Every finding on record at Arleigh Burke Pavilion

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for five of 25 residents in the survey sample, R3, R6, R11, R22 and R18. The findings include: 1.The facility staff failed to ensure R3 was free of unnecessary medications by monitoring anticoagulant as ordered. R3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to afib (atrial fibrillation). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/3/25, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring maximal assistance for mobility/transfers and bathing. Section N: anticoagulant- is taking, checked. A review of the comprehensive care plan dated 3/20/25 revealed, PROBLEM: At risk for bleeding secondary to use of anticoagulant medication-Eliquis. APPROACH: Ongoing monitoring for adverse effects such as unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling. Notify physician immediately if resident shows any of the above signs. A review of the physician's order dated 12/26/22 revealed, Eliquis 2.5 mg po twice daily. A review of the MAR (medication administration record) did not reveal evidence of anticoagulation monitoring. An interview was conducted on 1/15/25 at 9:00 AM with ASM (administrative staff member) #4, the Senior Director Clinical Services. When asked where to find the evidence of anticoagulation monitoring, ASM #4 stated, it should be on the care plan, we monitor it on the care plan. When asked where you would see evidence of anticoagulation monitoring by nursing staff, ASM #4 stated, in [AGE] years, I have not had that monitored, but we are looking into it starting it on the MAR. An interview was conducted on 1/15/25 at 10:30 AM with LPN (licensed practical nurse) #1. When asked what interventions if any are implemented for a resident on anticoagulants, LPN #1 stated, we monitor them for any bruising, bleeding or skin tears. When asked where the monitoring would be documented, LPN #1 stated, if we find something we document it in the progress notes. When asked if there is documentation that monitoring was completed, LPN #1 stated, the only documentation is when there is an issue. On 1/15/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the senior director clinical services were made aware of the above concerns. A review of the facility's Anticoagulation Protocol policy revealed, The nurse shall assess and document/report the following: Current anticoagulation therapy, including drug and current dosage. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. No further information was provided prior to exit. 2.The facility staff failed to ensure R6 was free of unnecessary medications by monitoring anticoagulant as ordered. R6 was admitted to the facility on [DATE] with diagnosis that included but were not limited to afib (atrial fibrillation), coronary artery disease and diabetes mellitus. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 12/17/24, coded the resident as scoring a 03 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers and bathing. Section N: anticoagulant- is taking, checked. A review of the comprehensive care plan dated 9/20/24 revealed, PROBLEM: At risk for bleeding secondary to use of anticoagulant medication-Eliquis. APPROACH: Ongoing monitoring for adverse effects such as unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling. Notify physician immediately if resident shows any of the above signs. A review of the physician's order dated 9/18/24 revealed, Eliquis 2.5 mg po twice daily. A review of the MAR (medication administration record) did not reveal evidence of anticoagulation monitoring. An interview was conducted on 1/15/25 at 9:00 AM with ASM (administrative staff member) #4, the Senior Director Clinical Services. When asked where to find the evidence of anticoagulation monitoring, ASM #4 stated, it should be on the care plan, we monitor it on the care plan. When asked where you would see evidence of anticoagulation monitoring by nursing staff, ASM #4 stated, in [AGE] years, I have not had that monitored, but we are looking into it starting it on the MAR. An interview was conducted on 1/15/25 at 10:30 AM with LPN (licensed practical nurse) #1. When asked what interventions if any are implemented for a resident on anticoagulants, LPN #1 stated, we monitor them for any bruising, bleeding or skin tears. When asked where the monitoring would be documented, LPN #1 stated, if we find something we document it in the progress notes. When asked if there is documentation that monitoring was completed, LPN #1 stated, the only documentation is when there is an issue. On 1/15/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the senior director clinical services were made aware of the above concerns. No further information was provided prior to exit. 3.The facility staff failed to ensure R11 was free of unnecessary medications by monitoring anticoagulant as ordered. R11 was admitted to the facility on [DATE] with diagnosis that included but were not limited to DVT (deep vein thrombosis), coronary artery disease and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/28/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for mobility/transfers and bathing. Section N: anticoagulant- is taking, checked. A review of the comprehensive care plan dated 8/28/24 revealed, PROBLEM: At risk for bleeding secondary to use of anticoagulant medication-Eliquis. APPROACH: Ongoing monitoring for adverse effects such as unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling. Notify physician immediately if resident shows any of the above signs. A review of the physician's order dated 11/8/24 revealed, Eliquis 5 mg po twice daily. A review of the MAR (medication administration record) did not reveal evidence of anticoagulation monitoring. An interview was conducted on 1/15/25 at 9:00 AM with ASM (administrative staff member) #4, the Senior Director Clinical Services. When asked where to find the evidence of anticoagulation monitoring, ASM #4 stated, it should be on the care plan, we monitor it on the care plan. When asked where you would see evidence of anticoagulation monitoring by nursing staff, ASM #4 stated, in [AGE] years, I have not had that monitored, but we are looking into it starting it on the MAR. An interview was conducted on 1/15/25 at 10:30 AM with LPN (licensed practical nurse) #1. When asked what interventions if any are implemented for a resident on anticoagulants, LPN #1 stated, we monitor them for any bruising, bleeding or skin tears. When asked where the monitoring would be documented, LPN #1 stated, if we find something we document it in the progress notes. When asked if there is documentation that monitoring was completed, LPN #1 stated, the only documentation is when there is an issue. On 1/15/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the senior director clinical services were made aware of the above concerns. No further information was provided prior to exit. 4.The facility staff failed to ensure R22 was free of unnecessary medications by monitoring anticoagulant as ordered. R22 was admitted to the facility on [DATE] with diagnosis that included but were not limited to afib (atrial fibrillation) and coronary artery disease. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 10/4/24, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assistance for mobility/transfers and bathing. Section N: anticoagulant- is taking, checked. A review of the comprehensive care plan dated 10/10/24 revealed, PROBLEM: At risk for bleeding secondary to use of anticoagulant medication-Eliquis. APPROACH: Ongoing monitoring for adverse effects such as unusual bruising, bloody or black tarry stools, red or dark brown urine, abdominal pain or swelling. Notify physician immediately if resident shows any of the above signs. A review of the physician's order dated 9/30/24 revealed, Eliquis 5 mg po twice daily. A review of the MAR (medication administration record) did not reveal evidence of anticoagulation monitoring. An interview was conducted on 1/15/25 at 9:00 AM with ASM (administrative staff member) #4, the Senior Director Clinical Services. When asked where to find the evidence of anticoagulation monitoring, ASM #4 stated, it should be on the care plan, we monitor it on the care plan. When asked where you would see evidence of anticoagulation monitoring by nursing staff, ASM #4 stated, in [AGE] years, I have not had that monitored, but we are looking into it starting it on the MAR. An interview was conducted on 1/15/25 at 10:30 AM with LPN (licensed practical nurse) #1. When asked what interventions if any are implemented for a resident on anticoagulants, LPN #1 stated, we monitor them for any bruising, bleeding or skin tears. When asked where the monitoring would be documented, LPN #1 stated, if we find something we document it in the progress notes. When asked if there is documentation that monitoring was completed, LPN #1 stated, the only documentation is when there is an issue. On 1/15/25 at 1:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the senior director clinical services were made aware of the above concerns. No further information was provided prior to exit. 32642 5. For Resident #18 (R18), the facility staff administered Amlodipine (1) outside of physician-ordered parameters multiple times in November and December 2024; and in January 2025. A review of R18's clinical record revealed the following order written 8/22/24: Amlodipine 5 mg (milligram) tablet 1 tablet by mouth every day. Hold for blood pressure less than 110/60. A review of R18's MARs (medication administration records) revealed Amlodipine was administered on the following days with the corresponding blood pressures: 11/4/24 - 120/57 11/11/24 - 115/53 11/16/24 - 118/56 12/10/24 - 119/57 12/11/24 - 126/59 12/15/24 - 129/59 12/17/24 - 129/59 1/5/25 - 128/59 1/13/25 - 121/53 1/14/25 - 117/59 A review of R18's care plan dated 11/18/24 revealed, in part: Resident will have no complications for cardiovascular disease and will not require outside medical intervention .Provide medication and treatment per physician's orders. On 1/15/25 at 11:01 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated if a resident has an order for a medication with blood pressure parameters, she stated the order should be reviewed, and the resident's blood pressure should be checked. She stated if the blood pressure readings are outside the parameters, the nurse should not give the medication, and document the reason in the clinical record. On 1/15/25 at 1:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. A review of the facility policy, General Dose Preparation and Medication Administration, revealed, in part: Prior to administration of medication .facility staff should .verify each time a medication is administered that it is the correct medication, at the correct dose .confirm that the MAR (medication administration record) reflects the most recent medication order .if necessary, obtain vital signs. No additional information was provided prior to exit. Reference (1) Amlodipine (Norvasc) is used alone or in combination with other medications to treat high blood pressure in adults and children 6 years and older. It is also used to treat certain types of angina (chest pain) and coronary artery disease (narrowing of the blood vessels that supply blood to the heart). Amlodipine is in a class of medications called calcium channel blockers. It lowers blood pressure by relaxing the blood vessels so the heart does not have to pump as hard. It controls chest pain by increasing the supply of blood to the heart. This information is taken from the website https://medlineplus.gov/druginfo/meds/a692044.html.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide evidence of written notification of a discharge for one of 25 residents in the survey sample, Resident # 15. The findings include: For Resident #15 (R15), the facility staff did not provide the resident written notification of the reasons for his discharge when he was transferred to the hospital on 1/5/25. A review of R15's clinical record revealed he was transferred to the hospital on 1/5/25 due to declining physical status. Further review of R15's record failed to reveal evidence of written notification to the resident of the reasons for the discharge on [DATE]. On 1/15/25 at 10:20 a.m., OSM (other staff member) #1, the social services manager, was interviewed. He stated when a resident is discharged to the hospital in an emergency situation, the nurses are responsible for notifying the resident in writing about the reasons for the discharge. On 1/15/25 at 11:01 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated nurses never provide written notification to a resident about a discharge to the hospital. On 1/15/25 at 1:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide evidence that a bed hold notice was issued at discharge for one of 25 residents in the survey sample, Resident # 15. The findings include: For Resident #15 (R15), the facility staff did not provide the resident a bed hold notice when he was transferred to the hospital on 1/5/25. A review of R15's clinical record revealed he was transferred to the hospital on 1/5/25 due to declining physical status. Further review of R15's record failed to reveal evidence of a bed hold notification issued to the resident at discharge on [DATE]. On 1/15/25 at 9:13 a.m., ASM (administrative staff member) #1, the administrator, stated the facility staff had just identified that they had not been issuing a bed hold notice when the resident is discharged , and that the improvement plan for this deficient practice has not been completed. On 1/15/25 at 1:05 p.m., ASM #1, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide residents (or resident representatives) a summary of the baseline care plan for two of 25 residents in the survey sample, Residents #36, and #35. The findings include: 1. For Resident #36 (R36), the facility staff failed to provide the resident (or representative) a summary of the baseline care plan. R36 was admitted to the facility on [DATE]. A review of R36's clinical record (including the baseline care plan dated 12/9/24 and progress notes for December 2024 and January 2025) failed to reveal the facility staff provided R36 or the resident's representative a summary of the baseline care plan. On 1/15/25 at 10:44 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurses develop residents' baseline care plans but do not provide a summary of the care plans to the residents or their representatives. On 1/15/25 at 1:18 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, Comprehensive Person-Centered Care Planning documented, The facility will provide the resident/resident representative with a written summary of the baseline care plan no later than completion of the comprehensive person-centered care plan that includes at a minimum: i) Initial goals of the resident ii) A summary of current medications and dietary instructions iii) Services and treatments to be provided or arranged by the facility and personnel acting on behalf of the facility; and iv) Any updated information based on details of the admission comprehensive assessment. No further information was presented prior to exit. 2. For Resident #35 (R35), the facility staff failed to provide the resident (or representative) a summary of the baseline care plan. R35 was admitted to the facility on [DATE]. A review of R35's clinical record (including the baseline care plan dated 12/19/24 and progress notes for December 2024 and January 2025) failed to reveal the facility staff provided R35 or the resident's representative a summary of the baseline care plan. On 1/15/25 at 10:44 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurses develop residents' baseline care plans but do not provide a summary of the care plans to the residents or their representatives. On 1/15/25 at 1:18 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 25 residents in the survey sample, Residents #42 and #18. The findings include: 1. For Resident #42 (R42), the facility staff failed to follow the resident's care plan for body alignment. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/19/24, R42 was coded as being impaired on one side for both arm and leg range of motion. She was coded as being completely dependent on staff for rolling in bed, moving from a sitting position to lying down, sitting to stand, and chair to bed transfers. On the following dates and times, R42 was observed positioned either in bed or the wheelchair with her neck severely leaning to the right side: 1/13/24 at 7:20 p.m., 1/14/25 at 9:19 a.m., 10:17 a.m., 11:20 a.m., and 12:46 p.m. At the 1/14/25 12:46 p.m. observation, the resident was sitting up in the wheelchair with her head severely leaning to her right side; at this time, a visitor was attempting to feed the resident lunch. A review of R42's most recent physical therapy note dated 11/27/24 revealed, in part: Pt (patient) and caregiver training: Instructed patient in positioning/pressure relieving techniques, positioning to the L (left) side to prevent R (right) ear skin irritation. RNP (restorative nursing program) for active assisted LE (lower extremity) exercises in order to facilitate improved functional abilities and preserve current level of function .Pt will benefit from RNP to maintain LE mobility. A review of R42's care plan dated 9/15/24 revealed, in part: Maintain proper body alignment. On 1/15/25 at 11:01 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated the purpose of the care plan is to know how to care for residents. She added: The care plan helps staff care well for the residents. She stated the care plan includes the residents' goals for their care. She stated the entire staff is responsible for implementing the care plan interventions. She stated R42's care plan was not being implemented when the resident was observed multiple times with her head severely leaning to the right side. On 1/15/25 at 1:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: The facility will develop and implement a comprehensive person-centered care plan for each residents that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .The resident will receive the services and/or items included in the plan of care. No additional information was provided prior to exit. 2. For Resident #18 (R18), the facility staff failed to follow the care plan to administer medications per physician's order. A review of R18's clinical record revealed the following order written 8/22/24: Amlodipine 5 mg (milligram) tablet 1 tablet by mouth every day. Hold for blood pressure less than 110/60. A review of R18's MARs (medication administration records) revealed Amlodipine was administered on the following days with the corresponding blood pressures: 11/4/24 - 120/57 11/11/24 - 115/53 11/16/24 - 118/56 12/10/24 - 119/57 12/11/24 - 126/59 12/15/24 - 129/59 12/17/24 - 129/59 1/5/25 - 128/59 1/13/25 - 121/53 1/14/25 - 117/59 A review of R18's care plan dated 11/18/24 revealed, in part: Resident will have no complications for cardiovascular disease and will not require outside medical intervention .Provide medication and treatment per physician's orders. On 1/15/25 at 11:01 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated the purpose of the care plan is to know how to care for residents. She added: The care plan helps staff care well for the residents. She stated the care plan includes the residents' goals for their care. She stated the entire staff is responsible for implementing the care plan interventions. She stated R18's care plan was not being implemented when the resident received blood pressure medications outside physician-ordered parameters. On 1/15/25 at 1:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. No additional information was provided prior to exit. Reference (1) Amlodipine (Norvasc) is used alone or in combination with other medications to treat high blood pressure in adults and children 6 years and older. It is also used to treat certain types of angina (chest pain) and coronary artery disease (narrowing of the blood vessels that supply blood to the heart). Amlodipine is in a class of medications called calcium channel blockers. It lowers blood pressure by relaxing the blood vessels so the heart does not have to pump as hard. It controls chest pain by increasing the supply of blood to the heart. This information is taken from the website https://medlineplus.gov/druginfo/meds/a692044.html.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to position the resident in optimal body alignment for one of 25 residents in the survey sample, Resident #42. The findings include: For Resident #42 (R42), the facility staff failed to position the resident with her neck upright in multiple observations on 1/13/25 and 1/14/24. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/19/24, R42 was coded as being impaired on one side for both arm and leg range of motion. She was coded as being completely dependent on staff for rolling in bed, moving from a sitting position to lying down, sitting to stand, and chair to bed transfers. On the following dates and times, R42 was observed positioned either in bed or the wheelchair with her neck severely leaning to the right side: 1/13/24 at 7:20 p.m., 1/14/25 at 9:19 a.m., 10:17 a.m., 11:20 a.m., and 12:46 p.m. At the 1/14/25 12:46 p.m. observation, the resident was sitting up in the wheelchair with her head severely leaning to her right side; at this time, a visitor was attempting to feed the resident lunch. A review of R42's most recent physical therapy note dated 11/27/24 revealed, in part: Pt (patient) and caregiver training: Instructed patient in positioning/pressure relieving techniques, positioning to the L (left) side to prevent R (right) ear skin irritaion. RNP (restorative nursing program) for active assisted LE (lower extremity) exercises in order to facilitate improved functional abilities and preserve current level of function .Pt will benefit from RNP to maintain LE mobility. A review of R42's care plan dated 9/15/24 revealed, in part: Maintain proper body alignment. On 1/15/25 at 11:01 a.m., LPN (licensed practical nurse) #2 was interviewed. She stated she is familiar with R42 and is aware of the resident's tendency to lean severely to the right. She stated the staff usually uses a neck pillow to help the resident maintain proper body alignment. She stated there is no order for the neck pillow, but the nursing staff know how to use it for the resident. On 1/15/25 at 12:19 p.m., OSM (other staff member) #3, a physical therapist, was interviewed. She stated R42 did not have good internal body support for positioning any part of her body. She stated R42 has a strong lean to the right, and continually turns her neck to the right. She stated therapy staff attempted to help the resident's positioning, and instructed the staff to position the resident toward her left side. She stated she was not certain if the facility staff wrote any kind of order for positioning to the left side, but she verbally told nursing it needed to be done. OSM #3 stated pillows should be used to help prevent R42's right neck lean in order to prevent additional neck stiffness, muscle tightness, and contractures. On 1/15/25 at 1:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. A policy related to resident positioning was requested. On 1/15/25 at 2:05 p.m., ASM #4 stated the resident's neck pillow had been placed on hold in order to avoid a pressure injury to R42's right ear. She provided a note from the wound physician to support this. After being informed that R42 did not have any support for her neck leaning to the right during the surveyor's observations, ASM #4 stated she was not aware of any additional interventions that the staff had attempted in the absence of the neck pillow. On 1/15/25 at 3:06 p.m., an email from ASM #1 containing policies requested by the survey team did not reveal a policy related to resident positioning. No additional information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide services to maintain or improve ADL (activities of daily living) function for one of 25 residents in the survey sample, Resident #42. The findings include: For Resident #42 (R42), the facility staff failed to provide evidence that they were offering the resident restorative nursing/maintenance services recommended by therapy staff. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 9/19/24, R42 was coded as being impaired on one side for both arm and leg range of motion. She was coded as being completely dependent on staff for rolling in bed, moving from a sitting position to lying down, sitting to stand, and chair to bed transfers. On the following dates and times, R42 was observed positioned either in bed or the wheelchair with her neck severely leaning to the right side: 1/13/24 at 7:20 p.m., 1/14/25 at 9:19 a.m., 10:17 a.m., 11:20 a.m., and 12:46 p.m. At the 1/14/25 12:46 p.m. observation, the resident was sitting up in the wheelchair with her head severely leaning to her right side; at this time, a visitor was attempting to feed the resident lunch. A review of R42's most recent physical therapy note dated 11/27/24 revealed, in part: Pt (patient) and caregiver training: Instructed patient in positioning/pressure relieving techniques, positioning to the L (left) side to prevent R (right) ear skin irritation. RNP (restorative nursing program) for active assisted LE (lower extremity) exercises in order to facilitate improved functional abilities and preserve current level of function .Pt will benefit from RNP to maintain LE mobility. A review of the facility Restorative Form for R42 dated 11/18/24 revealed, in part: Goals of restorative program: Maintain UB (upper body) strength and mobility. Recommended Treatment: 2 X (times) 10 within pain free range BUE (bilateral upper extremities) .shoulder flexion .free weight bicep curl .forearm supination/pronation .wrist flexion/extension .finger flexion/extension .Goals of restorative program: To maintain LE (lower extremity ROM (range of motion) and strength. Recommended Treatment: Active - assisted B/L (bilateral) hip-knee flexion, hip abduction .10 reps X 2 sets in supine .5 X per week. On 1/15/25 at 9:13 a.m., ASM (administrative staff member) #1, the administrator, was interviewed. She stated there is one facility aide who is responsible for restorative care. She stated she could not locate any evidence that restorative/maintenance care had been provided to R42. On 1/15/25 at 1:05 p.m., ASM #1, ASM #2, the director of nursing, ASM #4, the senior director of clinical services, and ASM #5, the chief operating officer, were informed of these concerns. A policy related to resident positioning was requested. On 1/15/25 at 2:05 p.m., ASM #4 stated the facility does not have a true restorative program, but does have one CNA (certified nursing assistant) who is responsible for providing the kind of ADL maintenance care as recommended by therapy. She stated the CNA responsible for this was not available for interview and not working during the remainder of the survey. She added that the facility staff needs education regarding the ADL maintenance services process. A review of the facility policy, Restorative Nursing Services, revealed, in part: Residents will receive restorative nursing care as needed to help promote optimal safety and independence .Residents may be started on a restorative nursing program upon admission, during the course of the stay, or when discharged from rehabilitative care. No additional information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care and services in a sanitary manner for one of 25 residents in the survey sample, Resident #141. The findings include: For Resident #141 (R141), the facility staff failed to store the resident's incentive spirometer in a sanitary manner. A review of R141's clinical record revealed a physician's order dated 1/1/25 for an incentive spirometer every shift. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 1/4/25, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 1/13/25 at 7:12 p.m., an uncovered incentive spirometer with the mouthpiece exposed to air was observed sitting on R141's bed. On 1/14/25 at 9:13 a.m., an uncovered incentive spirometer with the mouthpiece exposed to air and resting on a lamp base was observed sitting on R141's nightstand. On 1/15/25 at 8:24 a.m., an interview was conducted with R141. The resident stated he uses the incentive spirometer and has not been offered a bag or covering for it. On 1/15/25 at 10:44 a.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated incentive spirometers should be stored in Ziplock bags. On 1/15/25 at 1:18 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 staff did not provide a policy regarding incentive spirometers. No further information was presented prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to evidence that the required written notification of a transfer was sent to the resident's responsible party and the Ombudsman for a hospital transfer for one of 23 residents in the survey sample; Resident #16. The findings include: For Resident #16, the facility staff failed to evidence that the required written notification was provided to the resident's responsible party and the Ombudsman when the resident was transferred to the hospital on 6/23/22. Resident #16 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. On the most recent MDS (Minimum Data Set), a significant change assessment with an ARD (Assessment Reference Date) of 7/25/22, the resident was coded as being cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating and total care for all other areas of activities of daily living. A review of the clinical record revealed a nurse's note dated 6/23/22 that documented, Around 10:45 (PM) assigned aid notified writer about something happening to resident left affected eye; Upon arrival at scene, what writer saw was resident with severe eye injury, eye ball popped out of socket, blood smear all over left face and right fingers; it seems like resident might have caused the trauma to self by scratching or poking fingers into eye. 911 activated, resident sent to (hospital) for assessment and evaluation; MD (medical doctor) notified, RP (responsible party) made aware. Review of the clinical record revealed a physician's progress note dated 6/29/22 that documented, Admission to the hospital 6/23/2022 Date of Admission to the rehab-6/29/2022 was admitted on the 23rd with excess bleedings and discharge from the left eye while he was getting treatment with IV (intravenous) antibiotics and followed by oral antibiotics at the facility. Patient during the hospitalization was given IV [MEDICATION(S)] and [MEDICATION(S)] (antibiotics) also received ophthalmology consult for the orbital [CONDITION(S)] and the corneal defect of the left eye, advised to continue topical antibiotics and left eye shield since patient is a risky candidate for any surgical intervention A review of the Transfer Form dated 6/23/22 did not include any documentation that written notification was provided to the resident's responsible party or the Ombudsman. Further review failed to reveal any evidence that written notification was provided to the resident's responsible party and the Ombudsman after a hospital transfer on 6/23/22. On 8/10/22 at 3:25 PM, the facility was asked for evidence of what written notifications were sent. On 8/10.22 at 5:03 PM, ASM #1 (Administrative Staff Member) the Director of Nursing (acting administrator) stated that there was no documentation of the written notices. She stated that social services would be the one to talk to about that. At this time, the social services manager - OSM #1 (Other Staff Member) was brought into the room. He stated that he does not provide written notification to the resident's responsible party for hospital transfers and that the Ombudsman is only provided written notification of discharges that went home or to another long term care facility, but not to the hospital. The facility policy, Transfer/Discharge Emergency was reviewed. This policy documented, 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation; and g. Others as appropriate or as necessary . The policy did not specify the notification to the resident's responsible party had to include a written notification. The policy did not address notifying the Ombudsman as required, and in writing. No further information was provided by the end of the survey.

Based on resident interview, staff interview, clinical record review, and facility document review, it was determined facility staff failed to evidence a current [CONDITION(S)] contract between the facility and the outpatient [CONDITION(S)] center providing services for one of 23 residents in the survey sample, Resident #33. The findings include: On the most recent MDS (minimum data set), a five day admission assessment with an ARD (assessment reference date) of 7/9/2022, Resident #33 (R33) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section O documented R33 received [CONDITION(S)] while a resident. On 8/9/2022 at 2:04 p.m., an interview was conducted with R33 in their room. R33 stated that they were recently admitted to the facility after a hospitalization , for rehabilitation. R33 stated that they had been receiving [CONDITION(S)] services for about seven years from an outside center and went on Mondays, Wednesdays and Fridays. The comprehensive care plan for R33 dated 7/2/2022 documented in part, Hemodialysis r/t (related to) [CONDITION(S)] ([CONDITION(S)]). Under Approach it documented in part, Hemodialysis MWF (Monday, Wednesday, Friday) at [Name and phone number of outside [CONDITION(S)] center]. Leaves the facility at 10am . On 8/9/2022 at approximately 11:55 a.m., during entrance conference, a request was made to ASM (administrative staff member) #1, the director of nursing and acting administrator, to review the [CONDITION(S)] contracts held by the facility. On 8/10/2022 at approximately 5:00 p.m., a second request to review the [CONDITION(S)] contract between the facility and [Name of outside [CONDITION(S)] center] where R33 received treatment. On 8/11/2022 at 8:09 a.m., an interview was conducted with ASM #1, the acting administrator. ASM #1 stated that they had been trying to contact [Name of outside [CONDITION(S)] center] where R33 received treatments and had not been able to get in touch with them. ASM #1 stated that they knew that they were supposed to have a contract with the [CONDITION(S)] center but they did not have one to provide at this time. The facility policy End-Stage [CONDITION(S)], Care of a Resident with [CONDITION(S)] documented in part, .Agreements between this facility and the contracted [CONDITION(S)] facility include all aspects of how the resident's care will be managed, including: a. How the care plan will be developed and implemented; b. How information will be exchanged between the facilities . On 8/11/2022 at approximately 8:11 a.m., ASM #1 was made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to store and prepare foods in a sanitary manner in the main kitchen. In the refrigerator a bag of chocolate chips was open to the air and did not evidence any labeling indicated when the bag was opened; in the freezer a bag of spinach tortellini and a bag of stuffed pasta shells were opened and failed to evidence a date when the bags were opened. In addition observation dishwashing machine revealed temperature never rose above 160 degrees for five runs of dishes through the machine. The findings include: Observation of the kitchen was conducted on 7/7/2021 at 6:35 p.m. accompanied by OSM (other staff member) #3, the director of dining services. Observation was of the refrigerator revealed a bag of chocolate chips with plastic wrap open sitting under the bag and not covering the bag. There was no date indicating when the bag of chocolate chips were opened. A 5 lb (pound) container of garlic cloves was noted to have one third of the container left, did not have a label or was dated when the container was opened. Observation was of the freezer revealed a bag of spinach tortellini was sitting on the shelf. The bag was closed and there was approximately half a bag left. There was no evidence of a date when the bag of spinach tortellini was opened. A closed bag of stuffed pasta shells with approximately a half bag left was on the shelf. There was no evidence of a date when the bag of stuffed pasta shells opened. A quarter pan of barbeque was in the freezer. The label documented it was made on 5/20/21 and documented a date to be discarded or used by of 6/20/21. When asked if food in the refrigerator and freezer needed to be dated when opened, OSM #3 stated anything that if open from the original container should be labeled. Observation of the dishwashing machine was conducted at approximately 7:00 p.m. The rinse cycle temperature was observed for five runs of dishes through the machine. The temperature never rose above 160 degrees. Then the electronic digital reading box above the dish machine, where the readings of the temperature for wash and rinse cycle are located, started flashing red, Low rinse temperature repeatedly. OSM #4, the dietary aide continued to wash dishes. When asked what she should do when she sees the red flashing message, OSM #4 stated she didn't know. When asked if she had taken her temperature for her shift of doing the dishes after dinner, OSM #4 stated, I haven't done it yet. The temperature logs for the dish machine were observed. There were no recordings for 7/6/2021 at all. When asked how often the dish machine temperature should be checked, OSM #3 stated it should be checked with every meal. A copy of that log was requested. No copy of the log was received by the time the survey team exited for the evening on 7/6/2021. No copy of the log were presented prior to exit. The temperature logs for the past three months were reviewed. The April 2021 Dish machine Temperature Record was complete with one date with a temperature out of range. On 4/26/2021 for the dinner meal, it was documented, Low - 100. The May 2021 Dish machine Temperature Record was complete but had several dates of documentation of low temperatures. On 5/4/2021, the rinse temperature was documented, 110 low. For 5/6/2021, 5/9/2021, 5/11/2021, 5/12/2021. 5/14/2021 through 5/16/2021, the dinner dish machine temperature was documented as 100. Review of the June 2021 Dish machine Temperature Record did not evidence any documented temperatures under 180 degrees. On 07/07/21 03:30 p.m. ASM (administrative staff member) #1, the administrator, and OSM # 3, the director of dining services were made aware of the above concerns. A copy of the policy for labeling and dating food in the refrigerator and freezer was requested as well as the copy of the policy and procedure for taking the temperatures of the dish machine. The facility policy, Cleaning and Sanitizing Food Contact Surfaces documented in part, A high temperature dish machine must have a minimum final rinse temperature of 180 degrees. The policy, Purpose of the Food Product Shelf Life Guidelines. documented in part, There is a 'quality' tool, not for labeling requirements. Please refer to document 1.2.5 - Food Safety Labeling & Dating Guide for further guidance on date marking foods prepared and/or displayed in the operation. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review it was determined facility staff failed to provide privacy while providing care for two of 23 residents in the survey sample, Resident #19 and Resident #35. LPN (licensed practical nurse) #1 failed to provide privacy for Resident #19 and Resident #35 when obtaining the residents blood pressure readings. LPN #1 obtained the residents blood pressures while they were seated in the dining room with other residents. The findings include: Resident #19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/28/2021, coded Resident #19 as scoring a 6 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 6- being severely impaired for making daily decisions. Resident #35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/21/2021, coded Resident #35 as scoring a 8 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 8- being moderately impaired for making daily decisions. On 7/07/2021 at approximately 8:10 a.m., an observation was made of the dining area located in the facility. Four residents were observed seated at tables waiting for breakfast to be served. At approximately 8:12 a.m., LPN (licensed practical nurse) #1 was observed rolling a vital sign monitor into the dining area. LPN #1 approached Resident #19 at the dining table and explained that they were going to check their blood pressure. LPN #1 was observed placing the reusable blood pressure cuff on Resident #19's arm and recorded the blood pressure reading on paper. At approximately 8:21 a.m., LPN #1 rolled the vital sign monitor over to Resident #35's table. LPN #1 placed the blood pressure cuff on Resident #35's arm and recorded the blood pressure reading on paper. On 7/07/2021 at approximately 9:15 a.m., an interview was conducted with LPN #1. LPN #1 stated that Residents #19 and 35 had morning blood pressure medications ordered which required them to have their blood pressure checked prior to getting the medication. LPN #1 stated that normally they take vital signs in the resident rooms to provide privacy. LPN #1 stated that privacy was provided during care for residents by knocking on doors, pulling privacy curtains and providing care in the resident rooms. LPN #1 stated that obtaining vital signs in the dining room could be considered a privacy issue for the residents. The facility's Resident Rights documented in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents's right to: .t. privacy and confidentiality; On 7/07/2021 at approximately 4:20 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 2. Cognitive-communication deficit Acquired cognitive-communication deficits may occur after a stroke, tumor, brain injury, progressive [CONDITION(S)] brain disorder, or other neurological damage. These deficits result in difficulty with thinking and how someone uses language. This information is taken from the website https://sphsc.washington.edu/cognitive-communication-deficits. 3. [CONDITION(S)] disease, infarction or accident A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing [MEDICATION(S)] damage. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm .

Based on observation, staff interview and facility document review, it was determined facility staff failed to maintain infection control practices while providing care to four of 23 residents in the survey sample, Residents #19, #32, #35 and #11. The facility staff failed to wash and or use hand sanitizer before and after each resident contact when obtaining blood pressure readings for Residents #19, #32, #35 and #11, and failed to disinfect the reusable blood pressure cuff prior to and after obtaining each residents blood pressure reading. The findings include: Resident #19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/28/2021, coded Resident #19 as scoring a 6 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 6- being severely impaired for making daily decisions. Resident #32 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/24/2021, coded Resident #32 as scoring an 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. Resident #35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/21/2021, coded Resident #35 as scoring a 8 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 8- being moderately impaired for making daily decisions. Resident #11 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/20/2021, coded Resident #11 as scoring an 11 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 11- being moderately impaired for making daily decisions. On 7/07/2021 at approximately 8:10 a.m., observation of the dining area located in the facility, revealed four residents in wheelchairs seated individually at tables waiting for breakfast to be served. At approximately 8:12 a.m., LPN (licensed practical nurse) #1 rolled a vital sign monitor into the dining area and approached Resident #19, seated at the dining table. Observation revealed LPN #1 explained to Resident #19 that she was going to check their blood pressure. LPN #1 was observed placing the reusable blood pressure cuff on Resident #19's arm, obtaining the residents blood pressure reading and recording the reading on paper. LPN #1 removed the blood pressure cuff from Resident #19's arm and rolled the vital sign monitor over to Resident #32's table. LPN #1 failed to disinfect the blood pressure cuff, wash their hands or use hand sanitizer prior to moving to Resident #32. Observation revealed at approximately 8:14 a.m., LPN #1 placed the reusable blood pressure cuff on Resident #32's arm, obtained the residents blood pressure reading and recorded the reading on paper. LPN #1 removed the blood pressure cuff from Resident #32's arm, leaving the vital sign monitor in the dining room near Resident #32's table. LPN #1 failed to disinfect the blood pressure cuff after use on Resident #32. LPN #1 returned to the dining area at 8:21 a.m. and rolled the vital sign monitor over to Resident #35's table. LPN #1 placed the blood pressure cuff on Resident #35's arm, obtained the residents blood pressure reading and recorded the reading on paper. LPN #1 removed the blood pressure cuff from Resident #35's arm and rolled the vital sign monitor over to Resident #11's table. LPN #1 failed to disinfect the blood pressure cuff after use, and failed to wash their hands or use hand sanitizer between care and prior to care of residents. Further observation revealed at 8:24 a.m., LPN #1 placed the blood pressure cuff on Resident #11's arm, obtained the residents blood pressure reading and recorded the reading on paper. On 7/07/2021 at approximately 9:15 a.m., an interview was conducted with LPN #1. LPN #1 stated that Residents #19, 32, 35 and 11 all had morning blood pressure medications ordered which required them to have their blood pressure checked prior to getting the medication. LPN #1 stated that normally they take vital signs in the resident rooms to provide privacy. LPN #1 stated that they were not sure of the cleaning process for the blood pressure cuff. LPN #1 stated that they were supposed to use hand sanitizer or wash their hands between each resident. LPN #1 stated that they had provided sanitizing wipes for the residents at the tables to use but they had not used anything on their hands because the hand sanitizer was on the medication cart across the hallway. LPN #1 stated that they would check with their supervisor on the procedure for disinfecting the blood pressure cuff between residents. On 7/07/2021 at approximately 3:52 p.m., an interview was conducted with LPN #2. LPN #2 stated that they cleaned the blood pressure cuff after each use with disinfectant wipes. LPN #2 stated that they let the cuff sit 5 to 10 minutes to dry before they used it on the next resident. LPN #2 stated that hands were washed or hand sanitizer used between each resident encounter. LPN #2 stated that these procedures were for infection control purposes. The facility policy Infection Prevention and Control; Hand Hygiene dated 10/2017 documented in part, .When to Wash Hands; including but not limited to: .Before and after each resident contact. After touching a resident or handling his or her belongings . The facility policy Cleaning and Disinfection of Resident-Care Items and Equipment, undated, documented in part, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers.(2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location) . The Virginia Department of Health Frequently Asked Questions about Environmental Cleaning and Disinfection documents: Medical equipment that is shared between patients (e.g., blood pressure cuffs) should be disinfected between patients. This information was obtained from the website: http://www.vdh.virginia.gov/epidemiology/surveillance/hai/documents/pdf/EnvCleaningFactSheet%20-%20General.pdf The Centers for Disease Control and Prevention's Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 documents the following: . 3. Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection c. Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin. 4. Selection and Use of Low-Level Disinfectants for Noncritical Patient-Care Devices c. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly) . This information was obtained from the website: http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf. On 7/07/2021 at approximately 4:20 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit. Reference: 1. Dementia A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 2. Cognitive-communication deficit Acquired cognitive-communication deficits may occur after a stroke, tumor, brain injury, progressive [CONDITION(S)] brain disorder, or other neurological damage. These deficits result in difficulty with thinking and how someone uses language. This information is taken from the website https://sphsc.washington.edu/cognitive-communication-deficits. 3. Diabetes mellitus A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 4. [CONDITION(S)] A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: <https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html> 5. [CONDITION(S)] disease, infarction or accident A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing [MEDICATION(S)] damage. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm . 6. [CONDITION(S)] A group of diseases that can damage the eye's optic nerve. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 7. Major depressive disorder Major depression is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time. It also changes how your body works. This information was obtained from the website: https://medlineplus.gov/ency/article/ 5.htm.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide the necessary care and services to prevent pressure ulcer development and promote healing for one of 27 residents in the survey sample, (Resident #11). The facility staff, failed to identify, obtain and provide treatment for [REDACTED]. On 2/16/2020, CNA (certified nursing assistant) #1, documented a new area was identified on Resident #11's sacrum and notified the nurse. Staff did not complete an assessment of the area, until 2/19/2020, and documented a sacral wound was present with redness and eschar (a scab or crust that forms on the skin). Measurements and treatment for [REDACTED]. The findings include: Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (1) The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/2020 coded the resident as scoring a 2 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. Resident #11 was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living. In Section M - Skin Conditions, the resident was coded as having an unstageable pressure injury. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (2). Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed (3). On admission on 2/11/2020, the admission assessment failed to evidence documentation of any pressure injury. The admission assessment only documented the presence of bruising in multiple areas of the body, but not the sacrum. A nursing assessment dated [DATE] documented a check mark next to Skin intact. The Braden Scale for Predicting Pressure Sore Risk dated 2/11/2020 documented Resident #11 had scored a 12, indicating the resident was at risk for pressure ulcer development. The form documented, If the residents total is 12 or less, consider him/her at risk for pressure ulcer development. The CNA daily charting dated 2/16/2020 documented, Description: Skin Condition - Resident shows evidence of new skin problem? Yes, was documented under status/description. Skin Condition you must notify nurse. Check if nurse notified. A check mark was documented in the box. Review of the nurse's notes failed to evidence documentation regarding the new skin problem until 2/19/2020. A nurse's note dated, 2/19/2020 at 11:00 a.m. documented in part, Writer noted patient to have a wound on her sacrum with redness and eschar (a scab or crust that forms on the skin (4)) on 12 o'clock, pt (patient) denied pain on the area. The wound care, specialist note, dated 2/20/2020, documented the wound as an unstageable (due to necrosis) on sacrum. The 2/20/2020 not documented the wound measured 2.4 x 4.5 x 0.1 cm (centimeters), and was documented as thick adherent devitalized necrotic tissue in 70 % of the wound with 30% granulation tissue. The wound doctor did debridement on the wound to a depth of 1.4 cm. Review of the physician orders [REDACTED]. Review of the February TAR documented the above physicians order for Santyl. The first documentation of the medication was on 2/21/2020. The comprehensive care plan dated 2/11/2020 documented in part, Category: Pressure Ulcers: Actual and at risk for skin breakdown due to incontinence and impaired mobility .Left buttock 2/20/2020 pressure injury sacrum. A (approach) encourage and assist with turning and repositioning. Assist with toileting as needed. Skin assessment every week per protocol. Apply moisturizer/lotion to skin as needed. Use of pressure reducing mattress. Nutritional supplements as ordered. Labs (laboratory tests) as ordered, monitor nutrition related lab results. An interview was conducted with CNA # 1 on 3/12/2020 at 10:30 a.m. When asked if she routinely worked with Resident #11, CNA #1 stated that is her normal assignment. CNA #1 was asked if 2/16/2020 was it the first time she saw something on the resident's sacrum. CNA #1 stated she had been off for a few days and when she was assisting the resident to the restroom, she found this black area (on the resident's sacrum). CNA #1 stated the area was the size of a dime, and it was hard to see as it was in the crack of the buttock. CNA #1 stated she had to separate the buttocks to see the area. CNA #1 stated she notified the nurse. When asked what the nurse did, CNA #1 stated she didn't know what she (the nurse) did; she was not the normal nurse that works on the unit. When asked if she had documented the area she found, CNA #1 stated she documented it in the ADL (activities of daily living) records. When asked how often she looks at the resident's skin, CNA #1 stated on shower days, twice a week. We also look at the bottoms when we change them. We do it twice a week with the nurse. An interview was conducted RN (registered nurse) #2, the supervisor, on 3/12/2020 at 12:09 p.m., regarding when she was made aware of the area on Resident #11's buttock. RN #2 stated the aide (CNA #1) was taking her to the bathroom and said I needed to look at it. When asked about the date she saw the area, it, RN #2 stated she was a floor nurse on 2/19/19. When asked what she observed, RN #2 stated that it (wound on Resident #11's sacrum) was necrotic, black at the 12 o'clock area, and it was not blanchable. RN #2 stated she called the wound care doctor. He was due be in the facility the next day. When asked if she put a treatment in place at that time, RN #2 stated, no she just put a protective dressing over it. When asked if she measured the sacral wound, RN #2 stated, no, because the wound doctor would be there the next day and he would measure it. The wound was observed on 3/12/2020 at 10:30 a.m. with LPN (licensed practical nurse) #1. The wound was measured by LPN #1 and was found to be 4.5 cm in length, 3.5 cm in width and 4.2 cm in depth. There was noted slough and necrotic tissue inside the wound. The edges of the wound appeared to have some maceration. An interview was conducted with administrative staff member (ASM) #2, the director of nursing, on 3/12/2020 at 12:26 p.m. When asked about the process staff follows for resident skin assessments, ASM #2 stated currently, the process in place is for weekly skin assessments during showers. When asked if staff document these assessments, ASM #2 stated that the nurse is to document on the TAR. ASM #2 was asked about the process staff follows, if something is found during the assessment. ASM #2 stated they document it on a skin assessment tool in the computer. When asked about the process followed if a CNA finds something, ASM #2 stated the CNAs documents it in POC (point of care - computer program) and notify the nurse. The nurse is to then follow up with the information, look at it, assess it and notify the doctor and RP (responsible party). When asked about the nurse who was on duty on 2/16/2020, ASM #2 stated she was an as needed nurse and was unavailable for interview. ASM #2 was informed of the concern, and ASM #2 was asked if she had anything further to present. ASM #2 stated that she had the same information and nothing more. ASM #1, the administrator, and ASM #2 were made aware of the concern for harm related to the delay in treatment of [REDACTED]. An interview was conducted with the wound care doctor, ASM # 3 on 3/12/2020. When asked if it is his practice not to give treatment orders when the staff notifies him of a pressure injury, ASM #3 stated he would not prescribe anything until he [MEDICATION NAME] the area. When asked if the facility has, a protocol to use for wounds identified in between his visits, ASM #3 stated he was not sure. ASM #3 stated that he had seen the wound on 3/12/2020 and felt the wound had improved. On 3/12/2020 at 2:58 p.m., ASM #2 was asked if they had a wound protocol, they follow; ASM #2 stated they did not have a wound protocol at the time of the resident's wound. No further information was presented prior to exit. (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 26. (2) This information was obtained from the following website: https://cdn.ymaws.com/npuap.sitem.com/resource/resmgr/npuap_pressure_injury_stages.pdf. (3) This information was obtained from the following website: https://cdn.ymaws.com/npuap.sitem.com/resource/resmgr/npuap_pressure_injury_stages.pdf. (4) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 207. (5) This information was obtained from the following website: Lexi-Comp's Drug Reference Handbooks: Drug Information Handbook for Nursing: 8th Edition 2007 pg. 301

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to develop and/or implement the comprehensive care plan for four of twenty seven residents in the survey sample, Resident #6, #10, #94 and #18. The facility staff failed to develop a comprehensive care plan to address the use of side rails for Resident #6, Resident #10, and Resident #18, and failed to develop a comprehensive care plan to address Resident #94's use of a spirometer and failed to implement Resident #94's comprehensive care plan for the administration of oxygen. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (1)), [MEDICAL CONDITION], (plaque forming on the inner walls of the arteries of the heart) (2), and [MEDICAL CONDITION] (rapid/random contractions of the upper chambers of the heart). (3) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/13/20, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively moderately impaired. The resident was coded as requiring extensive assistance for bed mobility. Resident #6 was observed in bed with bilateral upper side rails raised on 3/10/20 11:44 AM and 3/10/20 at 4:24 PM. A review of Resident #6's comprehensive care plan documented in part, The Focus: dated 11/13/19 Impaired ADLs (activities of daily living) related to weakness, dementia and [MEDICAL CONDITION]. The Interventions: dated 11/13/19 Call bell within reach, use of sling lift with two staff assist, keep assistive devices within easy access for resident/caregiver use: wheelchair. The comprehensive care plan did not include the use of side rails under any focus area. A review of the physician orders [REDACTED]. An interview was conducted with Resident #6 on 3/10/20 at 4:24 PM. When asked if he used the side rails, Resident #6 stated, Yes, I use them to turn in bed and in getting in bed as a guide. An interview was conducted with on 3/10/20 at 5:04 PM with LPN (licensed practical nurse) #2, the LPN charge nurse. When asked the purpose of the care plan, LPN #2 stated, It is to document the identified care needed for each resident. When asked if the use of side rails should be part of the care plan, LPN #2 stated, Yes, they should be. An interview was conducted on 3/11/20 at 3:00 PM with RN (registered nurse) #1, the MDS coordinator. When asked who updates the care plan, RN #1 stated, I update the comprehensive care plan through the interdisciplinary team. I ask the CNA (certified nursing assistant) to attend the meeting, and if they are busy, I ask them to give me any information. When asked if the sue of side rails ordered by the physician should be part of the care plan, RN #1 stated, Yes, I look at physician orders [REDACTED]. On 3/11/20 at 5:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the above concern. The facility's Comprehensive Person-Centered Care Planning policy revised 1/2020, documents in part, The comprehensive care plan shall be developed by a Care Planning/Interdisciplinary Team based on orders obtained at admission. The comprehensive care plan will promote patient safety. The facility's Bed Entrapment Assessment policy revised 1/2020, documents in part, The reason for the side rails and their proper use will be integrated into the comprehensive care plan and revised as necessary. No further information was provided prior to exit. References: 1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498. 2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 52. 3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 54. 2. Resident #10 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. (3) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/27/20, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. The resident was coded as requiring extensive assistance for dressing, bathing and toilet use; limited assistance for bed mobility. Resident #10 was observed in bed with bilateral upper side rails raised on 3/10/20 4:04 PM and 3/11/20 at 9:30 AM. A review of Resident #10's comprehensive care plan documented in part, The Focus: dated 11/25/19 Impaired ADLs (activities of daily living) related to [MEDICATION NAME] vertebra 12/ post kyphoplasty (surgical filing of collapsed vertebra to restore original shape and configuration). The Interventions: dated 11/25/19 Provide assistance with ADL functioning as indicated. Report changes in resident function to nurse. Report immobility complications to physician. The comprehensive care plan did not include use of side rails under any focus area. A review of the physician orders [REDACTED]. An interview was conducted with Resident #10 on 3/10/20 at 4:04 PM. When asked if he used the side rails, Resident #10 stated, Oh, yes, I use them to help getting in and out of the bed. When I am in the bed, they give me something to use to turn. An interview was conducted with on 3/10/20 at 5:04 PM with LPN (licensed practical nurse) #2, the LPN charge nurse. When asked the purpose of the care plan, LPN #2 stated, It is to document the identified care needed for each resident. When asked if side rails should be part of the care plan, LPN #2 stated, Yes, they should be. An interview was conducted on 3/11/20 at 3:00 PM with RN (registered nurse) #1, the MDS coordinator. When asked who updates the care plan, RN #1 stated, I update the comprehensive care plan through the interdisciplinary team. I ask the CNA (certified nursing assistant) to attend the meeting, and if they are busy, I ask them to give me any information. When asked if a physician orders [REDACTED].#1 stated, Yes, I look at physician orders [REDACTED]. On 3/11/20 at 5:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the above concern. No further information was provided prior to exit. References: 1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 167/341. 2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 52. 3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 54. 3. a. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (1)), high blood pressure, and [MEDICAL CONDITION] reflux disease, (the backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/29/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was coded as requiring supervision after set up assistance was provided. The review of the comprehensive care plan dated 3/1/2020 failed to evidence the use of a spirometer. Observation and interview was conducted on 3/10/2020 at 11:45 a.m. Resident #94 was in bed and a spirometer was observed on the nightstand. The spirometer was not covered. When asked if she uses the spirometer, Resident #94 stated she should be using it, it came from the hospital with her. She stated she was using it when she first came to the facility. Review of the clinical record failed to evidence a physician order [REDACTED].>An interview was conducted with LPN (licensed practical nurse) #1, on 3/11/2020 at 1:47 p.m. When asked who develops the care plan for the use of a spirometer, LPN #1 stated the MDS nurse does it all the time. An interview was conducted with RN (registered nurse) #1, the MDS nurse, on 3/11/2020 at 2:54 p.m. When asked who updates the care plans, RN #1 stated, mainly me. The baseline care plan is to be started by the supervisor or the admitting nurse. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 3/11/2020 at 2:58 p.m. When asked who updates resident care plans, ASM #2 stated, I expect the nurse's to update the care plan as needed. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 423. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243. 3. b. Review of the comprehensive care plan dated 3/1/2020, failed to evidence the use of the side rails. Resident #94 was observed in her bed on 3/10/2020 at 11:45 a.m. and on 3/11/2020 at 9:00 a.m. During both observations, the resident was in bed with bilateral side rails up. When asked if she uses them, Resident #94 stated that they help her move in the bed. Review of the clinical record failed to evidence a consent signed for the use of the side rails. An interview was conducted with RN (registered nurse) #1 on 3/11/2020 at 3:33 p.m. When asked if the use of side rails should be on the care plan, RN #1 stated she care plans them if they have an order for [REDACTED]. The facility policy, Bed Entrapment Assessment documented in part, The reason for the side rails and their proper use will be integrated into the comprehensive care plan and revised as necessary. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. No further information was provided prior to exit 4. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) (1), high blood pressure, and [MEDICAL CONDITION] reflux [MEDICAL CONDITION](backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/19/2020 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make cognitive daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as using oxygen. The comprehensive care plan dated, 9/25/19, documented in part, Category: [MEDICAL CONDITION] - Monitor Oxygen saturation and administer oxygen per physician orders. Observation was made of Resident # 18 on 3/20/2020 at 12:35 p.m. during the initial tour. The resident was in bed with her oxygen on via a nasal cannula (a two-pronged tube that inserts into the nose). The oxygen concentrator was set at 2LPM (liters per minute). A second observation was made on 3/11/2020 at 10:15 a.m. The resident was again in bed with her oxygen on at 2LPM. The physician order [REDACTED].@ (at) 3 lit (liters) via N/C (nasal cannula) - every day as needed for SOB (shortness of breath). On 3/11/2020 at 3:51 p.m., LPN (licensed practical nurse) # 4 went to Resident #18's room. When asked to state the oxygen flow rate, LPN #4 stated it was at 2 LPM. LPN #4 was asked to review the resident's physician order [REDACTED].#4 stated its how we know more about the resident and what care we are to provide to them. When asked if the care plan was implemented if it documents to administer oxygen as ordered, and the resident is not receiving the prescribed flow rate of oxygen, LPN #4 stated, No, Ma'am. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 26. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to promote dignity for one of 27 residents in the survey sample with an indwelling catheter, (Resident #95). The Foley collection bag for Resident #95's Foley catheter was observed uncovered with urine visible in the bag during separate observations conducted. The findings include: Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Trauma is the usual cause (2)) and [MEDICAL CONDITION] (a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover (3)). There was no completed MDS (minimum data set) assessment at the time of the survey. The nursing admission assessment dated [DATE] documented the resident was alert and oriented to place and able to make decisions. The nursing admission assessment documented the resident required extensive assistance with position changes and totally dependent with transfers. Observation was made of Resident #95 on 3/10/2020 at 2:20 p.m. The resident was in bed; an indwelling catheter collection bag was hanging off the side of the bed closest to the door. There was no cover over the bag and urine was visible in the bag. A second observation was made on 3/11/2020 at 9:05 a.m. of Resident #95 in bed with an indwelling catheter collection bag hanging off the side of the bed closest to the door. There was no cover on the bag and urine was visible in the Foley bag. The baseline care plan date 3/8/2020 documented in part, Problem/Area of Concern: Resident has indwelling catheter - supra pubic. The Interventions/Approaches documented in part, Provide catheter care per order/facility policy. Report change in urinary output. An interview was conducted with LPN (licensed practical nurse) #1 on 3/11/2020 at 2:08 p.m., regarding the process staff follows for maintaining the collection bags for residents' with an indwelling catheter. LPN #1 stated if it (Foley catheter and collection bag) is attached to the resident, it has to have a privacy bag with it. When asked why there is a privacy bag, LPN #1 stated for privacy and to maintain dignity as well. The facility policy, Indwelling Urinary Catheter Maintenance documented in part, Place indwelling catheter drainage bag in privacy bag at all times. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and(NAME) page 487. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and(NAME) page 489. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and(NAME) page 380.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure the base line care plan included all the healthcare information necessary to properly care for one of 27 residents in the survey sample, Resident #95. The facility staff failed to ensure the base line care plan for Resident #95 addressed the residents Midline Catheter, care and failed to update the base line care plan when [MEDICATION NAME] was ordered for Resident #95. The findings include: Resident #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Trauma is the usual cause (2)) and [MEDICAL CONDITION] (a progressive disease in which nerve fibers of the brain and spinal cord lose their myelin cover (3)). There was no completed MDS (minimum data set) assessment at the time of the survey. The nursing admission assessment dated [DATE] documented the resident was alert and oriented to place and able to make decisions. The nursing admission assessment documented the resident required extensive assistance with position changes and totally dependent with transfers. The baseline care plan was reviewed on 3/10/2020 at 2:25 p.m. The baseline care plan dated 3/8/2020, failed to evidence documentation that the resident had a Midline Catheter (vascular access devices often referred to as ' middle ground ' intravenous catheters. Like peripherally inserted central catheters (PICCs), midlines are inserted in the peripheral veins of the upper extremity; however, unlike PICCs, midlines terminate in the peripheral, not the central veins.) (4) The physician orders [REDACTED]. The physician order [REDACTED]. An interview was conducted with LPN (licensed practical nurse) #1, on 3/11/2020 at 2:04 p.m., regarding the baseline care plan for a resident with a midline catheter. LPN #1 stated it (midline catheter) should be there. The order for [MEDICATION NAME] was reviewed with LPN #1. When asked if the [MEDICATION NAME] should be care planned, LPN #1 stated, yes it should be on the care plan. It increases the resident's risk for bleeding. The facility policy, Comprehensive Person-Centered Care Planning documented in part, A preliminary (interim) care plan to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. 1. To assure that the resident's immediate care needs are met and maintained, an interim care plan will be developed within 48 hours of the resident's admission. a) The interdisciplinary team will review the following to assist in developing the interim care plan: orders obtained at the time of admission. IDT (interdisciplinary team) initial evaluations and assessment .b) The interim care plan will be used while the comprehensive admission MDS assessment and CAA (care area assessment) review is being conducted. c) The interim care plan will form the foundation of the comprehensive care plan and be incorporated as the comprehensive care plan is developed. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 487. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 489. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 380. (4) Midline catheters are unique vascular access devices often referred to as ' middle ground ' intravenous catheters. Like peripherally inserted central catheters (PICCs), midlines are inserted in the peripheral veins of the upper extremity; however, unlike PICCs, midlines terminate in the peripheral, not the central veins. By definition, the tip of the midline catheter should be located at or near the level of the axilla, distal to the shoulder. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 66/

Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care and services for two of 27 residents in the survey sample, Residents #18 and #94. The facility staff failed to administer oxygen to Resident #18 according to the physician's orders [REDACTED]. The findings include: 1. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) (1), high blood pressure, and [MEDICAL CONDITION] reflux [MEDICAL CONDITION](a backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/19/2020 coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make cognitive daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as using oxygen. Observation was made of Resident # 18 on 3/20/2020 at 12:35 p.m. during the initial tour. The resident was in bed with her oxygen on via a nasal cannula (a two-pronged tube that inserts into the nose). The oxygen concentrator was set at 2LPM (liters per minute). A second observation was made on 3/11/2020 at 10:15 a.m. The resident was again in bed with her oxygen on at 2LPM. The physician order [REDACTED].@ (at) 3 lit (liters) via N/C (nasal cannula) - every day as needed for SOB (shortness of breath). The Treatment Administration Record for March 2020 documented the above order. There was no documentation related to the use of the oxygen. The comprehensive care plan dated, 9/25/19, documented in part, Category: [MEDICAL CONDITION] - Monitor Oxygen saturation and administer oxygen per physician orders. On 3/11/2020 at 3:51 p.m., LPN (licensed practical nurse) # 4 went to Resident #18's room. When asked to state the current oxygen flow rate, LPN #4 stated it was at 2 LPM. LPN #4 was asked to review the resident's physician order [REDACTED].#94, LPN #4 stated, no. The facility policy, Oxygen Administration documented in part, Policy, It is the policy of (Name of facility) to administer supplemental oxygen per physician's orders [REDACTED]. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. No further information was obtained prior to exit. References: (1) Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and Chapman, page 26. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243. 2. Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) (1), high blood pressure, and [MEDICAL CONDITION] reflux disease (a backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/29/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was coded as requiring supervision after set up assistance was provided. Observation was made of Resident #94's room on 3/10/2020 at 11:45 a.m. The resident was in bed and a spirometer was observed on the nightstand. The spirometer was not covered. When interviewed about the use of the spirometer, Resident #94 stated she should be using it; it came from the hospital with her. She stated she was using it when she first came to the facility. Review of the clinical record failed to evidence a physician order [REDACTED].>The review of the comprehensive care plan dated 3/1/2020 failed to evidence the use of a spirometer. An interview was conducted with LPN (licensed practical nurse) #1, on 3/11/2020 at 1:47 p.m. When asked if there needs to be an order for [REDACTED].#1 stated, we should have an order or get it discontinued. ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were made aware of the above concern on 3/11/2020 at 5:50 p.m. A policy on the use of a spirometer was requested on 3/11/2020 at 5:50 p.m. On 3/12/2020 at approximately 11:15 a.m., ASM #2 stated they did not have a policy on the use of spirometers. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 423. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure [MEDICAL TREATMENT] services, were provided consistent with professional standards of practice, and the comprehensive person-centered care plan, for one of twenty-seven residents in the survey sample, Resident #6. The facility staff failed to communicate with the [MEDICAL TREATMENT] facility for Resident #6, during his Monday/Wednesday/Friday [MEDICAL TREATMENT] treatments. The findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 2/13/20, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively moderately impaired. In Section G (functional status)- the resident was coded as requiring extensive assistance for bed mobility, transfer, locomotion on/off the unit, dressing, toilet use and personal hygiene; dependent for bathing and supervision for eating. In Section O (special procedures) - the resident was coded as receiving [MEDICAL TREATMENT] while a resident. On 3/10/20 at 5:00 AM, Resident #6's [MEDICAL TREATMENT] communication book was reviewed. There were no communication forms from the facility to the [MEDICAL TREATMENT] (mechanical purification of the blood as a substitute for normal kidney function) center since the resident was admitted on [DATE]. Resident #6 receives [MEDICAL TREATMENT] Monday/Wednesday/Friday [MEDICAL TREATMENT] treatments since 11/15/19 for a total of 50 [MEDICAL TREATMENT] visits. A review of the physician's orders [REDACTED]. A review of Resident #6's comprehensive care plan documented in part, the Focus: dated 11/13/19 [MEDICAL TREATMENT]: receives [MEDICAL TREATMENT] every Monday, Wednesday and Friday 10:00 AM - 3:00 PM, has potential for complication. The Interventions: dated 11/13/19 Assess thrill and bruit of access site on left upper arm each shift. If absent, notify the physician or [MEDICAL TREATMENT] nurse and document this information. An interview was conducted with on 3/10/20, at 5:04 PM with LPN (licensed practical nurse) #2, the LPN charge nurse. When asked the purpose of the [MEDICAL TREATMENT] communication book, LPN #2 stated, It is for the [MEDICAL TREATMENT] center to provide us with information on the treatment and if there are any new orders. When asked if the facility communicated with the [MEDICAL TREATMENT] center, LPN #2 stated, We only provide communication to the [MEDICAL TREATMENT] center if there is a change in medicines or status. We do not communicate with every visit. They perform weights at the [MEDICAL TREATMENT] center. When asked if Resident #6's fistula was assessed for bruit and thrill, LPN #2 stated, Yes, we check it every shift. When asked if that information was communicated in the [MEDICAL TREATMENT] book, LPN #2 stated, No. An interview was conducted on 3/11/20, at 3:15 PM with ASM (administrative staff member) #2, the director of nursing. When asked what communication is provided to the [MEDICAL TREATMENT] facility for Resident #6, ASM #2 stated, We document more in the negative, for instance, if there has been a change in condition, new orders or labs (laboratory tests). We do not send information if everything is the same. When asked if there is a policy, ASM #2, the director of nursing, stated, Yes, I will get it to you. On 3/11/20 at 5:30 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were informed of the above concern. The facility's policy on [MEDICAL CONDITION], Care of a Resident with [MEDICAL CONDITION], documented in part, Agreements between this facility and the contracted ERSD facility will include all aspects of how the resident's care will be managed, including: how the care plan will be developed/ implemented and how information will be exchanged between the facilities. The facility's contract with the [MEDICAL TREATMENT] facility, documented in part, Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all designated residents at the time of transfer to the center. This information, shall include, but is not limited to, where appropriate, the following: appropriate medical records, including history of the designated resident's illness, treatment presently being provided to the designated resident including medications, any changes in patient's condition and any other information that will facilitate the adequate coordination of care as reasonably determined by the center. No further information was provided prior to exit. References: 1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498. 2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 52. 3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 54.

Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to implement bed rail (side rail) requirements for one of 27 residents in the survey sample, Resident #94. The facility staff failed to obtain an informed consent prior to the use of side rails for Resident #94. The findings include: Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) (1), high blood pressure, and [MEDICAL CONDITION] reflux disease, (is the backflow of the contents of the stomach into the esophagus, usually caused by malfunction of the sphincter muscle between the two organs; symptoms include burning pain in the esophagus, commonly known as heartburn). (2) The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 2/29/2020 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. The resident was coded as requiring extensive assistance of one or more staff members for all of her activities of daily living except eating in which she was coded as requiring supervision after set up assistance was provided. Observation and an interview of Resident #94 was conducted on 3/10/2020, at 11:45 a.m. and again on 3/11/2020 at 9:00 a.m. During both observations, the resident was in bed with bilateral side rails up. When asked if she uses the side rails, Resident #94 stated that they help her move in the bed. Review of the clinical record failed to evidence a signed informed consent for the use of the side rails. Review of the comprehensive care plan dated 3/1/2020, failed to evidence the use of the side rails. An interview was conducted with LPN (licensed practical nurse) #1 on 3/11/2020 at 1:47 p.m. When asked about the process staff follows for the residents' use of side rails, LPN #1 stated they have to complete an assessment to see who needs them. They have to obtain a consent if the screening shows they need them (side rails). LPN #1 was asked to review Resident #94's clinical record for a signed consent for the use of side rails. LPN #1 stated, no, we didn't do it. The facility policy, Bed Entrapment Assessment documented in part, c. If the resident's assessment identifies him or her as appropriate for the use of side rails, following procedures will be followed: i.) Educate the resident/resident representative on the risks and obtain consent for use. ASM (administrative staff member) #1, the administrator, and ASM #2 were made aware of the above concern on 3/11/2020 at 5:50 p.m. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 423. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 243.