Every finding on record at Amelia Rehabilitation and Healthcare Center

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from financial exploitation for one resident (Resident #2) in a survey sample of fourteen residents. The findings included:On 5/14/26 at approximately 2:45 PM, an interview was conducted with Resident #2 (R2) in his room. When asked about an incident involving money being taken from him, R2 did reported that a staff member had taken money using his debit card, but she no longer worked there. R2 asked the surveyor to talk with the activities director and was reluctant to discuss the incident in detail. On 5/14/26, through staff interviews, it was determined that the activities director was not working that day and was not available for interview. On 5/14/26 a clinical record review was conducted of R2's chart. This review revealed R2 had diagnosis that included, but were not limited to cerebral palsy, major depressive disorder, contracture of the muscle, generalized anxiety disorder, and insomnia. According to R2's most recent minimum data set (an assessment) with an assessment reference date of 2/21/26, R2 was coded as having a brief interview for mental status score of 15 of 15, indicating he was cognitively intact. According to the clinical record there was no documentation of the incident/financial exploitation other than a progress note dated 5/11/26 that read, Resident received his direct express card, Resident requested for SS [social services] to help him, set up a new pin. SS assisted resident with setting up a new pin. Resident has his card and all mail that came with it. On 5/15/26 at 11:43 AM, a telephone interview was conducted with the facility's Activity Director (AD). The AD reported that ON Monday, May 4, [R2's name redacted] came to my office and asked me to check the balance on his debit card, he does this all the time. I dial the numbers for him and put it on speaker phone. When I checked his balance was low, he said something doesn't make sense and I asked if he wanted to listen to the transactions and he said yes. We listened to the transactions that told the dollar amount of each transaction; I wrote them down. One was a $604 ATM [automated teller machine] withdrawal. He hadn't been anywhere, so we selected the option for the details. It said it was an ATM transaction made on 5/1/26 at the [grocery store name redacted] in [city name redacted]. I realized something was going on and reported it to the administrator. I called my staff and [Activities Assistant #1's name redacted] asked if she knew anything about it, she said she didn't know anything about it. The Administrator asked her to come back out here and talk to her before starting work. She told the Administrator she didn't know anything about it, but when the police went and talked to her [Activities Assistant #1] she confessed she took the card, got the money out of the ATM, and we fired her. During the above interview, the AD was asked how someone would have gotten access to the debit card and she reported, His card lived in the lock box in my office. When asked why and if she kept anyone else's debit card, the AD said, No and stated that R2 was a special case, before I was the activity director thee one before me helped him with setting it up and he asked them to keep it. I inherited the lock box with the card in it; he is his own RP so after this we gave it to him. The AD went on to report, Apparently Monday when trying to figure out what was going on, [the activity assistant #1's name redacted] came after everyone got off and went to his room and got him to write a statement and gave it to the Administrator. She [the Activity Assistant #1] was arrested with a felony. On 5/15/26 at 2:01 PM, an interview was conducted with the Business Office Manager (BOM). When asked to discuss what she knew about R2's debit card being used by a staff member, the BOM said, All I know is they had contacted the administrator when they realized something did not add up with his debit card. I was not involved in the investigation. I handle the resident trust account, and he didn't have one at the time. When asked how it came to be that the activities department had R2's debit card, the BOM said, that had been in place for years. The BOM went on to report when they found out R2's debit card was compromised, they assisted R2 to cancel the card and a new card has been received and is now in R2's possession. The BOM went on to report that they have ordered a secured lock box for R2 to be able to keep the card and any other important items in. On 5/15/26 at 2:13 PM, an interview was conducted with the Social Services director (SSD). When asked to discuss what she knew about the incident involving R2, the SSD said, I wasn't with him when he first found out the information. I did talk with him afterwards and of course he was upset; we took the steps and called the police, and, in the end, he got his money back and was very happy about that. The SSD reported not really having any knowledge of how residents' money or bank cards are handled and stated she would need to talk with the business office manager. On 5/15/26 at 2:19 PM, an interview was conducted with the facility Administrator. The Administrator said, It was on the 4th day of May, the activities director came in here and said she had an issue with one of the resident's funds being accessed and we felt like it was taken, so I had some very basic information at that time. I instructed her [Activities Director] to take the lock box and put it in the business office. His card and any other contents were to be counted off with the Business Office Manager. When asked if it was common practice for activities to keep resident's bank cards, the Administrator said, It has been in this instance, it had been the practice that this resident needed assistant to access his funds and order things. During the above interview, the Administrator went on to report that So then she [Activity's Director] said she had talked to two of her assistants and was waiting to hear back from two more. She had left messages. I immediately called the other two and left messages for them as well. I interviewed the resident and he was a little confused about the money, was unsure if someone had taken it out, I asked if he wanted me to the call the police and he just kept saying he trusted [Activity's Director's name redacted]. I let him know no one was in trouble, we just had to protect his funds. We [activity's director and Administrator] left at 5:30 PM, agreed that if we heard from the other two assistants, we would let the others know. I spoke with one of them and she said she hadn't done it, didn't know who did, and didn't suspect anyone. [Activity's Director's name redacted] texted and said she talked with the [activities assistant #1's name redacted] who said she remembered she did it, we agreed that was sort of strange that you don't remember when asked the first time. She was scheduled to work the next day, so we told her to come in at 8AM to meet with me. I rolled up at 7:30 AM and she was coming into the building. I grabbed the Director of Nursing (DON) and we interviewed her. She (Activity Assistant #1) said 'yeah, I probably shouldn't have done it.' I didn't know she had spent the money. I told her she was suspended, we had her give a statement and she gave me what [R2's name redacted] had written out. The Administrator provided the surveyor with a file of the investigation conducted by the facility. Within the file was a statement from R2 that read, I sent [activity assistant #1's name redacted] to go out to send money, which was signed by R2. There was also a statement from the activity assistant #1 who wrote, On May 1st, Friday I was asked to go see [R2's name redacted]. When I came to his room he asked me to go to the atm. I went on my lunch break and got the money for him to mail off to someone. I had him sign a paper saying he let me go. On 5/15/26, a follow-up interview was conducted with the facility Administrator about the statement written by R2 that was in the facility investigation file. The Administrator reported that after they all left work for the day, the Activity Assistant #1 returned to the facility and coerced R2 into writing that document. The nurse saw her in the room and found it suspicious given the time of day and asked the employee to leave the facility. Also within the file was a statement from a certified nursing assistant who stated, that R2 reported, I'm so pissed right now. someone who works here stole $600 from my card at the ATM. R2 also reported that he was scared he would get kicked out if he reported it. According to the facility submitted documents, R2's misappropriated funds were returned to him and there was a copy of a check made payable to the resident in the amount of $600 in the file. The facility conducted an audit to ensure no other residents were affected, re-educated all facility staff on the abuse policy, conducted a root cause analysis, implemented that all financial items were relocated to the business office and access was restricted and a sign-in/sign-out dual control process was implemented. The Administrator was asked why the resident was only reimbursed $600 versus the $604 that was debited from his account. The Administrator reported that the police had arranged for the resident to be re-paid, and she thought it was the employee's stepfather who provided the reimbursement of the funds. The Administrator and the Regional Director of Clinical Services (RDCS) stated the $4 was the ATM fee and they hadn't thought of it. The RDCS went and gave R2 the $4. The facility's undated policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation was received and reviewed. The policy read in part, . The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. On 5/15/26 at 4:15 PM, after consulting with the state agency supervisory team, immediate jeopardy (IJ) was identified regarding financial exploitation, which began on 5/2/26. The facility administrator was provided a copy of the Immediate Jeopardy (IJ) template. The facility had self-identified the non-compliance and implemented a full plan of correction and achieved past non-compliance with a compliance date of 5/11/26. Following the removal of IJ the scope and severity was lowered to a level two isolated. No additional information was provided.

Based on staff interviews and clinical record review, the facility staff failed to ensure that basic life support, including cardio-pulmonary resuscitation (CPR), was initiated to a resident. This resulted in a failure to adhere to the resident's specific advance directive and code status for one of 14 residents in the survey sample, Resident #1 (R1).Findings included:On the morning of [DATE], R1 was observed not breathing and without a heartbeat. The facility nurse failed to initiate cardiopulmonary resuscitation despite R1 having a Full Code status.Resident #1 was originally admitted [DATE] and re-admitted [DATE] after a hospitalization for evaluation and treatment of sepsis secondary to a urinary tract infection. Diagnoses included but are not limited to hypertension, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, pulmonary emphysema, anemia, chronic obstructive pulmonary disease and Alzheimer's disease.A clinical record review revealed nurse progress note by RN#1(Registered Nurse) dated [DATE] at 7:42AM revealed, This RN was called to residents (R1) room. Resident (R1) noted to be lying in bed. No heart or breath sounds at this time. Resident (R1) warm and clammy to touch. LPN #1 (name redacted) notified and is contacting resident family and (name redacted) Nurse Practitioner (NP).A progress note documented dated [DATE] at 7:45 AM by LPN#1 (Licensed Practical Nurse), read in part, Writer notified NP, (name redacted) and (RP) Responsible Party, (name redacted) of resident (R1) expiring. RP requested that (name redacted) Funeral Home be notified and that resident (R1) would have family coming to facility prior to funeral home picking him up. Certified nursing assistants in complete post-mortem care. Writer has notified funeral home and of the personal request that writer notify them after family leaves.A progress note (discharge summary) documented by the NP (Nurse Practitioner) dated [DATE] at 8:00 AM, read in part Patient was found by RN1(Registered Nurse) at 7:42 AM with no heartbeat or breath sounds. This NP was notified at 7:44 AM that patient was pronounced deceased . Progress notes also revealed R1 with code status, FULL CODE.A review of R1's care plan revealed care plan focus for, Mr. (name redacted) R1 has advanced directives: Full Code, Date Initiated: [DATE], Revision on: [DATE], Cancelled Date: [DATE] with interventions to include Perform CPR. Notify physician of any change.A review of R1's physician orders for code status revealed a Full Code order dated [DATE], discontinued [DATE] and re-instated and signed by nurse practitioner on [DATE].On [DATE] at 9:35 AM, the NP was interviewed on incident with R1 observed not breathing and without a heartbeat and stated, the nurse called me that morning to inform me that Mr. (name redacted) R1 had expired. I had him on my list to discuss his code status with his family but this happened before I got around to it.On [DATE] at 11:47 AM, an interview was conducted with RN1. According to RN#1, she was rounding with the Wound Nurse Practitioner when two of the certified nursing assistants came looking for me so I could pronounce Mr. (name redacted) R1. I went to get my stethoscope, LPN#1 told me Mr. (name redacted) R1 did not have heartbeat or breath sounds, I pronounced him, I checked his pulse and breathing and pronounced him. That is typically our protocol. Normally I would know their code status. I took her (LPN#1's) word for it that he was a DNR (Do Not Resuscitate). I did not know until I was called into the office that he was a Full Code. I think I had one other time to pronounce death of a resident. I am the facility's wound nurse and as wound nurse, I would check the resident's code status for those residents I see. When asked if she thought the resident's wishes were honored, she responded, No, not if his wishes were for a FULL CODE and we did not do anything for him. I did not get report that morning as I was doing wounds, I only get report if a resident has a fall or new admission. I have been employed here since [DATE] and the other resident I pronounced was a resident receiving hospice services. When asked what the facility had done since this event she stated, They re-educated all of us on our responsibility to know and honor the resident's right for advanced directives to include code status, they implemented a DNR binder which is at each nurse's station and where to locate the resident's code status like on the resident dashboard in computer record system and to report during shift report, especially for fragile residents or those with change in condition.On [DATE] at 1:35 PM, a telephone interview was conducted with (Licensed Practical Nurse) LPN#1 who was the nurse on duty [DATE] caring for Resident #1. LPN#1 when asked about R1 not breathing and without a heartbeat on [DATE], she responded, The certified nursing assistants called me to R1's room, I could see he was not breathing, I checked him to see if he had a pulse and he did not have a heartbeat. I told the aides to get the RN (registered nurse) as I am an LPN and could not pronounce death. I did not check his code status, I don't know why, I just didn't - he wasn't breathing and he did not have a heartbeat, so I asked them to get the RN to pronounce him, and no, I did not start CPR. When asked if 911 was called or if anyone asked what R1's code status was she responded No, I have beat myself up over this, they suspended me immediately and I just came back yesterday [DATE]. I have been a nurse for 28 years and have never had a write-up or any disciplinary actions against me. I am just so torn up over this. They re-educated me and everyone else on our responsibility to honor the residents' right for advanced directive and code status, so now I know how to check the code status, it is on the resident's dashboard in the computer chart and in the DNR (Do Not Resuscitate) binder at the nurse's station. I just don't know why I didn't think about his code status.On [DATE] at 2:00 PM, an interview was conducted with C.N.A #5 who was one of the C.N.A.'s on duty with R1 on [DATE]. According to C.N.A#5 when she entered R1's room after report that morning he didn't look right so looked closer and did not see him breathing, I went to get the nurse and Miss (name redacted) LPN#1 came and checked his pulse on his neck and wrist and looked at his breathing and told me to go get Miss (name redacted) RN#1 because she needed an RN to pronounce him. So C.N.A. #5 and I went to find Miss (name redacted) RN#1. When asked if anyone called 911 or attempted CPR, she said, No. The facility returned to substantial compliance on [DATE] after implementing the following corrective actions:Corrective action for the Affected ResidentThe incident was investigated by the Director of Nursing and Administrator. The residents' record was reviewed and confirmed to reflect Full Code status. The physician and responsible party were notified. The nurse involved received corrective action, retraining and competency. An interdisciplinary review was completed.Identification of Other ResidentsA 100% audit of all residents was completed to verify accuracy of code status orders across documentation. Both goldenrod binders were audited by the Director of Nursing for accuracy. Any discrepancies were corrected immediately. Staff were re-educated on verification of code status during emergencies. Nursing CPR (cardiopulmonary resuscitation) audit was completed to ensure all certification s are current.Systemic ChangesPolicies were reviewed and revised, if indicated, to require verification of code status at key care points and prior to emergencies. Code status is now clearly displayed in the medical record and care tools. Staff received education and completed a code blue drill on [DATE]. Emergency protocols now include a mandatory verification step during the admission process and code blue drills will be completed on all shifts monthly x 3, then quarterly. Education and CPR competency skills will be added to the new hire orientation process.MonitoringThe Director of Nursing will conduct weekly audits for 4 (four) weeks, then monthly for 3 (three) months to ensure all new admission code status is entered into the resident record upon admission, and MOCK code drills will be completed monthly x 3 (three) months, then ongoing on a quarterly basis. The Director of Nursing/Designee will interview 5 (five) nurses weekly x 4 (four) weeks, then monthly x 2 (two) months to ensure nurses know how to determine code status. Results will be reviewed through QAPI (Quality Assurance Performance Improvement, non-compliance will result in corrective action.Date of ComplianceCompliance was achieved on [DATE] when audits, education, and system changes were completed.On [DATE], the survey team verified all components of the Immediate Jeopardy (IJ) by:1. Verifying corrective action for LPN#1 and RN#1to confirm re-education, retraining and competency on CPR skills and verification of residents' code status. Verified current CPR (cardiopulmonary resuscitation) certification for LPN#1 and RN#1.2. Five resident charts were reviewed to verify code status order matched care plan and code status was displayed on the resident dashboard. Verification that goldenrod binders were at each nursing station and reviewed code status for five residents in the binders.3. Reviewed education attendance sheets and interviewed licensed nurses, certified nursing assistants and therapy staff on what steps to take when they observe a resident who is not breathing and without a heartbeat. All confirmed they had received additional education since [DATE] incident and were able to articulate actions and where to locate the resident's code status. Reviewed attendance sheets on code blue drills that included nursing staff, activities, social services, business office manager, human resources, admissions staff, dietary and environmental staff dated [DATE]. The surveyor verified CPR and AED (automated external device) skills checklists were completed on all licensed nurses.4. Reviewed facility polices used in the staff's re-education: Do Not Resuscitate Order, Advance Directives, Emergency Procedure- Cardiopulmonary Resuscitation, and Compliance with Reporting Allegations of Abuse/Neglect.The survey team accepted the facility's past non-compliance on [DATE], no plan of correction is required.On [DATE] during the end of day meeting, the above findings were reviewed with the Administrator, Director of Nursing and Regional Director of Clinical Services, including the [NAME] President of Operations and Chief Clinical Nursing Officer via telephone conference. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure all staff received mandatory training on effective communication for six of six employees reviewed for training (RN #1, LPN #6, CNA #5, 6, 7, and 8). The findings included:On 5/14/26, as part of the extended survey review a sample of six employees were selected for review of training. The facility administrator was given the list of six employees and asked to provide their training records. On 5/15/26, the training records revealed that none of the six sampled employees (registered nurse #1, licensed practical nurse #6, and certified nursing assistants #5, 6, 7, and 8) had received training on effective communication. On 5/15/26, the above findings were reviewed with the facility's administrator, director of nursing (DON), and regional director of operations. On 5/15/26 at 2:06 PM, an interview was conducted with the DON and Regional Director, when asked how they identify training needs of staff they reported that based on policies and sometimes just talking to people or employees. When asked about training on effective communication, they reported that is not a topic included within their training program. The above findings were reviewed with the administrator, DON and regional director of operations. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure part of the facility's Quality Assurance and Performance Improvement (QAPI) program included training to facility staff on the program elements and goals for six of six employees reviewed (licensed practical nurse #6- LPN 6, registered nurse #1-RN 1, and certified nursing assistants #5, 6, 7, and 8). The findings included:On 5/14/26 during an extended survey review of staff training a sample of six employees was selected for review. The facility administrator was asked to provide evidence of each employees training. Review of the employee training records for LPN #6, RN #1, and CNA #5, CNA #6, CNA #7, and CNA #8, none of the employees had received training on the facility's quality assurance program elements and goals. On 5/15/26 at 2:06 PM, during an interview with the facility's director of nursing (DON) and regional director, the above findings were reviewed. They confirmed that their training program did not include training on the QAPI program. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to take measures to protect the resident from an alleged perpertrator who financially abused the resident while an investigation was being conducted for one resident (Resident #2-R2) in a survey sample of 14 residents. The findings included:On 5/14/26 in the afternoon, an interview was conducted with R2. R2 reported that his debit card was taken and money was removed from his bank account in the amount of $604. R2 said he had gotten his money back. On 5/14/26, the administrator provided the survey team with the facility's investigation file of the incident. Within the file was a signed statement from R2 that indicated he had asked the activity assistant to get money from his account. On 5/15/26 at 2:19 PM during an interview with the facility administrator, the statement referenced above was questioned. The administrator stated that after the investigation was initated and the activity assistant was suspended. That evening, on 5/4/26, after the adminstrative staff had left the facility, the employee returned to the facility and had the resident sign that statement. The facility administrator confirmed that facility's abuse policy indicates that staff involved or suspected of abuse are to be removed from the facility until the investigation is complete to protect the resident. According to the facility's abuse policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation read in part, . v. Protection: The facility will protect residents from harm during an investigation . On 5/15/26, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a comprehensive resident centered care plan for two of fourteen residents (Resident #1-R1 and Resident #11-R11). The findings included: 1. For Resident #11 (R11), the facility staff failed to develop a comprehensive care plan to include the residents' desire and wishes to be a Do Not Resuscitate. On [DATE], during a clinical record review, it was noted that R11 had a physician order dated [DATE] that indicated a Do Not Resuscitate code status. Within the clinical record R11 had a signed Durable Do Not Resuscitate form on file that had been executed on [DATE], prior to admission. Review of R11's care plan there was no evidence of the request for any advance directives or code status (wishes in the event of a cardiopulmonary arrest) event. On [DATE] at 2:01 PM, an interview was conducted with the care plan coordinator (CPC). When asked about care plans, the CPC stated that the care plan is a resident specific document used by all staff to let them know what care the resident needs and how to provide for their needs. When asked if their code status was something that would be in the care plan, the CPC said, yes. On [DATE], during an end of day meeting, the above findings were reviewed with the facility administrator and director of nursing. No additional information was provided. 2. For Resident #1, the facility failed to implement comprehensive care plan on resident's advance directive for full code status. Per clinical record review, a progress note dated [DATE], R1 was observed not breathing and without a heartbeat. A review of R1's care plan revealed the care plan focus, Mr. [name redacted] R1 has advanced directives: Full Code, Date Initiated: [DATE], Revision on: [DATE], Cancelled Date: [DATE] with interventions to include Perform CPR (cardiopulmonary resuscitation). Notify physician of any change. The facility nurse failed to implement R1's care plan for Full Code by not initiating cardiopulmonary resuscitation upon finding R1 not breathing and without a heartbeat despite R1 having a Full Code status. Resident #1 was originally admitted [DATE] and re-admitted [DATE] after a hospitalization for evaluation and treatment of sepsis secondary to a urinary tract infection. Diagnoses included but are not limited to hypertension, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, pulmonary emphysema, anemia, chronic obstructive pulmonary disease and Alzheimer's disease. A clinical record review revealed nurse progress note by RN#1(Registered Nurse) dated [DATE] at 7:42AM revealed, This RN was called to residents (R1) room. Resident (R1) noted to be lying in bed. No heart or breath sounds at this time. Resident (R1) warm and clammy to touch. LPN #1 [name redacted] notified and is contacting resident family and (name redacted) Nurse Practitioner (NP). A progress note documented dated [DATE] at 7:45 AM by LPN#1 (Licensed Practical Nurse), read in part, Writer notified NP, [name redacted] and (RP) Responsible Party, [name redacted] of resident (R1) expiring. RP requested that Funeral Home be notified and that resident (R1) would have family coming to facility prior to funeral home picking him up. Certified nursing assistants in complete post-mortem care. Writer has notified funeral home and of the personal request that writer notify them after family leaves. A progress note (discharge summary) documented by the NP (Nurse Practitioner) dated [DATE] at 8:00 AM, read in part Patient was found by RN#1(Registered Nurse) at 7:42 AM with no heartbeat or breath sounds. This NP was notified at 7:44 AM that patient was pronounced deceased . Progress notes also revealed R1 with code status, FULL CODE. On [DATE] at 9:35 AM, the NP was interviewed on incident with R1 observed not breathing and without a heartbeat and stated, the nurse called me that morning to inform me that Mr. (name redacted) R1 had expired. I had him on my list to discuss his code status with his family, but this happened before I got around to it. On [DATE] at 11:47 AM, an interview was conducted with RN#1. According to RN#1, she was rounding with the Wound Nurse Practitioner when two of the certified nursing assistants came looking for me so I could pronounce Mr. [name redacted] R1. I went to get my stethoscope, LPN#1 told me Mr. (name redacted) R1 did not have heartbeat or breath sounds, I pronounced him, I checked his pulse and breathing and pronounced him. That is typically our protocol. Normally I would know their code status. I took her (LPN#1's) word for it that he was a DNR (Do Not Resuscitate). I did not know until I was called into the office that he was a Full Code. I think I had one other time to pronounce death of a resident. I am the facility's wound nurse and as wound nurse, I would check the resident's code status for those residents I see. When asked if she thought the resident's wishes were honored, she responded, No, not if his wishes were for a FULL CODE and we did not do anything for him. I did not get report that morning as I was doing wounds, I only get report if a resident has a fall or new admission. I have been employed here since [DATE] and the other resident I pronounced was a resident receiving hospice services. When asked what the facility had done since this event she stated, They re-educated all of us on our responsibility to know and honor the resident's right for advanced directives to include code status, they implemented a DNR binder which is at each nurse's station and where to locate the resident's code status like on the resident dashboard in computer record system and to report during shift report, especially for fragile residents or those with change in condition. On [DATE] at 1:35 PM, a telephone interview was conducted with (Licensed Practical Nurse) LPN#1 who was the nurse on duty [DATE] caring for Resident #1. LPN#1 when asked about R1 not breathing and without a heartbeat on [DATE], she responded, The aides called me to R1's room, I could see he was not breathing, I checked him to see if he had a pulse and he did not have a heartbeat. I told the aides to get the RN (registered nurse) as I am an LPN and could not pronounce death. I did not check his code status, I don't know why, I just didn't - he wasn't breathing and he did not have a heartbeat, so I asked them to get the RN to pronounce him, and no, I did not start CPR. When asked if 911 was called or if anyone asked what R1's code status was she responded No, I have beat myself up over this, they suspended me immediately and I just came back yesterday [DATE]. I have been a nurse for 28 years and have never had a write-up or any disciplinary actions against me. I am just so torn up over this. They re-educated me and everyone else on our responsibility to honor the residents' right for advanced directive and code status, so now I know how to check the code status, it is on the resident's dashboard in the computer chart and in the DNR (Do Not Resuscitate) binder at the nurse's station. I just don't know why I didn't think about his code status. On [DATE] at 2:00 PM, an interview was conducted with C.N.A #5 who was one of the C.N.A.'s on duty with R1 on [DATE]. According to C.N.A#5 when she entered R1's room after report that morning he didn't look right so looked closer and did not see him breathing, I went to get the nurse and Miss [name redacted] LPN#1 came and checked his pulse on his neck and wrist and looked at his breathing and told me to go get Miss[name redacted] RN#1 because she needed an RN to pronounce him. So C.N.A. #5 and I went to find Miss [name redacted] RN#1. When asked if anyone called 911 or attempted CPR, she said, No. On [DATE], during a telephone interview with LPN#1, she was asked what the care plan purpose was. She responded, the care plan tells us what the resident's needs are and what the staff should be doing to address those needs. When asked if Mr. [Name redacted] R1's care plan was carried out as he had a care plan focus for Full Code status with an intervention to perform CPR, she stated, we did not follow his care plan.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for one resident (Resident #8-R8) in a survey sample of 14 residents. The findings included:For R8, the facility staff failed to review and revise the care plan to include the resident's code status of a DNR (do not resuscitate). On 5/14/26, during a clinical record review it was noted that R8 had a physician order dated 2/19/26, that read Do Not Resuscitate DNR. In the miscellaneous tab of the chart was a Durable Do Not Resuscitate signed and dated 2/19/26. According to R8's care plan a focus area initiated 1/22/26 that was revised on 3/23/26 read, [R8's name redacted] has exercised the right to self-determination. [R8's name redacted] has decided after informed decision making to be: Full Code. On 5/14/26 at 2:01 PM, an interview was conducted with the care plan coordinator (CPC). When asked about the purpose of a care plan, the CPC said, that is something that is developed and used by everyone on the interdisciplinary team. It is used as a guide to show what care to provide to the residents. It gives you a quick picture of the resident. Information included is ADL's (activities of daily living- bathing, dressing, toileting, etc.), if on any particular medication, if have any infections, activities, nutrition, and if there is anything more resident specific that require interventions. When asked if they have advance directives, does that go on the care plan? The CPC said, Yes. When asked, if they change code status, do you expect that change to be on care plan? The CPC said yes, anyone can update but here social services is responsible.On 5/14/26, during an end of day meeting the above findings were reviewed the facility administrator, director of nursing and regional director. No additional information was provided.

Based on staff interviews and facility document review, the facility failed to ensure RN (registered nurse) coverage included 8 (eight) consecutive hours for 2 (two) days of the past 30 (thirty) days on 2 (two) of 2 (two) units, (4/24/26, 4/30/26).Findings included:A review of staffing records was completed for the period of 4/14/26 through 5/14/26 revealing 4/24/26 had no RN coverage and 4/30/26 revealing 7.62 hours RN coverage.On 5/15/26, an interview was conducted with the Administrator, Director of Nursing and the Regional Director of Clinical Services who confirmed that 8 (eight) consecutive hours of RN coverage was a requirement and they strived to comply. The staffing sheets were reviewed with the facility management team noting no RN coverage for 4/24/26 and 4/30/26 without 8 (eight) consecutive hours.No further information was provided.

Based on staff interview and staff record review, the facility staff failed to ensure two of six employees had trianing on infection control (certified nursing assistants #6 and #8). The findings included:On 5/14/26 as part of the extended survey, a sample of six employees was selected for review of training requirements. The facility administrator was asked to provide evidence of each employees training. Review of the employee training records for CNA #6 and CNA #8, revealed no evidence of infection control training having been received. On 5/15/26 at 2:06 PM, during an interview with the facility's director of nursing (DON) and regional director, the above findings were reviewed. They confirmed that all staff should have training on infection control. No additional information was provided.

Based on staff interview and staff record reviews, the facility staff failed to ensure that staff were trained in compliance and ethics for two of six staff sampled (Certified nursing assistant #7- CNA 7 and certified nursing assistant #8- CNA 8). The findings included:On 5/14/26 as part of the extended survey, a sample of six employees was selected for review of training requirements. The facility administrator was asked to provide evidence of each employees training. Review of the employee training records for CNA #7 and CNA #8, revealed no evidence of compliance and ethics having been received. On 5/15/26 at 2:06 PM, during an interview with the facility's director of nursing (DON) and regional director, the above findings were reviewed. They confirmed that all staff should have training on compliance and ethics. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide written notice, including the reason for the change, prior to a room transfer for three of five residents reviewed, Resident #1, Resident #3 and Resident #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 2/15/2024. On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/30/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R1 documented the resident being their own responsible party. The census list for R1 documented a room change for R1 on 2/15/2024 from the North unit to the South unit. On 6/17/2024 at 11:35 a.m., an interview was conducted with R1 in their room. R1 stated that they had moved to their current on 2/15/2024 and had been forced to move to the other unit. R1 stated that no one provided a written notice stating why they had to change rooms before the move and they had been told a few days before they wanted them to move all the long term residents on the other unit and they refused to move and then they told them that the heater was broken and they had to move for it to be repaired. R1 stated that they did not trust the staff at the facility because they only told them what they wanted to hear and they felt that they had lied about the heater to get them to move. When asked if they still wanted to go back to their old room or were unhappy on the new unit, R1 did not answer and began to talk about another topic. The clinical record for R1 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 2/15/2024. A facility concern form dated 3/22/2024 for R1 documented in part, . [Name of facility administrator] did not give her in writing the reason why her room was changed. Requesting a copy of the moving situation document to keep for her records . Under Resolution of Concern it documented in part, .Resident provided letter stating she was moved due to broken ptac (heating/air conditioning) unit that could not be repaired. Written by [Name of facility administrator] given to [Name of R1] by [Name of business office manager] . The concern form was observed to be dated as resolved on 3/28/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that R1's room had to be changed due to the heater being broken and it could not be repaired immediately. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. She stated that for R1, she had played a larger role in the room change because she had a better relationship with the resident. She stated that she had spoken with R1 a few days prior to the move regarding moving to the other room for the fact that they were attempting to have most of the long term care residents on that unit for an attempt to create a more homelike environment over there. She stated that on that unit they were trying to create a more long term setting with the same residents, same staff and consistent schedules rather than the consistent changeover on the skilled unit. She stated that R1 had refused the room change that day and it was their right to refuse. She stated that a couple of days later the heater was broken and could not be repaired so they had been able to move them to the same room because it was still open and it was the only private room open at the time. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:20 p.m., ASM (administrative staff member) #1, the administrator stated that they did not have evidence that R1 was provided a written notice of transfer with reason for room change prior to the move on 2/15/2024. The facility policy, Room Change/Roommate Assignment dated May 2017 documented in part, .Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate . On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit. 2. For Resident #3 (R3), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 2/20/2024. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/27/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R3 documented the resident being their own responsible party. The census list for R3 documented a room change for R3 on 2/20/2024 from the South unit to the North unit. On 6/17/2024 at 2:10 p.m., an interview was conducted with R3. R3 stated that they had moved to the other unit for a while because they told them that other residents had COVID-19 and they needed the room for them. R3 stated that they did not give them anything in writing but they had moved them back to the room after a few weeks so they were satisfied. The clinical record for R3 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 2/20/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that she thought that R3's room had to be changed due to nursing reasons. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit. 3. For Resident #4 (R4), the facility staff failed to provide written notice of room transfer including the reason for room change, prior to the room change on 4/4/2024. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/10/2024, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for making daily decisions. The admission record for R4 documented the resident being their own responsible party. The census list for R4 documented a room change for R4 on 4/4/2024 from the North unit to the South unit. On 6/18/2024 at approximately 8:22 a.m., an interview was conducted with R4. When asked about their room change to the South unit, R4 nodded that they remembered the move. When asked if they were told the reason for the move, R4 nodded, No. When asked if they received a written notice with reason for room change prior to the move, R4 nodded, No. When asked if they liked their current room and roommate, R4 nodded, Yes. The clinical record for R4 failed to evidence documentation that a written notice of room transfer including the reason for room change was provided to the resident prior to the change on 4/4/2024. On 6/18/2024 at 10:00 a.m., an interview was conducted with OSM (other staff member) #7, the director of social services. OSM #7 stated that normally they were notified by nursing staff when a room change was needed. She stated that her responsibility was to contact the responsible party to notify them of the room change and notify the resident of the room change. She stated that she also completed a room change assessment in the medical record and completed a progress note prior to the room change. She stated that she did not provide a written notice of room change to the resident or the responsible party prior to room changes and thought that maybe the admissions director did. She stated that she thought that R4's room had to be changed due to nursing reasons. On 6/18/2024 at 10:06 a.m., an interview was conducted with OSM #8, the admissions director. OSM #8 stated that their role in room changes was limited to running the bed board. She stated that when a room change was required, the staff contacted her to ensure that a room was open and not being held for a new admission or hospitalized resident. She stated that she did not provide any written notice to the resident or the responsible party prior to a room change. On 6/18/2024 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that they were notified of room changes by social services putting a notice up at the nurses station telling them the date and location of the room change. She stated that she thought that they spoke to the resident and the responsible party regarding the room change and nursing did not provide any written notice of room change to the resident or the responsible party prior to the move. On 6/18/2024 at 12:28 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #4, the vice president of clinical services were made aware of the concern. No further information was presented prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to develop a policy for monthly medication regimen reviews with times frames for the different steps in the process, including identifying the time frame in which the physician/nurse practitioner should respond to the recommendations from the consulting pharmacist for five of five residents included in the unnecessary medication reviews, Residents #71, #17, #22, #32, and #5. The findings include: Resident #71, #17, #22, #32, and #5's clinical records were reviewed for unnecessary medications. A review of the facility policy, Medication Regimen Reviews documented in part, 11. If the Physician does not provide a timely or adequate response, the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director of (if Medical Director is the physician of record) the Administrator. The policy failed to include any documentation regarding the timeframe in which the physician must respond to the Consultant Pharmacist's recommendations. An interview was conducted with ASM (administrative staff member) #3, the vice president of clinical operations, on 11/14/2023 at 5:05 p.m. She presented a copy of the Medication Regimen Reviews policy and stated she added the words, within 30 days to the policy for the physician to respond. Administrative staff member (ASM) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations was made aware of the above findings on 11/15/2023 at 9:36 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to notify the physician of a potential need to alter treatment for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to notify the physician when the resident's medication Gemtesa (1) was not available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. Further review of R20's clinical record failed to reveal the resident's physician was notified and made aware the medication was not available for administration. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated nurses should notify the physician when a resident's medication is not available for administration because the doctor gave the order to give the medication for a reason, so the doctor needs to know if the medication is missed. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Notification of Change documented, 1. The nurse will notify the resident's Attending Physician / practitioner or physician on call when there has been a(an): e. Need to alter the resident's medical treatment significantly . Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.html

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 11/13/23 at 11:30 AM, the kitchen was inspected with OSM #5 (Other Staff Member) the Director of Dietary Services. The following items were noted: 1. A box of individual packages of animal crackers was on the floor in dry storage area. The box was open. 2. A baseball cap was on top of a box of thickened apple juice. 3. A large storage bin on wheels of thickener powder was left open with the bag of thickener also left open and exposed. There was no staff at the bin utilizing it. This bin was near the kitchen sink. 4. The stand mixer, which was clean and ready for use, and was covered, was stored next to meat slicer. The meat slicer was recently used for this day's lunch meal that was being prepared. It had been used to slice roast beef. A piece of roast beef (identified as such by OSM #5) was noted inside the mixing bowl of the stand mixer. On 11/14/23 at 2:47 PM, an interview was conducted with OSM #5 who stated that the animal crackers should not be on the floor. She stated that she addressed the ball cap that was on the thickened apple juice with the staff member, and that it should not be stored on top of food products. She further stated that personal items should not be in the kitchen area. Regarding the storage bin of thickener, she stated that staff took the lid off to wash it but it should not have been left open. Regarding the roast beef that was inside the mixing bowl of the stand mixer that was ready for use, she stated that she did not know how it got in the bowl because it had a cover over it. The facility policy, Food Receiving and Storage was reviewed. This policy documented, Foods shall be received and stored in a manner that complies with safe food handling practices 1. Food Services, or other designated staff, will maintain clean food storage areas at all times 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and sprinkler heads, sewage/waste disposal pipes and vents The policy did not address the other identified concerns above. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to monitor residents weights per physician's orders for six of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, and #5. The findings include: 1. For Resident #12, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight weekly. Further review of the clinical record revealed that there were no weights obtained during the following weeks (below dates run a Sunday through Saturday time frame): Week of May 14 through May 20, 2023. Week of May 21 through May 27, 2023. Week of May 28 through June 3, 2023. Week of June 4 through June 10, 2023. Week of June 18 through June 24, 2023. Week of July 2 through July 8, 2023. Week of July 9 through July 15, 2023. Week of July 16 through July 22, 2023. Week of July 23 through July 29, 2023. Week of July 30 through August 5, 2023. Week of August 6 through August 12, 2023. Week of August 27 through September 2, 2023. Week of September 10 through September 16, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. Week of October 15 through October 21, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 1/20/23 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/23 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #78, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 6/19/23 for Obtain weekly weight every evening shift every Monday. Further review of the clinical record revealed that there were no weights obtained on the Monday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 2 through July 8, 2023. Week of September 3 through September 9, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 11/21/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 11/21/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #90, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed an order 6/7/23 for Obtain weekly weight every night shift every Thursday for monitoring. Further review of the clinical record revealed that there were no weights obtained on the Thursday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 12/5/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 12/5/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #17, the facility staff failed to obtain weekly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 6/1/23 for Weight every day shift every Wednesday. Further review of the clinical record revealed that there were no weights obtained on the Wednesday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. There was no evidence the resident refused to be weighed the above week. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 1/20/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 5. For Resident #73, the facility staff failed to obtain monthly weights as ordered by the physician. A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight monthly. Further review of the clinical record failed to reveal any weights obtained for the month of June 2023. There was no evidence the resident refused the weight for June 2023. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. A review of the comprehensive care plan revealed one dated 6/4/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 6/4/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). The facility policy, Weight Assessment and Intervention was reviewed. This policy documented, 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter . The policy did not address obtaining weights per physician's orders, that may have a different frequency than the facility protocol of a monthly weight. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 27660 6. For Resident #5, the facility staff failed to obtain physician ordered weekly weights. The physician order dated, 6/19/2023, documented, Weight every evening shift, every Wed (Wednesday). Review of the clinical record failed to evidence documentation of the weights on the following Wednesdays: 7/5/2023 8/30/2023 9/13/2023 10/25/2023 11/1/2023. On 11/14/2023, ASM (administrative staff member) #2, the director of nursing, presented some of the weights that were previously missing and stated, yes, there were weights that were not obtained per the orders. An interview was conducted with LPN (licensed practical nurse) #5 on 11/14/2023 at 4:16 p.m. When asked if there is a physician order for weekly weights, what actions should the nurse take, LPN #5 stated, the weights should be obtained per the physician order. The comprehensive care plan dated, 4/3/2023, documented in part, Focus: The resident has compromised cardiovascular conditions or is at risk for compromise r/t (related to) CHF (congestive heart failure), Diabetes, Hypertension (high blood pressure). The Interventions documented in part, Monitor weight .per routine/prn (as needed)/orders. ASM #1, the administrator, ASM #2, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was obtained prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 42 residents in the survey sample, Resident #301 and Resident #45. The findings include: 1. For Resident #301, the facility staff failed to evidence complete and accurate documentation for incontinence care, bathing, and weights. A review of the ADL (activities of daily living) document for September 2023 and October 2023 revealed September Bathing documentation missing for three of twelve shifts: 9/21, 9/22, and 9/29/23; October Bathing documentation missing from five of nine shifts: 10/2, 10/2, 10/3, 10/4, and 10/5/23. A review of the ADL document for September 2023 revealed September incontinence documentation missing from three of twelve-day shifts 9/21, 9/22 and 9/29/23; two of twelve evening shifts 9/29 and 9/30/23, and four of twelve night shifts 9/22, 9/23, 9/24, and 9/26/23. A review of the ADL document for October 2023 revealed October incontinence documentation missing from five of nine-day shifts 10/1, 10/2, 10/3, 10/4 and 10/5/23, two of eight evening shifts 10/1 and 10/3/23, and two of eight night shifts 10/1 and 10/3/23. A review of the weights in the vital sign sheet and on the September TAR (treatment administration record) showed no missing weights. Weights were documented as done on the October TAR, with no evidence of the weight obtained either on the TAR or the vital sign sheet. Unable to locate manual/paper weight documentation. An interview was conducted on 11/13/23 at 3:10 PM with CNA (certified nursing assistant) #1. When asked the process for providing incontinence care and bathing for the residents, CNA #1 stated, we round every two hours and perform incontinence care. We bathe/shower residents twice a week. If they are incontinent or get sweaty/dirty then they are bathed more frequently. This is documented on the CNA form. When asked what it means if incontinence care or showers/baths are not documented, CNA #1 stated, it means it was not documented, not that it was not done. When asked if this is a complete and accurate medical record if there is missing documentation, CNA #1 stated, no, it is not a complete and accurate medical record. An interview was conducted on 11/14/23 at 8:30 AM with LPN (licensed practical nurse) #2, the unit manager. When asked about the missing documentation for Resident #301's bathing and incontinence care, LPN #2 stated they had a lot of agency aides at the time and the care was provided but not documented in PCC (point click care). LPN #2 stated they rounded on the residents and saw that care was being provided, the aides did not document it in PCC. An interview was conducted on 11/14/23 at 1:30 PM with LPN #4, when asked about Resident #301, and if her signature was on 10/4/23 weight line on the October 2023 TAR, LPN #4 stated, Yes, those are my initials. I do not why I did not put the weight in there. When asked the process for obtaining weights, LPN #4 stated, the CNAs write the weights on a sheet of paper and the nurses are to transcribe it into the medical record. She did not transcribe it. When asked if the medical record is complete and accurate, LPN #4 stated, no, there is no evidence of the weight. When asked if there are copies of the paper forms, LPN #4 stated, no. An interview was conducted on 11/14/23 at 8:15 AM with CNA #3. When asked the process for obtaining resident weights, CNA #3 stated, see this paper form, the nurse highlights in pink the residents that need weights and in yellow the residents that need vital signs. We document on this form and the nurses enter the information in PCC. On 11/14/23 at approximately 4:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations was made aware of the findings. A review of the facility's Charting and Documentation policy revealed All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. No further information was provided prior to exit. 42106 2. For Resident #45 (R45), the facility staff failed to maintain accurate ADL (activities of daily living) documentation for bathing/showers provided in August 2023 and October 2023. The ADL (activities of daily living) documentation for R45 dated 8/1/2023-8/31/2023 documented in part, ADL- Bathing (Prefers: Shower/Whirlpool). Review of the ADL documentation failed to evidence a shower/bath documented on 8/11/2023 and 8/22/2023. The areas for documentation on these dates were observed to be blank. The ADL documentation for R45 dated 10/1/2023-10/31/2023 documented in part, ADL- Bathing (Prefers: Shower/Whirlpool). Review of the ADL documentation failed to evidence a shower/bath documented on 10/17/2023 and 10/31/2023. The area for documentation on 10/17/2023 and 10/31/2023 was observed to be blank. On 11/14/2023 at 10:35 a.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that personal hygiene and bathing were completed every shift. She stated that showers were given according to a schedule and were about every two days. She stated that R45 often refused their showers and preferred bed baths. She stated that when residents refused showers they offered them a second time later that day and then notified the unit manager and charge nurse if they still refused. She stated that they had shower caps that they used for residents who preferred bed baths to wash their hair. She stated that there was a shower aide employed by the facility Monday through Friday and they completed the scheduled showers. She stated that all care was documented every shift and there should not be any blanks in the ADL documentation. She stated that if there were blanks in the documentation the staff probably failed to document and they could not say that the care was not provided. On 11/14/2023 at 1:44 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that R45 refused care often and often refused to get out of bed, refused to allow staff to brush their hair and refused showers. She stated that she had showers were twice a week and they attempted to get R45 to take them but they mostly refused. On 11/14/2023 at 2:00 p.m., an interview was conducted with CNA #4. CNA #4 stated that they worked Monday through Friday as a shower aide and used a schedule for know which residents were scheduled for showers each day. She stated that R45 mostly refused to shower but would accept bed baths. She stated that baths and showers were documented in the computer in the ADL documentation by the assigned CNA and she documented the bath/shower on a paper shower sheet or resident list. On 11/15/2023 at 8:42 a.m., an interview was conducted with LPN #2. LPN #2 stated that she had reviewed the paper shower/bath sheets and ADL documentation for R45 and was unable to find evidence a shower/bath on 8/11/2023, 8/22/2023, 10/17/2023 or 10/31/2023. She stated that they had a lot of agency staff in the building during that time and the documentation was not completed. She stated that the medical record was not complete and there was no excuse for not documenting the care provided or refusal of the care. On 11/15/2023 at 9:37 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 42 residents in the survey sample, Resident #20. The findings include: For Resident #20 (R20), the facility staff failed to ensure the medication Gemtesa (1) was available for administration on multiple dates in September 2023. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. A review of the facility backup medication supply list revealed the medication Gemtesa was not available in the supply. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated the nurses usually try to order medications six or seven days before they run out. LPN #5 stated that if a medication is not available for administration, the nurses should see if the medication is in the facility backup medication supply and if it is not, the nurses should notify the physician, possibly put a hold on the medication until it arrives from the pharmacy and let the pharmacy know they need the medication. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication and Treatment Orders documented, 11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 42 residents in the survey sample; Residents #12, #78, #90, #17, #73, #20, #5, and #62. The findings include: 1. For Resident #12, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 1/20/23 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/23 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight weekly. Further review of the clinical record revealed that there were no weights obtained during the following weeks (below dates run a Sunday through Saturday time frame): Week of May 14 through May 20, 2023. Week of May 21 through May 27, 2023. Week of May 28 through June 3, 2023. Week of June 4 through June 10, 2023. Week of June 18 through June 24, 2023. Week of July 2 through July 8, 2023. Week of July 9 through July 15, 2023. Week of July 16 through July 22, 2023. Week of July 23 through July 29, 2023. Week of July 30 through August 5, 2023. Week of August 6 through August 12, 2023. Week of August 27 through September 2, 2023. Week of September 10 through September 16, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. Week of October 15 through October 21, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #78, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 11/21/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 11/21/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 6/19/23 for Obtain weekly weight every evening shift every Monday. Further review of the clinical record revealed that there were no weights obtained on the Monday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 2 through July 8, 2023. Week of September 3 through September 9, 2023. Week of September 17 through September 23, 2023. Week of September 24 through September 30, 2023. Week of October 1 through October 7, 2023. Week of October 8 through October 14, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #90, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 12/5/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 12/5/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed an order 6/7/23 for Obtain weekly weight every night shift every Thursday for monitoring. Further review of the clinical record revealed that there were no weights obtained on the Thursday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. Week of October 22 through October 28, 2023. Week of October 29 through November 4, 2023. There was no evidence the resident refused to be weighed the above weeks. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 4. For Resident #17, the facility staff failed to follow the comprehensive care plan to obtain weekly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 1/20/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 1/20/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 6/1/23 for Weight every day shift every Wednesday. Further review of the clinical record revealed that there were no weights obtained on the Wednesday or any other day during the following weeks (below dates run a Sunday through Saturday time frame): Week of July 23 through July 29, 2023. There was no evidence the resident refused to be weighed the above week. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 5. For Resident #73, the facility staff failed to follow the comprehensive care plan to obtain monthly weights as ordered by the physician. The facility policy, Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident A review of the comprehensive care plan revealed one dated 6/4/22 for The resident has alteration or potential for alteration in renal function . This care plan included an intervention dated 6/4/22 for Obtain weights per orders. Use same scale and preferably same time of day wearing same amount of clothing when obtaining weights. Report significant gain or loss to MD (Medical Doctor). A review of the clinical record revealed a physician's order dated 5/10/23 for Obtain weight monthly. Further review of the clinical record failed to reveal any weights obtained for the month of June 2023. There was no evidence the resident refused the weight for June 2023. On 11/15/23 at 9:11 AM, an interview was conducted with LPN #7 (Licensed Practical Nurse). She stated that if there is an order to obtain weights weekly or monthly, then it is expected that they are obtained unless the resident refuses. She stated that if it is not documented, then it was not done. She stated that if it was care planned and not done, then the care plan was not followed. She stated that the purpose of the care plan is everything you are supposed to do for the resident, their individualized needs. On 11/14/23 at 3:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, and ASM #3, the [NAME] President of Clinical Operations were made aware of the findings. No further information was provided by the end of the survey. 31753 6. For Resident #20 (R20), the facility staff failed to implement the resident's comprehensive care plan for medication administration to treat overactive bladder. A review of R20's clinical record revealed a physician's order dated 7/10/23 for Gemtesa (1) 75 mg (milligrams)- one tablet by mouth in the morning for overactive bladder. R20's comprehensive care plan dated 7/24/23 documented, The resident has alteration or potential for alteration in renal function r/t (related to) BPH (benign prostatic hyperplasia), Diuretics, Kidney disease, Prostate enlargement, Overactive bladder. Interventions: Administer medications and treatments as ordered . A review of R20's September 2023 MAR (medication administration record) revealed the same physician's order for Gemtesa. On 9/4/23, 9/5/23, 9/6/23, 9/7/23 and 9/9/23, the MAR documented the code, 9= Other/ See Progress Notes. A nurse's note dated 9/4/23 documented, Medication pending pharmacy. A nurse's note dated 9/5/23 documented, Waiting on delivery from pharmacy. A nurse's note dated 9/6/23 documented, Awaiting pharmacy delivery. A nurse's note dated 9/7/23 documented, Waiting to be delivered by pharmacy. A nurse's note dated 9/9/23 documented, Waiting for pharmacy to deliver. On 11/14/23 at 4:05 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated, I know the care plan is there for us to check. Orders are put in, the care plan is updated, and everything is there for us to check to know how to take care of that person and everything that person needs. LPN #5 stated the nurses usually try to order medications six or seven days before they run out. LPN #5 stated that if a medication is not available for administration, the nurses should see if the medication is in the facility backup medication supply and if it is not, the nurses should notify the physician, possibly put a hold on the medication until it arrives from the pharmacy and let the pharmacy know they need the medication. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Gemtesa is used to treat overactive bladder. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a621015.html 27660 7. For Resident #5, the facility staff failed to implement the comprehensive care plan for obtaining weights per the physician orders. The comprehensive care plan dated, 4/3/2023, documented in part, Focus: The resident has compromised cardiovascular conditions or is at risk for compromise r/t (related to) CHF (congestive heart failure), Diabetes, Hypertension (high blood pressure). The Interventions documented in part, Monitor weight .per routine/prn (as needed)/orders. The physician order dated, 6/19/2023, documented, Weight every evening shift, every Wed (Wednesday). Review of the clinical record failed to evidence documentation of the weights on the following Wednesdays: 7/5/2023 8/30/2023 9/13/2023 10/25/2023 11/1/2023. On 11/14/2023, ASM (administrative staff member) #2, the director of nursing stated there were weights that were not obtained per the orders. An interview was conducted with LPN (licensed practical nurse) #5, on 11/14/2023 at 4:15 p.m. When asked the purpose of the care plan, LPN #4 stated, the staff can look at it to see what is going on and what the patient needs. LPN #5 was asked if the care plan documents to get weights as ordered and the weights are not obtained as ordered, is that following the care plan, LPN #5 stated, no. ASM #1, the administrator, ASM #2, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was obtained prior to exit. 8. For Resident #62 (R62), the facility staff failed to implement the comprehensive care plan to administer oxygen per the physician orders. The comprehensive care plan dated, 4/9/2021, documented, Focus: Resident has altered respiratory status or is at risk for breathing difficulty r/t (related to): COPD (chronic obstructive pulmonary disease), dependence on supplemental oxygen. The Interventions documented in part, OXYGEN THERAPY: OXYGEN SETTINGS: O2 as ordered. Observation was made of R62 on 11/13/2023 at approximately 1:30 p.m. The resident was sitting in her bed with her oxygen on via a nasal cannula (NC). The oxygen was set at 2.5 LPM (liters per minute). A second observation was made on 11/14/2023 9:10 a.m., the oxygen was in use by the resident and the setting was at 2.5 LPM. The physician order dated, 5/10/2023, documented, O2 (oxygen) at 3LPM via NC continuously. On 11/14/2023 at 12:41 p.m. an observation was made of R62 with LPN (licensed practical nurse) #5. R62 had her oxygen in use. When asked to read the setting of the oxygen, LPN #5 stated it was set at 2.5 LPM. When asked what the prescribed rate was for R62, LPN #5 stated, the resident is supposed to be on 3 LPM. LPN #5 was asked how often should the oxygen setting be checked by the nurse, LPN #5 stated at least once a shift. When asked the purpose of the care plan, LPN #4 stated, the staff can look at it to see what is going on and what the patient needs. LPN #5 was asked if the care plan documents to administer oxygen per the physician order and it's not at the prescribed rate, is that following the care plan, LPN #5 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 3:31 p.m. No further information was provided prior to ext.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to evidence communication with the dialysis center for one of one residents receiving dialysis services, Resident #82. The findings include: For Resident #82, the facility staff failed to ensure there was communication with the dialysis center each visit. The physician orders dated, 8/18/2023, documented, Hemodialysis at (name of dialysis center) M, W, F (Monday, Wednesday, Friday) and time to be picked up 0900 (9:00 a.m.). Review of the clinical record revealed the facility staff did not have the communication form, or the forms were missing communication information from either party (nursing facility or dialysis center) as follows: 9/4/2023 - no communication form 9/6/2023 - no communication documented from dialysis center on form. 9/8/2023 - no communication documented from dialysis center on form. 9/11/2023 - no communication documented from dialysis center on form. 9/13/2023 through 9/29/2023 - there was no communication forms. 10/13/2023 - no communication documented from dialysis center on form. 10/16/2023 - no communication documented from dialysis center on form. 10/18/2023 - no communication documented from dialysis center on form. 10/20/2023 - no communication documented from dialysis center on form. 10/23/2023 - no communication documented from dialysis center on form. 10/25/2023 - no communication documented from dialysis center on form. 10/27/2023 - no communication documented from dialysis center on form. 10/30/2023 - no communication documented from dialysis center on form. 11/1/2023 - there was no communication form. 11/6/2023 - no communication documented from dialysis center on form. 11/10/2023 - there was no communication form. The comprehensive care plan dated, 8/18/2023, documented in part, Focus: The resident has alteration or potential for alteration in renal function .needs hemo (hemodialysis). The Interventions documented in part, Hemodialysis at (name of dialysis center) in (town of facility) on M, W, F at 9:30 a.m. to be picked up by (name of transport company) at 9:00 a.m. An interview was conducted with LPN (licensed practical nurse) #5, on 11/14/2023 at 1:22 p.m. When asked what steps a nurse takes to send a resident out to a dialysis center, LPN #5 stated the staff get vital signs, and put them on the communication sheet and send the sheet with the resident. LPN #5 was asked when the resident returns, what do they do, LPN #5 stated they get a set of vital signs and review the communication form. LPN #5 stated many times the communication form is not filled in by the dialysis center. An interview was conducted with RN (registered nurse) #3 on 11/14/2023 at 1:34 p.m. When asked the purpose of the communication form sent with the resident to dialysis, RN #3 stated it to let the dialysis center know the stability of the resident upon discharge from the facility and the dialysis center is to let us know how the resident did at dialysis. The facility policy, Dialysis Communication documented in part, Nursing facility and dialysis centers will have effective communication and collaboration related to resident care. 1. Any changes in condition of resident will be communicated to the dialysis center by facility staff. Any changes in condition that occurs during time at dialysis center will be communicated by telephone or communication form. 2. Any changes in physician/treatment orders or lab (laboratory) values will be communicated to dialysis center by facility staff by communication form or telephone. Any changes made my nephrologist/dialysis center or changes in lab values will be made by telephone or communication form. ASM (administrative staff member) #1, ASM #2, the director of nursing and ASM #3, the vice president of clinical operations, were made aware of the above concern on 11/14/2023 at 5:04 p.m. No further information was provided prior to exit. (1) Hemodialysis filters your blood to rid your body of harmful wastes, extra salt, and water. This information was obtained from the following website: https://medlineplus.gov/dialysis.html.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide a dignified dining experience for one of 42 residents in the survey sample, Resident #16. The findings include: For Resident #16 (R16), the facility staff failed to provide lunch in a dignified manner on 11/13/23. R16 was served a meal on a Styrofoam plate and given plastic utensils. A review of R16's clinical record failed to reveal documentation that R16 should be served meals on a Styrofoam plate or given plastic utensils (the resident was not on isolation and did not present with dangerous behaviors). On 11/13/23 at 1:20 p.m., R16 was observed sitting up in bed and eating lunch. The resident's meal was on a Styrofoam plate and the resident was eating with plastic utensils. On 11/14/23 at 2:50 p.m., an interview was conducted with OSM (other staff member) #5 (the dietary director). OSM #5 stated that when she began employment 45 days ago, a lot of plates did not match, and she did not have enough plates. OSM #5 stated she requested four cases (each case containing 36 plates) of plates and had only received two cases. OSM #5 stated there was also a shortage of utensils and she had ordered multiple boxes of utensils because they get thrown in the trash or stockpiled in resident rooms. OSM #5 stated dining with a Styrofoam plate and plastic utensils is not dignified. On 11/14/23 at 4:57 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. ASM #1 stated four cases of plates had been ordered but two cases had not yet been received. The facility policy titled, Dignity documented, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: e. provided with a dignified dining experience .

Based on staff interview, facility document review, clinical record review, and in the course of a FRI (facility reported incident) investigation, it was determined that the facility staff failed to ensure an environment free of accidents and hazards for two of 47 residents in the survey sample; Residents #2, and #17. 1. The facility staff failed to use the proper transfer method and bathing device (shower stretcher) for Resident #2. On 6/14/18, the facility staff failed to use a Hoyer lift to transfer Resident #2, into a shower chair and failed to ensure the residents lower extremities were properly supported in the shower chair during transport to the shower room, resulting in a [MEDICAL CONDITION] distal femoral metaphysis (1) (femur bone with the fracture located just above the knee joint), and harm to the resident. 2. While using a Hoyer lift (1) to transfer Resident # 17, the facility staff failed to follow the recommended procedures, Resident # 17 fell from the lift and sustaining a head injury (hematoma), and was sent to a local hospital. The findings include: 1. The facility staff failed to use the proper transfer method and bathing device (shower stretcher) for Resident #2. On 6/14/18, the facility staff failed to use a Hoyer lift to transfer Resident #2, into a shower chair and failed to ensure the residents lower extremities were properly supported in the shower chair during transport to the shower room, resulting in a [MEDICAL CONDITION] distal femoral metaphysis (1) (femur bone with the fracture located just above the knee joint), and harm to the resident. Resident #2 was admitted to the facility on [DATE] and had the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a significant change assessment with an ARD (Assessment Reference Date) of 12/18/18. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for transfers, dressing, eating, toileting, hygiene, and bathing. A review of the nurse's notes revealed the following: · A note dated 6/14/18 at 12:15 PM: Resident up for shower this AM and was complaining she was in pain. Upon assessment of charge nurse resident noted with swelling and pain to the right knee upon palpation and movement. Charge nurse notified writer of assessment data and writer in to eval (evaluate) right knee. Right knee swollen, not warm/hot to touch. No injury noted. Upon ROM clicking noted to posterior knee with pain reported per resident. Dr. (doctor) (name of the doctor) (ASM #4 - Administrative Staff Member) made aware of above assessment data and ordered xray of the right knee this shift and [MEDICATION NAME] (3) 600 mg (milligrams) Q8H (every eight hours) x (for) 3 days for right knee pain. Attempted x1 (once) to contact RP (responsible party) with update in resident status and new orders this shift with no success noted. Message left, awaiting call back. Charge nurse aware of new orders. (Mobile xray company) phoned for mobile image and awaiting their arrival currently. · A note dated 6/14/18 at 4:52 PM: At approximately 1430 (2:30 PM) (name of mobile xray company) tech in to perform xray of the right knee Immediately after performing xray, tech notified writer of possible impacted femur [MEDICAL CONDITION] distal femur. (ASM #4) phoned by writer and made aware of preliminary reports of fracture to distal femur of right leg. New order written and noted to send resident to (name of hospital) for eval (evaluation) r/t (related to) fracture of right femur. ADON (Assistant Director of Nursing), Administrator, and Admissions department made aware of possible impacted distal right femur fracture. Attempted x1 to contact RP with information regarding status of resident and transfer of resident to (name of hospital) with no success noted. Unsure of bed hold status as unable to currently reach RP (responsible party). Message left and awaiting call back. Writer contacted 2nd contact (name of contact) and made her aware of status of resident and xrays results as well as impending transfer to (name of hospital) for eval. Writer and ADON in to further assess resident prior to transfer to (name of hospital) and resident is noted with faint positive pedal pulse to right LE (lower extremity). After exiting room for assessment of resident writer spoke on phoned (sic) with (name of mother) resident's mother and updated her on resident status and impending transfer to (name of hospital). (Name of transport company) unavailable to transport resident to (name of hospital) so charge nurse was instructed to contact 911 (emergency services) for transport. (Name of county emergency ambulance) into facility at around 1445 (2:45 PM) and receive report on resident condition from charge nurse and further information as provided to them by writer. Resident bed hold policy sent with resident to ER in transfer packet. Resident transported out of facility via stretcher accompanied by 2 EMTs (emergency medical technicians) to (name of hospital) at 1500 (3:00 PM) for further eval of femur fracture. · A note dated 6/14/18 at 7:26 PM: Resident admitted to (name of hospital) for fractured femur per (hospital) nurse; RP (name of RP) was notified and verbalized understanding and stated that she had just spoken to the physician from hospital. · A note dated 6/15/18 at 11:24 AM: Spoke with resident RP (name of RP) this a.m. about her concerns about her mothers condition. I assured her that we were doing a thorough investigation with the staff and would keep her updated. I ask how her mother was doing and she said they were doing some pre-op testing to see if her mother could tolerate the procedure a (sic) she would keep us updated during her hospital stay. A review of the hospital record revealed the following: · A History and Physical dated 6/14/18, documented, Here in the ER (emergency room ) her x-ray shows oblique [MEDICAL CONDITION] femoral metaphysis extending from lateral distal to medial proximal with angular deformity. She also has [MEDICAL CONDITION]. Other imagings (Sic.) including CT cervical spine, Ct head, x-ray of hip and pelvis, x-ray of right knee all negative for any acute injuries The patient denies any other pains besides right leg Assessment/Plan: 1. Right femur fracture. We will keep the patient n.p.o. (nothing by mouth) for possible surgical intervention · The hospital Discharge Note, dated 6/27/18, documented, Discharge Diagnoses: [REDACTED]. Therapy: · A review of the Physical Therapy Discharge Summary for services provided 4/11/18 to 5/4/18 documented, Discharge Status and Recommendations Functional Outcomes Transfers - Total · A review of the Occupational Therapy Evaluation and Treatment Plan dated 4/10/18 to 5/7/18, documented, Prior Level(s) Bathing = Total Functional Skills Assessment - Activities of Daily Living / Self Care Bathing = Total On 4/5/19 at 12:27 PM in an interview with OSM #4 (Other Staff Member - the Director of Rehabilitation), OSM #4 stated, We picked her up a month prior to the incident to try to improve transfer status because she was not total Hoyer lift. We saw her for a month and was not successful so she remained a Hoyer lift. We saw her after the incident as well because she returned to skilled services. Upon review of the therapy documents, when asked where it indicated that the resident was a Hoyer lift, OSM #4 stated that it was documented that the resident was Total assist which means use a Hoyer. When asked how this information is communicated to the floor staff, OSM #4 stated, We educate nursing and CNA's upon discharge from therapy. They have this documentation in their charts as well. Regarding the resident's shower status (use of a shower chair vs a shower bed/stretcher), OSM #4 stated that the resident was dependent for bathing and it was documented in therapy notes as such, and that when it is documented that a resident is total for bathing, this equates to the use of a shower stretcher. Total assist would mean resident was a Hoyer lift and total care for a shower stretcher. A review of the care plan for Resident #2 revealed the following: · A care plan dated 3/4 /18, for ADL (Activities of Daily Living) Functional / Rehabilitation Potential: (Resident #2) requires extensive to total assist of one or two with ADLS . This care plan documented the intervention, Hoyer lift used for transfers with 2 person assist as needed. This intervention was dated 3/14/18 and was a current care plan intervention in place at the time of the incident. · A care plan for Falls: (Resident #2) is at risk for falls r/t (related to) dx (diagnoses) of [MEDICAL CONDITION] d/o (disorder),[MEDICAL CONDITION](stroke) and MS ([MEDICAL CONDITION]). Needs extensive to total assist with all ADLS This care plan was dated 3/14/18, and was revised on 4/10/18. This care plan included the intervention, Use 2 staff as needed with transfers as well as hoyer lift. This intervention was dated 3/14/18 and was a current care plan in place at the time of the incident. · A care plan for Pain: (Resident #2) has dx: MS, chronic pain; left hip pain; osteopenia to right knee; potential for pain . This care plan was dated 3/14/18, and was revised on 4/10/18. This care plan included an intervention for Monitor and record swelling and discoloration to right leg. This intervention was dated 3/14/18 and was a current care plan in place at the time of the incident. · Further review of the care plan that was in place at the time of the incident failed to reveal any interventions regarding what method of showering was to be used with Resident #2 (shower chair vs. the shower bed/stretcher). A review of the facility FRI (Facility Reported Incident) form dated 6/14/18 revealed the following: · The initial FRI dated 6/14/18 documented, Describe incident, including location, and action taken: Resident (name of Resident #2) complained of right leg pain while finishing up with shower. C.N.A. (Certified Nursing Assistant) noted the pain and some swelling; she notified charge nurse. Charge nurse noted swelling and severe pain to right knee area; she notified unit manager of right knee and pain during ROM (range of motion) to right knee. (ASM #4) notified of assessment findings. New orders were written, and noted for an x-ray of right knee on (MONTH) 14, (YEAR). Preliminary x-ray results showed distal femur fracture at approximately 1430 hours. · The final report, dated 6/21/18 documented, FINAL: Staff were interviewed and statements were reviewed. Resident was interviewed, but couldn't properly verbalize the incident due to medical condition. The investigation showed that while the resident was being pushed to the shower room the resident put their right leg down. We believe this is most likely when the injury occurred. The x-ray showed acute fracture to distal femur above right knee. Resident diagnosed with [REDACTED]. The investigation showed no signs of a fall, abuse, or neglect. A 100% in service is being conducted on resident transfers to the shower room. · Review of an APS (Adult Protective Services) report dated 8/15/18 documented, staff consistently reported that when (Resident #2) was transferred from her bed to the shower chair/shower room, (names of CNA #9 and CNA #1) did not use a hoyer lift to complete the transfer. (CNA #9 and CNA #1) noted that they were both aware that (Resident #2) required a hoyer lift when transferring because she is a total care resident; however, they completed the transfer with a two-person assist Interviews: On 4/4/19 at 7:59 AM in an interview with CNA #1, she stated, I was on the floor and (CNA #9) asked me to help transfer her (Resident #2) from the bed to the shower chair. We sat the resident on the side of the bed, and we each got under an arm, lifted her up, and put her in the (shower) chair. When we got her in the shower chair, I left. When she (CNA #9) brought her (Resident #2) out the room, she was rolling her forward, and I told her (CNA #9) 'you need to turn her around and push her backwards. When you roll her forward, her legs need to be lifted up and supported because she can't do it herself.' So she (CNA #9) turned her (Resident #2) around and pushed her backwards, then I left. Then when she (Resident #2) was in the shower, she was complaining about her leg. I don't know if it got hung under the chair when being pushed forward. When asked about what method of lifting was required for Resident #2, CNA #1stated, She is a Hoyer lift. When asked how the resident was usually lifted, CNA #1 stated, Two person lift is what they usually do because she does not weigh that much. When asked what the purpose of a Hoyer lift is, CNA #1 stated, The purpose of a Hoyer lift is when they are total care and can't do anything for themselves. When asked why staff would choose not to use a Hoyer lift, if Resident #2 was supposed to be transferred with a Hoyer lift, CNA #1 stated, Because they used the shower chair and not a shower bed. That is something; I should have questioned but did not, I should have caught that. When asked how staff know the kind of transfer status of a resident, CNA #1 stated, It's in their chart. When asked if CNA's typically go in the charts to find out the transfer status, CNA #1 stated, Sometimes we do and sometimes the nurse just tells us. CNA #1 stated, After this, me and (CNA #9) went to Social Services (of the county) and talked to them and explained what happened. Then the Administrator talked to us. He just wanted to know what happened. He was saying we should have followed the procedure and used the shower bed and the Hoyer to put her (Resident #2) in it and we didn't do that. I did it (failure to use the Hoyer lift and shower bed) because that is the way they were doing it before and I just helped her (CNA #9). I should have caught that. On 4/5/19 at 9:53 AM, in an interview with CNA #6, when asked how she knows how to transfer a resident, she stated, I go by their care plans. We have care plan slips for the CNAs we use that is located in the closet, I can ask another staff member also. I look first to find out the correct transfer method for the resident. When asked if for showers, if a resident a shower needs chair or shower stretcher, she stated, I go by the care plan card in the closet and ask other staff also. We also have care plan books at the nurse's station also that we can look at. On 4/4/19 at 8:54 AM in an interview with RN #5 (Registered Nurse) who was the unit manager at the time of the incident, she stated, The charge nurse came to me and told me the resident was in shower and complained to the CNA of right lower extremity pain. The charge nurse assessed the situation and notified me and I called the doctor to get orders for an xray and pain medication. After that, we went back into the room and put her on the bed so I could assess the situation. She (Resident #2) had pain upon movement and clicking in the knee area. The xray was ordered and we were awaiting for the xray company at the time. I attempted to call the RP who did not answer so I left a message to call the facility back. Then mid-afternoon was when xray arrived. Once they arrived, the xray tech performed the xray with her (Resident #2) in the bed and after the xray was completed, he notified me of the results that she had a right femur distal impacted fracture. After that, I immediately notified the Administrator and ADON (Assistant Director of Nursing) (no longer at the facility) and the doctor, and got an order to send the resident to the ER (emergency room ). After the order, we called a transportation company who could not take her so we called 911. We assessed her pulses in that foot and they were very faint but present pedal pulses and the ADON was with me. Once we got hospital paperwork taken care of and transport taken care of, we attempted to call the RP back who did not answer again, so I called the second RP and notified her of the transfer. At that point, her mom had phoned and I updated her on the situation. After that, EMS (emergency medical services) got here, report was given to them, hospital paperwork was given to them and they took her to the hospital. Later that evening she (Resident #2) was admitted to the hospital for a femur fracture. She required surgery for [REDACTED].#5 stated, At the time that we noted she had pain we did not know how the injury occurred. We investigated after. From the conclusion I got from the staff is she was put in a shower chair and her leg possibly was pushed backwards when pushing the shower chair down the hall. The aids were supposed to use a Hoyer lift and should have used a shower bed instead of the shower chair and they were educated on that. She was a Hoyer lift at the time and was total care and nursing judgement would be to use a shower bed. When asked how the staff know what transfer status a resident is, RN #5 stated, The nurses provide information on level of assistance needed and how a resident should be transferred. Care plans are kept on the unit and the aids can look at that as well. When asked if the electronic clinical record system provides aids with transfer status information, RN #5 stated, I don't know. I can't see it from a CNA perspective. When asked if it identifies how to take care of a person, RN #5 stated, I'm not sure what it looks like to them and if they can see that information. The staff here, are told they may access the care plans (which were on paper in notebooks on the unit). If they are uncertain they should go back to the charge nurse and ask. When asked how a resident's transfer status is determined in the first place, RN #5 stated, It is a nursing judgement to use a Hoyer or a recommendation by the therapy department. It is not a doctor's order in this facility. The use of a Hoyer was a nursing judgement and the use of a shower bed versus a shower chair was a nursing judgement. At the time there was nothing in place that dictated which had to be done for a given resident. On 4/5/19 at 1:14 PM, in an interview with RN #3, a unit manager, when asked how the facility determines a resident's shower method (shower chair vs shower bed), RN #3 stated, I have used nursing judgement as unit manager or therapy directive. If a resident is Hoyer lifted, a shower chair may limit access to cleaning. I tend to recommend the staff use a stretcher if the resident is a Hoyer transfer. I have meetings with my staff on a regular basis, we discuss concerns, and they assist me in some of the processes. If they note a decline, they make sure this is communicated, and if therapy is not involved it would be nursing judgement. CNA's have access to the care plans to review for the CNA level. On 4/5/19 at 1:26 PM, in an interview with RN #1, a unit manager, when asked who decides a resident's transfer status, RN #1 stated, preferably therapy. When in doubt, I would get a consult. I wouldn't get anyone up without knowing their current status. When asked once this information is decided, how is information communicated to the floor staff, RN #1 stated, We have weekly huddles to discuss all our residents and their needs and if any of their status changes. When asked how a resident's shower method (shower chair vs shower bed) is determined, RN #1stated, Based on therapy recommendations or an RN assessment. Anything that deals with safety would preferably be an RN / Unit Manager that assesses that. Generally, if they are using a Hoyer, you will want to use the long shower stretcher because when you transfer them from a bed to a shower bed it is safer than transferring to a chair. She (Resident #2) has an AKA (above knee amputation) so her stability is not what it should be. Her (Resident #2) AKA was in the fall of (YEAR). When asked if the care plan was implemented and followed regarding, the resident's transfer status, RN #1 stated, No it was not. At the time, all the communication books about the residents were properly labeled and available to the staff. On 4/4/19 at 11:04 AM, ASM #1 (Administrative Staff Member) (the Administrator), ASM #2 (the Director of Nursing - DON), and ASM #3 (Regional Vice President of Clinical Services) were made aware of the concern for harm for Resident #2. At this time, a request was made for the facility to provide any further information they had regarding the concern. On 4/4/19 at 4:30 PM, ASM #1, ASM #2, and ASM #3 were reminded no further information had yet been provided. No further information was provided. References: (1) Distal Femoral Metaphysis - The distal femur is the area of the leg just above the knee joint. Information obtained from https://orthoinfo.aaos.org/en/diseases--conditions/distal-femur-thighbone-fractures-of-the-knee/ (2) ORIF - Open Reduction and Internal Fixation - a type of surgery used to fix broken bones. Information obtained from https://hcahealthcare.com/hl/?/ 4/Open-Reduction-and-Internal-Fixation-Surgery (3) [MEDICATION NAME] - used to relieve pain, tenderness, swelling and stiffness Information obtained from https://medlineplus.gov/druginfo/meds/a 9.html 2. While using a Hoyer lift (1) to transfer Resident # 17, the facility staff failed to follow the recommended procedures, Resident # 17 fell from the lift and sustaining a head injury, and was sent to a local hospital. Resident # 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident # 17's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 09/07/18, coded Resident # 17 as scoring a 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15 - being moderately impaired of cognition for making daily decisions. Resident # 17 was coded as requiring extensive assistance of one staff member for activities of daily living and independent with eating, totally dependent of two staff members for transfers. Under G0400 Functional Limitation in Range of Motion Resident # 17 coded as 2 (two) - impairment on both sides under Lower Extremities (hip, knee, ankle, foot). The comprehensive care plan for Resident # 17 dated 09/11/2018 documented, Category: ADL (activities of daily living) Functional / Rehabilitation Potential. (Resident # 17) is (sic) 63 female. She requires extensive assist (assistance) of one with ADLs; [MEDICAL CONDITION] with left sided [MEDICAL CONDITION], H/O (history of)[MEDICAL CONDITIONS] to right side but not as weak as the left-she is able to use her right arm/hand effective; Hoyer lift for transfers with 2 (two) person assist. Family has asked for comfort care. OOB (out of bed) daily in G/C (Geri chair) as tolerated; alert and oriented x2 (times two) with confusion; hearing adequate. RNP (restorative nursing program) for ROM (range of motion) and putting her brace on her left arm/elbow-use palm roll in left hand to prevent further contracture. Start Date: 09/11/2018. The facility's progress notes for Resident # 17 dated 09/14/2018 documented, At 1800 (6:00 p.m.), I was sitting at the nurse's station when screaming was heard. I immediately responded to determine the source. Upon going down the hall, the screaming was noted to be coming from resident's room. Upon entering room, resident was noted to be lying on the floor. Assessment reveals no immediate injuries to resident. A further detailed assessment found a small hematoma (5) to the right occipital (6) region of the resident's head. Resident c/o (complaint of) hurting all over but especially her head. No loss of consciousness was noted. V/S (vital signs) were noted to be: 98.1 (temperature), 74 (pulse), 18 (respiration), 97/68 (ninety-seven over sixty-eight blood pressure), 96% (oxygen saturation). Administrator, Unit manager, Assistant DON (director of nursing) (Name of Physician) and resident's RP (responsible party) - (Name of Responsible Party) were all notified. Received order from (Name of Physician) to send resident to ER (emergency room ) for evaluation. Further review of the progress note revealed it was written by, LPN (licensed practical nurse) # 12. The facility's incident report for Resident # 17 dated 9/14/18 documented, Brief Description: Resident was being transferred via (by) Hoyer lift and fell out of lift. Small hematoma noted to R (right) occipital area. Under witness it documented, (CNA (certified nursing assistant) # 8. The facility's Fall Investigation dated 09/14/2018 for Resident # 17 documented, Environmental/Situational Conditions: Inappropriate use of assistive device. Under Impact from Fall it documented, Head injury requiring neuro (neurological) check, Injury requiring diagnostic evaluation and Bruise/hematoma. The facility's FRI (Facility Reported Incident) dated 09/14/2018 for Resident # 17 documented, Allegation of neglect. Under Describe incident, including location and action taken: CNA (Name of CNA) attempted to transfer resident (Resident # 17) into bed with Hoyer lift without assistance in room (Room Number) on North unit. CNA stated resident thrashed herself out of the Hoyer Lift pad and resident landed on her head. Resident will be sent to local ER. MD (medical doctor) and RP (responsible party) notified. Under Employee action initiated or taken: CNA (Name of CNA) suspended 5 (five) work days during investigation. The (Name of Hospital) ED (emergency department) Report dated 09/14/2018 for Resident # 17 documented, Exams: CT (computerized tomography (CT) scan (7)) HEAD WO (without) IV (intravenous) CON (contrast). INDICATION: Fall with head trauma. IMPRESSION: No acute process or significant interval change. The (Name of Hospital) Discharge Summary dated 09/14/2018 at 9:14 p.m., for Resident # 17 documented, Your Discharge Instructions/Diagnoses: [REDACTED]. The facility's Clinical Orientation Checklist for Nurses Aides for CNA # 8 documented, X. Safety: 3. b. Mechanical Lift (Hoyer Lift). Further review of item number 3b, Mechanical Lift (Hoyer Lift) revealed the initials of a staff member next to mechanical lift. The facility's in-service sheet dated 06/21/2018 documented, 1. Topic To Be Discussed: Transferring residents facility policies. Under 2. Objectives: CNAs will know and understand the facility transfer policy and procedure. Under 4. Personnel Attending Inservice documented (Name of CNA # 8). Further review of the in-service training material documented in part, If a resident is a hoyer lift, which requires two people, or is a two person assist without the hoyer lift, you must transfer the resident as such, do not do it by yourself. The facility's FRI for the internal investigation dated 09/21/2018 for Resident # 17 documented, Final: Interviews completed and witness statements reviewed. Resident was interviewed, but couldn't properly verbalize the incident due to medical condition. Evidence exists that CNA (Name of CNA) failed to follow the resident's care plan for a two-person Hoyer Lift. CNA (Name of CNA) attempted to transfer resident by herself with a Hoyer Lift; the resident thrashed and fell out of the Hoyer Lift sling to the floor on her head which caused a minor hematoma. Resident was transported to ER; CT (computerized tomography) scan negative. CNA (Name of CNA's) actions violates this (sic) facilities policy and procedures for transferring a resident with Hoyer Lift. In-service on the proper method of transfer with Hoyer Lift will be conducted. Under Employee action initiated or taken: CNA (Name of CNA) terminated on 21Sept2018 (September 21, (YEAR)). During the days of the survey an attempt to interview LPN # 12 was unsuccessful due to her being out on sick leave. On 04/04/19 at 11:01 p.m. ASM (administrative staff member) # 1, administrator and ASM # 2, director of nursing, were informed that there was a concern for harm. On 04/04/19 at 12:45 p.m. ASM (administrative staff member) # 1, administrator stated that he was unable to locate an action plan related to Resident # 17's fall and injury. On 04/04/19 at 2:11 p.m., an interview was conducted with CNA (certified nursing assistant) # 1. When asked where she would obtain information on how to transfer a resident, CNA # 1 stated, I would ask the nurse and/or check the care plan if the nurse was not available. When asked to describe the procedure for using a Hoyer lift to transfer a resident, CNA # 1 stated, When using the Hoyer lift it is always at least a two person procedure. When asked how or where she obtained that information, CNA # 1 stated, It was presented in training. On 04/04/19 at 2:24 p.m., an interview was conducted with CNA # 6 When asked where she would obtain information on how to transfer a resident, CNA # 6 stated, The information is posted on the inside of the resident's closet door. It's a care card. When asked to describe the procedure for using a Hoyer lift to transfer a resident, CNA # 1 stated, It is always two persons. When asked how or where she obtained that information, CNA # 6 stated, In training. On 04/04/19 at 2:36 p.m., an interview was conducted with LPN (licensed practical nurse) # 1. When asked where a CNA would obtain information on how to transfer a resident, LPN # 1 stated, The CNA would ask their nurse or one of the other CNAs. When asked to describe the procedure for using a Hoyer lift to transfer a resident, LPN # 1 stated, When using the Hoyer lift there is always a minimum of two staff. We are instructed on that in our orientation and annual education/in-service. On 04/04/19 at 3:06 p.m., an interview was conducted with RN (registered nurse) # 3, unit manager. When asked where a CNA would obtain information on how to transfer a resident, RN # 3 stated, There is a transfer book at each unit, the book contains all the information for each resident to transfer them safely or the care plan or the direction of the charge nurse. When asked to describe the procedure for using a Hoyer lift to transfer a resident, RN #3 stated, Use of a Hoyer lift is always two persons, it is part of the staff's orientation. On 04/05/19 at 12:15 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. After reviewing, the facility's Clinical Orientation Checklist for Nurses Aides ASM # 2 was asked to describe the purpose of the initials after Mechanical lift (Hoyer Lift). ASM # 2 stated, The initials indicate the CNA demonstrated competency with the hoyer lift. On 04/04/19 at approximately 6:45 p.m. ASM (administrative staff member) # 1, the administrator, ASM # 2, director of nursing and ASM # 3, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. Reference: (1) Used for transfers when a person requires 90-100% assistance to get into and out of bed. A pad fits under the person's body in the bed and connects with chains to the Hoyer lift frame. A hydraulic pump is used to lift the person off the bed surface. This information was obtained from the website:http://www.free-foundation.org/hoyer-lifts (2) A loss of brain function that occurs with certain diseases. It

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary treatment and services consistent with professional standards of practice, to promote healing of pressure ulcers for two of 26 residents in the survey sample, Residents #13 and #4. 1. The facility staff inaccurately identified a new sacral area on 2/4/17 as an abrasion that was determined to be and documented as a Stage III (three)* pressure ulcer** upon Resident #13's admission the emergency department on 2/5/17, resulting in harm. Also weekly skin assessments from a licensed nurse could not be provided prior to the inaccurately identified sacral area 2/4/17. 2. Resident #4 was documented as having a stage II pressure sore on the sacrum and as receiving treatments without any initial or ongoing wound measurements/assessments and on 1/5/17 the wound care physician identified a deterioration of the pressure sore status to a stage 3 (2) with yellow necrotic wound tissue. The findings include: 1. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13's most recent MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 2/20/17. Resident #13 was coded as being severely impaired in the ability to make daily decisions scoring 03 on the Staff Interview for Mental Status Exam. Resident #13 was coded as requiring total dependence on one to two facility staff with transfers, bed mobility, locomotion on the unit, dressing, eating, personal hygiene and bathing. Resident #13's MDS assessment prior to 2/20/17, was a quarterly assessment with an ARD (assessment reference date) of 11/12/16. Section M. Skin Conditions of the MDS coded Resident #13 as being a risk of developing pressure ulcers. Section M2010. Unhealed Pressure Ulcer(s) documented the following: Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? A 0 (zero) was documented indicating Resident #13 had no pressure areas at that time. Review of Resident #13's clinical record revealed the following nursing note dated 2/4/17 at 3:05 a.m., Resi (Resident) is A&O x 1 (alert and oriented to self). Resi is able to communicate some needs. Resi is resting in bed with eyes closed at this time. Resp (Respirations) even and non-labored on RA (Room Air). HOB (Head of Bed) slightly elevated for comfort and to facilitate lung expansion. Resi continue to receive LTC (long term care) services r/t (related to) multiple Dx (diagnoses): to include [MEDICAL CONDITIONS](hypertension), dementia, high cholesterol and [MEDICAL CONDITION]. No s/sx (signs or symptoms) of distress or discomfort noted at this time. No c/o (complaints) pain voiced when questioned. Skin warm and dry to touch. Area noted to resident's sacrum and scrotum, resi positioned on side and note for treatment nurse to evaluate. Other treatments applied per MD (medical doctor) orders, resi tolerated well . Review of a non-pressure skin condition report for Resident #13 documented the following: Date First Observed: 2/4/17, Site/Location: Inner, upper, sacral fold. (Will have Dr. (Name of wound care doctor) eval (evaluate) 2/9/17. Condition is a . A check mark was documented under Abrasion indicating that two of the areas were found to be abrasions. A check mark was also documented under Old scar indicating that one of the areas was an old scar. Further review of the non-pressure skin condition report for Resident #13 documented the following: Date: 2/4/17, Size in cm (centimeters) 0.1 x 0.1 x 0, Exudate type: None, Exudate amount: None, Tunneling: 0, Undermining: 0, Wound Bed: Pink/Beefy red, Surrounding Skin Color: Normal for skin, Surrounding tissues/wound edges: Normal for skin. Culture sent: No, Progress: New, Treatment: Continue treatment, Comments: Top, Pin-point area sacral fold, Triad paste q (every) shift, Pinpoint area. Date: 2/4/17, Size in cm (centimeters) 2.0 x 1.0 x 0, Exudate type: None, Exudate amount: None, Tunneling: blank, Undermining: blank, Wound Bed: black/brown, Surrounding Skin Color: Normal for skin, Surrounding tissues/wound edges: Normal for skin. Culture sent: No, Progress: New, Treatment: Continue treatment, Comments: Scar area to sacral fold, scar area-firm, not mushy or boggy. Triad paste q (every shift). Date: 2/4/17, Size in cm (centimeters) 0.6 x 0.3 x .1, Exudate type: None, Exudate amount: None, Tunneling: 0, Undermining: 0, Wound Bed: Pink/Beefy Red, Surrounding Skin Color: Normal for skin, Surrounding tissues/wound edges: Normal for skin. Culture sent: No, Progress: New, Treatment: Continue treatment, Comments: Small abrasion at lower end of scar area. Triad q (every) shift. This non-pressure assessment was completed by the wound care nurse. Review of the Weekly CNA Skin Assessment sheet dated 2/2/17, prior to the sacral area found on 2/4/17, documented the resident as having an old skin tear to his left arm. No areas were identified to on the sacrum. A nursing skin assessment from a licensed nurse could not be found prior to the discovery of the sacral area found on 2/4/17. Resident #13's most recent Braden score prior to the 2/4/17 discovery of the sacral areas was documented on 1/20/17. Resident #13 was documented as having a score of 13-14 Moderate Risk for skin breakdown. Review of Resident #13's telephone physician orders [REDACTED]. Frequency: Every Shift. This order was created and verified by the wound care nurse. Further review of Resident #13's physician orders [REDACTED].o. (by mouth) BID (twice a day) to promote wound healing. This order was created and verified by the wound care nurse. Review of Resident #13's telephone physician orders [REDACTED]. This air mattress continued to be in place during survey 2/21/17 through 2/23/17 and 2/27/17 through 2/28/17. Review of Resident #13's nursing notes dated 2/5/17 at 1:32 p.m., revealed that Resident #13 had been sent out to the hospital. The following was documented: Remains slow to respond. Is not swallowing or accepting food or fluids. Remained in bed. VSS. (Vital Signs Stable). 114/78 (blood pressure), 89-(pulse), 16-(respirations), 97.9 (temperature), -196% (sic) (oxygen) RA (room air). Spoke with MD (medical doctor) (name of medical doctor) and approved to be sent to eval (evaluate) for AMS (altered mental status). RP (responsible party) (name of rp) aware. Further review of the nursing noted dated 2/5/17 at 2:15 p.m. documented the following: Resident d/c (discharged ) to (Name of Hospital) and was admitted . RP is not holding bed. Will follow up with hospital regarding return. Review of the emergency department notes dated 2/5/17 at 3:15 p.m. documented in part, the following: HPI (History of Present Illness) comments: [AGE] year old with past medical history significant [MEDICAL CONDITION](high blood pressure), [MEDICAL CONDITIONS], hypercholesteremia (high cholesterol) and dementia who presents to the ED (emergency department) via EMS (Emergency Services) with chief complaint of altered mental status. Pt's (patients) daughter reports pt has altered mental status from his baseline with decreased responsiveness, lethargy, and some confusion. Pt's daughter reports pt not normally very talkative but says over the last couple of weeks pt has had decreased responsiveness. Pt's daughter states pt has also had difficulty in swallowing and decreased po intake. Pt's daughter states pt is on pureed, thin liquid diet. Pt's temperature was found to be 100.4 F (Fahrenheit) rectally upon arrival to the ED. Pt's daughter stated pt has hx of [MEDICAL CONDITION] but recently stopped having tremors. Pt's daughter states staff at pt's nursing home thought pt may have had a [MEDICAL CONDITION] about a week ago and was seen at (Name of hospital) and had a negative work up .Physical exam . Stage 3 pressure ulcer to mid sacrum approx (approximately) 1.5 cm (centimeters) in length .[DIAGNOSES REDACTED].will likely need admission due to poor po (by mouth) intake. Review of the hospital history and physical dated 2/5/17 at 5:15 p.m., documented in part, the following: (Name of Resident) is a 79 y.o (year old) African American male who is admitted with infected decubitis ulcer .physical exam .skin: unstageable sacral decubitus ulcer, with debris in wound, drainage and odor .Assessment/Plan .Infected decubitis ulcer (2/5/17) -continue with [MEDICATION NAME] (4), add [MEDICATION NAME] (5) - Wound Care consult, may need surgical intervention. Review of the hospital general surgery consult dated 2/6/17 at 6:53 p.m., documents in part, the following: (Name of Resident #13) is a 79 y.o male who presents with foul smelling sacral ulcer .(Name of Resident #13) is poorly conversant, pleasant 79 M (male) who currently resides in a nursing facility for care of multiple ADL (activities of daily living). Per family history in the electronic record, he has accelerated altered mental status, less interactive from normal baseline over the last month. He has also been admitted to (name of hospital) with recent [MEDICAL CONDITION] activity. On a recent examination, he has been found to have a new sacral ulcer. He has been admitted for workup and evaluation. Review of the hospital OP (operative) note dated 2/8/17 documents in part, the following: Preoperative Diagnoses: [REDACTED]. Postoperative Diagnoses: [REDACTED]. Devitalized skin, subcutaneous tissue and muscle. 3. Gluteal abscess. Review of the hospital discharge summary dated 2/14/17 at 11:32 a.m., documented in part, the following: (Name of Resident) is a 79 y.o. admitted to (Name of hospital) and treated for [REDACTED]. Wound cultures isolated scant E coli (6), Proteus (7) and Strep (8) species, all sensitive to [MEDICATION NAME] (9). Seen by wound and surgery. He is sp (status) post debridement and drainage of abscess on 2/8. He has been on IV (intravenous) [MEDICATION NAME] but now going on hospice. Review of Resident #13's nursing notes revealed the following note dated 2/15/17 at 8:36 p.m.: MDS/Care plan review, (Name of Resident) was readmitted to this facility on 2/14/17 under hospice care; hospital states that (Name of Resident #13) was admitted to them with an infected decub (decubitus) to sacrum; wound care nurse evaluated resident's skin the day before hospitalization and there was only excoriation noted to his sacrum; Received IV ABX at hospital; wound was debrided on 2/8/17 .Resident will be done as a significant change with an ARD of 2/20/17 due to hospice care . Review of Resident #13's care plan dated 11/23/16 and revised 2/4/17, 2/15/17 and 2/16/17 documented the following under category: Pressure: Needs assist with all ADLS, transfers, and bed mobility; episodes of uncont (incontinence), Receives ASA (aspirin), potential for skin B/D (breakdown), bruising, skin tears, and circulatory skin issues, overlapping toes-receiving protective tx (treatment). Goal: Resident will remain intact. Approach Start Date: 11/23/16: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Approach Date: 11/23/16: Conduct a systemic skin inspection (specify weekly, daily, etc. Pay particular attention to the bony prominences. Approach date: 11/23/16: Encourage fluids and nutritional intake. Approach date 11/23/16: Encourage physical activity, mobility, and range of motion to maximal potential. Approach date 11/23/16: Keep clean and dry as possible. Minimize skin exposure to moisture. Approach date 11/23/16: Report any signs of skin breakdown (sore, tender, red, or broken areas). Approach date 11/23/16: Use INCONT (incontinent) products to maintain personal hygiene and dignity. Resident #13's care plan was updated on 2/4/17 and documented the following: 2/4- open areas noted to sacrum and sacral fold, Triad .Areas in sacrum will heal by 2/14. Resident #13's care plan was also updated on 2/15/17 and documented the following: 2/15 Resident treated with IV (intravenous) abx (antibiotics) at hospital for wound infection to sacrum-See new treatment orders. Area debrided at the hospital. Resident #13's care plan was updated again on 2/16/17 and documented the following: Sacral decub (decubitus) ulcer is a stage IV (four). Being followed by wound Dr (doctor) area on sacrum will heal by 3/12. Further Review of Resident #13's care plan revealed hand written interventions with dated 2/15/16 that documented the following: Assist in turning and repositioning freq (frequently) when in bed and when (arrow up) in g-chair (geri chair), Tx (treatment per order), refer to wound Dr. as indicated. Review of Resident #13's February 2017 TARS (Treatment Administration Record) documented that Resident #13 received Triad Paste on 2/4/17 day and evening shift, and 2/5/17 on day shift to his sacral areas. No documentation such as skin assessments regarding Resident #13's sacral area could be found in the clinical record from the time the abrasions were discovered and assessed by the wound care nurse to when the resident was admitted to the emergency department on 2/5/17 at 3:15 p.m. with a stage three sacral pressure ulcer. Further review of the clinical record revealed that the wound care specialist saw Resident #13 on 2/16/17. The wound care specialist documented the following: Stage 4 pressure of the sacrum. Wound size 8.2 x 7.8 x 2.0 cm. Exudate: light serous. On 2/27/17 at 10:19 a.m., an interview was conducted with LPN (licensed practical nurse) #4, a nurse who works regularly with Resident #13. When asked about the process of conducting skin assessments, LPN #4 stated that skin assessments were conducted weekly when the CNA (certified nursing assistant) gives the resident a shower. LPN #4 stated that the CNA will write any new skin areas on a CNA skin assessment sheet, or will document that no new areas were found. LPN #4 stated that she will sign the sheet after the CNA completes the sheet. When asked what her signature signifies, LPN #4 stated that her signature signifies that she has assessed the resident when the CNA alerts her of a new skin area. LPN #4 stated that she will go in and physically look at the new skin area. LPN #4 stated that she will not look at the resident if the CNA documents that no new areas were identified on the sheet. LPN #4 stated that the Unit manager will also sign the skin sheet but will not look at resident unless a new area is identified. When asked if nursing completed a skin assessment separate from the CNA's shower assessment, LPN #4 stated that if a new area is found, she will do her own assessment. When asked about the process followed by staff when a new area is identified by the CNA, LPN #4 stated that she would refer the resident to the treatment nurse if she is in the building. LPN #4 stated that if the treatment nurse is not in the building, she herself or the unit manager go in and assess the area and measure. LPN #4 stated that she was off when the sacral areas were identified to Resident #13. LPN #4 stated that when she returned to the facility the following week, Resident #13 was at the hospital. When asked if she was ever made aware or noticed any new skin areas to Resident #13 prior to 2/4/17, LPN #4 stated that she was not aware of any new skin areas or pressure sores and she did not notice any skin areas to Resident #13. LPN #4 stated that the nurse who identified the sacral areas on 2/4/17 no longer worked for the facility. The nurse who found the sacral areas could not be reached for an interview. On 2/27/17 at 10:32 a.m., an interview was conducted with LPN # 1, the wound care nurse. When asked her role in assessing skin areas, LPN #1 stated that she makes rounds on residents with wounds or assesses new skin areas. LPN #1 stated that nursing will alert her of new skin alterations. LPN #1 stated that the wound MD (medical doctor) also makes rounds every Thursday if a wound needs to be followed by him, such as a wound that looks infected. When asked if she was familiar with Resident #13, LPN #1 stated that she was. When asked if she could described the first time she saw Resident #13's sacral areas, LPN #1 stated that the night shift nurse had alerted her on Saturday morning 2/4/17, that Resident #13 had new areas to his sacrum. LPN #1 stated that she evaluated Resident #13 that morning, shortly after she arrived on shift, and agreed with the night shift nurse's treatment plan for Triad paste. When asked what she observed during her assessment, LPN #1 stated that she noticed a small open pin-point area to the top of Resident #13's sacral fold. LPN #1 stated that she also noticed an old scar to the resident's inner sacral fold. LPN #1 stated, The scar was at the top of the cleft, it was not mushy or anything in the center. I just thought it was the beginning of breakdown. LPN #1 also stated that she noted an abrasion to Resident #13's lower sacrum and also thought it was the beginning of skin breakdown. LPN #1 stated, I planned for the MD (medical doctor) to see it, but the resident went to the hospital. When asked who conducts weekly skin assessment on residents, LPN #1 stated that usually the CNA do the skin assessments during baths or showers. LPN #1 stated that if there is a change in the resident's skin condition, they will alert the nurse and the nurse will sometimes alert her. LPN #1 stated that she thinks the first time an aide saw a change in Resident #13's skin was on 2/4/17. LPN #1 stated, I think the CNA on night shift pointed it out to (Name of night shift nurse). When asked if Resident #13's sacral areas could have been possibly misidentified as abrasions and were pressure ulcers on 2/4/17, LPN #1 stated, It really didn't look like that. I was shocked when he came back with a stage 4. On 2/27/17 at 2:12 p.m., an interview was conducted with CNA #23, a CNA who used to regularly work with Resident #13. When asked how often CNAs check the resident's skin, CNA #23 stated, Everyday when providing care. If there is a new area we will notify the charge nurse or treatment nurse if she is on the unit. Nursing would take it from there. CNA #23 stated that she hadn't worked with Resident #13 when his sacral areas were found. She could not recall if Resident #13 had any current sacral areas. On 2/28/17 at 8:40 a.m., an interview was conducted with CNA (certified nursing assistant) #21, a CNA who had been identified by the DON (director of nursing) to have been the night shift CNA on 2/4/17. CNA #21 stated that she did not find Resident #13's skin area. CNA #21 stated, He was not my patient that night. CNA #21 stated that she was certain Resident #13's CNA was CNA #42 on 2/4/17, 11-7 shift. On 2/28/17 at 8:55 a.m., 9:20 a.m., and 10:02 a.m., interviews were attempted with CNA #42. CNA #42 could not be reached for an interview. On 2/28/17 at 9:55 a.m., observation of Resident #13's wound was conducted with LPN (licensed practical nurse) #1. Resident #13 was observed with a stage 4 pressure ulcer measuring 6.5 x 7 x 2.4 cm (centimeters). Light drainage was noted. On 2/28/17 at 2:09 p.m., an interview was conducted with CNA (certified nursing assistant) #18, a CNA who works regularly with Resident #13. CNA #18 was asked when CNA's look at the resident's skin. CNA #18 stated, Basically every day with bed baths and showers. If there are any changes in the skin we report this to the charge nurse or treatment nurse. CNA #18 stated that the nurse would look at the resident's skin after the CNAs alert them of a new condition. When asked if she ever saw Resident #13's skin prior to him going out to the hospital in early February, CNA #18 stated that she was not informed the resident had any skin issues until he came back from the hospital. On 2/28/17 at 2:27 p.m., an interview was conducted with ASM (administrative staff member) #2, the DON (Director of Nursing) and ASM #5, the previous DON. When asked if it was possible for a skin area to go from an abrasion to a stage three pressure ulcer in a 24 hour period, ASM #5 stated, Folks observe wounds in different ways. Maybe it was a DTI (deep tissue injury) and the nurse thought it was an abrasion. ASM#5 stated that the wound care nurse may have misdiagnosed or misstaged Resident #13's sacral area on 2/4/17. When asked if they could find any documentation assessing the sacral areas after the abrasions were found and before the resident went out to the hospital, ASM #2 stated, I'll see if I can find anything. ASM #5 stated, I'll help her. On 2/28/17 at 3:01 p.m., an interview was conducted with ASM #4, the wound care physician. When asked if he was familiar with Resident #13, ASM #4 stated that he has saw Resident #13 when he arrived back from the hospital with a stage 4. ASM #4 stated that he did not follow Resident #13 prior to re-admission. When asked if it was possible for an abrasion to the sacral area to turn into a stage three in a 24 hour period, ASM #4 stated that with Resident #13's condition it was very possible for a wound to decondition rapidly. ASM #4 stated, When I saw him, he was very debilitated. ASM #4 stated, When the areas were found, they were probably more than just abrasions. On 2/28/17 at 3:38 p.m., ASM #2, the DON and ASM #5, the previous DON were made aware of the concern for harm. Any documentation to eliminate the concern for harm was requested. When asked the process for conducting skin assessments, ASM #2 stated that CNAs would check the skin during a bath and if a new area is found, the CNAs would alert the nurses. ASM #2 stated that the nurse would come in to evaluate the new area. ASM #2 stated that most of the time, the nurses are dependent on the CNAs to look at the skin. When asked what type of education the CNAs have to assess the residents' skin, ASM #2 stated that the CNAs definitely know if something is different on the resident and to alert the nurse. When asked if a CNA would be able to determine any area of redness, ASM #2 stated they she was confident the CNAs could determine areas of redness. When asked if a CNA was qualified to conduct a skin assessment, ASM #2 stated that the CNAs were not qualified and the nurses should be assessing the skin if a new area is identified and reported. When asked if nursing should be conducting skin assessment in addition to the CNAs doing body checks during showers or care, ASM #2 stated, Nurses should be checking each resident, every shift. ASM #5 stated that 11-7 nurses used to be assigned residents to do weekly skin assessments. On 2/28/17 at approximately 4:50 p.m., ASM #5 presented a skin integrity policy. When asked when the nurses conduct skin assessments, ASM #5 stated, Daily. They aren't doing them. That's a problem. No further documentation could be presented regarding Resident #13's sacral wound prior to exit. Facility policy titled, Pressure Ulcer Prevention and Care includes the NPUP (National Pressure Ulcer Advisory Panel) Staging/Coding Guidelines. The following was documented: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. 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 serum filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration, or excoriation. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposty can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 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 include undermining and tunneling. Further description: The depth if a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into the muscle/and or supporting structures mating osteo[DIAGNOSES REDACTED] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Full thickness tissue loss in which the base if the ulcer is covered by slough (yellow, tan, gray, green, brown) and/or eschar (tan, brown, black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. The Facility policy titled, Skin Integrity, documents in part, the following: Standard: The skin integrity of resident is preserved through adequate nutrition and hydration, daily inspection of the skin, compliance with proper body alignment and positioning and maintenance of maximum mobility. Policy: Residents who have suffered loss of skin integrity receive appropriate treatment. Residents with any broken skin problems are seen by a physician and/or the treatment control nurse. Procedures: 1. Licensed nurse: a. inspects the areas for potential breakdown on a daily basis. b. assess for mobility level, hydration-nutrition status, and presence of irritants, such as tight clothing or topical substances .Follow standards, policies, and procedures for pressure sores . (1) Metabolic [MEDICAL CONDITION]-[MEDICAL CONDITION] is a term for any diffuse disease of the brain that alters brain function or structure. [MEDICAL CONDITION] may be caused by infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, [DIAGNOSES REDACTED] or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, [MEDICAL CONDITION], paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of [MEDICAL CONDITION] is an altered mental state. This information was obtained from The National Institutes of Health. https://www.ninds.nih.gov/Disorders/All-Disorders/[MEDICAL CONDITION]-Information-Page (2) Stage IV Pressure Ulcer- Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. This information was obtained from the National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (3) Prostat- Liquid based nutritional supplement that contains protein that may prevent malnutrition and weight loss. This information was obtained from The National Institutes of Health. https://www.cancer.gov/publications/dictionaries/cancer-drug?cdrid= 2. (4) [MEDICATION NAME]- Used to treat bacterial infections in many parts of the body. This information was obtained from the National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 50/?report=details. (5) [MEDICATION NAME]- Used to reduce the development of drug-resistant bacteria. [MEDICATION NAME] should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. This information is obtained from The National Institutes of Health. https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=e78bfa6d-d257-46a0-84a7-8d722c d. (6) E.Coli-Escherichia coli (E. coli) bacteria live in the intestines of people and animals, and are key to a healthy intestinal tract. Most E. coli strains are harmless, but some can cause diarrhea through contact with contaminated food or water while other strains can cause urinary tract infections, respiratory illness and pneumonia. This information was obtained from The National Institutes of Health. https://www.niaid.nih.gov/diseases-conditions/e-coli. (7) Proteus- Bacteria that is normally associated with UTIs (Urinary tract infections). (8) Streptococcus- There are many types of Streptococcus bacteria. Some can cause disease such as strep throat, meningitis and pneumonia. Others keep us healthy and are found in areas of the human body such as intestines, skin, mouth and nose. This information was obtained from the National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 88/. (9) [MEDICATION NAME]- Used to treat bacterial infections in many different parts of the body. This information was obtained from The National Institutes of Health. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT 21/. 2. Resident #4 was documented as having a stage II pressure sore on the sacrum and as receiving treatments without any initial or ongoing wound measurements/assessments and on 1/5/17 the wound care physician identified a deterioration of the pressure sore status to a stage 3 (2) with yellow necrotic wound tissue. Resident #4 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of 1/22/17, Resident #4 was coded as being severely cognitively impaired for making daily decisions. She was coded as being completely dependent on two staff members for bed mobility and transfers. She was coded as always being incontinent of both bowel and bladder. She was coded as having one stage 3 pressure ulcer that was not present at the time of her most recent admission. On the quarterly MDS with an assessment reference date of 10/22/16, Resident #4 was coded as being moderately cognitively impaired for making daily decisions. She was coded as being completely dependent on two staff members for bed mobility, and as requiring the extensive assistance of two staff members for transfers. She was coded as being frequently incontinent of both bow

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, it was determined that the facility staff failed to assess, monitor and treat pain following a fall with a major injury for one of seven residents in the survey sample, Resident #6. The facility staff failed to assess, monitor and treat Resident #6 ' s pain for approximately four hours following a fall, which resulted in a fractured femur. The findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 10/8/14. Resident #6 was coded as scoring three out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating that she was significantly cognitively impaired. Section J, Health Conditions, recorded that Resident #6 had not had any falls since admission/entry or reentry into facility (note Resident #6 sustained a fall on 9/26/14 as documented below). A review of the nursing notes revealed that on 9/26/14 at 4:30 a.m. Resident #6 was documented to be on the floor; " Observed resident with legs on floor and upper body still in bed." Resident #6 was documented as having pain in her right thigh and in left thigh with turning. Further review of the clinical record revealed, in part, the following nurses notes: ? "9/26/14 4:30 a.m. - Observed resident with legs in floor and upper body still in bed. Right knee caught under air conditioning unit. Resident confused and SOB (short of breath). Using accessory muscles to breathe. Assisted resident back into bed. Bruises noted to right knee. C/o (complaint of) pain right thigh. Also c/o pain in left thigh when turned. MD (medical doctor) notified. New order for x-rays to bilateral hips. (Name of X-Ray Company) notified." ? "9/26/14 08:42 a.m. - Acute: Res (resident) c/o 8/10 pain *, upon questioning states, "I just hurt all over. Mostly my legs." (Name of physician) phoned and new order noted for [MEDICATION NAME] 5/325 mg (milligrams) X 1. Charge nurse phoned aware." ? "9/26/14 9:56 a.m. - [MEDICATION NAME] 5/325 mg admin (administered) PO (by mouth) with very little effectiveness reported at this time. (Name of physician) in and aware of above, in to evaluate for readmit, and new order to transfer resident to ER noted." ? " 9/26/14 10:28 a.m. - patient care report given verbally by charge nurse to emergency squad. Pt transferred OOF (out of facility) via stretcher at 10:15 a.m. " An interview was conducted with CNA (certified nursing assistant) #3 on 11/6/14 at 7:35 a.m. CNA #3 was asked what she did when she found Resident #6 in the floor on 9/26/14 at 4:30 a.m. CNA responded, " I yelled for help and another aide came in, the other aide rang the call bell and we waited for the nurse to arrive to put her back in the bed. " CNA #3 was asked how they put Resident #6 back in the bed, CNA #3 responded, " Two of us had her top, one under each arm, and one lifted the legs. The nurse lifted her legs. She needs a Hoyer (a lifting device) because she can ' t bear weight but we couldn ' t get it in there so we picked her up. " On 11/6/14 at 8:10 a.m. an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 was documented as assisting Resident #6 immediately following the fall. CNA #5 was asked whether or not Resident #6 was in pain when she went to assist her. CNA #5 stated, " She (Resident #6) kept saying, " help me, help me " when we tried to move her legs, I told the other aide to go get the nurse so we could move her. When we got (Resident #6) back into the bed she was complaining of knee pain. She (Resident #6) was still moaning saying that her right leg was hurting her. The nurse said to make her comfortable and clean her up. (Resident #6) was breathing hard. The nurse knew she (Resident #6) was hurting, her right knee was swollen, whenever you touched the knee she hollered out. " On 11/6/14 at 8:30 a.m. CNA #4, the shower aide, was interviewed. CNA #4 stated that she had come into the facility around 6:00 a.m. to get started on the resident showers, " I asked the night shift nurse if there was anything I needed to know and she said no. I asked the night shift aide, (CNA #3) to help me get (Resident #6) up for her shower. We got her (Resident #6) up out of the bed then swung her into the shower chair. When I was putting the sheet over her she had a funny look on her face when I asked her what was wrong she (Resident #6) said that her leg hurt really bad. I asked her what happened to her leg and she said that she fell on the floor. At that time (CNA #3) confirmed that she (Resident #6) had fallen out of bed at around 4:00 a.m. I lifted up her gown and saw that her right leg was red and I wasn ' t comfortable giving her a shower. I then went to ask the nurse what was going on, that (Resident #6) was complaining that her leg was hurting. The nurse instructed me to put Resident #6 back in the bed. The nurse did nothing at that point. She (the nurse) did come in with the dayshift nurse to do rounds. She (the nurse) did not examine the resident. " CNA #4 then stated, " She (Resident #6) was having a lot of pain in her legs, I told the nurse and she told me to put her (Resident #6) back into bed. I went back to the room and me and the other aide picked her up from the shower chair and swung her back into bed. " An interview was conducted with LPN (licensed practical nurse) #3 on 11/6/14 at approximately 10:00 a.m. LPN #3 was the night shift nurse that provided care to Resident #6 immediately following the fall. When asked to provide her recollection of what occurred that night, LPN #3 responded, "I was called to the room by the aides, they used the call bell. When I entered the room the resident (Resident #6) was already in the bed. The aides had put her in the bed; I don't know how they did it (note this contradicts what was stated during interviews with CNA #3 and #5). The resident was complaining of pain in her right thigh and left hip. I looked at the areas she pointed to. The skin was not broken she just complained of pain. She was kind of confused and couldn't rate the pain." LPN #3 was asked how she was able to determine that Resident #6 was in pain, LPN #3 responded, "She was grimacing." LPN #3 was then asked what rating she would have given Resident #6 for her pain, given her presentation and grimacing, LPN #3 stated, "I would say she was at least a 9/10 *especially when we rolled her over to continue my assessment." **** Numeric Rating Scale: a scale used to rate the level of pain using a numeric scale; a zero is no pain whereas the upper level represents the worst pain possible. LPN #3 was asked what she did following her assessment, "I called the physician and he gave me an order for [REDACTED].#3 was asked if she requested pain medication to treat Resident #6's 9/10 pain. LPN #3 responded, "No I didn't." LPN #3 was asked whether in her opinion Resident #6 needed pain medication at that time, LPN #3 responded, "Yes she was in a lot of pain." LPN #3 was asked why she did not request pain medication at that time. LPN #3 responded, "I was so upset that she had fallen that I just couldn't think of everything." LPN #3 was asked when she next assessed Resident #6, LPN #3 responded, "It was about 5:15 a.m. She (Resident #6) receives 6:00 a.m. meds so I went in to give her those meds. She (Resident #6) was asleep; I had to wake her up to give her pills." LPN #3 was asked if she performed an assessment at that time, LPN #3 responded, "I looked at her leg but I didn't see anything." LPN #3 was asked whether or not Resident #6 was assessed for pain at this time, LPN #3 responded, "I asked her if she was hurting and she didn't say anything." LPN #3 was asked when she next went into the room to check on Resident #6, LPN #3 stated, "I went in when the day shift nurse came on duty. We talked at the nurses ' station, but we did not assess the leg. We went into the room together, the shower aide was in there, she had got her up and Resident #6 got sick and she put her back in the bed." LPN #3 was asked at what point pain medication was obtained for Resident #6, LPN #3 responded, "I guess the day shift nurse must have got some for her." A review of the MAR (medication administration record) revealed that an order was received to provide a pain medication to Resident #6 on 9/26/14 at approximately 8:40 a.m. The order was entered into the MAR indicated [REDACTED]. Special instructions: Re: Pain. Once-one time. 8:45 a.m." An interview was conducted on 11/5/14 at 5:00 p.m. with LPN (licensed practical nurse) #4. LPN #4 was asked what time the pain medication that was ordered at 8:40 a.m. was administered to Resident #6 following her fall. LPN #4 stated, "I gave it immediately. As soon as the physician provided the telephone order I pulled it and gave it." LPN #4 was asked whether or not she reassessed Resident #6's pain following administration of the pain medication, LPN #4 stated, "Not that I remember." A review of Resident #6 ' s care plan revealed, in part, the following information: " Problem start date: 7/3/14 (revised 10/2/14). Category: ADL Functional / Rehabilitation Potential. Total assist of one or two with most ADLS; Hoyer lift for transfers. Approach Start Date: 7/3/14: Mechanical lift and two staff for transfers. " A review of the care plan for Resident #6 revealed a hand written note dated 9/26/14 that documented the following: " 9/26/14 - To ER (emergency room ). ? (right) femur pain following sliding halfway oob (out of bed) with feet to floor and torso on bed. admitted (+) fracture. [MEDICATION NAME] for pain per orders. " A review of the hospital records for Resident #6 dated 9/26/14 revealed that the resident was received in the ER (emergency room ) at approximately 11:09 a.m. Resident #6 was administered [MEDICATION NAME] 2 mg (milligrams) by IV (intravenously) at approximately 13:32 (1:32 p.m.). A history and physical dated 9/26/14 performed by orthopedic surgery revealed, in part, the following documentation: "Radiographs of the knee, femur and hip are available for my (orthopedic physician) review; these demonstrate a distal third femoral shaft (also called the thigh bone **) spiral fracture (a fracture which runs around the axis of the bone ***) with mild shortening and angulation in the coronal plane." On 11/6/14 at approximately 10:35 a.m. the administrator and DON (director of nursing) were informed of the concern for harm and at this time a facility pain management policy was requested. A facility policy titled " Daily Pain Assessment, " was immediately provided. A review of the facility policy titled, "Daily Pain Assessment," the following directions are, in part, documented: "9. Observe how pain affects the resident's quality of life. Document all of this information in the chart. 10. Reassess pain in 30 to 60 minutes after giving medication and document effectiveness using the above mentioned scales." Pain Management Practices, Volume 6, Symptom Management Acute Pain, National Institute for Nursing Research, page 6, read, in part: " The primary responsibility for the assessment and management of pain belongs to the nurse. (According to the National Institutes for Health, 1987), the nurse plays a central role in pain management and should coordinate the activities. Sound assessment is necessary for implementation of appropriate pain management interventions. " A consensus statement from the American Academy of Pain Medicine, 1997, read in part: " Like many illnesses that at one time were not well understood, pain and its many manifestations may be poorly treated and seriously underestimated. Inappropriately treated pain seriously compromises patients ' quality of life, causing emotional suffering and can contribute to mood disorders such as depression. " The administrator and DON (director of nursing) were made aware of these findings on 11/6/14 at approximately 10:35 a.m. No further information was provided prior to the end of the survey. *[MEDICATION NAME] ? is indicated for the relief of moderate to moderately severe pain. <http://dailymed.nlm.nih.gov/dailymed/drugInfo.dfm?setid=1c7ff5b9- -4e8c-9060-2abcd3fb0dcf> COMPLAINT DEFICIENCY **This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 6.htm> ***This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/imagepages/1096.htm> **** This information was obtained from the website: <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 49/>