Every finding on record at Avante at Orlando Inc

Based on observation, interview and record review, the facility failed to provide medications as ordered by the prescriber, to meet the needs of 4 of 4 residents sampled for medication administration, (#1, #2, #3, and #4).Findings:1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included an unspecified fracture of the upper end of the right humerus, an acute embolism and thrombosis of the deep veins of the right upper extremity, type 2 diabetes mellitus (T2DM), and an unspecified mood disorder.Review of the most recent assessment dated [DATE], using the Brief Interview for Mental Status (BIMS), showed that resident #1 was cognitively intact.On 6/29/26 at 9:21 AM, resident #1 said that often while at the facility, she did not receive her prescribed medications and had asked to be sent to the hospital on 3/02/26. She explained she did not receive her insulin, blood pressure medication, blood-thinning medication, and other medications. She said staff told her, We don't have it.A review of the Medication Administration Record (MAR) showed that on 3/01/26, the following physician ordered medications were not administered:Amlodipine 10 milligrams (mg) once daily in the morning for hypertension.Enoxaparin sodium injection, prefilled syringe 80 milligrams/0.8 milliliters (mg/ml), one intramuscular injection daily for blood clots.Fluticasone propionate nasal spray 50 micrograms (mcg) per actuation, two sprays in each nostril once daily for allergies.Insulin deglu[DATE] units per milliliter (units/ml), 50 units subcutaneously at bedtime.Lisinopril 20 mg once daily in the morning for hypertension.Naltrexone hydrochloride 50 mg once daily for alcohol or opioid use disorder.Sertraline hydrochloride oral tablet, prescribed as 100 mg (MAR instructions Give 1.5 mg once a day appear incorrect), for anxiety.Thiamine hydrochloride 100 mg once daily.Albuterol sulfate hydrofluoroalkane (HFA) inhalation solution 108 micrograms (mcg) (90 mcg base) per puff, two puffs every four hours as needed for wheezing or shortness of breath.2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included lumbar spinal stenosis, postoperative after-care following nervous system surgery, low back pain, and cauda equina syndrome (compression of nerves in spinal cord).A review of the facility's grievance logs showed that resident #2's daughter reported in a care plan meeting her mother was not receiving her pain medication. The investigation showed that staff believed the resident did not have a prescription from the hospital.However, the medical record included a hospital prescription dated 5/01/26 for oxycodone-acetaminophen (Percocet) 5-325 mg, with instructions to take one tablet every four hours as needed, with a quantity of 12 tablets.A review of the May 2026 MAR showed the resident did not receive the medication until 5/04/26 at 9:29 PM, almost two days after admission.3. Resident #3 was admitted on [DATE] with diagnoses that included sequelae following unspecified cerebrovascular disease, type 2 diabetes mellitus, end-stage renal disease (ESRD), dependence on renal dialysis, and major depressive disorder.The most recent BIMS assessment on 6/09/26 revealed resident #3 was cognitively intact.On 6/29/26 at 9:58 AM, resident #3 said, They ran out of my medications Cymbalta and Wellbutrin last week.A review of the June 2026 MAR showed multiple missed doses of:Wellbutrin (bupropion) 300 mg once daily for depressionCymbalta (duloxetine) 60 mg twice daily for depressionSevelamer carbonate 800 mg three times daily for hyperphosphatemiaSome entries were marked as refusals, and others referred to nursing notes. Most nursing notes for Sevelamer stated on order.Review of resident #3's current care plan did not show behavioral refusals of medication or preferences not to take medications on dialysis days. There were no nursing notes showing communication to the physician about refusals or preferences.4. Resident #4 was admitted on [DATE] with diagnoses that included muscle wasting and atrophy, obstructive sleep apnea, and type 2 diabetes mellitus.The BIMS assessment on 6/26/26 showed the resident was cognitively intact.On 6/29/26 at 5:00 PM, resident #4 said, When I first came, they were missing my Xanax. I came Thursday and they said they had no Xanax.A review of the June MAR showed resident #4 missed four doses of Xanax (alprazolam) 0.25 mg twice daily for anxiety. The resident received the first dose on 6/27/26 at 9:00 PM, even though the medication was ordered on 6/25/26 at 9:00 PM.On 6/29/26 at 6:11 PM, in a joint interview, Licensed Practical Nurses (LPN)s A, B, and C explained that when new admissions arrived in the evening, orders sent to the pharmacy often did not arrive until the 2:00 AM delivery or the next day. They said the ordering system was slow because they had to send orders by email. They said the pharmacy often reported not receiving the orders, and delays occurred when residents did not arrive with their hospital prescriptions. LPN C said resident #4's Xanax prescription was sent on 6/25/26 and she showed a text message documenting communication with the physician. She said the pharmacy reported that it never received the order. She also said there were no Xanax 0.25 mg tablets in the facility's Pyxis machine. LPN A added that residents sometimes called 911 to return to the hospital in order to receive their medications.On 6/29/26 at 6:25 PM, during a joint interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), Assistant Director of Nursing (ADON), and [NAME] President of Clinical Quality Operations, leadership acknowledged that resident #1 did not receive medications on 3/01/26. They said LPN D was the assigned nurse that day and no longer worked at the facility. They were unable to contact the nurse for additional information. The ADON said they did not remember resident #1, and the DON said they would not have known the resident because they had not been employed in March and had only been working at the facility for less than two months. The ADON said for resident #2, prescriptions were sent on 5/02/26, but the pharmacy said they did not receive them. The ADON said for resident #3, the dialysis center supplied Sevelamer 800 mg, and the center was not sending it at the time when nurses documented on order. They said the missed doses of Wellbutrin and Cymbalta were due to the resident refusing them on dialysis days. Regarding resident #4, they said the delay was similar to resident #2's situation and confirmed that LPN C showed evidence that orders were sent to the pharmacy on 6/25/26. The NHA and DON said they identified pharmacy issues during their daily report in the last week of May and contacted the pharmacy. They said the pharmacy did not give a clear response, and the orientation visit was still pending. They said the issue was still in progress.The facility's Pharmacy Services Policy, issued and revised 3/02/19, indicated the facility would provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administration, and disposal of all drugs and biologicals to meet the needs of each resident.

Based on observation and interview the facility failed to ensure the garbage storage area was maintained in a sanitary condition to ensure garbage was properly contained in dumpsters and trash cans with lids to prevent the harborage and feeding of pests, for one of one garbage storage area reviewed.Findings: On 2/17/26 at 10:10 AM, a tour of the outside garbage storage area was conducted. Three dumpsters and one 55-gallon trash can without lid was present. There were clear used gloves, straws, empty snack wrappers, and a clear trash bag with blue pads and masks on the ground around the dumpster area. A 55-gallon trash can with no lid was over filled with clear garbage bags filled with brown bags, snack wrappers, and blue pads. The Certified Dietary Manager who was present during the tour, confirmed the findings. She stated she was not sure who was responsible to keep the area clean. The Dietary Manager explained, everyone was responsible to keep the area clean. (photo evidence obtained) On 2/18/26 at 10:00 AM, the Plant Operations Manager acknowledged the unsanitary garbage storage area and explained that housekeeping and maintenance staff should keep the area clean but said it was also all staff's responsibility.

Based on observation, interview, and record review the facility failed to maintain cleanliness and sanitation of frying pans and failed to ensure the pureed meal was maintained at the correct hot holding temperature for 5 out of 45 residents who received pureed foods. Findings: 1.On 2/17/26 at 9:50 AM, the initial kitchen inspection was conducted. On the clean pan rack there were two pans with scratched and dried food on the non-stick surfaces. The Certified Dietary Manager (CDM) placed her finger on the non-stick surface and tried to scratch off the dried food. She confirmed the pans should not be used due to their condition. (photo evidence obtained) On 2/19/26 at 11:15 AM, review of the lunch menu revealed, Chicken & Dumplings was the lunch main entree. The cook was checking the hot holding temperatures on the steam table. The hot holding temperature of potentially hazardous foods was confirmed with the cook to be 135 degrees Fahrenheit (F) or above. The cook used a digital system bayonet instant read thermometer which was inserted into the pureed chicken. The reading on the thermometer was below 135 degrees F. The cook stated she did not check the pureed chicken's temperature prior to placing the pan in the warming cabinet earlier in the morning. She confirmed she did not check the temperature before placing the chicken on the steam table.

Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were followed during medication pass and before meals for both staff and residents on one of one dining area; and failed to ensure approved alcohol-based hand sanitizer was available for use for residents on enhanced barrier precautions and/or contact isolation precautions on one of one units of the facility.Findings:1. During dining room observation on 2/17/26 at approximately 12:05 PM, staff served residents the noon meal in the North wing dining area. Staff were observed not consistently performing hand hygiene during meal distribution between each resident. Speech Therapist (ST) D assisted residents with their meal and was observed not to practice hand hygiene consistently between residents she served. At 12:07 PM, the lunch cart arrived in main dining area on the North wing. Staff failed to offer hand hygiene to residents and no residents in the dining area cleaned or sanitized their hands in the dining area before eating lunch. At 12:16 PM, ST (D) was observed washing her hands at the sink, but she failed to rub her fingers, thumbs and wrists with soap and rushed through the process of hand hygiene, prior to and after assisting residents.On 2/17/26 at 12:17 PM, and again at 12:20 PM, Certified Nursing Assistant (CNA) E washed her hands with soap and water for less than five seconds, shook the water on her hands off on top of the trash can next to the sink then dried her hands with a paper towel. CNA E's hand washing did not include washing between her fingers, thumbs or wrists vigorously for at least 15 seconds. CNA (E) was observed as she assisted residents with their meals and moved throughout the unit near the dining room.Handwashing protects both the healthcare worker and the resident/patient using either soap and water or antiseptic hand rub. Rub hands together vigorously for 15 to 20 seconds, covering all surfaces of the hands. Rinse, use a disposable towel to dry, then use the towel to turn off the faucet, (retrieved on 3/06/26 from www.cdc.gov).2. On 2/17/26 at 12:59 PM, hand sanitizer in wall mounted dispensers used throughout the facility was non-alcohol based, (see photo evidence). On 2/17/26 at 3:15 PM, the Nursing Home Administrator, Infection Preventionist (IP) and Director of Nursing (DON) acknowledged the hand sanitizer in the wall mounted dispensers was not alcohol-based.On 2/17/26 at 10:12 AM, enhanced barrier precaution and contact isolation sign from Florida Health on the doors of room [ROOM NUMBER] and 144 indicated to use a 60-90% alcohol-based hand rub. The instructions indicated that Everyone MUST: Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting.On 2/18/26 at 9:30 AM, alcohol-based hand sanitizer bottles were placed on top of the non-alcohol-based dispensers throughout the facility. A short time later at 9:45 AM, the DON and IP explained they were not involved in the decision to use non-alcohol-based product dispensers for hand sanitizing. Both the IP and the DON stated they were unaware the dispenser's product was not alcohol-based. The DON stated on 2/17/26 during the evening, she placed a bottle of alcohol-based hand sanitizer on top of every dispenser on the North wing.On 2/18/26 at 3:15 PM, in a joint interview with the Nursing Home Administrator and DON, the DON provided a sheet from the Material Safety Data Sheets (MSDS) binder, but it was not for the product actually in the dispensers. MSDS sheets provide detailed safety information about chemicals used in the facility. It was brought to the Administrator's attention that the information supplied was for another product, not the product in the dispensers. The Administrator stated they didn't have a different MSDS sheet nor did she have a Safety Data Sheet (SDS) for the product in the dispensers. The Administrator said she was not involved in the decision to use a product for hand hygiene that was not alcohol based. She said the facility also used ABHR gel supplied from another manufacturer that was 70% alcohol that was supplied in small bottles located on the medication carts on the North wing. On 2/19/26 at 3:15 PM, the IP and DON stated staff were educated on proper hand hygiene with education completed every time there was an infection. Per the IP, there were three infections in the month of January, and staff was educated twice in January. For the month of February, the IP identified 10 current infections. The IP said she used an application of a fluorescent product that showed up if handwashing was inadequate for on-the-spot training when she observed staff not performing adequate hand hygiene. She also used it for random hand hygiene audits. The IP conveyed that staff received infection control education including hand hygiene upon hire, during town hall meetings and during skills fair. The IP said she performed the competencies for hand hygiene with staff and competency sheets were observed. The IP provided three sign-in sheets for staff education for a Town Hall meeting held on 1/22/26, which included for staff to follow Personal Protective Equipment (PPE) use, hand hygiene, and isolation protocols at all times. There was a total of 24 staff present for the training, with six non-direct care staff, 14 direct hands-on care staff (therapy department staff and nursing staff), three nurses and six CNAs attended. There were no other signature pages for infection control education provided. The IP said that was the only education form she had signed by staff. 3. On 02/18/26 at 10:45 AM, an observation of a medication pass was conducted for resident #37. Registered Nurse (F) donned a contact gown and gloves prior to entering the resident's room to administer his medications. After administration, RN F removed the gown; however, did not perform hand hygiene after removing her gloves. A few minutes later, outside resident #37's room, the nurse confirmed the resident in the b bed, (#37) was on contact isolation. RN F confirmed the sign on the door indicated contact isolation. She was unsure if this applied to both the a and b bed and said she would have to check. On 2/18/26 at 1:55 PM, in a joint interview with the IP and DON, the IP said she was responsible for the facility isolation signage and education to residents, families and staff. Initially, the DON and IP said there was no need to wear gowns and gloves when entering the room of a resident on contact isolation. The DON said the only requirement for entering the room was to perform hand hygiene and staff need only wear PPE, if care was provided. She explained that resident #37 was on contact isolation but was not contagious because his wound was contained. Per the IP and DON, the nurse passing medications was expected to wear PPE. On 2/19/26 at 1:58 PM, Licensed Practical Nurse (LPN) G said there were different classes of isolation- droplet, contact, and enhanced barrier precaution. LPN G said she was not sure what the difference was between the signs. She said she knew that for contact isolation a gown and gloves were to be used and hand hygiene performed with ABHR before entering the room and when leaving the room. LPN G said enhanced barrier precautions were used for people with VRE and MRSA and contact isolation for people with open wounds. On 2/19/26 at 3:15 PM, in a joint interview with the IP and DON, the IP said she monitored the antibiotic stewardship program, hand washing, she checked the sharps containers and was responsible for education related to infection control. She confirmed PPE was used when personal care was performed on a resident on enhanced barrier precautions. Per the DON and IP, staff used gowns and gloves as soon as they entered the room of a resident on contact isolation. The DON said there was no need for the use of PPE if the wound was contained. The DON clarified that if the resident was assisted and close care was needed, PPE would be used. She said hand hygiene was required before entering a room and then exiting a room. The IP stated the DON was not correct, staff should wear PPE for a resident on contact isolation. The IP said she educated staff on wound containment. The IP said she educated non-nursing staff during orientation on wound containment. The IP said she was responsible for the signage for both EBP and all other transmission-based precautions including contact isolation. Review of the facility's policy, revised on 3/02/19, titled, Infection Control- Hand Hygiene revealed it was the policy of the facility to perform hand hygiene in accordance with national standards form the Centers for Disease Control and Prevention and the World Health Organization. The policy indicated hand hygiene should be performed before and after entering isolation precaution settings, before and after assisting a resident with meals, and prior to caring for residents, prior to performing a procedure, when moving from a contaminated body site to a clean body site, after caring for a resident including after glove removal, and after contact with the resident's environment.A second policy for hand hygiene provided by the facility on 2/18/26 at 10:00 AM, was dated 3/02/19 and revised 10/20/25. The policies were identical except for the second hand hygiene policy revised 10/20/25, did not include use of alcohol-based hand rub. It was removed from the policy but indicated the use of hand sanitizer was to be used for hand hygiene opportunities.

Based on observations, record review and interviews the facility failed to implement their Policy and Procedure and ensure contracted staff were screened before entering the facility for one of six sampled staff (Staff C). This deficient practice has the potential to affect all 102 residents that reside within the facility. Findings include: On 4/25/22 at 8:31 AM contract staff C was observed coming out of Unit 200 pushing a cart and picking up paper for shredding. He/she stated he/she goes to both units and pick up paper for shredding. Administrative staff D at 8:42 AM stated that he/she did not screen the contract staff who came to pick up paper for shredding because he/she comes in the back door. Contract Staff C said he/she cannot park up front, so he/she parks in the back and goes into the facility through the back door. He/she said their company sends people to the facility every two weeks. Staff C also stated that he/she just provided their vaccination status to the facility. Review of the vaccination record revealed the contractor staff C was fully vaccinated. Review of the Coronavirus Testing and Exposure policy stated, The facility will screen all staff each shift, each resident daily, and all persons entering the facility, such as vendors, volunteers, and visitors, for signs and symptoms of COVID-19. The facility failed to implement their policy which stated that vendors will be screened for signs and symptoms of COVID-19 on entering the facility.

Based on observation, record review and interview, the facility failed to prevent the development of a new pressure ulcer, and failed to provide care and services to promote healing once it developed for 1 of 2 residents sampled with pressure ulcers in a total sample of 35 residents, (#11). The facility's failure to implement preventative measures consistent with the resident's risk for skin breakdown and failure to implement treatment according to accepted standards of practice resulted in actual harm, development of a Stage III pressure ulcer to the right ear which worsened to a Stage IV pressure ulcer. Findings: Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely impaired for decision making and was totally dependent on 2 staff for bed mobility, transfers and toileting. The assessment showed he was always incontinent of urine, bowels and had 1 unstageable pressure ulcer upon admission. On 10/25/21 at 10 AM, the South Wing Unit Manager (UM) provided a list of residents with care needs. The list noted resident #11 was on continuous oxygen therapy at 3 liters per minute and received tube feedings. There was no mention of any pressure ulcers. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Weekly Skin Observation form dated 8/3/21 noted the resident had a pressure ulcer on the coccyx, at admission. The pressure ulcer was assessed by the wound Advanced Practitioner Registered Nurse (APRN) on 8/4/21 and noted the wound was on the sacrum not the coccyx. The sacral wound measured 2.5 centimeters (cm) in length X 2.5 cm in width X 0.5 cm in depth. The wound was from pressure and the APRN noted the wound was unstageable but not unavoidable. A Weekly Skin Observation form dated 8/13/21 read the resident did not have any new pressure ulcers. On 10/25/21 at 10:33 AM, the resident was in bed on an air mattress with the head of the bed (HOB) elevated at 30 degrees. His head was to the right side and his chin was down towards his chest. His right ear was touching the pillow and there no positioning device to maintain his head at midline. He had oxygen by nasal cannula and did not respond to verbal stimuli. On 10/25/21 at 11:17 AM, the resident's assigned Registered Nurse, (RN) D said the resident had a stage II pressure ulcer on the sacrum that was acquired at the facility. He did not mention any other pressure ulcers. On 10/25/21 at 4:39 PM, the resident was on his right side with his head down, chin touching his chest and the ear touching the pillow. The resident did not have any positioning devices. The oxygen nasal cannula was in place and the resident's eyes were closed. A Nursing Progress Note on 8/19/21 revealed the resident was transferred to the hospital for low oxygen levels. He was readmitted to the facility on [DATE] and was seen by the wound care APRN on 8/25/21. She noted the unstageable pressure ulcer on the sacrum now measured 1.8 cm x 0.9 cm x 0.2 cm. She also noted no other pressure ulcers upon re-admission. A review of the resident's care plan noted he had an unstageable pressure ulcer on the sacrum that was present on admission caused by prolonged pressure related to impaired bed mobility, incontinence . The approaches included to document any changes in skin integrity and notify licensed nurse of any new open areas, obtain weekly skin checks and notify physician of any changes in skin integrity. A review of the Weekly Skin Observation form noted the resident did not have any weekly skin checks done since he returned from the hospital on 8/21/21 until 9/15/21, indicating more than 3 weeks of weekly skin checks were missed. The evaluation dated 9/15/21 showed the resident had a new pressure ulcer to the right ear at stage III. The resident was seen by the wound care APRN on 9/15/21 and the note documented the resident had a facility acquired stage III pressure ulcer to the right ear that measured 2 cm X 0.5 cm X 0.3.Patient favors his head to the right. Necrotic tissue is noted with moderate drainage. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply honey fiber to wound bed and place non-adhesive foam between the ear and pillow daily . The wound care APRN wrote the right ear pressure ulcer was Unavoidable, but did not provide a rationale as to why the ear pressure ulcer was unavoidable. A note by the wound care APRN dated 9/22/21 showed the right ear pressure ulcer was facility acquired and had worsened to Stage IV.The ear wound is unavoidable since the patient favors his head laying this way and is difficult to offload. Patient has a history of left sided stroke which could contribute to the reason he favors his right side . Contrary to the APRN's note, the resident did not have a foam device to offload his right ear from the pillow. On 10/26/21 at 3:32 PM, the resident was again observed in bed with the head of bed elevated at least 30 degrees. His head was down with his chin towards his chest and towards the right side. His right ear was touching the pillow and there was no foam between the ear and the pillow. The resident's direct care Certified Nursing Assistant, (CNA) F stated the resident, doesn't really get out of bed. The CNA voiced no concerns about the resident's positioning or about the missing foam that was supposed to between his ear and the pillow. A few minutes later, RN D entered the resident's room, checked the oxygen concentrator for flow rate and indicated the CNAs would reposition the resident but made no mention of the foam that was missing between the resident's ear and pillow. On 10/27/21 at 12:45 PM, resident #11's wound treatment was observed with the facility's Wound Care Nurse (WCN), Director of Nursing (DON), wound care APRN and a Physician Assistant. The APRN stated the right ear pressure ulcer was unstageable and measured 1.6 cm X 0.6 cm X 0.2 cm indicating the ulcer had worsened. The APRN explained the facility's therapy staff were working on an offloading device for the ear as the resident favored his right side. On 10/27/21 at 1:37 PM, the residents daughter was at the bedside and stated that after the fourth stroke, her father had become a resident at this facility. She said he had a pressure ulcer on his right ear, He got that here. On 10/27/21 at 4:46 PM, the resident was in bed and had a U shaped pillow around his neck with a foam piece between the neck pillow and his right ear. The resident appeared to be positioned better, as he was midline, and not fixed to his right. Further review of the resident's care plans revealed the care plan had not been updated after the right ear pressure ulcer was discovered. There was no evidence the facility had any specific pressure offloading approaches for the right ear prior to the discovery of the pressure ulcer. The pressure injury care plan was updated to reflect the resident's right ear pressure ulcer, only when the U shaped pillow was started on 10/27/21. On 10/28/21 at 9:49 AM, RN D stated that weekly skin checks were to be completed by the nurses and for resident #11, checks were to be done on the 7 AM to 3 PM shift. He explained weekly skin checks were to be done even if the resident was being seen by the WCN. RN D stated when he first saw resident #11's right ear wound, it was a laceration. He said he put an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN D stated the U shaped pillow was just put on him, yesterday, from therapy. At 9:57 AM, the South Wing UM reviewed the weekly skin checks in the electronic medical record and found weekly skin checks dated 8/3/21, 8/13/21 and 9/15/21. She could not explain why there were missing weekly skin checks between 8/13/11 and 9/15/11. She explained if weekly skin checks were missed, the DON and/or the Assistant Director of Nursing (ADON) were responsible to ensure they were completed. On 10/28/21 at 10:25 AM, a meeting was held with the Administrator, DON, WCN and Regional Nurse. The DON explained that Weekly Wound Evaluations were completed by the WCN for residents with pressure ulcers and Weekly Skin Observations were completed by the direct care nurses on all residents including those with pressure ulcers. The DON was presented with Weekly Skin Observations for resident #11, dated 8/3/21, 8/13/21 and 9/15/21. She did not explain why the resident's weekly skin checks were not done. She explained the South West UM should have ensured they were done. The Administrator verbalized that direct care nurses completed the Weekly Skin Observations, but no one verified they were completed. The DON then stated the WCN did a head to toe check on residents. The WCN stated she did not do head to toe skin check every week on residents. The WCN said she placed a piece of foam under the resident #11's ear when the pressure ulcer was first discovered and if the foam needed to be repositioned, then the direct care nurse would do it. The DON noted the foam would have to be moved when the resident was repositioned. When informed the foam was not between the resident's ear and pillow on 10/25/21 and 10/26/21, the DON responded, it should have been. The DON explained the U shaped pillow was started yesterday, 10/27/21. On 10/28/21 at 12:44 PM, a meeting was conducted with the Chief Nursing Officer (CNO), Regional Nurse and Administrator regarding concerns with the right ear pressure ulcer. The CNO explained skin assessments on resident #11 were done by the physician's APRN G. She pointed out that APRN G saw the resident on 9/13/21 and did a head to toe skin assessment. On 10/28/21 at 1:44 PM, during a telephone interview, APRN G said she reviewed her progress note dated 9/13/21 and recalled she probably looked at resident #11's ears on this visit but she didn't note it. APRN G stated she tried to do a head to toe skin assessment when she examined the resident's sacral wound, but did not do a head to toe skin assessment on every visit. She stated she did not think the resident could have voiced his preference to be on his right side. She discussed ways to offload the pressure to his ears including turning him from side to side. She said she was informed about the U shaped neck pillow and agreed this would offload the pressure. She stated typical offloading was turning the resident from side to side. She explained the oxygen nasal cannula could had attributed to resident #11's right ear pressure ulcer. She explained padded tubing could had been used but there was no evidence the facility had tried padded oxygen tubing. APRN G reported she did not always do a head to toe skin assessment on every resident because she would need staff to assist with turning and repositioning and that staff were not always available. She acknowledged her note on 9/13/21 did not indicate a head to toe skin assessment was done. She stated, it's considered that if it is not documented, you didn't do it. On 10/28/21 at 2:46 PM, CNA E was in the resident's room and the resident was in bed asleep with the U shaped pillow around his neck and a foam piece between his right ear and neck pillow. CNA E said she often cared for resident #11. She identified 2 staff were required to turn and reposition the resident. She explained resident #11 preferred to be on his back. She said she had not seen the foam, that was under his right ear until today and the neck pillow was new since yesterday. On 10/28/21 at 3:27 PM, a meeting was held with the Therapy Director, Physical Therapist (PT) and the Certified Occupational Therapist Assistant (COTA). The therapy discharge notes were reviewed that indicated the resident had been on therapy from 8/22/21 to 9/10/21. A goal for Occupational Therapy noted, patient will achieve midline position in bed . The discharge summary noted on 9/10/21, Poor-unable ability to achieve midline. The therapist stated the resident leaned to the right and they tried to orient him to midline. The therapist said the resident leaned to the right maybe out of habit or related to multiple strokes. They stated they tried different approaches but the resident would always shifted his head to the right side. They acknowledged resident #11 did not have any purposeful movement and could not follow instructions. The Therapy Director explained the U shaped pillow was placed on him on 10/27/21 to aid with healing the right ear pressure ulcer. The therapists did not provide an answer when asked if they were consulted about off loading the ear prior to 10/27/21.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standards of practice for 1 of 1 sampled resident, (#11) in a total sample of 35 residents. Findings: The National Pressure Injury Advisory Panel (NPIAP) redefined the definition of a pressure injury (formerly pressure ulcer) in 2016. The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence .Stage 4 Pressure Injury: Full-thickness skin and tissue loss . If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (www.npiap.com). Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital medical records revealed a history and physical dated 8/1/21 that read, patient is nonverbal and non-communicative admitted to the hospital with altered mental status nearly vegetative state. Patient is not a candidate for any aggressive cardiac intervention outcomes of this patient is exceedingly poor. The most recent Minimum Data Set (MDS) assessment dated [DATE] showed resident #1's cognition was rarely/never understood. The resident was totally dependent on 1-2 persons for all activities of daily living (ADL) and was bedbound. Within the last 5 days prior to the MDS assessment, the resident had not received any scheduled or prn (as needed) pain medication and received no non-medication interventions for pain. The staff assessment for pain did not show any non-verbal sounds, facial expressions, or protective body movements for pain. A care plan dated 8/6/21 for potential alteration in comfort related to muscle weakness, sacral and ear wounds noted pain is often displayed by changes in body mechanics, i.e., tightening/stiffening, etc.rather than with facial movement/grimaces which are more a form of acknowledgement/communication than pain/discomfort include interventions to, Evaluate for nonverbal indicator of pain including but not limited to body tensing/stiffening, moaning, rapid/increased breathing and or/restlessness and evaluate the effectiveness of pain control and document, notify MD [Medical Doctor] if pain control is ineffective, and medicate for pain as ordered. The care plan revised 10/12/21 for unstageable pressure ulcer sacrum and stage 3 pressure ulcer right ear did not address potential for pain caused by dressing changes/wound care. There were no interventions to address potential for pain during wound care such as observe for non-verbal signs of increased discomfort with wound care. There were no goals mentioned to ensure resident #11's comfort would be maintained during wound care performed by nurses. According to the most recent MDS assessment and weekly wound evaluation forms, resident #11 was admitted with unstageable pressure ulcer/injury to his sacrum and developed a stage 3 pressure ulcer/injury of the right ear in the facility as of 9/15/21. The ear wound worsened and became a stage IV as of 9/23/21. The care plan for pressure ulcers did not address the potential for pain during wound care/procedures. Review of the facility Weekly Wound Evaluation form dated 10/25/21 revealed presence of the following wounds: Right ear facility acquired wound measuring 2 centimeters (cm) by 0.3 cm by 0.3 cm deep with 30% granulation tissue and 70%. The pressure unstageable pressure ulcer on the sacrum measured 1.5 cm by 1.3 cm by 0.1 cm deep with 10% granulation and 90% eschar. On 10/26/21 at 4 PM, resident #11 was observed resting in bed and appeared asleep with no signs of distress or discomfort noted. On 10/27/21 at 11:02 AM, the Wound Care Advance Practice Registered Nurse (APRN) M and Wound Care Physician Assistant (PA) N were on the North Wing of the facility rounding on residents. The APRN explained that resident # 11's ear wound was considered a stage 4 as there was no fat, muscle or bone in the ear. Since cartilage is the supporting structure, her guidance was to classify the wound as a Stage IV. The APRN indicated she had a busy schedule today and would see resident #11 later. She indicated she had another facility to visit after this one. On 10/27/21 at 12:45 PM, an observation of resident #11's wound care was conducted with the Wound Care Nurse (WCN), APRN-M, Physician Assistant and the Director of Nursing (DON). The APRN and WCN proceeded to turn the resident onto his left side and the DON began to remove the soiled brief. During turning the resident was observed with facial grimacing and slightly tightened his upper body. After the soiled brief was removed an observation of sacral wound revealed moist wound with yellow slough and surrounding pinkish/red tissue. The APRN proceeded to measure the sacral wound and called out the following measurements to the PA, 1.6 centimeters (cm) x 1.3 cm x 0.1 cm deep. During the procedure the WCN was holding the resident onto his left side while the APRN proceeded to clean the wound with normal saline (NS). The residents' facial expressions of wincing/grimacing became more exaggerated, as did tightening of the upper torso and he started moaning. The staff were asked to stop and were questioned whether the resident was medicated for pain prior to wound care. The staff continued with the dressing change and remarked that this was his usual during wound care. Staff indicated they thought he had Tylenol but could not say what time it was given or if they waited long enough for it take effect. The staff then positioned the resident onto his back and proceeded to do the wound care to his right ear. The ear wound appeared moist pink/red in color. The APRN called out the wound measurements to the PA of 1.7 cm x 0.6 cm x 0.2 cm deep. When the staff started to clean the ear wound with NS the resident again had increased grimacing, wincing, moaning and started to shake his head back and forth. The staff were again asked again to stop the procedure but proceeded with the wound care. The DON was asked why wound care was not stopped and she remarked that the physician would be called today for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She commented that this was the resident's usual disposition during wound care. She did not provide an answer when asked why she did not get something stronger for the resident's pain sooner. The APRN and DON were interviewed post wound care outside the resident's room. The APRN said that normally during wound care, they did not turn the resident onto his left side as this caused him discomfort. She added they turned him onto his uncomfortable side so the surveyor could observe his wound. They were informed that was no requested nor acceptable or discussed prior to this observation. The APRN stated that they visited every week and would have expected the facility to pre-medicate him for pain. The APRN was asked why she did not stop the wound care and wait for staff to order stronger pain medication, she stated, I don't know, we were nervous due to being observed. On 10/27/21 at 1:45 PM, the resident's assigned Register Nurse, (RN) D checked the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN explained he did not see the resident in any pain when lying in bed. It is only when they are doing care. On 10/21/21 at 1:50 PM, resident #11 was observed supine resting in bed with a U shaped pillow around his neck and showed no distress or pain. On 10/27/21 at 4:32 PM, an interview was conducted with the WCN, DON, Assistant Director of Nursing (ADON) and Regional Director of Regulatory Compliance (RDRC). The ADON said she had helped with the resident's care and anytime staff touched him, he would flare his nose, raise his eyebrows, had facial grimacing and moaned at times with re-positioning. The DON said they did not feel resident #11 was in enough distress to stop the procedure and they took a break between doing the 2 wounds. The DON acknowledged resident #11's reactions escalated when they touched the wounds. The WCN said she had not checked the time Tylenol was given and did not realize that it had only been given 15 minutes prior to wound care which was not enough time to be effective for pain. On 10/27/21 at 5:29 PM, Certified Nursing Assistant (CNA) E said resident #11 was on her assignment twice per week. She said the resident tightened his shoulders and moaned a little when turned, bathed or provided care. She added that he was fine when just lying on his back. On 10/27/21 at 5:35 PM, the Director of Therapy acknowledged resident #11 was on therapy last month for positioning and comfort. She said, the resident made faces and tightened up during positioning. We would know to stop the therapy when he would resist and try to get on to his back. The Therapy Director reviewed the therapy note dated 8/23/21 regarding pain and said, the patient is unable to communicate pain or lack of. It is to be determined based on patient behavior. The Therapy Director explained, when resident #11 started to move his head back and forth that would indicate he was trying to get away from pain. On 10/28/21 at 10:26 AM an interview was conducted with the WCN, DON, Executive Director (ED) and RDRC. The ED assisted with interpreting Spanish to English for the WCN. The WCN said, it was explained to her by the APRN that facial expressions were normal for resident #11 because he had history of 4 strokes. She said she thought all staff were aware that wound rounds were being done and she assumed the resident had been medicated but did not know when the Tylenol was given. The WCN said she normally went to the units and informed nurses to give pain medications 30-45 minutes prior to wound care. The DON said, we did not feel he was experiencing any additional pain except when she was cleaning the wounds and it was not for a prolonged period that he had pain. Review of the medical record with the facility staff acknowledged resident #11's pain was not addressed in the comprehensive care plan regarding potential for pain during wound care. The WCN stated, because he had never showed true discomfort it was not included in the plan of care. The staff acknowledged the Weekly Wound Evaluation assessment done by the WCN on 8/4, 9/13, 8/19, 8/27, 9/3, 9/10, 9/17, 9/23, 9/30, 10/8, and 10/15/21 were all inaccurate as the nurse documented the resident was cognitively intact and thus the assessment for no verbal signs of pain was not triggered/nor completed. The DON was asked if she checked the WCN's documentation and stated, I am just one person. The facility staff acknowledge the resident was not able to verbalize pain and that his facial expressions were a sign of discomfort as the resident did not know if staff were doing wound care or changing his brief. On 10/28/21 at 1:59 PM, during a telephone interview, the primary care physician's APRN G said the resident was vegetative and his pain was assessed by non-verbal indicators such as facial grimacing, body tensing, resisting care or becoming rigid. She added if pain medication was given after wound care, it's too late. The APRN added, it is a priority for him not to be in pain. Review of the facility policy and procedure for pain management revised 3/2/19 read, each resident receives necessary care and services in accordance with professional standards of practice The facility must ensure that pain management is provided to residents Behavioral signs and symptoms that may suggest the presence of pain include .Resisting care .Facial expressions: grimacing .Sighing, groaning Assessment and evaluation by appropriate member of the interdisciplinary team may include .Determining factors that may make the pain better or worse the interdisciplinary team is responsible for developing a pain management regiment .If when re-evaluating, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated

Based on observation, interview and record review, the facility failed to ensure dishes were washed at the appropriate temperature, as per the data plate and manufacturer's instructions. Finding: On 10/25/21 at 9:25 AM, Dietary Aide K placed a dish rack containing dishes into the dish machine. The dial on the dish machine showed temperature at 150 degrees Fahrenheit (F). The Data Plate on the machine, noted the wash temperature should be 160 degrees F. Dietary Aide K placed another rack of dishes into the dish machine and the wash temperature rose to 152 degrees F. Dietary Aide K said she started washing dishes at 9:20 AM and had already stored dishes that she had washed. The Regional Dietary Director acknowledged the wash temperature should be 160 degrees F. and the final rinse temperature should be 180 degrees F. The Certified Dietary Manager (CDM) produced the temperature log book for the dish machine dated 10/25/21 which noted the wash temperature should be at 160 degrees F. and the final rinse should be 180 degrees F. The Food and Drug Administration 2017 Food Code notes in section 4-501.15A, that a warewashing machine and its auxiliary components shall be operated in accordance with the machines data plate and other manufacturer's instructions.

Based on observation and interview, the facility failed to ensure garbage and refuse was disposed in a sanitary manner. Finding: On Monday, 10/25/21 at 9:25 AM, an uncovered dumpster was observed located at the back of the facility. The dumpster did not have a cover lid. The Certified Dietary Manager (CDM) said the dumpster was used by maintenance. The maintenance dumpster contained picture frames, old furniture, clear trash bags containing paper, food cartons and juice cups. The CDM stated that food items should not be in this dumpster. The Maintenance Assistant arrived at the site and acknowledged that food refuse should be in the regular dumpster and not in the maintenance dumpster. The CDM stated food and food cartons should be in the closed dumpster to prevent rodents and pests. The Food and Drug Administration's 2017 Food Code refers to the use of outside receptacles for waste in chapter 5-501.15(A). Receptacles and waste handling units for refuse, recyclables and returnables used with materials containing food residue and use outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview and record review, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: 1. Resident #54 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Minimum Data Set (MDS) assessment with reference date 9/26/21 revealed the resident had a [CONDITION(S)], received oxygen therapy, and suctioning. Resident #54 had care plan dated 12/05/18 for [CONDITION(S)] related to respiratory failure. She required continuous use of supplemental oxygen and care plan included interventions to, Observe respiratory rate, depth and quality oxygen as per orders On 10/25/21 at 12:50 PM, resident #54 was noted with oxygen therapy via her [CONDITION(S)] collar at 3 liters per minute (LPM). Review of the medical record revealed resident #54's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/21 at 2:30 PM, the resident's assigned nurse, Licensed Practical Nurse (LPN) B said her assignment sheet did not indicate resident #54 had oxygen and she did not check the oxygen rate today. On 10/25/21 at 2:25 PM, LPN A checked the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN A then went to resident #54's room, looked at the flow rate at eye level and said, I now see it is at 3 LPM. LPN A attempted to adjust the gauge on the concentrator and said it was broken and needed to be replaced. On 10/26/21 at 4:15 PM, resident #54 was noted with oxygen therapy via her [CONDITION(S)] collar at 2.5 LPM. On 10/26/21 at 4:20 PM, LPN L checked the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN L proceeded to resident #54's room and acknowledged the concentrator was set at 2.5 LPM. On 10/27/21 at 4:52 PM, the Director of Nursing (DON) stated the nurses should know the orders and check the oxygen liter rate at least once per shift, and whenever in the resident's room. 2. Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set, dated dated dated [DATE] indicated the resident was receiving oxygen and hospice care. A Care Plan dated 6/04/20 and revised on 9/09/20 and 3/11/21 read, . requires intermittent or PRN oxygen support. Goal: will maintain use of intermittent oxygen as directed . On 10/25/21 at 12:21 PM, resident #35 was observed lying in bed. He had oxygen via nasal cannula attached to an oxygen concentrator with oxygen flow rate at 3 liters/min. On 10/25/21 at 2:22 PM, the oxygen flow rate remained at 3 liters/min. On 10/25/21 at 4:05 PM, resident #35 was in bed and the oxygen flow rate was at 3 liters/min. On 10/25/21 at 4:12 PM, Licensed Practical Nurse, (LPN) H said she was assigned to resident #35. She stated the resident should have oxygen set at 2 liters/min via nasal canula. LPN H proceeded to resident #35's room, and acknowledged the oxygen concentrator was set at 3 liters/min. The LPN requested to have the Unit Manager (UM) come to the room. She informed the UM the resident's order for oxygen was for 2 liters/min and the UM verified the oxygen concentrator was set at 3 liters/min. The UM stated the expectation was that nurses check the oxygen concentrator at the start of the shift and periodically throughout the shift to ensure it was on the correct flow rate. Policy and Procedure: Physician Services dated 3/02/19 and revised 3/02/19 stated, 8. All physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff on 1 of 2 Wings (South) on the 7 AM to 3 PM shift to meet residents' needs related to timely administration of scheduled medications, for 13 of 48 residents on the South Wing, of a total census of 89 residents, and failed to ensure adequate staffing to meet the needs of residents on the North Wing. Findings: Observations and interviews conducted on the South Wing on 4/05/26 during the 7 AM to 3 PM shift revealed there were 2 nurses assigned to the South Wing which included the South Wing Unit Manager. The South Wing census was 48, with a capacity of 60 residents. Two nurses were assigned to the North Wing, which included the North Wing Unit Manager, and the Assistant Director of Nursing, (ADON). The North Wing census was 41. Observations on 4/05/21 at 10:43 AM, 11:07 AM, 11:30 AM, and 11:40 AM showed the Registered Nurse/ Unit Manager (RN/UM) for the South Wing, at the medication cart administering 9 AM medications. On 4/05/21 at 12:19 PM, the North Wing RN/UM was observed at the medication cart. The North Wing RN/UM stated the facility was very short staffed. She indicated the ADON, and the South Wing RN/UM were also working on the medication cart, administering medications. The North Wing RN/UM said she worked on the medication cart several days, and stated it was impossible to do her UM duties, since she had to administer medications. On 4/05/21 at 12:47 PM, the South Wing RN/UM stated she worked on the medication cart two 2-3 days per week and was not able to give medications on time. The South Wing RN/UM stated the facility needed more nurses. She said the regular nurse on the South Wing worked double shifts all the time. A review of the Daily staffing schedule for the period 3/01/21 to current was reviewed with the Administrator on 4/06/21 at 1:20 PM. The North Wing UM was assigned to a medication cart on 3/01/21, 3/02/21, 3/03/21, 3/15/21, 3/18/21, 3/22/21, 3/26/21, 3/29/21, 4/02/21, and on 4/05/21. The South Wing UM was assigned to a medication cart on 3/01/21, 3/12/21, 4/02/21, and 4/05/21. The Administrator stated that staffing was reviewed with the Director of Nursing (DON) and the Staffing Coordinator. He said that when the UMs worked on a medication cart, the facility tried to get an agency staff to cover the shift. On 4/05/21 at 3.47 PM, the 3 PM-11 PM RN/Supervisor worked on the medication cart. The 3 PM-11 PM Supervisor stated she had worked on the medication cart 3-4 times per week. She said she started working at the facility in February 2021, and was mostly doing admissions, discharges, phone calls, placing orders in the facility's electronic records but in the past month, she had been on the medication cart more, due to the facility being short staffed. On 4/05/21 at 4:58 PM, the DON said that staffing was completed daily by the Staffing Coordinator and reviewed by her throughout the day. She said that during the AM meeting, the current, and the following week's staffing were discussed. The DON stated the facility's census was low, and the facility had to use their resources wisely. She stated the facility had a call out, and one nurse was on light duty, so both UM and the ADON worked on the medication cart. Review of the Medication Administration Audit Report for the day shift on 4/05/21 revealed that 13 of the 48 residents on the South Wing, #7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, had not received their medications in the required timeframe. The facility's job description for Unit Manager (RN) read, Purpose: to supervise the day-to-day nursing activities of the facility during your tour of duty . to ensure that the highest degree of quality care is maintained at all times.

Based on observation, interview and record review the facility failed to ensure scheduled medications were administered as ordered, according to accepted professional standards during the 7 AM to 3 PM shift, on 1 of 2 units for 13 of 49 residents on the South Wing, (#7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20). Findings: On 4/05/21 at 10:43 AM, the South Wing Registered Nurse/ Unit Manager (RN/UM) stated she was working on the medication cart today, and she had eleven residents left to receive their 9 AM medications. On 4/05/21 at 11:07 AM, the South Wing RN/UM was observed at her medication cart, still administering 9 AM medications to residents. On 4/05/21 at 11:30 AM, the South Wing RN/UM was at her medication cart giving 9 AM medications to residents. RN/UM stated she had four more residents to give medications. On 4/05/21 at 11:40 AM, the South Wing RN/UM was still administering 9 AM medications. On 4/05/21 at 12:47 PM, the South Wing RN/UM stated she was now doing blood glucose (BG) monitoring and giving 12 PM medications. She stated she worked on the medication cart 2-3 times weekly. She acknowledged she was not able to give medications on time, which was one hour before/after the scheduled time. Review of the Medication Administration Audit Report for the day shift on 4/05/21, revealed the following: 1. Resident #7 received his scheduled 9 AM medications at 11:15 AM, including: [MEDICATION NAME] 10 milligram (mg) daily (QD) for depression, [MEDICATION NAME] 875 mg order twice daily (BID) for dental infection, and [MEDICATION NAME] 300 mg BID for [MEDICAL CONDITION]. 2. Resident #9 received his scheduled 9 AM medications between 11:20 AM and 11:21 AM, including: Eliquis 2.5 mg for [MEDICAL CONDITION], [MEDICATION NAME] 100 mg for high blood pressure, heart and [MEDICAL CONDITION], [MEDICATION NAME] sprinkles capsule delayed release sprinkle 125 mg ordered BID for mood stabilization, and [MEDICATION NAME]-[MEDICATION NAME] 20-10 mg BID for pseudobulbar affect. 3. Resident #10 received his scheduled 9 AM medications between 10:45 AM and 10:48 AM, including: Levetiracetam 500 mg every (Q) 12 hours for [MEDICAL CONDITION], [MEDICATION NAME] 25 mg BID for high blood pressure, and [MEDICATION NAME] 20 mg daily (QD) for depression. 4. Resident #11 received her scheduled 9 AM medications between 11: 56 AM and 12 PM, including: [MEDICATION NAME] 1 mg BID for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 5 mg for depression, Pioglitazone 15 mg in the morning for type II diabetes, Losartan Potassium-HCTZ 100-25 mg QD, and [MEDICATION NAME] 50 mg BID for high blood pressure. 5. Resident #12 received scheduled 9 AM medications between 11:31 AM and 11:29 AM, including: [MEDICATION NAME] Chloride 5 mg BID for neuromuscular bladder dysfunction, [MEDICATION NAME] 50 mg for high blood pressure, [MEDICATION NAME] 5 milliliter (ml) BID, and [MEDICATION NAME] 125 mg/5 ml three times daily (TID) both for [MEDICAL CONDITION]. 6. Resident #13 received his scheduled 9 AM medications between 12:05 PM and 12:06 PM, including: [MEDICATION NAME] 5 mg QD, [MEDICATION NAME] 50 mg QD both for high blood pressure, and [MEDICATION NAME] 500 mg QD for type II diabetes. 7. Resident #14 received scheduled 9 AM medications at 12:20 PM and 12:21 PM, including: [MEDICATION NAME] 100 mg QD for depression, [MEDICATION NAME] 100 mg 2 capsules BID for [MEDICAL CONDITION], and [MEDICATION NAME] 20 mg QD for [MEDICAL CONDITION]. 8. Resident #15 received her scheduled 9 AM medications between 10:15 AM and 10:31 AM, including: [MEDICATION NAME] 15 mg TID, [MEDICATION NAME] 1 mg BID both for anxiety, [MEDICATION NAME]-[MEDICATION NAME] Aerosol 160-4.5 MCG/ACT (microgram/actuation) 2 puffs Q 12 hours for shortness of breath or wheezing, [MEDICATION NAME] 20 mg QD for depression, [MEDICATION NAME] 3.125 mg BID for high blood pressure, and [MEDICATION NAME] 25 mg QD for hypertension/fluid buildup. 9. Resident #16 received his scheduled 9 AM medications between 11:01 AM and 11:04 AM, including: Levetiracetam 500 mg BID for convulsions, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 200 mg, [MEDICATION NAME] Extended Release 30 mg BID for high blood pressure. 10. Resident #17 received her scheduled 9 AM medications between 10:56 AM and 10:59 AM, including: [MEDICATION NAME] sprinkles 125 mg QD for mood stabilization, [MEDICATION NAME] 20 mg QD for depression, [MEDICATION NAME] 10 mg QD, and [MEDICATION NAME] 10 mg QD for high blood pressure. 11. Resident #18 received her scheduled 9 AM medications at 12:59 PM and 1:00 PM, including: Aspirin 81 mg QD for clot prevention, and [MEDICATION NAME] 20 mg QD for depression. 12. Resident #19 received her scheduled 9 AM medications at 12:42 PM and 12:43 PM, including: [MEDICATION NAME] 10 GM (gram)/15 ML QD, and [MEDICATION NAME] 100 mg BID both for constipation. 13. Resident #20 received her scheduled 9 AM medications at 11:46 AM, including: [MEDICATION NAME] 500 mg BID for [MEDICAL CONDITION], [MEDICATION NAME] 10 mg QD for depression, and [MEDICATION NAME] 100 mg 2 capsules TID for [MEDICAL CONDITION], and low back pain. On 4/05/21 at 4:58 PM, the Director of Nursing (DON) stated the parameters for medication administration included administering medications 1 hour before/ after scheduled time. The DON stated, that if medications were going to be late, the nurse should notify the physician, and document the communication. Record review revealed documentation could not be identified at this time to indicate the physician was notified of the late medication administrations for the sampled residents. On 4/06/21 at 10:40 AM, resident #7 stated she received her medications, but it takes them forever to give them to her. Resident #7 stated that sometimes she would get her 10 AM medication at lunch time. On 4/06/21 at 11:31 AM, a discussion was held with the DON, Administrator, Regional Nurse Consultant, and the Senior Regional Nurse Consultant. The DON stated at approximately 1 PM on 4/05/21, she was notified by the South Wing RN/UM that she was late with medications. The DON stated the facility realized there were some issues with timing of medications, and the sampled residents' medications were not administered timely. The DON said she worked on a medication cart last week, and had concerns herself, stating she struggled with the timely administration of medications on the South Wing. The Regional nurse stated they realized there was a problem with medication being given late on 4/05/21 and spoke with the nurse involved. Review of the facility's policy and procedure for Medication Administration Times with effective date 12/01/07 and revised on 5/01/10 read, Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration.

Based on observation and interview, the facility failed to ensure waste was contained and the garbage area was clean and free of debris. Finding: On Sunday 2/9/19 at 10:21 AM, the dumpster area at the back of the facility was noted to be unclean. There were disposed individual condiment packages that included salt, pepper, tarter sauce, numerous amount of cigarette ends and other debris near the 3 dumpsters. One of the dumpster's lid was open. At 10:45 AM, the certified dietary manager (CDM) arrived at the facility and stated that maintenance staff was responsible for keeping the dumpster area clean. The CDM added that no one should be smoking behind the dumpsters as there was a designated area for employees to smoke. The CDM said the dumpster doors must be closed and the area maintained in a sanitary condition to prevent the harborage and feeding of pests.

Based on observation, interview and record review, the facility failed to ensure newly hired, active and agency nursing staff were educated regarding clinical polices and procedures and evaluated for adequate competencies and skills to prevent unauthorized access to medication and treatment supplies on 1 of 2 units (North wing), and provide appropriate care and services for 6 of 55 sampled residents (#6, 34, 62, 72, 87 & 390). Findings: 1. On 11/14/18 at 9:15 AM, 2 unlocked storage cabinets and an unlocked treatment cart were observed on the North Wing. Both storage areas were well-stocked with central supply items such as hand sanitizer and barrier cream, and physician-prescribed ointments, creams, lotions and wound care supplies. At 9:18 AM, licensed practical nurse (LPN) P acknowledged she left the cart and cabinets unlocked. She explained she started wound treatments at about 8 AM that morning and retrieved supplies from the cart and cabinets and took them into residents' rooms. She stated she was not provided with keys for the cart or cabinets. LPN P explained a nurse on a medication cart had the key for the treatment cart and opened it for her. LPN P explained she worked for a nurse staffing agency and this was her second assignment in the facility. LPN P stated a nurse gave her instructions at the start of the shift, and described the process as very fast. She explained the instructions were quickly provided and not very detailed. LPN P did not recall any reviews of facility policy and procedures (P&Ps). On 11/14/18 at 9:44 AM, the North wing unit manager (UM) stated she usually did 1:1 training with agency nurses and certified nursing assistants (CNAs) at the start of their shifts. She explained she did not review LPN P's assigned tasks with her, but assumed she would secure the treatment cart and cabinets since it was standard nursing practice. However, the North wing UM confirmed she was aware LPN P did not have keys for either the treatment cart or the cabinet. 2. On 11/15/18 at 12:40 PM, LPN E provided wound care and applied a treatment to resident #62's sacral wound. She did not assess resident #62's pain level prior to starting the procedure and did not give pain medication in response to resident #62's complaints of pain during wound care. LPN E did not follow professional standards and the facility's P&P to avoid cross-contamination during the procedure. On 11/15/18 at 12:52 PM, LPN E stated she worked for a nurse staffing agency. She explained whenever she was called to a facility, it was usually an emergency or rush situation. She acknowledged she had never rounded with a wound physician as she was required to do that day, and had no specialized training in wound care. LPN E stated she was unsure of the requirements for rounding with the physician, and was not familiar with the residents' wounds. LPN E confirmed she was not familiar with the facility's process or the location of all necessary wound treatment supplies. On 11/16/18 at 3:07 PM, the assistant director of nursing (ADON) stated agency nurses usually did not do wound care. The ADON explained the facility employed a full time wound care nurse, who was currently on vacation. She stated education was provided verbally for new agency staff, followed by written education that would be signed by the nurse. The ADON acknowledged although LPN E was a nurse and therefore able to follow orders and do wound treatments, that particular assignment of rounds with the wound physician would have been more appropriate for the UM or a regular staff nurse. 3. On 11/16/18 at 8:58 AM, certified nursing assistant (CNA) M stated she had been on staff for about 6 months, and worked on an as needed (PRN) or part-time as needed basis. She was assigned to resident #72 who required extensive assistance of 2 staff members for transfers due to unsteady balance and left-side weakness. However, CNA M explained she transferred resident #72 between the bed and the wheelchair by herself. She stated she checked resident's care plans in a book kept at the nurses' station prior to giving care. The North wing UM interrupted and informed CNA M there was no book with that information, rather the facility used an electronic CNA care plan or Kardex. CNA M acknowledged she was not aware the facility used an electronic Kardex, and stated she did not recall completing any training on use of the electronic Kardex. 4. On 11/13/18 at 4:46 PM, registered nurse (RN) S gave medications to resident #87. Review of the Medication Administration Record [REDACTED]. RN S acknowledged she administered medications scheduled for later that shift in error. RN S acknowledged she did not check the scheduled administration time for all medications before she gave them to resident #87. In interviews conducted with the ADON, RN R and RN S on 11/16/18 from 3:09 PM to 4:38 PM, the ADON explained RN S was a new graduate nurse and worked under the supervision of RN R for a few days prior to being permitted to give medications on her own. She confirmed RN S's medication error occurred on her first unsupervised shift. The ADON acknowledged she was responsible for staff development and education, but did not recall reviewing the facility's P&P for medication administration with RN S. RN R informed the ADON she did not believe RN S was ready to work without supervision. RN S concurred, and stated she did not feel she should have been giving medications without supervision. The ADON stated a couple days prior to the medication error, she recalled RN R described the orientation period with RN S as going well. However, the ADON validated there was no orientation checklist to ensure nurses showed competence in all required tasks prior to working without direct supervision. 5. On 11/14/18 at 10:06 AM, during preparation of resident #34's scheduled morning medications, RN C included a tablet from a blister pack labeled with another resident's name and placed it in the pill cup. RN C acknowledged she did not adhere to the 5 rights of medication administration and check the name on the label prior to placing the pill in the cup. 6. Observations of resident #390 on 11/15/18 during the 7 AM to 3 PM shift revealed he had a urinary drainage bag with very dark amber urine and an extremely foul odor. During the shift, at 12:08 PM, CNA D stated she noticed the appearance and odor of resident #390's urine and informed RN C that morning. She stated RN C entered the room and observed the urine. At 2:31 PM, RN C confirmed CNA D reported concerns regarding resident #390's urine and acknowledged she did not follow-up appropriately. RN C said, I should have checked the tube output and called the physician. It could be an infection. 7. On 11/13/18 at 12:11 PM, during observation of lunch meal service on the South wing, CNA Q assisted resident #6. She buttered his roll while she held it with her bare hand. CNA Q stated that she worked at the facility for over 2 months, and no one had ever told her any other way to butter a resident's roll. On 11/16/18 at 3:25 PM, the ADON explained the Human Resources (HR) department reviewed facility P&Ps with all new employees, then nursing staff received further orientation on the units. She stated she educated agency nurses and had them sign off as confirmation of education. The ADON confirmed the facility did not have a standardized performance appraisal process to evaluate new hires or current employees. She explained there was no requirement or process in place for nursing staff to demonstrate competency in required skills. On 11/16/18 at 3:40 PM, the facility's HR manager stated she was responsible for new employees' pre-hire paperwork, and on their start dates, she reviewed HR policies and the corporate handbook. In contrast to the ADON's statement, the HR manager clarified she did not review any clinical P&Ps with new hire nurses. She explained nurses received their orientation on the units, and did assigned online classes and training. The HR manager stated RN C was hired about 6 weeks ago, and RN S was hired about 1 week ago. She was not able to provide transcripts with proof of completion of mandatory training prior to unsupervised interactions with residents. On 11/16/18 at 5:23 PM, the ADON confirmed neither RN C nor RN S had enrolled in any of the required online classes, including Medication Administration. Review of in-service attendance sheets revealed an in-service on medication administration given on 11/13/18 was attended by 10 of the facility's 31 nurses, and an in-service on food handling dated 11/13/18 was attended by 19 of 85 members of the nursing department. Review of attendance sheets provided by the ADON for in-services on code status (undated), [MEDICAL TREATMENT] communication (11/13/18), isolation precautions (10/25/18), smoking assessments (11/13/18), narcotic management (10/29/18), revealed less than 50% of the appropriate nursing staff were educated. The attendance sheet for food handling did not include a signature for CNA Q. The facility was not able to provide documentation of testing or evaluation of competencies related to the education provided. Review of the Facility Assessment, revised 11/01/18, detailed the facility resources needed to provide competent support and care for residents. The document specified mandatory staff education and competency requirements .that are necessary to provide the level and types of support and care needed The competencies included the areas of activities of daily living care, infection control, medication administration, resident assessment and evaluation and specialized care such as catheter care and wound dressings. The Facility Assessment did not include information on the method(s) the facility would use to evaluate competencies and validate knowledge and proficiency of nursing staff.

Based on record review and interview, the facility failed to effectively administer its resources to maintain a safe, clean and homelike environment, and failed to evaluate and ensure competency of nursing staff to meet the needs of residents. Findings: Cross reference: F558, F584, F686, F690, F726, F759, F761 and F812 Review of the job descriptions for the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed administrative functions including developing, evaluating and directing the nursing department. He/she was expected to assist in evaluating nursing personnel and ensure nursing staff were .performing duties in accordance with acceptable nursing standards The DON and ADON had staff development roles that included developing and implementing training and in-services for nursing staff. Review of the job description for the Nursing Home Administrator revealed he/she was responsible To direct the day-to-day functions of the facility to ensure that the highest degree of quality care can be provided to the residents at all times. The administrator was expected to ensure all facility employees complied with all policies and procedures (P&P) and identify problems and deficiencies His/her staff development duties included assisting with .planning, developing, conducting and scheduling orientation, in-service training, on-the-job training and other educational activities for personnel to ensure that current materials and programs are continuously provided. The administrator's duties also required that he/she would ensure the facility was maintained in good repair. On 11/16/18 from 2:59 PM to 3:25 PM, the ADON stated department managers were assigned to do room rounds every morning and were expected to provide the results to the administrator every day. However, she explained managers did not always comply, and acknowledged they required education since they were apparently not identifying environmental concerns. The ADON stated to her knowledge, newly hired nurses reviewed all facility policies and procedures (P&Ps) with the Human Resources (HR) Manager on hire. She explained new nursing staff then shadowed staff on the units, and were also expected to do mandatory online training. She stated agency nurses should be educated before their shifts. The ADON acknowledged the facility did not currently have an organized and consistent system to ensure nursing staff received all the mandatory education and demonstrated competencies prior to providing care and services for residents. In addition, she confirmed the facility did not have a standardized performance appraisal process to regularly evaluate competencies of active employees at regular intervals. On 11/16/18 at 3:40 PM, the HR Manager acknowledged she met with newly hired employees on their first day. However, in contrast to the ADON's statement, the HR Manager explained she reviewed the corporate handbook and only mandatory HR policies, such as abuse and residents' rights, with new employees. The HR Manager stated she was not involved in organizing or scheduling any additional orientation for clinical staff. On 11/16/18 at 4:18 PM, the administrator confirmed he was responsible for oversight of the new employee hiring process. He explained there should be a 2-day orientation for all new employees. The administrator acknowledged he was not aware newly hired nurses were not receiving a 2-day orientation nor being educated with the facility's clinical P&Ps. He acknowledged responsibility for oversight of the room rounds process and stated he did occasional audits of daily room rounds checklists, but performed regular inspections of the common areas only. The administrator validated there was lack of effective communication between administration and other departments.

Based on observation and interview, the facility failed to accommodate a preference to use side rails on the bed, for 1 of 55 sampled residents (#72). Findings: Resident #72 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment with assessment reference date of 10/16/18 revealed resident #72 had clear speech, was able to express ideas and wants, and had clear comprehension. She required extensive assistance from staff for bed mobility, transfers, dressing and personal hygiene. Resident #72 was unsteady during transfers and could stabilize only with assistance from staff. She had limitation in range of motion of her extremities on one side and used a wheelchair for mobility. The assessment showed resident #72 did not have side rails on her bed. On 11/13/18 at 11:17 AM, resident #72 stated she wanted side rails for her bed. She said, I've asked the head nurses and maintenance. She explained she slept on her back because she was afraid to roll to her side and fall off the bed. On 11/15/18 at 12:03 PM, resident #72 recalled she first asked the maintenance assistant about getting side rails attached to her bed. She explained she asked several staff members in the last 6 months, and discussed it again with the maintenance assistant as recently as within the past week. Resident #72 said,I really need them. She explained she once fell out of bed when she reached for a fork on the floor. She said, If I had side rails, I would have been able to hold on. Resident #72 stated it would also help to have side rails when staff rolled her from side to side in bed to provide care. On 11/15/18 at 3:17 PM, the maintenance assistant acknowledged resident #72 asked him about getting side rails for her bed more than 3 months ago. He explained he was not permitted to install side rails without authorization from nursing staff and his supervisor. The maintenance assistant stated he informed a member of the nursing staff of resident #72's request but received no follow-up. On 11/15/18 at 3:33 PM, certified nursing assistant (CNA) K stated she was aware resident #72 wanted side rails installed on her bed. She recalled resident #72 told her, One of these days I'm going to fall out of this bed. CNA K explained resident #72 had gained weight and felt she was too large to safely roll over in the bed. CNA K confirmed resident #72 asked her about getting side rails for her bed. She said, I told a nurse but I don't remember who. I think I also mentioned it to a co-worker. CNA K stated resident #72 required assistance for transfers and moving in bed. She acknowledged side rails would be helpful as resident #72 was weak on one side of her body. On 11/15/18 at 5:55 PM, registered nurse L validated resident #72 was alert, oriented and able to make her needs and wants known. She acknowledged resident #72 was a reliable historian, and surmised that staff probably did not follow up on resident #72's request for side rails. On 11/16/18 at 3:04 PM, the Assistant Director of Nursing stated her expectation was facility staff would communicate residents' requests appropriately, and accommodate their preferences if possible.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure a clean, safe and homelike environment in 3 of 24 rooms on the North Wing (124, 128 & 140). Findings: 1. On 11/13/18 at 1:03 PM, an inspection of room [ROOM NUMBER] revealed the ceiling tiles above bed A were not fitted properly in the supporting frame. Gaps between the ceiling tiles, the frame and surrounding wall exposed small areas of pink insulation material. Small particles of the insulation fell from the ceiling onto the resident in bed A and a visitor seated on a chair to the left of the bed. Across the room, a capped hose approximately 18 inches long, attached to the cold water supply line of the pedestal sink, protruded into the room at a 45 degree angle. Beside bed B, there was a wall-mounted air conditioning (AC) unit that was displaced from the wall about 1.5 inches. There were gaps between the wall and the air conditioner (AC) unit and remnants of old caulking around the edges of the AC unit's front panel. 2. On 11/15/18 at 4:37 PM, inspection of room [ROOM NUMBER] revealed a gap between ceiling tiles and the wall behind bed A. The ceiling tiles directly above bed B had significant sagging noted in the center of each tile. One ceiling tile above the window had a brown circular stain that covered approximately half the tile. The AC unit was displaced about 3/4 inch from the wall, and evidence of old caulking was visible around the unit. On 11/16/18 from 9:55 AM to 10:19 AM, a tour of rooms [ROOM NUMBERS] was done with the Director of Plant Operations (DPO). In room [ROOM NUMBER], the DPO acknowledged the AC unit did not fit the sleeve properly and noted someone used caulking to try and fill the gap around the unit. He described it as ugly. The DPO then checked the hose protruding from the right side of the pedestal sink and said, It is a water line, but to what I don't know. He validated the ceiling tiles above bed A did not fit properly and needed to be replaced. In room [ROOM NUMBER], the DPO confirmed the ceiling tiles were sagging, stained, improperly fitted and needed to be replaced. He stated the ceiling tile with the brown stain appeared to be old water damage. The DPO acknowledged the AC unit did not fit the sleeve in the wall. He suggested the spaces around the AC units in both rooms should have been covered with trim rather than caulking. The DPO acknowledged rooms [ROOM NUMBERS] did not have a pleasant, homelike appearance. The DPO explained he inspected the facility's common areas regularly, but did not do preventative maintenance rounds in residents' rooms. The DPO explained he depended on department heads who conducted room rounds every morning or housekeeping and direct care staff who were in residents' rooms regularly throughout the day to report any maintenance issues. He said, My assistant and I go into rooms when something is reported. We do focused visits but do not look at everything. On 11/16/18 at 2:59 PM, the assistant director of nursing (ADON) confirmed department managers were required to check assigned rooms every morning. Review of the Room Round Assignments form (revised 1/25/18) with the ADON revealed the Staffing Coordinator was responsible for daily inspection of 124 and the Business Office Manager was responsible for daily inspection of room [ROOM NUMBER]. She provided a copy of the Patient Satisfaction & Environmental Customer Service Daily Rounding Tool form that should be used to document environmental concerns. She explained staff were expected to give completed forms to the administrator, but said, We don't always fill out the form. We need to do education regarding things to look for in the environment. Review of work orders logged in the building management computer program for (MONTH) and (MONTH) (YEAR) revealed no reports of the concerns identified in rooms [ROOM NUMBERS]. The facility's policy and procedure for Preventative Maintenance Program, revised 1/01/18, revealed the intent to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public. The document indicated the Maintenance Director was expected to develop and implement a schedule of maintenance services and assess all aspects of the facility to identify preventative maintenance needs. The policy revealed required preventative maintenance could be determined from maintenance requests and grand rounds. 3. Observations conducted in room [ROOM NUMBER] on 11/15/18 at 9:08 AM, 12:34 PM and 3:39 PM, and on 11/16/18 at 7:46 AM and 7:50 AM revealed the wall behind the head of the bed for 128 B to have multiple dark brown stains. The wall behind the head of the bed for 128 A to have light brown drip stains from the ceiling down the wall. On 11/16/18 at 7:50 AM the North Wing Unit Manager (NWUM) stated that she conducts daily room rounds in all of the resident rooms observing for room cleanliness. The NWUM confirmed the above findings and stated that the wall needed to be cleaned. On 11/16/18 at 7:50 AM the Assistant Director of Nursing/Infection Control Nurse confirmed that the wall in room [ROOM NUMBER] was soiled. On 11/16/18 at 7:57 AM, the Environmental Services Director stated that the North wing has one (1) Housekeeper assigned to clean 24 rooms, 1 resident room for deep cleaning per day, the nurses' station and the dining areas all in a 7 hour shift. She said, This is way more rooms than the housekeeper can handle. Review of the Contracted Housekeeping Company Name, Daily Patient Room Cleaning, dated 6/2016, read, Timing and Method 3) Spot clean. With a cloth and disinfectant spot clean all vertical surfaces Review of the Facility Name, Room Round Assignments dated 1/25/18, read, Staffing Coordinator .128

Based on record review and interview, the facility failed to ensure that the bed hold notice was given to the resident or representative at the time of transfer or as soon as possible after admission to the hospital for 1 resident reviewed for hospitalization (#33). Findings: Resident #33 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. A review of the medical record revealed that on 10/30/18 at approximately 9 PM, the resident's wife informed staff the resident was having shortness of breath and mucous in his trachea. The nurse attempted to suction the resident but was unable to insert the catheter for suctioning. The oxygen (O2) saturation was 85-86% on 2 liters of oxygen. The O2 was increased to 3 liters with no O2 saturation improvement. The physician and emergency services were contacted. The on-call nurse practitioner ordered the resident to be sent to the hospital. There was no documentation in the clinical record that a bed hold notice was given to the resident or his wife at the time of discharge. There was no copy of the notice or a progress note stating that the information was provided. On 11/16/18 at 2:45 PM, an interview with the north wing unit manager (UM) revealed that the nurse at the time of the transfer to the hospital should have completed the forms. A copy was not kept. The North wing UM was not aware that the form had to be given to the resident or responsible party. On 11/16/18 at 2:48 PM, an interview with the medical records staff revealed that it was nursing responsibility to complete and send the transfer and bed hold form. On 11/16/18 at 3:03 PM, an interview with the admissions coordinator revealed that the bed hold policy was in the admission packet. She had no responsibility after admission for bed hold notices. Review of the facility acute care transfer document checklist noted the following information: inclusion of the transfer form, bed hold policy notice and information to be sent to the hospital. Review of the facility Bed hold and Readmission Policy (ADM-FL), effective 8/15/16, Bed hold defined the bed will be held if the facility has an occupancy of at least 95 %. The bed will not be held if the Medicaid occupancy was below the 95%. If the resident while in the hospital chooses not to return, the hospital of the resident is to notify the facility prior to the end of the 8-day allowable period. On 11/16/18 at 3:35 PM, the administrator confirmed that there was no documentation to confirm that bed hold notice and transfer notice were given to the resident or responsible party at the time of transfer or after they were admitted to the hospital.

Based on observation, interview and record review, the facility failed to ensure that 1 of 1 resident reviewed for hearing loss received the services to assist the resident in his ability to improve his hearing, (#78). Findings: Resident #78 was admitted to the nursing home after a hospitalization for left [MEDICAL CONDITION] with artificial hip replacement. On 11/15/18 at 10:09 AM, the resident repeatedly made requests to speak louder since he was hard of hearing. He stated that his left ear was much worse than his right ear. He said that he saw an audiologist a few months ago and was told he would have hearing aids in about two weeks. He had not received any hearing aids or assistive devices since them. Review of clinical record revealed an order for [REDACTED]. There was no documentation of the appointment. There were no results from the visit. On 11/15/18 at 4:42 PM, the social services assistant revealed that the facility tried to get him an appointment. They could not find a physician that accepted his Medicaid insurance. On 11/15/18 at 4:55 PM, licensed practical nurse A confirmed that he had been hard of hearing and had no assistive devices. She confirmed that no appointment for a hearing consult had been made due to insurance payment source. Review of the significant change minimum data set assessment (MDS), dated [DATE], revealed that resident #78's hearing was highly impaired and that he no hearing aid or other hearing appliance. A quarterly MDS assessment dated [DATE] also noted severe hearing impairment and no assistive hearing devices. Review of the plan of care initiated 6/01/18 and revised on 8/21/18 identified that resident #78 was identified that he was hearing impaired with no hearing in his left ear and has difficult time hearing of his right ear. Interventions included to use a megaphone to help communicate with resident. Put megaphone up to resident's right ear. The goal was to be able to make needs known through next review. Other interventions included: Approach resident in a manner that will not surprise or startle him. An auditory consult dated 6/01/18, minimize background noise. Refer Resident # 78 for a device intervention as appropriate. There was a documented order for Audiologist consult on 8/29/18. On 11/15/18 at 5:05 PM, the director of rehabilitation stated that he had not received any referrals to assess for assistive hearing devices, which he would refer to the speech therapist. The speech therapist would help assess his condition and make recommendations for a temporary device. On 11/16/18 at 11:30 AM, the speech pathologist said that when a resident has been identified with a hearing loss, that was a severe impairment, she would try an assistive hearing device that amplified sound using head phones. She would ask family if the resident had any hearing device prior to admission. No one had asked her to assess Resident #78's hearing loss. The resident was never given any assistive device or referred to therapy services to help improve his ability to hear information shared by staff or assist him communicating with other residents.

Based on observation, interview and record review, the facility failed to provide personal grooming related to removal of facial hair for 1 of 5 residents reviewed for activities of daily living, (ADLs), (#61). Findings: Resident #61 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 14-day assessment with assessment reference date of 10/15/18 revealed resident # 61 was alert and oriented however she needed extensive assistance of one person for dressing and personal hygiene. On 11/13/18 at 11:05 AM, resident #61 was seen seated in her wheelchair in the common dining area of the North Wing. She was noted to have several white facial hairs on her chin area, approximately half inch long. The following day, 11/14/18 at 9:07 AM, resident #61 was lying in bed. She still had long facial hair. At 1:36 PM, resident #61 sat in the common dining area in the North wing and her facial hair was still noticeable. On 11/15/18 at 9 AM, resident #61's facial hair remained unchanged. At 10:32 AM, resident #61 stated she would like her facial hair to be shaved regularly. She explained when she was at home, she was doing it by herself. On 11/15/18 at 11:07 AM, certified nursing assistant (CNA) Q stated that resident #61 was always cooperative with ADL care. At 2:50 PM, in an observation with the North wing unit manager (UM), she validated that resident # 61 had long facial hair. When the UM asked the resident if she wanted it removed, the resident replied yes. The UM acknowledged it was any CNA's responsibility to provide assistance with grooming. Review of resident #61's medical records on 10/02/18 revealed a care plan for grooming assisted by staff. The care plan goal was resident will be well groomed on a daily basis. The intervention included to allow resident to direct grooming. Review of progress notes from (MONTH) to (MONTH) (YEAR) revealed no documentation of refusal of ADL care for this resident. The policy and procedure for Activities of Daily Living, Supporting, revised (MONTH) (YEAR), indicated that residents who are unable to carry out ADL will receive the services necessary to maintain good grooming and personal hygiene. Review of the CNA job description revealed that the CNA is expected to assist residents with bathing and grooming.

Based on interview and record review, the facility failed to ensure residents were free from neglect by not providing adequate supervision and not being available for care and services during activity outings. This resulted in resident #1 who is dependent upon staff for assistance, attempting to toilet himself after he could not locate staff, sustained a fall, and fractured his right hip. Eight other residents attending the outing (#2, 3, 4, 5, 6, 7, 8, & 9) were left without any other staff supervision or assistance and were at high risk for potential serious injury/impairment/death. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. (42 CFR 488.301) On 02/08/17, during an activity outing to a large supercenter, 9 residents left the facility in 2 different buses with one staff member. All of the residents were long-term care residents, requiring 24-hour nursing care and had different levels of mobility and needs for assistance. During the outing, the staff member had to be paged by supercenter staff to come to assist resident #1 in the public restroom. The resident was incontinent of feces and fell in the restroom. While the staff member was with resident #1 for approximately one hour, the 8 other residents were left in the supercenter with no staff members to assist and with no mechanism to call for staff assistance. Resident #1 sustained serious injury, [MEDICAL CONDITION], requiring hospitalization . Cross Reference F248, F312, F323, F490, F520 The failure to identify and prevent neglect resulted in substandard quality of care and immediate jeopardy starting on 02/08/17 and it was determined to be ongoing as of the exit date on 04/07/17. Findings: An activity outing to a supercenter occurred on 2/08/17. Two buses departed the facility at 8:30 AM with 9 residents and one activity assistant to the supercenter. The activity director was to follow the buses in her own personal car, but she did not attend. At 9:15 AM, while she was still in the facility, she sent a text message on her personal cellular phone to the business office manager who was in the morning meeting with the administrator. The business office manager informed the administrator that the activity director sent her a message that she had to go home and would not be going to the outing at the supercenter, already in progress. The group of 9 residents and one activity assistant arrived at the supercenter at 9:00 AM and 7 residents, including resident #1, went in different directions in the store to shop. The activity assistant stayed with 2 residents, #2 and #4. Resident #2 required one person to move her wheelchair and #4 was cognitively impaired. A review of the care plans of the 9 residents attending the outing on 2/08/17 showed that 5 of the residents required wheelchairs for mobility (#1, 2, 3, 4 & 8), 3 residents required walkers (#5, 7 & 9) and one resident was independent with ambulation (#6). Three residents required extensive assistance with toileting and they were incontinent (#1, 2 & 3) and one resident (#8) required supervision with toileting. Resident #1, is a [AGE] year old resident with [DIAGNOSES REDACTED]. He was at high risk for falls and had 9 falls within the past year. He is dependent upon a wheelchair for mobility, has chronic pain and is dependent on staff for toileting and for his activities of daily living. On 4/04/17 at 9:50 AM, the resident stated that he had urgency for bowel movement shortly after arriving at the supercenter and could not find the activity assistant in the area. He went to the public restrooms. The resident said that he was aware that he needed assistance to use the toilet, but felt he had no choice because he could not find the activity assistant and did not want to have an incontinence accident in the store. As the resident attempted to transfer himself from his wheelchair onto to the toilet, his bowels began to move. He then slipped and fell to the floor in his feces. The resident said he heard a crack sound when he fell and started to yell for help. An unknown bystander was there and said that he would get help. The resident tried to pull himself up by using the safety rail, but he could not get up. He said the activity assistant came after some time to clean him and tried to transfer him into the wheelchair but could not do it by himself and had to get help from a bystander. The resident stated that even though he would have been embarrassed to have a bowel accident in his pants in the middle of the store, he was even more embarrassed about the accident in the restroom, falling in his feces, and having the activity assistant and a stranger clean him and try to help him back into his wheelchair. The activity assistant stated on 4/04/17 at 11:18 AM that on 2/08/17 he was with two residents when he heard his name being paged overhead requesting him to come to customer service. He stated that he went to customer service with residents #2 and #4 and was informed that someone from his group needed help in the men's restroom. He went to the men's restroom and told resident #2 and #4, female residents, to remain near the men's restroom. He stated that when he went into the restroom, he observed resident #1 hanging onto the safety rail trying to pull himself up. He said, when he (the resident) saw me enter the restroom, he let himself down to the floor and he was covered with feces on his clothing. There was feces on the floor and the toilet. He said he did not have any care supplies with him and the supercenter supervisor gave him latex gloves, paper towels and garbage bags. He cleaned the resident as much as he could and the supercenter housekeeping staff member had to help him transfer the resident into the wheelchair with difficulty because they were slipping in the feces. He said resident #1's clothes were soiled, so he had to ask the supervisor to buy new shorts, shirt, socks and sandals so that he could dress the resident. The activity assistant took approximately one hour to provide care to resident #1 in the men's restroom, leaving 8 other residents unsupervised and without any assistance in a large supercenter which was approximately 150,000 square feet in size. The activity assistant said that when they exited the restrooms at approximately 10:30 AM, resident #1 told him than he still wanted to buy something in the store. The activity assistant said that he did not want resident #1 to do any shopping because he smelled bad, but resident #1 wanted to go. Resident #1 then went to shop in an area of the store that was not within sight of the activity assistant. The activity assistant assisted residents #2 and #4 to another area in the front of the store, leaving resident #1 on his own. He said that they all met at the eating area in the supercenter to board the buses and returned to the facility at 12:15 PM. He stated that resident #1 did not complain of any pain and he rode on the same bus as resident #1 on the return trip to the facility. Resident #1 was found to have a fractured right hip one day after the outing. The activity assistant stated that he was not concerned about going on an outing by himself with 9 residents as that was the normal practice for outings to the supercenter. He said he had been going on outings as the only staff member attending for the past two years with 5-8 residents. He did not call the facility to report the resident's fall when it occurred. He said he did not think of calling the facility to ask what steps he should take or to get assistance after he found the resident on the floor in the restroom. He stated that he was in a hurry to get resident #1 off the floor and only asked him if he had any pain. He said the thought of calling for an ambulance did not cross his mind. He stated that he had not been trained about emergency care during activity outings that occur outside the facility. He said that he was aware that the other residents were on their own while he was with resident #1, but since he did not have any other options, he said he told residents #2 and #4 to remain near the restroom. On 04/04/17 at 10:35 AM the activity director stated that they have had monthly outings to the supercenter for many years with 5-8 residents and one activity assistant. The activity staff have never had any formal education regarding facility outings and emergency care while on outings and there was no policy and procedure for activity outings. She stated it is hard to prevent falls or accidents and anticipate their needs while at the supercenter because the residents are on their own. It is very tricky because it is such a big area, it is hard to keep track of the residents. An interview with the administrator on 4/04/17 at 12:50 PM revealed that the facility had not identified any of the events that occurred on 2/08/17 as neglect and did not consider neglect even after resident #1 fell and sustained a fracture on the outing. Their conclusion was that they did not provide enough staff attending the outing. He stated he was aware that 9 residents were going on the supercenter outing with only one activity assistant on 2/08/17, but he was not concerned as they usually had one assistant going on outings. When he was asked how one staff member could possibly assist a resident with toileting and at the same time supervise 8 other residents, the administrator stated, We never had any issues before and I didn't think anything of one staff being there with the residents. He said he did not think of canceling the outing or sending extra staff. He said he could have sent the other activity assistant or a certified nursing assistant who had been assisting with activities, but he did not think of it. He stated the staff on outings used their personal cellular phones if they had to contact the facility. He said looking back, he would do things differently and would send more staff to supervise. On 4/04/17 at 12:50 PM the administrator stated that he, the regional consultant, and the corporate risk manager developed a form to use for outings which would determine how many staff would accompany residents on outings. A review of the form dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request noted resident information. It listed the assistive device used by resident, level of assist for toileting, the fall risk score, the elopement risk score, the code status, any food or fluid restriction/allergy, and the resident's brief interview for mental status (BIMS) score. The BIMS is a brief screening tool that aids in detecting cognitive impairment. It does not assess all possible aspects of cognitive impairment. The form did not include any other special needs, such as oxygen. The administrator stated the activity director completes the form 3 days before the scheduled activity outing. The director of nursing reviews and signs off on the form and then it is his responsibility to determine the number of staff to go on the outing with the residents. He was not able to describe how he would determine the number of staff needed and how he would schedule the number of staff to go on the outing. The form did not clearly address a procedure for how to determine the level of supervision required for each resident while on outings, the sufficient number of staff to be present on an outing, a system to supervise the residents while on outings, and a system for residents in need of assistance and residents who require care and services. He stated the facility did not have a policy and procedure related to facility outings. The administrator stated on 04/04/17 at 12:50 PM that they used the new form for the next outing to the supercenter on 3/14/17. A review of the completed form that was used on the 3/14/17 outing showed that only 2 residents, #5 and #6, attended the outing. There were 4 residents who were scheduled to go on the outing, but 2 residents canceled on the morning of the outing. The form showed that resident #5 had a score of 5 for fall risk and resident #6 had a score of 4 for fall risk. The administrator was not able to explain what the score numbers indicated. He was not able to explain if the scores of 4 and 5 were high risk or low risk. He was also not able to explain what the elopement risk scores indicated on the form. When he was asked how he was able to determine the number of staff needed for supervision of these two residents when he did not have an understanding of the information on the form, he did not have an answer. When he was asked how he could determine whether or not the form was effective for the March outing, he stated only 2 residents attended the outing, so they could not make any determination of the effectiveness of the form. Another outing to the supercenter was planned for 4/11/17, but there were no other changes for the procedure for activity outings to the supercenter other than the Activity Outing Request form, even though the administrator could not explain the significance of the resident data collected or how it would be used to ensure residents are safe and supervised appropriately for resident outings.

Based on observation, interview and record review, the facility failed to implement activities in accordance with residents' identified care needs, resulting in 1 of 9 residents attempting to toilet himself, falling and sustaining a [MEDICAL CONDITION], (#1) and leaving 8 other residents at risk for potential serious injury/impairment/death (#2, 3, 4, 5, 6, 7, 8 & 9). On 02/08/17, during an activity outing to a large supercenter, nine residents left the facility in 2 different buses with one activity staff member. All of the residents were long-term care residents, requiring 24-hour nursing care and had different levels of mobility and needs for assistance. The staff member had to be paged by supercenter staff to come to assist resident #1 in the public restroom. While the staff member was with resident #1 for approximately one hour, the 8 other residents were left in the supercenter with no staff members to assist and with no mechanism to call for staff assistance. Resident #1 sustained serious injury, a [MEDICAL CONDITION], requiring hospitalization . Cross Reference: F223, F312, F323, F490, F520 This negative outcome and the facility's failure to recognize the need for and development of a system for activity outings for appropriate supervision and a way for residents and staff to call for assistance when needed resulted in substandard quality of care and immediate jeopardy starting on 02/08/17 and it was ongoing as of the exit date on 04/07/17. Findings: An activity outing to a supercenter occurred on 2/08/17. Two buses departed the facility at 8:30 AM and took 9 residents and one activity assistant to the supercenter. The activity director was to follow the buses in her own personal car, but she did not attend. At 9:15 AM, while she was still in the facility, she sent a text message on her personal cellular phone to the business office manager saying she had to go home and would not be attending the outing. She did not inform the administrator at that time. The business office manager informed the administrator that the activity director had to go home and would not be going to the outing at the supercenter, already in progress. The group of 9 residents and the activity assistant arrived at the supercenter at 9:00 AM. Seven residents, including resident #1, went in different directions in the supercenter to shop while 2 residents, #2 and #4, were with the activity assistant. A review of the care plans of the 9 residents attending the outing on 2/08/17 showed that 5 residents required wheelchairs for mobility (#1, 2, 3, 4 & 8), 3 residents required walkers (#5, 7 & 9) and one resident was independent with ambulation (#6). Three residents required extensive assistance with toileting and were incontinent (#1, 2 & 3) and one resident (#8) required supervision with toileting. Resident #1, was a [AGE] year old resident, with [DIAGNOSES REDACTED]. His care plan identified that he was able to voice his needs, was a high risk for falls, had 9 falls in the past year, was wheelchair dependent, had chronic pain, and was dependent on staff for toileting and activities of daily living including transfers, eating and dressing. He had a suprapubic catheter and was incontinent of bowel at times, but was also able to tell staff when he needed to use the toilet. On 4/04/17 at 9:50 AM, the resident stated that he enjoyed going to the supercenter and it was his favorite outing and he liked to shop. He stated that shortly after arriving at the supercenter, he had an urgent need to use the restroom, but he could not find the activity assistant in the area. He said he did not want to have an accident. He was aware that he needed assistance to use the toilet, but felt he had no choice. He said he attempted to transfer himself from his wheelchair onto the toilet, his bowels began to move, he slipped and fell . The resident said he heard a crack sound as he fell and started to yell for help. An unknown person was in the restroom and said he would get help. The activity assistant was paged and came after some time and cleaned him up, dressed him and tried to transfer the resident into the wheelchair, but could not do it on his own and had to get help. He stated that he was embarrassed about the accident in the restroom, falling, and having the activity assistant and a stranger clean him up. It was discovered that the resident sustained [REDACTED]. The resident was transferred to the hospital for surgical repair of the right [MEDICAL CONDITION] on 2/10/17. A review of the activities care plan with a target date of 6/01/17 noted that the interventions for resident #1 had not changed. The care plan read that the resident enjoyed attending facility outings. There were no interventions as to how the facility would supervise and keep the resident safe while on outings. The date of the last review and intervention was noted on 8/09/15. An interview with the activity assistant on 4/04/17 at 11:18 AM revealed that he had been an activity assistant for two years. He stated that there were monthly outings to the supercenter because it was a favorite outing for residents. He said he had attended numerous outings to the supercenter with 5-8 residents. He stated that on 2/08/17, two buses were used for transporting 9 residents and himself. There were 4-5 residents on each bus and he randomly chose which bus to ride. Because he was the only facility staff attending the outing, the residents on the other bus were without supervision. He stated that they arrived at the supercenter at 9:00 AM and 7 residents, including resident #1, went in different directions to shop. He stayed with residents #2 and #4. Resident #2 needed a staff member to move her wheelchair and #4 was cognitively impaired, but was able to mobilize her wheelchair without assistance. He stated that he was with these two residents when he heard his name being paged overhead requesting him to come to customer service. He stated that he headed to customer service with residents #2 and #4 and was informed that someone from his group needed help in the men's restroom. He went to the restroom and told the two residents to remain near the restroom even though one of the residents had severe cognitive impairment. He stated that when he went into the restroom, he observed resident #1 hanging onto the safety rail trying to pull himself up. The activity assistant said, when he saw me he let himself down. There was feces on his clothing, the floor, and the toilet. I asked the supercenter supervisor to help me, but she could not tolerate the odor in the restroom. She asked the supercenter housekeeping man to assist me. The activity assistant stated that he did not have any supplies with him and the supercenter supervisor gave him latex gloves, paper towels and garbage bags. He said he cleaned the resident up as much as he could and the supercenter housekeeping staff assisted him to transfer resident into the wheelchair. He said he had to ask the supervisor to buy some clothing for the resident #1 as his clothes were soiled. She bought shorts, shirt, socks and sandals so that he could dress the resident. When they exited the restrooms, resident #1 wanted to buy something in the jewelry section so he went there. He said that he did not want resident #1 to do any shopping as he smelled bad but he wanted to go. While resident #1 was shopping without supervision, he took resident #4 and resident #2 to the nail salon located in front of the supercenter. An interview with the advanced registered nurse practitioner (ARNP) on 4/06/17 at 10:08 AM noted that she had known resident #1 since September 2016. She said the resident had chronic constipation and chronic ileus, and his bowel movements were unpredictable. He could have the need use the toilet at anytime as he received several laxatives in the morning of the activity outing. She said resident #1 had dementia and was a very high fall risk. He had [MEDICAL CONDITION] and his legs were very weak. He should never go anywhere on his own, especially a large supercenter. Someone needed to have sight of him at all times. In the nursing facility, there are ways for residents to call for help, but not in a supercenter. An interview with the activity director on 4/05/17 at 11:05 AM revealed that she had worked at the facility for [AGE] years. She stated that the monthly supercenter outing was a favorite for residents. She had always sent one person on outings as that was their normal procedure. She stated that sometimes she would also attend the outings, but she did not provide assistance or supervision for the other residents. She was there to shop for residents who could not attend the outing. When questioned about residents who were falls risk, she stated, it is difficult to prevent falls at the supercenter because residents are on their own. It is tricky as it's a big area and hard to keep track of residents. An interview with the administrator on 4/04/17 at 12:50 PM revealed that the activity director managed the outing, but since 2/08/17, he is more involved in directing the outings. He stated that he was aware that 9 residents were going on the outing with only one activity assistant on 2/08/17, but he did not think anything of it because they usually only send one activity assistant on outings. He was familiar with the residents on the outing and their care needs. When he was asked how one staff member could possibly assist a resident with toileting, and at the same time supervise 8 other residents, the administrator stated, We never had any issues before and I didn't think anything of one staff being there (at the supercenter) with the residents. He stated that he, the regional consultant and corporate risk manager had recently developed a form to use for outings which would determine how many staff would accompany residents on outings. A review of the form dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request noted resident information from 3/14/17 for 2 residents, #5 and #6. It listed the assistive device used by resident, level of assist for toileting needed, the fall risk score, the elopement risk score, the cardiopulmonary resuscitation status, any food or fluid restriction/allergy and the resident's brief interview for mental status (BIMS) score. The administrator stated the activity director fills out this form 3 days before the scheduled activity outing, then the director of nursing signs off on the form, and then he is responsible to determine the number of staff that go on the outing with the residents. The form showed that resident #5 had a score of 5 for fall risk and resident #6 had a score of 4 for fall risk. The administrator was unable to explain how the fall scores were used to determine the number of activity staff needed to provide supervision and care needs to residents on outings. He did not explain how he would determine the number of staff and how he would schedule the staff needed to go on the outing. He stated that it was unusual for only 2 residents attend an outing, so they could not evaluate the effectiveness of the form. On 4/04/17 at 2:22 PM, resident #3 stated that she went to the supercenter in her motorized wheelchair and used oxygen continuously. She said that when they arrive at the store, everyone goes shopping in different directions. She stated that it took her a long time to use the restroom. She knew that the activity assistant had a personal phone, but did not know the number. She stated that if she needed assistance, she would have to find the activity assistant. If she had a fall or accident, she would have to scream for him. Although the resident stated that she enjoyed going to the monthly supercenter outings, there was no mention of the outings in her care plan with a target revision date of 5/02/17, and no interventions as to how to provide care and supervision when on outings. On 4/04/17 at 2:32 PM, resident #5 stated that she used a walker in the facility, but used the supercenter's electric scooter while on shopping outings. She stated she enjoyed the outings to the supercenter. She stated she was not aware of how she would find or contact the activity assistant when in the supercenter. The resident's care plan for activities, with a target date of 4/19/17, noted she enjoyed the outings to the supercenter, but there were no interventions identifying the need for supervision or assistance during outings. On 4/04/17 at 2:35 PM resident #7 stated he was independent with toileting in the facility, but it was different in a supercenter as it was not set up like his restroom in the facility. He stated he used a walker in the facility but required an electric scooter in the supercenter as he was unable to walk for long distances. He stated he parked the scooter outside the restroom and walked into the restroom slowly. He stated that if he needed assistance in the supercenter, he did not have any way of contacting the activity assistant except to look for them. He stated that it would take him at least 15 minutes to find them using the scooter as it is a large store and the activity staff person could be anywhere. A review of the resident's care plan for activities, with target a date of 5/01/17, did not have any documentation of any outings or supervision/assistance needed during outings. On 4/04/17 at 2:56 PM, resident #8 stated she liked the outings to the supercenter. She is independent with ambulation in the facility, but used her wheelchair while shopping. She stated that an activity assistant is in the store, but she did not know how she would contact him or where to find him. The resident's care plan showed no documentation of any outings. The resident's care plan for activities, with a target date of 4/17/17, did not show any measures for outings except, staff will invite resident to scheduled activities of known interest such as bingo, social events, music entertainment, group games and outings. On 4/04/17 at 2:50 PM resident #9 was observed walking from the dining room to her room using her walker. She stated that she enjoyed the supercenter outings and used her walker when she was in the store. She said she shopped on her own. She was not aware of how she would get in touch with the activity assistant while in the store. She stated that she was only aware that she had to return to the eating area when she finished shopping. A review of the activities care plan, with a target date of 4/17/17, showed no interventions regarding outings to the supercenter. There was no documentation of the resident's participation in supercenter or any other outings. A review of the activity care plans for residents #2, #4, and #6 did not show any interventions for supervision and assistance needed during outings. The facility had a [AGE] year old resident who did not receive the assistance he needed with toileting on an activity outing, and as a result fell while attempting to toilet himself, and sustained a fracture to his right hip.

Based on observation, interview, and record review, the facility failed to provide care and services to meet the needs for personal hygiene for 1 of 9 residents on an activity outing, #1, and failed to be available for possible needed care for 8 other residents (#2, 3, 4, 5, 6, 7, 8 & 9). For residents who are unable to carry out activities of daily living (ADL) meaning those residents who need assistance with toileting and personal hygiene, the facility must provide the necessary care and assistance. On 2/08/17, the facility had a [AGE] year-old resident who did not receive the assistance he needed with toileting during an activity outing and as a result, he fell while attempting to toilet himself and sustained a fracture to his right hip. This negative outcome and the facility's failure to develop a system for residents to be supervised and to call for assistance for care when needed during outings resulted in immediate jeopardy starting on 02/08/17, and it was determined to be ongoing as of the exit date on 04/07/17. Cross Reference: F223, F248, F323, F490, F520 Findings: Resident #1, is a [AGE] year-old resident, with [DIAGNOSES REDACTED]. According to his care plan, he was identified at high risk for falls and had 9 falls in the past year. He is wheelchair dependent, in chronic pain, and dependent on staff for toileting and for his activities of daily living. The resident attended an activity outing to the supercenter on 2/08/17. An interview with the resident on 4/04/17 at 9:50 AM with an interpreter revealed that the resident had to use the restroom for a bowel movement approximately 15 minutes after arriving at the supercenter. He stated that he knew he was not able to transfer onto the toilet by himself but he had no choice. He said he could not see the activity assistant in the area and had no way to call him for help, and was in urgent need to move his bowels. He stated that he did not want to have an accident in his briefs and decided to go to the toilet himself. He said it was difficult to get to the toilet in the wheelchair and he could not move quickly. He stated that he went into the large stall that had a hand rail and was attempting to transfer to the toilet when his bowels began to move. He said that he had a bowel movement on the floor and then slipped causing him to fall on the feces. He said he heard a crack sound as he fell and started to yell for help. An unknown person who was present in the restroom told him that he would get help. He said he was on the floor and tried to pull himself up by using the safety rail, but could not get up. He stated he had severe weakness from his illness. The activity assistant came after some time and cleaned him up, dressed him, and tried to transfer the resident into the wheelchair but he was unable to pick him up alone and had to get help. He was able to get assistance from the supercenter housekeeping man to transfer the resident into his wheelchair. The resident stated he was very embarrassed about the incident. He stated when he was in the facility, he used his call light to summon help, but there was no way to call for someone at the supercenter. An interview with the activity assistant on 4/04/17 at 11:18 AM revealed he had been an activity assistant for two years. He stated he attended the supercenter outing on 2/08/17. There were 2 buses with 9 residents and himself. There were 4 residents in one bus and 5 residents in the other bus. He stated that they arrived at the supercenter at 9:00 AM and 7 residents, including resident #1, went in different directions to shop. He stayed with residents #2 and #4 because resident #2 could not move her wheelchair alone resident #4 was cognitively impaired and used a wheelchair. He stated he was with these two residents when he heard his name being paged overhead requesting him to come to customer service. He stated he headed to customer service with residents #2 and #4 and was informed that someone from his group needed help in the men's restroom. He went to the restroom and told the two residents to remain near the restroom. He stated that when he went into the restroom, he saw resident #1 hanging onto the safety rail trying to pull himself up from the floor. He said when the resident saw him, the resident let himself down, and he was covered in feces including his clothing, the floor and the toilet. He said he asked the supercenter supervisor to help him but she could not tolerate the odor in the restroom. He said she asked the supercenter housekeeping man to assist him. The activity assistant did not have any supplies with him and the supercenter supervisor gave him latex gloves, paper towels and garbage bags. He cleaned the resident up as much as he could, but his clothes and shoes were soiled with feces. The housekeeping man assisted him to transfer the resident into the wheelchair. He said he had to ask the supervisor to buy some new clothing for the resident because his clothing and shoes were soiled. When they exited the restrooms, resident #1 wanted to buy something in the jewelry section so he went there alone, unsupervised. He said he did not want resident #1 to do any shopping as he smelled bad, but he wanted to go. The activity assistant took resident #4 to the nail salon to have her nails done. He said that they all met at the eating area of the supercenter to board the buses and returned to the facility at 12:15 PM. He stated that he stayed on the same bus as resident #1 on the return trip to the facility. He said the resident did not complain of any pain at that time. An interview with the advanced registered nurse practitioner (ARNP) on 4/06/17 at 10:08 noted that she had known the resident since September 2016. She said she was aware that the resident had a fall as a result of needing to use the restroom. She said the resident had chronic constipation and chronic ileus and his bowel movements were unpredictable. He could have the need to go at anytime as he received several laxatives in the morning of the activity outing. She said that resident #1 had dementia and was a very high fall risk. He had [MEDICAL CONDITION] and his legs were very weak. She said he should never go anywhere on his own, especially a large supercenter. Someone needs to have sight of him at all times. In the facility, there are ways for residents to call for help, but not in a supercenter. She stated that she was made aware of the resident's fall on 2/08/17. She saw him on 2/09/17 and when she extended his right knee, he had severe pain. She ordered x-rays and the results showed he had a fracture to his right hip. He was transferred to the hospital for surgical repair of the right hip on 2/10/17. An interview with certified nursing assistant (CNA) G on 4/04/17 at 10:00 AM revealed that resident #1 required one person assistant for toileting, transfers, and dressing. She stated that the resident always called for assistance when needing to use the toilet. He either used the call light to call for help or would tell staff he needs to go. She had never seen him attempting to toilet himself. He required one person to assist with toileting as he was able to hold on to the safety rail and pivot. She stated that as a result of the fall and fracture, he now required two people to assist with toileting. An interview with CNA H on 4/06/17 at 3:00 PM noted that she had known resident #1 for the past two months. She stated that the resident had a suprapubic catheter, was incontinent of bowels, but could also inform staff when he needed to move his bowels. She stated that he always called for assistance and had never attempted to toilet himself. She said he knows he cannot do it on his own, so he does not try. She was observed going to the resident's room on 4/06/17 at 3:05 PM with another CNA to assist the resident for toileting. A review of the minimum data set (MDS) assessment, dated 1/06/17, noted resident #1's brief interview for mental status (BIMS) score was 13 out of possible score of 15 indicating that he was cognitively intact. It showed that he required a wheelchair for mobility. He required extensive assistance of one person for transfers, toileting, eating, dressing, and was incontinent of bowels. A review of resident #1's care plan with target date of 6/01/17 showed he was at high risk for falls related to [MEDICAL CONDITIONS], gait/balance problems and narcotic pain medication use. He had 9 falls in the past year. It was also noted that he was at risk for decline in overall health status related to progression of his disease process. The resident's care plan, revised on 2/14/17, showed the resident had a decline in functional mobility as a result of the right [MEDICAL CONDITION]. A review of the care plans and MDS assessments of the 8 other residents who attended the outing on 2/08/17 noted that 4 of the residents required wheelchairs for ambulation, and therefore would require some assistance with toileting (#2, 3, 4 & 8). Three of the residents required walkers (#5, 7 & 9) and 1 resident was ambulatory without assistance (#6). Of the 8 residents, 2 required extensive assistance of 1 person for toileting (2 & 3), and 1 required supervision (#8). Although 5 residents were noted as independent with toileting, they would require some assistance in the supercenter restrooms to maneuver safely because the restrooms were not arranged in the same manner as the facility restrooms to which the residents were accustomed. On 4/04/17 at 2:35 PM resident #7 stated he was independent with toileting in the facility, but it was different in a supercenter as it was not set up like his restroom in the facility. He stated that he used a walker in the facility, but required an electric scooter in the supercenter as he was unable to walk for long distances. He stated he parked the scooter outside the restroom and then walked into the restroom slowly. He stated that if he needed assistance in the supercenter, he did not have any way of contacting the activity assistant except to look for them. He stated that it would take him at least 15 minutes to find them using the scooter as it's a large store and the activity staff person could be anywhere. A review of the resident's care plan, with a target date of 5/01/17, noted he was at risk for falls related to [MEDICAL CONDITION]. He used a walker, but had the potential for decline in ability to transfer and to ambulate related to obesity, [MEDICAL CONDITION], and [MEDICAL CONDITION]. A review of the MDS assessment for resident #3 dated 2/03/17 revealed she required extensive assistance with transfers, was totally dependent on staff for toilet use, was always incontinent of bladder, and frequently incontinent of bowel. Her balance was not steady and she required staff assistance with moving from seated to standing position, and moving on and off the toilet. Her care plan, with a target date of 5/02/17, noted she was at high risk for falls and used a wheelchair for mobility. Interventions included: anticipate and meet the resident's needs, provide gentle reminders not to get up unassisted, and keep personal items within reach. On 4/04/17 at 2:22 PM, resident #3 stated that she had attended outings to the supercenter using her motorized wheelchair and required oxygen at all times. She said when the group arrived at the supercenter, they split up to shop on their own without the staff. She stated that if she had to use the restroom during the outing, it would take her a long time. She was aware that the activity assistant had a personal phone, but she did not know the phone number. She stated if she had a fall she would have to scream out for help or use her personal mobile phone to call emergency services. On 4/04/17 at 2:32 PM, resident #5 stated she used a walker in the facility, but had to use the supercenter's electric scooter while on shopping outings. She stated she was not aware of how she would get find or contact the activity assistant when in the supercenter. A review of the resident's MDS assessment, dated 1/14/17, noted that she used a walker and was continent. Her care plan with a target date of 4/19/17 noted that she had episodes of forgetfulness. She was at risk for falls with an intervention to provide a safe environment with even floors free from spills and/or clutter. A review of resident #2's MDS assessment dated [DATE] noted that she was incontinent, required total assistance of 1 person for transfers and required assistance of one person with mobilizing the wheelchair. She was at risk for falls related to impaired mobility, and uncontrolled movements due to [MEDICAL CONDITION] and impaired safety awareness. Resident #4's MDS assessment dated [DATE] showed she used a wheelchair and was continent of bladder and bowel. Her care plan, with a target date of 6/20/17, showed she was at risk for wandering, elopement, impaired safety awareness, and was at risk for falls related to gait and balance problems. Although resident #4 was identified at risk for wandering and elopement, she was left unsupervised for an hour in the supercenter while the activity assistant was with resident #1 in the men's restroom. A review of resident #6's MDS assessment dated [DATE] showed she was ambulatory without any mobility devices and was continent. Her care plan with target date of 5/07/17 showed that although she was alert and oriented, she had delusional thought processes. She was at risk for falls related to use of [MEDICAL CONDITION] medications and had a fall on 10/27/16. An interview with the administrator on 4/04/17 at 12:50 PM revealed he was aware there were 9 residents going on an outing with only one staff member. He said he was not concerned since they had numerous outings previously to the supercenter with only one staff member for at least 5-8 residents. When he was asked how one staff member could possibly assist a resident with toileting, and at the same time supervise 8 other residents, the administrator stated, We never had any issues before and I didn't think anything of one staff being there with the residents. He said looking back, he would do things differently and would send more staff to supervise. He stated he, the regional consultant, and corporate risk manager had developed a form to use for outings which would determine how many staff would accompany the residents. A review of the form dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request noted that it contained resident information. Although this form captured pertinent resident information such as toileting assistance needed, the administrator could not identify how staff would provide supervision and how residents could contact the staff for assistance. The administrator stated on 4/05/17 at 10:00 AM that if he had 3 residents who required 2 persons to assist with toileting, he would need to send 7 staff persons on the outing. When he was asked how he would obtain 7 staff persons to attend the outing, he stated that he would call extra staff to work. On 4/07/17 at 10:30 AM, the staffing coordinator stated that the facility did not have additional staff available to come in to participate in outings. She stated their staffing pool was minimal and she would need at least a week to get even a few extra CNAs to come in for an extra half shift for outings.

Based on interview and record review, the facility failed to identify and provide supervision, care and services to prevent accidents for 9 residents during an activity outing. This resulted in resident #1 attempting to transfer and toilet himself, sustaining a fall and fracturing his right hip, and placed 8 other residents (#2, 3, 4, 5, 6, 7, 8 & 9) at high risk for potential serious injury/impairment/death. On 02/08/17, during an activity outing to a supercenter, resident #1 who required a wheelchair for mobility and staff assistance for transferring and toileting and was at risk for falls, was not supervised by facility staff. During the outing, he could not locate the activity assistant when he needed assistance. He went to the public restroom in the supercenter and attempted to transfer himself from his wheelchair onto the toilet and fell on to the floor in the restroom stall. The resident was found in the restroom shouting out for help by an unknown bystander. On 2/09/17, it was discovered that the resident had a fractured right hip as a result of the fall he sustained during the activity outing. Cross Reference F223, F312, F248, F490, F520 The failure to identify the level of supervision necessary and the failure to assistance to prevent accidents resulted in substandard quality of care and immediate jeopardy starting on 02/08/17 and it was determined to be ongoing as of the exit date on 04/07/17. Findings: On 02/08/17, 9 residents and the activity assistant went on an activity outing to a supercenter. They arrived at the supercenter at 9:00 AM and 7 residents, including resident #1, went in different directions to shop independently. Two residents remained with the activity assistant at that time. Resident #1, is a [AGE] year-old with [DIAGNOSES REDACTED]. He had 9 falls within the past year and continued to be at high risk for falls. The resident was dependent upon a wheelchair for mobility, was in chronic pain and dependent on staff for toileting and for his activities of daily living. Shortly after arriving to the supercenter, while the resident was unsupervised in the supercenter, the resident was in urgent need to use the toilet. On 4/04/17 at 9:50 AM, resident #1 stated that during the outing on 2/08/17 he could not find the activity assistant in the area and went to the public restroom because he had urgency for bowel movement. The resident was aware that he needed assistance to use the toilet, but he said he felt he had no choice because he could not find the activity assistant and did not want to have an incontinence accident. As the resident attempted to transfer himself from his wheelchair onto to the toilet, his bowels began to move, he slipped causing him to fall on the feces. The resident said he heard a crack sound and started to yell for help to anyone within earshot. An unknown bystander who was present in the restroom at that time said he would get help. The resident tried to pull himself up from the floor by using the safety rail, but could not get up alone. The activity assistant came after some time and cleaned him up and tried to transfer the resident from the floor into the wheelchair but could not do it on his own and had to summon help from the supercenter housekeeping staff because there were no other facility staff who attended the outing. On 4/04/17 at 11:18 AM, the activity assistant stated that on 2/08/17 he was with two residents when he heard his name being paged overhead at 9:30 AM, requesting him to come to customer service. He stated he went to customer service with residents #2 and #4, and was informed that someone from his group needed help in the men's restroom. He went to the men's restroom and told the two residents to remain near the men's restroom. He stated that when he went into the restroom, he observed resident #1 hanging onto the safety rail, trying to pull himself up. The activity assistant said that when resident #1 saw him, he let himself down to the floor. There was feces on his clothing, the floor, and the toilet. He said he did not have any supplies with him and the supercenter supervisor gave him latex gloves, paper towels, and garbage bags. He cleaned the resident up as much as he could. Because no other facility staff members were present to help, the supercenter housekeeping man tried to help him pick up the resident to put him into the wheelchair, but kept slipping due to the feces. He said he had to ask the supervisor to buy some clothing for the resident #1 because his clothes were soiled. She bought shorts, shirt, socks and sandals so that he could dress the resident. The activity assistant took approximately one hour to provide care to the resident leaving 8 other residents unsupervised in a large supercenter which was approximately 150,000 square feet in size. When they exited the restrooms, resident #1 wanted to buy something in another section of the store so he went to shop by himself. He said he did not want resident #1 to do any shopping as he smelled bad, but he wanted to go anyway. The activity assistant then took resident #4 and #2 to the nail salon in the front of the store, leaving resident #1 unsupervised and without assistance. He said that they all met at the eating area of the supercenter to board the buses and returned to the facility at 12:15 PM. He stated resident #1 did not complain of any pain, but he stayed on the same bus as resident #1 on the return trip to the facility. The activity assistant stated he was not concerned about going on an outing with 9 residents as that was their normal practice. He said he had been going on outings for the past two years with 5-8 residents. He did not think of calling the facility to ask what steps he should take or to get assistance after he found the resident on the floor in the restroom. He stated he was in a hurry to get the resident up and only asked the resident if he had any pain and the resident stated no. The thought of calling for an ambulance did not cross his mind. He stated he had not been trained about emergency care during outings or how to avoid possible further injury when a resident falls. He said he was aware that the other residents were on their own without any supervision while he was with resident #1, but he said he told residents #2 and #4 to remain near the restroom. Resident #4 had severe cognitive impairment and impaired safety awareness and she was left unsupervised in the supercenter for approximately 1 hour. Resident #1's minimum data set (MDS) assessment used to complete a comprehensive assessment dated [DATE] revealed he was cognitively intact, required a wheelchair for mobility, required extensive assistance of 1 person with transfers, dressing, and toilet use. He was always incontinent of bowel and had an indwelling urinary catheter. His balance was not steady and he was only able to stabilize with staff assistance when moving on and off the toilet. A care plan initiated on 07/03/14, with a target review date of 06/01/17, noted the resident was a high risk for falls and had 9 falls in the past year. A care plan was initiated on 02/12/14, with a target review date of 06/01/17, for activities of daily living (ADL) self-care deficit related to multiple sclerosis, requires extensive/total assistance with mobility and ADLs. Interventions included assistance for toileting, total assistance for catheter care and incontinent of bowel; will alert staff when incontinent care is needed and toileting assistance, and transfers. Resident #2's MDS assessment dated [DATE] revealed she required extensive assistance with transfers, was totally dependent on staff for toilet use, and is always incontinent of bowel and bladder. Her balance is not steady and only able to stabilize with staff assistance. She was at high risk for falls and used a wheelchair for mobility. In the care plan initiated on 09/26/12, with a target review date of 06/06/17, resident #2 was at risk for falls related to impaired mobility, uncontrolled movements due to [DIAGNOSES REDACTED] and impaired safety awareness. Interventions included: to encourage resident to ask for assistance with all transfers, and to wait for assistance. The care plan for self-care deficit initiated on 09/26/12 with a target review date of 06/06/17, was related to [DIAGNOSES REDACTED] with intervention for total assistance with transfers and toileting. Resident #3's MDS assessment dated [DATE] revealed she required extensive assistance with transfers, was totally dependent on staff for toilet use, and she is always incontinent of bladder and frequently incontinent of bowel. Her balance is not steady and she is only able to stabilize with staff assistance with moving from seated to stand position, moving on and off toilet, and surface-to-surface transfer. She was at high risk for falls and used a wheelchair for mobility. A care plan initiated on 12/05/13, with a target review date of 05/02/17, for at risk for falls related to incontinence, impaired mobility and history of falls included interventions to anticipate and meet needs and reminders not to get up unassisted. ADL deficit initiated on 12/05/13, with a target review date of 05/02/17, was related to limited mobility, dementia, and tremors with interventions to provide 2 staff participation with transfers. On 04/04/17 at 2:22 PM resident #3 stated she goes to the supercenter with her motorized wheelchair and wears her oxygen at all times. She said, When we arrive at the supercenter, we all split up and go shopping for what we want. When I use the restroom, it takes me a very long time. I know the activity assistant has a phone but I do not know their phone number. I would just have to look around for him. If I were to have a fall, I would have to scream for help. Resident #4's MDS assessment dated [DATE] revealed she was independent with transfers and toilet use, always continent of bowel and bladder, balance is not steady, but able to stabilize without staff assistance, low risk for falls, and used a wheelchair for mobility. A care plan initiated on 12/30/16, with a target review date of 06/20/17, for elopement risk/wanderer related to impaired safety awareness, forgetfulness and difficulty adjusting included interventions to assess for falls, and to observe her location on every shift. A care plan initiated on 12/30/16, with a target review date of 06/20/17, for at risk for falls related to gait /balance problems had interventions that the resident needs prompt response to all requests for assistance. The care plan for ADL deficit initiated on 12/27/16, with a target review date of 06/20/17, listed interventions for supervision with toileting, and assistance with transfers. Resident #5's MDS assessment dated [DATE] revealed she was independent with transfers and toilet use, always continent of bowel and bladder, balance is steady, low risk for falls, and used a walker for mobility. A care plan initiated on 08/10/12, with a target review date of 4/19/17, for at risk for falls related to history of falls and generalized weakness listed interventions to remind resident to ask for assistance. The ADL deficit care plan initiated on 08/10/12, with a target review of 4/19/17, related to spinal cord compression had an intervention to provide supervision at all times. On 04/04/17 at 2:32 PM, she stated she uses a walker in the facility, but uses the supercenter's electric scooter while shopping. She stated that she does not know how to contact the activity assistant when in the supercenter. Resident #6's MDS assessment dated [DATE] revealed she was independent with transfers and toilet use, always continent of bowel and bladder, balance is steady, low risk for falls, and ambulates independently. The care plan, initiated on 09/23/11, with a target review date of 05/07/17, for at risk for falls related to use of psychotropic medications and wearing sandals included interventions to encourage appropriate footwear. ADL deficit initiated on 09/23/11, with a target review date of 05/07/17, related to psychosis and schizophrenia listed the intervention for supervision with ADLs at times. Resident #7's MDS assessment dated [DATE] revealed he was independent with transfers and toilet use, always continent of bowel and bladder, balance is steady, high risk for falls and used a walker for mobility. A care plan, initiated on 01/23/14, with a target review date of 05/01/17, for risk for falls related to obesity, impaired balance and unsteady gait had interventions to observe resident for unsafe situations. The care plan for potential for decline in ability to transfer, move independently, and ambulate due to obesity, initiated on 01/23/14 with a target review date of 05/01/17 included interventions to assist with transfer and mobility as needed. The care plan for bladder incontinence initiated on 07/16/14, with a target review date of 05/01/17, was related to physical limitations with interventions for brief use. On 04/04/17 at 2:25 PM resident #7 stated he went on the activity outing to the supercenter on 02/08/17. While in the supercenter he uses an electric scooter to shop. He said he has used the restroom in the supercenter on previous outings. He parks the electric scooter outside the restroom and walks into the restroom. If he needs help he asks the supercenter staff to reach for things on the shelves. He stated that if he needs help from the activity staff he would have to find them. He said it would take him 15 minutes to find the activity assistant in his scooter since they could be anywhere in the store. It is a big store. Resident #8's MDS assessment dated [DATE] revealed she required supervision with transfers and toilet use, was always continent of bowel and bladder, balance was not steady but able to stabilize without staff assistance moving from seated to standing position, walking, moving on and off toilet, and surface to surface transfers, was a low risk for falls, and used a wheelchair for obesity. The care plan initiated on 11/23/14, with a target review date of 05/25/17, for risk for falls related to gait/balance problems and weakness listed interventions for reminders not to get up unassisted. ADL deficit initiated on, 11/23/14 with a target review date of 05/25/17, related to activity intolerance included interventions that the resident requires stand by assistance with toilet use and set up assistance with transfers. On 04/04/17 at 2:56 PM, she stated that she goes on the supercenter outings as often as she can and uses her wheelchair while she is shopping. She stated that the activity assistant is somewhere in the store, but she did not know how to contact him or where to find him. Resident #9's MDS assessment dated [DATE] revealed she was independent with transfers and toilet use, was always continent of bowel and bladder, balance was steady at all times, was a low risk for falls, and used a walker for mobility. A care plan initiated on, 01/31/17 with a target review date 04/17/17, for decline in functional mobility related to knee pain had interventions for skilled physical therapy. Risk for falls, initiated on 08/21/15 with a target review date 04/17/17, was related to unsteady gait with interventions to encourage resident to use assistive devices. Decline in ADL was initiated on 08/21/15, with a target review date 04/17/17, related to bipolar disorder with interventions to encourage use of walker. On 04/04/17 at 2:50 PM, she stated she uses a walker and shops by herself. She was not aware of how to contact the activity assistant if she needed assistance. She stated she would just go to the eating area and wait for activity the assistant to show up. On 02/08/17, 8 residents were left unattended for 1 hour in a large 150,000 square foot supercenter while the activity assistant provided care to resident #1. Two of the other 8 residents required extensive assistance with transfer and toileting (#2 & 3), 1 required supervision with transfer and toileting (#8), 4 residents used a wheelchair for mobility (#2, 3, 4 & 8), 3 residents used a walker for mobility (#5, 6 & 9), and all 8 residents were at risk for falls. On 04/04/17 at 10:35 AM, the activity director stated they have had monthly outings to the supercenter for many years with 5-8 residents and one activity assistant. The activity staff have never had any formal education regarding facility outings or emergency care while on outings, and there was no policy and procedure for activity outings. She stated it is hard to prevent falls while at the supercenter because the residents are on their own. It is very tricky because it is such a big area. It is hard to keep track of the residents. An interview with the administrator on 4/04/17 at 12:50 PM revealed their conclusion to the 02/08/17 incident was not enough staff attending the outing. He stated he was aware that 9 residents were going on the supercenter outing with only one activity assistant. He stated that he was not concerned as they usually had one assistant going on outings. When he was asked how one staff member could possibly assist a resident with toileting and at the same time supervise 8 other residents, the administrator stated, We never had any issues before and I didn't think anything of one staff being there with the residents. He said he did not think about canceling the outing or sending extra staff. He said he could have sent the other activity assistant or a certified nursing assistant who had been assisting with activities but he did not think of it. He stated that the staff on outings used their personal cellular phones if they had to contact the facility. He said looking back, he would do things differently and would send more staff to supervise. He stated that he, the regional consultant, and corporate risk manager had developed a form to use for outings which would determine how many staff would accompany residents on outings. A review of the form dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request noted resident information. It listed the assistive device used by resident, level of assist for toileting needed, the fall risk score, the elopement risk score, the cardiopulmonary resuscitation status, any food or fluid restriction/allergy, and the resident's brief interview for mental status (BIMS) score (aids in detecting cognitive impairment). The form did not include any other special needs, such as oxygen. The administrator stated the activity director filled out this form 3 days before the scheduled activity outing, then the director of nursing signed off on the form, and then he would be responsible to determine the number of staff that would go on the outing with the residents. He was unclear as to how he would determine the number of staff and how he would find the number of staff to go on the outing. The action plan did not clearly address the level of supervision required for each resident while on outings, the sufficient number of staff to be present on an outing, a system to supervise the residents while on outings, and a system for residents to contact staff when they needed assistance and care. He also stated the facility did not have a policy and procedure related to facility outings. Another outing to the supercenter was planned for 4/11/17, but there were no other changes for the procedure for activity outings to the supercenter other than the Activity Outing Request form, even though the administrator could not explain the significance of the resident data collected or how it would be used to ensure residents are safe and supervised appropriately for resident outings.

Based on interview and record review, the facility failed to administer its resources effectively to ensure that supervision, care and services were provided to residents during an outing to a supercenter on 2/08/17. This failure resulted in serious harm for 1 resident (#1) and potential for serious injury/impairment/death for 8 other residents (#2, 3, 4, 5, 6, 7, 8 & 9). On 02/08/17, during an activity outing to a large supercenter, 9 residents left the facility in 2 different buses with one staff member. All of the residents were long-term care residents, requiring 24-hour nursing care and had different levels of mobility and needs for assistance. During the outing, the staff member had to be paged by supercenter staff to come to assist resident #1 in the public restroom. The resident was incontinent of feces and fell in the restroom. While the staff member was with resident #1 for approximately one hour, the 8 other residents were left in the supercenter with no staff members to assist and with no mechanism to call for staff assistance. Resident #1 sustained serious injury, [MEDICAL CONDITION], requiring hospitalization on [DATE]. Cross Reference F223, F248, F312, F323, F520 Administration failed to provide a system to identify the level of supervision and staffing needed for all residents on outings and did not use all resources available to provide adequate care and services that led to Immediate Jeopardy on 02/08/17 and it was determined to be ongoing as of the exit date on 04/07/17. Findings: An activity outing to a supercenter occurred on 2/08/17. Two buses departed the facility at 8:30 AM with 9 residents and one activity assistant to the supercenter. The activity director was to follow the buses in her own personal car, but she did not attend. At 9:15 AM, while she was still in the facility. She sent a text message on her personal phone to another staff member that she had a personal emergency. She did not notify the administrator directly that she would not be joining the activity assistant at the supercenter due to a personal emergency. The outing continued with one activity assistant in a large supercenter with 9 residents. The care plans for the residents attending the outing on 2/08/17 showed that 5 of the residents required wheelchairs for mobility (#1, 2, 3, 4 & 8), 3 residents required walkers (#5, 7 & 9) and one resident was independent with ambulation (#6). Three residents required extensive assistance with toileting, and were incontinent (#1, 2 & 3) and one resident (#8) required supervision with toileting. The Administrator's job description read, To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times. Ensure that each resident receives the necessary nursing, medical and psychological services to attain and maintain the highest possible mental and physical functional status; supervise and direct all facility departments and overall operations, including programs, activities, policies and procedures and implement changes as necessary. An interview with the administrator on 4/04/17 at 12:50 PM revealed he was aware there was an outing on 2/08/17 to the supercenter and that 9 residents were going on the outing. He stated that previously, the activity director managed the outings but since 2/08/17, he was more involved in directing the outings. He stated they never had any fall incidents on outings before 2/08/17. He said the supercenter outing was discussed in the morning management meeting on 2/08/17. He was informed during the morning meeting that the activity director had to go home. He was aware that only one staff member was present for the outing and he said was not concerned as they had numerous outings to the supercenter with only one staff member onsite. He said he was familiar with the residents on the outing and stated that they had a shopping routine. When he was asked how one staff member could possibly assist a resident with toileting and at the same time supervise 8 other residents, the administrator stated, We never had any issues before, and I didn't think anything of one staff being there (at the supercenter) with the residents. He said he did not think about canceling the outing or sending extra staff. He said he could have sent the other activity assistant or a certified nursing assistant who had been assisting with activities, but he did not think of it. He stated the staff on outings used their personal cellular phones if they had to contact the facility. He said looking back, he would do things differently and would send more staff to supervise. He stated he, the regional consultant, and corporate risk manager had developed a form to use for outings which would determine how many staff would accompany the residents. A review of the form dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request noted that it contained resident information. It listed the assistive device used by resident, level of assist for toileting needed, the fall risk score, the elopement risk score, cardiopulmonary resuscitation status, any food or fluid restriction/allergy and the resident's brief interview for mental status (BIMS) score. The administrator stated the activity director fills out this form 3 days before the scheduled activity outing, then the director of nursing signs off on the form, and then he is responsible to determine the number of staff that would go on the outing with the residents. He was unclear as to how he would determine the number of staff and how he would find the number of staff to go on the outing. This form was used for an outing to the supercenter on 3/14/17 where 2 residents, #5 and #6 attended the outing. There were 4 residents scheduled to go on the outing, but 2 residents canceled on the morning of the outing. The form showed that resident #5 had a score of 5 for fall risk and resident #6 had a score of 4 for fall risk. When the administrator was asked to explain the fall scores, he was unable to explain what the fall risk scores indicated. He was asked if those scores were low risk or high risk for falls, but he was unable to answer. When he was asked what the score for residents #5 and #6 for elopement indicated on the form, he was unable to explain what the score numbers indicated. When he was asked how he was able to determine the number of staff needed for supervision of these two residents when he could not say if they were a fall and elopement risk, he did not have an answer. When he was asked if this form was effective, he stated that it was not usual that only 2 residents attend an outing, so they would have to further monitor the effectiveness of the form. An interview with the activity director on 4/05/17 at 11:05 AM revealed that the facility had outings to the supercenter monthly for the past several years with one staff accompanying 5-8 residents. She stated she had always sent one person on outings to the supercenter and that was their normal ratio. She stated sometimes she would also attend the outings, but her time and attention was focused on shopping for residents who could not attend the outing. She stated that now the number of staff attending outings will be based on toileting needs and the resident's BIMS scores. When questioned about falls risk, she stated, it is difficult to prevent falls at the supercenter because residents are on their own. It is tricky, as it's a big area and hard to keep track of residents. She stated that residents identified as high risk for elopement would not be attending the outing. On 4/05/17 at 12:00 PM, the minimum data set (MDS) nurse who was the previous director of nursing, stated if there were 3 residents who required 2 people to assist for toileting going on outing, they would need to send six staff and, we just don't have the staff. On 4/07/17 at 10:30 AM, the staffing coordinator stated that they had minimal staffing to pull from for activities. She said she would need at least a week to find a few extra staff for outings. Although the facility implemented a form to gather more data regarding resident needs for outings, the procedure for evaluating the data had not been addressed. The Administrator failed to consider and coordinate all the resources necessary for resident outings outside the facility.

Based on interview and record review, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program for failure to plan, supervise and be available for care and services during activity outings. This resulted in a dependent resident attempting to toilet himself, sustaining a fall and fracturing his right hip and placed 8 other residents (#2, 3, 4, 5, 6, 7, 8 & 9) at risk for potential serious injury/impairment/death. On 02/08/2017, during an activity outing to a supercenter, resident #1 identified as dependent on wheelchair and requiring assistance for toileting could not locate the activity assistant when he needed to use the restroom. He went into the public restrooms in the supercenter and attempted to transfer himself from his wheelchair onto the toilet and fell on to the floor in the restroom stall. The resident was found in the restroom shouting out for help by an unknown person and the activity assistant was paged. The activity assistant summoned assistance from the supercenter housekeeping staff and they lifted the resident from the floor into his wheelchair. The activity assistant took approximately one hour to provide incontinence care to the resident, leaving the 8 other residents unsupervised in the large supercenter which was approximately 150,000 square feet in size. The facility's QAA committee failed to identify quality deficiencies by not identifying the root cause of the incident, and failed to evaluate and analyze the risk once a fall and injury had occurred. The facility concluded that they had insufficient number of staff to meet the residents' needs on the outing. The facility failed to recognize and develop a system for residents to be supervised during outings, and did not have a method for residents to call for assistance for care when needed during outings. These failures led to Immediate Jeopardy beginning on 02/08/17 and it was determined to be ongoing as of the exit date on 04/07/17. Cross Reference: F223 ,F248, F312, F323, F490. Findings: An interview with the administrator on 04/04/17 at 12:50 PM revealed that although they identified resident #1's fall and fracture from 2/08/17 as a serious event, they did not have an emergency QAA meeting following the incident. The incident was first discussed officially at the QAA meeting 36 days later on March 16, 2017. He stated that the facility did not have a policy or procedure for activity outings, but they identified activity outings as an area for improvement. He stated that he had spoken to a few residents who went on the outing on 2/08/17, but said he could not provide any documentation of his findings. The facility's correction plan included developing an outing form and educating their activity staff. The outing form which was dated 2/15/17 and revised on 2/20/17 titled, Avante of Orlando Activity Outing Request was developed by the administrator, the regional consultant, and corporate risk manager. A review of the form noted that resident information was captured on the form such as the assistive device used by resident, level of assist for toileting needed, the fall risk score, the elopement risk score, the cardiopulmonary resuscitation status, any food or fluid restriction/allergy, and the resident's brief interview for mental status (BIMS) score to show any cognitive impairment. The form did not include any special needs, such as oxygen. The administrator stated the activity director completes the form 3 days before the scheduled activity outing, then the director of nursing signs off on the form, and then he receives it to determine the number of staff attending the outing with the residents. He was unclear as to how he would determine the number of staff and how he would find the number of staff to go on the outing, but stated that it depended on how much assistance residents required with toileting. He stated that toileting and BIMS score were the top factors in determining the number of staff accompanying residents on outings. He stated they used the new form for the supercenter activity 3/14/17 and another outing was planned for 4/11/17. A review of the completed form which was used for the March 14, 2017 outing showed 2 residents, #5 and #6 attended the outing. There were 4 residents who were scheduled to go on the outing, but 2 residents canceled on the morning of the outing. The form showed that resident #5 had a score of 5 for fall risk and resident #6 had a score of 4 for fall risk. When the administrator was asked to explain the fall scores, he was unable to explain what the fall risk scores indicated. He was asked if those scores were low risk or high risk for falls, but he was unable to answer. When he was asked what the score for residents #5 and #6 for elopement indicated on the form, he was unable to explain what the score numbers indicated. When he was asked how he was able to determine the number of staff needed for supervision of these two residents when he could not provide an answer if they were a fall and elopement risk, he did not have an answer. When he was asked if this form was effective, he stated it was unusual for only 2 residents to attend an outing, so they could not determine effectiveness. The administrator stated they had provided in-service education to the activity staff as a part of their plan. He showed a form which was signed by the activity director and activity assistant which read, Never go on outings alone and that they had reviewed the new activity outing request form. He was unable to provide education to show that activity assistant B and C were provided with this in-service. He stated after the incident on 2/08/17, the activity staff were in-serviced never to go on an outing alone. When the administrator was asked if the staff were provided with training on what to do in case of emergencies such as falls, illness, accidents, during activities, he could not provide any documentation. An interview with activity assistant A on 4/05/17 revealed he alternated with activity assistant B to attend outings. He went one month and she attended the outing the next month. He stated he did not have any training with outings, but he had shadowed the activity director once a few years ago, and she told him verbally what to do. He was not aware of what he would do if a resident became ill, had chest pain or [MEDICAL CONDITION] while on an outing. He stated he would probably have to call emergency services. He stated he would have to use his personal cellular phone to call because they did not have work phones on resident outings. When he was asked how residents would contact him if they required assistance during an outing, he stated it had never happened before. The facility focused on residents' toileting needs assistance and did not consider how they would provide supervision for other risks such as high fall risks and a method for residents to contact the staff for assistance. On 4/05/17 at 10:00 AM, the administrator indicated if he had 3 residents who required 2 people to assist for toileting, he would send 7 staff members on the outing. When he was asked how he would obtain 7 staff to attend the outing, since this is 6 more staff which usually attend, he stated he would call extra staff to work. On 4/07/17 at 10:30 AM, the staffing coordinator stated that the facility did not have staff available to call in for outings. She stated she would need at least a week to get even a few extra certified nursing assistants to come in for an extra half shift for outings. The facility had an at-risk [AGE] year-old resident who fell while attempting to toilet himself because he could not obtain assistance as needed during an activity outing, and he sustained a fracture to his right hip. The QAA committee failed to fully investigate this incident which occurred on 2/08/17. They did not identify the root cause of the fall and arrived at the conclusion that they did not have enough staff on the outing. Therefore, they focused on the number of staff for outings and not on the individual resident's needs and the process to ensure safe outings. They failed to implement a system for meeting all residents' needs for supervision and for required care and services during facility outings to address the potential for harm. Due to an incomplete investigation, the facility's action plan was inadequate to address the process for activity outings.

Based on record review and interview, the facility failed to obtain admission physician orders for immediate and essential care regarding life sustaining care and services for 1 of 4 residents reviewed for [MEDICAL TREATMENT] (#4). This failure resulted in deterioration of the resident's condition to a level requiring re-hospitalization within 8 days of admission to the facility. The resident received hospice care within 5 days of transfer to the acute care hospital and expired. The facility's failure to obtain orders to monitor kidney status for the need for [MEDICAL TREATMENT] resulted in Immediate Jeopardy staring on [DATE]. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of [DATE]. Findings: Cross Reference to F309, F281, and F386. Resident #4 was discharged from the Long Term Care Hospital (LTCH) and admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. [MEDICAL TREATMENT] is the clinical purification of blood to substitute for the absence of normal kidney function, and [MEDICAL CONDITION] is the lack of oxygen for several minutes or longer. Brain cells begin to die after approximately 4 minutes without oxygen. (Oxford dictionaries). The resident's LTCH History and Physical, dated [DATE], indicated she was receiving [MEDICAL TREATMENT] treatments since her admission to the LTCH on [DATE]. The most current documentation of the [MEDICAL TREATMENT] treatments was on the Mobil [MEDICAL TREATMENT] [MEDICAL TREATMENT] Run Sheet, dated [DATE], [DATE], [DATE] and [DATE]. The run sheets indicated that she required [MEDICAL TREATMENT] treatments up until the time she was admitted to the facility on [DATE], with the exception of a 1 time hold order on [DATE]. The resident's LTCH Discharge Summary, dated [DATE], indicated that she was followed by a Nephrologist (kidney doctor) while at the LTCH, was currently on [MEDICAL TREATMENT], and discussion with the family indicated they wanted her to be transferred to a skilled nursing facility for further care. Review of the facility's admission physician orders and nurses' notes for resident #4, dated [DATE], did not contain any documentation that the resident was to receive any [MEDICAL TREATMENT] or laboratory blood work (labs) to monitor kidney function. On [DATE] at 2:57 PM, Licensed Practical Nurse (LPN) A said that she called the physician on call on [DATE] to obtain admission orders [REDACTED]. She obtained orders from NP C for in-house [MEDICAL TREATMENT] 3 times a week for resident #4. LPN A said she obtained additional admission [MEDICAL TREATMENT] orders from NP C on [DATE], the day the [MEDICAL TREATMENT] was to start, to hold [MEDICAL TREATMENT] treatments. LPN A was unable to verbalize why resident #4's [MEDICAL TREATMENT] was ordered and then placed on hold before it started. Review of the physician orders, dated Wednesday [DATE], confirmed an order was taken by LPN A from NP C for in-house [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday for resident#4's [DIAGNOSES REDACTED]. End Stage [MEDICAL CONDITION] is when the kidneys are no longer able to work at a level needed for day to day life. (medlineplus.gov). Review of the physician orders, dated [DATE], confirmed LPN A took another order from NP C, to hold [MEDICAL TREATMENT] for 7 days, starting [DATE] through [DATE]. The orders did not include any labs to monitor the resident's kidney function while she was not receiving any [MEDICAL TREATMENT]. On [DATE] at 1:10 PM, the Director of Nursing (DON) confirmed that resident #4 was admitted to the facility on [DATE] from the LTCH, and the facility had documentation that this resident was receiving services from a Mobil [MEDICAL TREATMENT] company prior to her admission to the facility. She said her last treatment for [REDACTED]. Review of the LTCH Nephrology orders and notes, dated [DATE] through [DATE], revealed resident #4's labs were being closely monitored to determine duration and frequency of the [MEDICAL TREATMENT] treatments. There was a one-time order to hold [MEDICAL TREATMENT] on [DATE], give Potassium, and obtain a BMP on [DATE]. A Basic Metabolic Panel (BMP) is a blood test that measures sugar (Glucose) level, electrolyte (Potassium) and fluid balance, and kidney function (WebMD.gov). A telephone interview was conducted on [DATE] at 9:32 AM with the Nephrologist who treated resident #4 while at the LTCH regarding his order to hold [MEDICAL TREATMENT] on [DATE]. The Nephrologist indicated he had written the order on [DATE] to hold [MEDICAL TREATMENT] based on the most recent lab value for creatinine, which was normal on [DATE]. The blood creatinine level shows how well your kidneys are working. A high level may mean kidneys are not working as they should (WebMD.gov). He said that no conversation had taken place with the family regarding the discontinuation of [MEDICAL TREATMENT] because there would have needed to be more labs at a later date to make the decision regarding the frequency of [MEDICAL TREATMENT] treatments. The Nephrologist also indicated he was not made aware of resident #4's discharge on [DATE], and would have continued close monitoring, additional labs, and [MEDICAL TREATMENT] sessions. A review of the lab results from the LTCH, dated [DATE] at 1:55 AM, indicated the resident's creatinine was no longer in the normal range, and was elevated. On [DATE] at 11:11 AM, NP C confirmed that he gave admission orders [REDACTED]. NP C said that he gave the orders based on the information provided to him via a telephone call from the facility staff on [DATE] and [DATE], but could not provide details of the information provided. After reviewing the resident #4's medical records on [DATE], NP C stated, I cannot not find any evidence that the LTCH had any intention to stop (resident #4's) [MEDICAL TREATMENT], and had I known that [MEDICAL TREATMENT] was only on hold for one day at the LTCH, I would have ordered a STAT (immediate) nephrology consult and Basic Metabolic Panel. I can only base my decisions on the information provided to me by the facility since I did not see this resident until [DATE]. On [DATE] at 3 PM, the DON confirmed that the facility received an initial referral via FAX on [DATE] from the LTCH regarding resident #4's admission to their facility and that they were aware that it was undecided as to whether or not the resident would be getting [MEDICAL TREATMENT] at their facility. The DON said that the resident did not have a nephrologist when she entered their facility on [DATE] because she was not getting [MEDICAL TREATMENT] anymore. The DON stated, the Nurse Practitioner should have ordered the nephrology consult and I should have probed the primary care provider regarding, how do you want us to handle this since the resident's [MEDICAL TREATMENT] is on hold? Review of the acute care hospital Physician Consultation, dated [DATE], the day resident #4 was sent to the hospital from the Skilled Nursing Facility, revealed the resident was assessed to have Severe Azotemia and Uremia causing the resident to have a change in mental status, Acidosis from possible End stage [MEDICAL CONDITION] and missing [MEDICAL TREATMENT], along with [MEDICAL CONDITION] (high potassium) from [MEDICAL CONDITION] and Acidosis. The physician placed an order for [REDACTED]. Resident #4's Physician Consultation, dated [DATE], the day the resident was sent to the hospital from the SNF, reflected the resident had Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage [MEDICAL CONDITION] and Missing [MEDICAL TREATMENT] along with [MEDICAL CONDITION] from [MEDICAL CONDITION] and Acidosis. The physician ordered Resident #4 to begin [MEDICAL TREATMENT] immediately with the prognosis of POOR. Azotemia means insufficient kidney filtering. (Azotemia.net). Uremia is a serious complication of [MEDICAL CONDITION] when urea and other waste products build up in the body because the kidneys are unable to eliminate them. (WebMD.com). Acidosis is a condition in which there is too much acid in the body fluids. (Medlineplus.gov). The resident received hospice care within 5 days of transfer to the acute care hospital on [DATE], and expired on [DATE]. Review of the facility policy admission orders [REDACTED]. Resident #4 did not receive the necessary care and services regarding [MEDICAL TREATMENT] which is needed to sustain life. Review of the facility records from [DATE] to [DATE] revealed that at no time during her stay at the facility were any orders for essential care obtained for Nephrology consult or labs to monitor her kidney function after the [MEDICAL TREATMENT] was placed on hold.

Based on interview, record review and policy review, the facility failed to provide services to meet professional standards of quality for 1 of 4 sampled residents reviewed for [MEDICAL TREATMENT] treatments (#4). The resident's condition deteriorated to a level requiring hospitalization within 8 days of admission to the facility. The resident received hospice care within 5 days of transfer to the acute care hospital and expired. The facility's failure to monitor kidney status to identify the need for [MEDICAL TREATMENT] resulted in Immediate Jeopardy, staring on [DATE]. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of [DATE]. Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that The practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to subscribe such medications and treatments, (3) the supervision and teaching of other personnel in the theory and performance of any of the above acts. Review of documentation from a long-term care hospital (LTCH), dated [DATE], indicated Resident #4 was hospitalized after a motor vehicle accident and apparent [MEDICAL CONDITION]. The resident was intubated and suffered an [MEDICAL CONDITIONS]. [MEDICAL CONDITIONS] is the lack of inadequate oxygen for several minutes or longer. Brain cells begin to die after approximately four minutes without oxygen. (Oxford dictionary). Resident #4 was also assessed to be in Acute Renal (kidney) Failure, and in need of [MEDICAL TREATMENT]. Acute [MEDICAL CONDITION] means the kidneys are unable to excrete the daily load of toxins in the urine. (Oxford dictionary). [MEDICAL TREATMENT] is a process of purifying the blood of a person whose kidneys are not working normally. (Wikipedia). The LTCH history and physical dated [DATE] indicated the plan was to continue [MEDICAL TREATMENT] and incorporate the services of nephrology, the branch of medicine that deals with the kidneys (thefreedictionary.com/nephrology) and cardiology, the medical specialty that is concerned with the [DIAGNOSES REDACTED].com/nephrology), and monitor the resident for kidney function. The LTCH follow-up plan was to continue [MEDICAL TREATMENT] and incorporate the services of Nephrology and Cardiology and monitor the resident for kidney function. Review of the LTCH nephrology orders dated [DATE] through [DATE] revealed Resident #4's labs were being closely monitored to determine duration and frequency of the [MEDICAL TREATMENT] treatments. Review of the LTCH Discharge Summary, dated [DATE], indicated Resident #4 had been closely monitored and would be discharged from the LTCH to a Skilled Nursing Facility (SNF). A discussion was conducted with the family addressing [DIAGNOSES REDACTED]. The family voiced understanding and wished to get the resident to a SNF for further care. Resident #4 was discharged from the LTCH and admitted to the SNF on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's admitting physician orders [REDACTED]. Admitting nurses' notes for Resident #4, dated [DATE], contained no documentation that the resident was to receive [MEDICAL TREATMENT]. Resident #4's admitting care plan, dated [DATE], did not contain documentation that the resident was to receive [MEDICAL TREATMENT] and did not contain interventions to guide [MEDICAL TREATMENT] care. On [DATE] at 1:10 PM, the Director of Nursing (DON) confirmed the resident was admitted to the facility from a LTCH on [DATE] along with documentation the resident was receiving [MEDICAL TREATMENT] at the LTCH. The DON indicated the resident's last treatment in the LTCH for [MEDICAL TREATMENT] was dated [DATE]. In the discharge orders from the LTCH there was an order to hold the [MEDICAL TREATMENT] on [DATE]. The DON was unable to explain the lack of monitoring and follow-up [MEDICAL TREATMENT] treatment for [REDACTED]. Resident #4's record revealed a physician order [REDACTED]. The order was later discontinued by an order placed to hold [MEDICAL TREATMENT] for Resident #4 for seven days, from [DATE] through [DATE]. On [DATE] at 2:57 PM, an interview was conducted with the Unit Manager on the North Wing, Licensed Practical Nurse (LPN) A, who had received the new physician orders [REDACTED]. LPN A indicated she had called the facility ' s physician on call and had received the order to start and hold the [MEDICAL TREATMENT] from the Nurse Practitioner (NP). LPN A also explained she had called the mobile [MEDICAL TREATMENT] company who would be performing the in-house [MEDICAL TREATMENT] treatments for Resident #4 and indicated the mobile [MEDICAL TREATMENT] company had no record regarding [MEDICAL TREATMENT] treatment for [REDACTED]. LPN A was unable verbalize why Resident #4's [MEDICAL TREATMENT] was ordered then held. On [DATE] at 9:32 AM via telephone, nephrologist E who treated Resident #4 at the LTCH, indicated he had written the order on [DATE] to hold [MEDICAL TREATMENT] based on a laboratory value for creatinine which was normal at that time. He said no conversation had taken place with the family regarding the discontinuation of [MEDICAL TREATMENT] as there would have needed to be more labs at a later date to make the decision if anymore [MEDICAL TREATMENT] was necessary. Nephrologist E also indicated he was not made aware of the Resident #4's discharge and would have continued close monitoring and additional labs and [MEDICAL TREATMENT] sessions. On [DATE] at 10:40 AM, NP C, who had written the above orders concerning the plan of care for Resident #4, indicated any resident on [MEDICAL TREATMENT] is closely monitored and if their Creatinine levels were becoming stable the resident would have repeat lab work to monitor the kidney function. He confirmed that no further labs were ordered by him to evaluate Resident #4's kidney function. NP C confirmed after reviewing records from the LTCH that the LTCH nephrologist had no intention of stopping Resident #4's [MEDICAL TREATMENT]. NP C said that he gave an order for [REDACTED]. He said, I can only base my decisions on the information provided by the facility. I did not see this resident until [DATE]. Resident #4's Physician Consultation, dated [DATE], the day the resident was sent to the hospital from the SNF, reflected the resident had Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage [MEDICAL CONDITION] and Missing [MEDICAL TREATMENT] along with [MEDICAL CONDITION] from [MEDICAL CONDITION] and Acidosis. The physician ordered Resident #4 to begin [MEDICAL TREATMENT] immediately with the prognosis of POOR. Azotemia means insufficient kidney filtering. (Azotemia.net). Uremia is a serious complication of [MEDICAL CONDITION] when urea and other waste products build up in the body because the kidneys are unable to eliminate them. (WebMD). Acidosis is a condition in which there is too much acid in the body fluids. (Medlineplus.gov). The resident received hospice care within 5 days of transfer to the acute care hospital on [DATE], and expired on [DATE]. The facility policy Physician Visits and Physician Delegation, no date, indicated the nurse is to clarify all orders as needed and to document any special discussion between the physician and the nurse. The professional nursing staff failed to clarify the need for [MEDICAL TREATMENT] treatment for [REDACTED]. The communication between LPN A and NP C did not explore past medical history and the need for follow-up kidney care. The professional nursing staff did not use nursing judgement to evaluate the need for monitoring kidney status, and the significance of orders to hold [MEDICAL TREATMENT] for an additional 7 days after admission from the LTCH to the facility.

Based on interview, record review and policy review, the facility failed to provide [MEDICAL TREATMENT] (the clinical purification of blood to substitute for the absence of normal kidney function-oxford dictionaries) services along with monitoring kidney function for 1 of 4 sampled residents reviewed for [MEDICAL TREATMENT] (#4). This life sustaining treatment ([MEDICAL TREATMENT]) was placed on hold without any monitoring to determine resident #4's level of kidney function during that time. The resident's condition deteriorated to a level requiring hospitalization within 8 days of admission to the facility. The resident received hospice care within 5 days of transfer to the acute care hospital and expired. The facility's failure to monitor kidney status to identify the need for [MEDICAL TREATMENT] resulted in Immediate Jeopardy, staring on [DATE]. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of [DATE]. Findings: Review of documentation from a long-term care hospital (LTCH), dated [DATE], indicated Resident #4 was hospitalized after a motor vehicle accident and apparent [MEDICAL CONDITION]. The resident was intubated and suffered an [MEDICAL CONDITIONS]. [MEDICAL CONDITIONS] is the lack of inadequate oxygen for several minutes or longer. Brain cells begin to die after approximately four minutes without oxygen. (Oxford dictionary). Resident #4 was also assessed to be in Acute Renal (kidney) Failure, and in need of [MEDICAL TREATMENT]. Acute [MEDICAL CONDITION] means the kidneys are unable to excrete the daily load of toxins in the urine. (Oxford dictionary). [MEDICAL TREATMENT] is a process of purifying the blood of a person whose kidneys are not working normally. (Wikipedia). The LTCH history and physical dated [DATE] indicated the plan was to continue [MEDICAL TREATMENT] and incorporate the services of nephrology, the branch of medicine that deals with the kidneys (thefreedictionary.com/nephrology) and cardiology, the medical specialty that is concerned with the [DIAGNOSES REDACTED].com/nephrology), and monitor the resident for kidney function. The most current documentation of the [MEDICAL TREATMENT] treatments was on the Mobil [MEDICAL TREATMENT] [MEDICAL TREATMENT] Run Sheet, dated [DATE], [DATE], [DATE] and [DATE]. The run sheets indicated that Resident #4 required [MEDICAL TREATMENT] treatments up until the time she was admitted to the facility on [DATE], with the exception of a one time hold order on [DATE]. The LTCH's nephrology orders dated [DATE] through [DATE] revealed Resident #4's laboratory blood work values (labs) were being closely monitored to for kidney function to determine duration and frequency of the [MEDICAL TREATMENT] treatments. The physician's orders [REDACTED]. The nephrology note, dated [DATE], the day before the resident was transferred to the facility, reflected that the resident's labs showed some signs of kidney recovery, but the resident was still dependent upon [MEDICAL TREATMENT]. The nephrology order, dated [DATE], indicated the resident required potassium supplementation. The physician held [MEDICAL TREATMENT] that day and ordered labs for [DATE]. A review of the lab results from the LTCH, dated [DATE] at 1:55 AM, indicated the resident ' s labs were no longer in the normal range. The LTCH's Discharge Summary, dated [DATE], indicated Resident #4 had been closely monitored and would be discharged from the LTC hospital to a Skilled Nursing Facility (SNF). The summary reflected that a discussion was conducted with the family addressing [DIAGNOSES REDACTED]. The family voiced understanding and wished to get the resident to a SNF for further care, including [MEDICAL TREATMENT]. Resident #4 was discharged from the LTCH and admitted to the SNF on [DATE], with [DIAGNOSES REDACTED]. The SNF included these [DIAGNOSES REDACTED]. Review of the Admitting Minimum Data Set (MDS), dated [DATE], reflected the resident was assessed to have severely impaired cognitive skills for daily decision making and rarely/never able to understand or be understood. Resident #4 was assessed to be bedridden and totally dependent on a staff of two for all activities of daily living. Resident #4 required an indwelling urinary catheter, and was incontinent of bowel. The MDS included the dependence on kidney [MEDICAL TREATMENT] in the [DIAGNOSES REDACTED]. Resident #4's admitting physician orders, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT], and did not contain any orders for labs to monitor kidney function. The resident's admitting nurses' notes, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT]. The resident's admitting care plan, dated [DATE], did not contain documentation that the resident was to receive [MEDICAL TREATMENT], and did not contain interventions to guide [MEDICAL TREATMENT] care and to monitor kidney function. A physician's orders [REDACTED]. The order was then discontinued before the resident received [MEDICAL TREATMENT] on [DATE], and an order was written to hold [MEDICAL TREATMENT] for seven days, [DATE] through [DATE]. There were no orders for any lab work to monitor kidney function. On [DATE] at 12:15 PM, the director of nursing (DON) explained the process of the facility's in-house [MEDICAL TREATMENT] treatments. She said, In order for a resident to receive [MEDICAL TREATMENT] in-house, the [MEDICAL TREATMENT] company has to review their records and accept the resident prior to admission. Our [MEDICAL TREATMENT] company had no record to begin [MEDICAL TREATMENT] for Resident #4. At 1:10 PM, the DON confirmed the resident was admitted to the facility from a LTCH on [DATE] along with documentation the resident was receiving [MEDICAL TREATMENT] at the LTC hospital. The DON indicated the resident's last treatment for [REDACTED]. She indicated that the discharge orders from the LTCH contained an order to hold the [MEDICAL TREATMENT] on [DATE], the day before Resident #4 was transferred to the facility from the LTCH. The DON indicated she spoke with the social worker at the LTCH and the nephrologist, and maintained the patient was removed from [MEDICAL TREATMENT] based on improved kidney lab values. On [DATE] at 2:57 PM, North Wing Unit Manager Licensed Practical Nurse (LPN) A, who had received the new physician orders [REDACTED].#4, indicated she had called the facility's physician on-call and had received the order to start and hold the [MEDICAL TREATMENT] from NP C. LPN A indicated she had called the facility's on-call physician on [DATE], and received the order to start [MEDICAL TREATMENT] because she did not see an order for [REDACTED]. LPN A explained that she had called the [MEDICAL TREATMENT] company who would be performing the in-house [MEDICAL TREATMENT] treatments, and the [MEDICAL TREATMENT] company told her they had no record regarding [MEDICAL TREATMENT] treatment for [REDACTED]. LPN A said she informed NP C, and he gave her the order to hold [MEDICAL TREATMENT] for 7 days without any other orders or inquiry. On [DATE] at 9:32 AM via telephone, nephrologist E, who treated Resident #4 while at the LTCH, spoke about his order to hold the [MEDICAL TREATMENT] on [DATE]. He indicated he had written the order on [DATE] to hold [MEDICAL TREATMENT] based on Resident #4's laboratory value for creatinine, which was normal at that time. He said there was no conversation with the family regarding the discontinuation of [MEDICAL TREATMENT] because there would have needed to be more lab work obtained at a later date to make the decision if anymore [MEDICAL TREATMENT] was necessary. He also indicated he was not made aware of the Resident #4's discharge to the SNF, and would have continued close monitoring, additional lab work, and [MEDICAL TREATMENT] sessions. On [DATE] at 9:16 AM, the Admission's Coordinator (AC) confirmed she received the initial paperwork regarding Resident #4's referral to their facility via FAX from the LTCH on [DATE]. She said the DON reviews the admission packets. The AC said when a resident comes to their facility, the resident gets a new nephrologist to follow kidney care. She said she did not know if the nephrologist was ever contacted regarding Resident #4. A concurrent record review and interview was conducted on [DATE] at 10:40 AM with NP C who gave the orders concerning [MEDICAL TREATMENT] for Resident #4. NP C indicated any resident on [MEDICAL TREATMENT] is closely monitored and if the creatinine levels were becoming stable, the resident would have repeat labs to monitor the kidney function. He confirmed that he did not order any labs to evaluate resident #4's kidney function while she was not receiving any [MEDICAL TREATMENT]. The blood creatinine level shows how well your kidneys are working. A high level may mean your kidneys are not working as they should. (WebMD). NP C confirmed after reviewing records from the LTCH on [DATE] that the nephrologist there had no intention of stopping Resident #4's [MEDICAL TREATMENT]. NP C said that he gave an order for [REDACTED]. I can only base my decisions on the information provided by the facility. I did not see this resident till [DATE]. Review of NP C's History and Physical, conducted on [DATE], indicated he reviewed the resident's medical record, including medications verified/reviewed, discussed with nurse, telephone orders reviewed, lab/radiology, hospital records reviewed. The visit note included AKI (acute kidney injury)/CKD ([MEDICAL CONDITION]) history/of HD ([MEDICAL TREATMENT]). It did not include any assessment of kidney status or considering the need for [MEDICAL TREATMENT]. NP C did not write any orders to check the resident ' s kidney function even after he documented he reviewed the LTCH records on [DATE]. On [DATE] at 11:26 AM via telephone, Physician F vaguely remembered the resident from the LTC hospital and could not remember if the NP C had spoken with him prior to writing the hold [MEDICAL TREATMENT] order. He said, I would hope (NP C) would consult with me prior to providing care and treatment. Resident #4, admitted to the facility with a pressure ulcer, had been seen by the facility's wound care physician on [DATE] and [DATE]. Review of the Wound Care Specialist Evaluation, dated [DATE], indicated Resident #4 was assessed to have a non-specific rash and an unstageable (due to necrosis) sacrum wound measuring 8.7 centimeters (cm.) x 10.3 cm. The Wound Care Specialist Evaluation, dated [DATE] one week later, revealed resident #4 had developed nine additional wounds, unstageable (due to necrosis) wound of the left ear, unstageable (due to necrosis) wound of the right ear, unstageable deep tissue injury (DTI) of the left lateral heel, unstageable DTI of the left lateral thigh, unstageable DTI of the left upper back, unstageable DTI of the left lateral neck, Stage 2 pressure wound of the right lateral neck, unstageable DTI of the right lateral calf and an unstageable DTI of the right lateral head. Resident #4 was seen by the facility's wound care specialist B weekly throughout her stay at the facility, [DATE] through [DATE]. The Wound Care Specialist Evaluation, dated [DATE], indicated Resident #4 was assessed to have a non-specific rash and an unstageable (due to necrosis) sacrum wound measuring 8.7 cm. (centimeters) x 10.3 cm. A Surgical Excisional Debridement of Muscle procedure was performed to remove necrotic tissue and establish the margins of viable tissue. One week later, on [DATE], the Wound Care Specialist Evaluation indicated Resident #4 had developed nine additional wounds unstageable wound of the left ear, unstageable wound of the right ear, unstageable deep tissue injury (DTI) of the left lateral heel, unstageable DTI of the left lateral thigh, unstageable DTI of the left upper back, unstageable DTI of the left lateral neck, Stage 2 pressure wound of the right lateral neck, unstageable DTI of the right lateral calf, and an unstageable DTI of the right lateral head. On [DATE] 3:30 PM, an interview was conducted with the facility's wound physician regarding resident #4's change in condition evidenced by the development of nine additional wounds in one week. She stated she saw the resident specifically for wound management. She described Resident #4 to be in a vegetative state and did not open her eyes. She confirmed the resident was seen by her twice while at the facility. Initially she saw her for one pressure ulcer located on the sacral area, and then the following visit, one week later, the resident had developed nine additional wounds. At that point, the wound care physician said she called the family to discuss the disease process and proposed Resident #4 go to the emergency room versus end of life care. The wound care physician stated she was not aware resident #4 had been on [MEDICAL TREATMENT] prior to coming to the facility. When the wound care physician reviewed the [MEDICAL TREATMENT] records from the LTCH and realized that this resident did not have any [MEDICAL TREATMENT] treatments for eleven (11) days since [DATE], she said not receiving [MEDICAL TREATMENT] may have contributed to the rapid decline in skin and could explain why Resident #4 had the nine new black wounds all over her body within a week. She said the wounds were Kennedy ulcers. Kennedy Terminal Ulcers (KTU) is the term used for unavoidable skin breakdown or skin failure that occurs as part of the dying process (Schrank, 2009). (virtualhospice.ca). The wound care physician gave the orders to send the resident to the emergency room at 3 PM [DATE]. Resident #4's Physician Consultation, dated [DATE], the day the resident was sent to the hospital from the SNF, reflected the resident had Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage [MEDICAL CONDITION] and Missing [MEDICAL TREATMENT] along with [MEDICAL CONDITION] from [MEDICAL CONDITION] and Acidosis. The physician ordered Resident #4 to begin [MEDICAL TREATMENT] immediately with the prognosis of POOR. Azotemia means insufficient kidney filtering. (Azotemia.net). Uremia is a serious complication of [MEDICAL CONDITION] when urea and other waste products build up in the body because the kidneys are unable to eliminate them. (WebMD). Acidosis is a condition in which there is too much acid in the body fluids. (Medlineplus.gov). The resident received hospice care within 5 days of transfer to the acute care hospital on [DATE], and expired on [DATE]. The facility policy Resident Rights (no date) read, The resident has the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option he or she prefers. The facility was unable to provide any policies regarding [MEDICAL TREATMENT] care and treatment. The facility failed to monitor Resident #4's kidney function and provide life sustaining [MEDICAL TREATMENT]. The last time Resident #4 received [MEDICAL TREATMENT] was on [DATE]. She did not receive any monitoring of kidney function after admission to the facility, and went eleven (11) days without [MEDICAL TREATMENT].

Based on interview, record review and policy review, the facility failed to ensure the physician took an active role in the care and treatment, including monitoring of kidney function and the review of the resident ' s condition to determine the need for [MEDICAL TREATMENT], for 1 of 4 sampled residents (#4). The resident's condition deteriorated to a level requiring hospitalization within 8 days of admission to the facility. The resident received hospice care within 5 days of transfer to the acute care hospital and expired. The facility's failure to monitor kidney status to identify the need for [MEDICAL TREATMENT] resulted in Immediate Jeopardy, staring on [DATE]. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of [DATE]. Findings: Review of documentation from a long-term care hospital (LTCH), dated [DATE], indicated Resident #4 was hospitalized after a motor vehicle accident and apparent [MEDICAL CONDITION]. The resident was intubated and suffered an [MEDICAL CONDITIONS]. [MEDICAL CONDITIONS] is the lack of inadequate oxygen for several minutes or longer. Brain cells begin to die after approximately four minutes without oxygen. (Oxford dictionary). Resident #4 was also assessed to be in Acute Renal (kidney) Failure, and in need of [MEDICAL TREATMENT]. Acute [MEDICAL CONDITION] means the kidneys are unable to excrete the daily load of toxins in the urine. (Oxford dictionary). [MEDICAL TREATMENT] is a process of purifying the blood of a person whose kidneys are not working normally. (Wikipedia). The LTCH history and physical, dated [DATE], indicated the plan was to continue [MEDICAL TREATMENT] and incorporate the services of Nephrology, the branch of medicine that deals with the kidneys (medical-dictionary.thefreedictionary.com/nephrology) and Cardiology, the medical specialty that is concerned with the [DIAGNOSES REDACTED].thefreedictionary.com/nephrology), and monitor the resident for kidney function. The LTCH follow-up plan was to continue [MEDICAL TREATMENT] and incorporate the services of Nephrology and Cardiology and monitor the resident for kidney function. The LTCH nephrology orders, dated [DATE] through [DATE] revealed Resident #4's labs were being closely monitored to determine duration and frequency of the [MEDICAL TREATMENT] treatments. The LTCH Discharge Summary, dated [DATE], indicated Resident #4 had been closely monitored and would be discharged from the LTCH to a Skilled Nursing Facility (SNF). A discussion was conducted with the family addressing [DIAGNOSES REDACTED]. The family voiced understanding and wished to get the resident to a SNF for further care, including [MEDICAL TREATMENT]. Resident #4 was discharged from the LTCH and admitted to the SNF on [DATE] with [DIAGNOSES REDACTED]. Review of the Admitting Minimum Data Set (MDS), dated [DATE], reflected the resident was assessed to have severely impaired cognitive skills for daily decision making and rarely/never able to understand or be understood. Resident #4 was assessed to be bedridden and totally dependent on a staff of two for all activities of daily living. Resident #4 required an indwelling urinary catheter, and was incontinent of bowel. The MDS included the dependence on kidney [MEDICAL TREATMENT] in the [DIAGNOSES REDACTED]. Resident #4's admitting physician orders, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT]. The resident's admitting nurses' notes, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT]. The resident's admitting care plan, dated [DATE], did not contain documentation that the resident was to receive [MEDICAL TREATMENT], and did not contain interventions to guide [MEDICAL TREATMENT] care, and to monitor kidney function. On [DATE] 1:10 PM, the Director of Nursing (DON) confirmed the resident was admitted to the facility from a LTCH on [DATE] along with documentation the resident was getting [MEDICAL TREATMENT] at the LTCH. The DON indicated the resident's last treatment for [REDACTED]. She said the discharge orders from the LTCH contained an order to hold the [MEDICAL TREATMENT] on [DATE]. On [DATE] at 9:32 AM via telephone, nephrologist E who treated Resident #4 while at the LTCH, indicated he had written the order on [DATE] to hold [MEDICAL TREATMENT] based on a laboratory value for creatinine which was normal at that time. He indicated conversation had not taken place with the family regarding the discontinuation of [MEDICAL TREATMENT] because there would have needed to be more labs at a later date to make the decision if anymore [MEDICAL TREATMENT] was necessary. Nephrologist E also indicated he was not made aware of the Resident #4's discharge from the LTCH and would have continued close monitoring and additional labs and [MEDICAL TREATMENT] sessions, at the facility. Resident #4's physician's order was written by Nurse Practitioner (NP) C on [DATE], to begin in-house [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday, starting on [DATE]. The order was later discontinued and a new order was written to hold [MEDICAL TREATMENT] for Resident #4 for seven (7) days, from [DATE] through [DATE]. NP C gave an order to hold the [MEDICAL TREATMENT] for seven (7) days without a physician conducting an actual face to face examination and lab monitoring to determine appropriateness of care for Resident #4. On [DATE] at 10:40 AM, NP C, who had written the above orders concerning the plan of care for Resident #4, indicated any resident on [MEDICAL TREATMENT] is closely monitored and if their Creatinine levels were becoming stable, the resident would have with repeat laboratory blood work (labs) obtained to monitor the resident's kidney function. He confirmed that no further labs were ordered by him to evaluate Resident #4's kidney function. NP C confirmed after reviewing records from the LTCH that the LTCH nephrologist had no intention of stopping Resident #4's [MEDICAL TREATMENT]. NP C said that he gave an order for [REDACTED]. He said, I can only base my decisions on the information provided by the facility. I did not see this resident until [DATE]. NP C had not seen the resident or reviewed Resident #4's medical records prior to writing the order to hold [MEDICAL TREATMENT] for seven (7) days, from [DATE] through [DATE]. The resident's medical records provide invaluable information about the resident's prior and present medical condition. A review of the medical record is necessary in order to include an evaluation of the resident's condition and continued appropriateness of the current medical regime and plan of care. NP C did not order [MEDICAL TREATMENT] and monitoring of kidney function even though his visit notes and the history and physical, dated [DATE], indicated he reviewed the LTCH record. NP C could not recall if he had consulted the primary care physician. On [DATE] at 11:26 AM, Resident #4's primary care physician F indicated he vaguely remembered the resident from the LTCH and could not remember if NP C had spoken with him prior to writing the hold [MEDICAL TREATMENT] order. He said, I would hope (NP C) would consult with me prior to providing care and treatment. The facility was unable to provide documentation that the primary care physician had conducted the initial visit and reviewed Resident #4's labs to coordinate the plan of care and treatment for [REDACTED]. The facility ' s wound care specialist B weekly throughout her stay at the facility had seen Resident #4, from [DATE] through [DATE]. Review of the Wound Care Specialist Evaluation, dated [DATE], indicated Resident #4 was assessed to have a non-specific rash and an unstageable (due to necrosis) sacrum wound measuring 8.7 centimeters (cm.) x 10.3 cm. A Surgical Excisional Debridement of Muscle procedure was performed to remove necrotic tissue and establish the margins of viable tissue. The Wound Care Specialist Evaluation, dated [DATE] one week later, indicated Resident #4 had developed nine additional wounds (unstageable (due to necrosis) wound of the left ear, unstageable (due to necrosis) wound of the right ear, unstageable deep tissue injury (DTI) of the left lateral heel, unstageable DTI of the left lateral thigh, unstageable DTI of the left upper back, unstageable DTI of the left lateral neck, Stage 2 pressure wound of the right lateral neck, unstageable DTI of the right lateral calf and an unstageable DTI of the right lateral head. On [DATE] 3:30 PM, wound care specialist B stated she did see Resident #4 for wound management and described the resident to be in a vegetative state and did not open her eyes. She confirmed the resident was seen by her twice while at the facility. Initially she saw her for one pressure ulcer located on the sacral area, and then the following visit one week later, the resident had developed nine additional wounds. At that point, wound care specialist B called the family to discuss the disease process and proposed Resident #4 be sent to the emergency room versus end of life care. Wound care specialist B stated she had not been aware Resident #4 had been on [MEDICAL TREATMENT] prior to coming to the facility or that the [MEDICAL TREATMENT] had been on hold just prior to her admission. She indicated the discontinuation of Resident #4's [MEDICAL TREATMENT] may have contributed to the rapid decline in skin integrity and why Resident #4 had nine new black wounds all over her body within a week. Review of the Physician Consultation dated [DATE] the day the resident was sent to the hospital from the SNF, indicated Resident #4 had Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage [MEDICAL CONDITION] and Missing [MEDICAL TREATMENT] along with [MEDICAL CONDITION] from [MEDICAL CONDITION] and Acidosis. The physician placed an order for [REDACTED].#4 was placed on Hospice ([DATE]) and later expired ([DATE]). Azotemia is insufficient kidney filtering. (Azotemia.net). Uremia is a serious complication of [MEDICAL CONDITION] when urea and other waste products build up in the body because the kidneys are unable to eliminate them. (WebMD). Acidosis is a condition in which there is too much acid in the body fluids. (medlineplus.gov). On [DATE] at 12:35 PM, the Administrator said, We will take whoever (the physician or the NP) is available to obtain orders for the residents. Review of the facility policy Physician Visits and Physician Delegation, revised [DATE], indicated the facility is to ensure the physician is taking an active role in supervising the care of residents and the review of the total program of care including medications and treatments in each visit. The facility failed to ensure a physician was taking an active role in supervising and monitoring the need for life sustaining [MEDICAL TREATMENT] treatments for Resident #4.

Based on interview, record review and policy review, the physician failed to provide an initial visit to assess and evaluate the monitoring of kidney function and the need for [MEDICAL TREATMENT] for 1 of 4 sampled residents reviewed for [MEDICAL TREATMENT] (#4). The resident's condition deteriorated to a level requiring hospitalization within 8 days of admission to the facility. The resident received hospice care within 5 days of transfer to the acute care hospital and expired. The facility's failure to monitor kidney status to identify the need for [MEDICAL TREATMENT] resulted in Immediate Jeopardy, staring on [DATE]. This deficiency resulted in Substandard Quality of Care. Immediate Jeopardy was determined to be ongoing as of [DATE]. Findings: Review of documentation from a long-term care hospital (LTCH), dated [DATE], indicated Resident #4 presented after involvement in a motor vehicle accident and apparent [MEDICAL CONDITION]. The resident was hospitalized , intubated, and suffered an [MEDICAL CONDITIONS], the lack of inadequate oxygen for several minutes or longer. Brain cells begin to die after approximately four minutes without oxygen. (Oxford dictionary). Resident #4 was also assessed to be in Acute Renal (kidney) Failure and in need of [MEDICAL TREATMENT]. Acute Renal (kidney) Failure means the kidneys are unable to excrete the daily load of toxins in the urine. (Oxford dictionary). [MEDICAL TREATMENT] is the clinical purification of blood to substitute for the absence of normal kidney function. (Oxford dictionary). Resident #4's LTCH follow-up plan was to continue [MEDICAL TREATMENT] and incorporate the services of a nephrologist (kidney specialist) and cardiologist, and to monitor the resident's kidney function. The LTCH's nephrology orders, dated [DATE] through [DATE], revealed Resident #4's lab blood values were being closely monitored to determine duration and frequency of the [MEDICAL TREATMENT] treatments. The LTCH's Discharge Summary dated [DATE], indicated Resident #4 had been closely monitored and would be discharged from the LTC to a skilled nursing facility (SNF). According to the LTCH record, a discussion was conducted with the family addressing [DIAGNOSES REDACTED]. The LTCH record reflected the family voiced understanding and wished to get the resident to a SNF for further care. Resident #4 was discharged from the LTCH and admitted to the SNF on [DATE] with [DIAGNOSES REDACTED]. Resident #4's admitting physician orders, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT]. The resident's admitting nurses' notes, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT]. The resident's admitting care plan, dated [DATE], did not contain any documentation that the resident was to receive [MEDICAL TREATMENT], and did not contain interventions to guide [MEDICAL TREATMENT] care. On [DATE], Resident #4's physician's orders [REDACTED]. This order was later discontinued, and NP C ordered to hold [MEDICAL TREATMENT] for Resident #4 for seven days, [DATE] through [DATE]. On [DATE] at 1:10 PM, the Director of Nursing (DON) confirmed the resident was admitted to the facility from a LTCH on [DATE] along with documentation the resident was receiving [MEDICAL TREATMENT] at the LTCH prior to admission. The DON indicated the resident's last treatment for [REDACTED]. The DON was unable to explain why Resident #4 was not being monitored for kidney function to determine if additional [MEDICAL TREATMENT] was needed, and why the nephrologist was not contacted for clarification of the hold [MEDICAL TREATMENT] order. On [DATE] at 9:32 AM via telephone, nephrologist E who treated Resident #4 while at the LTCH indicated he had written the hold [MEDICAL TREATMENT] order on [DATE] based on a laboratory value for creatinine, which was normal at that time. He said no conversation had taken place with the family regarding the discontinuation of [MEDICAL TREATMENT] as there would have needed to be more lab work at a later date to make the decision if anymore [MEDICAL TREATMENT] was necessary. Nephrologist E also indicated he was not made aware of the Resident #4's discharge from the LTCH, and would have continued close monitoring, additional lab work, and [MEDICAL TREATMENT] treatments in the facility. On [DATE] at 10:40 AM, NP C indicated any resident on [MEDICAL TREATMENT] is closely monitored, and if their Creatinine levels were becoming stable, the resident would be given a trial of holding [MEDICAL TREATMENT], and repeat lab blood work to monitor the resident's kidney function. He confirmed that he did not order any further labs to evaluate Resident #4's kidney function. NP C confirmed after reviewing Resident #4's records from the LTCH that the nephrologist at the LTCH had no intention of stopping the resident's [MEDICAL TREATMENT]. NP C said that he gave an order for [REDACTED]. He said, I can only base my decisions on the information provided by the facility. I did not see this resident until [DATE]. NP C had not seen the resident or reviewed Resident #4's medical records prior to writing the order to hold [MEDICAL TREATMENT] order for seven days, [DATE] through [DATE]. NP C could not recall if he had consulted the primary care physician. On [DATE] at 11:26 AM, Resident #4's primary care physician vaguely remembered the resident from the LTCH, and could not remember if NP C had spoken with him prior to writing the hold [MEDICAL TREATMENT] order. He said, I would hope (NP C) would consult with me prior to providing care and treatment. Resident #4's Physician Consultation, dated [DATE], the day the resident was sent to the hospital from the facility, assessed the resident with Severe Azotemia and Uremia causing resident to have a change in mental status, Acidosis from possibly End Stage [MEDICAL CONDITION] and missing [MEDICAL TREATMENT] along with [MEDICAL CONDITION] from [MEDICAL CONDITION] and Acidosis. Azotemia is insufficient kidney filtering. (Azotemia.net). Uremia is a serious complication of [MEDICAL CONDITION] when urea and other waste products build up in the body because the kidneys are unable to eliminate them. (WebMD). The physician ordered Resident #4 to begin [MEDICAL TREATMENT] immediately, and wrote the prognosis was POOR. Resident #4 was placed on Hospice care on [DATE] and expired on [DATE]. On [DATE] at 12:35 PM, the Administrator was asked about the physician conducting the initial visit to assess and write orders for Resident #4. He said, We will take whoever (physician or NP) is available to obtain orders for the resident. The NP completed the initial comprehensive visit for Resident #4 seven (7) days after admission to the facility. NP C's documentation of the visit indicated it was conducted on [DATE] at 10:20 AM, and that the resident was a new admission. The history and physical contained the following areas reviewed and completed: history of present illness, allergies [REDACTED]. The following areas were checked: admit to facility, Rehab therapies ordered, medications verified/reviewed, discussed with nurse, telephone orders reviewed, lab/radiology, hospital records reviewed. The visit note also included AKI (acute kidney injury)/CKD ([MEDICAL CONDITION]) history/of HD ([MEDICAL TREATMENT]). It did not include any assessment of kidney status or [MEDICAL TREATMENT]. A comprehensive type of examination includes at least nine organ systems or body areas. (CMS.gov). Although this information was documented as completed by NP C, on [DATE] at 10:40 AM, he said, if he had known that the [MEDICAL TREATMENT] was only on hold, he would have ordered a STAT (immediate) nephrology consult. The facility policy Physician Visits and Physician Delegation, revised [DATE], contained a chart documenting the following information: In a Skilled Nursing Facility, Initial Comprehensive Visits/Orders MAY NOT be Performed or Signed by a Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist employed or not employed by the facility. The facility failed to ensure a physician conducted the first initial visit, and monitor the life sustaining [MEDICAL TREATMENT] treatment for [REDACTED].

Based on observation, interview, and record review the facility failed to treat a resident with Alzheimer's dementia with dignity and respect when the resident refused care for 1 of 31 sampled residents (#86). Due to this failure, the resident sustained [REDACTED]. Findings: (cross reference to F309, F282, F329) On 10/14/14 at 11:07 a.m., resident #86 was heard yelling. The room to the resident's door was closed, but the resident could be heard from the common area outside her room. After a staff person in the room granted permission to enter, observation revealed resident #86 was the only resident in the room. She was yelling, "get out." She was attempting to kick, bite, and hit 2 certified nursing assistants (CNAs), # C and #D. The resident continued to tell the CNAs to "get out of here," but they did not stop care and/or step away from the resident. CNA #D was holding both of the resident's hands tightly and the resident was trying the break free of her grip. CNA #C was attempting to button the resident's shirt and the resident continued to yell and attempt to bite, kick, and hit the CNAs. They did not stop attempting to provide care despite the residents repeated requests for them to get out and the resident's attempts to kick, hit, and bite them. The resident was visibly distressed. Both CNAs began to laugh at the resident as she resident continued to try to bite them and kick them. When asked why they were continuing to ignore the resident's requests to stop, they said they continued because the resident was soiled with bowel movement and they had to clean her. They said she then would not let them dress her so they held her hands so she couldn't hit them. Within a few minutes, the Unit Manager (UM) was informed and she entered the room. The resident was visibly upset and was yelling and screaming as she was saying, "help me" and "get out of here." She was still trying to hit, bite, and kick the CNAs while they stood at the bedside. They did not attempt to speak to the resident in a calm and respectful manner even after the UM entered. At that time CNA #D said to the UM, "this resident is crazy" in the presence of the resident and the UM. The UM then asked both CNAs to leave the room while she stayed with the resident. In an interview with CNA #C and #D on 10/14/14 at 11:30 a.m., CNA #D said she was assigned to care for resident that day and she was familiar with resident #86 because she cares for her every day she works. She said the resident is not always resistant to care. When she entered the resident's room to deliver care she said the resident told her to get out. She said she reported it to the nurse who instructed her to take another staff member with her to provide care. CNA #D said she did not want to leave the resident who was incontinent of BM at that time without cleaning her even though the resident was refusing care at that time. CNA #B said when a resident resists care we usually come back later, but we could not leave the resident soiled. When asked why they did not stop as the resident continued to refuse and became more and more agitated, they said, "we had to finish because we could not leave her that way." During observation on 10/14/14 at approximately 12:00 p.m., the resident was observed being taken out of her room in a wheeled recliner. The resident was calm and was not attempting to kick, hit or bite staff. At that time the UM said the resident was upset and continued to attempt to hit and kick her, but she eventually became calm because she did not attempt further care, watched the resident from a distance, and spoke to her in a calm voice. After she was calm, the UM said she was able to finish care. In an interview withe the UM at 10/14/14 at 12:55 p.m., she said she thought the both CNAs behavior was not acceptable. They did not treat the resident with dignity or respect. They should not laugh at resident's or call them names like "crazy." She thought the resident's agitation and distress could have been avoided had the CNAs not continued to provide care when the resident first expressed her wishes for them to get out. They should have not have started care against the resident's wishes and should not have continued when the resident became extremely upset. She said she thought what happened was not acceptable and they should have done a better job caring for a resident with dementia because they care for many residents with dementia. "That is the type of residents we care for." Record review revealed resident #86 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She requires extensive assistance with all ADLs and has severe cognitive impairment. Social Services notes dated 7/07/14 indicated the resident is able to make needs known to staff.

Based on observation, interview, and record review, the facility failed to implement the care plan for residents with Alzheimer's dementia for episodes of being combative during care, communication, and antianxiety medication for one resident reviewed for dementia with behaviors of 31 sampled residents (#86). Findings: (cross reference to F309, F329) Record review revealed resident #86 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The goal is for the resident to maintain a stable mood and behaviors, will respond to redirection and re-approaches when resisting care. Interventions dated 4/02/14 included: observe for things that could cause anxiety and restlessness, ask simple questions during care routines, observe for agitation during care-step away and re-approach if needed. An intervention was added on 7/07/14 to offer words of encouragement, a listening ear, and utilize diversional activity if needed during episodes of crying. An intervention was added on 9/09/14 to talk resident through each care routine, step away if needed if resident becomes combative. Review of her minimum data set assessment dated [DATE] revealed the resident exhibited physical behaviors such as hitting, kicking, pushing, scratching, or grabbing 1-3 times per week and rejected care 1-3 times per week. She requires extensive assistance with all ADLs and has severe cognitive impairment. Social Services notes dated 7/07/14 indicated the resident is able to make needs known to staff. On 10/14/14 at 11:07 a.m., resident #86 was heard yelling. The room to the resident's door was closed, but the resident could be heard from the common area outside her room. After a staff person in the room granted permission to enter, observation revealed resident #86 was the only resident in the room. She was yelling, "get out." She was attempting to kick, bite, and hit 2 certified nursing assistants (CNAs) # C and #D. The resident continued to tell the CNAs to "get out of here," but they did not step away from the resident. CNA #D was holding both of the resident's hands tightly and the resident was trying the break free of her grip. CNA #C was attempting to button the resident's shirt and the resident continued to yell and attempt to bite, kick, and hit the CNAs. They did not stop attempting to provide care despite the residents repeated requests for them to get out and the resident's continued attempts to kick, hit, and bite them. The resident was visibly distressed and continued to be combative. When asked why they were continuing to ignore the resident's requests to stop, they said they continued care because the resident was soiled with bowel movement and they had to clean her. They said she then would not let them dress her so they held her hands so she couldn't hit them. In an interview with CNA #C and #D on 10/14/14 at 11:30 a.m., CNA #D said she was assigned to care for resident that day and she was familiar with resident #86. She said the resident is not always resistant to care. When she entered the resident's room to deliver care that morning, she said the resident told her to get out. She said the reported it to the nurse who instructed her to take another staff member with her to provide care. CNA #D said she did not want to leave the resident who was incontinent of BM at that time without cleaning her even though the resident was refusing care at that time. CNA #B said when a resident resists care we usually come back later, but we could not leave the resident soiled. When asked why they did not stop as the resident continued to refuse and became more and more agitated, they said, "we had to provide care because we could not leave her that way." In an interview withe the UM at 10/14/14 at 12:55 p.m., she said she thought the both CNAs behavior was not acceptable and they did not follow the plan of care for this resident. She thought the resident's agitation and distress could have been avoided had the CNAs not continued to provide care when the resident first expressed her wishes for them to get out. They should have followed any of the care plan interventions to step away from the resident. Resident #86 had a care plan for communication problem related to [DIAGNOSES REDACTED]. The goal was for the resident to be able to make basic needs known on a daily basis. The interventions included but were not limited to: anticipate and meet needs, monitor/document for physical/nonverbal indicators of discomfort or distress. In interviews on 10/16/14 with LPN #B at 10:16 a.m., RN #F at 10:33 a.m., and the social service director at 11:50 a.m., they confirmed the resident had combative behavior when resisting care. They said the documentation of the behaviors should be in the nurses notes. Review of nurses notes revealed they did not include documentation or monitoring of physical or nonverbal indicators of distress occurring 1-3 times a week. Resident #86 had a care plan for antianxiety medication related to anxiety initiated on 3/28/14 and revised on 9/19/14. The goal was for the resident to be free of discomfort or adverse reactions related to [MEDICAL CONDITION] medications. One of the interventions was to administer the antianxiety medication per the physician's orders [REDACTED]. The [MEDICATION NAME] was listed on the medication record to be given at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The target behavior on the behavior monthly flow record was listed as delusions and hallucinations. The record indicated the resident was not exhibiting either behavior. On 8/27/14, a telephone order was documented for [MEDICATION NAME] 0.5 mg for one dose for the same reason, agitation. However, the nurses notes documented the resident was given the medication on 8/27/14 for refusing care by kicking, hitting, and spitting at staff. The resident received another order for [MEDICATION NAME] 0.25 mg every 6 hours as needed(PRN)for agitation on 8/28/14. The order did not include any other target behaviors. From 9/06/14 to 10/14/14 the resident received the PRN medication 8 times. The reason for giving the medication was documented in the nurses notes as being combative with staff, anxiety or restlessness on 3 of those times. The other times agitation was listed, but the description of the resident's agitation was not documented. In an interview with RN #F on 10/16/14 10:33 a.m., he said he will give the PRN [MEDICATION NAME] when the CNAs tell him the resident is agitated when they want to give care. He said he did not does see combative behavior because she is usually calm with him. In an interview with LPN #B on 10/16/14 10:16 a.m. she said the resident gets combative when she gets bothered. She said the resident had that behavior approximately 1-3 times a week. She said if the resident is agitated when the CNAs want to give care, they tell her so she can administer the PRN [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to provide care in a manner to promote the highest practicable mental, psychosocial, and physical well-being for a resident with Alzheimer's dementia who resisted care that resulted in substantial psychological distress and physical injury for 1 of 1 resident reviewed out of 31 sampled residents (#86). Findings: (cross reference to F241, F282, F329, F498) Record review revealed resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) assessment dated [DATE] indicated the resident had severe cognitive impairment. She is usually understood and can express her needs. She has no hallucinations or delusions. She exhibits physical behavioral symptoms directed towards others such as, hitting, kicking, pushing, scratching 1-3 days a week. She rejects care 1-3 days a week. The resident is always incontinent of bladder and frequently incontinent of bowel. She requires extensive assistance with activities of daily living. On 10/14/14 at 11:07 a.m., resident #86 was heard yelling. The room to the resident's door was closed, but the resident could be heard from the common area outside her room. After a staff person in the room granted permission to enter, observation revealed resident #86 was the only resident in the room. She was yelling, "get out." She was attempting to kick, bite, and hit 2 certified nursing assistants (CNAs) # C and #D. The resident continued to tell the CNAs to "get out of here," but they did not stop care and/or step away. CNA #D was holding both of the resident's hands tightly and the resident was trying the break free of her grip. CNA #C was attempting to button the resident's shirt and the resident continued to yell and made repeated attempts to bite, kick, and hit the CNAs. Neither CNA #D, nor CNA #C stopped attempting to provide care despite the resident's repeated requests for them to get out and the resident's continued attempts to kick, hit, and bite them. The resident was visibly distressed. Both CNAs began to laugh at the resident as she resident continued to try to bite them and kick them. When asked why they continued to ignore the resident's requests to stop, they said they continued because the resident was soiled with bowel movement and they had to clean her. They said she then would not let them dress her, so they held her hands so she couldn't hit them. Within a few minutes, the Unit Manager (UM) was informed of the observation and she entered the room. The resident was visibly upset and was yelling and screaming as she was saying, "help me" and "get out of here." She was still trying to hit, bite, and kick the CNAs while they stood at the bedside. They did not attempt to speak to the resident in a calm and respectful manner. At that time CNA #D said to the UM, "this resident is crazy" in the presence of the resident and the UM. The UM then asked both CNAs to leave the room while she stayed with the resident. Later the same day, at 11:20 A.M. licensed practical nurse (LPN) #B was observed preparing medication and walked into resident #86's room. When she exited the room she said it was [MEDICATION NAME] ([MEDICATION NAME]) 0.25 milligrams (mg) and it was ordered as needed (PRN) for agitation. She said the resident would not take it so she was going to call the physician to ask for an antianxiety medication to be given via an intramuscular (IM) injection. In an interview with CNA #C and #D on 10/14/14 at 11:30 a.m., CNA #D said she was assigned to care for resident today and she was familiar with resident #86. She said the resident is not always resistant to care, it depends on her mood. When she entered the resident's room to deliver care she said the resident told her to get out. She said she reported it to the nurse who instructed her to take another staff member with her to provide care. CNA #D said she did not want to leave the resident who was incontinent of BM at that time without cleaning her even though the resident was refusing care at that time. CNA #B said "when a resident resists care we usually come back later, but we could not leave the resident soiled." When asked why they did not stop and step away as the resident continued to refuse and became more and more agitated, they said, "we had to finish because we could not leave her that way. What else were we supposed to do? We couldn't let her hit us." During an observation on 10/14/14 at 12 p.m., the resident was observed being taken out of her room in a wheeled recliner chair. At that time, the UM said the resident was upset and continued to kick and swing at her for the next 40-45 minutes. During that time, she said she stayed in the room with the resident to observe her, but out of her reach and spoke to the resident in a calm manner. She said the resident refused the [MEDICATION NAME] pill, so she instructed the nurse to call the physician to ask for a medication that could be given via intramuscular (IM) injection. The UM said the resident eventually became calmer and agreed to finished getting dressed and transfer to the chair with staff assist. The physician ordered [MEDICATION NAME] 0.5 mg IM one time for agitation, but the UM said they did not need to give it because she was able to help the resident become calmer and allow care. On 10/14/14 at 12:40 p.m., the resident was observed being taken away from the lunch table by CNA #E. "Refused" was marked on her meal ticket. The resident was calm and was not yelling, kicking or hitting. In an interview with CNA #E at that time she said resident would not eat. She said she has cared for the resident before and depending on the resident's mood she will feed herself, let staff assist, or refuse. In an interview withe the UM at 10/14/14 at 12:55 p.m., she said she thought the both CNAs behavior was not acceptable. They did not treat the resident with dignity or respect. She thought the resident's distress could have been avoided had the CNAs not continued to provide care when the resident first expressed her wishes for them to get out. They should have not have started care against the residents wishes and should not have continued when the resident became extremely upset. She said she thought what happened to the resident was not acceptable and they should have done a better job caring for a resident with dementia because they care for many residents with dementia. "That is the type of residents we care for." Review of the facility assignments September and October revealed CNA #D was the CNA who cared for the resident every day she worked for 8 shifts in October and 22 shifts in September. CNA #C worked 19 shifts in September and 11 shifts on October. The facility had consistent assignments. On 10/14/14 3:55 p.m. the resident was observed in TV area in the recliner chair across from her room. She was listening to the music program and alternatively closing eyes. The first knuckle on the back of her right hand was red and swollen. On 10/15/14 at 10:15 a.m. the resident was observed in bed eyes with her eyes closed. After a knock on the door, she opened eyes and spoke calmly. The first knuckle on the back of the right hand was red, swollen, and had a purple area extending towards her fingers. The knuckle on the right hand middle finger was red. The resident smiled and moved her right hand freely. In an interview with the UM on 10/15/14 at 10:30 a.m., she said the resident initially complained of pain in her right hand on 10/14/14 and said "they hurt me" as she pointed to her right hand. She said the physician was notified and an X ray was obtained. It was negative for [MEDICAL CONDITION] and showed [MEDICAL CONDITION]. The UM said the resident became calm after she stepped away from the bedside and spoke to her in a calm manner. In an interview with the hospice CNA caring for the resident on 10/15/14 at 12:19 p.m., she said she is aware the resident can be combative with care, but she said it depends how you approach the resident. She said if the resident says no and/or attempts to swing at her, she steps away and tells the nurse that the resident refused care at that time. She said usually she can go back and sit with the resident and hold her hand, she will not become combative or agitated, and she will agree to care. She said she often works with another hospice CNA, but they provide care in small steps and explain each step of care along the way. The social services director was interviewed on 10/16/14 at 10:50 a.m. regarding how she determines what to document on the MDS assessment regarding resident #86's behavior. She said she documents in her social service progress notes what she retrieves from nurses notes, hospice notes, and CNA interviews. She said her behavior is calm when she is in the recliner chair out in atrium. She said it depends on her mood on whether or not she allows care. The quarterly review notes dated 9/09/14 indicated the resident has episodes of crying and restlessness at times and she also becomes combative with ADL care and will attempt to kick and scratch caregivers. The notes did not address any attempt to determine why the resident exhibits the behaviors or that the resident received orders for PRN [MEDICATION NAME] in addition to routine [MEDICATION NAME] for increased agitation after the resident refused care on 8/27/14. Review of the record revealed the physician's progress note dated 8/28/14 noted nursing staff report increased agitation. Nurses notes documented the resident refused care and was kicking, hitting, and spitting. The physician wrote an order dated 8/28/14 to receive [MEDICATION NAME] 0.25 mg every 6 hours related to dementia and agitation. Review of the Medication Administration Record [REDACTED]. The nurse, LPN #B, attempted to give the [MEDICATION NAME] again on 10/14/14 for refusing care and being combative with staff and when the resident refused, she planned to get an order to give her an injection. A care plan was initiated on 4/02/14 for [MEDICAL CONDITION] and a history of anxiety, agitation, and depression. The care plan included interventions to: observe for agitation during care-step away and re-approach if needed. On 9/09/14 the interventions was added to talk resident through each care routine, step away if needed if resident becomes combative. The care plan did not include interventions to give the resident PRN [MEDICATION NAME] when she became combative, although staff interviews and documentation revealed the resident was given the medication for refusing care. In an interview with RN #F on 10/16/14 10:33 a.m., he said he will give the PRN [MEDICATION NAME] when the CNAs tell him the resident is agitated when they want to give care. He said he did not does see combative behavior because she is usually calm with him. In an interview with LPN #B on 10/16/14 10:16 a.m. she said the resident gets combative when she gets bothered. She said the resident had the behavior approximately 1-3 times a week. She said if the resident is agitated when the CNAs want to give care, they tell her so she can administer the PRN [MEDICATION NAME]. On 10/14/14 at 3:55 p.m. the director of nursing was asked to provide any policies or procedures for care of residents with dementia and behaviors. On 10/15/14 she provided a policy for abuse and neglect. The policy referred to a catastrophic reaction as an extraordinary reaction of residents to ordinary stimuli, such as the attempt to provide care. The heading of "identification, correction and intervention in abusive/neglectful situations " included: deployment of staff to meet the needs of the residents and assure staff have the knowledge of the individual residents' care needs; supervision of staff to identify inappropriate behaviors; assessment, care planning, and monitoring of resident with needs and behaviors with might lead to conflict or neglect, such as residents with aggressive behaviors. The facility Clinical Protocol for Problematic Behavior Management included: identify individuals with impaired cognition (dementia), document details about behavior such as onset, frequency, and precipitation factors, document features of any changes over time, staff will use protocols to identify pertinent interventions, other than medications, for the nature and causes of the individual's behavior. The policy for Behavior Assessment and Monitoring indicated the facility will comply with regulatory requirements related to the use of medications to manage problematic behavior. The "monitoring" section of the policy indicated staff will document in progress notes or behavior assessment forms the following information: number and frequency of episodes, preceding or precipitating factors, interventions attempted, and outcomes associated with interventions. During a meeting with the Administrator, DON, UM for 200 wing, and acting ADON/Independent Nurse Consultant for all Avante buildings on 10/15/14 10:30 a.m., the events of the previous day involving resident #86 were discussed. They all confirmed the manner in which the resident was cared for was not acceptable and the resident sustained [REDACTED]. Although the DON and acting DON described training in progress, they indicated the UM completes random observations of care and they had no formal process to observe care of CNAs/nurses and document findings. They had not provided the free Centers for Medicare and Medicaid Services training for Person-Centered Care of Persons with Dementia and Prevention of Abuse to their staff.