. Since the resident was Med A, the facility would have to authorize the medication and pay for it prior to the pharmacy ordering it. In cases like this where the resident needed the medication quickly, usually the facility would ask the family to supply the medication until the pharmacy could get the supply to the facility. The Envarsus was delivered to the facility on [DATE]. The letermovir was never approved by the facility so it was never sent. They are not the same medications. The Envarsus is a anti-rejection medication and the levermovir is an anti-viral medication. Review of an order faxed to the facility from the kidney transplant center, dated [DATE], showed an order from the resident's physician requesting weekly labs for: -Complete blood count (CBC, determines general health status and screens for and monitors for a variety of disorders including anemia); -Renal function panel (series of tests to evaluate kidney function); -Tacrolimus (blood work to check blood levels when taking medication called tacrolimus (an immunosuppressive agent used for organ rejection post-transplant); -Magnesium (Mg) blood tests; The physician requested the results be sent to the transplant center. Review of the resident's progress notes, showed: -On [DATE] at 2:08 P.M., EMAR note, Envarus, XR oral tablet. Awaiting delivery from pharmacy; -On [DATE] at 2:42 P.M., the resident's family member and POA inquired about when the resident would be able to go home. Writer spoke with therapy and they felt resident was at baseline. Writer called family member back and let him/her know the resident was able to return home whenever convenient for them. At 3:57 P.M., the nurse answered the phone at the nurse's desk and someone from the transplant team was inquiring about the labs that were ordered. The person said he/she spoke to the nurse about the lab orders. No lab orders were found in the resident's electronic record. The nurse notified the caller the resident was due for discharge as early as this day and was waiting on family to pick up. The caller was annoyed and stated he/she would contact the family and have the labs drawn somewhere so he/she could get the results and hung up; -On [DATE] at 2:33 P.M., Social Services spoke with family family member, stated he/she will be picking the resident up around 3:45 P.M.; -On [DATE] at 8:18 A.M., resident discharged to family member's private home. During an interview on [DATE] at 12:00 P.M., the resident's family member said the resident called him/her a couple days after being admitted to say he/she needed his/her medications. The facility told the resident if the family could not bring in the medications, they were going to have to eat the cost of them. He/she called the resident's responsible party to find out about the medications and went to get them. He/she brought a box of medication to the facility. He/She thought it was a couple of days after the resident was admitted . He/She could not remember the name of the medication. During an interview on [DATE] at 12:30 P.M., the resident's family member said the resident received his/her kidney transplant on [DATE]. He/she was released from the hospital to home on [DATE], but had to go back into the hospital on [DATE]. He/she had several set backs while at the hospital with infections and did not get out until [DATE], when he/she went directly to the facility. The resident was on anti-rejection medications after he/she got out of the hospital, including the Envarsus. The pharmacy sent the Prevymis to him/her after he/she was back in the hospital. They told him/her it was a substitute for one of the anti-viral medications and it would be covered by insurance but he/she did not know which one it was substituted for. He/She was out of town when the resident was admitted to the facility and does not know what was told to the admitting nurse about the medications. The resident called a family member a couple of days after he/she was there and told him/her the facility was not administering his/her medications. The family member called him/her and he/she told him/her about the medication the pharmacy had sent. He/She went to the house and got the medication and brought it to the facility. The staff never notified anyone the resident did not have his/her medications. The family member found out the resident was not getting his/her lab work done when the hospital called on [DATE] to say they were not going to fill the residents medications because the lab work had not been completed. He/She called the transplant coordinator's office to find out what was happening because he/she was supposed to be bringing the resident home and they said they would try to find out for him/her. He/She had talked to the facility earlier that day and they told him/her the resident was ready to come home. On [DATE], the transplant coordinator told him/her they had made several requests to the facility for the lab work and it had not been completed. They told him/her the resident had two appointments the next day at the hospital and to take him/her to a lab earlier in the day to get blood work completed so it would be ready before the appointments. The family member picked up the resident on the [DATE]. He/She said he/she was a little lethargic and seemed, Out of it. He/She took him/her for the blood work and by the time they got to the first appointment the next day, the resident could not walk. Before they could get to the second appointment, the transplant coordinator called and said take him/her immediately to the emergency room because his/her blood work showed his/her labs were critical. He/She took the resident to the emergency room and they admitted him/her to the hospital. During an interview on [DATE] at 11:20 A.M., the Director of Nursing (DON) said the order for the medication got changed from Envarus to premyvis. She did not remember who got the order changed. She believed it was the generic form of the medication. The family brought it in. He/she did not call the transplant physician to discuss changing the medication. During an interview on [DATE] at 9:30 A.M., Licensed Practical Nurse (LPN) N said he/she took the order for the lab work from the transplant center on [DATE], but could not enter it into the computer because he/she did not have access to enter labs into the system. He/She told the nurse about it and did not know why it did not get done. Review of the resident's hospital admission records, dated [DATE], showed: -The resident was admitted to the emergency room after being referred by his/her transplant team for abnormal outpatient labs; -Pt had a kidney transplant on [DATE]. Patient's family member stated the rehab facility had not drawn labs for over two weeks. The family member states patient is not acting like him/herself. Patient's coordination is off. He/She is confused. He/She is having trouble putting together sentences. He/She has been slurring sentences since last Friday; -The rehab facility did not did not draw the labs prescribed by the transplant team and when the patient went to the transplant center today his/her labs had elevated blood urea nitrogen (BUN, measures the amount of urea nitrogen found in your blood. Urea nitrogen is a waste product made when liver breaks down protein. It is carried in blood, filtered out by kidneys, and removed from the body in urine) and creatinine levels (a waste product filtered out of the blood by the kidneys, an increased concentration in the blood may indicate a temporary or chronic disease in the kidney function); -The resident's diagnoses includes acute kidney injury likely secondary to graft failure; -Attending summary of care: Patient presenting with concern for acute renal failure (a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), uremic encephalopathy (UE, cerebral dysfunction due to the accumulation of toxins resulting from acute or chronic renal failure) are concern for acute rejection of renal transplant. During an interview on [DATE] at 8:30 A.M., the transplant hospital social worker said their staff spoke with a nurse at the facility on [DATE] and sent the orders over for the labs after they did not receive them from the hospital. It has been really hard to get hold of anyone at the facility. There had been multiple attempts to try and get hold of a nurse and they kept getting their voice mail. They called the facility again on [DATE] to inquire about the labs and found out the facility was getting ready to discharge the resident home. It is vital they have the labs before the resident goes home to know if his/her system is rejecting the kidney. It is vital that the resident take the medications prescribed. A family member called the social worker with a concern about the resident's medication. He/She was not sure what medications the resident was being administered. The family had taken some medication to the facility that had been sent to them by the pharmacy but this medication had not been approved by the physicians at the transplant center. It was very important the resident take precisely what was prescribed to him/her and get the bloodwork done on a regular basis to make sure the medications were working like they were supposed to. No one called the transplant center to ask if there was another medication he/she substitute or let them know he/she had missed any doses of his/her anti-rejection medication. It was dangerous for him/her to even miss one dose of the Envarsus or the Prednisone. His/Her immune system is suppressed and the antiviral medications are vital. When he/she got to the hospital, he/she was in septic shock. He/She was extremely altered and could not communicate with the staff. During an interview on [DATE] at 3:45 P.M., a nurse practioner at the transplant hospital said the resident needed to be on a therapeutic level of his/her medication to prevent his/her body from rejecting the kidney. The Envarsus and Privmysus are both anti-rejection medications, but they are not the same and he/she should have been getting both medications. It was important to get the labs and blood work every week to monitor the levels and determine whether the medication was working. When he/she left the hospital on [DATE], his/her labs were normal and his/her Envarsus was at a therapeutic level. When they admitted him/her to the hospital on [DATE], his/her labs were critical and his/her Envarsus was under a therapeutic level which could lead to kidney rejection. The resident was now back on dialysis. Had they been able to catch this at an earlier time, they could have adjusted his/her medications to have potentially prevented this. The resident is now on regular dialysis, is on a feeding tube, has pneumonia and is awaiting a biopsy to determine if his/her kidney is salvageable. He/She is in pretty bad condition. During an interview on [DATE] at 9:45 A.M., a nurse from the hospital transplant team said the resident expired this morning. 2. Review of Resident #27's admission MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing and vision; -Cognitively intact; -Diagnoses included paraplegia (paralysis), fracture of left shoulder, multiple fractures of ribs, spinal stenosis (narrowing of the spine), acute kidney failure, major depressive disorder and insomnia (sleep disorder). Review of the resident's ePOS, showed an order dated [DATE], for Rexulti 2 milligrams (used to treat depression), give one tablet by mouth one time a day. Review of the resident's eMAR, showed: -At 8:00 A.M. on [DATE], [DATE] and [DATE], Rexulti not administered. Nothing documented; -At 8:00 A.M. on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], Rexulti not administered. A 9 documented. (Chart Codes: 9 = See progress notes/other.) Review of the resident's progress notes, showed the following: -On [DATE] at 11:17 A.M., Rexulti, med unavailable; -On [DATE] at 9:13 A.M., Rexulti, med unavailable; -On [DATE] at 9:25 A.M., Rexulti, med unavailable; -On [DATE] at 12:40 P.M., Rexulti, med unavailable; -On [DATE] at 9:41 A.M., Rexulti, med unavailable; -On [DATE] at 10:40 A.M., Rexulti, med unavailable; -On [DATE] at 10:41 A.M., Rexulti, med unavailable. During an interview on [DATE] at 11:20 A.M., the resident said he/she has been in the facility since September. He/She was shot and is now paralyzed. He/She is in constant pain and this causes him/her to be depressed. He/She has not received his/her depression medication since he/she was admitted to the facility. He/She asked the nurses about it, but no one ever has an answer to why he/she was not getting it. During an interview on [DATE] at 12:45 P.M., Certified Medication Technician (CMT) E said the resident has not received his/her depression medication from the pharmacy. There was an issue with the medication being covered by his/her insurance and it never got worked out, so the resident did not get his/her medication. During an interview on [DATE] at 1:10 P.M., LPN O said the resident did not get his/her prescription because it fell through the cracks. The resident came from the hospital with the prescription. The facility accepted him/her with the prescription. The pharmacy notified the facility about the cost of the prescription. Today was the first time the nurse was aware the resident was still not receiving his/her medication. The admitting nurse enters the orders into the residents' medical records and sends the orders to the pharmacy. If the medications are not received, staff should let the nurse know. As a floor nurse, he/she does not audit the medications. During an interview on [DATE] at 2:25 P.M., the DON said if the resident's medication was not available or is too expensive, then staff should ask the pharmacy for a referral for a less expensive medication. Then staff can call the resident's physician and ask for approval for the alternative medication. If the physician wants the resident to be on the original medication and the resident has Med A insurance, then the facility must pay for the original medication. When they are making decisions about accepting residents, they should look at these medications and determining whether the facility can pay for them before they accept them as residents. Only the DON and the ADON can approve these specialty medications from the pharmacy if the insurance does not cover it. She did not know why the resident's medication had not been approved from the pharmacy yet. During an interview on [DATE] at 8:35 A.M., LPN C said he/she could not find the resident's medication. He/She had not heard of it and had not given it to the resident. During an interview on [DATE] at 9:15 A.M., CMT D said he/she could not find the medication on the medication cart and as far as he/she knew, the facility never had it. If it was marked as given, it was probably marked by mistake. During an interview on [DATE] at 9:25 A.M., a representative at the resident's pharmacy said they received a prescription for the medication on [DATE], but the facility never requested it be filled and sent over to them. 3. During an interview on [DATE] at 6:35 P.M., the Regional Director of Operations (RDO) said the DON is responsible for auditing the MARS and TARS. Staff should document when a resident is missing a medication for any reason. During an interview on [DATE] at 2:00 P.M., the Medical Director (MD) said sometimes pharmacies will not carry a medication and will not order it until it is paid for. These are specialty medications. The pharmacy should send over a list of alternative medications and this information should be relayed to the resident's physician so he/she can make the decision to keep or change the prescription. Staff should call the physician and get a decision about the medication and get this information back to the pharmacy. This should not take more than ,d+[DATE] days at the most. 4. Review of Resident #21's admission MDS, dated [DATE], showed: -admitted [DATE]; -Adequate hearing and vision; -Cognitively intact; -Diagnoses include pressure ulcer of the sacrum (tail bone), diabetes and end stage renal disease (ESRD, kidney disease). Review of the resident's ePOS, showed: -Order dated [DATE], to cleanse left medial (closer to the midline of the body) lower leg with neosporin (triple antibiotic ointment, an antibiotic medication used to reduce the risk of infection), apply Xeroform (a non-adherent dressing that provides a moist wound environment that clings and conforms to the body), cover with abdominal pad (abd, absorbent pad) and kling, every day shift, every two days; -Order dated [DATE], to cleanse the left lateral (to the side of, or away from, the middle of the body) lower leg everyday with neosporin, apply xeroform, cover with abd and kling every day shift; -Order dated [DATE], to cleanse the right medial lower leg everyday with neosporin, apply Xeroform and cover with border foam. Every day shift every 2 days; -Order dated [DATE], to cleanse the right lateral lower leg with neosporin and apply Xeroform and cover with border foam. Every day shift every 2 days; -Order dated [DATE], for Collagenase ointment (Santyl, ointment to debride wounds), define 250 unit/gm. Apply to left outer leg topically ever day shift. Cleanse area to left lateral leg with neosporin, apply Santyl, cover with calcium alginate (highly absorptive dressing), to fit cover with border foam. Review of the resident's electronic Treatment Administration Record (eTAR), showed: -On [DATE], [DATE] and [DATE], for cleanse left medial lower leg with neosporin, apply Xeroform, cover with abd and kling, there was nothing documented; -On [DATE], [DATE] and [DATE], for cleanse the left lateral lower leg with neosporin, apply Xeroform, cover with abd and kling every day shift, there was nothing documented; -On [DATE], cleanse the right lateral lower leg with neosporin and apply Xeroform and cover with border foam. Every day shift every 2 days. There was nothing documented. On [DATE], a 9 documented; (Chart Codes: 9 = See progress notes/other.) -On [DATE], to cleanse the right medial lower leg everyday with neosporin, apply Xeroform and cover with borderfoam. Every day shift every 2 days. There was nothing documented. On [DATE], a 9 documented; -On [DATE] and [DATE], for collangenase ointment. Apply to left outer leg topically ever day shift. Cleanse area to left lateral leg with neosporin, apply Santyl, cover with calcium alginate to fit cover with border foam. There was nothing documented. During observation and interview on [DATE] at 9:50 A.M., the resident lay in bed. He/She said he/she did not get his/her wounds dressed over the weekend. The dressings were coming loose and were yellowish. They had a date of [DATE] on them. He/She said no one looked at them since Friday afternoon. The wounds were very itchy and it was becoming painful. Observation and interview on [DATE] at 9:20 A.M., showed the resident lay in bed. He/she had bandages on both his/her legs above his/her ankles. The bandages were dated [DATE]. The bandages had yellowish drainage on them that seeped onto the bedding. The resident said no one had changed his/her dressings all weekend. The wounds were beginning to itch and ache. Observation on [DATE] at 9:30 A.M., showed the resident's bandages were dated [DATE]. During an interview on [DATE] at 8:50 A.M., CNA A said residents complain about not getting their treatments. Weekends are especially horrible. Wounds are not being dressed. The smell is horrible. Wounds are open. He/She will let the nurse know and the nurse will say they are going to try to get to it. If they do not get to it, the resident usually has to wait until Monday when the Wound Nurse comes back. During an interview on [DATE] at 8:30 A.M., LPN L said the wound treatment list is extensive and it is a struggle with two nurses. The wound treatments get done when the wound nurse is there but not if he/she is off. Wound treatments are not being done on the weekends. Skin assessments are not being done. Treatments should be documented in the TAR. A resident's treatment and rejection of treatment is documented in the chart. If wounds are not treated, they can lead to infections, sepsis and even death. During an interview on [DATE] at 2:00 P.M., the MD said he expected staff to complete treatments as ordered. They should be triaged to complete the ones that are the worst first. If wounds are not treated as ordered, then harm can come to the residents. During an interview on [DATE] at 6:35 P.M., the RDO said he expected the nurses to complete wound treatments. The charge nurse should do the treatments if the Wound Nurse is not there. This should be documented on the resident's TAR. If a nurse is not available, staff should reach out to an on-call nurse and let them know. It is not appropriate to document the Wound Nurse is not available. The DON is responsible for auditing the MARS and TARS. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level J. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00225309 MO00225999 MO00227567 MO00227453 MO00227926 MO00228154

Based on observation, interview and record review, the facility failed to ensure scheduled pain medication was available and/or administered as ordered, failed to document the reason the residents missed doses and failed to document the measures they took to obtain the medication, for four of 28 sampled residents (Residents #6, #27, #21 and #1). Resident #6 experienced pain resulting in the resident crying out and rocking back and forth and calling family members crying. Resident #27 was unable to get out of bed because he/she was in so much pain he/she could not sit up in his/her wheelchair. Resident #21 described their pain as excruciating. The facility also failed to administer pain medications to Resident #1 prior to completing wound care. The resident described their pain as an eight out of ten, aching and steady to the areas where he/she had wounds. The census was 51. Review of the facility's Medication Reordering policy, revised 4/7/22, showed: -Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident; -Policy Explanation and Compliance Guidelines: --The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident; --Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner; --In the event of new orders, the facility is allowed 24 hours to begin a medication unless otherwise specified by the medical provider; --For STAT (immediate) medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy. The STAT medication can be stored in a portable, but sealed emergency box or container, or may be stored in an electronic dispensing system. Review of the facility's Pain Management Policy, revised 9/1/21, showed: -The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences; -In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility shall: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs; c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences; -Facility staff shall be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: *Hurting or aching; *Throbbing; *Burning: *Numbness, tingling, shooting or radiating; *Soreness, tenderness, discomfort; -Pain assessment: The facility shall utilize a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain; -Pain Management and Treatment: Based upon the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, and monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission; -Pharmacological interventions shall follow a systematic approach for selecting medications and doses to treat pain. The interdisciplinary team shall develop a pain management regimen that is specific to each resident who has pain or who has the potential for pain. The following are general principles the facility will utilize for prescribing analgesics: *Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain; *Consider administering medication around the clock instead of PRN (pro re nata/on demand) or combining longer acting medications with PRN medications for breakthrough pain. 1. Review of Resident #6's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/28/23, showed: -Unclear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain presence, yes; -Diagnoses included Parkinson's disease (a progressive disorder that affects the nervous system), acute and chronic respiratory failure, heart failure, pain and diabetes. Review of the resident's care plan, dated 10/13/23, showed: -Focus: Resident has impaired cognitive function/dementia or impaired thought processes; -Interventions: Administer medications as ordered, Monitor/document for side effects and effectiveness; -Focus: Resident has alteration in comfort due to pain; -Interventions: Administer analgesia as ordered. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review of compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor for side effects of pain medication. Observe for new onset of increased agitation, restlessness, confusion, hallucinations. Report occurrences to the physician. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. Review of grievances filed by the resident, showed: -On 8/28/23: -Were you able to report the concern to a staff member: Yes; -If yes, please provide staff member's name: Administrator's name; -Please describe the concern in detail: Resident says he/she is not getting his/her medicine as he/she should. He/She has to wait too long for his/her medicine; -On 9/20/23, a customer and concern feedback form, showed: -Were you able to report the comment/concern to a staff member? Yes; -If yes, please provide staff member name: The Administrator and Director of Nursing (DON)'s name; -Describe in detail the comment or concern: States night shift staff refused to give him/her pain medication every fours hours as needed; -Investigation findings: The resident's order is for every four hours as needed. Resident was educated he/she would have to ask for the medications, as they are not scheduled. Review of the resident's progress notes on 9/20/23 at 8:31 P.M., showed the staff received a call from the resident's physician's office. The physician did not approve the resident's Norco to every 4 hours as needed. The staff member explained to the physician's office the resident and his/her family member complained of the every four hours not being administered. The office contacted the physician who gave a new order for the Norco every 6 hours scheduled. Review of the resident's electronic physician order sheet (ePOS), showed: -Order, dated 8/2/23, for acetaminophen (used to relieve mild to moderate pain) oral tablet 500 milligrams (mg), give two tablets by mouth three times a day for mild pain; -Order, dated 9/7/23, for baclofen (muscle relaxer), 10 mg, give one tablet every eight hours related to pain; -Order, dated 10/13/23, for hydrocodone-acetaminophen tablet (Norco) 5-300 mg (opiate pain medication), give one tablet by mouth every six hours for pain. Review of the resident's medication administration record (MAR), showed: -On 10/14/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded. At 8:00 P.M., staff documented the resident's pain level at a six (pain level 0 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain). Two tablets of acetaminophen 500 mg were administered; -On 10/18/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/19/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/26/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/27/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/28/23 at 12:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; a 9 was recorded; -On 10/29/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/3/23 at 6:00 P.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Staff did not document the Norco as administered; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Staff did not document the acetaminophen 500 mg or baclofen as administered; -On 11/6/23 at 6:00 A.M. and 6:00 P.M., staff did not document the resident's pain level. There was no documentation of Norco administered. At 6:00 A.M., there was no documentation of Acetaminophen 500 mg or baclofen administered; -Chart codes: 9 = Other/See progress notes. Review of the resident's progress notes, showed: -On 10/14/23, no documentation about 6:00 P.M. Norco; -On 10/18/23 at 1:19 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the Norco medication or why the medication was not administered; -On 10/19/23 at 1:53 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of medication or why the medication was not administered; -On 10/25/23 at 11:27 P.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of medication or why the medication was not administered; -On 10/27/23 at 12:06 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the medication or why the medication was not administered; -On 10/28/23 at 3:49 A.M., a note to give one tablet of hydrocodone-acetaminophen by mouth every six hours for pain. No documentation of administration of the medication or why the medication was not administered. Review of the resident's controlled drug receipt forms, showed: -On 10/22/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next Norco signed out on 10/23/23 at 4:00 A.M. (missed 12:00 A.M. dosage); -On 10/25/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/26/23 at 6:00 A.M. (missed 12:00 A.M. dosage); -On 10/26/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/27/23 at 5:00 A.M. (missed 12:00 A.M. dosage); -On 10/27/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/28/23 at 6:00 A.M. (missed 12:00 A.M. dosage); -On 10/30/23, hydrocodone-acetaminophen signed out at 6:00 P.M., next hydrocodone-acetaminophen signed out on 10/31/23 at 5:30 A.M. (missed 12:00 A.M. dosage); -On 11/3/23, hydrocodone-acetaminophen signed out at 11:25 A.M., next hydrocodone-acetaminophen signed out on 11/4/23 at 12:00 A.M. (missed 6:00 P.M. dosage); -No documentation of why the missed medication was not administered. During an interview on 11/1/23 at 8:10 A.M., the resident said he/she was in pain all of the time. It was especially bad at night. He/She put his/her light on and it will take a long time for the staff to respond, and sometimes they will not respond at all. He/She was confused, so sometimes he/she could not always remember when he/she last got his/her medication. The staff will come and turn his/her light off and tell him/her they will be back, and then they will not come back, and he/she will be in pain all night. During an interview on 11/1/23 at 2:00 P.M., the resident's family member said he/she complained to administration in September about the staff not responding to the resident's pain at night. The resident will be due for his/her medication, and he/she will ask the staff about it and will be told the resident will get the medication when the staff can get to him/her. After he/she complained, the resident's physician changed his/her medication from as needed every four hours to routinely every six hours, but the resident was still not always getting it. The resident will call the family member crying and say he/she is in pain, and the staff will not bring him/her the pain medication. Review of Resident #22's admission MDS dated [DATE], showed: -Adequate hearing and vision; -Cognitively intact. During an interview on 11/7/23 at 12:40 P.M., Resident #22 said Resident #6 stays in the room next to him/her. He/She could sometimes hear Resident #6 cry out in pain in the mornings. This often happens between 4:00 A.M. and 5:00 A.M., and it wakes him/her up. Resident #6 will call out for the nurse and this will go on for a long time sometimes. Resident #22 could hear Resident #6 yelling for his/her pain medication. Resident #22 has gotten out of bed a couple of times to find staff to get assistance for Resident #6. During an interview on 11/2/23 at 11:48 A.M. Registered Nurse (RN) P said if he/she was working and noticed a resident was running low on pain medication, he/she would go to the resident summary in the electronic (e)MAR and hit reorder. If that did not work, he/she would call the pharmacy and ask them to reorder the medication. He/She would make sure to give the pain medication before he/she left. For Norco, staff should reorder seven days before the prescription runs out because they need to call the physician and the pharmacy to get the order refilled. The staff have to call the physician to sign the Norco script to send to the pharmacy or have the pharmacy call the physician to get the script approved. Staff should not be waiting until the last day to get the order filled in case they need to do all of this. They can get an order for a Norco out of the emergency medication system (e-kit) in an emergency. Observation and interview on 11/7/23 at 4:45 P.M., showed Resident #6's call light on. The resident said he/she was in pain. He/She was crying and rocking back and forth. He/She said he/she had asked the staff for pain medication several times already. He/She did not remember getting a pain pill earlier in the day. At 5:35 P.M., Certified Nurse's Aide (CNA) C entered the room, spoke to the resident, turned off the resident's light and left the room. At 5:45 P.M., the resident turned his/her light back on. During an interview on 11/7/23 at 5:50 P.M., CNA C said the resident had turned on his/her light to complain about being in pain. He/She had asked for a pain pill earlier and the CNA reported this to the Certified Medication Technician (CMT) on duty. Review of the resident's MAR dated 11/7/23, showed: -At 12:00 A.M., Norco administered; pain level assessed at a 3 ; -At 6:00 A.M., Norco administered; pain level assessed at a 6; -At 12:00 P.M., no documentation for pain level or Norco administration; -At 2:00 P.M., staff recorded a pain level of 0 and administered two tablets of acetaminophen; -At 6:00 P.M., Norco administered; pain level assessed at a 10. Review of the resident's drug receipt form, showed: -On 11/6/23, Norco signed out at 12:24 P.M., next Norco signed out on 11/7/23 at 12:00 A.M. (missed 6:00 P.M. dosage). This was listed as the last Norco in the prescription; -On 11/7/23 at 6:00 A.M., a Norco signed out with no information regarding where the medication was obtained. Review of a medication re-order form dated 11/7/23, showed an order sent to the pharmacy for the resident's Norco at 6:28 A.M., that morning. Review of the resident's progress notes dated 11/7/23, showed no documentation of the resident's complaints of pain, steps taken to alleviate the pain, the unavailability of the narcotic medication, where the Norco was obtained or if obtained for the 6:00 A.M. administration, or actions taken to obtain the medication from the pharmacy. During an interview on 11/8/23 at 7:00 A.M., CMT K said the resident was supposed to be administered pain medication at midnight but never woke up asking for it. It probably should not be ordered for every six hours. If it was not administered, there should be documentation why it was not administered. If the resident was not needing it at night, staff should contact the physician to see about getting the order changed. During an interview on 11/7/23 at 6:10 P.M., CMT E said he/she knew the resident was in pain, but they had run out of his/her Norco the day before, and the refill had not arrived from the pharmacy yet. He/She had let both nurses know the resident was out of medication that morning. CMT E had given the resident 1000 mg of acetaminophen earlier. CMT E did not know why staff had not reordered the medication until after it had run out. They were supposed to order the medication when it got to the last line on the card, usually three to five days before the medication ran out, so residents would not be without their medication. The CMTs could do this by reordering it on the computer, faxing or calling the order into the pharmacy. If the medication was a Norco, then they would let the nurse know because this usually required a script and the nurse would have to notify the physician to get the script sent to the pharmacy. They had called the pharmacy earlier that day about the medication, and it was on order but would not arrive until after midnight. He/she had not administered any Norco to the resident earlier that day and had not notified the nurse to pull the medication from the e-kit. During an interview on 11/7/23 at 5:55 P.M., Licensed Practical Nurse (LPN) N said the CMT should have notified the nurse on duty about the resident being out of his/her pain medication so he/she could have called the pharmacy to get a code to pull the medication from the e-kit. The staff should be ordering the medication prior to it running out. Narcotics require a script from the physician and sometimes the facility or the pharmacy must contact the physician to get this, and it can hold the medication from being filled. The staff should be contacting the resident's physician if they could not get the script filled to find out if there was anything else they could give the resident for pain. Review of the resident's MAR, showed: -On 11/9/23 at 2:00 P.M., baclofen not documented as administered; a 9 was recorded; -On 11/10/23 at 6:00 A.M. and at 10:00 P.M., baclofen not documented as administered; a 9 was recorded; -On 11/10/23 at 12:00 A.M., staff did not document the resident's pain level. Norco was not documented as administered; a 9 was recorded. During an interview on 11/7/23 at 10:30 A.M., the Director of Nursing said it depended on the resident or resident's family if staff would wake them up in the middle of the night to administer pain medication. If the resident was sleeping, staff should document why the medication was not administered. If the resident continued to sleep through that medication time, then staff should contact the physician and get the order changed to omit that medication time. The resident occasionally asked for his/her pain medications at night. He/she requested them during the day and evening. He/She had Parkinson's Disease and experienced anxiety more than pain. The staff had to work with him/her to try and avoid the anxiety as much as possible. He/She complained of pain a lot. The staff should be ordering the medication seven days prior to it running out. If it is a nurse that notices the medication, he/she should contact the physician to get a script from the physician to send to the pharmacy. If it is a CMT that notices the medication is down to seven days, then he/she should notify the nurse to make the notifications. If the resident has completely run out, then the nurse could call the pharmacy to get an access code to access the e-kit to get the medication from the e-kit. A resident should not have to go for three days without a pain pill. 2. Review of Resident #27's admission MDS, dated [DATE], showed: -Clear speech, understood, understands, clear comprehension; -Cognitively intact; -Behavior: Rejection of care: Behavior not exhibited; -Pain management: -Resident is on a scheduled pain medication regimen and received as needed pain medications; -Pain presence, yes; -Pain intensity: Moderate; -Diagnoses included fracture of the left shoulder, multiple fractures of the ribs, paraplegia (paralysis), spinal stenosis (narrowing of the spine) and unspecified fractures of the T-5 and T-6 vertebrae (T-5 thoracic spinal cord injuries primarily affect the muscles in the upper chest, upper back, and inner arms. T-6 spinal cord injuries can affect balance, walking, and bowel and bladder functions). Review of the resident's care plan, dated 10/13/23, showed no documentation of the resident's pain or interventions for pain. Review of the resident's ePOS, showed: -Order, dated 9/18/23, for acetaminophen, 325 mg, give two tablets by mouth as needed for pain. Give with oxycodone; -Order, dated 10/9/23, for oxycodone HCL (a pain medication) oral tablet 10 mg, give one tablet by mouth every four hours. Review of the resident's MAR, showed: -On 10/13/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/14/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/21/23 at 2:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 10/22/23 at 8:00 A.M., staff recorded the the resident's pain level as a 1. Oxycodone was not documented as administered; a 9 was recorded. At 10:00 A.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded. At 2:00 P.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded. At 6:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 10:00 P.M., staff recorded the resident's pain level as an 8. Oxycodone was not documented as administered; a 9 was recorded; -On 10/23/23 at 6:00 A.M., staff did not document the resident's pain level or administration of oxycodone. At 10:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 2:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. At 6:00 P.M., staff documented a 0 for the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 11/2/23 at 6:00 P.M., staff did not document the resident's pain level or administration of oxycodone; -On 11/5/23 at 6:00 A.M., staff did not document the resident's pain level. Oxycodone was not documented as administered. At 6:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered. At 10:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded; -On 11/6/23 at 6:00 A.M., staff did not document the resident's pain level or administration of oxycodone; -On 11/15/23 at 6:00 P.M., oxycodone was not documented as administered; a 9 was recorded. At 10:00 P.M., staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. Review of the resident's progress notes, showed: -On 10/21/23 at 6:26 A.M., the resident only had one remaining pain pill. He/She was not given the 2:00 A.M., dose and instead, given the 6:00 A.M. dose. Medication was faxed to pharmacy for refill. Waiting for medication to arrive at facility. Staff explained this to the resident and resident verbalized his/her understanding. At 11:17 A.M., oxycodone, not available. At 3:12 P.M., medication not available. At 7:32 P.M., medication not available -On 10/22/23 at 6:36 A.M., oxycodone, medication on order. At 3:59 P.M., medication not available. At 6:38 P.M., medication not available; -On 10/23/23 at 11:41 A.M., oxycodone medication unavailable, called pharmacy, waiting on script. At 12:03 P.M., nurse faxed script for oxycodone refill to the physician's office. At 2:19 P.M., oxycodone 10 mg, medication unavailable; -On 10/24/23 at 7:35 A.M., resident voiced complaint over no pain medications over the weekends; -On 10/25/23 at 5:16 A.M., physician's progress note- Will continue physical and pain control. Patient is at high risk for functional impairment without therapy and adequate pain control. Patient has a high risk for developing contractures, pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), poor healing if not receiving adequate therapy and pain control. Observation and interview on 11/2/23 at 11:20 A.M., showed the resident seated in a wheelchair. The resident said he/she was shot in the shoulder in September and has chronic pain. He/She has run out of his/her pain medication a couple of times since being admitted and the last time it took a few days to get it refilled. He/She takes oxycodone for the pain and was without it from a Saturday morning until Monday night. He/She actually started going through withdrawals by the time he/she was able to get the medication. The only thing the staff offered him/her was Tylenol (acetaminophen), which does nothing to help ease the pain. During an interview on 11/2/23 at 12:40 A.M., CMT E said the resident ran out of his/her oxycodone last month, and he/she told the nurse. The resident never complained to him/her about the pain. He/She would just say he/she was going to flip out. The nurse would pull the pain medication from the e-kit but could only pull one pill a day. The resident has his/her pain medication now. During an interview on 11/2/23 at 11:15 P.M., LPN O said sometimes when a resident's prescription for a narcotic runs out, the pharmacy will not fill it unless the physician sends a new script. They were unable to get in contact with the resident's physician that weekend in October to get the script renewed and had to wait until Monday before they could get it filled. Sometimes if a resident comes in from the hospital without a script over the weekend, they will have to wait 72 hours or more for the physician to sign the script. The pharmacy will not send the medication without a script and the primary care physician will not give them the medication unless the hospital sends a script with them. The physician has said he/she has 72 hours to sign the script, so the resident will go days without their pain medication. If a resident is in extreme pain, the physician says to send them to the hospital, but the nurses have to get permission from the DON to send a resident to the hospital, and the staff have not always been able to reach her. Medications should be ordered seven days before the resident runs out. The CMT orders it unless it is a narcotic, then the nurse would call the physician to get a prescription sent to the pharmacy. They call the pharmacy for an access code to the e-kit. They cannot get a code to the e-kit unless there is a script for that medication. They can only pull a limited supply of a medication from the e-kit, and there is a limited supply of medications in the e-kit. If it is a narcotic, they can only pull one medication for a resident in a 24 hour period. They do not keep a list of what is in the e-kit. Further review of the resident's progress notes on 11/15/23 at 5:53 A.M., showed a eMAR note if oxycodone 10 mg, medication on order. At 11:04 A.M., medication unavailable. At 1:17 P.M., the nurse placed a call out out to the pharmacy to inquire about the resident's pain medication. The person the nurse spoke with informed him/her it would be sent out on the next medication run. The nurse requested a code for the e-kit and it was received. At 5:15 P.M., the medication was unavailable. At 8:00 P.M., the medication was on order; not in from the pharmacy. Review of the facility's card count medication sign off, dated 11/15/23, showed staff signed off as receiving 12 oxycodone pills between 7:00 P.M. and 7:00 A.M. During an interview on 11/16/23 at 8:35 A.M., LPN C said the resident was out of medication on 11/15/23 because they needed a new signed prescription from the physician. He/She pulled one from the e-kit for one dose the day before, and the pharmacy sent the new cards either last night or that morning. He/She talked to the resident's physician to request an order for more than nine days of medication since it requires a script each time it is renewed. Further review of the resident's MAR on 11/26/23 at 2:00 P.M., showed staff did not document the resident's pain level. Oxycodone was not documented as administered; a 9 was recorded. Further review of the resident's progress notes, showed: -On 11/26/23 at 5:12 P.M., showed staff placed a call to the pharmacy regarding the oxycodone being out of stock. The pharmacist said they will stat (should be prioritized first as it's needed urgently) out an order. Staff notified the resident and he/she is thankful for the follow up; -On 12/4/23 at 3:52 P.M., the resident's physician in to see the resident with the following order change made: Increase oxycodone to 15 mg, one tablet by mouth every four hours scheduled; -On 12/5/23 at 5:59 P.M., eMAR note, only 10 mg of oxycodone available. Staff informed resident and he/she agreed to take what is available; -On 12/6/23 at 1:24 P.M., the nurse placed a call to the pharmacy and inquired about the pain med. The pharmacy informed the nurse they were waiting for the script to be signed by the physician; -On 12/7/23 at 5:57 A.M., eMAR note, oxycodone 15 mg, not available waiting for MD to sign script. At 6:50 A.M., staff informed the resident he/she was out of his/her oxycodone. The resident became loud and agitated, and would not allow the staff to explain they were waiting on a script from the physician. Staff called the pharmacy and requested they call the physician's office but the person who answered the phone at the on call physician's office could not sign for the medication. Staff would pass this information on to the morning nurse. At 8:08 A.M., staff spoke to someone at the resident's physician's office who requested the phar [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers received necessary treatments and services to promote healthy healing by failing to follow orders for antibiotics for one resident (Resident #1). Additionally, the facility failed to complete wound treatments, failed to complete skin assessments upon admission, re-admission and weekly and failed to complete weekly wound assessments for two residents (Residents #1 and #26). The sample size was three. The census was 51. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured blister; -Stage III: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure. Review of the facility's pressure injury prevention and management policy, revised on 3/3/22, showed: -The facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries; -The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or removed underlying risk factors; monitoring the impact of interventions; and modifying the interventions as appropriate; -Licensed nurses will conduct full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record; -Assessments of pressure injures will be performed by a licensed nurse and documented in the medical record. Review of the facility's wound treatment management policy, revised on 9/1/22, showed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician order; -Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change; -Treatments will be documented on the Treatment Administration Record (TAR); -The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progress of healing; Changes in characteristics of the wound (location, pressure ulcer stage, size, drainage, pain, presence of infection, condition of issue in wound bed, condition of peri-wound); and changes in the resident's goals and preferences. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/12/23, showed: -Cognitively intact; -Rejection of care behavior not exhibited; -Impairment on both side of lower extremities; -Total dependence for toilet use; -Required substantial assistance for dressing, bed mobility and transfers; -Always incontinent of bladder; -Bowel not rated, resident has a colostomy (a piece of the colon is diverted through an artificial opening in the abdominal wall and stool passes through the colon through the abdominal wall into a bag located on the outside of the body to collect stool); -At risk for pressure ulcers; -One Stage IV unhealed pressure ulcer (PU) present upon admission; -Two unstageable PUs present upon admission; -Diagnoses included Stage IV PU of sacrum (sacral, triangular bone located above the coccyx (tailbone)), elevated blood cell count (showing infection) and anemia (iron poor blood). Review of the resident's medical record, showed: -An order, dated 10/11/23, for the specialty wound management to evaluate and treat as indicated; -An order, dated 10/11/23, discontinued 10/15/23, to cleanse wound to the sacrum area, apply wet to moist to wound bed, cover with abdominal pad (abd pad, absorbent pad) and tape, every day; Review of the resident's specialty wound management report, dated 10/12/23; showed: -Rounded with Wound Nurse. Extensive wound with exposed bone, necrotic muscle and necrotic fat. Wound culture and sensitivity test ordered; -Stage IV pressure ulcer at sacrum; measured 33 centimeters (cm) by 21 cm by 2.1 cm; necrotic muscle, bone and necrotic adipose (fat) were exposed; moderate amount of serosanguinous (composed of serum and blood) drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound (area around wound) presents with signs and symptoms of infection; -Stage III pressure ulcer at left hip, measured 3.9 cm by 5 cm by 0.3 cm with scant amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -A note, dated 10/12/23 at 2:47 P.M., the resident was seen by specialty Wound Nurse Practitioner (NP) for initial visit. Sacral wound was evaluated with bone evident, drainage and pain. Sacral wound orders include cleansing, Santyl (ointment to debride wounds) alginate (absorbent dressing) and abd pad. Hip order was to cleanse, apply Santyl, alginate and foam dressing; -An order, dated 10/13/23, to perform skin assessments every day shift on Fridays; -An order, dated 10/13/23, discontinued on 10/18/23, to cleanse, apply Santyl, alginate and abd pad, once a day for wound care. There was no location noted; -An order, dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day for wound care; -There was no documentation found that the resident's wound culture and sensitivity test had resulted and a new order was received from the Wound NP; -An order, dated 10/14/23 discontinued on 10/16/23, for Meropenem (antibiotic) intravenously (IV, administered into a vein), give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacrum for 5 days; -A note, dated 10/14/23 at 6:39 P.M., Meropenem was not administered because it did not arrive from the pharmacy. There was no documentation the pharmacy was contacted to follow up, the PCP was notified, or the nursing supervising team was notified; -A note, dated 10/14/23 at 9:41 P.M., Meropenem was not administered because it did not arrive from the pharmacy. There was no documentation the pharmacy was contacted to follow up, the PCP was notified, or the nursing supervising team was notified; -A note, dated 10/15/23 at 7:37 A.M., Meropenem was not administered because the resident did not have a peripherally interested central catheter (PICC, thin long tube inserted into vein in arm, leg or neck). There was no documentation found the PCP or nursing supervising team was notified; -A note, dated 10/15/23 at 10:46 A.M., the nurse attempted to insert an IV into the resident's arm and failed twice. The Director of Nursing (DON) was notified; -A note, dated 10/15/23 at 6:43 P.M., the nurse attempted to insert an IV into the resident's arm and failed; -A note, dated 10/16/23 at 1:09 P.M., the resident had new orders to go out to the hospital to get a PICC line placed; -A note, dated 10/16/23 at 2:23 P.M., the resident left for the hospital; -A note, dated 10/16/23 at 11:04 P.M., the resident returned from the hospital with a PICC line in his/her right arm; -An order dated 10/16/23, discontinued on 10/20/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer at sacrum for 5 days; -A note, dated 10/19/23 at 12:17 P.M., Wound NP to see the resident. The resident's Stage IV sacral PU measured 39 cm by 29 cm by 2.1 cm. Santyl with Calcium alginate. The resident's Stage III pressure ulcer measured 5 cm by 3 cm by 0.3 cm. Cleanse and apply border foam. The resident was his/her own responsible party. Review of the resident's specialty wound management report, dated 10/19/23; showed: -On 10/14/23, the results of wound culture showed positive for multiple strands bacteria; Meropenem (antibiotic) intravenous (IV, give through the vein) for five days ordered; -Stage IV PU at sacrum; measured 39 cm by 29 cm by 2.1 cm; necrotic muscle, bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III PU at left hip, measured 5 cm by 3 cm by 0.3 cm with scant amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day; -A note, dated 10/20/23 at 4:39 P.M., nurse unable to complete resident's treatments as wound nurse was not on shift. There was no documentation found the PCP or nursing supervisory team was notified; -A note, dated 10/23/23 at 4:49 P.M., the resident was sent to the hospital due to infiltration of the IV line; -A note, dated 10/23/23 at 10:54 P.M., the resident returned to the facility at or around 10:15 P.M. The resident's PICC line was in place and functioning properly; -A note, dated 10/24/23, at 5:58 P.M., the resident was sent to the hospital to receive a blood transfusion due to a low hemoglobin level (protein contained in red blood cells that is responsible for delivery of oxygen to the tissues). The ambulance was called and transported the resident to the hospital. Review of the resident's electronic Treatment Administration Record (eTAR), dated October 2023, showed: -An order, dated 10/11/23, discontinued 10/15/23, to cleanse wound to the sacrum area, apply wet to moist to wound bed, cover with abd pad and tape, every day, was documented as blank (showing not administered) on 10/15/23; -An order, dated 10/13/23, for weekly skin assessments, every Friday, was documented as completed on 10/13/23; -An order, dated 10/13/23, discontinued 10/18/23, to cleanse, apply Santyl, alginate and abd pad, once a day for wound care (no location specified) was documented as not given due to out to hospital on 10/16/23; -An order dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day, was documented as resident refused on 10/14/23, not given due to out to hospital on 10/16/23, not completed due to wound nurse not on shift on 10/20/23 and not done due to resident out at hospital on 10/25/23; -An order, dated 10/14/23 discontinued on 10/16/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacral region for 5 days was documented as not given due to medication not available at 2:00 P.M. and at 10:00 P.M. on 10/14/23, not given due to no PICC line at 8:00 A.M. on 10/15/23 and not given due to no IV access at 2:00 P.M. on 10/15/23, documentation was blank at 10:00 P.M. on 10/15/23 and at 8:00 A.M. on 10/16/23; -An order dated 10/16/23, discontinued on 10/20/23, for Meropenem IV, give 2 grams every 8 hours for wound care related to Stage IV pressure ulcer of sacral region for 5 days was documented as blank at 10:00 P.M. on 10/16/23 and blank at 8:00 A.M. on 10/17/23; -An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day, was documented as not done due to wound nurse not on shift on 10/20/23. Review of the resident's medical record showed: -There was no documentation the resident returned to the facility from the hospital; -There was no skin assessment completed after the resident was readmitted from the hospital; -A note, dated 11/2/23 at 12:57 P.M., where the Wound NP visited the resident. The resident's Stage IV sacral PU measured 39 cm by 32 cm by 1.9 cm, a terminal (a wound that will not heal) wound, Santyl and calcium alginate. The resident's left hip wound measured 16 cm by 15.5 cm by 1.2 cm, a terminal wound, Santyl and calcium alginate. The resident was his/her own responsible party and aware. Review of the resident's specialty wound management report, dated 11/2/23; showed: -Stage IV PU at sacrum; measured 39 cm by 32 cm by 1.9 cm; necrotic muscle, bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III PU at left hip, measured 16 cm by 15.5 cm by 1.2 cm with small amount of serosanguinous drainage noted; 1% to 25% granulation and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -There was no documentation the resident refused wound treatments on 11/2/23; -An order, dated 11/2/23, Meropenem IV, give 1 gram every 8 hours for bacterial infection until 11/28/23 at 10:47 A.M.; -There was no documentation why Meropenem was not given at 10:00 P.M. on 11/2/23; -A note, dated 11/3/23 at 5:14 A.M., Meropenem was not administered because there was no IV pump in the room; -A note, dated 11/3/23 at 3:14 P.M., Meropenem was not administered because it was not delivered by the pharmacy. There was no documentation the pharmacy was called to follow up on the order, the PCP was notified, or the nursing supervising team was notified; -A note, dated 11/5/23 at 5:23 A.M., Meropenem dose was missed; caught after 2:00 A.M. Next dose due at 6:00 A.M.; -On 11/7/23, at 1:42 P.M., there was no documentation of a base line care plan or a care plan was started or completed; -Review of the skin assessment, dated 11/7/23, no new wounds identified during the skin check. There was no documentation found regarding any existing wounds; -There were no other weekly skin assessments documented; -There was no order found to complete weekly wound assessments; -There were no weekly wound assessments found documenting all characteristics of the wounds; -A note, dated 11/9/23 at 10:47 A.M., Wound NP saw resident today. The resident's sacral wound measured 38.5 cm by 31 cm by 1.7 cm. Order changed. Resident's left hip wound measured 13 cm by 10 cm by 0.4 cm. Order changed. The resident was his/her own responsible party and aware. Review of the resident's specialty wound management report, dated 11/9/23; showed: -Stage IV pressure ulcer at sacrum; measured 38.5 cm by 31 cm by 1.7 cm; necrotic muscle, necrotic bone and necrotic adipose were exposed; moderate amount of serosanguinous drainage noted with a mild odor; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed. Peri-wound presents with signs and symptoms of infection; -Stage III pressure ulcer at left hip, measured 13 cm by 10 cm by 0.4 cm. with moderate amount of serosanguinous drainage noted; 1% to 25% granulation , 1% to 25% slough and 76% to 100% eschar tissue present in wound bed. Review of the resident's medical record, showed: -A PCP progress note, dated 11/10/23, showing on 11/7/23, requesting hospice consult due to terminal wounds and overall decline. The resident was currently treated with IV antibiotics and receiving wound care, both would have to stop if brought into hospice; -An order, dated 11/10/23, for sacral wound; Cleanse entire area with normal saline (NS), mix collagen powder (stimulates new tissue growth) with hydrogel (keeps wounds moist and apply to entire area every day shift; -An order, dated 11/10/23, for left hip wound, cleanse area with NS, mix collagen powder with hydrogel and apply, cover with abd pad, every day shift; -There was no documentation why the resident did not receive treatments on 11/11/23 or 11/12/23. Review of the resident's eTAR, dated November 2023, showed: -An order, dated 10/13/23, for weekly skin assessments every day shift on Fridays, was documented as no on 11/3/23, and blank on 11/10/23; -An order dated 10/13/23, discontinued on 11/9/23, for Santyl to sacrum every day, was documented as blank on 11/1/23, resident refused on 11/2/23, and blank on 11/4/23; - An order dated 10/19/23, discontinued on 11/9/23, for left hip, apply Santyl, alginate and foam dressing every day, was documented as blank on 11/1/23, 2 on 11/3/23, blank on 11/3/23 and blank on 11/4/23; -An order, dated 11/2/23 at 2:00 P.M., for Meropenem IV, 1 gram every 8 hours, was documented as blank at 2:00 P.M. and see progress notes at 10:00 P.M. on 11/2/23, as see progress notes at 8:00 A.M. and 2:00 P.M. on 11/3/23, as blank at 11:00 P.M. on 11/5/23, and as blank at 8:00 A.M., on 11/6/23; -An order, dated 11/10/23, for sacral wound, administer collagen powder with hydrogel, every day, was documented as blank on 11/10/23, see progress notes on 11/11/23, blank on 11/12/23, and blank on 11/14/23; -An order, dated 11/10/23, for left hip wound, administer collagen powder with hydrogel, cover with abd pad, every day, was documented as blank on 11/10/23, see progress notes on 11/11/23, blank on 11/12/23, and blank on 11/14/23. During an interview on 11/13/23 at 10:40 A.M., the resident said his/her wound treatments had not been changed in days. He/She did not always receive his/her antibiotics or dressing changes as ordered. Observation on 11/13/23, at 10:41 A.M., showed the resident lay in his/her bed on his/her back. The absorbent pad which was placed underneath the resident's waist to mid-thigh was visibly drenched with a foul smelling substance. The pad had dark brown and yellow rings extending from beneath the resident towards the edges of the pad. Licensed Practical Nurse (LPN) N and Certified Nurse Assistant (CNA) J turned the resident to his/her side, exposing the resident's sacrum. The bandage, dated 11/9/23, located at the resident's sacrum was soaked through with brown, yellowish drainage with a strong, foul odor. The bandage was soaking wet with foul drainage, it slipped off the resident's body. During an interview on 11/13/23 at 10:56 A.M. and at 12:55 P.M., CNA J said he/she was assigned to the resident that day. He/She worked with the resident regularly, if not almost daily. He/She had never experienced the resident refusing care. He/She had never seen the resident's treatment or bed as soaking wet with drainage as it was today. The resident's wounds did weep, but if the treatments were changed regularly, the wetness was not as bad and did not come through the dressing. Review of the PCP progress note, dated 11/13/23, showed: -History: The resident was laying in his/her bed, sleeping and barley able to wake up to talk to the PCP. A change of consciousness from the last visit was noted. The resident was not answering questions appropriately and had numerous wounds on his/her body and has been on IV antibiotics. There has been some mention of hospice care. PCP will go ahead and order a hospice consult and may have to contact the power of attorney (POA, legal authorization for a designated person to make decisions about another person's property, finances, or medical care) for this patient if he/she has one because of his new change in mental status; -Plan: -Gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection): Resident has numerous wounds and has been receiving IV antibiotics, continue IV antibiotics; -Decubitus ulcer of sacral region, unstageable: Continue present care at this moment resident unable to tell PCP one way or the other if he/she wants hospice care; -Acute alteration in mental status: Resident is probably a candidate for hospice at this time he/she could not answer questions appropriately and may need to contact next of care guardian, hospice consult initiated; -Overall Plan: 1. Reviewed current medications continue all medications, 2. Referral for hospice care may also need to contact this resident's guardian as he/she was unable to answer questions for the PCP on the day the PCP saw him/her. During an interview on 11/14/23, at 12:35 P.M., the Wound NP said: -She ordered Meropenem IV for 5 days on 10/14/23 after the wound culture resulted on that same day with multiple strains of bacteria; -She was not aware the resident did not receive the antibiotic as ordered. During an interview on 11/16/23 at 7:54 A.M., CNA J said if he/she noticed a dressing was soiled he/she would report it to the Charge Nurse. CNA J said seeing soiled dressings happens so often, he/she cannot remember who he/she has reported it to. CNA J said he/she has seen soiled dressings at least every other day. CNA J said the resident acted like his/her normal self on 11/13/23 while he/she was working day shift. When the resident returned from the hospital on 11/1/23, the resident was doing better, eating well, communicating well. It really surprised CNA J the resident passed away on 11/15/23. During an interview on 11/20/2023 at 2:21 PM, the Wound Nurse Practitioner (NP), said she described the photo of the resident's coccyx wound, taken upon admission, dated 10/6/23, as having 60% granulation, 30% slough and 10% necrotic tissue present in the wound base, with scant sero-sanguineous drainage present. She assessed the resident's coccyx wound in person on 10/12/23 and noted the wound had increased slough and potentially increased necrotic tissue in the wound bed as well as increased drainage compared to the wound picture taken on 10/6/23. The quality of the wound tissue declined, wound margins appeared to have expanded distally and proximally from initial wound size in the admission photo. 2. Review of Resident #27's admission MDS, dated [DATE], showed: -Cognitively intact; -No behaviors noted; -Impairments on both sides of lower body; -Required total assistance for toileting, bathing, personal hygiene and transfers; -Required substantial assistance for dressing and bed mobility; -Used a wheelchair for mobility; -Used a catheter (tube inserted into bladder to drain urine) for bladder; -Was always incontinent of bowel; -Diagnoses included kidney disease, heart failure, diabetes mellitus, osteomyelitis (bone infection) and atrial fibrillation (irregular heartbeat; -At risk for pressure ulcers; -Had one, unhealed Stage III pressure ulcer upon admission; -Had three un-stageable pressure ulcers present upon admission; -Received dialysis (treatment for kidney disease) while a resident. Review of the resident's care plan, dated 9/7/23, showed: -The resident had actual impairment to his/her skin integrity; -Interventions included monitor/document location, size and treatment of skin injury, report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to Medical Director (MD); Weekly skin assessments done by nurse; Weekly treatment documentation to include measure of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the resident's medical record, showed: -A skin assessment, dated 9/27/23, the resident had unstageable pressure ulcers located at his/her right and left heels. There was no other documentation found describing the characteristics of the wound; -An order, dated 9/28/23, discontinued on 10/10/23, to apply Santyl to right heel, cover with calcium alginate, abdominal pad and wrap with kling (flexible, rolled gauze dressing) every day; -An order, dated 9/29/23, discontinued on 10/5/23, for skin prep (forms protective barrier) to left heel, cover with abd pad and cover with kling wrap, every day; -A note, dated 10/5/23 at 12:27 P.M., the resident was sent to the hospital for evaluation due to excessive swelling in upper arms and knees. Review of the resident's specialty wound management report, dated 10/5/23; showed: -An unstageable PU, at left heel present; measured 3.5 cm by 3.0 cm by 3.1 cm with 76% to 100% eschar tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 3.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 1% to 25% granulation, 26% to 50% slough and 1% to 25% eschar tissue present at wound base. Review of the resident's medical record, showed: -A note, dated 10/12/23 at 6:55 P.M., the resident returned back from the hospital. There was no documentation regarding the resident's skin integrity; -There was no skin assessment completed after the resident was readmitted on [DATE]; -A note, dated 10/16/23 at 7:56 A.M., the resident was sent to the hospital; -A note, dated 10/18/23 at 6:18 P.M., the resident was readmitted to the facility. There was no documentation regarding the resident's skin integrity; -There was no skin assessment completed after the resident was readmitted on [DATE]. Review of the resident's specialty wound management report, dated 10/19/23; showed: -An unstageable PU, at left heel present; measured 2.4 cm by 1.2 cm by 0.2 cm; 26% to 50% granulation, 26% to 50% slough and 1% to 25% eschar tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 2.8 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 1% to 25% granulation, 1% to 25% slough and 26% to 50% eschar tissue present at wound base. Review of the resident's medical record, showed: -A note, dated 10/19/23 at 10:48 A.M., the resident was seen by the Wound NP via video. The resident's wound located at his/her left heel measured 2.4 cm by 1.2 cm by 0.2 cm and the resident's wound located at his/her right heel measured 1.5 cm by 2.8 cm by 0.2 cm; -An order, dated 10/19/23, complete weekly skin assessments every Thursday. If there are any skin issues, identify on skin assessment; -An order, dated 10/20/23, to apply Santyl to right heel, cover calcium alginate, abd pad, and kling wrap, every day; -An order, dated 10/20/23, to apply Santyl to left heel, cover calcium alginate, abd pad, and kling wrap, every day; -There were no orders found for specialty wound management team to evaluate and treat the resident's wounds; -There were no orders found for weekly skin assessments for the time period from 9/22/23 through 10/18/23; -There was no documentation found that skin assessments were completed from 10/4/23 through 10/18/23 by a nurse; -A skin assessment, dated 10/25/23, the resident had a Stage III PU at his/her right heel, measuring 1.5 cm by 2.8 cm by 0.2 cm and an un-stageable PU located at his/her left heel measuring 2.4 cm by 1.2 cm. Review of the resident's specialty wound management report, dated 10/26/23; showed: -A Stage III PU, at left heel present; measured 3.5 cm by 2.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed; -Stage III PU, at right heel present; measured 1.5 cm by 2.4 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present at wound base. Review of the resident's electronic medication administration record (eMAR), dated October 2023, showed: -An order, dated 9/28/23, discontinued on 10/10/12, for treatment to right heel, every day, was documented blank (showing not completed as ordered) on 10/2/23 and 10/3/23; -An order, dated 9/29/23 and discontinued on 10/5/23, for treatment to the left heel was documented as blank on 10/1/23 and 10/2/23; - An order, dated 10/20/23, for treatment to left heel every day, was documented as not administered due to wound nurse not present on 10/20/23, not administered on 10/23/23 or on 10/27/23 due to resident out to dialysis or 10/30/23 because resident was absent; -An order, dated 10/20/23, for treatment to right heel, every day, was documented as not administered due to wound nurse not present on 10/20/23, not administered on 10/23/23 or on 10/27/23 due to resident out to dialysis or 10/30/23 because resident was absent. Review of the resident's specialty wound management report, dated 11/02/23, showed: -Stage III PU, at left heel present; measured 1.7 cm by 1.5 cm by 0.2 cm with small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed; -Stage III PU, at right heel present; measured 1.2 cm by 2.0 cm by 0.2 cm with a small amount of sero-sanguineous drainage noted; 26% to 50% granulation and 26% to 50% slough tissue present in wound bed. Review of the resident's medical record, showed: -A note, dated 11/9/23 at 11:14 A.M., showed the Wound NP saw the resident. The wound at the resident's left heel measured 1.9 cm by 1.4 cm by 0.2 and the wound at the resident's right heel measured 1.2 cm by 2.0 cm by 0.4 cm; -There were no orders for weekly wound assessments; -There were no weekly wound assessments completed by the facility from date of admission. Review of

Based on interview and record review, the facility failed to keep one of two sampled residents free from self-harm by not providing behavioral health care that created an environment which promoted emotional and psychosocial well-being to meet a resident's needs. The facility also failed to develop and implement individualized, person-centered interventions related to the resident's conditions, review and revise the resident's care plan, identify the resident responses to stressors, and identify cultural needs to support the resident's dignity, independence, choice and safety (Resident #1). The resident demonstrated agitated behavior on the morning he/she committed suicide in the facility's shower room. The census was 51. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed the following: -admitted to the facility on [DATE]; -Brief Interview for Mental Status (BIMS, a screening tool used to determine cognitive impairment), score of 15 out of 15 (cognitively intact); -No behavioral symptoms; -No rejection of care; -No discharge plan to return to the community; -[DIAGNOSES REDACTED]. Review of the resident's social services notes, showed the following: -[DATE], spoke with the resident regarding his/her desire to leave the facility. The resident said he/she wanted to go back to his/her tribe in New Mexico but does not know how he/she would get there. Informed the resident that she could call Money Follows the Person (a demonstration program focused on moving Medicaid beneficiaries living in institutions to a less restrictive community setting) to see if he/she would qualify for the program to help him/her return to the community. She let the resident know that the likelihood of him/her returning to the tribe at this time was not an option. However, the program would be able to help him/her get back out in the community. The resident said he/she would think about it and let her know in a couple of days; -[DATE], the assistant Director of Nurses (ADON) said the resident wanted to return to his/her tribe in New Mexico, she informed the resident he/she needed to speak with her to discuss his/her options. The resident said he/she was done talking to people here. Went to speak with the resident however he/she was participating in a cooking class, will try after activity is over; -[DATE], met with the resident about concerns with wanting to leave the facility. The resident did not want to talk about it. He/she did want her to write out instructions that his/her daughter be left all his/her belongings when he/she passes. The resident wrote down the name of a gentleman that had his/her will and all of his/her contact information. This paper was in the resident's file. Review of the resident's care plan, dated [DATE] and updated [DATE], showed the following: -Focus: Advanced Care Planning; -Goal: The resident will be informed of his/her right to complete advanced directives to direct his/her medical care and make his/her values and treatment goals known. The resident's stated desires will be honored; -Interventions: Advanced Directives of the resident's choice will be completed and placed in his/her medical record under the advanced directives tab; -The resident had completed the following advanced directives: Do Not Resuscitate, (DNR, instructs health care providers not to perform cardiopulmonary resuscitation); -Focus: Has episodes of verbal aggression towards staff, making threatening statements and gestures directed towards staff. The resident has confabulated in his/her own mind that staff does not like him/her because he/she is an Indian and will frequently threaten to report staff to his/her tribe. He/she will demand immediate gratification from staff and accuse staff of discriminating against him/her, often refusing to eat, take his/her medications, shower, etc. When immediate gratification is not received, he/she will accuse staff of being racist and in turn make racial statements directed towards staff and physicians. He/she has been witnessed throwing clothing and towels he/she has taken from rooms into the hallway and calling staff filthy because they dispose of paper towels and gloves in the trash can in his/her room. The resident has pertinent [DIAGNOSES REDACTED]. -Goal: The resident will remain safe to him/herself and others through the review date. He/she will state understanding of need to control verbal aggression/threats through the review date and choose to express him/herself in a more positive manner. He/she will choose to decrease the number of times he/she refuses care, meals, showers and will be re-educated of risk associated with refusal of care; -Interventions: Administer medications as ordered. Monitor and document side effects and effectiveness; -Assist the resident to develop more appropriate methods of coping and interacting (encourage verbalization of feelings and frustration verses verbal aggression and threats. Encourage resident to seek out a staff member he/she feels comfortable with when he/she is feeling frustrated). Encourage the resident to express feelings appropriately. -Caregivers to provide opportunity for positive interaction and attention. Stop and talk with him/her as passing by; -Document behaviors and interventions attempted via behavior monitoring logs; -Follow up with psychiatrist as needed; -If reasonable, discuss the resident's behavior. Explain why behaviors are inappropriate and/or unacceptable; -Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take to an alternative location as needed; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential cause; -Monitor for potential harm to self and/or others related to behavioral symptoms and intervene immediately; -Praise any indication of the resident's progress/improvement in behavior; -When the resident is being verbally aggressive or making threatening gestures, ensure that he/she is safe. Walk away and allow time for him/her to calm down before conversation/task; -Focus: The resident uses antidepressant medication related to [DIAGNOSES REDACTED]. -Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy; -Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift; -Monitor/document/report as needed any adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, withdrawal, decline in activity of daily living (ADL) ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls, dizziness/[MEDICAL CONDITION], fatigue, [MEDICAL CONDITION], appetite loss, weight loss, nausea/vomiting, dry mouth, dry eyes; -Focus: The resident used anti-anxiety medications related to anxiety disorder; -Goals: The resident will be free from discomfort or adverse reactions related to anxiety; -Interventions: Administer medications as ordered by physician. Monitor/document side effects and effectiveness every shift; -Monitor for safety. Anti-anxiety meds are associated with an increased risk of confusion, amnesia, loss of balance, cognitive impairment that looks like dementia and increases risk of falls, broken hips and legs; -Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medication as needed; -Monitor/document/report as needed any adverse reactions to anti-anxiety therapy, drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion, disorientation, depression, dizziness, lightheadedness, impaired thinking, judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects include mania, hostility, and rage, aggressive or impulsive behavior; -Focus: Resident will refuse meals related to not receiving immediate gratification. The resident will repeat he/she is on a hunger strike, when in fact he/she is eating snacks in his/her room that his/her family member bought. Further review of the resident's social services notes, showed the following: -[DATE], per the resident's request, a call was placed to Money Follows the Person to come out and evaluate him/her for the program. They will come out [DATE] at 2:00 P.M. to start the interview process to determine eligibility; -No notation of hunger strike behaviors. Review of the resident's psychiatric consult, dated [DATE], showed the following: -Chief complaint: The resident has been doing better with his/her mood, still can be condescending at times. Sleeping well. He/she did report, I have mores situational depression. He/she denies suicidal thoughts, I am too handsome to die. My mood is better; -Current Diagnosis: [REDACTED]. -Interval history reviewed. Staff consulted and records reviewed. Staff reports no current behavioral concerns, compliant with medications and no side effects. The resident sleeps fair and restful, has a fair appetite and weight is stable. His/her mood fluctuates, can become extremely hostile with staff when he/she does not get what he/she wants; -No sad tearful episodes reported; -No suicidal or homicidal ideation; -Reports feeling anxious; -No [MEDICAL CONDITION], no delusional thinking elicited; -Spoke of day to day stressors; -No sedation noted or reported; -Well groomed, good hygiene, good eye contact, cooperative and friendly; -Thought process logical; -Fair to good with: Judgment, insight; -Memory grossly intact; -Assessment: clinical opinion resident is at baseline, compliant with the treatment recommendations. Gradual dose reduction not recommended due to potential risk of returning anxiety. Discussed mood stabilizer, and encouraged the resident to pursue more positive behaviors such as talking to staff. Complexity of mental condition is moderate. Current medications are helping; -[DIAGNOSES REDACTED]. Further review of the resident's social services notes, showed the following: -[DATE], a representative from Money Follows the People was here today, to do the resident's interview. Will follow up with the rep tomorrow to check on the resident's eligibility; -[DATE], the resident wanted to address some issues he/she had over the weekend. He/she was very upset with the night shift staff, one certified nurse aide (CNA) in particular. Informed the resident, she would have to talk with the Director of Nurses (DON) to have his/her concerns addressed and that she was not in charge of nursing staff. The resident became very irate and upset, started yelling at her that she did not do anything around here and questioning her position in the facility. At that point, she asked the resident to leave her office. He/she was making her feel uncomfortable and the discussion could resume when the administrator came in. The resident continued to yell, the business office manager came over to intervene. The resident stood up and walked towards her, she asked the resident to please leave her office. He/she was yelling and called staff white trash. Nurse C came in and the resident left with him/her. She will inform the administrator and the DON of the resident's behaviors and concerns that he/she presented her with. Review of the resident's nurse notes, showed the following: -[DATE] at 10:30 P.M., resident is standing in the hallway yelling that the CNA did not close his/her door properly. He/she is aggressive verbally despite attempts to reason or re-direct. The resident is upset about his/her roommate getting a snack despite the resident getting a snack earlier. He/she continues to open and close the door and stand in the doorway. He/she states he/she is going to talk to administrator tomorrow. He/she continues to verbally berate both CNAs, accusing the CNAs of opening his/her door on purpose and leaving dirty diapers in the trashcan. No dirty diapers or dirty linens found in trash cans of resident's room. Resident instructed to go to sleep and can discuss more tomorrow; -Undated and untimed note, the resident came back to the desk requesting staff to remove dirty linen and trash from his/her room. The resident was informed that someone would be there as soon as possible to remove linens and trash. The resident said, Why can't you do it, you are not doing anything. Informed the resident again staff would remove trash and linens. The resident walked back down hallway. Nurse went to dining room and was informed by certified medication technician (CMT) that the resident was going out to smoke. Nurse went out to the smoking area and found two residents smoking. The resident refused to extinguish his/her cigarette or give staff the lighter. He/she said I don't have cigarettes or a lighter. The other resident left and put out his/her cigarette. Review of the resident's MDS, dated [DATE], showed the following: -BIMS, score of 14 out of 15 (cognitively intact); -Ability to understand others and to make him/herself understood; -Adequate speech, hearing and vision with glasses; -Verbal behavioral directing toward others; -No rejection of care; -No mobility device needed; -Independent with mobility and activities of daily living (ADLs); -Supervision, set up and oversight needed for bathing; -Always continent of bowel and bladder; -No discharge plan to return to the community; -[DIAGNOSES REDACTED]. Further review of the resident's care plan, showed no documentation of discharge planning, no documentation of cultural needs, no documentation of his/her history of alcoholism and no documentation of resident's criminal past and/or need to register as a sex offender. No documentation of the resident'[MEDICAL CONDITION] diagnosis, plans [MEDICAL CONDITION] treatments and no documentation of the resident's emotional support needed in dealing with his/her spouse's death. During an interview on [DATE] at 11:00 [NAME]M. and [DATE] at 11:17 [NAME]M., the MDS coordinator said she worked at the facility for three months. Her responsibilities included residents' care plans. The resident refused to come to the last care plan meeting. She was not aware of the resident's need to register as a sex offender. If she was, she would want to know if the resident was having current issues. She wondered if this was on the care plan, if staff would treat the resident differently. The behavior monitoring log is a sheet the nurses document on daily, every shift. The resident was very high functioning, had [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Discharge planning was not on the care plan because the resident was at the facility for long-term care. Further review of the resident's nurse notes, showed the following: -[DATE] at 10:15 [NAME]M., the resident walked into nursing office and said, I am coming to your office in a good mood. Just had blood drawn and the nurse (blood draw technician) said I was dehydrated. The resident became verbally abusive and argumentative. Explained to the resident that writer (DON) didn't appreciate being talked to in such a manner and the writer didn't appreciate the verbal abuse and if he/she was going to continue the writer would appreciate it if he/she would speak with social service designee (SSD). The resident refused to leave the office area and stated, I can do anything I want, you can't make me leave. I'm calling my daughter. The resident then left the office. After the resident removed him/herself, had charge nurse give him/her a fresh pitcher of ice water and informed charge nurse of his/her behavior. Asked resident in the future, to bring pitcher to staff and/or nurse desk if he/she needs water at any time; -[DATE] at 10:30 [NAME]M., the resident came to nurse and asked for fresh ice water. The resident was grateful; -[DATE] at 12:00 P.M., the resident returned to the facility with daughter and grandkids, laughing and joking with staff. Nurse attempted to give him/her medication as ordered. The resident said No, I have to go to the bathroom first, I will be back. Twenty minutes later the resident did not return. Went to the resident's room to give medication. The resident said No, I am not going to take it, throw it away. You all don't like me and might want me dead, just leave me alone to sleep. Review of the resident's psychiatric consult, dated [DATE], showed the following: -Chief complaint: Staff reports the resident is non-compliant with medication. The resident is wanting to stop some meds, he/she has been taking medications this week and his/her mood is better. The resident said I don't need all those psych meds. The resident has limited insight into his/her mood and how it affects others. The resident went out with his/her daughter today; -Interval history reviewed. Staff consulted and records reviewed. Staff reports no current behavioral concerns, compliant with medications and no side effects. The resident sleeps fair and restful, has a fair appetite and weight is stable. His/her mood fluctuates, can become extremely hostile with staff when he/she does not get what he/she wants; -No sad tearful episodes reported; -No suicidal or homicidal ideation; -Reports feeling anxious; -No [MEDICAL CONDITION], no delusional thinking elicited; -Spoke of day to day stressors; -No sedation noted or reported; -Well groomed, good hygiene, good eye contact, cooperative and friendly; -Thought process logical; -Fair to good with: Judgement, insight -Memory grossly intact; -Assessment: clinical opinion resident is at baseline, compliant with the treatment recommendations. Gradual dose reduction not recommended due to potential risk of returning anxiety. Discussed mood stabilizer, and encouraged the resident to pursue more positive behaviors such as talking to staff. Complexity of mental condition is moderate. Current medications are helping; -[DIAGNOSES REDACTED]. Further review of the resident's nurse notes, showed the following: -[DATE] at 8:00 [NAME]M., the resident approached and informed two nurses that he/she would like to know why his/her name was not written down to see the doctor yesterday. Nurse and DON clearly indicated that the resident was examined on [DATE] by the physician. The resident interrupted us both very loud and accusatory of other nurse that his/her name was not on the list. Attempted to ask the resident what list he/she was referring to as the physician already seen him/her on [DATE]. The resident continued to be loud, argumentative and speaking making loud statements that were attacking me (DON). Informed the resident she would write in his/her chart and he/she needed to go to the morning meal. He/she did do so but again had very loud cruel words to say and then walked away; -[DATE] at 2:30 P.M., no further interactions at this time. Calm; -[DATE] at unknown time, the resident has been refusing his/her medication at bedtime and refused the dose this morning. He/she said I don't take that anymore, I was told it is for my mind to keep me calm. I am calm now I don't need it anymore. Call placed to the resident's psychiatric Nurse practitioner (NP) to inform her of resident's refusal to take medication; Review of the resident's psychiatric consult, dated [DATE], showed the following: -Chief complaint: The resident has been refusing some of his/her medication. He/she denies depression or anxiety. Discussed the resident's frustration at times and how the medication will help with that. The resident said I don't need all those drugs. I am getting fat. Reviewed medications with resident and he/she agreed to continue on his/her morning meds. I sleep fine. The resident is less hostile with this visit; -Interval history reviewed. Staff consulted and records reviewed. Staff reports no current behavioral concerns, his/her mood has improved but he/she has limited insight into medications. The resident sleeps fair and restful, has a fair appetite and weight is stable. His/her mood fluctuates, can become extremely hostile with staff when he/she does not get what he/she wants. He/she has multiple complaints about people; -No sad tearful episodes reported; -No suicidal or homicidal ideation; -Reports feeling anxious; -No [MEDICAL CONDITION], no delusional thinking elicited; -Spoke of day to day stressors; -No sedation noted or reported; -Well groomed, good hygiene, good eye contact, cooperative and friendly; -Thought process logical; -Fair to good with: Judgment, insight; -Memory grossly intact; -Assessment: clinical opinion resident is at baseline, compliant with the treatment recommendations. Gradual dose reduction started, due to the resident refusing medications. Resident said he/she will attempt to be more compliant with medications. Discussed mood stabilizer, and encouraged the resident to purse more positive behaviors such as talking to staff. Complexity of mental condition is moderate. Current medications are helping; -[DIAGNOSES REDACTED]. Further review of the resident's nurse notes, dated [DATE], showed the following: -9:38 [NAME]M., the resident came to the nurse office demanding that You people need to get me a new bed. Someone took my bed. I (ADON) reminded him/her that on [DATE] I discussed with him/her about changing his/her bed frame and keeping his/her mattress, and that he/she was agreeable. The resident said I remember, but you treat me like a second class citizen because I'm an Indian. You better get that bed switched back today, or something bad is going to happen. I explained to the resident that the mattress is the same, the bed is electronic and I could not change it out. The resident became very loud and leaned across the desk threatening You are discriminating against me and today something is going to happen. The resident was yelling, pointing his/her finger and leaning toward me. The administrator and the DON were present in the office and intervened to calm him/her down. The resident started yelling at them pointing his/her finger. You are discriminating against me and I will not put up with it. He/she went on to say I don't like you or you or you or you and today I will do something about it mark my words. Send me out of here today, right now. I want to go. Administrator said we can check on other nursing home forhim/her to go to but he/she cannot yell and threaten staff. The resident then left the office and returned to his/her room. When passing the resident's room, the resident came out and followed behind saying You don't like Indians that is why you treat me like a second class citizen. The resident continued to follow closely, taunting the ADON and accusing her of treating him/her unfairly, discriminating against him/her because he/she is an Indian. The resident stood in front of nurse and said Look at me when I am talking to you. The administrator intervened and spoke to the resident. The resident again returned to his/her room, stopping on the way to talk to family members of other residents and residents. He/she said I am being discriminated against because I am an Indian, they don't take care of me and they don't take care of any resident. He/she was talking to anyone who would listen; -11:20 [NAME]M., Was called out to smoking lounge by staff who informed ADON the resident took two cigarettes, smoked one and would not return the other. Attempted to reason with the resident, administrator present but to no avail the resident started talking about No one takes care of anyone around here. I am not giving you my cigarette, I pay for them not you and I am going to do something about it. Called the resident's daughter to inform her of the resident's behavior this morning and how he/she was aggressive with staff, speaking poorly of staff and facility to visitors, families and residents while being very accusatory of staff stating if he/she was white he/she would not be treated like this. Ask the daughter if she would speak with the resident. And try to talk to him/her as the only other available choice would be to call psych NP or to refer the resident to another facility as the resident has requested to leave here. The daughter said Do what you have to do, I cannot do this anymore. The daughter asked that the resident call her in a little bit as she just arrived at her child's school. Informed charge nurse, in 10 minutes to have resident call his/her daughter. At this time resident is calm and in lunch room at 11:50 [NAME]M.; -12:00 P.M., Dialed the resident's daughters phone number. The resident spoke with daughter at the nurse station. The resident is calm and walked away from nurse station and went down 300 hall per facility camera. At nurse station observed the resident go to activity office then walk outside. Called the activity director who reported the resident was smoking a lit cigarette outside. Went out to smoking area with charge nurse and the resident was smoking. Asked the resident to please give her the lighter and he/she stated while smoking, he/she did not have one. Stayed with the resident while smoking. He/she came inside when finished. Charge nurse (Nurse C) asked for the lighter, the resident walked into the 300 bathroom and threw it, (the lighter) in the toilet. The charge nurse retrieved and secured the lighter at this time. When on the phone with the daughter, I (DON) informed her the resident had a lighter and would not give it to staff and due to the way the resident was acting by yelling at staff they might have to call the police or send him/her out; -12:00 P.M., call placed to psych NP to inform her of the resident's behavior, message left; -12:30 P.M., Spoke with psych NP, discussed the resident's behavior this morning. She said they could send the resident out for a psych evaluation. The resident might refuse to go or become more agitated, so they might want the police there when you call the ambulance; -1:14 P.M., staff was yelling my name (DON) as DON was in her office, ran towards nurses station and CNA A told DON to come to the shower room with ADON following. Found the resident sitting on his/her buttocks leaning to the right a tad bit, no glasses on face with white cloth like material around his/her neck and other end secured to knob on top cabinet. The resident was without a pulse and not breathing, attempted to pick up resident to release pressure from his/her neck. Other Nurse with scissors cut material around neck. CPR initiated. Nurse informed to call 911. CPR performed by several staff until emergency medical services (EMS) arrived and called time of death at 1:32 P.M. Further review of the resident's social services notes, showed the following: -[DATE], administration informed me this morning that the resident expressed interest in finding a new facility for placement. Will reach out to our sister facilities to see about an available bed. Around 9:00 [NAME]M., the administrator asked me to go with her to the smoking area, the resident was being aggressive verbally with staff during a smoke break. Screaming at CNA A that he/she did not do his/her job. The resident had a cigarette in his/her pocket and refused to give it to CNA A when he/she asked for it. The DON asked repetitively for the resident to give the cigarette back as the resident kept yelling at her and stepping closer to her. The resident said he/she can smoke whenever he/she wants because the staff does. The DON was redirecting the resident many times saying that the residents have designated smoke times and the staff was allowed to take breaks. I was told to send out the resident's referral packet for new placement per the resident's request. Our sister facilities have an open smoking policy. The resident's referral was sent to a facility for potential placement, waiting on fax numbers for other facilities. Review of the EMS report, dated [DATE], showed the following: -EMS responded to the facility's 911 call on [DATE] at 1:19 P.M.; -Arrived on scene at 1:29 P.M.; -Nursing home staff report CPR started at 1:15 P.M., the resident is unresponsive; -At 1:31 P.M., advanced life support (ALS) assessment found the resident's response as unchanged, unresponsive; -At 1:32 P.M., 3-lead electrocardiogram (ECG a graphic recording of the changes occurring in cardiac activity) started with the resident's response as unchanged, unresponsive; -At 1:33 P.M., CPR stopped, DNR provided to EMS by nursing staff. The resident's response is unchanged, unresponsive; -Observation found bruising around the resident's neck from rope/sheet used to hang him/herself. Review of the police report, dated [DATE], showed the following: -Call received on [DATE] at 1:18 P.M.; -Arrived at the facility on [DATE] at 1:32 P.M.; -Police responded to the facility for a report of a person who had committed suicide by hanging; -The resident was located in the shower room and had already been cut free of the noose. He/she was deceased , laying on his/her back on the floor and covered with a white sheet; -The resident was last seen by CNA B at 12:45 P.M.-12:50 P.M., walking to the shower room. The resident told CNA B he/she was going to take a shower. CNA B said this was not unusual and the resident has done this on many occasions; -The resident was found by CNA A, hanging. CNA A said he/she was looking for another resident and checked the shower rooms. He/she looked in the left shower room at 1:14 P.M., and saw the resident hanging from a strip of white cloth, tied in to a cabinet knob and around the resident's neck; -It appeared the resident cut the strip of cloth from the hemmed end of the bed sheet that was located on his/her bed. The strip of cloth was cut from the resident's neck by staff members and CPR was started; -EMS responded while CPR was being performed on the resident. The resident's valid DNR was located, CPR was stopped; -The resident was pronounced dead at 1:33 P.M. by EMS; -The ADON said the resident has been diagnosed with [REDACTED]. The ADON said on [DATE] at 9:30 [NAME]M., the resident was complaining about a bed that had been switched on [DATE]. The resident said he/she wanted his/her bed back or something bad was going to happen. The ADON thought this was a threat against her and not that the resident would harm him/herself. During an interview on [DATE] at 10:38 [NAME]M., the ADON said the resident was alert and oriented, up ad lib (up when he/she prefers), independent with his/her ADLs and care. The resident did have some psych issues with some verbal aggressions periodically. The resident was very artistic. He/she could be beautifully behaved one week and be paranoid the next. The staff notified the physician with behavior changes. He/she needed help making appointments. The resident would never attempt to leave the facility. He/

Based on observation, interview and record review, the facility failed to adequately assess, monitor and document regarding one expanded sample resident, who complained of pain after an improper mechanical sit to stand/stand up lift transfer in which the resident ended up on the floor. The resident complained of right leg pain for approximately one to two weeks, until he/she complained of severe pain, and an x-ray was done which showed a femur (thigh bone) fracture. The sample was 12. (Resident #14) The census was 50. Review of Resident #14's care plan, updated 9/9/16, showed the following: -Problem: Required assistance with activities of daily living; -Approach: Assist of two for bathing, bed mobility, dressing, toileting and transfers with a mechanical lift; -No documentation regarding any leg pain. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/16, showed the following: -[DIAGNOSES REDACTED]. -BIMS (Brief interview for mental status, a score used to determine how cognitively intact a resident is) score of 13 (a score of 13-15 means the person is cognitively intact); -Short term memory loss; -No behaviors; -Required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Range of motion: Lower extremity impairment on both sides; -Incontinent of bowel and bladder; -Pain: No presence of pain, no scheduled or as needed pain medicine and no non medication interventions for pain; -No falls. Review of the resident's nurse's notes, dated 1/17/17, the first notes documented since 12/6/16, showed the following: -2:15 P.M.: Complaints of right leg pain, right leg tender to touch, call placed to the resident's physician, awaiting return call; -4:16 P.M.: No call back from the resident's physician, call placed to the medical director, awaiting return call; -4:20 P.M.: Medical Director returned call, new order received for an x-ray of the right knee, right femur and tibia (lower leg bone). Review of the resident's physician's orders [REDACTED]. -Order dated 1/17/17, for a stat x-ray of the right knee, femur and tibia; -No orders for any routine or as needed pain medication. Review of the resident's Medication Administration Record [REDACTED] -Front of MAR: -Pain assessment every shift. Ask patient on a scale of 1-10 if they are experiencing pain. If yes record action taken; -8:00 A.M.: Staff initialed as complete 1/1-17/17, Pain: 0 for no pain 1/1-17/17; -2:00 P.M.: Staff initialed as complete 1/1-17/17, Pain: 0 for no pain 1/1-17/17, blank 1/8/17; -8:00 P.M.: Staff initialed as complete 1/1-3/17, 1/5/17, 1/7-17/17, blank for 1/4 and 1/6/17, Pain: 0 for no pain 1/1-3/17, 1/5/17, 1/7-12/17, 1/13/17: 4 out of 10, 1/14-16/17; -Back of MAR: 1/3, 1/5, 1/10, 1/14 and 17/17: A.M. refused medications. Review of the resident's radiology report, dated 1/17/17 at 8:01 P.M., showed a femur fracture. Review of the resident's POS, dated 1/17 through 31/17, showed an order dated 1/17/17, to send to the hospital for evaluation of right femur fracture. Review of the resident's nurse's notes, dated 1/17/17, showed the following: -4:30 P.M.: Call placed to mobile x-ray, x-ray ordered, no documentation regarding the resident's pain; -8:30 P.M.: X-ray report received via fax, call placed to on call physician, message left. No documentation regarding the resident's pain; -8:45 P.M.: Return call received from on call physician, informed of the x-ray results. Transfer order received. No documentation regarding the resident's pain; -8:46 P.M.: Call placed to responsible party/guardian, message left. No documentation regarding the resident's pain; -9:30 P.M.: Resident transferred to hospital. No documentation regarding the resident's pain. Review of the resident's emergency room note, dated 1/18/17 at 6:02 A.M., completed by the emergency room physician, showed the following: -Chief complaint: Lower extremity problem, pain at right lower extremity since fall at the nursing home one week ago. X-ray at the facility showed femur fracture; -Presents to emergency room , complained of fall at the nursing home one week ago. Patient said he/she fell while using a chair lift. He/she now complained of severe, constant, aching pain right leg pain. Pain is significantly worse with movement and pressure on the injury; -Physical exam: Extremities: Extremely tender right lower extremity; -X-Ray: Right femur trauma. Fracture femur; -Final Diagnoses: [REDACTED]. Review of the resident's hospital history and physical, dated 1/18/17 at 8:03 P.M., completed by the resident's primary physician showed the resident was sent to the emergency department after an x-ray at the facility showed a right femoral fracture. The resident had fallen about a week before and pain was not subsiding. In the emergency department the resident said he/she fell off a chair lift. Review of the resident's nurse's notes, dated 1/20/17 at 9:00 P.M., showed the following: -9:00 P.M.: readmitted to the facility via ambulance, appears to be in pain with facial grimaces and verbal cues; -[MEDICATION NAME] IR (a narcotic pain medication used to treat moderate to severe pain) and [MEDICATION NAME] 0.5 milligrams administered for complaints of pain 10/10. Right leg immobilizer in place. During an observation and interview on 1/23/17 at 12:24 P.M., the resident lay in bed with an immobilizer on his/her right leg. The resident said he/she fell from the lift and Nurse N put him/her in the wheelchair. During an interview on 1/18/17 at 2:35 P.M., Resident #15 said Resident #14's room was right next to his/her room. About two weeks ago he/she heard the resident tell a certified nurses aide (CNA), he/she didn't have him/her connected to the lift correctly. Right after that he/she heard a thump and heard the resident yelling. That morning when the resident came to the dining room he/she heard Resident #14 say the CNA hurt him/her and he/she kept repeating it in the dining room. Lately it had been really bad, when staff transferred the resident. He/she could hear Resident #14 complain of pain from his/her room. Resident #14 used to come to exercise classes but stopped coming right after the incident occurred. He/she has heard him/her ask for something for pain but didn't know if he/she got anything. During a interview on 1/23/17 at 12:30 P.M., the resident's roommate said he/she didn't remember how long Resident #14 had been in pain but he/she had been complaining lately his/her leg hurt. Resident #14 said his/her leg really hurt and he/she had screamed a lot about it. During an interview on 1/23/17 at 9:14 A.M., Nurse L (night shift nurse, 7:00 P.M. to 7:00 A.M.) said approximately one and a half weeks ago he/she was at the desk charting when he/she heard screaming on the 100 hall, the hall where the resident resided. When he/she reached the resident's room, he/she saw the resident with his/her arms extended upward and his/her body sliding out of the sit to stand lift. The belt wasn't buckled around the resident's waist. Before he/she could reach the resident, he/she had slid to the floor. The resident said he/she was dropped after the incident and complained of leg pain. He/she instructed CNA F not to move the resident and went to get his/her nurse. He/she told Nurse N the resident had fallen from the sit to stand lift and he/she needed to do an incident report. Nurse N asked him/her how he/she knew if the resident fell . He/she said he/she saw the resident slide from the sit to stand to the floor. Nurse N went to the resident's room and he/she went to assist another resident on his/her assignment. Nurse N returned to the desk and said CNA F said the resident hadn't fallen and he/she had lowered the resident to the floor. He/she told Nurse N he/she saw the resident slide from the sit to stand lift to the floor. He/she told Nurse N he/she still needed to fill out a incident report. He/she doesn't know if a incident report was done. He/she told a day shift nurse but doesn't know what was done after that. During an interview on 1/23/17 at 9:49 A.M., Nurse N (night shift nurse) said, the resident required total assistance with care and was a two person transfer with the sit to stand lift. One night several weeks ago, a night nurse, Nurse L, said he/she thought the resident had fallen in his/her room. When he/she entered the resident's room, the resident sat in his/her wheelchair. He/she asked CNA F if the resident had fallen. CNA F said he/she lowered the resident to the floor. The resident didn't say anything and sat in his/her wheelchair. The resident had always complained of pain since he/she had worked at the facility. He/she doesn't recall the resident complaining of pain at the time. When asked why he/she didn't document the incident, Nurse N said Nurse L should have documented if the incident happened the way he/she said it did. During a interview on 1/20/17 at 6:38 A.M., CNA R (night shift CNA) said the resident used a stand up lift with two people for transfers. A week or more ago he/she heard CNA F call for help. He/she entered the room and saw the resident in the stand up lift with the belt on backwards. The belt was attached to the standup lift but wasn't snapped around the resident's waist. The resident slid down to the floor with his/her arms extended above his/her head. One leg was bent in a awkward position and the other was straight. The resident was yelling. He/she helped CNA F position the resident on the floor. He/she asked CNA F why he/she didn't ask for help and said they were to have two staff when transferring the resident with a stand up lift. He/she told Nurse N, CNA F had the stand up lift belt on backwards. Nurse N and CNA F used the hoyer lift pad to transfer the resident to the wheelchair. During an interview on 1/25/17 at 9:23 A.M., CNA F (night shift CNA) said he/she had worked at the facility for less than a month. He/she couldn't remember what day it was, but remembered he/she transferred the resident using the sit to stand lift. During the transfer the resident began to slide out of the lift sling toward the floor. He/she started lowering the resident to the floor, because he/she was sliding out. Nurse N asked the resident if he/she hurt his/her leg or hit the floor, the resident said No. Nurse N also helped him/her put the resident in the bed. The resident complained of pain, but he/she usually complained of pain. He/she did take care of the resident after the incident but the resident didn't want him/her to come into his/her room. He/she had to have another CNA to help him/her when it was time to take care of the resident. During an interview on 1/19/17 at 6:59 A.M., CNA K (night shift CNA) said a week or more ago, he/she and CNA F were walking in the hall past the resident's room. The resident told CNA F to get out of his/her room, because he/she dropped him/her. He/she repeated he/she didn't want CNA F in his/her room because he/she dropped him/her from the lift and hurt his/her leg. Later that night he/she reported it to Nurse L what the resident said. CNA F said he/she doesn't know why the resident keeps saying he/she dropped him/her. The resident repeated CNA F hurt his/her leg and complained his/her right leg hurt. During an interview on 1/19/17 at 9:40 A.M., the dietary supervisor said the resident had been complaining his/her leg hurt. On 1/3 or 4/17 the resident was in the dining room and complained his/her leg really hurt. She reported the resident's complaints of pain to Nurse D and Nurse A. She said the resident had been complaining his/her leg really hurt for a couple of days. Nurse D said he/she would check on the resident after he/she finished doing the blood sugar checks. During an interview on 1/18/17 at 7:44 A.M., Nurse A (day shift nurse, 7:00 A.M. to 7:00 P.M.) said the last time he/she took care of the resident was approximately two weeks ago. The resident complained of leg pain on 1/3/17. Someone in dietary reported the resident said his/her leg hurt. He/she pushed the resident to his/her room and the resident said his/her right leg hurt. He/she asked if he/she wanted something for pain and the resident refused. He/she touched the resident's right knee to the ankle and the resident didn't complain of pain. During an interview on 1/19/17 at 5:45 A.M., CNA J (night shift CNA) said he/she took care of the resident about a week ago. The resident said his/her right leg was very painful. During the night the resident would yell out loudly in pain during care. He/she had heard the resident holler out in pain when he/she received care while in bed. During an interview on 1/19/17 at 7:40 A.M., CNA O (day shift CNA) said a week ago the resident complained of pain in his/her right leg. He/she complained of pain when he/she received care. He/she would say ouch ouch when staff turned him/her and provided care. He/she would also complain of right leg pain when transferred with the lift. He/she notified the nurse and thought the nurse knew of the resident's complaint's of pain. During an interview on 1/19/17 at 7:00 A.M., CNA M (day shift CNA) said he/she normally worked on another hall and didn't take care of the resident very often, but during the weekend, 1/14/and 15/17, he/she had the resident on his/her assignment. The resident complained of right leg pain, when moved during care. He/she told the nurse of the resident's complaints of pain. During an interview on 1/19/17 at 7:45 A.M., CNA P (day shift CNA) said last week the resident complained of right leg pain while in the dining room. The resident said his/her leg felt better when he/she sat in the wheelchair rather than lay in the bed. During an interview on 1/19/17 at 7:54 A.M., CNA Q (day shift CNA) said he/she had worked at the facility for about a week. He/she took care of the resident the weekend of 1/14 and 15/17. The resident complained of right leg pain during care. The resident asked if he/she knew how to use the stand up lift because another staff member had dropped him/her and complained his/her leg has been messed up ever since. The resident complained of pain when he/she got him/her up using the stand up lift. He/she told the nurse of the resident's complaint of pain. During an interview on 1/19/17 at 5:35 A.M., Nurse H (night shift nurse) said he/she worked on the 100 hall. The resident complained of pain in both legs, but especially the right leg on 1/13 and 14/17. He/she didn't assess the resident because he/she frequently complained of leg pain. It was not necessary to assess a resident each time if you knew the resident had a history of [REDACTED]. He/she gave the resident [MEDICATION NAME] (antianxiety medication) for inability to sleep. He/she believed he/she documented it on the 1/14/17, shift report sheet and reported it to the day shift. He/she talked to the resident on 1/13/17, about possibly getting an x-ray. On 1/14/17, the resident said he/she wanted the x-ray. He/she documented on the shift report sheet twice asking for an x-ray. On Monday night, 1/16/17, the resident complained of right leg pain with swelling which he/she hadn't noticed before. Nurse N, who worked on the 200 hall, placed a call to another resident's physician. Nurse H thought the physician was the resident's physician and left a message for the physician requesting an x-ray. He/she later realized it was the wrong physician. He/she did not document the assessment or the resident's complaints of pain in the medical record. Nor did he/she call the resident's physician after realizing he/she had called the wrong physician. During an interview on 1/19/17 at 7:20 A.M., the social service designee said on Monday 1/16/17, the resident said his/her leg was very uncomfortable several times while he/she was in the dining room. While clocking in, on 1/17/16 at around 6:25 A.M., he could hear the resident screaming. It was very loud, not normal, and he felt something wasn't right. He stopped to ask what was wrong and the resident asked him to tell the nurse his/her leg really hurt. Nurse N was charting in the charting room on the same hall of the resident. He told Nurse N the resident was crying and screaming his/her leg hurt. The social service designee could hear the resident screaming as he came down the hall to find Nurse N. Nurse N said he/she would take care of it and turned and went down the hall. During an interview on 1/18/17 at 2:25 P.M., CNA C (day shift CNA) said he/she was helping the CNA assigned to the resident, early the morning of 1/17/17, during first rounds and at around 10:00 A.M. The resident moaned and screamed while they turned him/her saying his/her leg hurt. After lunch he/she complained of excruciating leg pain and he/she could tell the pain had progressed since the first time they changed him/her. During an interview on 1/18/17 at 2:10 P.M., Certified Medication Technician (CMT) B (day shift CMT) said he/she worked the floor instead of passing medications on 1/17/17. The first time he/she saw the resident, on 1/17/17 was at 11:00 A.M., when two CNAs were providing care. He/She complained his/her leg hurt really bad. CMT B told Nurse E and he/she was going to check to see what the resident had for pain. CMT B reported what the resident said to Nurse D. CMT B said the resident complained of right leg pain on 1/16/17 and he/she reported this to the nurse. Before lunch on 1/17/17, Nurse D asked the resident if he/she was going to get up for lunch and the resident refused saying his/her right leg hurt really bad. He/she didn't know whether the nurse checked on the resident's leg on 1/16/17. On 1/17/17, two staff went in to provide care and the resident screamed in pain. His/her right leg was warm to touch and swollen but without bruising. During a interview on 1/20/17 at 9:26 A.M., the Unit Manager said CNA G approached the desk, not sure of the date, and asked if the resident could please have something for pain. When she the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) assessed the resident's right leg she noticed it was swollen and painful. The resident said he/she wasn't lying, he/she had fallen and Nurse N got him/her off the floor. She checked the reports sheets to see if someone had documented the resident had fallen. She did see Nurse H had documented on the report sheet the resident had complained of pain over the weekend of the 1/14 and 15/17. Nurse D said he/she knew about the resident's complaints and had made her aware, but she didn't recall staff telling her this. No one told her the resident was in pain prior to 1/17/17. Nurse N should have done an incident report and documented in the nurse's notes. Nurse H should have notified her of the resident's complaints of pain and wanting an x-ray during the weekend of 1/14 and 15/17. During an interview on 1/18/17 at 2:55 P.M., Nurse D (day shift) said he/she worked on 1/17/17. The CMT told him/her the resident complained of right leg pain on Monday 1/16/17. CNA G came to the desk and said the resident was complaining of right leg pain. He/she complained of pain and said ouch ouch when he/she assessed it. Nurse D called the doctor and told staff to leave him/her in bed. He/she didn't offer the resident any pain medication because he/she often refused medications. During report, no one reported anything about the resident. During an interview on 1/18/17 at 7:44 A.M., Nurse A said Nurse D said the resident really complained of right leg pain on 1/17/17. Nurse D said he/she called the physician but he/she never called back. The new DON instructed Nurse D to call the Medical Director. During an interview on 1/19/17 at 8:22 A.M., the ADON said on 1/17/17, staff said the resident wouldn't allow them to get him/her out of the bed because his/her right leg was hurting. That was the first time she heard about the pain. She and the DON went to talk to the resident around breakfast time. He/she complained his/her right leg was hurting. He/she looked at the resident's leg but didn't notice anything unusual. The resident said he/she had fallen. The unit manager said he/she hadn't heard of a fall in report. The DON informed Nurse D of the resident's refusal to get out of bed and complaints of right leg pain. The DON instructed Nurse D to call the physician. The resident remained in bed after lunch and refused to get up because his/her right leg hurt. The resident said Nurse N was lying when he/she said he/she hadn't fallen. The ADON realized there was a problem. The resident pointed at his/her right upper leg. The DON asked if the physician called back and instructed Nurse D to call the Medical Director for a stat x-ray. The x-ray was done at around 5:30 P.M. The results of the fracture came later in the evening and the resident was sent to the hospital. Nurse N called her from work on 1/17/17, about the resident. Nurse N said a week or so ago he/she was called to the resident's room and CNA F said he/she lowered the resident to the floor. He/she said the resident hadn't fallen and if he/she had fallen he/she would have notified her. The resident also said Nurse N and CNA F lifted him/her off the floor with a special blue pad which was a hoyer lift pad. She also interviewed Nurse L who said he/she heard yelling from the resident's room. When he/she arrived at the resident's room, he/she saw the resident slip out of the stand up lift sling onto the floor. He/she told CNA F not to move the resident and went to get Nurse N. He/she explained to Nurse N what he/she observed and they returned to the room. CNA F said the resident hadn't fallen, he/she lowered the resident to the floor. Nurse L repeatedly told Nurse N the resident had fallen and he/she needed to do an incident report. Nurse N said CNA F said he/she lowered the resident to the floor. Nurse N didn't do a incident report until 1/18/17, after the resident was noted to have a fracture. She would have expected Nurse N to fill out a incident report and document the incident in the nurse's note and on the 24 hour report sheet. She believes the incident could have occurred 1/2/17 or 1/8/17, because those were the nights all three staff members worked. During an interview on 1/19/17 at 12:15 P.M., the DON said Nurse H documented on the shift report sheet 1/14 and 15/17, the resident's complaints of right leg pain, but not in the resident's nurse's notes. She would have expected the nurse to document and identify the location of the resident's complaint of pain. She also would have expected Nurse N to document there was a fall with complaints of pain so there could have been follow up. Nurse N also should have notified the unit manager, ADON and herself so they could have given guidance on what to do. During an interview on 1/20/17 at 11:10 A.M., the DON said she would have expected the nurse to fill out the incident report, follow up and document. She doesn't know why the nurse failed to complete the incident report. During an interview on 1/20/17 at 1:00 P.M., the facility's Medical Director said the facility staff called him for an order for [REDACTED]. He would have expected the staff to follow the facility's policy, write a incident report and document the incident in the medical record. During an interview on 1/26/17 at 12:00 P.M., the resident's physician said the resident was sent to the emergency room for a fractured femur. The resident said he/she had fallen from a lift at the facility. The fracture probably occurred when he/she fell from the lift. He/she suffered with the pain of a fractured femur for probably about a week. Staff should have assessed him/her and called for an x-ray. It's possible the staff made the fracture worse when getting the resident up with the lift. The orthopedic doctor decided not to treat the resident with surgery because he/she hadn't walked in a couple of years. Review of the facility's policy on Accident/Incident Reporting, dated 5/1/13, showed the following: -Policy: The staff will report and investigate all incidents and accidents in a timely manner; -Procedures: #1 Complete the appropriate non-employee accident/incident form immediately upon discovery of the accident/incident stating facts only. #2 Document the accident/incident in the medical record stating only the facts relating to that patient. Interview all individuals with first hand knowledge of the accident/incident and create a written summary of all interviews. #6 Physician and qualified legal representative are notified of the accident/incident. #8 The unit director or designee begins an investigation into the any accident/incident and takes action, if appropriate. #9 Staff is educated regarding the accident/incident and preventive measures are identified if appropriate. Review of the facility's policy on Pain Management, dated 2011, showed the following: -Policy: Staff will implement the Facility Pain Management Program, including Evaluation/Re evaluation for patients/residents experiencing either acute or chronic pain; -Definition of pain: Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (National Institute of Nursing Research, 1994). It is a complex phenomenon that takes into consideration sensory stimulation that has been modified by the individual's pain memory, expectations and emotions. :Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does; -Procedures: #2. Upon admission, re-admission, quarterly and with a significant change in condition complete Section E of the Nursing Data Collection Tool. A. If pain is triggered, initiate a pain management care plan which includes non-pharmacological and pharmacological interventions for the resident's pain relief. B. Interventions should be specific for the resident based on the information collected during the evaluation and interview process. C. Initiate the Pain Flow Sheet for ongoing documentation of as needed medication administration and effectiveness. D. Document pain as the fifth vital sign, evaluating or checking with the resident for the presence of pain during the morning, afternoon, evening medication pass and as needed. #3. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool. Initiate the Pain Flow Sheet as determined by resident need, following documentation parameters set forth above. #4. Obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. This information should be incorporated into the development of the resident's pain management care plan. #5. Utilize the standard: A. Numeric Rating Scale: (0-10)(0 means no pain-10 means worst pain you've ever felt). B. Verbal Descriptor Scale (mild, moderate, severe, very severe-horrible). C. Staff evaluation of pain or possible pain in cognitively impaired or non-verbal residents using non-verbal sounds, vocal complaints, facial expressions, protective body movements. MO 224 MO 590

Based on observation, interview and record review, the facility failed to ensure staff were adequately trained on the use of mechanical lifts. The facility identified two residents who transferred with a sit to stand/stand up mechanical lift (a device used to assist a resident who could bear weight to transfer). One was selected as a sampled resident and the other was an expanded sample resident. The expanded sample resident was transferred, by one staff member who failed to properly apply the lift belt and the resident slid out of lift to the floor. Staff did not fill out an incident report, regarding the transfer, per facility policy and the resident complained of right leg pain for approximately one to two weeks, until an x-ray was done which showed a fractured femur (thigh bone). The sample was 12. (Resident #14) The census was 50. Review of Resident #14's care plan, updated 9/9/16, showed the following: -Problem: Required assistance with activities of daily living; -Approach: Assist of two for bathing, bed mobility, dressing, toileting and transfers with a mechanical lift. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/16, showed the following: -[DIAGNOSES REDACTED]. -BIMS (Brief Interview for Mental Status, a score used to determine cognition) score of 13 (a score of 13-15 indicates intact cognition); -Short term memory loss; -No behaviors; -Required total staff assistance for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing; -Range of motion: Lower extremity impairment on both sides; -Incontinent of bowel and bladder; -No falls; -Height: 60 inches; -Weight: 250 pounds. Review of the resident's nurse's notes, dated 1/17/17, and the first note documented since 12/6/16, showed the following: -2:15 P.M.: Resident has complaints of right leg pain, right leg tender to touch, call placed to the resident's physician, awaiting return call; -4:16 P.M.: No call back from the physician, call placed to the medical director, awaiting return call; -4:20 P.M.: Medical director returned call, new order received for an x-ray of the right knee, right femur and tibia (lower leg bone). Review of the resident's physician's orders [REDACTED]. Review of the resident's radiology report, dated 1/17/17 at 8:01 P.M., showed an acute femur fracture. Review of the resident's emergency room note, dated 1/18/17 at 6:02 A.M., completed by the emergency room physician, showed the following: -Chief complaint: Lower extremity problem, pain at right lower extremity since fall at the nursing home one week ago. X-ray at the facility showed femur fracture; -Presents to emergency room , complained of fall at the nursing home one week ago. Patient said he/she fell while using a chair lift. He/she now complained of severe, constant, aching pain right leg pain. Pain is significantly worse with movement and pressure on the injury; -Physical exam: Extremities: Extremely tender right lower extremity; -X-Ray: Right femur trauma. Fracture femur; -Final Diagnoses: [REDACTED]. During an interview on 1/23/17 at 12:24 P.M., the resident said he/she fell from the lift and Nurse N put him/her in a wheelchair. During an interview on 1/18/17 at 2:35 P.M., Resident #15 said the resident's room was right next to his/her room. About two weeks ago he/she heard the resident tell a certified nurses aide (CNA), he/she didn't have him/her connected to the lift correctly. Right after that he/she heard a thump and could hear the resident yelling. That morning when the resident came to the dining room he/she heard him/her say the CNA hurt him/her. He/she said the CNA hurt him/her several times in the dinning room. Lately it's been really bad, when staff transfer they resident. He/she could hear Resident #14 complain of pain from his/her room. Resident #14 used to come to exercise classes but stopped coming right after the incident occurred. During a interview on 1/23/17 at 12:30 P.M., the resident's roommate said he/she wasn't in the room when the resident said he/she fell from the lift. The resident told him/her a staff member didn't put him/her in the lift correctly and he/she slipped out of it to the floor. Nurse N picked him/her up off the floor. He/she didn't remember how long ago it had happened. During an interview on 1/19/17 at 6:59 A.M., CNA K (night shift CNA, 7:00 P.M. to 7:00 A.M.) said a week or more ago, he/she and CNA F were walking in the hall past the resident's room. The resident told CNA F to get out of his/her room and that he/she had dropped him/her. The resident repeated he/she didn't want CNA F in his/her room because he/she dropped him/her from the lift and hurt his/her leg. He/she later reported to Nurse L what the resident said. CNA F said he/she didn't know why the resident kept saying he/she dropped him/her. The resident repeated CNA F hurt his/her leg and complained his/her right leg hurt. During an interview on 1/25/17 at 9:23 A.M., CNA F (night shift CNA) said he/she had worked at the facility for less than a month. He/she went through orientation on the day shift with two CNAs and didn't receive any training on the use of the lifts. He/she watched the CNAs use the lifts but didn't really participate because he/she was in orientation. He/she couldn't remember what day it was but remembered he/she was transferring the resident from his/her bed into his/her wheelchair using the sit to stand lift. During the transfer the resident began to slide out of the lift sling toward the floor. He/she started lowering the resident to the floor, because he/she was sliding out. The resident didn't fall to the floor, he/she lowered him/her to the floor. Nurse N asked the resident if he/she hurt his/her leg or hit the floor. Nurse N also helped him/her put the resident back into bed. He/she complained of pain but he/she usually complained of pain. The facility policy on the lifts was for two people but he/she was unable to find anyone to help him/her because the facility was understaffed that night. He/she did take care of the resident after the incident but the resident didn't want him/her to come into his/her room. He/she had to have another CNA help him/her when it was time to take care of the resident. During an interview on 1/20/17 at 6:38 A.M., CNA R (night shift CNA) said the resident used a stand up lift with two people to transfer. A week or more ago he/she heard CNA F call for help. He/she entered the room and saw the resident in the stand up lift with the belt on backwards. The belt was attached to the stand up lift but wasn't around the resident's waist. The resident was sliding down to the floor with his/her arms extended above his/her head with one leg bent in an awkward position and the other out straight. The resident was yelling. He/she helped CNA F position the resident on the floor, asked CNA F why he/she didn't ask for help and said that they were supposed to have two staff when transferring a resident with a stand up lift. He/she told Nurse N, CNA F had the stand up lift belt on backwards. Nurse N and CNA F used a hoyer lift pad (a pad used when transferring a resident who required a total lift) to transfer the resident into his/her wheelchair. During an interview on 1/23/17 at 9:14 A.M., Nurse L (night shift nurse) said approximately one and a half weeks ago he/she was at the desk charting when he/she heard screaming on the 100 hall (the hall where the resident resided). When he/she reached the resident's room, he/she saw the resident with his/her arms extended upward and his/her body sliding out of the sit to stand lift. The belt wasn't attached/buckled around the resident's waist. Before he/she could reach the resident, he/she had slid to the floor. The resident said he/she was dropped after the incident and complained of leg pain. He/she instructed CNA F not to move the resident and went to get his/her nurse. He/she told Nurse N, the nurse assigned to the resident that shift, the resident had fallen from the sit to stand lift and he/she needed to do an incident report. Nurse N asked how he/she knew the resident fell and Nurse L said he/she saw the resident slide from the sit to stand lift to the floor. Nurse N went to the resident's room and he/she went to assist another resident on his/her own assignment. Nurse N returned to the desk and said CNA F said the resident hadn't fallen and he/she had lowered the resident to the floor. Nurse L told Nurse N he/she saw the resident slide from the sit to stand lift to the floor. He/she told Nurse N he/she still needed to fill out an incident report. He/she didn't know if an incident report was done. He/she told a day shift nurse but didn't know what was done after that. During an interview on 1/23/17 at 9:49 A.M., Nurse N (night shift nurse) said, the resident required total assistance with care and was a two person transfer with the sit to stand lift. One night several weeks ago, a night nurse, Nurse L said he/she thought the resident had fallen in his/her room. When he/she entered the resident's room, the resident sat in his/her wheelchair. He/she asked CNA F if the resident had fallen. CNA F said he/she lowered the resident to the floor. The resident didn't say anything and sat in his/her wheelchair. The resident had always complained of pain since he/she had worked at the facility. He/she doesn't recall the resident complaining of pain at the time. When asked why he/she didn't document the incident, Nurse N said Nurse L should have documented if the incident happened the way he/she said it did. During an interview on 1/19/17 at 5:45 A.M., CNA J (night shift CNA) said he/she took care of the resident about a week ago and the resident said he/she fell out of the lift. He/she thought it had been reported. During an interview on 1/19/17 at 7:40 A.M., CNA O (day shift CNA) said a week ago the resident complained of pain in his/her right leg when transferred with the sit to stand lift. During an interview on 1/19/17 at 7:45 A.M., CNA P (day shift CNA) said last week the resident said staff told him/her he/she didn't fall, but the resident said he/she fell from the lift on the night shift. The resident was very fearful of the stand up lift and kept saying he/she fell from the lift. During an interview on 1/19/17 at 7:00 A.M., CNA M (day shift CNA) said the resident required the use of a stand up lift for transfers. He/she usually worked on another hall and didn't take care the resident often, but during the past weekend, 1/14 and 15/17, the resident kept asking about a new CNA and complained he/she was rough with him/her. He/she said the new CNA didn't know what he/she was doing and didn't want him/her to take care of him/her. During an interview on 1/19/17 at 7:54 A.M., CNA Q (day shift CNA) said he/she had worked at the facility for about one week. He/she took care of the resident the weekend of 1/14 and 1/15/17. The resident asked if he/she knew how to use the stand up lift because another staff had dropped him/her and complained his/her leg has been messed up ever since. He/she complained of pain when he/she got the resident up using the stand up lift. During an interview on 1/18/17 at 2:10 P.M., Certified Medication Technician (CMT) B (day shift CMT) said he/she worked the floor instead of passing medications on 1/17/17. The first time he/she saw the resident on 1/17/17 was at 11:00 A.M., when two CNAs were providing care. The resident said he/she had a fallen on the night shift and that a new staff member, CNA F let him/her fall. CMT B reported what the resident said to Nurse D. During an interview on 1/18/17 at 2:55 P.M., Nurse D (day shift CNA) said he/she worked on 1/17/17. The resident said he/she had fallen and he/she told the resident he/she would look on the report sheet. Nothing was written about the resident falling. During report, no one reported anything about the resident. During an interview on 1/19/17 at 8:22 A.M., the Assistant Director of Nurses (ADON) said on 1/17/17, staff said the resident wouldn't allow them to get him/her out of the bed because his/her right leg was hurting. That was the first time she heard about the pain. She and the Director of Nurses (DON) went to talk to the resident around breakfast time. He/she complained his/her right leg was hurting. He/she looked at the resident's leg but didn't notice anything unusual. The resident said he/she had fallen. The unit manager said he/she hadn't heard of a fall in report. The DON informed Nurse D of the resident's refusal to get out of bed and complaints of right leg pain. The DON instructed Nurse D to call the physician. The resident remained in bed after lunch and refused to get up because his/her right leg hurt. The resident said Nurse N was lying when he/she said he/she hadn't fallen. The ADON realized there was a problem. The resident pointed at his/her right upper leg. Nurse N called her from work on 1/17/17, about the resident. Nurse N said a week or so ago he/she was called to the resident's room and CNA F said he/she lowered the resident to the floor. He/she said the resident hadn't fallen and if he/she had fallen he/she would have notified her. The resident said Nurse N and CNA F lifted him/her off the floor with a special blue pad, which was a hoyer lift pad. She interviewed Nurse L who said he/she heard yelling from the resident's room. When he/she arrived at the resident's room, he/she saw the resident slip out of the stand up lift sling onto the floor. He/she told CNA F not to move the resident and went to get Nurse N. He/she explained to Nurse N what he/she observed and they returned to the room. CNA F said the resident hadn't fallen, he/she lowered the resident to the floor. He/she repeatedly told Nurse N the resident had fallen and he/she needed to do an incident report. Nurse N said CNA F said he/she lowered the resident to the floor. Nurse N didn't do a incident report until 1/18/17, after the resident was noted to have a fracture. She would have expected Nurse N to fill out an incident report and document the incident in the nurse's note and on the 24 hour report sheet. She believes the incident could have occurred 1/2/17 or 1/8/17, because those were the nights all three staff members, Nurse N and L and CNA F, worked together. Review of the staffing assignment sheets, showed 1/2/17, was the only night Nurses N and L and CNAs F and R worked together. During a interview on 1/20/17 at 9:26 A.M., the Unit Manager said when she the DON and ADON assessed the resident's right leg, on 1/17/17, she noticed it was swollen and painful. The resident said he/she wasn't lying, he/she had fallen and Nurse N had gotten him/her off the floor. She checked the reports sheets to see if someone had documented the resident had fallen. Nurse N should have done an incident report and documented in the nurse's notes. Review of CNA F's employee file, showed a hire date of 12/27/16, and no documentation whether he/she received orientation or training on the use of mechanical lifts. During an interview on 1/20/17 at 7:30 A.M., the DON said she became the DON on 1/16/17. She was not sure what type of orientation new CNAs received and had not had any formal orientation for staff since she started. She believed the facility policy was for two staff to assist with the sit to stand lift transfers. During an interview on 1/20/17 at 11:10 A.M., with the administrator and the DON, the administrator said the facility had no orientation check list for staff and no training or check off with therapy for proper use of the mechanical lifts. On 1/17/17, when it was discovered the resident had a fracture an investigation began. During the course of the investigation it was discovered that an incident occurred on 1/2/17, involving a transfer. As of 1/17/17, there had been no inservicing conducted regarding transfers, with the sit to stand lift, for staff including CNA F. The DON said they would just not use the sit to stand lift anymore. Review of the facility's Nursing Daily Staffing and Assignment Sheets, showed CNA F worked the 100/300 hall assignment, where the resident resided, on the night shift (7:00 P.M. to 7:00 A.M.) on 1/2, 1/4, 1/11, 1/13 and 1/16/17. During an interview on 1/20/17 at 1:00 P.M., the facility's Medical Director said he would expect the staff to report and document any time a resident had an incident. He would have expected the staff to follow the facility's policy, write a incident report and document the incident in the medical record. During an interview on 1/26/17 at 12:00 P.M., the resident's physician said the resident was sent to the emergency room for a fractured femur. The resident said he/she had fallen from a lift at the facility. The fracture probably occurred when he/she fell from the lift. He/she suffered with the pain of a fractured femur for probably about a week. Staff should have assessed him/her and called for an x-ray. Staff continuing to get the resident up with the sit to stand lift could have made it worse. Review of the undated manufacturer's instructions for the Sit to Stand Lift, showed the following: -User guide for standing sling: Place the sling behind patient's back between base of shoulder blade and bottom of rib cage. Attach the support straps around the front of the patient. Ensure that the patient's arms are outside the sling; -Lifting with the Sit to Stand Lift: Position the lift so that the patient's feet fit in the foot tray and knees rest against the pad. Initially attach the longer loops of the sling to the gray hooks at the end of the Stand up lift hand grips. The patients hands should be placed on the handgrips. Then push UP button on the hand control to raise the patient to the standing position; -Warning: Always plan your operations before commencing (beginning). Always familiarize yourself with the operating control and safety features of a life before lifting a patient. Always fit the sling according to the instructions in the user manual. Do not lift a patient unless you are trained and competent to do so. Review of the facility's policy on Fall Management, dated 5/1/2015, showed the following: -Definition: A fall is defined as a patient/resident being found on the floor, a patient/resident sliding to the floor unassisted, rolling off the bed or chair onto the floor, rolls off from low bed to floor mat, a resident falling off or out of any equipment/ apparatus including that used for therapy or a transfer. A fall also includes when a resident trips or slips and complains of a bodily injury or an episode where a patient/resident lost his/her balance and would have fallen, were it not for staff intervention (intercepted fall). A fall may be reported by a patient/resident, any staff member, visitor, family member, vendor, ambulance or van driver; -Procedure: #4. If a fall occurs, qualified staff evaluates patient/resident for injury from the fall and initiates any immediate medical interventions necessary, investigates the potential reason for the fall, determines appropriate interventions to prevent future calls and completes a Fall investigation Worksheet. #6. The physician and family are promptly notified and a incident report is completed. MO 224 MO 590

Based on observation, interview and record review, the facility failed to notify the physician in a timely manner of a resident's change in condition, when the resident had difficulty breathing, staff identified abnormal breath sounds in all lung lobes and the percentage of oxygen in the resident's blood dropped to 85%. Staff failed to notify the resident's physician of the resident's condition in a timely manner. The resident was sent to the hospital and admitted to the Intensive Care Unit with diagonses of pneumonia [MEDICAL CONDITION] (whole body inflammation caused by an infection). Facility staff also inaccurately documented the resident's wound upon readmission and for 24 days failed to consistently measure, document, monitor and maintain appropriate treatment orders for a blistered bruise on the back of the resident's left thigh which developed into an unstageable wound. The sample size was 12. (Resident #5) The census was 56. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/3/15, showed the following: -[DIAGNOSES REDACTED]. -No short/long term memory deficits; -No cognitive impairment; -Required extensive assistance of staff for bed mobility; -Required total assistance of staff for transfers, dressing, toilet use, personal hygiene and bathing; -No shortness of breath; -Gastrostomy tube ([DEVICE], a tube surgically inserted through the abdomen into the stomach, used to provide nourishment, fluids and medicine): Received 25% or less of total calories and 500 cubic centimeters (cc) or less of fluid from feeding tube; -Coughing or choking during meals or when swallowing medications; -Mechanically altered diet; -Speech therapy; -Incontinent of bowel and bladder; -At risk for pressure ulcers; -No pressure ulcers; -No wounds or other skin conditions; -No [MEDICAL CONDITION]. Review of the resident's care plan updated 2/11/15, showed the following: -Problem: Risk for weight loss related to feeding tube, mechanically altered diet and choking during meals; -Goal: Risk of aspiration will be minimized through current interventions; -Approach: Monitor for signs and symptoms of aspirations (breathing in secretions or food materials into the lungs), abnormal lung sounds, elevated temperature, mental status changes, shortness of breath. Intervene as necessary and notify the physician. Monitor oxygen saturations (O2 sats, percentage of oxygen in the blood, with normal being above 90%) every shift and and record. Vest Airway Clearance System (a portable high-frequency chest wall oscillation device used to help remove secretions from the lungs) four times per day; -Problem: Incontinent of bowel and bladder related to [DIAGNOSES REDACTED]. Increased risk for development of pressure ulcers related to immobility and incontinence; -Goal: Risk for development of pressure ulcers will be minimized through review; -Approach: Totally dependent on staff for toileting needs. Low air loss mattress to bed. Monitor perineal area during incontinence care for redness, excoriation, reddened areas that do not blanch and report to charge nurse if areas are noted. Weekly body audits to be completed and documented by the charge nurse, notify the physician of any abnormal findings. Review of the resident's physician's orders [REDACTED]. -Order dated, 12/11/14: O2 sats monitor and record every shift; -Order dated, 2/17/15: Change diet to regular solids and regular liquids; -Order dated, 2/24/15: Discontinue Vest Airway System. Review of the resident's Daily Skilled Nurse's Notes, showed the following: -Directions: For each shift, check all applicable boxes. Document specifics regarding other concerns and changes in condition on side two or per facility policy. After completion, sign under appropriate shift. Identify services, provide on side two. -Date: 2/24/15: Front page: Day shift vital signs (VS): Temperature (T): 97.1 (normal: 98.6), Pulse (P): 68 (normal range: 60 to 100), Respiration (R): 18 (normal 16 to 20), Blood Pressure (BP): 110/76 (normal 120/80). Night shift VS: T: 97.7, P: 62, R: 18 and B/P: 108/72. Respiratory: Normal breathing checked for day and night shift. O2 sats blank for day and night shifts. Back page: Day shift: New order, discontinue Vest Airway Clearance System. Night shift: 6:00 A.M: Respirations even and non labored, resident able to make needs known; -Date: 2/25/15: Front page: VS: Blank for day and night shifts. Respiratory: Nothing marked for day shift and normal breathing checked for night shift. O2 sats for day shift: blank and night shift: 98%. Back page: Day shift: Seen by advanced nurse practitioner, no new orders, up in electric wheelchair, able to drive self, no complaints or signs or symptoms of distress or pain noted. Night shift: Resident in bed resting, no complaints of pain; -Date: 2/26/15: Front page: VS: Blank for day shift. Night shift: T: 98.3, P: 70, R:18, B/P 128/80. Respiratory: Nothing marked for day shift and normal breathing checked for night shift. O2 sats for day shift blank and night shift: 96%. Back page: Day shift blank and night shift: Resident has no sign or symptoms or complaints of shortness of breath, pain, discomfort, or distress. Friendly and positive attitude, denies any issues or concerns at this time. Review of the resident's Speech Therapist Progress and Discharge Summary, dated 2/27/15, showed the following: -Diagnosis: [REDACTED]. -Date of onset: 1/27/15; -Short term goals: Ability to self monitor: Will demonstrate the ability to self monitor swallowing skills and perform appropriate compensatory techniques with only independent (0% impairment; no observable signs or symptoms of dysphagia, aspiration or weight loss) given 20% verbal instruction/cues. Status: Goal Met on 2/27/15. Airway Protection: Will complete hard throat clear re-swallow to increase airway protection during swallow exhibiting only independent (0% impairment, no observable signs or symptoms of dysphagia, aspiration or weight loss. Status: Goal Met on 2/23/15; -Long Term Goals: General: Will tolerate a regular diet with the use of compensatory strategies 90% of the time with no signs or symptoms of aspiration to optimize nutrition and hydration. Goal Met: 2/27/15. Safety swallowing Strategies: Will follow safety strategies for safe by mouth intake with 90% accuracy with no instruction or cues. Goal met:2/27/15; -Summary of Skills provided since start of care: Met short term and long term goals with 100% accuracy; -Impact on Burden of Care/Daily Life: No longer dependent on caregiver for safe by mouth intake; -Precautions: Aspiration; -Updated standardized tests: Bedside swallow test revealed patient uses strategies with no signs of aspiration. Review of the resident's POS, dated 2/1/15 through 2/28/15, showed an order dated, 2/27/15, to discontinue speech therapy. Review of the resident's Daily Skilled Nurse's Notes, showed the following: -Date: 2/27/15: Front page: VS: Blank for day and night shifts. Respiratory: Nothing for day shift and normal breathing checked for night shift. O2 sats: blank for days and night shifts. Back page: Blank. Review of the resident's POS, dated 2/1/15 through 2/28/15, showed an order dated, 2/28/15, for [MEDICATION NAME] (antibiotic) 100 mg twice a day for ten days, [MEDICATION NAME] Dose Pack (steroid used to reduce inflammation), Start Airway Vest System every shift and as needed, Chest X-ray on 3/1/15. During an interview on 4/16/15 at 1:28 P.M., the pharmacist said the facility faxed the order for the [MEDICATION NAME] 100 mg twice a day and the [MEDICATION NAME] Pack at 7:56 P.M. on 2/28/15. The medications were not delivered until 3/2/15. Review of the resident's treatment administration record (TAR), dated 2/1/15 through 2/28/15, showed the following: -Front of TAR: O2 sats monitor and record every shift. 2/28/15: 7:00 A.M. to 7:00 P.M.: 97%. 2/28/15: 7:00 P.M. to 7:00 A.M.: 82%; -Back of TAR: Showed no documentation regarding the 2/28/15, O2 sats of 82%. Review of the resident's Daily Skilled Nurse's Notes, undated, showed the following: -Date: Blank: Front page: Completely blank. Back page: First entry for the day, 2/28/15 at 8:00 P.M.: Resident throwing up and restless. Verbalizes he/she's OK. Noted to have difficulty breathing. O2 sats: 85%. Encouraged to cough. Lung sounds: crackles (rattling sounds usually caused by secretions in the large airways) heard in all lung lobes. Percussion treatment (Airway Vest System) given, will monitor. (No further documentation regarding the resident's respiratory status until 10:00 P.M.) 10:00 P.M.: Resident complained of light headedness, dizziness, headache, O2 sats: 82% on O2 at 3L. Call placed to physician and condition reported to DON. (No further documentation until 10:30 P.M.). 10:30 P.M.: Resident continues to complain of light headedness and difficulty breathing, 911 called, continues to have emesis (vomiting). O2 sats:84%, on O2 at 4L. Review of the resident's SBAR (Situation, Background, Assessment, Request) Communication Form and Progress Note, dated 2/28/15, showed the following: -Situation: The change of condition, symptoms, or signs you are calling about: Blank; -This started on: 2/28/15 written in; -Since this started it has gotten: The word "worse" checked. Things that make the condition better are: The word "none" written in. This condition, symptom, or sign has occurred before: The word "yes" checked. treatment for [REDACTED]. Other relevant information: The condition ran for 6:00 P.M. (no explanation); -Background: Resident description: This resident is in the nursing home for: Post Acute Care checked. Primary Diagnoses: [REDACTED]. Other pertinent history: [MEDICAL CONDITION], myasthenia (is a chronic condition that causes muscles to tire and weaken easily) and depression. Medication alerts: resident is on [MEDICATION NAME]/[MEDICATION NAME] (blood thinner). VS: BP: 132/85, P: 90, T: 98.4, O2 sats: 82%. On O2 at 3L per minute. Mental Status Changes: New or worsening behavioral symptoms checked. Describe symptoms: Restlessness. Functional Status Changes: Trouble swallowing checked. Describe symptoms or signs: Prone to aspiration. Respiratory: Shortness of breath, abnormal lung sounds, productive cough and labored breathing checked. Advance directives: Full code; -Assessment: Restless and hard to breath; -Request: Transfer to the hospital checked; -Nursing notes (for additional information on the change in condition): Resident aspirated at dinner and started throwing up, coughing, accompanied with low O2 sats at 82%. Complained of lightheadedness, dizziness and headache. O2 sats didn't go up after putting resident on O2 at 3L. Resident denied feeling bad to nurse but kept telling Certified Nurse Assistant (CNA) of the above mentioned conditions. Physician called at 10:20 P.M. Resident continues throwing up, lung sounds: crackles (abnormal lung sounds caused by secretions in the small airways) in all lobes with difficulty breathing. Paleness and cyanosis (caused by lack of oxygen, skin turns a bluish color) 911 called. 10:45 P.M.: Resident picked up by 911 and transferred to hospital. Review of the resident's hospital Emergency Documentation, dated 2/28/15, showed the following: -Service date: 2/28/15 at 11:40 P.M.; -History of Present Illness: Presents with difficulty breathing. The onset was just prior to arrival. The patient presents to the Emergency Department from the nursing home with reports of shortness of breath, low oxygen saturation and brown sputum production. EMS reports he/she had audible rhonchi (coarse rattling sounds usually caused by secretions in the large airways) en route and nasal suction and [MEDICAL CONDITION] (a type of noninvasive ventilation machine that helps patients keep their airways open and their oxygen saturation levels up); -Impression and Plan: Diagnoses: [REDACTED]. Admit to Intensive Care Unit. Continued [MEDICAL CONDITION], started on antibiotics and nebulizer treatments. Review of the resident's hospital Consultation Notes, completed by the hospital physician, dated 3/1/15, showed the following: -Reason for consult: Acute [MEDICAL CONDITION] and right middle lobe pnuemonia; -History of present illness: [AGE] year old with a history of [MEDICAL CONDITION]. Had a prolonged hospitalization in September and October 2014 for [DIAGNOSES REDACTED] (ARDS) which required prolonged mechanical ventilation, [MEDICAL CONDITION] and gastrostomy tube. He/She had a second hospitalization , in the ICU, in November and December 2014 when he/she developed aspiration pneumonia, but had not been hospitalized since the discharge in December. He/She was in his normal state of health until last evening when he/she started having more secretions, which were somewhat purulent (containing pus). He/She states around 6:00 P.M. he/she was eating dinner and started having increasing shortness of breath, which was fairly abrupt in onset. He/She didn't feel like he/she aspirated (breathe in) any of the food that he/she was eating, but it did correlate with time that he/she was eating. His/Her gastrotomy tube had not been used in several weeks. When found by EMS, he/she reportedly had oxygen saturations in the low 80's. He/She was placed on [MEDICAL CONDITION] and NT suctioning (nasotracheal suction, the insertion of a thin flexible tube into a nostril to the trachea (windpipe) in order to clear excessive secretions from lower airways that are disrupting breathing) with significant improvement and brought to the emergency department; -Impression and Recommendations: 1. Acute [MEDICAL CONDITION] in the setting of a right middle lobe pneumonia. At this point will use his/her [DEVICE] for all medications and keep nothing by mouth (NPO). 2. Broad spectrum antibiotics: Meropenum, [MEDICATION NAME] and [MEDICATION NAME]. During an interview on 4/13/15 at 3:00 P.M., Nurse E said he/she worked from 7:00 P.M. on 2/28/15 until 7:00 A.M. on 2/29/15. During report the day shift nurse said the resident vomited during dinner. The day shift nurse called the physician and got orders for an antibiotic. Nurse E assessed the resident after report and noted the resident had difficulty breathing, O2 sats of 85% and crackles in his/her lungs. He/She gave the resident a percussion treatment but didn't call the physician at that time to notify him of the resident's O2 sats of 85%, because the day shift nurse had called and received orders for an antibiotic. Later in the shift when he/she checked the resident's O2 sats which were 82%, he/she called the physician and sent the resident to the hospital. Further review of the Daily Skilled Nurses Notes, showed no entry for the 7:00 A.M. to 7:00 P.M. shioft on 2/28/15. Review of the facility's policy on Physician Communication/Change in Condition, revised 9/2011, showed the following: -Policy: #2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition; -Procedure:1. Complete assessment of the patient/resident which may include but not limited to: A. Patient/resident name, age and primary diagnosis. B. Current physical condition. C. Patient's/resident's previous condition (declining, improving, stable). D. Vital Signs, temperature, pulse, respirations, blood pressure, lung sounds, nausea and vomiting, abdominal assessment, pain, last bowel movement, blood glucose level. F. Recent labs, x-ray results. G. Medication. H. allergies [REDACTED]. J. Hospital of choice. K. Patient/resident/family wishes. L. Any interventions/first aid provided to the patient/resident; -2. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record; -7. In the event of a life threatening event-contact 911 immediately; -Physician Communication Grid: Shortness of breath: Acute onset or with chest pain, change in VS, labored breathing, O2 sats less than 95%. During interviews on 4/13/15 at 1:03 P.M. and 4/22/15 at 1:00 P.M., the DON said she didn't recall whether the nurse called to inform her of the resident's O2 sats of 85%. If he/she had he/she would have instructed the nurse to send the resident to the hospital. She would expect the nurse to send a resident to the hospital for O2 sats of 85%. The resident had an long hospitalization in November after his/her family took him/her out of the facility for Thanksgiving. He/She had a [MEDICAL CONDITION] (trach, a surgically created opening through the neck into the trachea) at that time, but was weaned off in December. During an interview on 4/16/15 at 9:22 A.M., the resident's physician said the resident had a history of [REDACTED]. When the nurse assessed the resident and the resident's O2 sats had dropped to 85% he would have wanted to be notified. Anytime a resident's O2 sats dropped below 90%, the physician should be notified. He did not know if it would have made a difference in the outcome. Review of the resident's hospital Discharge Summary, dated 3/20/15, showed the following: -Diet: NPO; -Speech Therapy; -Tube Feeding: [MEDICATION NAME] 1.2 at 70 milliliters (ml) per hour continuous over 24 hours with 60 ml free water flushes every four hours; -Vital signs every A.M and P.M.; -Weigh weekly. Review of the resident's readmission Nursing Data Collection Tool, dated 3/20/15, showed the following: -Time of arrival: 5:00 P.M.; -Diagnoses: [REDACTED]. -Nutritional approaches: Gastrostomy tube; -Always incontinent; -Respiratory: Special treatments and Procedures: Oxygen therapy, [MEDICAL CONDITION] and respiratory treatments; -Skin condition: Check all that apply: Other Skin conditions: Reddened area/blanchable (skin loses redness with pressure, the redness returns when pressure relieved) and bruising checked. (No location documented for the reddened/blanchable and bruised areas); -Medical Necessity Documentation: Medical condition that exceeds routine care and required the skills of a licensed nurse: suctioning, O2 monitoring and tube feeding. Due to the resident having a knowledge deficit related to the tasks below or being unable to complete these tasks safely on their own, the following must occur in the nursing facility and the nurse must use empiric (one who relies on practical experience) knowledge and specific nurse training to complete the following: Checked by staff: Nurse must provide wound care and skin monitoring and assessment. Review of the resident's readmission POS, dated 3/20/15, showed the following: -[MEDICATION NAME] 1.2 at 70 ml per hour continuous, 7 A.M. to 7 P.M. and 7 P.M. to 7 A. M.; -Flush [DEVICE] with 120 ml of water four times per day; -[MEDICAL CONDITION] with a high humidity tracheotomy mask at 30% at 10 Liters (L); -[MEDICAL CONDITION] needed; -Speech evaluation; -(No treatment order or documentation regarding reddened/blanchable area). Review of the resident's Daily Skilled Nurse's Notes, dated 3/20/15, showed the following: -Front of page: Skin: Desensitized to pain or pressure checked for nights. Bruise checked, with the word blister written in. Back of page: Comments/Concern Day shift: Resident arrived via ambulance at 5:00 P.M. (No documentation regarding bruise, reddened or blistered area) Night shift: 3/21/15 at 2:00 A.M. (documented on the same page): Resident has a blister/bruise on the left hip. Skin prep applied. Assessment paperwork completed. Review of the resident's Weekly Skin Assessment, dated 3/20/15, showed the following: -Week One: Skin: Intact; -Front of the Body Diagram: Left upper outer thigh circled, with the words: Blistered bruise written in; -Special equipment in use: pressure relief mattress; -Signed by a nurse. Review of the resident's Braden Scale For Predicting Pressure Sore Risk form, dated 3/20/15, showed the following: -A total score of 18 or below indicated risk. If 18 or below, the Skin Risk Analysis and Interventions form must be completed and the CNA Daily Skin Checks must be initiated; -Total score: 12. Review of the resident's Skin Risk Analysis and Interventions, dated 3/20/15, showed the following: -Skin Risk Analysis: Risk Factors for Developing Pressure Ulcers (Check all that Apply): Chronic Bowel Incontinence, Chronic Urinary Incontinence, [MEDICAL CONDITION] and Contractures; -Problem: Bruising blister on left hip; -Interventions: Inspect skin daily, especially bony prominences. Cleanse skin at the time of soiling. Avoid hot water, use mild cleansing agent. Avoid massage over bony prominences. Minimize exposure to moisture due to incontinence, perspiration or wound drainage. Use absorbent briefs/underpads. Review of the resident's Certified Nurse Assistant (CNA) Daily Skin Inspection Record, no month documented, (completed by the CNAs for the entire month) showed the following: -Directions: Skin assessment form to be completed on daily basis. Record letter of site on chart that identifies location of skin problem and mark area on body figure with an "X". CNA to report any change in skin condition to nurse immediately. Licensed nursing staff to perform Nurses Weekly Skin Documentation and document; -Front of the body diagram, showed section "H" was the left hip, groin thigh area with an "X" marked on the left hip; -Back of the body diagram, showed section "M" included the left buttock and section "R" included the right buttock with a circle marked at the area where the right buttock met the thigh; -Day 21 (the first day staff documented on the sheet): Redness (site) the letter "H" written in. Open area (site): the word "Left hip" written in. Signed by CNA. Shift: 7 A to 7 P written in; -Day: 22: Redness (site) "H". Open area (site): the word "Left hip" written in. Signed by CNA. Shift:7 A to 7 P written in. Review of the resident's Daily Skilled Nurse's Notes, showed the following: -3/21/15: Front page: Skin: Desensitized to pain or pressure checked for days and nights. Back page: 7:35 P.M.: (No documentation regarding the left hip wound). Night Shift Comments: No time: Open area to left hip. (No documentation of size or description of wound); -Undated: Front page: Skin: Desensitized to pain or pressure checked for days. Back page: Comments/Concerns Day Shift: 3/22/15 at 4:00 P.M.: Noted left hip area that was blanched and red from the hospital. New orders to monitor left hip twice a day, apply Skin Prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective coating) twice a day until healed. Follow up with Mobile Wound Solution. (No documentation of measurements or description of left hip wound). 3/23/15 at 12:00 A.M. (Documented on the same page): Skin Prep applied to sore on left hip. Turn every two hours. (No documentation of measurements or description of left hip wound). Review of the resident's POS, dated 3/1/15 through 3/31/15, showed the following orders dated 3/22/15: -Monitor left hip twice a day and apply Skin Prep twice a day; -Follow up with Mobile Wound Solutions. Review of the resident's TAR, dated 3/20/15 through 3/31/15, showed the following: -Front of TAR: Order dated 3/22/15: Monitor Left hip twice a day and apply Skin Prep twice a day until healed. Staff initialed as completed once on 3/22/15 and then twice a day through 3/26/15 and then once on 3/27/15; -Back of the TAR: Blank. Review of the facility's Weekly Wound Tracking Worksheet, dated 3/23/15, showed no documentation regarding the resident's left hip wound. Review of the resident's Daily Skilled Nurse's Notes, showed the following: -Date 3/23/15: Front page: Skin: Desensitized to pain or pressure checked for days and evening. Pressure ulcer checked for day and evening shift; -Back page: No date: Comments/Concerns Dash: Time: 11:30 A.M.: Deep tissue injury to the left hip monitored. Significant family member signed the consent form for resident to be seen by Mobile Wound Solution. Comments/Concerns Night Shift: Time: 7:00 P.M. to 7:00 P.M.: No date: (No documentation regarding left hip wound). Review of the resident's CNA Daily Skin Inspection Record, no month documented, for day 23: Blank. Review of the resident's Daily Skilled Nurse's Notes, showed the following: -Date 3/24/15: Front page: Skin: Desensitized to pain or pressure checked for days and nights. Pressure ulcer: Blank. Back page: Comments/Concerns Day shift: 4:00 P.M.: (No documentation regarding left hip wound). Comments/Concerns Night Shift: (No documentation regarding left hip wound). Review of the resident's CNA Daily Skin Inspection Record, no month documented, for day 24: Redness (site): letters: "MRH" written in. Open area (site): letters: "HR" written in. (unable to determine what "MRH" or "HR" means) Signed by CNA. Shift: 7 A.M. to 7 P.M. Review of the resident's Daily Skilled Nurse's Note, dated 3/25/15, showed the following: -Date 3/25/15: Front page: Skin: Desensitized to pain or pressure: Blank. Pressure ulcer: checked for day and night shift. Back page: Comments/Concerns Day shift: 5:30 P.M.: (No documentation regarding left hip wound). Comments/Concerns Night Shift: (No documentation regarding left hip wound). Review of the resident's CNA Daily Skin Inspection Record, no month documented, for day 25: Redness: Blank. Open Area (site): Letters "HR" written in. Signed by a CNA. Shift 7 A.M. to 7 P.M. Review of the resident's SBAR Communication Form and Progress Note, dated 3/26/15 at 3:30 P.M., showed the following: -Situation: The change in condition, symptoms, or signs you're calling about: Wound to left buttocks. Started: While in the hospital, written in. Since this started has: Gotten worse. Things that make the condition worse: Moisture; -Background: The resident in the nursing home for Long Term Care. Primary [DIAGNOSES REDACTED]. Describe symptoms or signs: Hospital stay and bed bound; -Assessment: What do you think is going on with the resident: Wound Infection written in; -Request: New order obtained to clean wound with wound cleaner, apply Santyl (topical ointment used to remove dead tissue) and cover with a dry dressing every shift and as needed. Wound doctor to evaluate on 3/30/15; -Signed by the nurse on 3/26/15 at 3:30 P.M. Review of the resident's CNA Daily Skin Inspection Record, no month documented, for day 26: Redness (site): Blank. Open Area (site): letters: "HR" written in. Signed by CNA. Shift: 7 A.M. to 7 P.M. Review of the resident's nurse's note, dated 3/26/15 at 5:00 P.M., showed the following: -Order obtained to treat the wound on left buttocks with Santyl and dry dressing every shift and as needed; -Wound acquired while resident was in hospital. Review of the resident's POS, dated 3/20/15 through 3/31/15, showed an order dated 3/26/15, to apply Santyl to left buttocks cover with dry dressing every shift and as needed. Review of the resident's Weekly Skin Documentation, completed by a nurse, dated 3/26/15, showed the following: -Week Two: Skin: Not intact checked; -Front of Body diagram: Circle drawn on left outer thigh, the words "area opened" written in. (No documentation or measurement regarding left outer thigh); -Back of Body diagram: Circle drawn on left outer thigh, the word "area opened" written in. (No documentation or measurement regarding left outer thigh); -Special equipment: Pressure relief mattress; -Signed by the nurse. Review of the resident's TAR, dated 3/26/15 through 3/31/15, showed the following: -Front of TAR: Order dated: 3/26/15: Clean wound on left buttocks with wound cleaner, apply Santyl and cover with dry dressing every shift and as needed. Staff documented as complete: 7:00 A.M. to 7:00 P.M.: 3/26 through 30/15. 7:00 P.M. to 7:00 A.M.: 3/26 through 29/15 and 3/30/15 circled to indicate not done (no explanation noted); -Back of TAR: Blank. (No measurement or documentation regarding left buttocks/thigh wound). Review of the facility's Weekly Wound Tracking Worksheet, completed by a nurse, dated 3/30/15, showed no documentation regarding the resident's left hip wound. Review of the resident's nurse's note, dated 3/31/15 at 12:40 P.M., showed the following: -Treatment done to left lateral thigh. Area has opened up into two wounds: Upper wound measured: 1.5 centimeters (cm) by 2.1 cm by unable to determine (utd) depth, wound bed 100% yellow slough (dead tissue); -Lower wound measured: 1 cm by 3 cm by utd depth, wound bed 100% yellow slough; -Periwound (area surrounding the wound): purple/pink in color; -New treatment orders received; -No further documentation. Review of the resident's POS, dated 3/26/15 through 3/31/15, showed the following orders dated 3/31/15 at 12:25 P.M.: -Discontinue current treatment order to left buttocks; -Left lateral thigh (upper): Cleanse with wound cleaner. Skin prep to periwound. Apply Santyl to wound bed then CA Alginate (a dressing that absorbs wound drainage) and cover with gauze and secure with tape once a day and as needed; -Left lateral thigh (lower): Cleanse with wound cleaner. Skin prep to periwound. Apply Santyl to wound bed then CA Alginate and cover with gauze and secure with tape once a day and as needed. Review of the facility's Weekly Wound Tracking Worksheet, dated 4/6/15, showed the following: -Wound type: Other. Stage II: (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.); -Previous week: Stage II; -Current week: Stage II; -Location of wound: Thigh; -Onset date: 3/23/15; -Worst tissue type present: Words "admitted with" written in; -Comments: Words "measure 4/8/15" written in; -First documentation of thigh/buttock wound on facility wound report. No measurement documented. Observations of the resident showed the following: -4/8/15 at 1:30 P.M., he/she lay in bed with a [MEDICAL CONDITION]. He/She gestured that he/she needed to be suctioned. The DON entered at that time and suctioned the resident. -4/9/15 at 10:30 A.M., he/she lay in bed on a low air loss mattress with a [MEDICAL CONDITION] connected to humidified air and tube feeding infusing; -4/10/15 at 4:40 A.M., he/she lay in bed on a low air loss mattress, with a [MEDICAL CONDITION] connected to humidified air and tube feeding infusing sleeping. At 10:28 A.M., he/she sat in electric wheelchair at bedside, with a [MEDICAL CONDITION] connected to humidified air and tube feeding off at that time. During an interview on 4/10/15 at 8:30 A.M., CNA K said he/she was not the resident's regular aide. He/She knew the resident had an open area but didn't know when it started. Observation and interview during a skin assessment, on 4/13/15 at 9:10 A.M., showed the resident lay in bed on a low air loss mattress. Nurse A said the resident had a wound on the left posterior thigh and was seen by the wound care management nurse practitioner that morning. The nurse practitioner assessed and measured the wound. Nurse A said the wound measured 2.6 cm by 2.2 cm by 0.2 cm and was unstageable (Slough and/or eschar (dead tissue): Known but not stageable due to coverage of wound bed by slough and or/eschar) because of slough. The Nurse practitioner changed the treatment orders to Santyl and Vaseline gauze and a dry dressing. During an interview on 4/13/15 at 10:00 A.M., the wound care management nurse practitioner said he/she saw the resident's wound for the first time that morning, 4/13/15. The wound was not over a bone and she didn't think it was caused by pressure. She visits the facility once a week, usually on Monday. During an interview on 4/13/15 at 11:15 A.M., the Assistant Director of Nurses said the order for the wound care management consult was obtained on 3/22/15. The resident's family signed the consent form on 3/23/15 and it was faxed to the wound care management office on 4/9/15. He/She didn't know why it took until 4/13/15 for the resident to be seen or why staff failed to document on the back of the TAR the appearance of the wound. During an interview on 4/13/15 at 12:51 A.M., Nurse A said he/she started the readmission paperwork for the resident becau

Based on interview and record review, the facility failed to provide services to promote the highest practicable physical well-being for one of three sampled residents. The facility failed to carry out physician's orders [REDACTED]. The resident was transferred to the hospital with two subdural hematomas (a collection of blood outside the brain) (Resident #1). The facility also failed to obtain a PT/INR for one resident as ordered by the physician (Resident #3). The census was 50. 1. Review of Resident #1's care plan, dated 3/14/14, showed: -Stroke related to cerebral aneurysm; -Prescribed anticoagulant daily; -Monitor resident's PT/INR as per order and notify the resident's physician of the results; -Report abnormal lab or diagnostic results to the resident's physician and follow-up as indicated. Review of the resident's physician's orders [REDACTED]. -An order, dated 9/2/14, for an increase in [MEDICATION NAME] (blood thinner) to 7.5 milligrams (mg) daily and re-check PT/INR in one week; -An order, dated 9/9/14, to continue with 7.5 mg of [MEDICATION NAME] daily and recheck PT/INR on 9/23/14. Review of the resident's discharge Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/20/14, showed: -[DIAGNOSES REDACTED]. -Verbal behavioral symptoms directed at others (e.g. threats, screaming, cursing); -Required extensive assistance with bed mobility, dressing and personal hygiene; -Total dependence on full staff performance of transfers, locomotion, toileting and bathing. Review of the resident's medical record, showed no PT/INR results on 9/23/14. Review of the resident's POS, showed the following: -An order, dated 9/25/14, for [MEDICATION NAME] 4 mg daily; -An order, dated 9/27/14, for [MEDICATION NAME] ([MEDICATION NAME]) 5 mg daily; -An order, dated 9/27/14, for PT/INR to be drawn on 9/27/14 and then once weekly while the resident received antibiotics. Review of the resident's laboratory results, showed the following: -9/27/14, PT 18.4 H (H=high, normal range 9.5-11.8 seconds), INR 1.7 H (normal range 0.9-1.1; -10/3/14, PT 27.1 H, INR 2.4 H. Review of the resident's nurse's note, dated 10/4/14 at 4:40 P.M., showed staff reported PT/INR lab results to the resident's nurse practitioner and received an order to recheck the resident's PT/INR in two weeks. Staff ordered a lab draw for 10/17/14. Review of the resident's POS, dated 10/14/14, showed an order to send the resident to the hospital. Review of the hospital discharge summary dated 10/25/14, showed the resident was admitted to the hospital on [DATE] with respiratory distress,[MEDICAL CONDITION] and pneumonia. He/she was discharged back to the facility on [DATE]. Review of the resident's POS, dated 10/25/14 through 10/31/14, showed: -A standing order for PT/INR weekly while antibiotics prescribed; -An order dated 10/25/14, for [MEDICATION NAME] (ear drops containing an antibiotic and steroid) 0.3-0.1% four drops (gtts) in the right ear twice a day for five days, stop date 10/30/14; -An order dated 10/25/14 for [MEDICATION NAME] 7.5 mg once daily; -An order, dated 10/25/14, for a PT/INR to be drawn on 10/27/14. Further review of the medical record, showed no PT/INR results for 10/27/14, and there were no results for PT/INRs in 11/2014. During an interview on 1/8/15 at 11:40 A.M., the Director of Nurses (DON) said responsibility for carrying out a physician's orders [REDACTED]. The facility used a lab tracker form to monitor the resident's lab work and ensure that staff carried out physician's orders [REDACTED]. The resident's physician called in an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review of the resident's care plan, showed an update on 11/20/14, which showed the resident continued to be at increased risk for falls related to [MEDICAL CONDITION] and poor safety awareness. Review of Nurse A's written statement showed on 11/23/14, the resident complained of a headache. Nurse A noted no bruising or swelling to the resident's head. He/she only noted bruising to the resident's abdominal injection sites and swelling of the left hand and arm. Review of the resident's medical assessment, dated 11/25/14 (no time documented), showed the resident was alert and oriented times four (not defined on assessment) with no complaints. The resident denied chest pain shortness of breath, fever or chills. He/she had some [MEDICAL CONDITION] plus one, of the bilateral lower extremities. During an interview on 1/7/15 at 2:09 P.M., the resident's nurse practitioner said he completed the medical assessment and conducted a routine visit with the resident on 11/25/14 and saw no unusual bruising, swelling or abrasion. During an interview on 12/21/14 at 3:21 P.M., Certified Nurse Aide (CNA) E said he/she noticed and reported decreasing alertness in the resident for two days at the end of November and felt frustrated over the response of nursing staff. The nurses would go in, check the resident's vital signs, say they were great and that a nurse would check on the resident in a little while and then call the resident's physician with any cause for concern noted. CNA E knew the resident's level of alertness was decreasing because he/she began making nonsensical statements and yelling "I don't know" over and over again. The resident normally yelled a lot, but it was always staff names; he/she would go down the list and then start over again. During the weekend of 11/22/14 through 11/23/14, the resident was not constantly sleeping. That change in his/her condition occurred sometime between 11/24/14 and 11/26/14, because when CNA E returned to work on 11/27/14, the resident slept through his/her entire shift. On 11/28/14, Nurse F instructed the CNAs to reposition the resident and elevate his/her head because it was swelling off and on. Nurse F had the CNAs check on the resident every half hour and instructed them to inform Nurse F if they noted any change in the resident's condition. During an interview on 12/17/14 at 6:19 A.M., Nurse F said in November, the resident began sleeping more. The change occurred quickly during the last week of that month. Nurse F found the resident hard to rouse on 11/27/14, but at no time was the resident barely conscious. His/her family expressed concern about the resident's swollen face. The resident used the remote control to lower his/her bed into the Trendelenburg position (body laid flat on the back with the feet higher than the head by 15-30 degrees), which caused swelling in his/her cheek and brow. The rest of his/her head looked normal. Nurse F repositioned the resident in order to alleviate the pressure and the swelling went down. Further review of the resident's nurse's notes, dated 11/28/14, showed the following: - (no time documented), The resident was unresponsive, displayed [MEDICAL CONDITION] on the left side of the body, but had normal, unlabored breathing. He/she awoke to take medications with a drink of water and mumbled; -Staff documented the following vital signs: pulse (P) 108, respiration (R) 18, blood pressure (B/P) 128/79, oxygen saturation (O2 SAT) 97% (normal range: Pulse 60-100 beats per minute, respiration 12-18 breaths per minute and blood pressure 90/60 to 120/80 and oxygen saturation 95%-100%); -(no time documented) Staff contacted the resident's nurse practitioner who advised staff to call back on 11/29/14, if staff observed no change in the resident's condition. During an interview on 12/15/14 at 2:47 P.M., Nurse D said the resident's unresponsiveness on 11/28/14, was not unusual because he/she went through stages of alertness. The resident tended not to rouse at times, when he/she did not wish to be bothered by staff. Nurse D provided care to the resident a total of two times. On 11/28/14, he/she slept, but roused for the 12:00 P.M. medication pass. Nurse D sat the resident up in bed. The resident did not open his/her eyes or speak, but swallowed the medications. Normally, the resident was very vocal. Sometime between 12:00 P.M. and 2:00 P.M., Nurse D checked on the resident and became concerned for the first time because the resident was still unresponsive. Nurse D later became concerned again over the resident's continued unresponsiveness. He/she withdrew from the pain of a sternal rub and foot poke, but still would not talk. Nurse D called the resident's physician (time unknown). The physician's nurse practitioner called back around 5:00 P.M. and instructed staff to watch the resident through the evening and if there was no change or worsening of his/her condition, they were to call back the following morning. From 7:00 A.M. to 7:00 P.M., Nurse D noted swelling to the left side of the resident's body, but another nurse said it was typical. Nurse D saw no change in the resident's condition by the end of his/her shift. He/she passed on the nurse practitioner's instructions to Nurse A, who arrived at change of shift. During an interview on 1/7/15 at 2:09 P.M., the resident's nurse practitioner said on 11/28/14, staff said the resident was unresponsive in the morning, came around and then was unresponsive again that afternoon. He could not recall what time staff called or the reason staff gave for the resident's unresponsiveness. During an interview on 12/19/14 at 6:20 A.M., Nurse A said the resident was normally up all night, constantly activating the call light and calling out for various day shift staff. However, during his/her last week at the facility, the resident was confused and began to sleep more often. It became very difficult to wake the resident for medication passes. He/she would awake delusional, take the medications and go back to sleep. Sometimes, the resident would not talk, he/she would just groan saying, "uh uh." On 11/28/14, Nurse F said the resident woke for brief periods during the day and then went back to sleep. Usually, the resident would wake for his/her medications. During Nurse A's shift on 11/28/14, the resident only groaned and did not wake for medication pass. During an interview on 12/12/14 at 11:18 A.M., CNA B said on 11/28/14 at 8:30 P.M., the resident appeared to be asleep. CNA B did not know the resident was unresponsive. Nurse A said not to bother the resident, to wait until the resident called for assistance, otherwise he/she would be up all night. During the eleven o'clock hour, Nurse A went in to check on the resident, noticed his/her O2 SAT was low and his/her blood pressure was not right. Staff called an ambulance and paramedics took the resident away at 11:55 P.M. During an interview on 12/19/14 at 6:20 A.M., Nurse A recalled an aide reporting at 8:30 P.M. that the resident was unresponsive. Nurse A told the aide not to disturb him/her. Usually, the resident was asleep when not activating the call light. Nurse A went into the resident's room between 8:00 P.M. and 8:45 P.M., to administer his/her insulin. He/she called the resident's name and the resident just groaned. Nurse A left the room, thinking maybe the resident was asleep. At that point, was 8:45 P.M. Nurse A returned to the resident's room at 11:00 P.M. for medication pass. Nurse A knew something was wrong when the resident would not wake up and take the medications, because the resident always took his/her medications. Nurse A took the resident's vital signs and noted swelling in the resident's temporal lobe as well as in the left arm. Further review of the resident's nurse's notes, dated 11/28/14 at 11:00 P.M., showed the resident lay in bed unresponsive with a swollen temporal lobe. He/she had [MEDICAL CONDITION] plus two to three (2+: somewhat deeper pit/4 mm, disappears in 10-15 sec) on the left arm. The resident's temporal lobe was swollen. He/she only groaned when staff performed a sternal rub and did not awaken. Staff documented the following vital signs: BP 198/99, P 114, temperature 100.4 (Normal temperature 97.8 - 99.1 degrees Fahrenheit), R 24, O2 SAT 94%. Staff contacted the resident's physician and obtained an order to send him/her to the hospital. Review of the resident's hospital records, showed the following: -Altered mental status and was unresponsive to voice. The resident withdrew slightly to painful stimuli in the right, upper extremity and appeared to be [MEDICAL CONDITION] (had a pulse rate greater than 100 beats per minute. Normal rate 60-100). -(Facility) staff reported the resident became progressively more confused and less responsive over the course of a few days, to the point that staff could not wake him/her. -He/she had a urinary tract infection, [MEDICAL CONDITION], diffuse swelling and pneumonia. -The resident's PT was 45.5 and his/her INR was "markedly" elevated at 5.2. -CT scan showed a new large, left-sided subdural hematoma (a collection of blood on the surface of the brain) on the left side that appeared to be acute and subacute with a large amount of left to right shift (shift of the brain past its central line) as well as chronic right volume loss (atrophy) from prior aneurysm surgery and an additional right posterior occipital subdural hematoma (bleeding between the brain and brain cover). -The resident required emergency surgery, but needed his/her INR adjusted prior to surgical intervention. The resident's mental status deteriorated and hospital staff intubated him/her due to acute [MEDICAL CONDITION]. -On 11/29/14 at 3:40 A.M., the resident's INR was 2.8. At 11:00 A.M., it was 1.6 and at 9:00 P.M., it was 1.5. The resident underwent [REDACTED]. During an interview on 12/23/14 at 8:45 A.M., the resident's surgeon said the resident presented at the hospital with two subdural hematomas which were traumatic in nature. One hematoma was chronic and indicated an older injury. The resident's INRs were elevated to three times their normal level, which worsened the bleeding of the ruptured vein. During interviews on 1/7/15 at 10:32 A.M. and on 1/12/15 at 10:02 A.M., the resident's physician said [MEDICATION NAME] was affected by everything the resident ate, by episodes of constipation or diarrhea, as well as the level of vitamin K in the resident's intestines. Taking antibiotics could also play a role in the impact of [MEDICATION NAME] on the system. It was common for the INR levels of a resident taking [MEDICATION NAME] to be too high or too low. Consequently, he felt it important that staff carry out physician's orders [REDACTED]. Individuals at increased risk for falls were not normally candidates for [MEDICATION NAME] therapy. He allowed the resident to receive the medication because the resident was not ambulatory, which reduced his/her fall risk. The physician said although the resident had a history of [REDACTED]. the resident's INRs becoming too elevated and worsening the bleed of his/her subdural hematomas. Review of the facility's policy, entitled "Anticoagulation Monitoring Program" dated 3/7/13, showed direction for staff to follow specific risk reduction guidelines for high risk anticoagulant therapy in order to minimize medication-related adverse events. The boxed warning for [MEDICATION NAME] included increased risk of major or fatal bleeding necessitating INR monitoring in all treated residents. Drugs, dietary changes and other factors affect INR levels achieved with [MEDICATION NAME] therapy. [MEDICATION NAME] doses were to be adjusted based on results of the most recent INRs. Staff was to order INRs to be drawn per physician's orders [REDACTED]. The prescriber was expected to provide the nurse with new orders for an INR above or below the identified target value. The nurse was to contact the medical director and request new orders if the prescriber did not respond before the next dose of [MEDICATION NAME] was due. 2. Review on 1/27/15, of Resident #3's admission MDS, dated [DATE], showed the following: -Cognitively intact; -[DIAGNOSES REDACTED]. -Shortness of breath/trouble breathing with exertion. Review of the resident's physician's orders [REDACTED]. The next PT/INR was due in one week, on 12/27/14. Review of the resident's medical records, showed facility staff did not obtain a PT/INR on 12/27/14. Review of the resident's next documented PT/INR lab results were dated 1/1/15. It showed [MEDICATION NAME] 13.7(H) and INR 1.3 (H). Review of the facility's undated performance improvement project, showed on 12/11/14, the facility identified inconsistencies in staff [MEDICATION NAME] tracking due to a lack of communication among nurses on the 24-hour report and in the [MEDICATION NAME] lab tracking book. Nurses were expected to use the 24-hour documentation tool to alert one another of pending labs, changes in condition, new medications and incidents. The actions that the DON/assistant director of nurses (ADON) planned to take by 12/15/14, were review of the 24-hour documentation against a review of the previous day or night events, a thorough review of the new admission and readmission process using the checklist created for those processes and use of a large desk calendar to indicate when staff was to obtain weekly PT/INR lab draws. By 1/13/15, the DON and ADON were also expected to conduct inservices on the importance of the 24-hour communication and lab tracking, in addition to reviewing the orders residents discharged on prescribed medications were readmitted with. Review of a facility inservice sign in sheet, dated 1/12/15, showed all nursing staff received training on the following objectives: [MEDICATION NAME] lab tracking follow-up and re-orders, 24-hour communication, incident/accident investigative and SBAR (situation, background, assessment/appearance and request) forms as well as dignity and respect of residents. Observation on 1/27/15 at 12:30 P.M., showed an accordion file at the nurse's station containing resident lab order requisitions and binder containing [MEDICATION NAME] lab logs for all residents with physician's orders [REDACTED]. Review of a facility lab order audit, dated 1/13/15, showed staff reviewed all of the facility's charts and determined they were all in compliance. Review of an e-mail sent to the administrator from a clinical reference lab chart auditor, showed a company representative reviewed all of the facility's charts on 1/19/15, to make sure they were all in order. Review of the clinical reference lab chart audit documentation and receipt, showed the laboratory found no record of the resident's PT/INR test being performed on 12/27/14. During an interview on 1/27/15 at 1:00 P.M., the DON said each nurse who placed a lab order for a resident was responsible for printing a requisition form documenting the order and filing it in the accordion file at the nurses' station. The requisitions were to be filed on the same day the order was entered into the database. Each nurse who received a lab result was responsible for contacting and notifying the physician of those results. The DON kept the large calendar dedicated to [MEDICATION NAME] monitoring and tracking in her office. Primarily, the DON and ADON were the only staff with access to it and the DON was responsible for updating it. The calendar served as a second check on the lab order tracking process. Lab tracker verification was never done on weekends. On Monday through Friday, the DON double checked the lab tracker verification and followed-up on any labs ordered during the weekend. On a daily basis, the DON and/or a designee reviewed the 24-hour communication report against day and night events, on an ongoing basis. The review consisted of comparing the report to residents' labs in order to ensure consistency in reporting across shifts. The night shift nurse was responsible for checking the chart of each resident who received a lab order that day and follow-up as appropriate. In an effort to improve communication between nurses and CNAs, the CNAs were instructed to report any change in condition to nursing staff and document their observations on the 24-hour communication report. Any staff person in the facility was allowed to document observed changes in condition on that report. The DON took the 24-hour report to the morning meetings. Nursing staff used the SBAR form in order to ensure complete documentation of an incident or change in condition. Note: At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the on-site visit, the facility developed a plan of correction which included in-servicing staff on an updated process for tracking laboratory orders as well as timely communication among nurses and CNAs of resident changes in condition, a review of all current residents' records for compliance with physician-ordered laboratory tests on 1/12/15 and 1/13/15, verification of [MEDICATION NAME] ([MEDICATION NAME]) monitoring and tracking via a calendar to which staff will have 24-hour access and printing laboratory requisitions. The quality assurance performance improvement committee will review the systemic changes, effectiveness of the changes and continued compliance for three months or as long a period as the committee deems appropriate. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review, the facility failed to protect one of three sampled residents from a previously identified accident hazard by not replacing a bed with faulty side rails (Resident #2). The census was 50. Review of Resident #2's side rail evaluation, dated 9/17/14, showed: -An inability to support trunk in upright position contributed to the resident's need to use side rails; -Side rails would assist the resident to avoid rolling out of bed and provide a sense of security; -Side rails recommended at all times when the resident is in bed. Review of the resident's physician's orders [REDACTED]. Review of the resident's consent for use of side rails, dated 12/31/13, showed indications for side rail use were safety and low air loss mattress protocol. Review of the resident's care plan, dated 10/13/14, showed: -Impaired visual function; -Bed rest due to non-healing cervical (neck) fractures; -Gastrostomy tube nutrition, keep head of bed elevated at least 30 degrees at all times; -Reposition every two hours and as needed (PRN); -Contracted bilateral lower extremities, hands and arms; -Dependent on staff for activities of daily living due to dementia and impaired physical mobility. Review of the resident's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 11/5/14, showed: -Hospice care; -[DIAGNOSES REDACTED]. -No speech, absence of spoken words; -Total dependence on assistance of one with bed mobility, eating, toilet use, personal hygiene and bathing. During an interview on 12/12/14 at 11:18 A.M., Certified Nurse Assistant (CNA) B said for quite some time, he/she had problems with the resident's side rail collapsing. Sometimes, when CNA B turned the resident, the side rail would drop down. It happened several times throughout the year. The resident's air mattress came up pretty high past the side rails on the bed and the head of the bed had to remain elevated due to his/her tube feedings. He/she worried about the resident falling out of bed. When CNA B told the charge nurses about it, they said maintenance kept working on it. He/she informed the maintenance supervisor about the issue several times face-to-face. During an interview on 1/12/15 at 8:34 A.M., Hospice Aide G said he/she went to turn the resident (date and time unknown) and the side rail on the opposite side of the bed fell . Hospice Aide G pulled the rail back up and before he/she was able to return to the opposite side of the bed, the side rail fell a second time. Hospice Aide G reported the issue to Nurse F who tested the rail and it fell again. Nurse F reported the issue to the maintenance supervisor who explained that there was a prong on the side rail which had to catch in order to prevent it from falling. He adjusted the side rail, put full pressure on it and it did not fall. During an interview on 12/17/14 at 6:19 A.M., Nurse F said one day a hospice aide (she could not recall the date) reported an issue with a side rail on the resident's bed collapsing when he/she leaned over it. The side rail was back up when Nurse F entered the room. He/she shook the rail back and forth and it held. Nurse F applied weight to the top of the side rail and it fell twice. Nurse F went out and got the maintenance supervisor who also tested it. The maintenance supervisor pushed down on the side rail and it held. He pulled the locking mechanism, dropped the side rail down, "messed with" a knob and then pulled the side rail back up. Nurse F was not aware of any further issues with the side rail on the resident's bed. Review of the resident's nurse's notes, dated 12/6/14 at 1:00 A.M., showed the charge nurse saw the resident on the floor with an aide pulling a drawer off of the resident. The aide explained that while putting the resident to bed one of the side rails fell down causing the resident to roll out of the bed. The charge nurse assessed the resident who was alert and oriented times two to three without clear speech. The resident bled from the right, frontal lobe and had a "golf ball-sized bump" on his/her head. Due to the resident's contractures, the charge nurse could not assess him/her for changes in range of motion. The resident's right eye was reactive to light and the left eye remained closed. Staff assisted the resident back to bed, checked his/her vital signs and conducted neuro-checks. At 6:45 A.M., the charge nurse discovered new bruising on the resident's knees and left deltoid which was also scratched. During an interview on 12/10/14 at 2:29 P.M., CNA H said during the night shift at approximately 1:00 A.M. on the day of the incident, both of the resident's side rails were up when he/she went in to change him/her. The top of the resident's air mattress was 6 to 8 inches above the side rails. CNA H removed the resident's saturated brief and bed liner, placed clean ones underneath the resident's left side, rolled the resident onto his/her back and then walked over to the right side of the bed. As CNA H rolled the resident onto his/her right side, CNA H leaned over the railing, it collapsed and the resident rolled off of the bed. The resident hit the right side of his/her head on the corner of a nightstand next to the bed with a "thud" and landed on the floor on his/her right side. When the resident fell against the nightstand, the drawer rolled open about 3 inches, but did not land on the resident or otherwise make contact with him/her. CNA H could tell the resident was in pain by the way he/she squinted after the fall. Nurse E, who was the charge nurse, entered and discovered the collapsed side rail was not latching properly. Together, CNA H and Nurse I pulled the rail up hard. At that point, they heard the locking mechanism click. Afterwards, the railing held when they applied pressure to it and it did not go back down. During an interview on 12/19/14 at 9:39 P.M., Nurse I said after the resident fell out of bed, Nurse I entered and saw both side rails on the bed were down. The resident's nightstand drawer was all the way out of the stand and laying on the resident's head. The resident was conscious. The resident's grimacing indicated that he/she was in pain. Nurse I tested the side rail and found that it required force to latch. The resident's air mattress was bulky and the side rail had to be "forced" up past the air mattress. The side rail latched once it was all the way up past the mattress. There was a maintenance tag on the bed showing maintenance recently tightened the side rail. Later in the shift, bruising began to appear in other areas of the resident's body which corresponded to the fall. The resident also experienced a change in condition and was less responsive. Normally, the resident communicated with Nurse I by blinking a certain number of times, to indicate "yes" or no", in response to questions. After the resident fell , he/she stopped responding to questions. During interviews on 12/9/14 at 1:10 P.M. and 12/15/14 at 11:19 A.M., the maintenance supervisor said the bed was old and staff should not have used it. He regularly had to tighten the bolts along the bottom of the side rails because the bolts tended to loosen. Those bolts mounted the railing to the bed. Approximately a month and a half prior to the resident falling out of bed on 12/6/14, Nurse F told him the railing would not stay in place because it was not locking. When he pushed down on the railing with two hands, it held. He explained that they must depress the lever until it clicked or the side rail would go back down. No one else told him about the side rail collapsing or not locking in place. MO 427

Based on observation, interview and record review, the facility failed to fully assess, adequately monitor and update the physician regarding one resident's vomiting, elevated temperatures and the condition of his/her lower extremities and failed to obtain a stool specimen as ordered to test for a [MEDICAL CONDITION] infection. The resident was admitted to a local hospital with [DIAGNOSES REDACTED]. The resident received intravenous antibiotic therapy and underwent surgical debridement of the lower extremities. The sample was 12 (Resident #1). The census was 52. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/2/13, showed the following: -No cognitive impairment; -One, Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister); -Height: 67 inches; -Weight: 476 pounds; -[DIAGNOSES REDACTED]. Review of the resident's care plan, updated on 11/16/13, showed no issues regarding skin integrity and no staff instructions on how to care for or assess the resident's skin including his/her legs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No cognitive impairment; -No pressure ulcers; -Height: 67 inches; -Weight 544 pounds. Review of the resident's "Certified Nurse Aide (CNA) Daily Skin Inspection Records", showed the following: February 1 - 3, 8, 13, 15 - 17, 20, 22 - 25 and 27, 2014, staff documented redness and bruising to legs. Staff did not document on the rest of the month. March 1, 2, 4 - 8, 10-12 2014, staff documented redness and bruising to legs. Staff did not document on 3/9/14. Review of the resident's "Weekly Skin Documentation" sheets, signed by a licensed nurse, showed the following: 2/7/14, 2/14/14, 2/21/14 and 3/7/14, showed the same assessment and the same nurse's signature: -Skin is intact; -Skin color is within normal limits (not pale, cyanotic (blue), jaundiced, flushed); -Skin turgor (elasticity) is good; -Special equipment in use - not addressed; -[MEDICAL CONDITION] - not addressed. The assessment for 2/28/14, was blank and not signed by a nurse. Review of the nurse's notes, showed the following: -On 3/9/14 at 9:30 P.M., the resident vomited one large amount with no further complaints. The nurse did not document vital signs (temperature (T), pulse (P), respirations (R) and blood pressure (B/P)), an oxygen saturation (O2 sat) level, a physical assessment (can include changes in orientation, pain, lung sounds, abdominal sounds/tenderness, skin condition) or physician notification; -On 3/10/14 at 4:30 A.M. (the next nurse's note since 3/9/14 at 9:30 P.M.), the resident continued to sleep without any further complaints. No vital signs or assessments were documented; -On 3/10/14 at 6:30 P.M. (the next nurse's note since 3/10/14 at 4:30 A.M.), the resident had numerous episodes of loose stool. T: 98.8 degrees Fahrenheit (F). At 6:00 P.M., T: 102.5 degrees F. Staff administered Tylenol. He/She refused to eat during the shift. The nurse did not document vital signs other than the resident's temperature, a physical assessment or if the resident's physician had been notified; -On 3/11/14 at 6:30 A.M. (the next nurse's note since 3/10/14 at 6:30 P.M.), T: 101.5 degrees F, body aches and described the pain as a six out of ten on the pain scale. He/She experienced no diarrhea at that time. The nurse did not document any vital signs other than the resident's temperature, a physical assessment or if the resident's physician had been notified; -On 3/11/14 at 6:00 P.M. (the next nurse's note since 3/11/14 at 6:30 A.M.), T: 100.1 degrees F and received Tylenol. No further emesis (vomiting) or diarrhea at that time. The nurse did not document any vital signs other than the resident's temperature, a physical assessment or if the resident's physician had been notified; -On 3/11/14 at 10:15 P.M. (the next nurse's note since 3/11/14 at 6:00 P.M.), vital signs were: T: 102.9 degrees F, B/P: 142/80 (normal is 120/80), P: 96 (normal is 60 - 100), R: 18 (normal is 16 - 20), O2 sat 97% (normal is 100%). No complaints other than feverish. Denied nausea, vomiting, diarrhea and received Tylenol for fever. The nurse did not document a physical assessment or if the resident's physician had been notified; -On 3/12/14 at 3:30 (time of day unspecified), the resident still had diarrhea and T: 101.6 degrees F. He/She requested and received [MEDICATION NAME] (a non-steroidal anti-[MEDICAL CONDITION] medication to treat pain, fever and inflammation). The nurse contacted the physician's nurse practitioner, who ordered a complete blood count (CBC, laboratory test used to assess the white blood cells (an elevated count indicates infection), red blood cell count and platelets), basic metabolic panel (BMP, laboratory test used to assess electrolytes and renal (kidney) function) and stool specimen for a [MEDICAL CONDITION] (C. diff, an infectious bacteria that causes diarrhea) test. Review of the resident's physician's orders [REDACTED]. diff. Review of the resident's Certified Medication Technician's Medication Administration Record [REDACTED] -Pain assessment: staff documented no pain in the pain assessment boxes for 3/1 - 12/14 at 8:00 A.M., 2:00 P.M. and 8:00 P.M.; -Tylenol administered for an elevated temperature on 3/10/14 at 7:00 P.M., 3/11/14 at 9:00 A.M. and 4:00 P.M., and on 3/12/14 at 7:00 A.M. and 12:00 P.M. Review of the resident's nurse's MAR, dated 3/1 - 31/14, showed staff documented no pain in the pain assessment boxes for 3/1 - 12/14 at 8:00 A.M., 2:00 P.M. and 8:00 P.M., except on 3/12/14 at 8:00 P.M., the resident's pain was marked as a 4 out of 10. Review of the resident's treatment administration record, dated 3/1 - 31/14, showed an order, dated 12/18/13, for [MEDICATION NAME] Creme (a moisturizer) to lower extremities each shift and as needed. There were no initials to indicate it was ever applied or the condition of the resident's legs. Review of the resident's care plan, updated on 3/13/14, showed no issues regarding skin integrity and no staff instructions on how to care for or assess the resident's skin including his/her legs. Review of the resident's medical record, showed staff obtained the CBC and BMP (results still pending as of 3/13/14 at 9:00 A.M.), but did not obtain the resident's [DIAGNOSES REDACTED] specimen. Review of the resident's nurse's notes, showed the following: -On 3/13/14 at 12:30 A.M. (the next nurse's note since 3/12/14 at 3:30), the resident still had diarrhea and T: 100.2 degrees F. The nurse did not document any vital signs other than the resident's temperature or physical assessment; -On 3/13/14 at 6:45 A.M. (the next nurse's note since 3/13/14 at 12:30 A.M.), the resident called the nurse to take his/her temperature. Vital signs were: B/P: 180/80, P: 114, T: 103.5 degrees F, R: 28 and O2 sat 98%. The nurse left a message for the nurse practitioner because the resident requested to go to the hospital. The resident said he/she had a headache, chills and felt sick; -On 3/13/14 at 7:15 A.M., the nurse practitioner called back and approved the order for the resident to go to the hospital; -On 3/13/14 at 9:00 A.M., ambulance personnel transported the resident to the hospital. Review of the resident's hospital "Emergency Documentation" (from the emergency room ), dated 3/13/14 at 10:16 A.M., showed the following: -Chief complaint: Fever with vomiting and loose stools; -Resident presents with fever. The onset was four days ago. Resident reports this started with some vomiting, then diarrhea the next day; -White blood cell count (an elevated level indicates an infection): 20.4 which is marked with an (*) as a critical level, (normal range is 4.3 - 10.0); -Creatinine level (a blood test used to measure kidney function): 1.0, normal range is 0.5 - 1.4; -Chest x-ray: No active cardiopulmonary disease; -[DIAGNOSES REDACTED]. -admitted as inpatient to the hospital. Review of the resident's hospital "History and Physical Report", dated 3/13/14 at 4:18 P.M., showed the following: -Resident presents with sudden onset fever, diarrhea, nausea and vomiting for 4 days. Resident states he/she is experiencing fever but the nausea, vomiting and diarrhea has improved; -Musculoskeletal: Bilateral lower extremity [MEDICAL CONDITION] (swelling) and [DIAGNOSES REDACTED] (redness). Review of the resident's hospital "Consultation Notes", dated 3/14/14 at 11:12 A.M., showed the following: -Suspect tachypnea (rapid breathing) [MEDICAL CONDITION] (blood infection) secondary to left leg [MEDICAL CONDITION] (a bacterial infection of the skin that can cause inflammation, redness and warmth). Review of the resident's hospital "History and Physical Reports", dated 3/14/14 at 12:40 P.M., showed the following assessment and plan: -Cellulitus: Resident started on [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] (antibiotic); -Chest x-ray does not show pneumonia; -Resident does not have a urinary tract infection; -Increased D-dimer (blood test used to detect the presence of blood clots), can be secondary [MEDICAL CONDITION]; -The resident has bilateral lower extremity [MEDICAL CONDITION] (a condition localized fluid retention and tissue swelling) with ankle and feet swelling; -The resident has bilateral lower extremity [DIAGNOSES REDACTED] (redness); -Possible gastroenteritis (flu like symptoms such as diarrhea, nausea, vomiting), will get stool for [MEDICAL CONDITION]. Review of the resident's hospital "Consultation Notes", dated 3/14/14 at 1:40 P.M., showed the following: -Reason for consultation: [MEDICAL CONDITION]; -Asked to see resident for a concern of a severe [MEDICAL CONDITION] resulting [MEDICAL CONDITION] syndrome; -The resident does have signs of [MEDICAL CONDITION]. The resident says he/she has always had some degree of redness on his/her legs, but he/she is not sure if this is worse or not; -The resident's legs are massively [MEDICAL CONDITION]. This has somewhat of a chronic, woody appearance to it. There is some non-confluent (flows together) [DIAGNOSES REDACTED], more prominent over the left leg, extending from the foot up to the proximal thigh/buttock area; -Impression: Lower extremity cellulitus, left lower extremity greater than right,[MEDICAL CONDITION]. Review of the resident's hospital "Consultation Notes", dated 3/14/14 at 2:49 P.M., showed the following: -Resident has a significant [MEDICAL CONDITION] of bilateral lower extremities, his/her left leg is much redder than his/her right leg and there is some blistering. Review of the resident's hospital "Consultation Notes", dated 3/16/14 at 4:09 P.M., showed the following: -Reason for consultation: Severe acute (sudden) kidney injury; -Creatinine level on 3/14/14 was 0.7, on 3/15/14 it was 2.4 and on 3/16/14 it is 4.4; -Nurses noted yesterday that resident was not making much urine, today he/she had no urine output; -The resident feels very thirsty; -An increase of swelling and [DIAGNOSES REDACTED] in the left leg. Very concerning; -A tremendous amount of swelling and [DIAGNOSES REDACTED], left more than right; -Bullous (blisters) in the left lower extremity. Review of the resident's hospital "Operative Reports", dated 3/17/14 at 3:57 P.M., showed the following: -Preoperative Diagnosis: [REDACTED]. -Procedure: Extensive skin debridement of left lower extremity and incision and drainage of the deeper foot abscess. Incision and drainage of anterior shin abscess right leg; -The resident is going into [MEDICAL CONDITION] and does not seem to respond to antibiotics; -Plan is to unroof some of these blisters, get rid of the necrotic skin, aspirate (remove a sample) the areas and see if there is any fluid that could be cultured; -There were three relatively large areas where the skin was necrotic. Fluid underneath was somewhat clear and a little murky. This was all debrided (removed) down with the scissors to the dermis (the lower or inner layer of the two layers of cells that make up the skin); -The left foot was very swollen and there appeared to be a pocket that was opened with a three or four centimeter incision, then aspirated and cultured; -There was one abscessed area on the right leg that was really concerning. It was surgically opened and a culture was taken; -Impression: Lower extremity cellulitus, abscess,[MEDICAL CONDITION] syndrome secondary to the lower extremity cellulitus, possible [MEDICAL CONDITION] infection, acute [MEDICAL CONDITION], tinea pedis (demagogical infection of the foot/feet, characterized by [DIAGNOSES REDACTED], scaling, maceration (softening of the tissue) and bulla formation) ; -Recommendations: Cultures were collected, will continue the same antibiotics, dose adjusted for [MEDICAL CONDITION]. [MEDICAL CONDITION] is pending as well; -The resident demonstrates poor understanding of the situation and was told this infection that started out as cellulitus, coalesced (to come together to form one whole) into abscess formations necessitating drainage despite the use of intravenous (IV) antibiotics. Review of the resident's hospital "Progress Notes, Physician", dated 3/21/14 at 8:19 A.M., showed the following: -Positive for [MEDICAL CONDITION]. Review of the resident's medical record, showed a readmission to the facility on [DATE] at 4:00 P.M.. Review of the resident's care plan, dated 3/28/14, showed the following: -Problem: History of alteration in skin integrity. At increased risk for alteration in skin integrity related to decreased mobility, bowel and bladder incontinence, [MEDICAL CONDITION] (localized fluid retention and tissue swelling caused by a compromised lymphatic system) and obesity. Currently has Stage II pressure ulcers related to lower buttocks and unstageable pressure ulcers (Unstageable-slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar at the time of admission) to the left heel and right foot. -Approaches included: Certified Nurse Aides (CNAs) to inspect skin daily, document and report any new opened or reddened areas to the charge nurse, licensed nurse to monitor wound status with dressing changes, perform and document weekly skin assessments and notify the doctor of any changes in wound appearance or size and development of any new open areas, observe and report signs of [MEDICAL CONDITION] (skin infection, care plan specified localized pain, redness, swelling, tenderness, drainage, fever, chills, malaise (general feeling of discomfort or uneasiness), [MEDICAL CONDITION](heart rate that exceeds the normal range) and low blood pressure as symptoms that may display with this condition), observe and report signs of osteo[DIAGNOSES REDACTED] (bone infection, care plan specified pain, redness, swelling in affected joint, chills, fever, diaphoresis (profuse sweating), [MEDICAL CONDITION] restlessness and irritability as symptoms that may display with this condition), observe and report signs [MEDICAL CONDITION] (blood infection, care plan specified fever, malaise, change in mental status, [MEDICAL CONDITION] low blood pressure, anorexia, nausea, vomiting, diarrhea, headache, lymph node tenderness or enlargement as symptoms that may display with this condition). During an interview on 4/29/14 at 11:25 A.M., the administrator said the hospital admitted the resident, on 3/13/14, with a [DIAGNOSES REDACTED]. During a telephone interview on 5/1/14 at 8:58 A.M., CNA C said the resident had [MEDICAL CONDITION] for a while. His/Her legs and stomach area felt warm to touch in March. The CNA reported this to Nurse D, but the nurse did not assess the resident. CNA C said the resident had been hospitalized due to a [MEDICAL CONDITION] infection. During an interview on 4/29/14 at 12:23 P.M., Nurse E said the resident had red areas on his/her bottom and had [MEDICAL CONDITION] with no changes with it in March. He/She had a lot of dry skin with no open areas. The nurse did not typically work on the resident's hall until another nurse stopped working at the facility. He/She has been working on the resident's hall consistently, for approximately one month, before that he/she worked on the resident's hall occasionally. He/She had not noticed a difference in the resident's legs due to elephantitis (abnormal swelling in the tissue and skin of the lower portion of body) and [MEDICAL CONDITION]. The nurse does not look at the CNA daily skin inspection record. It is the CNA's responsibility to report any new areas to the nurse. Review of the facility "Physician Communication/Change in Condition" policy, revised on 9/2011, showed the following: -Policy: To improve communication between physicians and nursing staff in order to promote optimal resident care. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition; -Procedures: Complete assessment of the resident which may include but is not limited to: current physical condition, resident's previous condition (declining, improving, stable), previous and current mental status, vital signs (temperature, pulse, respirations, blood pressure, intake/output, lung sounds, nausea/vomiting abdominal assessment, pain, last bowel movement, blood glucose), recent labs/x-rays, medications, code status, hospital of choice and any interventions provided to the resident; -Notify the physician of the change in medical condition. The physician notification grid may be used as a reference tool regarding acceptable notification time frames. The nurse will document all assessments and changes in the resident's medical record. Review of the facility "Physician Communication Grid", revised on 9/2011, showed staff should notify the physician in the following time frames for the following conditions: -Treatment required within four hours: single episode of vomiting/emesis and temperatures greater than 101.5 degrees F. During an interview on 4/29/14 at 8:25 A.M., the DON said when a resident vomits, she would expect the nurse to do a full assessment, which consists of asking about appetite, how the resident feels and to document what the vomit consisted of. She would expect the nurse to take vital signs. She expects the nurse to document this in the nurse's notes. The nurse should have notified the doctor after the first vomiting episode, then again when the resident's temperature reached 102.5 degrees F. Staff should notify the doctor when any resident's temperature reaches over 101 degrees F. The nurse should have come back within an hour to check the resident's temperature to see if the Tylenol effectively treated the resident's temperature and taken vital signs every four hours. The nurse should have assessed the resident for infection. She expects the nurse to document the location of the resident's body aches. The laboratory tests should have been done one day prior to the day they had been done. She would have contacted the doctor to send the resident to the hospital when the resident's temperature read 101.5 degrees F. She would have expected to see hourly documentation on the resident. During an interview on 4/29/14 at 1:22 P.M., the resident's physician, who is also the facility medical director said staff should have notified him when the resident vomited on 3/9/14. He would have expected staff to obtain a full set of vitals at that time. Staff should have notified him immediately on 3/10/14, when the resident had loose stools and a temperature of 102.5 degrees F. There are usually three potential types of infection that cause an elevated temperature; respiratory, urinary or skin. He would have ordered a chest x-ray, blood work, a urine test and a test for [MEDICAL CONDITION]. Staff should have notified him again on 3/11/14, when the resident had a temperature of 101.5 degrees F. Staff should have rechecked the resident's temperature within an hour, two at the latest, since he/she had a fever. The physician reviewed the resident's hospital records, from 3/13/14 through 3/28/14, and said the resident's [MEDICAL CONDITION] infection caused the abscess under the resident's skin. He might not expect staff to have been aware of the abscesses since they were located underneath the skin and the resident's legs are so large, but they should have recognized the signs of [MEDICAL CONDITION] such as [DIAGNOSES REDACTED]. Had staff contacted him when the temperatures had first started, the resident could have started on antibiotics sooner and he/she might not have become quite as sick as he/she was and might have avoided acute [MEDICAL CONDITION].

Based on observation, interview and record review, the facility failed to ensure one of eight sampled residents, who were readmitted with pressure ulcers and developed additional pressure ulcers, received appropriate care and treatment to aid in the healing and prevention of pressure ulcers. Staff failed to notify the physician and obtain treatment orders in a timely manner, and continually assess and monitor the condition of the resident's pressure ulcers. Upon readmission the resident had Stage I and II pressure ulcers. Fourteen days later the facility began treating the resident's multiple unstageable pressure ulcers. The facility identified nine residents with pressure ulcers, two were sampled and problems were found with one. (Resident #8) The census was 50. 1. Review of Resident #8's physician's orders [REDACTED]. -Admit: 1/4/13; -Admit to hospice; -Keep bilateral knees wrapped with ace wrap (elastic bandage) until further notice due to fractured left femur; No orders regarding the pressure ulcer to the left lateral knee or right lateral foot. Review of the resident's nurse's notes, dated 1/4/13, showed the following: -7:00 P.M.: Transferred to the facility via stretcher, alert and oriented times two (person and place, but not time), no signs or symptoms of distress. Multiple purple bruises near perineal area, left buttocks, left posterior knee and left lateral knee with a yellow blister, right lateral foot red, hardened and slightly opened in the center; -9:00 P.M.: Spoke with the resident's physician, order received to admit to hospice, keep urinary catheter (a sterile tube inserted through the urethra into the bladder, used to drain urine) in until further notice, keep bilateral lower extremities wrapped with elastic bandage. Review of the resident's Wound/Skin Healing Record, dated 1/4/13, showed the following: -Directions: Use separate sheet for each pressure ulcer site. Evaluate each item by picking the response that best describes the wound and check the appropriate box; -Diagram of right inner foot with a circle drawn in the center; -Date of onset: 1/4/13; -Site/Location: Right inner foot; -Date: 1/4/13; -Presents as: Stage I, Stage II, Stage III, Stage IV and Unstageable: nothing marked; -Size in centimeters (cm): 0.1 cm by 0.1 cm; -Depth: 0.01 cm; -Exudate: None; -Odor: None; -Wound bed: Pink/Beefy Red; -Surrounding skin: Bright red; -Wound edges: Maceration: (soft, white, deteriorating around the site of the original injury, occurs when too much moisture) checked; No documentation regarding left lateral knee blister. Review of the resident's Wound Condition Report, showed the following: -Date 1/4/13; -Type of Wound: Pressure Ulcer; -Developed in house: No; -Present on admission:Yes; -Location: Left medial knee; -Size: 3.0 cm by 3.0 cm; -Color: Yellow/Brown; -Wound bed: Slough; -Stage: II: (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister); -Treatment: Skin Prep: (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) twice a day; -Date: 1/4/13; -Type of Wound: Pressure Ulcer; -Developed in house: No; -Present on admission: Yes; -Location: Right lateral foot; -Size: 2.2 cm by 0.8 cm by 0.0 depth; -Color: Brown; -Wound bed: Eschar (slough or dead tissue); -Stage: II. Review of the resident's medical record, did not show the facility staff contacted the physician or obtained treatment orders. Review of the resident's weekly skin assessment, dated 1/7/13, completed by the facility staff, showed the following: -Skin: Intact. Written in: 1) Bruised left medial and posterior thigh, noted on admission. 2) Quarter sized blanchable red area on the right hip. 3) Both heels reddened; -Diagram: Blank; No documentation regarding the right inner foot or the left medial knee blister. Further review of the resident's nurse's notes, dated 1/7/13, showed the following: -Place bunny boots (pressure relieving device) to bilateral feet; No documentation regarding the pressure ulcers to the right inner foot or left medial knee. Review of the initial assessment from hospice (located in the resident's record) dated 1/7/13, showed the following: -[MEDICAL CONDITION] with general debility; -Assess and monitor resident's right heel/foot; -Heel boots on at all times; -Educate staff to report increased breakdown to nurse for follow up; -Facility wound doctor to see resident. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/11/13, showed the following: -Diagnoses: [REDACTED]. -Short/Long term memory problem; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and bathing; -Range of motion: Lower extremity impairment on one side; -Incontinent of bowel; -Pressure Ulcers: Stage II: one; Unstageable: (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and or/eschar) pressure ulcers): three, one present upon admission; -Special Programs: Hospice. Review of the resident's weekly skin assessment, dated 1/14/13, showed the following: -1/14/13: Skin: Not intact. -Written in: 1) Pressure ulcers to bilateral medial ankles. 2) Pressure ulcers to bilateral medial between knees, bruise left hip; -Diagram: circle on left hip, circles on left and right inner knee, circles on left and right inner ankles. Further review of the resident's nurse's notes, showed the following: -1/14/13 through 1/16/13, no documentation regarding the pressure ulcers to the bilateral ankles, bilateral medial knees or whether the facility notified the physician and obtained treatment orders. Review of the resident's POS, showed an order dated 1/16/13, for Skin Prep to all pressure ulcers twice a day and as needed and soft lambswool. No documentation to indicate where to place the lambswool. Review of the resident's nurse's notes, dated 1/17/13 at 2:30 P.M., showed the following: -A certified nurse aide (CNA) notified the nurse of a pressure ulcer to the right medial knee, a dark purple area with red inflamed periwound (area surrounding wound), skin intact, left medial knee and left medial ankle wound; -Right medial and left lateral pressure ulcers (not documented where the pressure ulcers located) were noted on 1/16/13; No documentation whether staff notified the physician. Review of the resident's Wound Conditioning Reports dated 1/16/13, showed the following: -1/16/13; -Location: Right medial foot; -Type of wound: Blank; -Developed in facility: Blank; -Present on admission: Blank; -Size 2.2 cm by 1.8 cm; -Color: Brown; -Wound bed: Eschar: -Stage: Unable to determine; Review of the resident's treatment administration record (TAR), dated 1/1/13 through 1/31/13, showed the following: -Skin Prep to all pressure ulcers noted twice a day and as needed, started on 1/16/13 (first treatment order noted since admission); -Left and right medial knees, left and right medial ankles, right lateral foot, started on 1/16/13 (first treatment order noted since admission); -Bunny Boots (pressure relieving device) on bilateral feet, started on 1/16/13; Review of the resident's Wound Conditioning Reports dated 1/17/13, showed the following: -Location: Right medial knee; -Type of wound: Pressure; -Developed in facility: Yes; -Present on admission: No; -Date first observed: 1/17/13; -Comments: written in: Brown eschar with red periwound; -Size: 1.2 cm by 1.9 cm; -Color: Brown; -Wound bed: Eschar; -Stage: Unable to determine; -Treatment: Skin prep; -Location: Left medial ankle; -Type of Wound: Pressure; -Developed in facility: Yes; -Present on admission: No; -Comment: written in: Dark purple/brown area, periwound red and inflamed; -Size: 2.8 by 2.1; -Color: Dark brown; -Wound bed: Slough, eschar; -Stage: Unable to determine; -Treatment: Apply skin prep twice a day. Review of the resident's treatment administration record (TAR), dated 1/1/13 through 1/31/13, showed the following: -Lambswool between legs at all times, started on 1/21/13. During an interview on 4/10/13 at 11:00 A.M., the Director of Nurses (DON) said the resident returned from the hospital with a large ace wrap around both his/her upper legs and an order for [REDACTED]. The hospice aide did the resident's showers two times per week and the facility staff did weekly skin assessments. She would expect the nurses to to remove the ace wrap, assess for any redness, bruises, pressure areas, check pedal pulses for circulation, notify the physician and document in the nurse's notes. During an skin assessment on 4/11/13 at 9:01 A.M., Nurse F measured the resident's pressure ulcers. Right inner knee: Stage II: 0.1 cm by 0.1 cm, Left inner knee: Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling): 1.3 cm by 0.6 cm, Right inner foot: Stage IV: 2 cm by .07 cm, Left inner above ankle: No stage given: 1.6 cm by 1.6 cm. The nurse said the pressure ulcers were bad when they were discovered but have improved since that time. Review of the facility's policy regarding Wound and Skin Care and Protocol, updated 11/12/10, showed the following: -Purpose: To prevent pressure ulcer formation by identifying those residents who are at risk for pressure ulcers and to develop appropriate interventions. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of pressure ulcers in a cost efficient and timely manner; -Procedure: Risk Identification and Assessment: 1) The purpose of the assessment is to collect enough information to evaluate the resident's general condition, characterize a pressure ulcer and identify related causes and complications. 5) Residents should be examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. 6) CNAs should complete a Comprehensive CNA Shower Review on all residents when they are bathed or showed and given to the charge nurse. Additionally, CNAs should observe skin integrity during the daily provision of routine care and report any impairments to the charge nurse for appropriate follow up. 7) Any skin impairments, including pressure ulcers, non-pressure ulcer wounds, surgical wounds, skin tears, abrasions, should be assessed and documented weekly by the Wound Nurse or designee, on the Wound Evaluation Flow Sheet. During an interview on 4/11/13 at 1:15 P.M., with the DON, Nurse B, Nurse F and the Assistant Director of Nurses (ADON), the DON said the nurses document on the PUSH Tool (a commonly used assessment instrument used for pressure ulcer monitoring), weekly skin assessments and in the nurse's notes. Nurse B said staff did not inform him/her of changes in the resident's skin until 1/16/13. Nurse F said when staff notified him/her of changes he/she informed the ADON. Nurse B and Nurse F said they did not monitor the resident's skin daily for changes. The ADON said once they knew about the pressure ulcers, interventions were put in place. The DON said staff should have assessed the resident's skin more frequently, notified the physician and documented in the nurse's notes. The DON said they were unable to locate the resident's shower sheets. During an interview on 4/17/13 at 8:45 A.M., the resident's physician said the facility should have monitored the resident's skin more closely, notified him and documented in the medical record. He said the facility did notify him, of the pressure ulcers, but he could not recall the actual date. The hospice company didn't notify them of the development of the pressure ulcers. The facility should work together with the hospice company to monitor and assess the resident's skin. They should not rely on the hospice company to notify them of changes with the resident's skin.