Every finding on record at Avante Rehabilitation Center

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #1) of four residents. The facility failed to ensure Resident #1's admission MDS assessment dated [DATE] accurately reflected that Resident #1 was receiving dialysis (a life-sustaining medical treatment that filters waste, extra salt and fluid from the blood when the kidneys fail. This failure could place the residents at risk of not receiving care and services to meet their needs, diminished function of health, and regression in their overall health. Findings included: Review of Resident #1's admission MDS Assessment, dated 05/27/26 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including: cerebral infarction (the death of brain tissue caused by sudden loss of blood flow and oxygen), dysphagia (difficulty or discomfort when swallowing food, liquids, or even salvia), malignant neoplasm of lung (cancerous tumor) and end stage renal disease (the final permanent stage of chronic kidney disease). Resident #1 had a BIMS score of 15 indicating intact cognition. The admission MDS Assessment did not indicate that Resident #1 was receiving dialysis. Review of Resident #1's electronic medical record and interview on 08/25/26 at 11:50 AM with the DON revealed Resident #1 discharged from the facility on 05/27/26. The DON stated that Resident #1 did not have a completed Baseline Care Plan prior to her discharge. The DON confirmed that dialysis was not indicated on the admission MDS assessment dated [DATE] for Resident #1 and that dialysis should have been indicated since Resident #1 received dialysis three times a week including on 05/25/26. The DON stated that the purpose of the admission MDS assessment was to paint a complete picture of the resident. The DON stated that the risk of dialysis not being indicated on Resident #1's admission MDS assessment would be the assessment did not paint an accurate picture. The DON stated that the MDS Coordinator was responsible for ensuring assessment accuracy. Review of Resident #1's physician orders from May 2026 revealed on order dated 05/23/26, Resident has dialysis: Monday, Wednesday and Friday. Interview on 08/25/26 at 11:55 AM with the Administrator revealed that the admission MDS assessment should be accurate to ensure it reflected the resident appropriately for reimbursement and care. Telephone interview on 08/25/26 at 12:02 PM with the MDS Coordinator revealed she did not know why Resident #1's dialysis was not coded on admission MDS assessment, dated 05/27/26. The MDS Coordinator stated she must have missed indicating Resident #1's dialysis and would correct the MDS. The MDS Coordinator stated that it was important for the MDS to be accurate to indicate the services that a resident received. The MDS Coordinator stated the risk of an inaccurate MDS would be not presenting a full picture of the resident. Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) Manual updated October 2025 reflected under O0110J1, Dialysis: Code peritoneal or renal dialysis which occurs at the nursing home or at another facility. Review of the facility's policy titled Resident Assessment Instrument, dated December 2025 revealed .3. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity.

Based on interview and record review, the facility failed to develop a Baseline Care Plan within 48 hours of a resident's admission for one (Resident #1) of four residents reviewed for comprehensive care plans. Resident #1's was admitted on [DATE] and the facility failed to complete a Baseline Care Plan within the required 48-hour timeframe of admission. This failure could place residents at risk of not receiving the necessary care and services or having important care needs identified upon admission. Findings included: Review of Resident #1's admission MDS assessment, dated 05/27/26 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including: cerebral infarction (the death of brain tissue caused by sudden loss of blood flow and oxygen), dysphagia (difficulty or discomfort when swallowing food, liquids, or even salvia), malignant neoplasm of lung (cancerous tumor) and end stage renal disease (the final permanent stage of chronic kidney disease). Review of Resident #1's electronic medical record and interview on 08/25/26 at 11:50 AM with the DON revealed Resident #1 discharged from the facility on 05/27/26. The DON stated that Resident #1 did not have a completed Baseline Care Plan prior to her discharge. The DON stated that the Baseline Care Plan was required to be completed within 48 hours of admission. The DON stated that the admitting nurse would have be responsible for completing the Baseline Care Plan. The DON stated that LVN A was the nurse working on 05/22/26 when Resident #1 was admitted . The DON stated that the Baseline Care Plan is important since it provides a guide for staff to take care of the residents. The DON stated that the risk of not completing a Baseline Care Plan could result in staff not knowing the residents' care needs. Interview on 08/25/26 at 11:55 AM with the Administrator revealed that Baseline Care Plans were required within 48 hours of a resident's admission. The Administrator stated he was not aware that Resident's #1 Baseline Care wasn't completed prior to her discharge on [DATE]. The Administrator stated that the admitting nurse would be responsible for completing the Baseline Care Plan. Telephone interview on 08/25/26 at 1:01 PM with LVN A revealed that the admitting nurse was required to complete the Baseline Care Plan on a resident. LVN A stated she is aware that the Baseline Care Plan is required for new admissions. LVN A stated she did not remember why the Baseline Care Plan wasn't completed for Resident #1. LVN A stated that she was newly hired in May 2026, and had never did admission paperwork on residents which could have contributed to the Baseline Care Plan not being completed for Resident #1. LVN A stated that Baseline Care Plans are important since they are the pathway for caring for the residents, and without the pathway, the resident is at risk of missing care. Review of facility's policy Care Plans-Baseline dated December 2016 reflected, A baseline plan of care to meet resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #1) of four residents reviewed for pharmacy services. The facility failed to ensure MA B did not administer Resident #1's blood pressure/pulse altering medication on 05/25/26 when her blood pressure/pulse was not within the required parameters per the physician's order. This failure could place residents who at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization. Findings included: Review of Resident #1's admission MDS assessment, dated 05/27/26 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including: cerebral infarction (the death of brain tissue caused by sudden loss of blood flow and oxygen), dysphagia (difficulty or discomfort when swallowing food, liquids, or even salvia), malignant neoplasm of lung (cancerous tumor) and end stage renal disease (the final permanent stage of chronic kidney disease). Review of Resident #1's admission MDS Assessment, dated 05/27/26, reflected Resident #1 had a BIMS score of 15 indicating cognitively intact. Review of Resident #1's electronic medical record and interview on 08/25/26 at 11:50 AM with the DON revealed Resident #1 discharged from the facility on 05/27/26. The DON stated that Resident #1 did not have a completed Baseline Care Plan prior to her discharge. Review of Resident #1's May 2026 physician orders reflected the following orders:Diltiazem HCL ER Oral Capsule Extended Release 24 Hour 120 MG. Give 1 capsule by mouth one time a day for BP Hold for BP less than 110/60 or HR less than 60. Start date 05/23/26.Carvedilol Oral Tablet3.125 MG. Give 1 tablet by mouth two times a day for BP Hold for BP less than 110/60 or HR less than 60. Start date 05/23/26. Review of Resident #1's May 2026 eMAR reflected on 05/25/26, MA B documented Resident's #1's blood pressure as 109/66 and pulse as 79. MA B documented that she administered Resident #1's Diltiazem HCL ER at 9:00 AM. Review of Resident #1's May 2026 eMAR reflected on 05/25/26, MA B documented Resident #1's blood pressure as 109/66 and pulse as 79. MA B documented that she administered Resident #1's Carvedilol at 9:00 AM. On 08/25/26 at 9:49 AM, an attempt was made to call MA B, however, a recording stated phone was restricted and there was no option of leaving a message. A text message was also sent at this time to MA B requesting a returned phone call. Interview on 08/25/26 at 9:50 AM, MA C stated it was important to check vital signs before giving medications that could affect them because if they gave a blood pressure medication and their blood pressure was low, you could drop the blood pressure lower which could lead to hypotension (low blood pressure), falls, and hospitalization. Interview on 08/25/26 at 9:59 AM, MA D stated it was important to check vital signs before giving medications that could affect them because if you gave blood pressure medication and their blood pressure was low, you could drop the blood pressure lower which could lead to falls or dizziness. Interview on 08/25/25 at 10:16 AM with the facility's MD, the MD stated his expectation was for staff to call him or his NP if a resident's BP is outside of the medication's parameters. The MD stated with Resident #1's BP reading being one point off, there was no risk of harm since Resident #1's BP medications do not stay in the body's system long. MD stated that Resident #1's BP readings were up for 05/26/26, the next day. Interview and record review on 08/25/26 at 11:52 AM, the DON stated she did not know why MA B gave Resident #1 her BP meds on 05/25/26 with her BP being outside of the order parameters (109/66). The DON stated that MA B no longer worked at the facility. The DON stated that the staff are trained to look at the medication and parameters before administering. The DON stated in-services on medication administration and documentation were done often and they had just done an in-service on BP medications and documentation which included documentation if a medication was held due to being outside of parameters, within the last couple of weeks. The DON stated they notified the provider if the BP or pulse was high or low, or consistently high or low. The DON stated if Resident #1's blood pressure dropped too low he may have experienced possible dizziness, weakness or become lethargic. On 08/25/26 at 2:47 PM, an attempt was, again made to call MA B, however a recording stated phone was restricted and there was no option to leave a message. Review of MA B's training record titled Medication Administration Skill Assessment, dated 05/19/26 revealed Clinical Proficiency Criteria.5. For medications with parameters, vital signs are taken prior to administration, indicating a pass grade. Record review of the facility's Administering Medications policy revised April 2019 reflected in part:.4. Medications are administered in accordance with prescriber orders, including any required time frame .11. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #1) of 2 residents reviewed for infection control. The facility failed to ensure LVN A performed hand hygiene and changed gloves during wound care for Resident #1 on 4/23/2026. This failure could place residents at risk for infection and cross contamination.Record review of Resident #1's Comprehensive MDS assessment, dated 02/24/26, reflected a [AGE] year-old female with an admission date of 02/16/25 with diagnoses that included pressure ulcer of sacral region (triangular bone at the base of the spine), and adult failure to thrive (A condition in older adults characterized by a rapid decline in physical and cognitive function, unintentional weight loss, poor nutrition, and social withdrawal). Resident #1 had a BIMS score of 02 which indicated Resident #1's cognition was severely impaired. Resident#1 required maximum assistance of two-person physical assistance with activities of daily living. In an observation and interview of wound care on Resident #1 by LVN A on 04/23/26 at 11:22 AM, revealed LVN A at the treatment cart. LVN A placed gauze, a calcium alginate dressing (a soft conformable, highly absorbent dressing), and a foam dressing on the bedside table. LVN A and RN B entered the resident's room, they washed their hands and put on gloves and gowns. LVN A uncovered resident, unfastened the brief and turned resident on her side. RN B supported the resident on the side; it revealed the dressing on Resident #1's sacrum. LVN A removed the old dressing and discarded it in the biohazard bag. LVN A then removed her gloves and put on clean gloves without performing hand hygiene and she reached onto the bedside table and pulled vials of normal saline and gauze and cleaned the wound bed. With the same gloves on, she patted the wound bed dry with the gauze. With the same gloves on, she retrieved the calcium alginate dressing and the collagen powder. She covered the wound with collagen and the calcium alginate dressing and covered it with the foam dressing. LVN A then removed her gloves and gown and washed her hands. In an interview with LVN A on 04/23/26 at 11:42 AM, she stated she was supposed to sanitize her hands after each glove change and stated she had failed to do that. She stated she was supposed to change gloves after she cleaned the wound and before she reached out to get the dressing. She stated failing to perform hand hygiene and changing gloves properly created a risk of infection for the resident. In an interview with the DON on 04/23/26 at 11:27 AM, she stated staff were to change their gloves and perform hand hygiene when going from dirty to clean. She stated failing to keep supplies from contamination and failing to perform hand hygiene after glove changes placed residents at risk of infection and cross contamination. Record review of the facility's policy updated December 2025, titled Hand Washing / Hand Hygiene reflected, . This facility considers hand hygiene the primary means to prevent the spread of infections.

Based on observation, interview, and record review, the facility failed to ensure it was free of a medication rate of five percent (5%) or greater. There were three medication errors observed out of 31 opportunities resulting in an 9% medication error rate. One (LVN B) of two staff observed made two errors during the medication pass for one (Resident #81) of two residents observed. 1. LVN B on 07/29/2025 administered Resident #81 MiraLAX Oral powder 17grm (for constipation) without the appropriate amount of fluid. 2. LVN B on 07/29/2025 failed to administer Advair HFA Inhalation Aerosol 115-21 mcg to Resident #81. 3. LVN B on 07/29/2025 failed to administer Isosorbide Mononitrate ER oral tablets 60mg to Resident #81. These failures could affect the residents, by placing them at risk for not receiving their therapeutic dosage medications as ordered by the physician and decreased health status. Findings included: Review of Resident #81's in progress admission assessment dated [DATE] revealed she was an[AGE] year-old-female admitted on [DATE] with diagnosis to include: Hypertension (increased blood pressure), constipation, blood clots, and generalized weakness. Review of Resident #81's current physician orders, dated 07/29/2025, revealed MiraLAX Oral Powder17gm give one packet by mouth daily with 4-6 ounces of fluid was ordered to be given every morning at 9:00 a.m., Advair HFA inhalation aerosol 115-21 mcg 2 puffs inhale orally was ordered to be given two times a day at 9:00 a.m. and 9:00 p.m., and Isosorbide Mononitrate ER oral tablet extended release 24 hour 60 mg give one tablet by mouth was ordered to be given two times a day at 9:00 a.m. and 9:00 p.m. Review of Resident #81's MAR dated 07/29/2025 revealed the MiraLAX oral powder 17 gm give one packet by mouth daily with 4-6 ounces of fluid was given at 9:00 a.m., Advair HFA inhalation aerosol 115-21 mcg 2 puffs inhale orally was not given at 9:00 a.m., and isosorbide mononitrate ER oral tablet extended release 24 hours 60 mg give one tablet was not given at 9:00 a.m. Observation on 07/29/2025 at 10:00 a.m. during a medication pass revealed LVN B administered Resident #81's MiraLAX Oral powder 17gm (for constipation) in an unmarked cup, without the appropriate amount of fluid (recommended 4- 8 ounces of fluid). Further observation during the medication pass revealed, LVN B failed to administer Advair HFA Inhalation Aerosol 115-21 mcg (for lung disease) to Resident #81 and failed to administer Isosorbide Mononitrate ER oral tablets 60mg ( used to help with chest pain). Interview with LVN B on 07/29/2025 at 10:42 a.m. revealed Resident #81 was a new admit and the resident had admitted on the night shift the night before (07/28/2025). LVN B stated the night nurse had ordered the medications, but none of them had come in on the morning delivery from the pharmacy. LVN B stated she could administer most of the medications that had been ordered, by taking the meds out of the pharmacy provided stock machine, but these two medications (Advair and isosorbide) were not in the machine. The LVN stated she would follow-up with the physician and check with the pharmacy. The LVN stated she had told the resident during the morning medication pass. The LVN stated she had let the DON know about the lack of medications and how none of the medications had been delivered. Interview with the DON on 07/31/2025 at 10:30 a.m. revealed that the problem was with the pharmacy, when the facility had late admissions, the medications do not arrive timely. The DON stated she had spoken to the Administrator about this problem and possibly changing pharmacies, but nothing had been decided yet. The DON stated she had been working at the facility for two months. The DON stated her expectations of the nursing staff, concerning new admissions, was the nurses were to complete their own admissions, and order the medications from the pharmacy then the medications must be here in a timely manner so they can be given as ordered by the physician. The DON stated the nursing staff was to contact the physician and myself to inform them that the meds were unavailable. The nursing staff is to call the pharmacy to follow-up on the medications. The DON stated if the residents did not receive their meds as ordered, it could affect their physical conditions. Interview with the Administrator on 07/31/2025 at1:00 p.m. revealed he was unaware of any problems related to medication delivery and late (after 5pm) admissions. He stated he thought the pharmacy could be contacted for medications twenty-four hours a day. The Administrator stated the residents needed to have the meds the doctor had ordered for the treatment of their medical conditions. Review of the facility's policy and procedure titled Medication Administration Schedule dated December 2024 reflected, 1. Medications shall be administered according to the established schedules. 3. A physician ‘s order.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1.The facility failed to ensure food items in the freezer were stored sealed and not exposed to air in accordance with the professional standards for food service.2. The facility failed to ensure food items in the refrigerators and freezer were labeled with the item description (handwritten or manufacturer's label), had the received by date, the opened date and/or the consume by or expiration by dates.These failures could place residents at risk for food-borne illness and cross contamination.Findings Include:Observation of the freezer in the rear of the kitchen by the sink on 07/29/2025 at 9:14 am revealed the following:- 4 large pizzas wrapped and sealed with no item description label or distinguishing date.- 5 bags with tater tots (shredded potatoes) sealed with no item description label or distinguishing date.- 4 bags with triangular hash browns (shredded potatoes) sealed with no item description label or distinguishing date.- 1 bag with triangular hash browns (shredded potatoes) with no item description label or distinguishing date, opened was exposed to air.- Left side of walk-in refrigerator, 3 shelves down from top, 4 hardboiled eggs in storage bag, sealed with no item description label, dated July 2025, the day of item was indistinguishable. In an interview with the Kitchen Supervisor on 07/29/2025 at 9:26 am, said the facility labels their frozen items with a label maker and sometimes the label falls off. In an interview with the Kitchen Supervisor on 07/31/2025 at 10:11 am, she said if a label falls off an item in the refrigerator or freezer, they would relabel the item with the date of an identical item currently stored in the refrigerator or freezer. In the event there is no identical item present, the item would be labeled with the date it was found to be without a label. In an interview with Kitchen Supervisor on 07/31/2025 at 10:11 am, she said the PM Kitchen Aide was responsible for labeling the items in dry storage, the AM Kitchen Aide was responsible for labeling the walk-in refrigerator, and the cook was responsible for labeling the items in the freezer. She stated she would do the labeling for all areas if other staff wasn't available, and whoever used the food or took it out was responsible for updating the label.In an interview with [NAME] A on 07/31/2025 at 10:25 am, she stated everybody labeled the food and they put the open date on the label.Record review of the facility's Food Storage Policy, dated December 2023, revealed, All food stored in the refrigerator or freezer will be covered, labeled, and dated ( use by date).Review of the U.S. FDA Food Code 2022, Chapter 3 Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated.

Based on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for review for 1 of 5 residents (Resident #6) reviewed for assessments. The facility failed to complete a quarterly assessment for Resident #1 every 3 months since [DATE]. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings included:Record review of Resident #6's electronic health record MDS tab reflected Resident #6 received a quarterly assessment on [DATE] and had no reassessment as of [DATE]. Resident#6's re-admission assessment [DATE] reflected BIMS 12 and medical conditions included: Cerebral Palsy, Generalized Anxiety Disorder, and Major Depressive Disorder. In an interview on [DATE] at 12:09 pm, the DON stated the MDS nurse handled the MDS assessments, and the one in the system dated [DATE] for Resident #6 was the last one she saw in the system. She stated the MDS nurse was not in the office today, but she may be able to provide a more recent copy or update. She stated that she did not know the exact dates MDS assessments were due, but she expected them to be completed on time. She stated the MDS reports helped guide services the residents received.In an interview on [DATE] at 12:45 pm the MDS coordinator stated the MDS RUG had not expired, and the resident was on the list for reassessment in August. She confirmed the last MDS was completed on [DATE]. She stated that she believed the assessment was valid as the RUG was still open. She stated that they follow computer system to determine the dates for MDS reviews. She stated that she believed they had 180 days for this re- evaluation.Record review of the facility policy dated [DATE] titled MDS Completion and Submission Timeframes reflected: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.1. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to _ [CMS database] system in accordance with current federal and state guidelines.2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to maintain quat sanitizer at a proper level in all three sanitation buckets, having levels of 500 ppm, and sanitation compartment of the three-compartment sink having level of 400 ppm. The facility failed to maintain the chlorine at a proper level in the dishwasher sanitizer cycle, having a level of 200 ppm. These failures could place all residents who eat off facility dishes at risk for exposure to higher than necessary levels of sanitizer chemicals, potentially leading to irritation of the digestive tract, and intestinal symptoms. Findings Included: An observation on 07/30/24 at 8:52 AM revealed the DS used quat test strips to check the levels of quaternary sanitizer in the three buckets used for sanitizing food preparation surfaces in the kitchen, and the dishwashing sink, which also used quaternary sanitizer for sanitizing hand-washed cooking equipment. All three buckets registered as 500 ppm on the test strips, and the sink registered closer to 400 ppm. The DS indicated by pointing at the strip that the level should have been at 400. The DS then checked the sanitizer in the sanitizing step of the dishwasher cycle with the chlorine test strips, and the cycle registered as 200 ppm. The DS again indicated by pointing at the test strip that it was supposed to match the high number (200 ppm). She said that the Dietary Manager had come, and she could not remember the exact date, but she thought it was on 07/05/24 or 07/06/24 and had checked the levels, and the lady from the city had been there, and it had been fine when they checked, and it always had been fine. She said they were supposed to dilute the buckets a little if it was too strong, and it was dispensed from the wall-mounted dispenser. She said having the chemicals too high could be a danger because it could cause some chemicals to be in the food, and residents could get sick. An interview on 07/31/24 at 7:34 AM with HR/DM revealed the sanitizer in the buckets was supposed to be at about 200 ppm, and the dishwasher at 100 ppm. She said she had the vendor come out on 07/30/24 and adjust the levels and she had checked everything today, and the levels were correct. She said it could potentially be hazardous to residents if it had too much chemical, and could also be hard on the staffs hands. She said they did not normally have an issue with it being high in the buckets or the dishwasher. An interview and observation on 08/01/24 at 8:06 AM revealed the DS checked the sanitizer buckets, which were at 200 ppm, and the dishwasher sanitizer cycle, which was at 100 ppm. She said she was normally the one who checked the chemicals every morning. An interview on 08/01/24 at 3:59 PM with the Administrator revealed her expectations of kitchen staff were that they checked the sanitizer chemical levels thoroughly and reported any incorrect levels to the DS, or if the DS discovered it, she would report to her manager, so they could immediately look into corrective action. She said levels of chemical too high could be toxic. Review of the sign, provided by the vendor of the company which provided the quaternary sanitizer system, posted above the three compartment sink next to the wall-mounted dispenser reflected a pictorial and text instructions for testing sanitizer levels in the three compartment sink, and food contact surface sanitizer. The sign reflected testing solution should be between 150-400 ppm with a picture of the testing strip package, and the acceptable range bracketed. Review of the MSDS sheet for the quat sanitizer product, issued 02/04/20, reflected only that the product in its diluted state could cause eye irritation. Review of the facility policy Dietary Services- Kitchen Operation: Sanitization, revised October 2008, reflected: Policy Statement: The food service area shall be maintained in a clean and sanitary manner.; Policy Interpretation and Implementation: [ .] 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-100 ppm chlorine solution; b. 150-200 ppm quaternary ammonium compound (QAC) [ .] 8. Dishwashing machines must be operated using the following specifications: [ .] Low-Temperature Dishwasher (Chemical Sanitization) [ .] b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. [ .] 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: [ .] c. Sanitize with hot water or chemical sanitizing solution. Chemical sanitizing solutions may consist of: ( 1) Chlorine 50 ppm for 10 seconds;

Based on interview and record review the facility failed to submit discharge MDS assessments for five of fifteen residents (Residents #2, #37, #45, #80, and #82) reviewed for discharge MDS submission. The MDS Coordinator failed to successfully submit discharge MDS assessments Residents #2, #37, #45, #80, and #82 when they discharged from the facility. This failure could place residents at risk of communication about a resident's status from not being transmitted to CMS and could interfere with residents receiving needed services after discharge. Findings include: 1. Review of Resident #2's Admission Record, dated 08/01/24, reflected she was admitted on [DATE]. She was 78-years-old, and had a primary admitting diagnosis of myasthenia gravis with (acute) exacerbation (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle). Review of Resident #2's discharge progress note, dated 04/17/24, reflected she was discharged home. Review of Resident #2's census information in the EMR on 08/01/24 reflected her discharge on 04/17/24. Review on 08/01/24 of a list of MDS submissions in the EMR for Resident #2 reflected her admission MDS for 02/20/24 submission was accepted, but no discharge MDS was listed. 2. Review of Resident #37's Admission Record, dated 08/01/24, reflected she was admitted on [DATE]. She was an [AGE] year-old woman with a primary admitting diagnosis of cerebral infarction (stroke). Review of Resident #37's discharge progress note, dated 03/23/24, reflected she was discharged on that day at 1:00 PM. Review of Resident #37's census information in the EMR on 08/01/24 reflected her discharge on 03/23/24. Review on 08/01/24 of a list of MDS submissions in the EMR for Resident #37 reflected her admission MDS for 02/27/24 submission was accepted, but no discharge MDS was listed. 3. Review of Resident #45's Admission Record, dated 08/01/24, reflected he was admitted on [DATE]. He was a [AGE] year old male, with a primary admitting diagnosis of type 2 diabetes mellitus with ketoacidosis (a complication of diabetes in which the body breaks fat down too quickly, which can be potentially life-threatening) without coma. Review of Resident #45's discharge progress note, dated 03/24/24, reflected his discharge, with a family member present. Review of Resident #45's census information in the EMR on 08/01/24 reflected his discharge on 03/24/24. Review on 08/01/24 of a list of MDS submissions in the EMR for Resident #45 reflected his admission MDS for 02/15/24 submission was accepted, but no discharge MDS was listed. 4. Review of Resident #80's Admission Record, dated 08/01/24, reflected she was admitted on [DATE]. She was an [AGE] year-old female, with a primary admitting diagnosis of fracture of unspecified part of neck of right femur, sequelae (broken hip.) Review of Resident #80's progress note, dated 03/26/24, reflected confirmation with the resident's family member that she planned to pick up Resident #80 on 03/27/24, at 1:00 PM. Review of Resident #80's census information in the EMR on 08/01/24 reflected his discharge on 03/27/24. Review on 08/01/24 of a list of MDS submissions in the EMR for Resident #80 reflected her admission MDS for 03/05/24 submission was accepted, but no discharge MDS was listed. 5. Review of Resident #82's Admission Record, dated 08/01/24, reflected he was admitted on [DATE]. He was a [AGE] year-old male, with a primary admitting diagnosis of other acute osteomyelitis (bone infection), left ankle and foot. Review of Resident #82's discharge progress note, dated, reflected his discharge on 03/21/24. Review of Resident #82's census information in the EMR on 08/01/24 reflected his discharge on 03/21/24. Review on 08/01/24 of a list of MDS submissions in the EMR for Resident #82 reflected his admission MDS for 03/09/24 submission was accepted, but no discharge MDS was listed. An interview on 07/31/24 at 3:01 PM with the Administrator revealed their Former MDS, who did the skilled MDS from March 2024 to 07/05/24, was not available for interview; but MDS was currently doing the skilled ones remotely, until their new MDS Coordinator started on 08/05/24. An interview on 08/01/24 at 1:57 PM with MDS revealed that if there had been a discharge MDS done, it would show up in the EMR. She would not have been the person who did the MDS at the time the missing discharge MDS were done, so she was not sure why they were not done. She said she thought Former MDS, who was doing them at that time was behind on them, and had completed a lot before she left, because she noticed about 40 completed ones in the portal, but she may have missed some. She said if they were done, she did not know of any potential consequences for the resident, but it could have an impact on staffing. An interview on 08/01/24 at 3:59 PM with the Administrator revealed she did not know why the MDS' were not all completed, but she would be working with their new MDS coordinator to make sure they were all done. She said it would be part of the QAPI process. She was not aware of any direct repercussions to the resident, but thought it could potentially affect staffing levels. Review of the facility policy Resident Assessment and Care Planning - Minimum Data Set (MDS): Resident Assessments, revised December 2019, reflected Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.; Policy Interpretation and Implementation: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements: [ .] (5) Discharge Assessment-Conducted when a resident is discharged from the facility.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8.57 % based on 3 errors out of 35 opportunities, which involved 3 of 9 residents (Resident #9, Resident #35, and Resident #46) reviewed for medication errors. The facility failed to ensure MA C and ADON B administered Resident #9's external pain reliving patch to her right lateral (directional term describing outer side of the body part) hip as ordered by the physician. The facility failed to ensure MA C administered Resident #35's antibiotic eye ointment only in the left eye as ordered by the physician. The facility failed to ensure Resident #46 received his daily Vitamin D tablet as prescribed on 07/31/24. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications, negative side effect and a decline in health. Findings Included: 1. Resident #9 Review of Resident #9's face sheet, dated 08/01/24, reflected a [AGE] year-old female that admitted the facility on 07/01/19. Her diagnoses included lumbar region disc degeneration (back pain caused by loss of cushioning between the discs of the spine ), age related osteoporosis (a condition in which bones become weak and brittle) blood clots in vein, unspecified cellulitis (a skin infection that causes inflammation, redness, and burning of skin), lower back pain, generalized osteoarthritis (a joints condition when the flexible tissue wears down at the ends of bones causing pain), uncontrolled blood sugar, high blood pressure, cardiomyopathy without heart failure (a condition of the heart that makes it hard for the heart to deliver blood to the body and can lead to heart failure). Review of Resident #9's admission MDS assessment, dated 07/17/24, reflected a BIMS sore of eight out of fifteen indicating moderate cognitive impairment. Review of Resident #9's care plan on 08/01/24, revealed Resident #9 had age related osteoporosis. The goal was to remain free of injuries and at a level of discomfort acceptable to Resident #9 through review date. Interventions included encouraging physical activity, giving analgesics (pain medication) as needed for pain, giving medications as ordered, monitoring, documenting of side effects and effectiveness. The care plan further revealed focus of acute (immediate) pain, chronic arthritis pain, and degenerative disc disease. The goal was that resident would report satisfactory pain control. Interventions were to administer pain medications per order. Review of Resident #9s orders , dated 07/30/24, reflected Salonpas [topical analgesics] pain relieving external patch with 4 % lidocaine. The directions were to apply to the resident's right lateral hip topically one time a day for arthritis pain and remove per schedule. Start date 11/18/23. Review of Resident #9's July 2024 MAR reflected Salonpas pain reliving external patch with 4 % Lidocaine was applied topically to right hip from 07/01/24 to 07/19/24. No application on 07/20/24 and 07/21/24. Resumed medication application on 07/22/24 to both knees from 07/22/24 to 07/30/24 at 12:58 PM. Observation of Resident #9 on 07/30/24 at 01:52 PM, revealed Resident #9 was in bed, she appeared sleeping. Resident #9's knees were exposed revealing a medication patch on each knee dated 07/30/24. In an interview with MA C on 07/30/24 at 02:02 PM, she stated that she was in training and the nurse training her told her to ask Resident #9 where she wanted the pain patches placed on her body. MA C stated that Resident #9 indicated that she wanted the pain patches on both knees below the knee cap. MA C did not state the risk to Resident #9's for not following prescribed medication order. MA C stated that she placed the medication patches on both knees as it indicated on the MAR but not according to the physician's orders. In an interview with ADON B on 07/30/24 at 02:05 PM, he stated he was helping train MA C. He stated that the MAR showed Resident #9's pain patch was to be applied to her bilateral (both) knees. He stated he would reach out to the physician and change the orders to reflect the patches to be applied topically to both knees. He stated the risk to the resident not getting the medication was uncontrolled illness . 2. Resident #35 Review of Resident #35's face sheet dated 08/01/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Cerebral infraction (Stroke) Cerebral ischemia (a condition in which there is insufficient blood flow to the brain), high cholesterol, metabolic encephalopathy, atrial fibrillation (an irregular heart rhythm), unspecified dementia (cognitive decline), unsteady on his feet, and Benign prostatic hyperplasia without urinary tract symptoms (is a condition of an enlarged prostate gland that can cause urination difficulty). Resident #35 was his own RP. Review of Resident #35's admission MDS assessment, dated 04/29/24, reflected a BIMS score of two out of fifteen, indicating severe cognitive impairment. Review of Resident #35's orders , dated 05/01/24, reflected Erythromycin Ophthalmic Ointment 5 MG/GM Erythromycin. Instill 1 ribbon of ointment in left eye in the morning for redness to left eye . Review of Resident #34's MAR for July 2024, reflected Erythromycin Ophthalmic Ointment 5 mg/gm, instill 1 ribbon in left eye in the morning for redness to left eye. In an interview with Resident #35 on 07/30/24 at 10:54 AM, revealed Resident #35 was with family at bedside. Resident #35 stated that he was having blurred vision in both eyes. He stated that MA C had put the eye medication in both his eyes instead of only in the left eye. He stated he did not question her because he did not know if his order had been changed. Resident #35's family stated that he saw MA C put the eye medication in both of Resident #35's eyes but it did not dawn on him to ask. The family stated Resident #35 had vision problems due to having numerous strokes and he had seen an eye specialist for his vision problems; therefore, the complaint of blurred vision did not alarm him when Resident #35 started to complain about it after eye medication administration. In an interview with MA C on 07/30/24 at 11:32 AM, she stated it was her third day on the job at the facility. She stated she administered the eye medication in both eyes as ordered in the MAR. Upon review of the MAR, MA C stated she would notify the nurse that she had made a mistake by administering the eye medication in both eyes instead of only in the left eye. MA C left to find the nurse and did not state the risk to the resident. In an interview with RN J on 07/03/24 at 03:00 PM, she stated MA C notified her of the medication error for Resident #35. She said she notified the physician and Resident #35's right eye was washed with normal saline to wash the medication out of his eye. She stated that they would monitor the resident for twenty-four hours for any adverse reactions. She stated the risk to resident getting medication in the wrong eye could cause an adverse reaction. In an interview with ADON B on 08/01/24 at 11:14 AM, he stated he assumed responsibility to train MA C on her last day of training and he should have kept closer monitoring on her medication administration. He stated the resident would be monitored for twenty-four hours and the physician was notified. He stated the risk to the resident was possible adverse reaction. He stated he started an in-service on medication administration. 3. Resident #46 Review of Resident #46's face sheet dated 08/01/24, reflected an [AGE] year-old male that was admitted at the facility on 12/12/23. His diagnoses included Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), cerebral ischemia (a condition in which there is insufficient blood flow to the brain), major depression, anxiety, wedge compression fracture, constipation, muscle wasting, heart diseases, atrial fibrillation (an irregular heart rhythm), and abnormal walking. Review of Resident #46's quarterly MDS assessment, dated 06/14/24, reflected a BIMS score of seven out of fifteen, indicating severe cognitive impairment. Review of Resident #46 orders , dated 12/12/23, reflected Cholecalciferol [Vitamin D] Oral Tablet 75 MCG (3000 UT). Give 1 tablet by mouth in the morning for supplements. Observation and interview with MA D on 07/31/24 at 09:09 AM, reveled MA D took Resident #46's medications out of the bubble pack and placed them into a medication cup. She then stated she could not find Resident #46's Cholecalciferol Tablet 75mcg. She asked ADON B to check the medication room for the missing medication. MA D stated she would administer the medications she had taken out and come back for the missing Cholecalciferol Tablet. Resident #46 was seated at the edge of the bed. MA D took his BP and gave him his medications minus the Cholecalciferol Tablet. She told Resident #46 that he was missing his Vitamin D and she would be back to administer the missing medication. MA D stated if there was no more of Resident #46's medication, she would notify the person in charge of ordering the medications to get more. She stated she would notify Resident #46's nurse too. Review of Resident #46's MAR for July 2024, for the Cholecalciferol Oral Tablet 75mcg (3000 UT), reflected a number nine in place of medication administration for 07/31/24 by MA D. Interview with MA E on 08/01/24 at 09:10 AM, she stated MA D was not in the facility. She stated that the number nine on the MAR meant other which was an indication that the resident did not receive medication or was missing a dose of the medication. MA E stated MA D should have looked at the order and paid attention to the 3000-unit part of the order instead of the 75mcg part and she would have seen the house stock of the medication in the med cart. MA E stated that Resident #46 would take 3 tablets of the Cholecalciferol to total up to the ordered 3000 UT of the Cholecalciferol. In an interview with ADON B on 08/01/24 at 11:14 AM, he stated all missing doses of medications should be reported by the MA to the nurse. He said documentation should reflect the missing dose and the nurse should follow up or the MA should follow up and administered medication when it is available. He said he expected MAs to administer medications as ordered. He stated the risk to the resident not getting medication was uncontrolled illness. In an interview with the Administrator on 08/01/24 at 03:58 PM, she stated the pharmacy delivered medication to the facility two times a day in the morning and in the evening therefore they always have medications that they need. She stated nursing staff should reach out to pharmacy for missing medication. She stated she expected staff to slow down and look at the orders and to follow the order as prescribed. She stated if a resident no longer had hip pain, then call the physician and change the order for the correct intervention needed. She expected staff to follow the formal medication error process. She stated the risk to resident getting wrong medication was adverse effects and risk for missing medication was not achieving desired therapeutic outcome. Record review of the facility's Administering Medications revision date April 2019 read in part, . Medications shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 4. Medications must be administered in accordance with the orders . 9. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication .

48520 Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #20, #46, #78 and #83) of 9 residents reviewed for infection control. The facility failed to ensure MA D sanitized blood pressure cuff between use on Residents #20, #46, and Resident #83. The facility failed to implement an infection control and prevention plan that included gastronomy care (G-tube- resident received food through a tube into his stomach) for Resident #78. These failures could place residents at risk of cross contamination and infectious diseases. Findings included: 1. Resident #20 Review of Resident #20's face sheet dated 08/01/24, reflected a [AGE] year-old female that admitted to the facility on [DATE]. Her diagnoses included encephalopathy (loss of brain function due to imbalance), lack of coordination when walking, difficulty walking, cerebral infarction (stroke), unsteady on her feet, hypertension (high blood pressure), type 2 diabetes (uncontrolled blood sugar), and bipolar disorder (a mental disorder). Review of Resident #20's admission MDS assessment, dated 06/19/24, reflected a BIMS score of 15, indicating cognitive intact. Review of Resident #20's care plan on 07/31/24, revealed a focus on hypertension related to heart diseases without heart failure. The goal was for Resident #20 to be free of signs and symptoms of hypertension (Headache, visual problems, confusion, disorientation, lethargy, nausea, and vomiting) through review date 10/16/24. Interventions included Avoiding taking the blood pressure reading after physical activity or emotion distress, giving anti-hypertensive medications as ordered, monitoring for side effects such as orthostatic hypotension [low bp upon standing] and increased heart rate and effectiveness, and monitoring for and documenting any edema [swelling]. Monitor/document abnormalities for urinary output. Report significant changes to the MD. Monitor/record medication side effects. Report to MD as necessary. Review of Resident #20's orders on 07/31/24, reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth in the morning Hold for BP < 110/ 60. Lisinopril Oral Tablet 5 MG (Lisinopril) Give 2 tablet by mouth in the morning for HTN GIVE 10 mg po daily. Atenolol Tablet 100 MG Give 0.5 tablet by mouth in the morning for hypertension Hold for BP < 110/60 and HR < 60. 2. Resident #46 Review of Resident #46's face sheet dated 08/01/24, reflected an [AGE] year-old male that was admitted at the facility on 12/12/23. His diagnoses included Chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), cerebral ischemia (a condition in which there is insufficient blood flow to the brain), major depression, anxiety, wedge compression fracture, constipation, muscle wasting, heart diseases, atrial fibrillation (an irregular heart rhythm), and abnormal walking. Review of Resident #46's quarterly MDS assessment, dated 06/14/24, reflected a BIMS score of seven out of fifteen, indicating severe cognitive impairment. Review of Resident #46 orders on 07/31/24, reflected: Carvedilol Oral Tablet 3.125 MG (Carvedilol) Give 1 tablet by mouth in the morning for HTN Hold if BP < 110/60 and/or HR 55 bpm. 3. Resident #83 Record review of Resident #83's face sheet dated 08/01/24, reflected a [AGE] year-old female admitted to facility on 03/18/24 with diagnoses that included stroke, difficulty talking related to stroke, difficulty sleeping, reflex, high cholesterol, high blood pressure, and heart disease without heart failure. Review of Resident #83's Orders on 07/30/24 reflected: Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) GIVE 1/2 tablet (12.5mg) by mouth two times a day for Hold for BP<110/60 or HR< 60 [This medication is used to treat high blood pressure]. Review of Resident #83's care plan on 07/31/24, revealed a focus on hypertension related to heart diseases without heart failure. The goal was for Resident #83 to be free of signs and symptoms of hypertension (Headache, visual problems, confusion, disorientation, lethargy, nausea, and vomiting) through review date 10/16/24. Interventions included avoiding taking the blood pressure reading after physical activity or emotion distress, giving anti-hypertensive medications as ordered, monitoring for side effects such as orthostatic hypotension [low bp upon standing] and increased heart rate and effectiveness, and monitoring for and documenting any edema [swelling]. Observation and interview with MA D on 07/31/24 from 08:50 AM to 09:20 AM, revealed MA D stated that she always placed BP medication in a separate cup until after checking the BP. She said if the BP was out of range she would hold the medication and notify the nurse. She then went into Resident #83 room, and she placed the wrist BP cuff on Resident #83's left wrist then walked to the wall with gloves and put a glove on her right hand. Resident #83' BP reading was 122/84, pulse was 61. MA D removed the BP cuff and gave Resident #83 her medication. MA D removed the glove from her right hand and went back to the medication cart and placed the used BP cuff on top of the medication cart. Hand hygiene was performed. MA D did not sanitize the BP cuff. MA D looked up Resident #46';s medication and placed Resident #46's BP medications in a separate medication cup. MA D did not perform hand hygiene after taking all medications and touching keys for control medication and signing the control book. MA D then went into Resident #46's room with the used BP machine and placed the BP cuff on Resident #46's right wrist. Resident# 46's BP reading was 133/82, pulse was 78. After removing the BP cuff off Resident #46 she gave him his medications. MA D then placed the used wrist BP cuff in her right arm pit and went into Resident #46's restroom and washed her hands with soap and water. She then walked out of Resident #46's room with the BP cuff in her arm pit and placed the BP cuff on top of medication cart. The BP cuff was not sanitized after use and before placing it on top of the medication cart. Resident #20 came out of her room to where MA D was in the hallway on her way to an appointment. MA D took Resident #20's medications out including her BP medications. MA D took the used BP cuff off the top of medication cart and placed the BP cuff on Resident #20's wrist. The BP reading was 146/84, pulse was 109. MA D removed the BP cuff off Resident #20 and placed it on top of the medication cart. MA D administered Resident #20's medications. MA D performed hand hygiene after she administered medications to Resident #20. MA D attempted to continue with another resident, but the surveyor intervened and stopped MA D. MA D stated that she forgot to sanitize the wrist blood pressure cuff in between residents. She stated she was expected to sanitize the wrist BP cuff after each resident use. She stated that she was not even thinking about it when she placed the wrist BP cuff in her arm pit. She stated she had been used to working in hospital setting where residents had individualized bp cuffs for each person. She said the risk to the residents for not cleaning the bp machine between each resident use was cross contamination and spread of infection. 4. Resident #78 Review of Resident #78's face sheet, dated 08/01/24, reflected the resident was a [AGE] year-old man, admitted to the facility on [DATE]. His diagnoses included dementia (cognitive decline), dysphagia following cerebrovascular (trouble swallowing after a stroke), a pacemaker (a small device used to treat irregular heartbeat), and gastronomy status (G-tube- resident received food through a tube into his stomach). Review of Resident #78's quarterly MDS assessment, dated 05/10/24, reflected Resident #78 was rarely understood by others, and rarely able to understand others. The staff assessment for mental status reflected he had long and short-term memory problems, and severely impaired daily decision-making skills. He continuously displayed inattention and disorganized thinking. Resident #78 had physical behavioral symptoms directed toward others (for example kicking, hitting, or grabbing others). The document reflected he had one-sided impairment in his upper and lower extremities, was always incontinent, and was completely dependent on staff for all his ADLs. He did not sit up or transfer during the assessment period, due to his clinical condition. Resident #78 received 51% or more of his nutrition through his g-tube. Review of Resident #78's care plans on 07/31/24 reflected: I have a condition that requires Enhanced Barrier Precautions. EBP are related to G-Tube or PEG Tube, Wound Care Date Initiated: 07/02/2024; Revision on: 07/02/2024 o Infection control intervention to reduce the transmission of multidrug-resistant organisms. Date Initiated: 07/02/2024; Target Date: 08/21/2024 o Resident is not on isolation and should not be restricted to their room or limited from participating in activities. Date Initiated: 07/02/2024 o Staff must don gown and gloves after entering the room to provide high contact resident care activities such as dressing, bathing/ showering, transfers, providing hygiene, changing linens, toileting/ brief changes, device care, med administration vis [sic] enteral tube or central line, trach care and wound care. Observation and interview with RN I on 07/31/24 at 08:10 AM, she stated that Resident #78 was on enhanced barrier precautions and required Personal Protection Equipment (PPE) for G-Tube medication administration. She stated Resident #78 at times hit staff, so she asked CNA F to assist her. Both staff put on PPE and entered Resident #78's room. CNA F went to the right side of Resident #78, and she picked bed remote and lowered Resident #78's head down and lowered Residents #78 covers to expose the abdomen area. CNA F them moved to the left side of Resident #78 and held his right hand. RN I went to the right side of Resident #78 and placed the medication cups and water on the uncleaned bedside table. RN I then went into the bathroom, washed her hands, and put on clean gloves. RN I then stopped Resident #78's feeding and disconnected his feeding from the G-tube. RN I then attached a large syringe to the G-tube entry and poured some water into it. After a few minutes of the water sitting in the syringe not flowing into Resident #78's G-tube, RN I stated that it appeared Resident #78's G-tube to be clogged. CNA F then told RN I to flush the G-tube or to milk (method to dislodge residue) the G-tube. RN I told CNA F to hold the G-tube while she looked for a flush. CNA F did not change her gloves nor wash her hands after touching the bed and the covers and Resident #78's hand, CNA F took hold of Resident #1's G-tube and started milking it a little. RN I then told CNA F to get the ADON. RN I disconnected the syringe, locked the G-tube, and laid it on Resident #78's top sheet covering his hips. ADON A entered Resident #78's room without putting on any PPE on, without gloves and without hand washing. ADON A picked up Resident #78's G-tube and milked it one time. ADON A then stated, Ooh I need to put on some gloves. ADON A then left Resident #78's room to find PPE. Resident #78 had no PPE outside his room or inside his room. In an interview with CNA F on 07/31/24 at 09:39 Am, she stated she did not think to change her gloves and perform hand hygiene before holding Resident #78's G-tube and she stated she should not have touched it nor milk it as that was out of her scope of practice. She stated she was only trying to help RN I do what other nurses have done in the past. CNA F stated that she had done an in-service last week on infection control and hand hygiene. She stated the risk to Resident #78 was passing on germs to him and infection. In an interview with RN I on 07/31/24 at 11:04 AM, she stated that Resident #78's G-Tube was clogged, and they managed to unclog it and administered his medications. RN I stated she had been in-served on G-tube cleaning, medication administration, infection control, and EBP. She stated that all staff were required to wear PPE when administering medication and feeds for Resident #78. She stated that she did not say anything to ADON A when she touched Resident #78's G-tube without gloves or PPE in front of surveyor but she said something afterwards. RN I stated not following proper G-tube care risked Resident #78 to infection. In an interview with ADON A on 07/31/24 at 01:00 PM, she stated The moment I touched the G-tube without gloves I knew I messed up. She stated that she should have put on PPE upon entry to Resident #78's room. She stated she and DON had done an in service two days ago on EBP, and the correct way to administration G-tube medication. ADON A stated the EBP was to be adhered by all staff and they must wear gown and gloves upon entering the room to provide high contact resident care activities such as dressing, bathing/ showering, transfers, providing hygiene, changing linens, toileting/ brief changes, device care, medication administration via enteral tube or central line, trach care and wound care. ADON A stated the risk to Resident #78 was contamination of the G-tube and infection. In an interview with ADON B on 08/01/24 at 11:14 Am, he stated all nursing staff were expected to follow all precautions, policies, and procedure of the facility. He stated an in-service had just been given by DON on EBP, proper G-tube care, and hand hygiene. He stated all nurses should know that with G-Tube, they need PPE. He stated he expected nursing staff to have a gown and gloves and a [NAME] as particles can fly. He sated nurse should make to follow infection control precautions when taking care of entry port to residents because Infection is a big risk to entry ports. He stated touching a G-tube without gloves could introduce bacteria to the resident. ADON B stated all staff need to perform hand washing before and after procedures. ADON B stated his expectations were that all staff wash hands and or use hand sanitizer during medication administration. He stated he expected the blood pressure cuff wiped down between residents and or use a different one while the other one was on being kill time. ADON B stated the cleaning wipes had a cure time to 5 minutes to kill the bacteria on the equipment. He stated not following infection control of sanitizing equipment between residents was a risk facility accrued infections. An interview with the Administrator on 8/01/24 at 3:58 PM, she stated the DON was on vacation. She stated it was her expectation that staff wore PPE in EBP rooms. She stated her expectations were that all staff wash hands or use hand sanitizer during medication administration. She stated she expected staff to follow the infection control facility policy. She stated there was a risk of spreading germs when staff did not follow infection control precautions of hand hygiene, wearing PPE and disinfecting equipment between residents. Review of facility's policy titled, Hand Washing/Hand Hygiene, revised August 2019, reflected the following: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: before and after entering isolation precaution settings .Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident); After removing gloves or aprons Review of the facility's policy titled Infection Control-Oversight, revision date October 2018, revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .all personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control .

Based on observation, interview and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #73) 24 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #73's Significant Change MDS Assessment, dated 06/18/24, did not inaccurately reflect Resident #73 having had a tracheostomy (a surgical opening in the windpipe to allow air into the lungs). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. Findings included: Review of Resident #73's Admission Record, dated 07/31/24, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of lung cancer, heart disease, asthma, and chronic kidney disease. He was noted to be his own Responsible Party. Review of Resident #73's Significant Change MDS, dated [DATE], reflected he had moderate difficulty hearing, but was able to understand others, and be understood by others. He had a BIMS score of 10, indicating possible moderate cognitive impairment. The document reflected no indication of mood or behavior problems. Resident #73 used a wheelchair, and required substantial staff assistance for most of his ADL's. In the document, the resident was noted to have tracheostomy care while a resident of the facility. The document was electronically signed by Former MDS, and RN K. An interview on 07/30/24 at 12:21 PM with Resident #73 indicated he looked puzzled when asked if he had a tracheostomy. He said he did not have one now, and he did not think he ever did. He showed the surveyor his neck, and there was no tracheostomy, scarring, or bandage. Review of Resident #73's order summary, dated 08/01/24, reflected no order for tracheostomy or the care of one. Review of Resident #73's care plans reflected no care plans for tracheostomy, or the care of one. An interview on 07/30/24 at 12:32 PM with RN J revealed she had never known Resident #73 to have a tracheostomy. An interview on 07/31/24 at 3:01 PM with the Administrator revealed she did not think Resident #73 had ever had a tracheostomy. She explained that Former MDS was not available for interview on the date of this interview. She did not know why the MDS had trach care documented for the resident. She said they had a new MDS Coordinator starting on 08/05/24. An interview on 07/31/24 at 3:19 PM with MDS revealed Resident #73 never had a tracheostomy. She was not the person who did his MDS, and did not know why the mistake occurred, but she felt it was probably just human error, and most likely was a matter of someone meaning to click on the thing above or below it. She said they might have caught it if they ran an 802 (a table of residents with checkmarks in their areas of needed care) but they did not run them very often. She did not think the error would cause any problems for the resident, and she said she would correct it that evening. Review of the facility policy Resident Assessment and Care Planning - Minimum Data Set (MDS) Resident Assessments revised November 2019, reflected: Policy Statement: A comprehensive assessment of every resident's needs is made at intervals designated by OBRA and PPS requirements.; Policy Interpretation and Implementation: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews [ .] 11. All persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to the accuracy of such information. Review of the facility policy Resident Assessment and Care Planning - Minimum Data Set (MDS)- Certifying Accuracy of the Resident Assessment, revised November 2019, reflected Policy Statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.; Policy Interpretation and Implementation; [ .] 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse.

Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for one (Resident #1) of three residents reviewed for CPR. The facility failed to retrieve the automatic external defibrillator (AED) and initiate the basic life support sequence of events (chest compressions, airway, breathing) per the facility's Emergency Procedure-Cardiopulmonary Resuscitation Policy for Resident #1 for approximately two to seven minutes when he was found unresponsive and assessed as full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) on [DATE] at approximately 4:30 AM while awaiting EMS arrival. The facility staff called the medical examiner and the resident was unable to be revived by EMS. An IJ was identified on [DATE]. The IJ template was provided on [DATE] at 1:58 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at a scope of isolated and a severity level of no actual harm that was not Immediate Jeopardy because the facility is still monitoring the effectiveness of their plan of removal. This failure placed residents at risk for harm up to and including death by the denial of all life saving measures as trained. Findings included: Review of Resident #1's electronic medical record, revealed an admitted [DATE] and a death discharge date of [DATE], with diagnoses which included sepsis (a life threatening complication of an infection), glaucoma (a group of eye conditions that can cause blindness), encephalopathy (any brain disease that alters brain function or structure), pneumonia (infection that inflames air sacs in one or both lungs which may fill with fluid), atherosclerotic heart disease (build-up of fat in the artery walls), diabetes mellitus (too much sugar level in the blood), chronic kidney disease (kidneys are damaged and cannot filter blood well) and cardiomyopathy (difficulty for the heart to deliver blood to the body). Review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was an [AGE] year-old male admitted from a short-term general hospital and was scheduled discharge to the community . Resident #1 had a weight of 171 pounds and was 68 inches in height (5 foot 8 inches). Review of Resident #1's physician's order dated [DATE] revealed MD A documented a physician's order for Resident #1 to receive care as CPR/Full Code. Review of Resident #1's care plan dated [DATE], revealed, Focus: I am a Full code. Goals: My wish will carry out through next review. Interventions: call 911, discuss my code status with me/family, if found absent of vital signs initiate CPR and keep my family and MD updated on my condition. Review of facility's General Plan of Care Form signed by Resident #1 and dated [DATE] revealed Curative Plan of Care: This POC (Plan of Care) directs providers to aggressively treat all conditions and to attempt to maintain life with every available resource. This POC directs providers to hospitalize the patient if deemed necessary. Review of facility's Medical Orders for Scope of Treatment form signed by Resident #1 and dated [DATE]. Revealed: Physician Resuscitation Order: No pulse and not breathing. Attempt Resuscitation (CPR) Tube in windpipe, electrical shocks to the chest, chest compression, and IV fluids and medications. Review of Resident #1's electronic eInteract Change in Condition Evaluation document dated [DATE] at 04:50 AM revealed, A1. Mental Status Evaluation: Unresponsive. A2. Functional Status: Evaluation: no pulse detected. Review Findings and Provider Notifications: 1c. patient deceased . 4. At 04:30 AM Resident #1 found laying on stomach in room unresponsive. Notes blood on shirt, face, and floor. Notes walker ahead of resident. No pulse detected. Review of Resident #1's electronic nursing progress note dated [DATE] at 4:50 AM revealed LVN B stated CNA called this nurse to resident's room at 4:30 AM. Resident was noted to be on the floor laying on stomach. Resident unresponsive. Notes large amount of blood on resident's shirt and on the floor. Called 911 and stayed with resident. Instructed nurse to call MD A. Called DON then called the medical examiner. Called resident's Family Member C. Emergency personnel arrived immediately and pronounced the resident deceased . Family Member C and Family Member D arrived shortly after. DON arrived as well and resident released to medical examiner. Review of the facility's cell phone call log provided by the DON on [DATE] at 9:50 AM revealed a placed outgoing call to phone number 911 on [DATE] at 4:32 AM with a call duration of two minutes. Request for City E Fire Station F's 911 call response report was requested on [DATE] at 11:40 AM and was not available by time of exit on [DATE]. Interview on [DATE] at 10:46 AM with the DON she stated that during the [DATE] CPR event for Resident #1 that CPR was not initiated, the AED was not utilized, and EMS services arrived at the facility after the 911 call, approximately 2 minutes. The DON stated she did not know why the AED was not utilized and further stated that LVN B had told the DON that EMS arrived quickly. The DON stated that review of the facility's camera footage revealed that a police officer arrived at the facility first and the actual time was unknown. According to the facility camera footage EMS arrived seven minutes after the police and EMS was on site for a total of five minutes. The DON stated LVN B and RN G were involved in the CPR event for Resident #1. The DON stated it was her expectation for a resident that is full code for CPR to be initiated and to continue CPR until EMS arrives and for the AED machine to be placed on the resident. The DON stated it was her expectation for a resident that is full code and found responsive for CPR to be started even if a resident's body is assessed as stiff. Interview on [DATE] at 10:59 AM with RN G she stated on [DATE] she worked from 7:00 PM to 7:00 AM. RN G stated she was providing patient care on Hall 100 when CNA H from Hall 300 told her LVN B needed her, and Resident #1 was unresponsive. RN G stated she ran to Resident #1's room, the resident was on the floor with blood and LVN B was on the phone with 911. RN G stated she did not touch Resident #1, she did not get the crash cart (wheeled container carrying medicine and equipment for use in emergency resuscitations), she did not get the AED machine or start CPR. RN G stated she thought LVN B had already assessed Resident #1 that is why RN G did not initiate CPR. RN G stated 911 EMS arrived quickly and did not start CPR. RN G stated she helped LVN B by calling the DON and MD A. RN G stated she printed the paperwork for Resident #1 needed for EMS and that is when RN G saw on Resident #1's face sheet that Resident #1 was full code, prior to that RN G stated she did not know Resident #1's code status. RN C stated the facility's AED was stored on the facility's crash cart. RN C stated she was CPR trained by the American Heart Association. RN C stated her training included the use of an AED during CPR as soon as the AED is available. Interview on [DATE] at 12:40 PM with LVN B stated she worked on [DATE] from 7:00 PM to 7:00 AM and was assigned to Resident #1. LVN B stated on [DATE] around 4:30 AM CNA H reported to her Resident #1 was unresponsive and on the floor in his room. LVN B stated she told the CNA H to get RN G and immediately arrived at Resident #1's room. LVN B stated Resident #1 was on the floor on his stomach with red substance on his body and floor. LVN B stated she assessed Resident #1 as a full code and without a pulse and not breathing. LVN B stated she did not begin emergency CPR with chest compressions since Resident #1 was cool/cold, stiff and on his stomach. LVN B stated she thought RN G checked Resident #1's pulse. LVN B stated she attempted to roll Resident #1 over but was unsuccessful since it was difficult to push him, his arms were in the way. LVN B stated she did not ask for help in rolling over Resident #1. LVN B stated she did not ask for the crash cart, she did not get the AED machine since there was no time, she called 911 and that CPR was not an option since the resident was cold, stiff and on his stomach. LVN B stated 911 EMTs were at the bedside quickly approximately 2 minutes. LVN B stated when EMS arrived Resident #1 was assessed, and EMS did not start CPR and EMS left the facility. LVN B stated she knew Resident #1 was full code-which meant to try to revive a resident until EMS arrives. LVN B stated she was trained for CPR by the American Red Cross Association. LVN B stated her training included the use of an AED during CPR as soon as the AED was available. LVN B stated that prior to the incident around 4:30 AM she had last seen Resident #1 around 1:00 AM. Interview on [DATE] at 2:18 PM with CNA H revealed she worked on [DATE] from 10:00 PM to 6:00 AM. CNA H stated around 4:00 AM she went to check on Resident #1 and discovered Resident #1 on the floor in his room near the bathroom doorway with blood around him. CNA H immediately got help from LVN B. CNA H stated that when LVN B arrived to Resident #1's room LVN B touched Resident #1's hand for a pulse and immediately called 911. CNA H stated LVN B had instructed her to get help from RN G. CNA H stated that RN G did not assess or touch Resident #1. CNA H stated that RN G called the DON. CNA H stated that prior to the 4:00 AM incident she had last observed the Resident #1 around 1:,d+[DATE]:00 AM. Interview and observation on [DATE] at 02:40 PM with the DON stated Resident #1 was discovered unresponsive and was not provided emergency CPR care. The DON stated she was certain the cart crash and AED was not used. The DON proceeded to demonstrate the AED to the surveyor. The AED was stored on the facility's emergency crash cart along with CPR equipment such as an oxygen tank, and oxygen delivery equipment and included a suction pump with accessories. The DON demonstrated the AED as functional and stated the AED had not been used and could not recall the last time it had been used. The DON stated that nothing had been used from the crash cart. The DON stated LVN B and RN G were directly involved with Resident #1's CPR care. Interview on [DATE] at 2:49 PM with MD A revealed he had been notified that Resident #1 had been found face down on the floor bleeding from the mouth and with no pulse. MD A stated he was told from LVN B's standpoint Resident #1 looked like he had been on the floor for some unknown period of time and LVN B called 911. MD A stated it was his expectation if a resident is full code and found unresponsive/without a pulse that CPR is started immediately including the use of the AED machine. Interview on [DATE] at 11:37 AM with the ADON revealed her expectation if a resident was discovered unresponsive and was full code that CPR was started immediately including obtaining the AED machine. The ADON stated that her expectation was for CPR to be started even if a resident's body was stiff. Interview on [DATE] at 10:16 AM with Agency (a company that provides a particular service) LVN I revealed she worked on [DATE] from 7:00 PM to 7:00 AM. Agency LVN I stated she was assigned to work Hall 200 on [DATE]. Agency LVN I stated she could not recall if a code blue (meaning unresponsive resident) was called during the shift. Agency LVN I stated she was providing patient care at an unknown time when a staff member (name unknown) stated they needed a nurse on the Hall 300. Agency LVN I stated when she arrived to Hall 300 Agency LVN she saw a resident (name unknown/room number unknown) on the floor in his room with blood around him. Agency LVN I stated that at the time she saw the resident (name unknown) on the floor LVN B and RN G were at the nursing station with the police, no one instructed her on anything so Agency LVN I stated she returned to Hall 200. Review of LVN B's employee's file revealed a certificate from the American Red Cross for completion of Adult and Pediatric CPR/AED on [DATE] with expiration date of two years . Review of LVN's Employee Disciplinary Record dated [DATE] revealed: Describe the action(s) that made it necessary to prepare this report. Include dates and any witnesses; LVN charge nurse failed to provide CPR to a full code resident once resident was found to be without vital signs. Type of Action: Suspension. Review of RN G's employee's file revealed a certificate from the American Heart Association for completion of Basic Life Support (CPR and AED) Program on [DATE] with expiration date of [DATE]. A record review of the facility's Emergency Procedure Cardiopulmonary Resuscitation policy dated [DATE], revealed, Policy Statement: personnel have completed training on the initiation of cardiopulmonary resuscitation and basic life support including defibrillation for victims of sudden cardiac arrest. General guidelines: .4. The chances of surviving sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. 5. Early delivery of a shock with a defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival .Emergency Procedure-Cardiopulmonary Resuscitation: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911. b. Instruct a staff member to retrieve the automatic external defibrillator. c. Verify or instruct a staff member to verify the DNR or code status of the individual. d. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (Chest compressions, airway, breathing). 8. Continue with CPR/BLS until emergency medical personnel arrive . Review of the facility's Automatic External Defibrillator, Use and Care of, dated [DATE], revealed, Policy Interpretation and Implementation: The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected .remove the device from its case .check the battery cartridge to ensure it is in place .remove the film seals from the pads .turn on the device and follow the prompts . Review of the American Heart Association's website Part 3: Adult Basic and Advanced Life Support; 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-and-advanced-life-support, accessed [DATE], revealed, Top 10 take home messages for adult cardiovascular life support: [ .] On recognition of a cardiac arrest event, a layperson should simultaneously and promptly activate the emergency response system and initiate cardiopulmonary resuscitation (CPR). Performance of high-quality CPR includes adequate compression depth and rate while minimizing pauses in compressions. Early defibrillation with concurrent high-quality CPR is critical to survival when sudden cardiac arrest [ .] Defibrillation is most successful when administered as soon as possible [ .]. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:58 PM. The facility ADM and DON were notified. The ADM was provided with the IJ template on [DATE]. The following Plan of Removal was accepted on [DATE] at 11:06 AM. Plan of Removal Undated 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]). Facility Medical Director was notified of the incident. ([DATE]) The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy. Inaccuracies were not identified. ([DATE]) Reviewed CPR policy and no update was needed. ([DATE]) The licensed nurse who did not perform CPR on the full code status resident was suspended pending investigation ([DATE]) 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion date: [DATE]) If a resident is full code, then CPR would be initiated according to policy. Disciplinary action was taken with licensed nurse who did not initiate CPR on the full code resident. The DON or designee educate all licensed nurses on the facility's policy and procedure for initiating CPR and location of code status for each resident. Licensed nurses were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift. RN shift supervisor given new responsibility to direct/assign staff roles during code/initiation of code. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented, DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration on CPR process. Compliance checks will be conducted 2 times weekly for three months. Findings will be reported at monthly QAPI Committee meetings. DON or designee will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue daily for three months. Findings will be reviewed at the monthly QAPI Committee meetings. A Code Blue drill was performed with licensed nursing staff on all shifts until every nurse had participated at least once. Code Blue drills will continue to be held 2 times a month for 3 months. Findings will be reviewed at the monthly QAPI Committee meeting. Date Facility Asserts Likelihood for Serious Harm no Longer Exists: [DATE]. Plan Of Removal Verification Interview with MD A on [DATE] at 2:49 PM confirmed he was notified of the incident with Resident #1 on [DATE]. Interview with the DON on [DATE] at 6:00 AM revealed the facility DON/designee completed a 100% audit of residents' advanced directives. The audit was completed on [DATE]. No residents were identified to have improper advanced directives. Record review of the facility census revealed 22 residents requested they receive CPR (Cardiopulmonary Resuscitation) care and had full code orders signed by a physician. A record review of Resident #2's code status revealed Resident #2 was a full code. A record review of Resident #3's code status revealed Resident #3 was a full code. A record review of Resident #4's code status revealed Resident #4 was a full code. A record review of Resident #5's code status revealed Resident #5 was a full code. A record review of Resident #6's code status revealed Resident #6 was a full code. A record review of Resident #7's code status revealed Resident #7 was a full code. A record review of Resident #8's code status revealed Resident #8 was a full code. A record review of Resident #9's code status revealed Resident #9 was a full code. A record review of Resident #10's code status revealed Resident #10 was a full code. A record review of Resident #11's code status revealed Resident #11 was a full code. A record review of Resident #12's code status revealed Resident #12 was a full code. A record review of Resident #13's code status revealed Resident #13 was a full code. A record review of Resident #14's code status revealed Resident #14 was a full code. Disciplinary action was confirmed for LVN B on [DATE]. Review of Employee Disciplinary Record for LVN B revealed she was suspended on [DATE]. Review of in-service training on ,d+[DATE]-[DATE] revealed the DON/designee initiated immediate competency-based training on the facility's policy and procedure for initiating CPR/location of crash cart, code blue, AED location/set up, emphasis on the expectation that the AED is retrieved immediately after checking for pulse and respirations, location of code status for each resident and documentation of CPR with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Review of in-service training revealed the DON/designee initiated immediate training on the RN shift supervisor given the new responsibility to direct/assign shift roles during/initiation of code on both shifts on [DATE]. All education was at 100% completion as of [DATE]. Any RN on leave will receive education prior to their next scheduled shift. Review of in-service training revealed The DON/designee initiated immediate training on the facility's policy and procedure for identifying acute change in condition with all nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Review of facility's census for new admissions since [DATE] revealed one new admission on [DATE], Resident #15. A record review of Resident #15's code status revealed Resident #15 was a full code. Review of in-service revealed Nurse Manager/MDS Coordinator will in-service licensed nursing staff over Code Blue drill with return demonstration until every nurse had participated at least once. Monitoring will be conducted twice monthly for 3 months to determine if compliance is being sustained. Sustained compliance or corrective actions will be discussed and documented in QAPI Meeting. The Director of Nursing/designee initiated immediate training on Mock Codes, Rapid Response, AED, CPR and documentation of code process training with nursing staff on all shifts on [DATE]. All education was at 100% completion as of [DATE]. Any nursing staff on leave will receive education prior to their next scheduled shift. Observation of a mock CPR AED event on [DATE] at 7:00 AM, revealed the LVN J called out that a resident was unresponsive. LVN J yelled out Code Blue from a resident's room. LVN J then delegated responsibilities to each staff, and instructed one staff to go get the crash cart. LVN J then proceeded to place a backboard under the mock resident while communicating out loud the importance of the backboard and if there was no backboard then to place the unresponsive resident on the floor. LVN J began compressions while counting out loud to 30, followed by using the AMBU (a type of device known as a bag valve mask, which is used to provide respiratory support) bag for the two breaths. The crash cart arrived during this time. The Nurse Manager/MDS Coordinator showed staff, while doing it, how to remove the AED from its case, opened the AED cover, which automatically began the verbal AED prompt protocols. The Nurse Manager/MDS Coordinator removed the AED pads from the case, attached the electrical pad leads to the AED, and placed the pads on the CPR mannequin, and continued to follow the AED verbal prompts. The Nurse Manager/MDS Coordinator stated to the mock CPR AED participants, Continue CPR with the AED until EMS arrives. (The following staff participated in the mock Code Blue: RN K, CNA L, RN M, CNA N, CNA O, MA P, RN Q, CNA R and LVN S) A record review of the facility's nursing roster revealed 24 nurses were employed by the facility over all 2 shifts of 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. Nurses from both shifts were interviewed for participation in code blue training with return demonstration, CPR/AED training and were able to identify and use of AED with the emphasis on those that are full code and CPR documentation. Interview on [DATE] at 9:39 AM with CNA T she stated she worked the 2:00 PM-10:00 PM shift. CNA T stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:31 AM with LVN U she stated she worked the 7:00 PM-7:00 AM shift. LVN U stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:55 AM with CNA N she stated she worked the 6:00 AM-2:00 PM shift. CNA N stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 11:57 AM with CNA V she stated she worked the 2:00 PM-10:00 PM shift. CNA V stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:03 PM with CNA Z she stated she worked the 6:00 AM-2:00 PM shift. CNA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:05 PM with CNA AA she stated she worked the 6:00 AM-2:00 PM and 2:00 PM-10:00 PM shift. CNA AA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:09 PM with CNA BB she stated she worked the 6:00 AM-2:00 PM shift. CNA BB stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:11 PM with CNA O she stated she worked the 6:00 AM-2:00 PM shift. CNA O stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:16 PM with LVN W she stated she worked the 7:00 AM-7:00 PM shift. LVN W stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:28 PM with LVN X she stated she worked the 7:00 AM-7:00 PM shift. LVN X stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:43 PM with LVN Y she stated she worked the 7:00 AM-7:00 PM shift. LVN Y stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 12:53 PM with CNA CC she stated she worked the 6:00 AM-2:00 PM shift. CNA AA stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 1:12 PM with CNA DD she stated she worked the 10:00 PM-6:00 AM shift. CNA DD stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 1:56 PM with CNA EE she stated she works all three shifts. CNA EE stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 2:15 PM with CNA FF she stated she worked the 2:00 PM-10:00 PM shift. CNA FF stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 5:42 AM with CNA GG she stated she worked the 10:00 PM-6:00 AM shift. CNA GG stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR training with emphasis on the expectation that the AED is retrieved immediately after checking for a pulse and respirations, CPR documentation, advance directives, crash cart, and acute change documentation. Interview on [DATE] at 6:03 AM with CNA HH she stated she worked the 10:00 PM-6:00 AM shift. CNA HH stated she had received training this week on code blue drill responsibility with demonstration return, emergency procedures/response, AED location/usage, CPR train [TRUNCATED]

Based on interviews and record review, the facility failed to notify and consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status for one (Resident #1) of one resident reviewed for notification of changes. The facility failed to ensure LVN B immediately notified the physician on [DATE] when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. The facility failed to ensure LVN A notified the physician on [DATE] that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On [DATE] at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. The facility failed to ensure LVN B immediately notified the physician on [DATE] at 1:10 AM there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 from the facility. On [DATE], after 5:00 PM, Resident #1 was sent to the ER. Resident #1 was admitted with a primary diagnosis of enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and severe sepsis (body's extreme reaction to an infection, can lead to organ failure, tissue damage and death) with acute kidney failure without septic shock. Additional diagnoses included acute cystitis (infection that only affects the bladder) without hematuria (blood in the urine); gastric outlet obstruction (a result of any disease process caused by mechanical and motility disorders associated with abdominal pain and postprandial vomiting); lung infiltrate (the presence of some unusual substance in the lungs); nausea and vomiting; and pyelonephritis (inflammation of the kidney, typically due to a bacterial infection). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1's Admission Record, printed on [DATE], revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date [DATE]: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: [DATE]] - Order date [DATE]: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date [DATE]: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date [DATE]: UA with C & S one time only r/o UTI. - Order date [DATE]: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date [DATE]: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until [DATE] 11:59 PM. - Order date [DATE]: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated [DATE] indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: [DATE]; Revision on: [DATE]] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or [NAME] blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to [DATE] was dated [DATE]]: - Nurse's Note Effective Date: [DATE] at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P ,d+[DATE]. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: [DATE] at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination [DATE] (measured at 3:33 AM) BP: ,d+[DATE] HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed [DATE], pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: [DATE] at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP ,d+[DATE], P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated [DATE] revealed lab results collected on [DATE] at 9:35 AM and resulted in PCC (Resident #1 chart) on [DATE] at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on [DATE] at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until [DATE] at 1:18 PM. - Laboratory Results Note Effective Date: [DATE] at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: [DATE] at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on [DATE] revealed: (at 3:52 PM) BP: ,d+[DATE] HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: [DATE] at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P,d+[DATE] 02sat 96%RA . ([DATE]) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place ([DATE]) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: [DATE] at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on [DATE] around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On [DATE] at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On [DATE] at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On [DATE] at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On [DATE] at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On [DATE] at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On [DATE] at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On [DATE] at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's [DATE] MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on [DATE] at 11:15 AM. Resident #1's [DATE] MAR reflected no other medications were administered to reduce an elevated temperature on [DATE] at 4:23 PM or as documented in nurse's progress notes: On [DATE] at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On [DATE] at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated [DATE] reflected Resident #1 arrived at theER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: ,d+[DATE]; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated [DATE] at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on [DATE] at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in theER on [DATE] at 5:53 PM resulted [DATE] at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on [DATE] at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated [DATE] at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of [DATE] at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on [DATE] at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on [DATE]. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of [DATE] and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on [DATE] at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on [DATE] to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on [DATE] around 7:00 AM, she received a snapshot of a progress note from LVN B (worked [DATE] 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning ([DATE]) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on [DATE]. During an interview on [DATE] at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room ([DATE]) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on [DATE] at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of [DATE] - [DATE]) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on [DATE] at 1:37 PM, a family member stated concerns started on [DATE] when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in [DATE] with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on [DATE]. The family member stated the fever continued until [DATE], which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on [DATE] that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on [DATE], that nothing could be done, and the resident would benefit from palliative care. On [DATE], Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on [DATE]. The family member said that Resident #1 passed away because of the sepsis. During an interview on [DATE] at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on [DATE] at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on [DATE] and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon ([DATE]) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day ([DATE]) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident #1 on [DATE]. LVN A stated that she did not recall working on that day and if she worked, she would have checked for the lab results and notified the MD. During a follow up interview on [DATE] at 1:27 PM, LVN A said that she checked with the staffing coordinator and verified she worked on [DATE] and was assigned to Resident #1. LVN A said that she did know how Resident #1's labs were missed and not reviewed. LVN A said that the risk to a resident if labs were not reviewed in a timely manner would be in a delay in treatment and worsening of an infection. During an interview on [DATE] at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and her care needs as the primary assigned nurse. LVN B said that Resident #1 was totally dependent for ADLs, confused, could respond to questions with a head nod/shake or answer yes or no, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any trauma, signs, or symptoms of infection. LVN B said she gently tugged on the catheter tubing at the insert site to check for placement and checked if the balloon was inflated. LVN B said there was an order to encourage Resident #1 to drink fluids because she did not drink enough water, and there was sedimentation often noted in the urine. LVN B said that she flushed Resident #1's FC every night with 60 cc NS and monitored urine output per orders to prevent catheter complications. LVN B said the risk of not flushing the catheter would cause problems such as, catheter leakage, blocked catheter, catheter coming out, or an infection. LVN B said s/sx of an UTI included fever, sleepiness, decreased urine output, dark, foul smelling urine. LVN B said that the MD should be notified immediately. LVN B said that she worked on [DATE], 7P - 7A. Resident #1's progress notes were reviewed with LVN B. LVN B acknowledged she entered the progress note on [DATE] at 5:12 AM that reflected Resident #1 had a fever and threw up brownish partially digested food. LVN B said she did not recall the specific time. LVN B denied the emesis appeared like coffee grounds (dark brown in color with a lumpy texture. The appearance comes fr [TRUNCATED]

Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for 1 of 1 resident (Resident #1) reviewed for neglect. The facility failed to ensure LVN A and LVN B did not neglect Resident #1. They failed to implement nursing interventions as written in Resident #1's care plan. LVN B failed to immediately contact the physician when Resident #1 had an acute change in condition. LVN A failed to immediately contact the physician of abnormal labs results, which indicated infection and dehydration, when received. These cumulative failures caused a delay in medical treatment to Resident #1, who was then hospitalized with diagnoses of enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and severe sepsis (body's extreme reaction to an infection, can lead to organ failure, tissue damage and death) with acute kidney failure. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Risk management: Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property policy, Effective Date: [DATE], Change date(s): [DATE], revealed: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect - Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure 4. The NFA, DON and Risk manager are also ultimately responsible for the following: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. 5. Implementation and ongoing monitoring consist of the following: Screening, training, prevention, Screening Potential employees will be screened during the hiring process for history of abuse, neglect, or mistreatment of residents. Training Facility orientation program & ongoing training programs will include, but may not be limited to Freedom from ANE requirements. Prevention: Post a statement that the resident may file a complaint with eh State Survey Agency . Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect . Investigation An Event Report is initiated. Reporting The facility will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. DCF, HHS, Law Enforcement will be notified immediately via telephone or fax. Record review of Resident #1's Admission Record, printed on [DATE], revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected: - Order date [DATE]: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: [DATE]] - Order date [DATE]: Monitor indwelling catheter for blockage, leakage, sediment, buildup, output, urine color and odor every shift for retention. - Order date [DATE]: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date [DATE]: Nurse is to ensure CNA provide catheter care with baby shampoo and warm water, rinsing and patting dry every shift. This includes cleaning inner labia. - Order date [DATE]: Irrigate foley with NS every shift for control of sediment - Order date [DATE]: Discontinue foley (indwelling catheter) one time only for bladder spasms - Order date [DATE]: Trospium Chloride Oral tablet 20 mg. Give 1 tablet by mouth two times a day for bladder spasms - Order date [DATE]: Monitor output every shift d/t discontinuation of f/c - Order date [DATE]: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date [DATE]: UA with C & S one time only r/o UTI. - Order date [DATE]: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date [DATE]: May insert Midline IV (a long, thin, flexible tube inserted into a large vein in the upper arm used to administer medication into the bloodstream) for infusion - Order date [DATE]: Sodium Chloride Soln 0.9%. Use 100 mL/hr IV every shift for hydration for 3 days. (Give 2 liters of NS 0.9% via midline) - Order date [DATE]: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until [DATE] 11:59 PM. - Order date [DATE]: Merrem (antibiotic) IV soln 500 mg. Use 500 mg IV two times a day for UTI for 7 days. - Order date [DATE]: Ceftriaxone (antibiotic) 1 GM injection solution. Inject 1 gram intramuscularly STAT for UTI. - Order date [DATE]: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated [DATE] indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: [DATE]; Revision on: [DATE]] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or [NAME] blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to [DATE] was dated [DATE]]: - Nurse's Note Effective Date: [DATE] at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P ,d+[DATE]. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: [DATE] at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination [DATE] (measured at 3:33 AM) BP: ,d+[DATE] HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed [DATE], pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: [DATE] at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP ,d+[DATE], P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated [DATE] revealed lab results collected on [DATE] at 9:35 AM and resulted in PCC (Resident #1 chart) on [DATE] at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on [DATE] at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until [DATE] at 1:18 PM. - Laboratory Results Note Effective Date: [DATE] at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: [DATE] at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on [DATE] revealed: (at 3:52 PM) BP: ,d+[DATE] HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: [DATE] at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P,d+[DATE] 02sat 96%RA . ([DATE]) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place ([DATE]) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: [DATE] at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on [DATE] around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On [DATE] at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On [DATE] at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On [DATE] at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On [DATE] at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On [DATE] at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On [DATE] at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On [DATE] at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's [DATE] MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on [DATE] at 11:15 AM. Resident #1's [DATE] MAR reflected no other medications were administered to reduce an elevated temperature on [DATE] at 4:23 PM or as documented in nurse's progress notes: On [DATE] at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On [DATE] at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated [DATE] reflected Resident #1 arrived at theER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: ,d+[DATE]; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated [DATE] at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on [DATE] at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in theER on [DATE] at 5:53 PM resulted [DATE] at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on [DATE] at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated [DATE] at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of [DATE] at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on [DATE] at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on [DATE]. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of [DATE] and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on [DATE] at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on [DATE] to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on [DATE] around 7:00 AM, she received a snapshot of a progress note from LVN B (worked [DATE] 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning ([DATE]) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on [DATE]. During an interview on [DATE] at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room ([DATE]) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on [DATE] at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of [DATE] - [DATE]) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on [DATE] at 1:37 PM, a family member stated concerns started on [DATE] when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in [DATE] with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on [DATE]. The family member stated the fever continued until [DATE], which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on [DATE] that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on [DATE], that nothing could be done, and the resident would benefit from palliative care. On [DATE], Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on [DATE]. The family member said that Resident #1 passed away because of the sepsis. During an interview on [DATE] at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on [DATE] at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on [DATE] and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon ([DATE]) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day ([DATE]) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident # [TRUNCATED]

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent neglect for 1 of 1 resident (Resident #1) reviewed for provision of care and services by staff. The facility failed to oversee the implementation of required structures and processes to meet the needs of Resident #1. The facility failed to oversee LVN A and LVN B followed resident care policies and procedures during the provision of care and services to Resident #1. The facility failed to conduct ongoing monitoring and supervision of LVN A and LVN B to assure the implementation of Resident #1's care plan as written. The facility failed to ensure there was an effective communication system across all shifts for communicating necessary care and information between staff, practitioner, and resident representatives. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of the facility's Risk management: Abuse, Neglect, Exploitation, Mistreatment of Resident, or Misappropriation of Resident Property policy, Effective Date: [DATE], Change date(s): [DATE], revealed: The facility has designated and implemented processes which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of residents' property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Neglect - Failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Procedure 4. The NFA, DON and Risk manager are also ultimately responsible for the following: Implementation, ongoing monitoring, reporting, investigation, tracking and trending. 5. Implementation and ongoing monitoring consist of the following: Screening, training, prevention, Screening Potential employees will be screened during the hiring process for history of abuse, neglect, or mistreatment of residents. Training Facility orientation program & ongoing training programs will include, but may not be limited to Freedom from ANE requirements. Prevention: Post a statement that the resident may file a complaint with eh State Survey Agency . Post information & contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect . Investigation An Event Report is initiated. Reporting The facility will identify the staff member responsible for the initial reporting, investigation of alleged violations & reporting abuse, & to determine the direction of the investigation. DCF, HHS, Law Enforcement will be notified immediately via telephone or fax. Record review of Resident #1's Admission Record, printed on [DATE], revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date [DATE]: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: [DATE]] - Order date [DATE]: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date [DATE]: Monitor output every shift d/t discontinuation of f/c - Order date [DATE]: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date [DATE]: UA with C & S one time only r/o UTI. - Order date [DATE]: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date [DATE]: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until [DATE] 11:59 PM. - Order date [DATE]: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated [DATE] indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: [DATE]; Revision on: [DATE]] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or [NAME] blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. Review of Resident #1's progress notes indicated [last note prior to [DATE] was dated [DATE]]: - Nurse's Note Effective Date: [DATE] at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P ,d+[DATE]. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: [DATE] at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination [DATE] (measured at 3:33 AM) BP: ,d+[DATE] HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed [DATE], pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: [DATE] at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP ,d+[DATE], P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A record review of Resident #1's lab results report dated [DATE] revealed lab results collected on [DATE] at 9:35 AM and resulted in PCC (Resident #1 chart) on [DATE] at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on [DATE] at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until [DATE] at 1:18 PM. - Laboratory Results Note Effective Date: [DATE] at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: [DATE] at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on [DATE] revealed: (at 3:52 PM) BP: ,d+[DATE] HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: [DATE] at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P,d+[DATE] 02sat 96%RA . ([DATE]) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place ([DATE]) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: [DATE] at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on [DATE] around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On [DATE] at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On [DATE] at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On [DATE] at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On [DATE] at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On [DATE] at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On [DATE] at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On [DATE] at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's [DATE] MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on [DATE] at 11:15 AM. Resident #1's [DATE] MAR reflected no other medications were administered to reduce an elevated temperature on [DATE] at 4:23 PM or as documented in nurse's progress notes: On [DATE] at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On [DATE] at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated [DATE] reflected Resident #1 arrived at theER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: ,d+[DATE]; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated [DATE] at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on [DATE] at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in theER on [DATE] at 5:53 PM resulted [DATE] at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on [DATE] at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated [DATE] at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of [DATE] at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on [DATE] at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on [DATE]. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of [DATE] and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on [DATE] at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on [DATE] to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on [DATE] around 7:00 AM, she received a snapshot of a progress note from LVN B (worked [DATE] 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning ([DATE]) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on [DATE]. During an interview on [DATE] at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room ([DATE]) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on [DATE] at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of [DATE] - [DATE]) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on [DATE] at 1:37 PM, a family member stated concerns started on [DATE] when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in [DATE] with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on [DATE]. The family member stated the fever continued until [DATE], which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on [DATE] that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on [DATE], that nothing could be done, and the resident would benefit from palliative care. On [DATE], Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on [DATE]. The family member said that Resident #1 passed away because of the sepsis. During an interview on [DATE] at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on [DATE] at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on [DATE] and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon ([DATE]) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day ([DATE]) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident #1 on [DATE]. LVN A stated that she did not recall working on that day and if she worked, she would have checked for the lab results and notified the MD. During a follow up interview on [DATE] at 1:27 PM, LVN A said that she checked with the staffing coordinator and verified she worked on [DATE] and was assigned to Resident #1. LVN A said that she did know how Resident #1's labs were missed and not reviewed. LVN A said that the risk to a resident if labs were not reviewed in a timely manner would be in a delay in treatment and worsening of an infection. During an interview on [DATE] at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and her care needs as the primary assigned nurse. LVN B said that Resident #1 was totally dependent for ADLs, confused, could respond to questions with a head nod/shake or answer yes or no, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA wit [TRUNCATED]

Based on interview and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one (Resident #1) of five residents reviewed for Urinary Tract Infection (UTI). On [DATE] Resident #1's FC was discontinued after unknown nurse reported leakage. The facility failed to ensure LVN B immediately notified the physician on [DATE] when Resident #1 had an elevated temperature of 100.3 F and N/V brownish partially digested food. The facility failed to ensure LVN A notified the physician on [DATE] that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On [DATE] at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. The facility failed to ensure LVN B immediately notified the physician on [DATE] at 1:10 AM there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 from the facility when Resident #1 had a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor . On [DATE], after 5:00 PM, Resident #1 was sent to the ER. Resident #1 was admitted with a primary diagnosis of Enterocolitis (inflammation in both intestines at once especially in a severe reaction to common infections) and Severe sepsis with acute renal failure without septic shock. Additional diagnoses included acute cystitis (infection that only affects the bladder) without hematuria (blood in the urine) An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed residents at high risk of serious injury, harm, impairment, or death by not receiving treatment, developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: Record review of Resident #1's Admission Record, printed on [DATE], revealed a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected: - Order date [DATE]: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: [DATE]] - Order date [DATE]: Monitor indwelling catheter for blockage, leakage, sediment, buildup, output, urine color and odor every shift for retention. - Order date [DATE]: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date [DATE]: Nurse is to ensure CNA provide catheter care with baby shampoo and warm water, rinsing and patting dry every shift. This includes cleaning inner labia. - Order date [DATE]: Irrigate foley with NS every shift for control of sediment - Order date [DATE]: Discontinue foley (indwelling catheter) one time only for bladder spasms - Order date [DATE]: Trospium Chloride Oral tablet 20 mg. Give 1 tablet by mouth two times a day for bladder spasms - Order date [DATE]: Monitor output every shift d/t discontinuation of f/c - Order date [DATE]: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date [DATE]: UA with C & S one time only r/o UTI. - Order date [DATE]: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date [DATE]: May insert Midline IV (a long, thin, flexible tube inserted into a large vein in the upper arm used to administer medication into the bloodstream) for infusion - Order date [DATE]: Sodium Chloride Soln 0.9%. Use 100 mL/hr IV every shift for hydration for 3 days. (Give 2 liters of NS 0.9% via midline) - Order date [DATE]: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until [DATE] 11:59 PM. - Order date [DATE]: Merrem (antibiotic) IV soln 500 mg. Use 500 mg IV two times a day for UTI for 7 days. - Order date [DATE]: Ceftriaxone (antibiotic) 1 GM injection solution. Inject 1 gram intramuscularly STAT for UTI. - Order date [DATE]: Send to ER for further evaluation. A review of Resident #1's comprehensive care plan initiated [DATE] indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: [DATE]; Revision on: [DATE]] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or [NAME] blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. A record review of Resident #1's lab results report dated [DATE] revealed lab results collected on [DATE] at 9:35 AM and reported on [DATE] at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on [DATE] at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: [DATE] at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 P92 R20 B/P ,d+[DATE]. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: [DATE] at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis of undigested food and temp 100.4. Currently afebrile. Positive for suprapubic tenderness. Physical Examination [DATE] (measured at 3:33 AM) BP: ,d+[DATE] HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed [DATE], pt was voiding around the catheter. Monitor wet diapers . - Nurse's Note Effective Date: [DATE] at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP ,d+[DATE], P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. Review of Resident #1's progress notes did not reflect any other progress notes until [DATE] at 1:18 PM. - Laboratory Results Note Effective Date: [DATE] at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician Progress Note Effective Date: [DATE] at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on [DATE] revealed: (at 3:52 PM) BP: ,d+[DATE] HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB - Nurse's Note Effective Date: [DATE] at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P,d+[DATE] 02sat 96%RA . ([DATE]) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place ([DATE]) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: [DATE] at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on [DATE] around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On [DATE] at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On [DATE] at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On [DATE] at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On [DATE] at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On [DATE] at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On [DATE] at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On [DATE] at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's [DATE] MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on [DATE] at 11:15 AM. Resident #1's [DATE] MAR reflected no other medications were administered to reduce an elevated temperature on [DATE] at 4:23 PM or as documented in nurse's progress notes: On [DATE] at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On [DATE] at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated [DATE] reflected [Resident #1] arrived at theER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: ,d+[DATE]; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member [Resident #1] was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of ER triage notes of an initial evaluation by a qualified medical provider focused examination dated [DATE] at 5:42 PM indicated [Resident #1] appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on [DATE] at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of blood labs collected in theER on [DATE] at 5:53 PM resulted [DATE] at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on [DATE] at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated [DATE] at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . [Resident #1] was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of [DATE] at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis (a bacterial infection causing inflammation of the kidneys), acute renal failure, and atrial flutter. During an interview on [DATE] at 10:38 AM, LVN F said he was familiar with Resident #1 care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, family member was at bedside daily and assisted with care. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuate outside of MD acceptable parameters. LVN F said if a resident had a temperature of 99 degrees or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when last assigned to Resident #1 on [DATE]. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of [DATE] and was surprised when returned from vacation that Resident #1 was sent to the hospital. During an interview on [DATE] at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that on or about [DATE], she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses informed her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on [DATE] to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on [DATE] around 7:00 AM, she received a snapshot of a progress note from LVN B via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning ([DATE]) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had a UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for higher level of care on [DATE]. During an interview on [DATE] at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room ([DATE]) when Resident #1 was sent out to hospital. Resident did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on [DATE] at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before sent to hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative as examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident condition to be able to recognize change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI. The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on [DATE] at 1:37 PM, a family member stated concerns started on [DATE] when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in [DATE] with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on [DATE]. The family member stated the fever continued until [DATE], which at that time, Resident #1 had a low-grade fever of 99.8 degrees. The family member said that they were notified on [DATE] that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on [DATE], that nothing could be done, and the resident would benefit from palliative care. On [DATE], Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on [DATE]. The family member said that Resident #1 passed away because of the sepsis. During an interview on [DATE] at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident - not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine cause of change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about resident clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1 that appeared lethargic, didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on [DATE] at 12:41 PM, LVN A said that she was familiar with Resident #1 and their care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any given. LVN A said signs of an UTI were strong-smelling urine, urine that looked cloudy, fever, and the resident may become confused. LVN A said that she worked on [DATE] and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon ([DATE]) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. During an interview on [DATE] at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and their care needs as the primary assigned nurse. LVN B said that Resident #1 was total dependent for ADLs, confused, could respond to questions with a head nod/shake or answer Yes or No, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any trauma, signs, or symptoms of infection. LVN B said she gently tugged on the catheter tubing at the insert site to check for placement and checked if the balloon was inflated. LVN B said there was an order to encourage Resident #1 to drink fluids because she did not drink enough water, and there was sedimentation often noted in the urine. LVN B said that she flushed Resident #1 FC every night with 60 cc NS and monitored urine output per orders to prevent catheter complications. LVN B said the risk of not flushing the catheter would cause problems such as, catheter leakage, blocked catheter, catheter coming out, or an infection. LVN B said s/sx of an UTI included fever, sleepiness, decreased urine output, dark, foul smelling urine. In a continued interview on [DATE] at 7:06 PM, LVN B said that she worked [DATE] and [DATE], 7P - 7A. LVN B said she did not recall if Resident #1 had a fever but did perform an in/out (straight) cath one night after the MD was called and received an order. LVN B said the order was to leave the fc in place if the urine output was 250cc or more. LVN B said that there was 200cc reddish brown urine output and did not leave the catheter in place. LVN B indicated she wrote the progress note that described the urine output as reddish-brown, foul smelling, and with white sediment. LVN B denied she notified the MD of the urine characteristics because that was common for Resident #1. LVN B restated s/sx of an UTI included dark colored urine, foul odor, and a fever. LVN B said that it is the facility procedure to notify the physician immediately of a resident change in condition. LVN B defined a change in condition as anything abnormal for the resident. LVN B denied Resident #1 presented a decline or change in condition. During a phone interview on [DATE] at 4:36 PM, the NP described a change in condition as a deviation from the resident norm such as, AMS (confusion), abnormal VS, or lab results. The NP said early s/sx of an UTI included AMS, lack of appetite, increased sleepiness. The NP said early s/s of sepsis are generally the same as that of an UTI. The NP said a temperature greater than 100 F, HR greater than 90 bpm, RR of more than 20, and a very low blood pressure (SBP <100; DBP <60 or otherwise stated by the physician) are vital signs that indicate sepsis. The NP said she expected to be notified ASAP about a resident change in condition. The NP said that her expectation on notification of labs was for the nurse to call instead of text if there were critical labs, but to always notify as soon as lab results are available for review. The NP said the risks to not being notified as soon as possible or not notified at all place residents at risk of delayed treatment or not receive the appropriate care needed. The NP said she was familiar with Resident #1. The NP described Resident #1 as unable to care for self, had end stage dementia, required feeding, and was fc dependent for a long time. The NP denied she was notified that the lab results were available on [DATE]. The NP said that she tried to monitor resident [NAME] [TRUNCATED]

Based on interviews and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges for one (Resident #1) of five residents reviewed for Laboratory Services. The facility failed to ensure LVN A notified the physician on [DATE] that Resident #1's laboratory results were released to the facility on [DATE] at 12:55 PM. On [DATE] at 1:23 PM, the NP reviewed labs in PCC. Labs resulted WBC 22. UA with many bacteria, dehydration, and UTI. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity level of actual harm that is not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice place residents at risk of not receiving treatment, developing sepsis, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1's Admission Record, printed on [DATE], revealed the resident was a [AGE] year-old female, who admitted to the facility on [DATE] with the following diagnoses: Unspecified sequelae (a condition which is the consequence of a previous disease or injury) of cerebral infarction (also called ischemic stroke, occurs when a vessel supplying blood to the brain is obstructed); Dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Alzheimer's disease (a progressive disease beginning with mild memory loss); Dysphagia (swallowing difficulties); COPD (a group of diseases that cause airflow blockage and breathing-related problems); neurogenic bladder (bladder dysfunction caused by nervous system conditions); and urinary (or urine) retention (a condition in which you are unable to empty all the urine from your bladder). Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was always incontinent of bowel and bladder and had an indwelling catheter (a flexible tube inserted into the bladder, via the urethra, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician's orders reflected: - Order date [DATE]: Eliquis Tablet 2.5 mg. Give 1 tablet by mouth every morning and at bedtime for A-fib [D/C: [DATE]] - Order date [DATE]: Acetaminophen Tablet 325 m. Give 2 tablets by mouth every 4 hours as needed for Pain, mild; elevated temperature. - Order date [DATE]: CBC (blood test that measures RBCs [cells which carry oxygen] and WBCs), BMP (blood test that measures fluid balance in the body and electrolytes levels in blood and kidney function) one time only for pain in bladder area, fever for one day. - Order date [DATE]: UA with C & S one time only r/o UTI. - Order date [DATE]: UA with C & S STAT (immediately in medical terms) r/o UTI - Order date [DATE]: May straight cath (a catheter used temporarily to empty urine from the bladder intermittently), if urine output is greater than 250cc leave foley in place. One time only for urine retention until [DATE] 11:59 PM. - Order date [DATE]: Send to ER for further evaluation. Review of Resident #1's progress notes indicated [last note prior to [DATE] was dated [DATE]]: - Nurse's Note Effective Date: [DATE] at 5:12 AM, LVN B entered, [Resident #1] is alert and able to answer questions. Noted to have nausea with vomiting brownish partially digested food. No c/o stomach discomfort after vomiting. Abdomen soft and non-distended, good active bowel sounds in all four quads. No c/o of needing to urinate with palpating of bladder area. Skin warm and dry to the touch. T100.4 [degrees Fahrenheit] P92 R20 B/P ,d+[DATE]. Will notify doctor of resident's condition. - Physician Progress Note Effective Date: [DATE] at 1:30 PM, the NP entered, LATE ENTRY: At 5:00 this am [Resident #1] had emesis (action or process of vomiting) of undigested food and temp 100.4. Currently afebrile (not feverish). Positive for suprapubic (region of the abdomen located below the umbilical region) tenderness. Physical Examination [DATE] (measured at 3:33 AM) BP: ,d+[DATE] HR 93 RR 18 T 98.6 SPO2 (percentage of oxygen in the blood) 92% RA WT 103.0 LB . slightly irregular (heart) rhythm . Acute urinary retention: Foley dependent . Foley removed [DATE], pt was voiding around the catheter. Monitor wet diapers - Nurse's Note Effective Date: [DATE] at 4:01 PM, LVN A entered, [Resident #1] verbalized pain upon palpation of lower abdomen, no distension of the bladder noted. VS are stable BP ,d+[DATE], P64 T99.5, R19, SPO2 95%, given Tylenol for pain/fever and discomfort. WCTM. A review of Resident #1's comprehensive care plan initiated [DATE] indicated: Focus: [Resident #1] is on Anticoagulant therapy (Eliquis) r/t atrial fibrillation (a type of arrhythmia, or abnormal heartbeat) [Initiated: [DATE]; Revision on: [DATE]] Interventions included activities or actions that a nurse and/or CNA were expected to perform to achieve Resident #1's goals. Interventions focused on daily skin inspection; report lab results to the MD; monitor/document/report to MD PRN s/sx of anticoagulant complications: blood tinged or [NAME] blood in urine . nausea, vomiting, lethargy, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s; and RP education. Additional Focus items on Resident #1's comprehensive care plan reflected: ADL dependence, Advance Directive - DNR, Risk for falls, Impaired cognition, psychoactive/anti-depressant medications, Resident Rights, occasional pain, enabler use, regular diet, and ADL self-care deficit. The care plan interventions reflected observation, monitoring, educating, assess, evaluate, and report to MD. A record review of Resident #1's lab results report dated [DATE] revealed lab results collected on [DATE] at 9:35 AM and resulted in PCC (Resident #1 chart) on [DATE] at 12:55 PM. - BUN (measures the amount of urea nitrogen [a waste product] that kidneys remove from the blood) 40 mg/dL [High] [Range: 7 - 25] - Creatinine (measures how well kidneys are filtering waste from the blood) 1.4 mg/dL [High] [Range: 0.6 - 1.2] - WBC - 22.0 per mcL [High] [Range: 3.8 - 11.8] Record review of Patient characteristics with high or low blood urea nitrogen in upper gastrointestinal bleeding (2015). World Journal of Gastroenterology, accessed on [DATE] at https://doi.org/10.3748/wjg.v21.i24.7500 reflected elevated BUN and Creatinine lab results suggested dehydration and are characteristics of acute upper GI bleeding. The elevated WBC lab result suggested Resident #1 had an infection. Review of Resident #1's progress notes did not reflect any other progress notes until [DATE] at 1:18 PM. - Laboratory Results Note Effective Date: [DATE] at 1:18 PM, the NP entered, abnormal lab WBC 22 . BUN 40, Cr 1.4, UA with many bacteria, leukocytes. C&S pending. Dehydration. UTI. Plan of care discussed with [MD] and [family member] . Midline to be inserted with 1 Liter 0.9%NS at 100 cc/hr. AM labs CBC and BMP. ABX therapy per C&S results. - Physician's Progress Note Effective Date: [DATE] at 4:30 PM, the NP entered, LATE ENTRY [Family member] reports [Resident #1] more sleepy . not eating or drinking much either. Low grade temp 99.8 yesterday morning. Plan of care discussed with [MD] and [family member] . UA today is nitrite neg (nitrites in urine may mean UTI. Even if no nitrites are found, may still have an infection). Physical Examination on [DATE] revealed: (at 3:52 PM) BP: ,d+[DATE] HR 72 RR 17 T 98. SPO2 92% RA WT 103.0 LB. - Nurse's Note Effective Date: [DATE] at 12:25 AM, LVN B entered, Resident is breathing heavy and c/o pain with palpation of lower abdomen, bladder area. Skin warm and dry to the touch, has a small amt of urine in brief, dk brown in color. T97.6 P92 R22 B/P,d+[DATE] 02sat 96%RA . ([DATE]) at 1:00 AM [Resident #1] abdomen distended continues to c/o pain with palpating of bladder. Call placed to [MD] . new order to straight cath if urine output is greater than 250 leave foley in place ([DATE]) at 1:10 AM . inserted #18Fr foley cath into [Resident #1] bladder and a stat return of reddish-brown urine with lots of white sedimentation and had a foul odor. Bladder drained only 200cc of urine. Foley cath removed as ordered. - Physician Progress Note Effective Date: [DATE] at 11:32 AM, the NP entered, LATE ENTRY Reason for this visit: Upon exam, [Resident #1] lethargic, opens eyes to verbal stimuli . not eating. UA positive for infection, C&S pending. afebrile (not feverish) today. Temp max was 100.4F on [DATE] around 5AM. [family member] requested manage resident at SNF like always and did not want Resident #1 to be sent to the hospital. The NP explained to [family member] that Resident #1 will be sent to hospital if does not improve with IVF and IV abx . [family member] agreed. IVF at higher rate and one dose of ceftriaxone IM 1g . started Merrem IV 500 mg q12h. A record review of Resident #1's Weights and Vitals Summary reflected: Temperature Summary: - On [DATE] at 1:25 PM, measured by LVN G with a forehead thermometer - 98.1 F - On [DATE] at 3:33 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 4:23 PM, measured by LVN A with a forehead thermometer - 99.5 F - On [DATE] at 2:32 AM, measured by LVN B with a forehead thermometer - 98.7 F - On [DATE] at 11:10 AM, measured by LVN A with a forehead thermometer - 99.8 F - On [DATE] at 3:21 AM, measured by LVN B with a forehead thermometer - 98.0 F - On [DATE] at 3:52 PM, measured by LVN AB with a forehead thermometer - 97.7 F - On [DATE] at 3:50 AM, measured by LVN B with a forehead thermometer - 98.6 F - On [DATE] at 1:22 PM, measured by RN AC with a forehead thermometer - 97.8 F Review of Resident #1's [DATE] MAR revealed LVN A administered Acetaminophen 325 mg, 2 tablets for elevated temperature, 99.8 F on [DATE] at 11:15 AM. Resident #1's [DATE] MAR reflected no other medications were administered to reduce an elevated temperature on [DATE] at 4:23 PM or as documented in nurse's progress notes: On [DATE] at 5:12 AM, LVN B indicated Resident #1 had a temperature of 100.4 F On [DATE] at 4:01 PM, LVN A indicated Resident #1 had a temperature of 99.5 F . given Tylenol for pain/fever and discomfort. [Was not reflected on MAR at that time] A review of Resident #1's hospital medical records dated [DATE] reflected Resident #1 arrived at theER on [DATE] at 5:14 PM. Resident #1's initial vital signs in ER at 5:24 PM revealed: BP: ,d+[DATE]; HR: 89; Temp: 98.9 F; Resp: 18; Weight: 100 lbs.; SpO2: 91% on RA (without supplemental oxygen or rescue ventilation). The ER triage notes reflected a brief history of present illness (reason for ER visit) per family member Resident #1 was fatigued, decreased appetite, in and out of consciousness over the past 3 days . fever, vomiting, symptoms of UTI. Review of the ER triage notes of an initial evaluation by a qualified medical provider focused examination dated [DATE] at 5:42 PM indicated Resident #1 appeared drowsy with mild distress. The ER provider physical exam revealed Resident #1 appeared ill with tachycardia (heart rate over 100 beats a minute), abdominal tenderness, guarding, right and left CVA (abdominal exam of anatomic relationship of the 12th rib and lumbar vertebrae) tenderness (often indicates a UTI or other kidney problems), was disoriented, displayed weakness and pallor (an unhealthy pale appearance). An ECG (non-invasive test that records the electrical activity of the heart) interpretation on [DATE] at 5:36 PM revealed tachycardia, atrial flutter (a type of abnormal heart rhythm), 160 bpm. Sepsis IV fluids were administered with HR response to the 140s (bpm). Review of Resident #1's blood labs collected in theER on [DATE] at 5:53 PM resulted [DATE] at 6:11 PM (*critical lab results) revealed: WBC: 21.8 per mcL (H) [Range: 4.5 - 11] Lactate: 2.6 mmol/L (*) [Range: 0.9 - 1.7] BUN: 83 mg/dL (H) [Range: 7 - 18] Creatinine: 2.20 mg/dL (H) [Range: 0.55 - 1.02] BUN/Cr Ratio: 38 (H) [Range: 7 - 25] Record review of Blood Urea Nitrogen to Creatinine ratio in Differentiation of Upper and Lower Gastrointestinal Bleedings; a Diagnostic Accuracy Study. (2019). Archives of academic emergency medicine, accessed on [DATE] at https://pubmed.ncbi.nlm.nih.gov/31432040/ reflected A BUN/Cr ratio of greater than or equal to 36 suggest upper gastrointestinal bleeding. A review of the ER provider assessment and clinical consideration dated [DATE] at 10:00 PM indicated [Resident #1] with low-grade fever and decreased responsiveness. Urine cloudy . tenderness to suprapubic abdomen that is considerable . UA remarkable for significant leukocyte esterase and WBCs . Lactic acid (substances produced by cells) is elevated at 2.6 consistent with severe sepsis . Resident #1 was found to have severe sepsis, atrial flutter (160s - 170s bpm) with a high WBC count, fever, and emesis during evaluation. A consultation with ICU determined Resident #1 would be best served in PCU (step-down unit from ICU designed to care for seriously ill patients who require constant monitoring but whose condition does not warrant care in the Intensive Care Unit). A palliative care (specialized medical care focused on providing relief from pain and other symptoms of a serious illness) consult was pending. Final diagnoses as of [DATE] at 12:45 AM: Enterocolitis, lung infiltrate, severe sepsis, acute urinary retention, pyelonephritis, acute renal failure, and atrial flutter. During an interview on [DATE] at 10:38 AM, LVN F said he was familiar with Resident #1's care needs. LVN F stated Resident #1 required staff assistance with ADLs, had a foley catheter, a family member was at bedside daily and assisted with care. LVN F defined a change in condition as a change in functioning such as a verbal decline, fever, not eating . anything out of the ordinary from the resident baseline. LVN F said that he would assess the resident that experienced a change in condition and notify the MD using the SBAR technique (a framework for communication between members of the health care team about a patient's condition). LVN F said that a resident who was unable to communicate verbally could be assessed by visual inspection of non-verbal signs such as grunts, moans, guarding, and behaviors that suggest distress. LVN F said signs that a resident may have a UTI included, N/V, feeling sluggish, abdominal, side, and back pain, and dark colored urine with foul odor, cloudy or with sediment (white particles in urine). LVN F said that early s/sx of sepsis included fever, confusion, and decreased level of consciousness. LVN F said that reportable vital signs to the MD would be measurements that fluctuated outside of the MD's acceptable parameters. LVN F said if a resident had a temperature of 99 degrees (Fahrenheit) or higher, he would check if there was an order to administer a medication for fever reduction or try other measures such as making sure the resident had on light clothing, remove blankets, cover with a light sheet, and then notify the MD. LVN F said that Resident #1 did not present with s/sx of infection or decline when he was last assigned to Resident #1 on [DATE]. LVN F said that leakage around the fc was not noted when provided care. LVN F said that he did not work the week of [DATE] and was surprised when he returned from vacation that Resident #1 was sent to the hospital. During an interview on [DATE] at 11:22 AM, the MD said that she was very familiar with Resident #1. The MD indicated that Resident #1 admitted to the SNF in 2021 with advanced dementia. The MD said that Resident #1 had a catheter and a history of frequent UTIs and pneumonia. The MD said that she received multiple notifications from a nurse overnight that Resident #1 had a wet brief, and that urine was leaking around the catheter. The MD said that leakage around a resident's catheter was caused by a catheter blockage or bladder spasms. The MD said that she ordered a medication to treat bladder spasms for Resident #1. The MD said that there were orders in place to flush the catheter each shift (twice a day/two shifts) to prevent build up and to maintain patency, encourage fluid intake, and appropriate catheter care. The MD said that other causes for leakage around the catheter could be related to a kinked catheter tubing, a full drainage bag, the foley balloon (holds the catheter in the urinary bladder) deflated, or an infection. The MD said that the nurses inform her of every symptom or resident concern before collecting clinical data or performing interventions. The MD said that she was not notified that Resident #1 presented any signs or symptoms of an infection. The MD said that she gave an order on [DATE] to remove the catheter and monitor briefs for urine retention and would implement voiding trial (assesses the ability of the bladder to empty). The MD said on [DATE] around 7:00 AM, she received a snapshot of a progress note from LVN B (worked [DATE] 7P - 7A shift) via the messaging app that indicated Resident #1 had emesis and a fever overnight. The MD said that was unacceptable and should be notified immediately. The MD said that Resident #1 was seen by the NP later that morning ([DATE]) and labs were ordered. The MD said that the NP informed that lab results revealed Resident #1 had an UTI and was dehydrated. The MD said that Resident #1 had sepsis in the past and was treated in the facility. The MD said that the NP discussed a plan of care to send Resident #1 to the hospital if IV abx therapy was not effective. The MD said that she acknowledged understanding and was informed that Resident #1 was sent to the hospital for a higher level of care on [DATE]. During an interview on [DATE] at 12:41 PM, the MDS said that she was familiar with Resident #1 and was present in the room ([DATE]) when Resident #1 was sent out to hospital. Resident #1 did not appear to be well and was not eating. The MDS said that the NP informed the family member that Resident #1 needed to go the hospital, because the treatment provided was not as effective as the NP hoped. The family member acknowledged understanding but never gave a definitive yes. The MDS said that the family member wanted care and treatment provided at the SNF. The MDS stated that the NP determined Resident #1 would be sent to the hospital for further evaluation. During an interview on [DATE] at 1:07 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 initially had a foley catheter that was recently removed. The DON said that Resident #1 had frequent UTIs and received IV abx therapy before being sent to the hospital. The DON said that Resident #1 required one person assistance with ADLs. The DON defined a change in condition as anything outside of normal for a resident's clinical status. The DON stated behavior changes, the need or want to sleep more, vital sign changes and not talking much when usually talkative were examples of a change in condition. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize a change and be knowledgeable of nursing interventions. The DON said that she recalled Resident #1 had a fever (could not state a specific date and time, referred to the week of [DATE] - [DATE]) that the nurse resolved with treatment. The DON said that she was not informed that Resident #1 had any change or symptoms that would trigger the process to determine care needs. The DON stated nurses should document when the nurse reviewed lab results, notified the MD, and if orders were received. The DON indicated when the MD wrote orders for labs, the primary nurse completed a lab request. The DON said her expectations were for the nurse to review and notify the MD as soon as lab results were received and if any new orders were received, they should be carried out and documented. The DON said as the Infection Preventionist, she monitored the infection log and was aware that Resident #1 received an IM antibiotic one-time treatment for a UTI (before transferred to hospital). The DON said she was present when the MD spoke with the family member about sending Resident #1 to the hospital for assessment and evaluation for the UTI. The DON said that the family member requested Resident #1 be treated at the SNF. The DON said that the NP made the decision to send Resident #1 to the hospital for further evaluation. During a phone interview on [DATE] at 1:37 PM, a family member stated concerns started on [DATE] when Resident #1's catheter (indwelling) was removed because (urine) was leaking around the catheter. The family member stated Resident #1 admitted to SNF in [DATE] with a fc and had one in place for over two years. The family member said that leaking around the catheter happened in the past and resolved once the catheter was replaced. The family member said that Resident #1 had a temperature of 101 degrees, was not feeling well and had a change in condition on [DATE]. The family member stated the fever continued until [DATE], which at that time, Resident #1 had a low-grade fever of 99.8 degrees (Fahrenheit). The family member said that they were notified on [DATE] that a urine test was done, and the results indicated Resident #1 had an UTI and was dehydrated. The family member said that Resident #1 received antibiotic therapy through a midline. The family member said that when Resident #1 had UTIs in the past, the SNF would place a PICC line and Resident #1 would get better. The family member said after 1 day, Resident #1 did not show improvement and (family member) wanted to send Resident #1 to hospital by ambulance. The family member said that the SNF denied calling an ambulance because it was not an emergency and called a non-emergency transport service. The family member said that Resident #1 was transferred to the hospital on [DATE], arrived around 5:30 PM, her heartrate was 170, bp was low and Resident #1 was mostly out of it. The family member said blood work was collected and the hospital staff informed [family member] that Resident #1 was dehydrated, had sepsis and other complications from sepsis. The family member stated that they were informed on [DATE], that nothing could be done, and the resident would benefit from palliative care. On [DATE], Resident #1 discharged home from the hospital under hospice services. The family member said that Resident #1 died at home on [DATE]. The family member said that Resident #1 passed away because of the sepsis. During an interview on [DATE] at 3:48 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs, had a fc, had a midline for IVF and IV abx, and had a poor appetite. The ADON said that catheter care was performed by the CNA when they provided incontinent care. The ADON said that it is the nurse responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the foley remain patent. The ADON described a change in condition as anything outside of what is normal for the resident, not eating or sleeping more than usual. The ADON said that early s/sx of sepsis were lethargy, pain, abnormal lab values, change in behavior, or fever. The ADON said that the nurse should assess the resident to determine the cause of the change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about the resident's clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON said that one day she noticed a change in Resident #1, that she appeared lethargic (lack of energy), didn't want to sit up, and stayed in bed. The ADON said that Resident #1 ate in the dining room at all meals. The ADON said that she knew that the MD and NP treated Resident #1 for an infection. The ADON said that she worked as a floor nurse around the time Resident #1 appeared ill and had administered an IM antibiotic injection to Resident #1 as ordered. The ADON said that Resident #1 acknowledged feeling better but did not show much improvement. The ADON said that she was not aware that Resident #1 had lab results that were not reviewed by the nurse, or the MD was not notified when the results were available. The ADON said that it was the nurse's responsibility to follow up on lab results, review the results, and notify the MD. The ADON said that she tried to assist nurses by reviewing lab orders in the lab binder daily to ensure labs were drawn as ordered, specimens picked up, monitor lab results, and ensure the MD is notified and care measures are taken, but it is not always possible. The ADON said that her expectation is that every nurse be responsible for the assignment given and for nurses to inform leadership when they are busy and need assistance. During an interview on [DATE] at 12:41 PM, LVN A said that she was familiar with Resident #1 and her care needs. LVN A described Resident #1 as alert and oriented to self, required one person assist with ADLs, and had a FC until recently discontinued. LVN A defined a change in condition as abnormal vital signs, altered mental status, or an elevated temperature. LVN A said that she would assess a resident that experienced a change in condition, check vital signs, notify the MD and act on orders if any were given. LVN A said signs of an UTI were strong smelling urine, urine that looked cloudy, a fever, and the resident may become confused. LVN A said that she worked on [DATE] and was informed in report that Resident #1's fc was removed because it kept leaking. LVN A said that the reporting nurse [LVN B] said that Resident #1 threw up overnight once and had a fever. LVN A said that the NP saw Resident #1 in the early afternoon ([DATE]) and wrote orders for labs and an UA with C & S. LVN A said that she collected the urine specimen and called the lab company to schedule the lab draw and pick up the urine specimen. LVN A said that when she collected Resident #1's urine specimen, the urine had a foul smell. LVN A said that the procedure for lab tests is to enter the order, complete a requisition, and call the laboratory to schedule. LVN A said that the nurse checked the resident chart for the lab results. If the lab results were not reported by the end of their shift, the nurse should give report to the oncoming nurse to check for lab results. Once the lab results are received, electronically sent directly to the resident chart by the lab, the nurse will review and immediately notify the MD that the results are ready for review or inform of any abnormal/critical lab results. LVN A said the MD is notified via the messaging app or if critical lab results, the nurse must call the MD, and document notification/communication with the provider. LVN A said that she was not assigned to Resident #1 the next day ([DATE]) when the labs were scheduled to be drawn and results expected to return. Resident #1's vital signs were reviewed with LVN A and attention directed to the temperature summary that reflected an elevated temperature entered by LVN A and the MAR revealed LVN A administered acetaminophen to Resident #1 on [DATE]. LVN A stated that she did not recall working on that day and if she worked, she would have checked for the lab results and notified the MD. During a follow up interview on [DATE] at 1:27 PM, LVN A said that she checked with the staffing coordinator and verified she worked on [DATE] and was assigned to Resident #1. LVN A said that she did know how Resident #1's labs were missed and not reviewed. LVN A said that the risk to a resident if labs were not reviewed in a timely manner would be in a delay in treatment and worsening of an infection. During an interview on [DATE] at 7:06 PM, LVN B said that she worked the evening shift, 7P - 7A and was familiar with Resident #1 and her care needs as the primary assigned nurse. LVN B said that Resident #1 was totally dependent for ADLs, confused, could respond to questions with a head nod/shake or answer yes or no, and had a FC that was removed. The FC was scheduled to be changed every 3 weeks or PRN. LVN B said that the CNA was responsible for providing catheter care during incontinent care. The task was on the MAR, and the nurse had to sign off nightly that the CNA performed catheter care using baby shampoo. LVN B said that she assisted the CNA with catheter care nightly, so she would assess if there was any trauma, signs, or symptoms of infection. LVN B said she gently tugged on the catheter tubing at the insert site to check for placement and checked if the balloon was inflated. LVN B said there was an order to encourage Resident #1 to drink fluids because she did not drink enough water, and there was sedimentation often noted in the urine. LVN B said that she flushed Resident #1's FC every night with 60 cc NS and monitored urine output per orders to prevent catheter complications. LVN B said the risk of not flushing the catheter would cause problems such as, catheter leakage, blocked catheter, catheter coming out, or an infection. LVN B said s/sx of an UTI included fever, sleepiness, decreased urine output, dark, foul smelling urine. LVN B said that the MD should be notified immediately. LVN B said that she worked on [DATE], 7P - 7A. Resident #1's progress notes were reviewed with LVN B. LVN B acknowledged she entered the progress note on [DATE] at 5:12 AM that reflected Resident #1 had a fever and threw up brownish partially digested food. LVN B said she did not recall the specific time. LVN B denied the emesis appeared like coffee grounds (dark brown in color with a lumpy texture. The appearance comes from old and coagulated [solid or semisolid state] blood in the GI tract). LVN B said Resident #1 threw up partially digested food often, it was not abnormal [for Resident #1], and was not a change in condition that required immediate MD notification. LVN B said, I know I gave [Resident #1] Tylenol (for the fever); I probably did not chart it . I do not recall. LVN B said the MD told her in the past not to chart doctor was notified, and that was why she wrote will notify the doctor, took a picture of the progress note and sent the snapshot to the MD via the messaging app. LVN B said when she sent the snapshot the doctor was notified to her knowledge. LVN B said that the messaging app was like a group text and included the MD/NP/DON/ADON. LVN B said that when resident lab results arrived in a resident's chart, she would send a message to the MD/NP that lab results available to review. LVN B said sending a text via the messaging app was considered doctor notification and documentation that the doctor was notified. In a continued interview on [DATE] at 7:06 PM, LVN B said that she worked [DATE] and [DATE], 7P - 7A. LVN B said she did not recall if Resident #1 had a fever but did perform an in/out (straight) cath one night after the MD was called and received an order. LVN B said the order was to leav [TRUNCATED]

Based on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS system for three (Residents #23, #36 and #88) of eight residents reviewed for resident assessments. The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments was transmitted within 14 days after they discharged this facility. This failure could affect discharged residents from getting the appropriate continuity of care with other healthcare providers in the community or other Nursing facilities if they continued to appear to be a resident at this facility which could cause a decline in benefits and affect the facility's census statistics in the CMS database. The findings included: A)Record review of Resident #23's face sheet dated 06/02/23 revealed an [AGE] year old female who initially admitted [DATE] and readmitted [DATE] with diagnoses of Spinal Stenosis, Protein -Calorie Malnutrition, Depression, Chronic pain, and Lack of Coordination. Further revealed the resident discharged [DATE]. Record review of Resident #23's Simple LTC Final Validation Report undated revealed an ARD target date of 04/14/23and a Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days after the assessment reference date (ARD). B)Record review of Resident #36's face sheet dated 06/02/23 revealed a [AGE] year old female who admitted [DATE] with diagnoses Lymphedema, Iron Deficiency, morbid obesity, encephalopathy, hypertensive heart disease, congestive heart failure. Further review revealed the resident discharged on [DATE]. Record Review of Resident #36's LTC Final Validation Report undated revealed an ARD target date 04/14/23 and Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days after the assessment reference date (ARD). C)Resident review of Resident #88's face sheet dated 06/02/23 revealed an [AGE] year old female who admitted [DATE] with diagnoses left femur fracture, protein-calorie malnutrition, intellectual disabilities, end stage renal disease. Further review revealed the resident discharged on [DATE]. Record review of Resident #88's Simple LTC Final Validation Report undated revealed an ARD target date of 03/06/23 and Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days after the assessment reference date (ARD). Interview on 06/01/23 at 2:13 pm, MDS A stated she was the only MDS Coordinator and there were no issues with completing the MDS assessments. She stated if a resident was not coming back to this facility, she completed the discharge MDS assessments and she and the DON signed, then it was submitted to CMS. She stated she had seven days to submit the discharge MDS Assessments into the CMS Portal and stated the MDS assessments were done for billing purposes and when the resident's Medicare stays ended. She stated she was responsible for ensuring the MDS Assessments were completed timely and accurate and was not sure what could happen if MDS assessments were not completed in a timely manner. She stated Residents #23, #36, and #88 went home with home health care services but she had not completed their discharge MDS Assessments. She stated she had started working on the Discharge MDS Assessments on 03/01/23 but had not completed them because of her workload and was behind on doing them. Interview on 06/01/23 at 4:37 pm, the DON stated MDS A did the MDS Assessments that were reviewed by her (the DON) to ensure they were accurate. She stated there were reminders on the EMR dashboard that showed which MDS Assessment were due and added MDS A was usually pretty good about completing the MDS assessments. Interview on 06/02/23 at 1:44 pm, MDS A stated she kept up with when she needed to complete the discharge MDS Assessments by checking the facility's communication forms for discharging residents. She stated she opened the resident's discharge MDS Assessment so that it would flag as a reminder in the EMR queue and also reviewed the MESAV reports but had not completed Residents #23, #36, #88's MDS Discharge Assessments. Interview on 06/02/23 at 6:44pm, the DON stated her expectations was for herself, MDS A and Corporate Nurse to split up the duties of completing the MDS assessments. She stated the discharge assessments had not been done because they had a busy schedule and MDS A was the only MDS Coordinator. Interview on 06/02/23 at 7:04 pm, the Administrator stated the expectations she had for MDS Assessment was to better improve their processes by accurately coding them and submitting them timely. Record Review of the facility's Electronic Transmission of the MDS policy dated 2001 revealed, Policy statement: All MDS assessments and discharge and reentry records are completed and electronically encoded into our facility's MDS information system and transmitted to CMS QIES Assessment Submission and Processing (ASAP) system in accordance with current OBRA regulations governing the transmission of MDS data .Policy Interpretation and Implementation: 1. All staff members responsible for completion of the MDS receive training on the assessment, data entry and transmission processes in accordance with the MDS RAI Instruction Manual before being permitted to use the MDS information system . Record Review of the CMS RAI Version 3.0 Manual dated October 2019 Page 2-10 revealed, A discharge assessment is required with all types of discharges .any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .5-3 .Discharge assessment, encoding must occur within 7 days after the MDS completion date .Assessment transmission, All other MDS assessments must be submitted within 14 days of the MDS completion date

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for four (Residents #23, #36, #54 and #88) of eight residents reviewed for Medical records. 1. The facility failed to ensure Residents #23, #36, #88's MDS discharge assessments were completed and in their medical records after they discharged this facility. 2 The facility failed to have accurate 14 day Admission and Quarterly MDS Assessments completed for Resident #54, since she readmitted [DATE]. These failures could cause all residents to be at risk of inadequate care if inaccurate diagnoses or missing documentation were not included in their medical records, resulting in not properly assessing, monitoring and treating a resident and causing them distress, pain and decreased psycho-social well- being. Findings included: A)Record review of Resident #23's face sheet dated 06/02/23 revealed an [AGE] year old female who initially admitted [DATE] and readmitted [DATE] with diagnoses Spinal Stenosis, Protein -Calorie Malnutrition, Depression, Chronic pain, Lack of Coordination . and discharged [DATE]. Record review of Resident #23's Simple LTC Final Validation Report undated revealed ARD target date 04/14/23 and Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days after the assessment reference date (ARD). B)Record review of Resident #36's face sheet dated 06/02/23 revealed a [AGE] year old female who admitted [DATE] with diagnoses Lymphedema, Iron Deficiency, morbid obesity, encephalopathy, hypertensive heart disease, congestive heart failure .and discharged on [DATE]. Record Review of Resident #36's LTC Final Validation Report undated revealed ARD target date 04/14/23 and Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days after the assessment reference date (ARD). C) Record review of Resident #54's face sheet dated 06/02/23 revealed she was private pay with Managed care insurance as secondary and her most recent hospital stay was 12/13/22 - 12/17/22. Record review of Resident #54's MDS Assessment completed by MDS A dated 12/24/22 revealed, A check marked: None of the Above .5 day scheduled PPS assessment .a [AGE] year old female who initially admitted [DATE] .with a BIMS score of 05 (severe cognitive impairment) with active diagnoses part of neck of left femur fracture, muscle wasting, unsteadiness on feet, benign neoplasm of mesothelial tissue of peritoneum (Tumor of stomach lining) . Record review of Resident #54's MDS Assessment completed by MDS A dated 12/13/22 revealed, A check marked for None of the above assessment and none of the above PPS Assessment .a [AGE] year old female who initially admitted [DATE] with a BIMS score of 02 (severe cognitive impairment) . D)Record review of Resident #88's face sheet dated 06/02/23 revealed an [AGE] year old female who admitted [DATE] with diagnoses left femur fracture, protein-calorie malnutrition, intellectual disabilities, end stage renal disease .and discharged on [DATE]. Record review of Resident #88's Simple LTC Final Validation Report undated revealed ARD target date 03/06/23 and Warning: assessment completion date (planned discharge 06/01/23) was more than 14 days late after the assessment reference date (ARD). Interview on 06/01/23 at 2:13 pm, MDS A stated she had been the MDS Coordinator for a year and added they did not have a Medical Records Director and was not sure who was responsible for ensuring the resident's medical records were accurate. She stated if the resident's medical records were not accurate something could be missed like medications, consents for treatment, tracking behavioral patterns, so many things. Interview on 06/01/23 at 2:13 pm, MDS A stated if the resident's medical records were not accurate something could be missed like medications, consents for treatment, tracking behavioral patterns, so many things. Interview on 06/02/23 at 6:44pm, the DON stated they needed to hire someone for the medical records position because they did not have a Medical Records Director. She stated she was responsible for ensuring the medical records were accurate. She stated she was aware of the issues with completing the MDS assessments but had not resolved the problem yet. She stated the plan was for she, MDS A and the Corporate Nurse to split up the MDS assessments to get them done because they had a busy schedule and MDS A was the only MDS Coordinator. She stated her expectations for MDS Assessments was for them to be done timely according to the schedule and was not sure who was responsible for ensuring the MDS Assessments were complete and accurate. She stated she was not sure when MDS A had an MDS Assessment training. Interview on 06/02/23 at 7:04 pm, the Administrator stated her expectations was for getting MDS Assessments and care plans done timely and accurately. She stated for medical records, making sure the staff accurately put in the the resident's information. Record review of the facility's Charting and Documentation Policy Dated July 2017 revealed, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .