Every finding on record at Battlefield Park Healthcare Center

Based on visitor interview, staff interview, clinical record review and facility document review the facility staff failed to report an allegation of neglect for 1 of 3 residents, Resident #1.The findings included:Resident #1's clinical record listed diagnoses which included but not limited to vascular dementia and diabetes mellitus.Resident #1's most recent minimum data set with an assessment reference date of 01/29/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section B, Hearing, Speech, and Vision, coded the resident as having clear speech. Section P, alarms and restraints, coded the resident as using a wander/elopement alarm daily. Resident #1's comprehensive care plan was reviewed and contained a plan for . wanders aimlessly from place to place and is an elopement risk. Interventions for this care plan include notify staff of wandering and elopement risk and wanderguard in place to right ankle.Resident #1's physician's order summary was reviewed and contained an order which read in part, Place wanderguard bracelet on the RIGHT wrist if appropriate .Check wanderguard placement every shift, Check wanderguard function daily every night shift for Wanderguard function, Check wanderguard function daily one time a day for Wanderguard function and Check Wanderguard function every shift every day shift for elopement.Resident #1's electronic treatment administration records for the month of January 2026 were reviewed and contained entries as above. All entries were documented as completed per the physician's orders. Surveyor observed Resident #1 on 02/04/26 at 6:45 pm. Resident was seated in the dining room alone. Surveyor asked resident his name and resident stated, . (Resident #1 first name only). Surveyor observed a wanderguard in place on resident's right wrist. Surveyor spoke with a facility visitor on 02/05/26 at 9:40 am. Visitor stated they had come to the facility on [DATE] at 6:00 pm to return laundry for a family member. Visitor stated when they arrived at the facility, the front door was locked, and no one was at the reception desk. Visitor stated they rang the doorbell, but no one came to the door. Visitor stated they could hear an alarm going off inside the facility. Visitor stated they were at the front door for about 10 minutes, when they heard someone coming around the building, so they stepped back to look, and saw a facility resident walking around from the right side of the building, dressed in pants and short sleeved shirt, no coat and was visibly cold. Visitor stated this resident had a wanderguard to right wrist. Visitor stated they asked the resident his name and he stated . (Resident #1) Visitor stated they called the facility around four times but no one answered the phone. Visitor stated they then called 911 for assistance. Visitor stated that the 911 operator called the facility twice before anyone answered. Visitor stated a female staff person came to the door, stated to the resident, how did you get out?, and took the resident back inside toward Unit 1 of the facility. Visitor stated they did not know this staff person. Visitor stated they called the facility the following day and spoke with the director of nursing (DON) to make sure someone reported the resident being outside. Visitor stated the DON said they would investigate.Surveyor spoke with the local police department's communications manager on 02/05/26 at 8:30 am regarding the 911 call. Communications manager stated they have no documentation related to a 911 call, and stated, I guess because they answered the phone and we didn't send anybody out, we didn't log the call. Surveyor asked communications manager if they have a transcript of 911 calls received, and communications manager stated that information would have the be requested via Freedom of Information Act. Surveyor spoke with the executive director (ED) and DON regarding the allegation of Resident #1 having been found outside on 02/05/26 at 10:15 am. ED stated that no one called them or the DON regarding Resident #1 having been found outside of the facility. When surveyor informed ED that a visitor had found the resident outside and asked his name, ED stated that Resident #1 is non-verbal. Surveyor informed ED they had asked Resident #1 his name, and he stated his name. Surveyor informed ED and DON that they had spoken with the visitor that allegedly found the resident outside, and that visitor stated they had talked with the DON, DON stated, that was the call I got on 01/30/26. The person that called said the resident's name was . (similar sounding name as Resident #1), and I told them we don't have a resident by that name. DON stated they did an investigation related to the call they had received but could not determine whether any resident had been found outside. Surveyor requested and was provided with a facility policy titled Abuse, Neglect, and Exploitation which read in part, Neglect is the intentional carelessness, negligence, or disregard of policy, or care, that causes or could reasonably be expected to cause pain, injury, or death.Examples of neglect include, but are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Failure to report observed or suspected abuse, neglect or misappropriation of resident property or property. Failure to adequately supervise a resident known to wander from the facility without staff knowledge.V. Reporting of Incident and Facility Response. 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause this allegation involve or result in serious bodily injury a. If the events that cause the allegations do not result in serious bodily injury, reporting to the administrator (Executive Director) and to other reporting regulatory bodies must occur within twenty-four (24) hours.VII. Reporting and Response. VIRGINIA i. Within 24 hours of learning of an incident the facility must report it to the OLC (Office of Licensure and Certification) unless the incident is an allegation of abuse or involves serious bodily injury and then the facility must report to the OLC within 2 hours.The concern of not reporting an allegation of neglect was discussed with the ED and DON on 02/05/26 at 1:00 pm.No further information was provided prior to exit.

Based on visitor interview, staff interview, clinical record review and facility document review the facility staff failed to complete a thorough investigation of allegation of neglect for 1 of 3 residents, Resident #1.The findings included:Resident #1's clinical record listed diagnoses which included but not limited to vascular dementia and diabetes mellitus.Resident #1's most recent minimum data set with an assessment reference date of 01/29/26 assigned the resident a brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident is severely cognitively impaired. Section B, Hearing, Speech, and Vision, coded the resident as having clear speech. Section P, alarms and restraints, coded the resident as using a wander/elopement alarm daily. Resident #1's comprehensive care plan was reviewed and contained a plan for . wanders aimlessly from place to place and is an elopement risk. Interventions for this care plan include notify staff of wandering and elopement risk and wanderguard in place to right ankle.Resident #1's physician's order summary was reviewed and contained an order which read in part, Place wanderguard bracelet on the RIGHT wrist if appropriate .Check wanderguard placement every shift, Check wanderguard function daily every night shift for Wanderguard function, Check wanderguard function daily one time a day for Wanderguard function and Check Wanderguard function every shift every day shift for elopement.Resident #1's electronic treatment administration records for the month of January 2026 were reviewed and contained entries as above. All entries were documented as completed per the physician's orders. Surveyor observed Resident #1 on 02/04/26 at 6:45 pm. Resident was seated in the dining room alone. Surveyor asked resident his name and resident stated, . (Resident #1 first name only). Surveyor observed a wanderguard in place on resident's right wrist. Surveyor spoke with a facility visitor on 02/05/26 at 9:40 am. Visitor stated they had come to the facility on [DATE] at 6:00 pm to return laundry for a family member. Visitor stated when they arrived at the facility, the front door was locked, and no one was at the reception desk. Visitor stated they rang the doorbell, but no one came to the door. Visitor stated they could hear an alarm going off inside the facility. Visitor stated they were at the front door for about 10 minutes, when they heard someone coming around the building, so they stepped back to look, and saw a facility resident walking around from the right side of the building, dressed in pants and short sleeved shirt, no coat and was visibly cold. Visitor stated this resident had a wanderguard to right wrist. Visitor stated they asked the resident his name and he stated . (Resident #1) Visitor stated they called the facility around four times but no one answered the phone. Visitor stated they then called 911 for assistance. Visitor stated that the 911 operator called the facility twice before anyone answered. Visitor stated a female staff person came to the door, stated to the resident, how did you get out?, and took the resident back inside toward Unit 1 of the facility. Visitor stated they did not know this staff person. Visitor stated they called the facility the following day and spoke with the director of nursing (DON) to make sure someone reported the resident being outside. Visitor stated the DON said they would investigate.Surveyor spoke with the local police department's communications manager on 02/05/26 at 8:30 am regarding the 911 call. Communications manager stated they have no documentation related to a 911 call, and stated, I guess because they answered the phone and we didn't send anybody out, we didn't log the call. Surveyor asked communications manager if they have a transcript of 911 calls received, and communications manager stated that information would have the be requested via Freedom of Information Act. Surveyor spoke with certified nurse's aide (CNA) #1 on 02/05/26 at 9:30 am regarding Resident #1. Surveyor asked CNA #1 if they recalled the resident being outside on 01/29/26, and CNA #1 stated they did not.Surveyor spoke with CNA #2 on 02/05/26 at 10:00 am regarding Resident #1. Surveyor asked CNA #2 if they recalled the resident being outside on 01/29/26 and CNS #2 stated they did not. Surveyor spoke with registered nurse (RN #1) on 02/05/26 at 10:05 am regarding Resident #1. RN #1 stated they do not recall Resident #1 having been outside on 01/29/26. Surveyor spoke with the executive director (ED) and DON regarding allegation of Resident #1 having been outside on 01/29/26. ED stated that no one called them or the DON regarding Resident #1 having been found outside of the facility. When surveyor informed ED that a visitor had found the resident outside and asked his name, ED stated that Resident #1 is non-verbal. Surveyor informed ED they had asked Resident #1 his name, and he stated his name. Surveyor informed ED and DON that they had spoken with the visitor that allegedly found the resident outside, and that visitor stated they had talked with the DON, DON stated, that was the call I got on 01/30/26. The person that called said the resident's name was . (similar sounding name as Resident #1), and I told them we don't have a resident by that name. DON stated they did an investigation related to the call they had received. DON provided surveyor with witness statements from herself, RN #1, Licensed practical nurse (LPN) #2, CNA #2, CNA #3, and CNA #4. DON's witness statement was dated 01/30/26. All other witness statements were dated 01/29/26. DON also provided a Body/Skin Inspection Form for Resident #1 dated 01/30/26. Surveyor asked DON who took the statements, and DON stated the unit manager.Surveyor spoke with LPN #1, who is the unit manager, on 02/05/26 at 11:05 am regarding witness statements. Surveyor asked LPN #1 when they took the witness statements, and LPN #1 stated they took them on 01/30/26. Surveyor pointed out to LPN #1 that all statements except the DON's were dated 01/29/26. LPN #1 stated they told each witness to date the statements for the day of the incident.Surveyor spoke with CNA #3 on 02/05/26 at 11:10 am regarding Resident #1. CNA stated they do not recall resident getting out of building. Surveyor asked CNA #3 if they were asked to provide a witness statement, and CNA #3 stated, Yes, I gave a statement yesterday (02/04/26).Surveyor spoke with CNA #2 on 02/05/26 at 11:12 am regarding giving a witness statement. CNA #2 stated they were never asked to provide a witness statement.Surveyor spoke with RN #1 on 02/05/26 at 11:15 am. Surveyor asked RN #1 if they were asked to give a witness statement and when. RN #1 stated that they were asked to provide a witness statement yesterday evening (02/04/26).Surveyor unable to speak with LPN #2, CNA #1 and CNA #2 regarding witness statements.Surveyor requested and was provided with a facility policy entitled Abuse, Neglect, and Exploitation which read in part, Neglect is the intentional carelessness, negligence, or disregard of policy, or care, that causes or could reasonably be expected to cause pain, injury, or death.Examples of neglect include, but are not limited to: Failure to take precautionary measures to protect the health and safety of the resident. Failure to report observed or suspected abuse, neglect or misappropriation of resident property or property. Failure to adequately supervise a resident known to wander from the facility without staff knowledge. Investigation of Incidents. 1. In the event a situation is identified as abuse, neglect or misappropriation, an investigation by the executive leadership will immediately follow. i. Documentation of the facts and findings will be completed in each resident medical record.2. Suspected abuse. A. Neglect or Misappropriation Investigation reports will be initiated by the Director of Nursing or designee.d. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. This statement should be in writing, signed, and dated at the time it is written. f. Findings/conclusion of the investigation are then reported to the physician (with the exception of misappropriation of funds/property) and resident representative and documented on the investigation form. g. by the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state.The concern of not conducting a thorough investigation was discussed with the ED and DON on 02/05/26 at 1:00 pm.No further information was provided prior to exit.

Based on observations, staff interviews, and review of clinical records, the facility staff failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one of four residents (Resident #3) in the survey sample. The findings included:Resident #3 was initially admitted to the facility on [DATE], as a transfer from another long-term care facility. The current diagnoses included a history of a stroke, diabetes, high blood pressure, and a contracted right hand with in-hand curled fingers. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of April 25, 2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated that Resident 3's cognitive abilities for daily decision-making were intact.In section GG0130. (Self-Care), Resident #1 was coded as independent with eating, toileting, rolling in bed, and transitioning from lying to sitting in bed, requiring assistance with oral care and chair to bed transfers, dependent in the following areas: upper and lower body dressing, putting on/taking off footwear, and personal hygiene. During an interview with Resident #3 on July 24, 2025, at approximately 12:17 PM, the resident stated that his right hand was hurting because of his long fingernails. An observation was made of a right-hand splint on the over-the-bed table. The resident said he removed the splint because it was hurting. An observation of the resident's right hand revealed healed scars, dry skin, and long, rammed fingernails. The resident stated he could not remember the last time that the staff cut his fingernails. The person-centered care plan revision date was May 3, 2023, with a problem, which stated (name of the resident) has a potential for pain related to limited mobility, a contracture of the right hand requiring use of a palm guard, and deep vein thrombosis. The goal stated that the resident will not exhibit nonverbal signs and symptoms of pain (grimacing, groaning, agitation, yelling, moaning, resisting care, crying, refusal to eat), through the target date of July 24, 2025. The interventions included pain management consult, provide medication as ordered, monitor for signs and symptoms of side effects, and evaluate effectiveness of medication, Physical Therapist / Occupational Therapist to assess and treat as ordered, and a palm guard as ordered (the resident refuses to wear the palm guard at times). An interview was conducted with the Unit 2 Manager (U2M) on July 24, 2025, at approximately 4:10 PM. The U2M stated that it was care planned for the resident to be non-compliant with fingernail care, resulting in his fingernails being extremely long. The U2M could not provide documentation of instances where the resident resisted fingernail care or of education provided. On July 25, 2025, at approximately 12:15 PM, the U2M stated that Resident #3 allowed her to assess his fingernails on the evening of July 24, 2025, and they were indeed rammed. The U2M stated Resident #3 agreed to have his fingernails soaked, clipped, and filed, and to use a rolled washcloth to assist with contracture management if the splint was not tolerated. The U2M stated the resident tolerated the care well.On July 25, 2025, at approximately 2:15 PM, the above information was reviewed with the Administrator, DON, ADON, two Unit Managers, and a Corporate Consultant. They acknowledged understanding of the findings and voiced no concerns.

Based on staff interviews and review of clinical records, the facility staff failed to ensure that the written plan of care included both the most recent hospice plan of care and a description of the services for one of four residents (Resident #1) in the survey sample. The findings included: Resident #1 was initially admitted to the facility on [DATE], as a transfer from another long-term care facility under hospice care. The current diagnoses included malignant ovarian and endometrial cancer, use of a right nephrostomy tube secondary to hydronephrosis with a ureteral stricture, and bilateral lymphedema of the lower extremities. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of July 10, 2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. In section GG0130. (Self-Care), Resident #1 was coded as dependent in the following areas: oral care, toileting, upper and lower body dressing, personal hygiene, rolling in bed, and transitioning from lying to sitting in bed; she required setup assistance with eating.During an interview with Resident #1 on July 24, 2025, at approximately 10:35 AM, the resident stated that she was receiving hospice services before admission to the facility. A review of the Physician's Order Summary revealed an order dated April 14, 2025, that stated to admit to (name of the hospice agency) malignant neoplasm of the ovaries and a-fib. A review of the clinical record failed to reveal the hospice agency's plan of care; therefore, an interview was conducted with the Assistant Director of Nursing and the Unit 1 Manager on July 25, 2025, at approximately 4:10 PM. The ADON stated that if the hospice care plan was not in the clinical record, it was likely not uploaded by Medical Records, and she would ask to have it uploaded. On July 25, 2025, at approximately 1:00 PM, a hospice document dated July 25, 2025, at 12:25 PM, titled Hospice IDG Comprehensive Assessment and Care Plan Update Report, was added to the clinical record. The report revealed the benefit period was May 17, 2025, to July 15, 2025, which does not cover the current period.On July 25, 2025, at approximately 2:15 PM, the above information was reviewed with the Administrator, DON, ADON, two Unit Managers, and a Corporate Consultant. They acknowledged understanding of the findings, and the Corporate Consultant stated the requirement was that the hospice care plan be included with the facility's care. Since it wasn't, they would work on ensuring the requirement was met going forward.

Based on observations, resident interviews, staff interviews, and a review of clinical records, the facility staff failed to make reasonable efforts to honor and meet the meal choices and preferences of one of four residents (Resident #1) in the survey sample. The findings included: Resident #1 was initially admitted to the facility on [DATE], as a transfer from another long-term care facility under hospice care. The current diagnoses included malignant ovarian and endometrial cancer, use of a right nephrostomy tube secondary to hydronephrosis with a ureteral stricture, and bilateral lymphedema of the lower extremities. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of July 10, 2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. In section GG0130. (Self-Care), Resident #1 was coded as dependent in the following areas: oral care, toileting, upper and lower body dressing, personal hygiene, rolling in bed, and transitioning from lying to sitting in bed; she required setup assistance with eating. During an interview with Resident #1 on July 24, 2025, at approximately 10:35 AM, the resident stated that she was often nauseated and had vomited for five days straight because she was not consuming her preferred plant-based diet, as the facility would not provide the mostly beans, fresh vegetables, and fresh fruit diet that they had agreed upon. Resident #1 further stated that she had purchased bean burritos from a local restaurant and had them stored in her refrigerator. However, the staff threw them out because they were not permitted to store them beyond a specific date. The resident also stated that the facility's staff informed her that she was not allowed to have a personal refrigerator in her room because of the care required to maintain one. The resident's current nutritional care plan, with a revision date of April 28, 2025, had a problem which stated the resident was at risk for malnutrition secondary to a malignant neoplasm of her ovaries and endometrium, morbid obesity, and a-fib. The goal stated to provide comfort care through October 10, 2025. The interventions included identifying the resident's food and beverage preferences, monitoring her meal intake, and offering substitutions if the provided meal was declined. An interview was conducted with the Assistant Director of Nursing (ADON) on July 24, 2025, at approximately 4:10 PM. The ADON stated that the Interdisciplinary Team (IDT) was aware that the resident's preferred meal was plant-based and that her friends brought items in for her, and she purchased items to obtain the foods she desired. The ADON stated they would revisit the policy on personal refrigerators and have the Registered Dietitian revisit food preferences with the resident again. An interview was conducted with the Director of Nursing (DON) on July 25, 2025, at approximately 12:05 PM. The DON stated that the resident's person-centered care plan failed to reflect the plant-based food preferences. The DON also said that, after further review of the refrigerator policy, they learned that the resident could have a personal refrigerator. The DON further stated that the dietary department had updated the resident's plant-based diet preference and would make a greater effort to accommodate the resident's nutritional preferences. The DON stated the Registered Dietitian met with the resident on July 24, 2025, and they reviewed her dietary preferences and, in the future, will make greater efforts to meet the resident's preferences, much like providing the peanut butter and jelly sandwiches. On July 25, 2025, at approximately 2:15 PM, the above information was reviewed with the Administrator, DON, ADON, two Unit Managers, and a Corporate Consultant. They acknowledged understanding of the findings and voiced no concerns.

Based on resident interviews, staff interviews, and a review of clinical records, the facility staff failed to develop a care plan that addressed the preference for a plant-based diet for one of four residents (Resident #1) in the survey sample. The findings included: Resident #1 was initially admitted to the facility on [DATE], as a transfer from another long-term care facility under hospice care. The current diagnoses included malignant ovarian and endometrial cancer, use of a right nephrostomy tube secondary to hydronephrosis with a ureteral stricture, and bilateral lymphedema of the lower extremities. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of July 10, 2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. In section GG0130. (Self-Care), Resident #1 was coded as dependent in the following areas: oral care, toileting, upper and lower body dressing, personal hygiene, rolling in bed, and transitioning from lying to sitting in bed; she required setup assistance with eating. During an interview with Resident #1 on July 24, 2025, at approximately 10:35 AM, the resident stated that she was often nauseated and had vomited for five days straight because she was not consuming her preferred plant-based diet, as the facility would not provide the mostly beans, fresh vegetables, and fresh fruit diet that they had agreed upon. Resident #1 further stated that she had purchased bean burritos from a local restaurant and had them stored in her refrigerator. However, the staff threw them out because they were not permitted to store them beyond a specific date. The resident also stated that the facility's staff informed her that she was not allowed to have a personal refrigerator in her room because of the care required to maintain one.The resident's current nutritional care plan, with a revision date of April 28, 2025, had a problem which stated the resident was at risk for malnutrition secondary to a malignant neoplasm of her ovaries and endometrium, morbid obesity, and a-fib. The goal stated to provide comfort care through October 10, 2025. The interventions included identifying the resident's food and beverage preferences, monitoring her meal intake, and offering substitutions if the provided meal was declined.An interview was conducted with the Assistant Director of Nursing (ADON) on July 24, 2025, at approximately 4:10 PM. The ADON stated that the Interdisciplinary Team (IDT) was aware that the resident's preferred meal was plant-based and that her friends brought items in for her, and she purchased items to obtain the foods she desired. The ADON stated they would revisit the policy on personal refrigerators and have the Registered Dietitian revisit food preferences with the resident again.An interview was conducted with the Director of Nursing (DON) on July 25, 2025, at approximately 12:05 PM. The DON stated that the resident's person-centered care plan failed to reflect the plant-based food preferences. The DON also said that, after further review of the refrigerator policy, they learned that the resident could have a personal refrigerator. The DON further stated that the dietary department had updated the resident's plant-based diet preference and would make a greater effort to accommodate the resident's nutritional preferences. On July 25, 2025, at approximately 2:15 PM, the above information was reviewed with the Administrator, DON, ADON, two Unit Managers, and a Corporate Consultant. They acknowledged understanding of the findings and voiced no concerns.

Based on observations, resident interviews, staff interviews, and a review of clinical records, the facility staff failed to administer medications as ordered for one of four residents (Resident #1) in the survey sample. The findings included: Resident #1 was initially admitted to the facility on [DATE], as a transfer from another long-term care facility under hospice care. The current diagnoses included malignant ovarian and endometrial cancer, use of a right nephrostomy tube secondary to hydronephrosis with a ureteral stricture, and bilateral lymphedema of the lower extremities. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of July 10, 2025, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. In section GG0130. (Self-Care), Resident #1 was coded as dependent in the following areas: oral care, toileting, upper and lower body dressing, personal hygiene, rolling in bed, and transitioning from lying to sitting in bed; she required setup assistance with eating.On July 24, 2025, at approximately 10:35 AM, an observation was made of two white pills and one orange pill in a medication cup on the resident's over-the-bed table. At 1:50 PM, another observation was made of the medication cup containing two white pills and one orange pill still on the resident's over-the-bed table. At 1:50 PM on July 24, 2025, an interview was conducted with Resident #1 regarding the two white and one orange pill in the cup on the over-the-bed table. Resident #1 stated she was not aware that they were there, and she did not know what pills were in the cup or what time they were left there. Resident #1 stated she was not going to take the pills because she had vomited for five days straight, and she remained nauseated but was now experiencing some relief. An interview was conducted with Registered Nurse (RN) #1 on July 24, 2025, at approximately 1:57 PM. RN #1 stated she had not seen pills on the resident's over-the-bed table, and she had not left any pills on the resident's over-the-bed table. RN #1 entered the resident's room, viewed the items on the over-the-bed table, and observed the cup of three pills. RN #1 stated after a review of the medication administration record (MAR) that the pills were two Reglan tablets, five milligrams (mg) each, and one Benadryl, which were poured at 6:00 AM.The Physician's order summary revealed the following medication orders: Diphenhydramine HCl Capsule 25 mg - Administer one capsule orally every six hours for itching until July 26, 2025, as needed (PRN), for seven days for nausea and itching, with a start date of July 19, 2025. Reglan Oral Tablet ten mg - Give one tablet by mouth every six hours as needed for nausea for 14 days - Start Date: July 21, 2025.An interview was also conducted with the Unit One Manager (U1M) on July 26, 2025, at approximately 2:15 PM. The U1M stated she had rounded on Resident #1's room several times that day, and she did not see the cup of pills on the over-the-bed table. The U1M also stated that the medications should not have been left at the resident's bedside and that all medicines should be ingested in the presence of the nurse.On July 25, 2025, at approximately 2:15 PM, the above information was reviewed with the Administrator, DON, ADON, two Unit Managers, and a Corporate Consultant. They acknowledged understanding of the findings and voiced no concerns.

Based on observation, resident interview, and staff interview, the facility's staff failed to offer and provide snacks at bedtime. The findings included: There were no observations made during this survey from 9/17/24 to 9/19/24 of snacks being offered or provided to residents. During the unit council meeting held in the facility on 9/18/24 at approximately 2:30 PM, the six residents that attended complained that they do not get offered snacks and do not receive snacks on a regular basis. The residents stated that it is random and rare to receive snacks at bedtime. The residents also stated, when they do get snacks, they are full of sugar, such as fig bars and cakes. The residents further stated that they have witnessed the dietary staff bring snacks to the unit occasionally, and the nursing staff left them at the desk. The residents stated this allowed the residents who could get to the desk get a snack but the residents who could not, did not. An interview was conducted with the Dietary Manager (DM) on 9/19/24 at approximately 3:15 PM. The DM stated that he is aware snacks are a problem and is in the process of revamping the snack program where healthy options will be offered. The DM also stated that he will be working with nursing leadership to assure the facility gets back on track with passing snacks to all residents as they should. The DM stated he has provided nursing staff a guide, so they will know what snack residents can have based on their ordered diet. The facility staff was able to provide unit council minutes for 7/16/24 and 9/16/24. The facility staff provided a unit council sign in sheet dated 5/21/24 without any minutes, no meeting was held in June, sign in sheet and minutes were provided for 7/16/24, no meeting was held in August, and sign in sheet and minutes were provided for 9/16/24. On 9/19/24 at approximately 5:00 PM, the above findings were shared with the Executive Director (Administrator), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, interview, and facility documentation the facility staff failed to ensure a clean, comfortable homelike environment for the Residents on the 100's hall and any Residents that receive food from the kitchen. The findings included: For the Residents on the e100's hall and those receiving food from the kitchen the following observations were made: 9/17/24 - 9/19/24 - during the 3 days of survey flies and gnats were noted in the conference room by all surveyors, dead bugs were noted in light fixtures throughout the building. 9/17/24 at 11:55 a.m. - floors in the hallway have stains near room [ROOM NUMBER] and 111. 9/17/24 at 12:05 p.m. - room [ROOM NUMBER] A area above bed has been repaired and spackled but not painted. 9/17/24 at 12:10 p.m. - room [ROOM NUMBER] B IV pole and floor have brownish substance dried on them appears to be tube feeding. 9/17/24 at 1:30 p.m. - Shower room was cluttered with 4 shower chairs a shower stretcher a weight scale, 2 vital signs machines, an IV pole. There were dirty wet towels on the sink/vanity as well as draped across the sharps container that was mounted on the wall. A nebulizer machine that was unlabeled and undated was sitting on the vanity/sink area. There were several missing tiles on the base board and floor and the clean linen cart had no towels, wash cloths, or hospital gowns on it only a few pillowcases. On 9/18/24 at 9:00 a.m. the shower room was noted to be in the same condition with the clutter and dirty linens as well as the nebulizer and lack of linens. A review of the pest control service book revealed that between April 2024 and August 2024 the pest control company made monthly recommendations to the facility to aid in keeping pests at bay the recommendations included cleaning drains, replacing and repairing door sweeps and drywall, cleaning the kitchen shelves of food debris, and sealing up areas where mice were entering. These recommendations were made monthly and appear to continue to be an issue and have gone unaddressed. On 9/18/24 at 10:30 a.m. am interview was conducted with CNA B who stated that the shower room was not used for storage it was an actively used for showers daily. When asked what items should be on the linen cart in the shower room, she stated that there should be wash cloths, towels and hospital gowns as well as sheets on the cart. On 9/18/24 at 12:40 p.m. an interview was conducted with the DON. She was asked if the shower room appeared cluttered, she stated that it did. When asked if the nebulizer machine should be left in there, she stated that since it is not labeled she had no idea of who it belonged to but if it is not in use, it should be in the dirty utility room so that it may be sanitized. When asked if the linen cart should be filled, she stated that it should. When asked about the missing tiles she stated she was unaware they needed repair. On 9/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure a Resident's right to a dignified existence for 4 Residents (# 5, # 33, # 58 and #114) in a survey sample of 42 Residents. The findings included: 1. For Resident #5 the facility staff failed to ensure the facial hair on her chin was removed. Resident #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/27/24 coded Resident #5 as having a BIMS (Brief Interview of Mental Status) score of 5/15 indicating severe cognitive impairment. Resident #5 was coded as requiring partial or moderate assistance of 1 staff with bathing, dressing and grooming. Resident #5 had diagnoses that included but were not limited to type 2 Diabetes, COPD (Chronic Obstructive Pulmonary Disease), chronic kidney disease stage 4, hypertension, congestive heart failure, depression, cellulitis of left lower limb, and atrial fibrillation. On 9/17/24 at approximately 12:00 p.m. Resident #5 was observed sitting in bed she was dressed in a hospital gown, her hair unkempt and gray facial hair approximately 1 inch long on her chin. Resident #5 was questioned about the facial hair, and she stated that she tries to pull it out, but she can't. When asked if the CNA's shave her on bath days she stated that they did not help her with her bath, she stated that most times she just washes up. A review of the clinical record revealed that the POC (Point of Care - CNA documentation record) coded Resident #5 as, 06 - Independent Resident performs activity without assistance. On 9/17/24 at approximately 2:00 p.m. an interview was conducted with CNA B who stated that Resident #5 needed help with most things including bathing. When asked if she should be left to do her own shower or bath, she stated that it would not be safe to do so and even if it was safe she wouldn't be able to complete the task properly due to her cognitive and physical status. When asked if facial hair should be removed during bath or shower days, she stated that it should. On 9/17/24 at approximately 3:00 p.m. the DON escorted surveyor down the hall and observed Resident #5 the DON was then asked if facial hair should be removed from female Residents and she stated that it should. When asked what impact that could have on a female Resident, she stated it could make them feel bad about themselves as a woman. She stated that it is, a dignity issue. On 9/19/24 during the end of day meeting the Administrator was made aware of the concern and no further information was provided. 2. For Resident # 33 the facility staff failed to ensure the Resident was dressed in clean clothing. Resident #33 was admitted to the facility on [DATE] with diagnoses that included but were not limited to history of stroke with hemiplegia, dementia, and diabetes. Resident #33's most recent MDS with an ARD of 6/29/24 scored the Resident as having a BIMS score of 9/15 indicating severe cognitive impairment. On 9/17//24 at approximately 11:45 a.m. Resident #33 was observed sitting in the doorway of his room in his wheelchair. Resident #33 was dressed in dark pants and a white t-shirt. The pants were stained in the front and had crumbs in his lap the shirt had brownish yellow stains that appeared dry. Resident #33 was unable or unwilling to answer questions when asked by the surveyor. On 9/17/24 at 2:30 p.m. Resident #33 was still wearing the same t-shirt and pants with the stains on them. On 9/17/24 at 3:00 p.m. an interview was held with CNA C who stated that she was not assigned to Resident #33, but she agreed that his clothing was dirty and needed to be changed. She stated would get him cleaned up as his clothing did appear soiled and his face and hands could use washing. On 9/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 3. For Resident # 58 the facility staff failed to cover the foley urine drainage bag with a dignity cover. Resident #58 was admitted to the facility on [DATE] with diagnoses that included but were not limited to coronary artery disease, congestive heart failure, peripheral vascular disease, diabetes, chronic kidney disease and dementia. Resident #58's most recent MDS with an ARD of 7/25/24 scored the Resident as having a BIMS score of 5/15 indicating severe cognitive impairment. On 9/17//24 at approximately 11:25 a.m. Resident #58 was observed sitting in a wheelchair dressed appropriately however she had a foley urinary drainage bag hooked to the wheelchair that was not covered with a dignity bag. On 9/17/24 at 3:00 p.m. Resident #58 was observed again without a dignity bag covering her foley drainage bag. On 9/17/24 at approximately 4:15 p.m. an interview was conducted with CNA B who stated that foley drainage bags should be covered with a dignity bag. On the morning of 9/18/24 Resident # 58 was not in the building, and interview was conducted with the DON who stated that all Residents who have foley catheters should have them covered with a dignity bag to protect their privacy and preserve their dignity. The DON stated that CNA's are supposed to ensure the foley bag is covered. On 9/19/24 the Administrator was made aware of the findings and no further information was provided. 34894 4. For Resident # 114, the facility failed to ensure personal clothing was worn on 9/18/2024. Resident # 114 was dressed in a hospital gown. Resident # 114 was admitted to the facility in August 2024 with diagnoses that included but were not limited to:Schizophrenia, history of traumatic brain injury, Anxiety Disorder, Glaucoma, legal blindness and Chronic Embolism and Thrombosis. The most recent MDS (Minimum Data Set) was an Admission Assessment with an ARD (Assessment Reference Date) of 8/21/2024. The MDS coded Resident # 114 as having a BIMS (Brief Interview of Mental Status) score of 3/15 indicating severe cognitive impairment. Resident # 114was coded as requiring assistance of 1 staff with bathing, dressing and grooming. On 9/18/2024 at 1:15 p.m., Resident # 114 was observed wearing a hospital gown while sitting in a wheelchair at the bedside. The gown was short and exposed Resident # 114's knees. When the surveyor spoke to Resident # 114, he was observed attempting to cover himself by placing his hands on his lap and pulling the gown toward his knees. On 9/18/2024 at 3:08 p.m., Resident # 114 was observed sitting in the wheelchair in the doorway to the room and still dressed in a hospital gown. On 9/18/2024 at 4:00 p.m., Resident # 114 was observed sitting in the wheelchair in the doorway to the room and still dressed in a hospital gown. On 9/18/2024 at 4:30 p.m., Resident # 114 was observed lying in bed with a hospital gown on. Review of the Clinical Record revealed no documentation of Resident # 114 refusing to wear personal clothing on 9/18/2024 or any other day. Review of the Care Plan revealed Resident # 114 needed assistance with Activities of Daily living to include maximum assistance with dressing. There was no problem/concern listed indicating a history of refusing care or assistance. On 9/19/2024 at 9:00 a.m., a Certified Nursing Assistant (CNA)-E was observed providing morning care to Resident # 114. The Certified Nursing Assistant (CNA-E) dressed the resident in Dark blue shorts and a blue T-shirt. An interview was conducted with Certified Nursing Assistant-E who stated the expectation was for residents to be dressed in their own personal clothing every day after their baths or morning care. On 9/19/2024 at 9:30 a.m., an interview was conducted with the Director of Nursing who stated the expectation was for all residents to be dressed in their personal clothing unless they refuse. The Director of Nursing stated there was no documentation that Resident # 114 refused to be dressed in personal clothing on 9/18/2024. On 9/19/2024 at 12:15 p.m., an interview was conducted with the the Administrator who stated the expectation was for residents to be dressed in their own clothing. The Administrator stated residents should wear regular clothing just like everyone else. She stated that was a dignity issue. On 9/19/2024 at 2:45 p.m., the Administrator, Assistant Administrator, Regional Consultant and Director of Nursing were informed of the findings. No further information was provided.

Based on observation, resident interview, staff interview, and review of facility documents, the facility's staff failed to ensure residents were aware of their right to contact the Ombudsman to advocate for them and of their right to file a complaint with the state certification agency. The findings included: During the unit council meeting held in the facility on 9/18/24 at approximately 2:30 PM, zero of the six residents that attended was aware of what or who their Ombudsman was or how to contact them. Also, zero of the six residents in attendance were aware that they could make a complaint with the state agency and where they could find the information to do so. An interview was conducted with the facility's Activities Assistant (AA) on 9/18/24 at approximately 4:00 PM. When asked, Has it been your practice to assure residents know how to contact the Ombudsman and/or file a complaint with the state agency if necessary? The AA said, no. When asked, Have you ever observed the previous AD assure residents were aware of how to find this information? The AA said, no. An interview was conducted with the Admissions Coordinator (AC) on 9/18/24 at approximately 7:45 PM over the phone. The AC stated it was a collaborative effort of all facility staff and leadership to inform residents on where to find information on how to contact the Ombudsman and/or state agency. The residents who were in attendance of the unit council meeting on 9/18/24 were all shown where this information was located. The residents were thankful to know where they could find recourses to help them when they have concerns. This information was observed in the facility's lobby to the right as you walk in. It was observed in a high traffic area as it is right at the entrance to the facility. The facility's policy titled Resident's Rights, undated reads, Residents have a right to make complaints. On 9/19/24 at approximately 5:00 PM, the above findings were shared with the Executive Director (Administrator), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on resident interview, staff interview, and review of facility documents, the facility's staff failed to arrange regular unit council meetings for residents and/or family representatives. The findings included: An interview was conducted with the facility's Activities Assistant (AA) on 9/17/24 at approximately 1:30 PM. The AA stated that the Activities Director (AD) had been out on leave since January of this year, and she had been working alone in the department since then. The AA also stated that she was not officially trained to set up unit council meetings, but she has been doing the best she could. The AA stated that the Executive Director (ED) helped her with the most recent unit council meeting this month. The AA further stated that she did miss ensuring meetings were held some months this year. An interview was conducted with the ED on 9/18/24 at approximately 11:45 AM. The ED stated that the AD went out on leave in January and then resigned last month. ED also stated that the position is posted and that she has been working with the AA to assure unit council meetings are held monthly. The ED acknowledged that meetings had not been consistent. The ED was able to provide unit council minutes for 7/16/24 and 9/16/24. The ED provided a unit council sign in sheet dated 5/21/24 without any minutes, no meeting was held in June of 2024, a sign in sheet and minutes were provided for 7/16/24, no meeting was held in August of 2024, and sign in sheet and minutes were provided for 9/16/24. The facility's policy titled Resident's Rights, undated reads, Residents have a right to form or participate in a resident group to discuss issues and concerns about the facilities policies and operations such as resident council. On 9/19/24 at approximately 5:00 PM, the above findings were shared with the Executive Director (Administrator), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, staff Interview and facility documentation review, the facility staff failed to prepare and serve food in a safe and sanitary manner. The findings included: The facility staff failed to ensure the ice machine plumbing had an air gap to prevent the back flow of contaminated water, and failed to maintain a sanitary food storage and preparation area in accordance with professional standards for food service safety. On 9-17-24 at approximately 12:00 PM, the kitchen area of the facility was inspected with the dining services manager, and Regional food Services Director. In the main kitchen food preparation and cooking area a clean silverware tray was found on a rolling cart with a dish sponge on a stick commingled with the clean silverware. the sponge was wrapped in plastic wrap and when opened dead insects resembling small flies fell out, and some were still imbedded in it. On a separate cart covered in a brown liquid sticky substance, was noted bread clips, food crumbs and food debris, commingled with clean glasses which were stacked on the cart for use with the lunch meal being prepared. On a green cart with a segmented tray on top was found forks, knives, and spoons each in a segment for ease of placing on food trays. The cart was wheeled out of the dishwashing room, reportedly clean, and was observed to have approximately a quarter inch of cloudy liquid, and pieces of food debris in each of the segments. In the dry storage area, a cart containing trays full of individual small plastic cups with lids full of mandarin oranges was found which had been taken from a multiple portion large can. The cups had not been refrigerated and were reportedly for use the following day. Another rolling cart was in the dry storage area adjacent to the oranges which was wet on top, and contained a butter knife encrusted with what appeared to be peanut butter, a large carving knife with a brown dried on substance on the blade, brown and tan crumbs and food debris. In the dry storage area on and around the shelving units which held the supplies, clear hard plastic bins were found which contained single use condiment packets such as ketchup, mustard, etc. In the bins with the condiments, were bread bag ties, paper clips which were rusted, crumbs and food debris, and what appeared to be smears of open single use condiments which had spilled into the bin. On one of the shelving units was found a Styrofoam food take out box which contained a dried hamburger which was half eaten and had obviously been there for a substantial period of time as the bread and meat were hard like cardboard. Under all of the shelving units were more cracker crumbs, food debris, mouse feces, and a mouse trap which was so crusted on top that the name of the device was obstructed and could not be read. The floors were sticky throughout the kitchen and almost pulled the surveyors shoe off. In one area by the back counter a thick greasy substance was encountered on the floor which caused slipping. The large Ice machine for the kitchen and for hydration for the Residents was observed and found to have the drain pipe directly on the floor of the kitchen with mildew and a black mold like substance around the base board and floor in that area. Water damage was clearly noted to the wall behind the pipe, and the pipe end had also become encrusted with the black substance. The Dining Services Manager stated that they would begin to clean the kitchen immediately, and that he had forgotten to ask anyone to take care of the mouse trap, and stated Yes there was a problem with mice I will admit. On 9-17-24 the Regional manager and Dining Services Manager were made aware of the issues, and had no further information to provide. On 9-18-24 the Regional Director stated that a deep cleaning had begun and also stated that the Dining Services Manager had resigned. No further information was provided.

Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to coordinate mental health services for a resident with a diagnosis of depression, who was voicing feelings of increased depression for 1 of 42 residents (Resident #81), in the survey sample. The findings included: Resident #81 was originally admitted to the facility 04/15/22 and readmitted to the facility from an acute care hospital stay on 11/2/23. The current diagnoses included a depression disorder diagnosed , 10/16/2015. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #76's cognitive abilities for daily decision making were intact. In section D (Resident Mood Interview) the resident was assessed as feeling tired or having little energy 7 - 11 days, having trouble falling or staying asleep, or sleeping too much 12 -14 days and having little interest or pleasure in doing things 12 -14 days, over the 2 weeks period ending 6/19/24. On 9/17/24 during the initial tour at approximately 3:05 PM, Resident #81 was observed sitting on side of his bed. The resident stated the facility takes all his money except $40.00 each month and after he pays his cellphone bill, he has only $20.00 left to make purchases the remainder of the month. The resident also stated that he had a urologist appointment on 6/24/24 for follow-up after a surgical procedure, but because of scheduling and transportation problems he had not been seen by the surgeon. The resident concluded by stating he had been very depressed for five to six months regarding his circumstances which included residing in the facility, no means of making money, lack of family support, and to top it off the facility did not have mental health services available. The resident's Level 1 Preadmission Screening and Resident Review (PASRR) was completed by the Social Services Director (SSD) on 12/23/23 but it did not capture the admission diagnosis of depression. The current Physician's Order Summary (POS) included an order dated 11/06/2023 for Duloxetine (Cymbalta) HCl Oral Capsule Delayed Release Particles - Give 60 mg by mouth in the morning for Depression and Sertraline (Zoloft) HCl Oral Tablet 50 MG - Give 25 mg by mouth in the morning for Depression started on 6/11/2024. The chart review included two psychiatric visits: one on 10/13/22 and another on 12/16/22. The 12/16/22 psych progress note had a recommendation to increase the Zoloft from 25 mg every day to 50 mg every day, but the POS did not reflect the change or documentation that the resident did not agree to the increase in the Zoloft. The resident's person-centered care plan read (resident's name) uses anti-depressants for a diagnosis of Depression. The goal read (resident's name) will be without complications of anti-depressant medication side effect, through the target date, 12/18/24. The interventions included, encourage resident to voice feelings, and discuss coping skills and consult with pharmacy/medical provider to consider dosage reduction when clinically appropriate. An interview was conducted with the Social Services Director (SSD) on 9/19/24 at approximately 11:30 AM. The SSD stated she was not aware that Resident #81 was experiencing signs of depression but she would visit and offer him support and services of the new mental health practice which was making visits within the facility. A nurse's note dated 9/19/24 at 12:53 PM read that the resident's mood was assessed and he scored 11 on the PHQ-9. The note additionally stated that the resident had no thoughts of being better off dead or inflicting self harm. On 9/19/24 at approximately 4:30 PM, a final interview was conducted with the Administrator and three Corporate Consultants. The administrative team was informed of the above information and the Administrator stated that the SSD and the Nurse Practitioner were ensuring the resident received immediate care and scheduling mental health services. Duloxetine is used to treat depression and anxiety. Duloxetine belongs to a group of medicines known as selective serotonin and norepinephrine reuptake inhibitors (SSNRIs). These medicines are thought to work by increasing the activity of chemicals called serotonin and norepinephrine in the brain. (https://www.mayoclinic.org/drugs-supplements/duloxetine-oral-route/description/DRG-20067247) Sertraline belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs). It works by increasing the activity of a chemical called serotonin in the brain. Sertraline is used to treat depression, obsessive-compulsive disorder (OCD), panic disorder, premenstrual dysphoric disorder (PMDD), posttraumatic stress disorder (PTSD), and social anxiety disorder (SAD). Sertraline belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs). It works by increasing the activity of a chemical called serotonin in the brain. (https://www.mayoclinic.org/drugs-supplements/sertraline-oral-route/description/drg-20065940)

Based on observation, staff interviews, and review of facility documents, the facility staff failed to remove expired Covid 19 tests, an expired medication, and expired wound dressings stored in 2 of 2 medication storage rooms; failed to provide the date medications were opened and stored in 1 of 4 medication administration carts. The findings included: 1. On 9/18/24 at 3:10 PM an observation of the medication storage room on Wing 2 with LPN (D) revealed 11 boxes of BinaxNow Covid19 tests expired on 10/27/23. On 9/19/24 at 11:10 AM an interview was conducted with the Regional Nursing Consultant. The Regional Nursing Consultant stated that the BinaxNow Covid 19 tests are expired, and the facility is not able to use these tests. She also stated that these tests have been disposed of, so they are no longer able to be used. 2. On 9/18/24 at 3:48 PM an observation of the medication storage room on Wing 1 with Registered Nurse (RN) (B) revealed: in the refrigerator, there was 1 opened multi-dose vial of Insulin Lantus 100 units/ml with an open date of 7/12/24. A review of the manufacturer's literature indicated to discard the insulin multi-dose vial 28 days after opening. In the cabinet, there was 10 Collagen Wound Dressings with an expiration date of 11-2023. An interview was conducted with RN (B) on 9/18/24 at 3:55 PM. RN (B) stated that she believes the Insulin Lantus is good for 30 or 45 days after opening the vial but is not sure about this. RN (B) also stated that the 10 Collagen Wound Dressings should not be used due to the expiration date. 3. On 9/18/24 at 4:02 PM an observation of the medication administration cart on Wing 1 with Licensed Practical Nurse (LPN) (C) reveled the following medications were opened and undated: 1 bottle of 81 mg Aspirin, 1 bottle of Vitamin D 10 mcg, and 1 bottle of Osmotic Laxative. An interview was conducted with LPN (C) on 9/18/24 at 4:10 PM. LPN (C) stated that per training/competency, every nurse should put the date of opening on medications. The facility's Storage of Medications policy with an effective date of 09-2018 read: All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. On 9/19/24 at approximately 4:15 p.m., a final interview was conducted with the Administrator, Assistant Administrator, Regional Director of Operations, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident interview, staff interview, and review of facility documents, the facility's staff failed to ensure residents packages were received unopened. The findings included: During the unit council meeting held in the facility on 9/18/24 at approximately 2:30 PM, three of the six residents that attended complained that their packages are always opened when received. These residents said that their mail is received unopened, but packages were always opened. The residents were frustrated and said it was an invasion of their privacy. An interview was conducted with the facility's Executive Director (ED) on 9/18/24 at approximately 4:15 PM. The ED stated that residents should received their mail and packages unopened and that she was unaware that resident's packages have been received open. The facility's policy titled Resident's Rights, undated reads, Residents have a right to have privacy in sending and receiving mail. On 9/19/24 at approximately 5:00 PM, the above findings were shared with the Executive Director (Administrator), Director of Nursing, Assistant Director of Nursing, Regional Minimum Data Set Coordinator, and Regional Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program so that the facility is free of pests and rodents. The findings included For the facility, the facility staff failed to follow the pest control company recommendations for reducing / eliminating pests from the facility. On 9/17/24 during the initial tour of the kitchen Surveyor C noted mouse droppings in the dry storage area, small flies in a dish washing sponge placed in a tray with Clean silverware 9/17/24 - 9/19/24 - during the 3 days of survey flies and gnats were noted in the conference room by all surveyors, dead bugs were noted in light fixtures throughout the building, and gnats and flies noted throughout the building in various Resident rooms. A review of the pest control book revealed the following excerpts from the service receipts: 4/19/24: Finding: Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door in 100 wing facing sheds is rusted and potentially needs to be replaced. Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door facing auxiliary parking lot is rusted and potentially needs to be replaced. Action Needed: Install / replace door sweeps. Exclusion measures here will reduce the number of pests entering the facility. 5/10/24:Finding: Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door in 100 wing facing sheds is rusted and potentially needs to be replaced. Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door facing auxiliary parking lot is rusted and potentially needs to be replaced. Action Needed: Install / replace door sweeps. Exclusion measures here will reduce the number of pests entering the facility. 6/13/24 Findings -Kitchen - Mice noted during service 1 mouse captured in kitchen additional traps laid and discussed plan of action with Director of Maintenance. Action Needed - Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door in 100 wing facing sheds is rusted and potentially needs to be replaced. Exit door doesn't close /seal properly 1/4 inch or greater gap exists. Fire door facing auxiliary parking lot is rusted and potentially needs to be replaced. Action Needed: Install / replace door sweeps. Exclusion measures here will reduce the number of pests entering the facility. 7/26/24 - Finding: Floor drains need cleaning. Floor drains throughout kitchen need thorough cleaning. Food debris found. Lots of food build up in kitchen under shelving. Action needed: Please clean in and around drains frequently to help prevent pest breeding sites. Please clean regularly. [under shelving] 8/30/24 Finding: Small flies noted during service fruit flies in kitchen. Drywall over baseboards I kitchen are rotten Excess water noted standing on ground beneath sink in kitchen. Action Needed: Please address structural concern. [drywall] Keep areas dry [under sink] This area was inspected and serviced. On the afternoon of 9/19/24 observations of the kitchen revealed that the drywall over the kitchen baseboards had not been repaired or replaced, the exit doors still had gaps where the door sweeps needed replacing, and the floor drains continued to need cleaning, fruit flies were noted in the kitchen. On 9/19/24 at approximately 2:00 p.m. an interview was conducted with the Maintenance Director who stated that he had fixed the doors, but the wheelchairs keep hitting them and knocking off the door sweeps. When asked if the other repairs and recommendations by the pest control company had been completed, he stated that he was not aware that repairs were needed. On 9/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, resident interviews, staff interviews, and review of the clinical record, the facility staff failed to provide appropriate care and services to manage indwelling catheters for 2 of 42 residents (Resident #67 and 81), in the survey sample. The findings included: 1. The facility staff failed to ensure that Resident # 67's indwelling catheter was anchored to prevent dislodgement and or trauma. Resident #67 was originally admitted to the facility 2/4/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included quadriplegia, stage 4 pressure ulcers of the left groin and right gluteal fold and an obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #67's cognitive abilities for daily decision making were intact. The resident's active Physician Order Summary (POS) included the following orders dated 7/4/24. Foley catheter 18 french with a 10 milliliters balloon to continuous drainage for a diagnosis of obstructive uropathy. Provide a privacy bag and secure the indwelling catheter's tubing using an anchoring device to prevent movement and urethral traction. The resident's person-centered care plan revised on 1/25/24 read (resident's name) has a #18 indwelling catheter related to a diagnosis of obstructive uropathy. The goal read (resident's name) will be/remain free from catheter-related trauma through review date, 11/04/2024. The interventions included, ensure the stat lock is in place to anchor the Foley tubing. Foley catheter -18 french with a 10 milliliters balloon. Position catheter bag and tubing below the level of the bladder and provide privacy bag. Secure catheter to the leg with security device. On 9/18/24 at 11:26 AM an observation was made of wound care for Resident #67 with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #E. The resident's indwelling catheter was observed dangling enough to cause penile trauma for it was not anchored. Neither nurse appeared to recognize the catheter tubing was not anchored and secured the catheter prior to leaving the resident. On 9/19/24 at approximately 10:45 AM another observation was made of Resident #81's catheter tubing with the ADON and LPN #E. Both nurses stated after viewing the resident's indwelling catheter that it was unsecured. The ADON stated she was not aware of the resident ever declining to have the catheter tubing anchored. An interview was conducted with Resident #67 on 9/19/24 at 11:29 AM. Resident #67 stated he was unaware that the catheter tubing was not anchored and that he had not declined to allow staff to anchor the catheter tubing. 2. The facility staff failed to schedule and ensure that Resident #81 was transported to a follow-up urology appointment regarding his indwelling catheter. Resident #81 was originally admitted to the facility 04/15/22 and readmitted to the facility from an acute care hospital stay on 11/2/23. The current diagnoses included and obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #81's cognitive abilities for daily decision making were intact. In section H (Appliances) the resident was coded as requiring use of an indwelling catheter. The resident's active Physician Order Summary (POS) included the following orders dated 6/2/24. Foley catheter - 18 french with a 10 milliliters balloon to continuous drain for a diagnosis of obstructive uropathy. Provide a privacy bag. The current care plan dated 6/23/24 had a problem which read (name of the resident) has an indwelling catheter related to obstructive uropathy. The goal read the resident will show no signs or symptoms of a urinary tract infection through the next review, 12/18/24. The interventions included the resident has a 18 French Foley. Position catheter bag and tubing below the level of the bladder and provide privacy bag. Secure catheter to the leg with security device. On 9/17/24 during the initial tour at approximately 3:05 PM, Resident #81 was observed sitting on the side of his bed with an indwelling catheter attached. The resident stated that he had a urologist appointment on 6/24/24 for follow-up after a surgical procedure, but because of scheduling and transportation problems he had not been seen by the surgeon. The resident stated the first time the urology appointment was scheduled the transportation company dropped him off at the hospital which required him to attempt to get to the physician's office alone, although the office was on the grounds with the hospital. The resident further stated before he reached the urologist office the transportation company picked him up and transported him back to the facility. The resident stated eight more appointments were scheduled with the urologist and he had yet to be seen by the urologist. An interview was conducted with the scheduling coordinator on 9/19/24 at approximately 1:10 PM. The scheduling Coordinator stated she just scheduled the rides, she does not keep details of the appointments but the nurses do. An interview was also conducted with the ADON on 9/19/24 at approximately 2:00 PM. The ADON stated that Resident #81 did not miss eight appointments but staff did drop the ball regarding Resident #81's urology appointment, which was originally scheduled for 6/24/24. The ADON stated she contacted the urologist office on 9/19/24, scheduled an appointment for 10/3/24 at 2:30 PM and confirmed that she would ensure that the Resident was transported and seen for the newly scheduled visit. On 9/19/24 at approximately 4:30 PM, a final interview was conducted with the Administrator and three Corporate Consultants. The administrative team was informed of the above findings. The Regional [NAME] President of Operations stated they were aware and plans Resident #67's catheter had been secured and another appointment had been scheduled for Resident #81 to be seen by the urologist.

Based on observation, Resident interview, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 3 Residents(Residents #92, #104, & #84) in a sample of 42 residents. The Findings included: 1. Resident #92 was admitted on [DATE] with diagnoses including: Major depressive disorder with psychotic symptoms, anxiety disorder, and avoidant restrictive food intake disorder. Physicians orders for medications were reviewed and revealed several psychotropic medications actively being administered for agitation, frustration, yelling and ongoing behavior monitoring. Those medications are listed as follows; Trazadone/Desyrel - for depression Mirtazipine/Remeron - for clinical depression Buspar/buspirone - for depression Duloxetine/cymbalta - for major depressive/anxiety disorder It is notable to mention that Trazodone, Duloxetine, and Buspar are not recommended to be administered together as combined they may cause Serotonin Syndrome which can be life threatening and may show early symptoms of anxiety, restlessness, disorientation, and delirium according to the National Institutes of Health (NIH). On 9-17-24, an observation was conducted of Resident #92. The Resident was moving quickly around his room and refused to respond to the surveyor who had entered the room and addressed him in a greeting while attempting conversation and interview. The Resident was talking to himself with questions and answers to an apparent inner monolog with himself. On 9-18-24 a review of Resident #92's clinical record was conducted. No previous to admission PASARR (preadmission screening & resident review) for mental illness or intellectual disability was found in the Electronic Health Record (EHR). The only PASARR found was dated 12-13-23, 8 months after admission on 4-5-23. Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed prior to that date. On 9-18-24, an interview was conducted with the Director of Nursing (DON), and the Administrator who stated that this error would be corrected in the future. The Administrator and Director of Nursing were informed of the findings again at the end of day meeting on 9-18-24. The Administrator stated, we will correct this immediately and indicated they would be auditing residents' PASARR's. No further documents were provided. 2. For Resident #104, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission. Resident #104 was admitted on [DATE] with diagnoses including: Depression, and dementia with agitation. Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for pacing, refusal of care, yelling and ongoing behavior monitoring. Those medications are listed as follows; Citalopram/Celexa - for major depressive disorder. Divalproex/Valproate - for seizures and bipolar disorder. It is notable to mention that using Celexa and Divalproex together can cause seizures, and or hyponatremia (low blood sodium) which can also lead to dehydration when administered together according to the National Institutes of Health (NIH). On 9-17-24, an observation was conducted of Resident #104. The Resident was moving quickly around her room talking to family and her spouse in erratic jerking motions. The Resident was notably frail, under weight, and had poor skin turgor. Her daughter was in the room at the time and an interview was conducted with the family. The Resident was intent on caring for her husband and did not respond to the surveyor who had entered the room and addressed them in a greeting. The Resident appeared confused and responded to her daughter in a word salad response which was indiscernible. On 9-18-24 a review of Resident #104's clinical record was conducted. No previous to admission PASARR (preadmission screening & resident review) for mental illness or intellectual disability was found in the Electronic Health Record (EHR). The only PASARR found was dated 9-17-24, the day survey began. Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed prior to that date. On 9-18-24, an interview was conducted with the Director of Nursing (DON), and the Administrator who stated that this error would be corrected in the future. The Administrator and Director of Nursing were informed of the findings again at the end of day meeting on 9-18-24. The Administrator stated, we will correct this immediately and indicated they would be auditing residents' PASARR's. No further documents were provided. 40026 3. For Resident #84 the facility staff failed to obtain a PASARR (Preadmission Screening and Resident Review) prior to admission on 3/18/24. Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to gastrostomy tube, epilepsy, history of venous thrombosis and embolism, dvt/pulmonary embolism, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, aphasia (inability to speak) following cerebrovascular disease, and depression. Resident #84's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/21/24 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 99 - unable to evaluate as Resident is nonverbal. On the afternoon of 9/17/24 during clinical record review it was discovered that Resident #84 did not have a PASARR level 1 completed prior to admission to the facility from the acute care hospital. On 9/18/24 at approximately 1:00 p. m. an interview was conducted with the Social Worker who stated that she has been catching up the ones that have not been done prior to admission. She stated that she was aware that they should be done prior to admission and when they were not done prior, she would do them once they were admitted to the facility. According to the clinical record Resident #84 was admitted to the facility on [DATE] and the PASSAR was completed on the evening of 9/17/24 and uploaded into the clinical record On 9/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on review of the resident record, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharges for 1 of 42 residents (Resident #67), in the survey. The findings included: Resident #67 was originally admitted to the facility 2/4/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included quadriplegia, stage 4 pressure ulcers of the left groin and right gluteal fold and an obstructive uropathy. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #67's cognitive abilities for daily decision making were intact. A Nurse Practitioner's note dated 11/8/23 read that Resident #67 was observed unresponsive by a Certified Nursing Assistant (CNA). The note further read that the resident was observed lying in bed with a blank stare but he would track with his eyes when his name was called and the resident's temperature was 101.4 (forehead). The resident was transferred to a local hospital on 11/8/23 and admitted for seizure activity and sepsis. A nurse's note dated 03/13/24 read that Resident #67 was transferred to a local hospital after he was observed having seizure like activity, staring, drooling, and with confusion. The nurse's note further revealed the following abnormal vital signs; blood pressure 92/55, heart rate 122, and a temperature of 102.7. The resident was admitted to the hospital 3/13/24 for a urinary tract infection and seizure activity. An interview was conducted with the Social Services Director (SSD) on 9/19/24 at approximately 11:30 AM. The SSD provided me with documentation that the Ombudsman was notified of Resident #67's 6/13/24 discharge and stated that she was giving me all that was available. The documents she provided did not include information that the Ombudsman was notified of Resident #67's discharges to the hospital on 11/8/23 and 3/13/24. On 9/19/24 at approximately 4:30 PM, a final interview was conducted with the Administrator and three Corporate Consultants. The administrative team was informed of the missing Ombudsman notifications for Resident #67's discharges and an opportunity was offered to the facility's staff to present additional information. The Regional [NAME] President of Operations stated the SSD had provided all the information they had available to them.

Based on observation, staff interview, resident interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure 3 residents were free from abuse and/or neglect (Residents #37 and 93, who was abused by Resident #43) in a survey sample of 42 residents. This resulted in harm for Resident #37. The findings included: 1. For Resident #37, the facility staff neglected to provide goods and services to prevent continuing significant weight loss, resulting in severe malnutrition, and an unstageable pressure sore not identified by staff until the wound was first identified with eschar, and unstageable, all resulting in harm. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, [MEDICAL CONDITION], arthritis, [MEDICAL CONDITION] moderate, high cholesterol, [MEDICAL CONDITIONS], and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card. On 9-15-19 at 12:00 noon, observations and interviews were conducted with the Resident. After introduction, the Resident was asked if we could help him with anything while we were there, and he complained of hunger, and stated he wanted something to eat. He stated his family brought him things and he enjoyed that food. The lunch meal tray did not arrive at the bedside until 12:45 p.m., and at 2:30 p.m., no staff had entered the room to assist the Resident to eat. Surveyor A, and this surveyor looked at the tray which was uncovered, and untouched. We then went to the nursing station to enquire as to how long it would be for the Resident to be fed. The staff stated they were very understaffed, and were unable to use the dining room, and had to close it as they were unable to staff it, so the feeders who would normally be fed there had to be fed in their rooms. They stated that Resident #37 was a self feeder, and independent. At 2:30 p.m., the Resident was again observed and was sitting in bed falling over onto his left side with a small Styrofoam or paper cup containing magic cup supplement, which was an ice cream like substance in his hand. The Resident was licking the inside of the cup to obtain the contents, and the surveyor asked him if he was able to hold the spoon that was on his tray, and he stated not too good, I am so weak now, I just don't have the strength. The Resident picked up the spoon and tried to use it, however, the small amount he was able to get onto the spoon after much effort, fell down onto the bed linens. The rest of the tray was untouched, and no 2 cal supplement was on the tray. At 2:45 p.m., the HR (human resources) Director entered the Resident room to feed him. The surveyors returned at 3:30 pm to find the tray had been left there and the thick pudding consistency portions of food had approximately 2 spoonfuls missing from 2 of the 3 scoops of pureed food. Each of the scoops measured approximately 3 inches by 3 inches circular, and 1/2 inch depth, and had spread out into each other on the plate. The Resident stated I can't eat that stuff, it's awful like cold wet bread. He went on to say I told them when I got here that I can't eat that stuff, and I don't have any trouble eating if I like the food, but they don't listen. On 9-16-19 at 10:00 a.m., another observation was conducted for this Resident by Surveyor C. Surveyor C reported that for the breakfast meal the tray was followed and went into the Resident's room, left uncovered, and removed from the room untouched and returned to the kitchen. On 9-16-19 at 3:00 p.m., the Resident's lunch meal tray was again left untouched, and the Resident was not fed. No supplement was in the room for either meal The ADL (activities of daily living) report was requested and received. The report documented that the Resident was independent with eating for breakfast and lunch every day in September, for 20 of the 32 breakfast and lunch meal opportunities. The 12 meal exceptions where the staff assisted the Resident occurred on the following days; 9-1-19 dependant (fed) for both meals, and consumed nothing for breakfast and 51-75% for lunch. 9-5-19 dependant (fed) for both meals, and consumed 51-75% for both meals. 9-7-19 limited assistance (not fed) for both meals, and consumed nothing for both meals. 9-8-19 limited assistance (not fed) for breakfast, and consumed 26-50%. 9-10-19 limited assistance (not fed) for lunch, and consumed nothing. The behavior portion of the ADL record was also reviewed and revealed at no time did the Resident refuse assistance or care. The other 20 opportunities for staff support with feeding, and the Resident was not fed, occurred on the following days; 9-2-19 The Resident consumed 51-75% both meals 9-3-19 The Resident consumed 26-50% both meals 9-4-19 The Resident consumed 26-50% both meals 9-6-19 The Resident consumed 26-50% at breakfast, and 76-100% at lunch 9-8-19 The Resident consumed 26-50% at lunch 9-9-19 The Resident consumed 76-100% both meals 9-10-19 The Resident consumed nothing for breakfast 9-11-19 The Resident consumed nothing for breakfast, and 76-100% at lunch 9-12-19 The Resident consumed nothing both meals 9-13-19 The Resident consumed 26-50% both meals 9-14-19 The Resident consumed 26-50% breakfast, and 75-100% at lunch 9-15-19 The Resident consumed nothing both meals 9-16-19 The Resident consumed 26-50% for breakfast, nothing for lunch It is notable to mention that on 9-16-19 the Resident's breakfast tray was followed by Surveyor C from delivery by CNA N, to discard, and it was not disturbed, nor did the Resident attempt to consume it. No staff member attempted to assist with the meal, and the tray was simply removed from the room, untouched, and discarded. CNA O documented 26-50% consumed. CNA N (certified nursing assistant) was interviewed, and stated he ate a little of his sherbet cup so I said he ate 25%, however, CNA N did not sign the ADL document, another staff member, CNA O was documented as having fed Resident #37 his breakfast. CNA N was asked if she fed the Resident, and she stated no he can feed himself. CNA N was asked if she had been trained on how to calculate the amount of a meal that a resident consumes, and she stated no. CNA O stated that she only removed the tray, and did not feed the Resident. During this 16 day period from 9-1-19 through 9-16-19, nine different staff members signed the meal consumption record, only 3 of which delivered the meal to the Resident consistently more than one day in the 16 days. The Resident's weight record was requested and revealed that from 7-3-19 until the time of survey on 9-16-19, the Resident had lost 23.4 pounds of weight in less than 12 weeks. Those weights follow: 4-15-19 - On admit 122.4 lbs (pounds) 4-23-19 - 119.2 5-1-19 - 115.2 - weight loss of 7 pounds after admission for 2 weeks. 5-22-19 - 120.2 - weight gain of 5 pounds and stabilizes after 3 more weeks. 6-25-19 - diet modified to ground texture begun, and significant weight loss begins. 6-26-19 - 119.0 7-3-19 - 119.0 7-24-19 - 117.0 7-31-19 - 117.0 8-26-19 - 108.0 9-1-19 - 103.0 9-9-19 - 101.8 9-11-19 - diet modified to pureed texture begun after significant weight loss of 17.2 pounds from 7-3-19 to 9-9-19. 9-16-19 - 95.6 - significant weight loss increased in less than 12 weeks to 23.4 pounds, equaling 20% of the Resident's entire body weight, and 26.8 pounds, since admission. On 9-16-19 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), and Unit manager RN (registered nurse) D, by surveyors in the conference room. They stated that they were talking to the family, and there were lots of family dynamics, .we want to have a care plan meeting with him and his family, wife, son or brother, that is our next step with him I am aware he is loosing weight. They were asked why it had taken 5 months to get a plan going, and they stated At first his family was bringing in food that he was eating, he doesn't like the pureed texture or the nectar thick liquids. Therapy had been working with him, and he had a FEES study on 9-10-19 that he failed. We have talked with his wife, and his son and brother. He has biological children, a wife and a stepson. He had to go to the hospital for a blood transfusion, and at the hospital his wife refused it. He is his own RP (responsible party). The hospital sent him back to us, and his biological children were upset . Our social worker (name) Employee O was working with him, and his son and daughter got involved and we sent him back, to the hospital, the spouse didn't have his best interest. They were asked why the physician had not talked with the Resident himself and decide a course of action? They stated We discussed the doctor talking to him (the Resident), and we didn't have a social worker as Employee O has been gone about a month and a half ago, and he has lost weight since that. The DON stated I see we need to make a decision and talk to him to see if he wants a peg tube because he doesn't like the pureed texture to maintain his BMI (Body Mass Index). The DON and unit manager continued with, Speech therapy did a swallowing eval, and he didn't do well. They were asked when that occurred as no therapy notes were found in the clinical record. She stated, I don't know, I will get those for you. The family brings in McDonalds, and that he eats. She was asked if he had ever aspirated or been hospitalized , or treated for [REDACTED]. They were asked why the Resident was not being fed by staff who thought he was independent, when his MDS showed he needed extensive assistance from staff to eat since the 7-12-19 MDS which included a seven day look back to 7-5-19. They responded He should be fed. On 9-16-19 at 3:15 p.m., Employee E, the speech language pathologist (ST/SLP) entered the interview in progress in the conference room with surveyors, and with the unit manager and DON. She stated he was on ground meat with pureed solids and the Resident didn't like it so the family requested an upgrade so he would eat, and then the FEES study was ordered on 9-10-19. I asked if there was no problem, or outcome with the regular diet that the family brought in that the Resident did eat, why the change. She stated he needs positioning and encouragement to not aspirate, he is at risk for silent aspiration. She continued he wasn't really eating the ground texture, or anything off of the pureed tray but pudding, oatmeal, and cream of wheat, and that's why the FEES study was done. A bedside swallowing evaluation was done by another speech therapist who was full time here. I am not typically treating most of the time. Her last day was weeks ago, I don't remember how many, we have a new one starting today. Between the last one and this one we have had PRN (as needed) staff and I have been helping treat as well. She was asked if she had assessed or treated Resident #37, and she stated no. The ST notes were again requested. The FEES (Dysphagia systems test) study was requested at 3:15 p.m., during the interview with Employee E, and received at 4:00 p.m. The study documented no diagnoses linked to dysphagia, and documented that the Resident took his medications whole. The document describes the Potential risks to the Resident, and documents that the Resident is at Potential risk for aspiration. Any and all ST notes from Resident #37's time of admission to today were requested again. On 9-16-19 at 4:00 p.m., the Registered Dietician (RD), and Assistant Director of Nursing (ADON) were interviewed by surveyors in the conference room. The current RD stated there had been a lot of turnover in the department and there had been one RD from (MONTH) to may 2019, and then travel and consultant RD's had come in as needed until mid (MONTH) 2019 during his significant weight loss, and she herself (employee G) started work in the facility in mid august, and had been there just under a month. Physician's progress notes were reviewed and indicated no weights on the assessments conducted by the physicians. The area in the form for weight were all left blank. There is no indication that the physician's were aware of the significant weight loss from 6-25-10 to 8-29-19. A review of the physician's orders [REDACTED]. They revealed the following timeline of interventions; 4-15-19 - admission regular diet with thin liquids. - weight 122.4. 4-16-19 - ST, TO (occupational therapy), PT (physical therapy) all evaluate and treat as necessary order entered. 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 6-25-19 - Weight 119.0, which had rebounded from initial admission loss, proving the Resident had no difficulty gaining weight back (for the 2 months and 10 days since admission) while eating a regular diet, and taking a small amount of supplement. During this time there were no problems associated with aspiration. 6-25-19 The diet change to dysphagia ground diet with thin liquids, which the Resident did not like. No other interventions occurred to prevent significant weight loss from 5-2-19 until 8-28-19 when the new RD arrived, and the significant weight loss had already occurred. - weight 108.0 (14.4 pound (10%) weight loss since admission, and an 11 pound weight loss in 2 months.) 7-25-19 through 7-29-19 the Resident had symptoms of illness, and had laboratory blood tests drawn. As a result of those tests it was revealed that the Resident had become dehydrated. Resident #37 then was ordered to receive IV (intravenous) normal saline fluids for dehydration. The infusion was started initially through a peripheral IV in his left wrist, however, the IV was not positioned well and had to be removed, and the staff was unable to replace it, so a specialist nurse was brought in to insert a mid line PICC (peripherally inserted central line catheter) to infuse the fluids. 7-26-19 - physician's orders [REDACTED]. Resident recently ended PT, TO, and ST services. Will continue to monitor for further decline and have therapy screen as needed. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-2-19 - Resident found to have a pressure ulcer to his right lateral ankle directly over the bone, and it was first identified with eschar (Black,dead, necrotic, hard tissue) covering the entire cap over the ankle bone. - weight 103.0. 9-3-19 - Resident lab test resulted for pre-[MEDICATION NAME] (measures recent dietary intake). Pro-stat protein supplement for wound healing was ordered. 9-9-19 - FEES study (Dysphagia systems test) completed. - weight 101.8. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. 9-16-19 - at the time of survey weight was - 95.6. On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. He stated We had speech look at the patient, and they said he isn't able to eat regular food. The family said no to a PEG (Per Endoscopic Gastrostomy) tube, there is nothing else to do. The doctor was asked why was speech therapy was consulted, if the Resident had no signs of aspiration, was not hospitalized or ever suffered from any respiratory illness associated with aspiration, and had been here in the facility for 5 months. He stated that the family was concerned. The doctor was asked why the family was allowed to make decisions for the Resident when the staff made surveyors aware that the family did not have the Resident's best interest at heart. Further, for a Resident, who was alert and oriented, could make his needs known, and was his own Responsible Party (RP). The Resident had not been deemed incompetent, and had the right to make his own decisions. The doctor responded I was not aware of that, and if we let him eat whatever he wants, that's how we get sued. The doctor was then asked why the wound on the Resident's ankle was being called a Vascular ulcer, and he stated it's a pressure sore, and most likely the result of the patient's severe malnutrition. He was asked if he was aware that the RD, ST, and social worker had all been multiple different people (on an as needed basis) with no regular consistency, from (MONTH) through (MONTH) in the facility, and that the social worker had been gone for 6 weeks, and a new one was starting that day. He stated no. On 9-17-19 at 5:00 p.m., a Summary Report of Meeting document for the last 2 days of staff huddle meetings was presented to surveyors by the DON. The document described the subject of the meetings to be in regard to Passing trays at meal times, assisting feeders, documenting on amounts eaten. and was signed by those in attendance. This was evidence of training begun by the facility to rectify deficient practice in the meal delivery and assistance system. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the weight loss and pressure sore. There were no interventions for hydration, and it was simply placed in with the nutrition (weight loss) hydration plan below; (Weight loss) F[NAME]US: (name) Resident #37 has the potential for nutrition/hydration imbalance related to hypertension, [MEDICAL CONDITIONS], history of [MEDICAL CONDITION], [DIAGNOSES REDACTED]. initiated on 4-19-19, revised on 5-5-19, 6-25-19, and 9-13-19. GOAL: Resident will remain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through review date. INTERVENTIONS: (all created and initiated on 4-19-19 immediately after admission) Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered, honoring resident preferences. Monitor intake and record every meal. RD to monitor and follow up per protocol. Weigh per facility protocol. (initiated 6-25-19) No hot liquids for safety. No changes were made to any interventions after the Resident suffered a significant weight loss. The significant weight loss was not care planned, none of the interventions that were initiated for the weight loss were care planned, none of the supplements were care planned, none of the diet changes were care planned, and the need of the Resident to be fed by extensive assistance of staff was not care planned. Most goals are not measurable, and the Residents preferences were not honored. (Pressure sore) F[NAME]US: (name) Resident #37's pressure ulcer was documented on the care plan on 9-2-19 when the ulcer was identified as a pressure ulcer to right outer heel related to decreased mobility and altered nutrition. On 9-4-19 it was changed to vascular ulcer to the right outer heel. On 9-12-19 it was changed again to vascular ulcer right outer ankle. GOAL: Wound will be free from infection through review date. INTERVENTIONS: (all created and initiated on 9-2-19 at identification) Air mattress. Heel lift boots as tolerated. Resident/family education as needed. (initiated 9-12-19) Supplements as ordered for wound healing (10 days after identification). There was no Hydration care plan initiated, even after the Resident suffered from dehydration requiring IV fluid infusions on 7-25-19. The doctor, and nursing staff identified the wound as a pressure ulcer. None of the supplements for healing are care planned, the heel lift boots application is not measurable and has no guidance for use. No interventions for wound development prevention were present prior to the development of an unstageable pressure ulcer found with eschar upon identification, and likely caused by the Resident's malnutrition, as stated, and diagnosed by the doctor. A wound Observation was conducted on 9-17-19 at 9:30 a.m. with LPN H. The Resident was alert and oriented to person, place, time, and situation. Both legs and the right ankle were exposed, as the Resident was laying partially on his left side, revealing cool, smooth leg skin, with no [MEDICAL CONDITION], scars, scratches, scales nor brawny appearance. There was hair on both legs, no [MEDICAL CONDITION], or [DIAGNOSES REDACTED] in either extremity, and the Resident had palpable popliteal (behind the knee), dorsalis pedis (top of foot), and tibial (behind the ankle bone) pulses. The Resident had a brisk capillary refill when the toe nails were depressed, and at less that 1 second blood return. The Resident had no wounds on his heels or shins, and exhibited only 1 wound which was directly on top of the right lateral ankle bone (lateral malleolus). The depth of the pressure ulcer could not be ascertained as the wound was covered by black dead thick necrotic tissue with only the outer circumference beefy red, as the de-vitalized tissue was shrinking leaving an open thin boarder around the circular necrotic wound. There was no slough visible, and no drainage, nor odor to indicate infection. The wound was clean and had a minuscule amount of serosanguineous clear drainage making the edges around the wound shiny. The wound was approximately the size of a 1/2 dollar coin. A Skin Grid Pressure initial assessment document was completed by RN [NAME] on 9-2-19 at initial identification of the wound. The document was reviewed and revealed that the wound was a new pressure area, house acquired, risk factors impaired mobility and altered nutrition, unstageable pressure wound, right outer ankle, measured 2.5 cm (centimeters) x 2.2 cm, edges not clearly visible, granulation and eschar present, color red and necrotic, small amount of serous drainage, no odor, peri wound black or hyper-pigmented, no pain, question, does the Resident have a turning and repositioning program in place? answer, no. 5 Physician orders [REDACTED]. 1. L Elemental [MEDICATION NAME] packet for wound healing once per day for 7 days, and was completed at the time of survey. 2. Multivitamin for wound healing one time per day. 3. Pro-stat protein supplement 30 ml one time per day. 4. Zinc Sulfate 220 mg (milligrams) one tablet 1 time per day for wound healing. 5. Cleanse right outer ankle with normal saline, pat dry, apply skin prep to peri-wound, [MEDICATION NAME] and calcium (Softens hard dead tissue, and inhibits bacterial growth while absorbing drainage) alginate to wound bed, cover with dry dressing until resolved. Every day shift for wound care. On 9-11-19 a new order was obtained for Santyl [MEDICATION NAME] ointment 250 unit/GM (gram) apply to right outer ankle topically every day shift for wound for 14 days. (Enzymatic [MEDICATION NAME] agent for the removal of dead necrotic tissue), was currently being used during survey. Abuse, neglect policies were requested and received. They revealed that the facility policy described neglect as, failure to provide timely and consistent services, treatment or care to a resident to obtain or maintain a resident's health, safety to comfort: or a failure to provide timely and consistent goods and services necessary to avoid physical harm, mental anguish . The document goes on to say; Examples of neglect include but are not limited to: Failure to provide adequate nutrition and fluids. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials . .(within 2 hours for serious injury or within 24 hours if no serious injury). On 9-17-19 at 5:00 p.m., the DON was again asked for ST notes, and none were supplied. At that time, the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY 2. For Resident #93, the facility staff failed to ensure that she was not abused by Resident #43. Resident #43 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #43's diagnoses upon admission included Cardiovascular Disease, Anxiety Disorder, [MEDICAL CONDITION] with Behavioral Disturbance, Unspecified [MEDICAL CONDITION], and Diabetes Mellitus -Type 2. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 5/15/19 was reviewed. Resident #43 was coded as having a Brief Interview of Mental Status Score of 8, indicating moderately impaired cognition. In addition, he was coded as requiring 1 person for physical assistance to ambulate. Resident #93 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #93's diagnoses included Unspecified Dementia, Muscle Weakness, and Hypertension. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 9/4/19 was reviewed. Resident #93 was coded as having a Brief Interview of Mental Status Score of 4, indicating severely impaired cognition. On 9/15/19 at 3:15 P.M., an observation was conducted of Resident #43 in his room. He was lying awake on his bed. A Certified Nursing Assistant (CNA L) was providing 1:1 supervision. She stated that Resident #43 was doing well and did not exhibit any inappropriate behaviors. On 9/16/19 at 12:00 P.M., a second observation was conducted of Resident #43. He was sitting in the dining room with CNA [MI] There were 2 other residents at his table. He sat quietly and did not interact with anyone. On 9/15/19 a review was conducted of facility documentation, revealing a Facility Reported Incident dated 11/28/18. An excerpt read, (Resident #43) was noted by a dietary staff member holding (Resident # 93) with her hands behind her back and stating 'I am not gonna let you go, I'm going to twist your arm off.' Staff intervened and separated them. There were no injuries or further incidents. According to the nursing progress notes, the incident occurred at about 7:30 P.M. The facility submitted a follow-up report on 11/30/18. An excerpt read, (Resident #43) was observed by a dietary staff member who was leaving the kitchen, holding (Resident #93) with her hands behind her back and yelling 'I am not gonna let you go, I am going to twist your arm off. The dietary staff member alerted nursing staff and the two were separated. Both residents were assessed for injuries. There were no injuries noted. Their physician's and Responsible Party's were notified. Resident #43 was seen by the facility's Psychiatric Nurse Practitioner for aggression, and Resident #93 was seen for emotional support by the Psychiatric Nurse Practitioner. On 9/16/19 a review was conducted of Resident #43's clinical record, revealing a care plan. An excerpt read, 4/12/18. [MEDICAL CONDITION] with auditory hallucinations and paranoia. Behaviors include, but not limited to: resisting care, physical aggression, verbal abuse, talking to self. Monitor/record occurrence of target behavior symptoms .violence/aggression towards staff/others. After the incident on 11/28/18, the care plan was updated. An excerpt read: 11/28/18. (Resident #43) is/has potential to demonstrate abusive behaviors towards staff and residents r/t (related to) dementia. Assess and anticipate needs. Assess coping skills and support system, give as many choices as possible. In addition, Resident #43 was placed on 1:1 supervision at that time. Resident #43's clinical record contained a report by a Licensed Clinical Psychologist. Resident #43 was seen in (MONTH) (YEAR), and on 8/23/19. An excerpt read, (Resident #43's) statements regarding his belief that he needs to use violence to defend himself, his paranoid/unrealistic thought process regarding the motivations and intentions of others, and his history of becoming verbally and physically aggressive with residents and staff suggests that (Resident #43) may not be appropriate for this current setting. He needs significant focus on his psychiatric concerns at this time. According to the nursing progress notes, there were multiple preceding incidents earlier in the afternoon on 11/28/18. At approximately 3:30 P.M. Resident #43 was noted to use profane language at staff, including making sexual comments. He also threatened other residents when they walked past him in the hallway, attempting to trip them with his walker or hit them with his belt. Attempted redirection was unsuccessful, and Resident #43 refused to take his medications. During the month of November, (YEAR), Resident #43 had refused to take his medications about 50% of the time. He was care-planned for refusing to take his medications on 4/17/18. After the incident with Resident #43 on 11/28/18, facility staff monitored her. Resident #93 did not exhibit any physical, mood, or behavioral changes. There had been no further incidents with Resident #43, or any other residents. No further information was received.

Based on observation, staff interview, resident interview, clinical record review, and facility document review, and in the course of a complaint investigation, the facility staff failed to provide treatment and services to prevent and heal pressure sores for one Resident (Residents #37) in a survey sample of 42 Residents, resulting in harm for Resident #37. The findings included; 1. For Resident #37, the facility staff failed to provide adequate nutrition, and preventive devices, and care, for a Resident at risk of developing pressure sores, leading to the development of a pressure sore first identified as an unstageable ulcer with eschar, resulting in harm. Resident #37 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. A review of the physician's orders [REDACTED]. They revealed the following timeline of interventions; 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-2-19 - Resident found to have a pressure ulcer to his right lateral ankle directly over the bone, and it was first identified with eschar (Black,dead, necrotic, hard tissue) covering the entire cap over the ankle bone. - weight 103.0. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. The doctor was then asked why the wound on the Resident's ankle was being called a Vascular ulcer, and he stated it's a pressure sore, and most likely the result of the patient's severe malnutrition. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the pressure sore. (Pressure sore) F[NAME]US: (name) Resident #37's pressure ulcer was documented on the care plan on 9-2-19 when the ulcer was identified as a pressure ulcer to right outer heel related to decreased mobility and altered nutrition. On 9-4-19 it was changed to vascular ulcer to the right outer heel. On 9-12-19 it was changed again to vascular ulcer right outer ankle. GOAL: Wound will be free from infection through review date. INTERVENTIONS: (all created and initiated on 9-2-19 at identification) Air mattress. Heel lift boots as tolerated. Resident/family education as needed. (initiated 9-12-19) Supplements as ordered for wound healing (10 days after identification). No interventions for wound development prevention were present prior to the development of an unstageable pressure ulcer found with eschar upon identification A wound Observation was conducted on 9-17-19 at 9:30 a.m. with LPN H. The Resident was alert and oriented to person, place, time, and situation. Both legs and the right ankle were exposed, as the Resident was laying partially on his left side, revealing cool, smooth leg skin, with no [MEDICAL CONDITION], scars, scratches, scales nor brawny appearance. There was hair on both legs, no [MEDICAL CONDITION], or [DIAGNOSES REDACTED] in either extremity, and the Resident had palpable popliteal (behind the knee), dorsalis pedis (top of foot), and tibial (behind the ankle bone) pulses. The Resident had a brisk capillary refill when the toe nails were depressed, and at less that 1 second blood return. The Resident had no wounds on his heels or shins, and exhibited only 1 wound which was directly on top of the right lateral ankle bone (lateral malleolus). The depth of the pressure ulcer could not be ascertained as the wound was covered by black dead thick necrotic tissue with only the outer circumference beefy red, as the de-vitalized tissue was shrinking leaving an open thin boarder around the circular necrotic wound. There was no slough visible, and no drainage, nor odor to indicate infection. The wound was clean and had a minuscule amount of serosanguineous clear drainage making the edges around the wound shiny. The wound was approximately the size of a 1/2 dollar coin. A Skin Grid Pressure initial assessment document was completed by RN [NAME] on 9-2-19 at initial identification of the wound. The document was reviewed and revealed that the wound was a new pressure area, house acquired, risk factors impaired mobility and altered nutrition, unstageable pressure wound, right outer ankle, measured 2.5 cm (centimeters) x 2.2 cm, edges not clearly visible, granulation and eschar present, color red and necrotic, small amount of serous drainage, no odor, peri wound black or hyper-pigmented, no pain, question, does the Resident have a turning and repositioning program in place? answer, no. 5 Physician orders [REDACTED]. 1. L Elemental [MEDICATION NAME] packet for wound healing once per day for 7 days, and was completed at the time of survey. 2. Multivitamin for wound healing one time per day. 3. Pro-stat protein supplement 30 ml one time per day. 4. Zinc Sulfate 220 mg (milligrams) one tablet 1 time per day for wound healing. 5. Cleanse right outer ankle with normal saline, pat dry, apply skin prep to peri-wound, [MEDICATION NAME] and calcium (Softens hard dead tissue, and inhibits bacterial growth while absorbing drainage) alginate to wound bed, cover with dry dressing until resolved. Every day shift for wound care. On 9-11-19 a new order was obtained for Santyl [MEDICATION NAME] ointment 250 unit/GM (gram) apply to right outer ankle topically every day shift for wound for 14 days. (Enzymatic [MEDICATION NAME] agent for the removal of dead necrotic tissue), was currently being used during survey. On 9-17-19 at 5:00 p.m., the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. COMPLAINT DEFICIENCY

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review facility staff failed to ensure Residents were free from accidents and hazards, for 2 residents (Residents #38, and #31) of 42 residents in the survey sample, resulting in harm for Resident #38. In addition, the facility staff failed to maintain water temperatures in a range to prevent burns, scalding and other injuries on 2 of 2 nursing units. The findings included: 1. For Resident #38, the facility staff failed provide the 2 needed staff members for ADL (Activities of Daily Living) care leading to a fall, fracture, and head injury, resulting in harm. Resident #38 was most recently admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The closest Minimum Data Set (MDS) assessment to the time period associated with the event that injured Resident #38, was a significant change assessment with an assessment reference date (ARD) of 3-18-19. Resident #38 was coded with a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment and the Resident required extensive assistance of 2 staff for bed mobility, and extensive to complete dependence, on staff for all activities of daily living. The Resident was coded with no aberrant behaviors. This MDS was compared to the previous MDS with an ARD of 12-19-18 which was a quarterly assessment. and the Resident was coded as extensive assistance of 2 staff for bed mobility in that assessment as well. The Resident was not interviewable. An initial facility reported incident (FRI) was received in the Virginia Department of Health, Office of Licensure and Certification (VDH/OLC) on 3-4-19 in regard to Resident #38 having a fractured and lacerated finger requiring emergency room hospitalization on [DATE]. Nursing progress notes were reviewed, and revealed the following course of events; On 3-3-19 at 4:10 p.m. Licensed Practical Nurse (LPN) (I) was called to the Resident's room by Certified Nursing Assistant (CNA) (T). The LPN found the Resident to have a deep laceration to her left pinky finger which measured approximately 1 inch in length, and it was bleeding, and a pressure dressing was applied, and the Resident was sent out to the hospital emergency room via stretcher at 4:50 p.m. On 3-4-19 at 12:50 a.m., the Resident returned with [DIAGNOSES REDACTED]. Neurological checks were begun in the facility due to the head injury. Hospital records, and orthopedic follow up documents were reviewed and indicated that the Resident had experienced a head contusion injury (bruised brain) bleeding in the brain which can cause swelling from a fall which also produced an open fracture (bone visible) of the distal phalanx of the little finger. The Resident's care plan was reviewed and revealed a focus for fracture of left pinky finger related to a fall on 3-3-19. The director of nursing was requested to bring all investigation records for (MONTH) 2019 involving Resident #38. The investigation information was provided, and revealed the following: 3-3-19 Resident #38 experienced a fall with contusion to the brain and an open [MEDICAL CONDITION] requiring hospitalization for CT of the head and sutures and splint to the severely fractured finger. On 3-3-19, and 3-4-19 witness statements were obtained verbally and in written form. The Residents room mate stated that Resident #38 had fallen from bed and CNA (T) and 2 other staff members had picked her up and taken her out of the room. CNA (T) called for LPN (I), who responded to the room, and LPN (I) then called LPN (J) to assist her. The 2 LPN's arrived in the room to assess the injuries. LPN (J) documented that the laceration to the finger was down to the bone/tendon, nail still intact. The other CNA's working with CNA (T) that evening denied being present or any knowledge of the incident. CNA (T) could not name any other staff assisting him when the Resident fell from the bed. On 3-4-19 the Summary of Alleged Incident was completed by the DON (Director of Nursing). The timeline in the document describes that on 3-3-19 at 3:00 p.m. the Resident had no injury. At 4:10 p.m., according to statements LPN (I) was called to Resident #38's room by CNA (T) where she found the Resident with the injury. At 4:50 pm the Resident was sent to the hospital by stretcher. On 3-4-19 at 12:45 a.m., the Resident returned by ambulance with a negative head CT for injury, and 8 sutures to the fractured and lacerated finger which was bandaged now. The summary Conclusion, documented that the injuries were the result of a fall for Resident #38, and the employee (CNA (T) was terminated. The Summary of Alleged Incident report determined that CNA (T) was in the room providing care for Resident #38 alone when the resident was turned by the CNA toward the window and the Resident fell out of the bed. After the Resident was injured other staff were called into the room by CNA (T) to pick up the Resident and send her out to the hospital for treatment of [REDACTED]. On 9-16-19 the Employee record for CNA (T) was reviewed and revealed documents that described on 1-28-19 the CNA had been counseled for abandoning his post without replacement, and he was terminated on 3-7-19 for injuring a Resident. On 9-17-19 at 5:00 p.m., the facility Administrator and Director of nursing were made aware of findings, at the end of day meeting. The facility stated they had no further information to provide. 2. For Resident #31, the facility staff failed to demonstrate safe use of the mechanical lift while obtaining a weight on 09/16/2019. Resident #31, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #31's most recent Minimum Data Set with an Assessment Reference Date of 07/15/2019 was coded as a quarterly assessment. Functional status for eating was coded as requiring a one-person physical assist and supervision (oversight, encouragement, or cueing) during meals. Functional status for bed mobility was coded as requiring extensive assistance from staff. Transferring between surfaces was coded as requiring limited assistance from staff. Walking in room was coded as requiring supervision (oversight, encouragement, or cueing) from staff. Mobility devices selected were walker and wheelchair. On 09/16/2019 after 4:52 PM, CNA H, CNA I, and this surveyor entered the room of Resident #31 with the mechanical lift. CNA H and CNA I removed the sling (pad) from the handle bar of the mechanical lift and placed it under Resident #31. CNA H began to raise Resident #31 in the lift. Resident #31's shoulders remained on the bed while his lower torso was being elevated in the sling. This surveyor told CNA H to stop and lower Resident #31 to the bed. CNA H did so and then CNA H and CNA I readjusted the sling under Resident #31, attempting to raise it up further under his back toward the shoulders. CNA H began to raise Resident #31 in the sling and as the sling elevated just above the bed, Resident #31's eyes darted around and he turned his head to the right and reached his right arm out to grab the side rail of the bed. This surveyor told the CNA's to stop and lower Resident #31 to the bed. After completing care for Resident #31 and exiting the room, CNA H stated residents don't have their own pad. CNA I stated she didn't think the pad didn't fit correctly for (Resident #31) but it was the only one she could find. CNA H stated that We don't normally do weights, restorative does it. On 09/17/2019 at 10:44 AM, the DON was notified that this surveyor had to prompt (CNA H and CNA I) to stop when Resident #31 was being raised via mechanical lift for a weight. The DON stated that each resident should have their own pad and that they come in different sizes. The DON also stated that the CNA's should have stopped and readjusted before continuing. When asked why, the DON stated we Don't want him to fall out of the lift. The facility staff provided their policy entitled, Mechanical Lifts and Transfer. The last sentence under the header entitled, Policy documented, Follow manufacturer's recommendations for specific mechanical lift equipment. The facility staff provided the manufacturer's instructions for the mechanical lift. Under the header entitled, Slings it was documented, All slings are size-coded with different colored edge binding or attachment strap coloring .always refer to the label on the sling being used to make sure of its actual safe working load. On 09/17/2019 at approximately 7:00 PM, the administrator and DON had no further information or documentation to offer. 3. The facility staff failed to maintain water temperatures in a range to prevent burns, scalding and other injuries on 2 of 2 nursing units. On 9/17/19 at 4:22 PM, surveyor F went to the office of the maintenance director. The maintenance director was asked if he checks water temperatures and the maintenance director stated, he checks temperatures daily. Review of his water temperature logs revealed that temperatures are only checked in the kitchen, laundry, lobby and shower rooms. No Resident rooms are checked. When the maintenance director was asked how often he calibrates the thermometer he uses to check temperatures, the maintenance director stated, I haven't ever calibrated it. When the maintenance director was asked about water temperatures he indicated he likes the temperatures to be 110-115, 110 is safe for Residents and 115 stops any bacteria or growth. The maintenance director was asked what temperature is too hot, he stated, anything over 125 degrees when asked the risks, he stated, you risk scalding, especially for Residents. On 9/17/19 at approximately 4:30 PM, surveyor F and the Maintenance Director met with the dietary manager, (Employee D). Employee D stated she calibrates the kitchen thermometers daily. Employee D provided surveyor F with one of her calibrated thermometers. The maintenance director and surveyor F then checked water temperatures using the maintenance thermometer and the kitchen's calibrated thermometer and found the following: * Resident room [ROOM NUMBER]: 124 degrees Fahrenheit using the kitchen thermometer and 122.2 degrees Fahrenheit using the maintenance thermometer. The maintenance director stated, it's hot when asked to touch the water with his hand. * Resident room [ROOM NUMBER]: 123.6 degrees Fahrenheit using the kitchen thermometer and 121.8 degrees Fahrenheit using the maintenance thermometer. The maintenance director stated, it's time for me to get a new thermometer. The maintenance director then asked, does usage effect it? This time of day they are not using a lot of water. * Station 1 shower room: 125.4 degrees Fahrenheit using the kitchen thermometer and 124 degrees Fahrenheit using the maintenance thermometer. When the maintenance director was asked how long it takes for a Resident to get scalded he stated, less than a minute. * Resident room [ROOM NUMBER]: 124.7 degrees Fahrenheit using the kitchen thermometer and 123.5 degrees Fahrenheit using the maintenance thermometer. * Resident room [ROOM NUMBER]: 125.4 degrees Fahrenheit using the kitchen thermometer and 123.6 degrees Fahrenheit using the maintenance thermometer. *Resident room [ROOM NUMBER]: 111 degrees Fahrenheit using the kitchen thermometer and 109 degrees Fahrenheit using the maintenance thermometer. *Resident room [ROOM NUMBER]: 125.2 degrees Fahrenheit using the kitchen thermometer and 123.8 degrees Fahrenheit using the maintenance thermometer. On 9/17/19 at approximately 5:00 PM the facility Administrator and Director of Nursing were made aware of the concern regarding water temperatures. On 9/17/19 at 5:31 PM, during the end of day meeting the facility administrator advised the survey team that the water temperatures had cooled down, they have notified the vendor, had initiated water temperatures and had drained the boiler. Review of the water temperature logs revealed that the water temperatures in the Resident shower rooms and bath rooms ranged temperatures of 112 degrees to 114 degrees from 7/22/19-9/17/19, with the exception of 9/12/19 all of the temperatures were recorded at 100 degrees. Review of the facility policy titled water management plan revealed only information about maintaining temperatures in excess of 108 degrees to prevent the growth and spread of microorganisms such as Legionella. This policy made no reference to acceptable water temperature ranges for Resident use. Access to water at 124 degrees, which was noted in 5 of the areas observed, for 3 minutes can cause 3rd degree burns, according to Moritz, [NAME]R., Henriques F.C. Jr. (1947). Studies of Thermal Injury: 11. The Relative Importance of Time and Surface temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720,. No further information was provided.

Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to ensure the nutrition and hydration status of 3 residents, (Residents #37, 28, and 31) in a survey sample of 42 residents, resulting in harm for Resident #37. The findings included; 1. For Resident #37, the facility staff neglected to ensure the resident was free from malnutrition and dehydration, resulting in harm. Resident #37 was admitted to the facility on [DATE]. Diagnoses included: hypertension, [MEDICAL CONDITION], arthritis, [MEDICAL CONDITION] moderate, high cholesterol, [MEDICAL CONDITIONS], and a history of dysphagia. The most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9-9-19. Resident #37 was coded with a Brief Interview of Mental Status score of 11 indicating mild to no cognitive impairment and the Resident required extensive assistance, to complete dependence, on staff for all activities of daily living. This included extensive assistance of 1 staff member's physical assistance to eat. The Resident was coded with no aberrant behaviors, and no refusals of care or assistance from staff. This MDS was compared to the previous MDS with an ARD of 7-12-19 which was a 90 day assessment, and the comparison is as below: MDS 7-12-19 - BIMS = 11, at risk for wounds, no current wounds, no preventative measures for wounds, no weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. MDS 9-9-19 - BIMS =11, at risk for wounds, one current vascular (incorrect identification) wound, pressure reduction devices for chair and bed, for wounds, ointments and dressings for the wound, nutrition management, significant weight loss, mechanically altered diet, Bed mobility extensive assistance needed, eating extensive assistance needed. On 4-15-19, Resident #37 was admitted on a Regular diet with low potassium, regular texture, thin liquids. On 6-25-19 the Resident's diet was changed to Dysphagia ground texture, thin consistency low potassium diet. On 9-11-19 the Resident's diet was again changed to Regular diet puree texture, nectar consistency, for dysphagia. On 9-15-19 at 12:00 noon, observations and interviews were conducted with the Resident. After introduction, the Resident was asked if we could help him with anything while we were there, and he complained of hunger, and stated he wanted something to eat. He stated his family brought him things and he enjoyed that food. The lunch meal tray did not arrive at the bedside until 12:45 p.m., and at 2:30 p.m., no staff had entered the room to assist the Resident to eat. Surveyor A, and this surveyor looked at the tray which was uncovered, and untouched. We went to the nursing station to enquire as to how long it would be for the Resident to be fed. The staff stated they were very understaffed, and were unable to use the dining room, and had to close it as they were unable to staff it, so the feeders who would normally be fed there had to be fed in their rooms. They stated that Resident #37 was a self feeder, and independent. At 2:30 p.m., the Resident was again observed and was sitting in bed falling over onto his left side with a small styrofoam or paper cup containing magic cup supplement, which was an ice cream like substance in his hand. The Resident was licking the inside of the cup to obtain the contents, and the surveyor asked him if he was able to hold the spoon that was on his tray, and he stated not too good, I am so weak now, I just don't have the strength. The Resident picked up the spoon and tried to use it, however, the small amount he was able to get onto the spoon after much effort, fell down onto the bed linens. The rest of the tray was untouched, and no 2 cal supplement was on the tray. At 2:45 p.m., the HR (human resources) Director entered the Resident room to feed him. The surveyors returned at 3:30pm to find the tray had been left there and the thick pudding consistency portions of food had approximately 2 spoonfuls missing from 2 of the 3 scoops of pureed food. Each of the scoops measured approximately 3 inches by 3 inches circular, and 1/2 inch depth, and had spread out into each other on the plate. The Resident stated I can't eat that stuff, it's awful like cold wet bread. He went on to say I told them when I got here that I can't eat that stuff, and I don't have any trouble eating if I like the food, but they don't listen. On 9-16-19 at 10:00 a.m., another observation was conducted for this Resident by Surveyor C. Surveyor C reported that for the breakfast meal the tray was followed and went into the Resident's room, left uncovered, and removed from the room untouched and returned to the kitchen. On 9-16-19 at 3:00 p.m., the Resident's lunch meal tray was again left untouched, and the Resident was not fed. No supplement was in the room for either meal. It is notable to mention that on 9-16-19 the Resident's breakfast tray was followed by Surveyor C from delivery by CNA N, to discard, and it was not disturbed, nor did the Resident attempt to consume it. No staff member attempted to assist with the meal, and the tray was simply removed from the room, untouched, and discarded. CNA O documented 26-50% consumed. CNA N (certified nursing assistant) was interviewed, and stated he ate a little of his sherbet cup so I said he ate 25%, however, CNA N did not sign the ADL document, another staff member, CNA O was documented as having fed Resident #37 his breakfast. CNA N was asked if she fed the Resident, and she stated no he can feed himself. CNA N was asked if she had been trained on how to calculate the amount of a meal that a resident consumes, and she stated no. CNA O stated that she only removed the tray, and did not feed the Resident. The ADL (activities of daily living) report was requested and received. The report documented that the Resident was independent with eating for breakfast and lunch every day in September, for 20 of the 32 breakfast and lunch meal opportunities. The 12 meal exceptions where the staff assisted the Resident occurred on the following days; 9-1-19 dependant (fed) for both meals, and consumed nothing for breakfast and 51-75% for lunch. 9-5-19 dependant (fed) for both meals, and consumed 51-75% for both meals. 9-7-19 limited assistance (not fed) for both meals, and consumed nothing for both meals. 9-8-19 limited assistance (not fed) for breakfast, and consumed 26-50%. 9-10-19 limited assistance (not fed) for lunch, and consumed nothing. The behavior portion of the ADL record was also reviewed and revealed at no time did the Resident refuse assistance or care. The other 20 opportunities for staff support with feeding, and the Resident was not fed, occurred on the following days; 9-2-19 The Resident consumed 51-75% both meals 9-3-19 The Resident consumed 26-50% both meals 9-4-19 The Resident consumed 26-50% both meals 9-6-19 The Resident consumed 26-50% at breakfast, and 76-100% at lunch 9-8-19 The Resident consumed 26-50% at Lunch 9-9-19 The Resident consumed 76-100% both meals 9-10-19 The Resident consumed nothing for breakfast 9-11-19 The Resident consumed nothing for breakfast, and 76-100% at lunch 9-12-19 The Resident consumed nothing both meals 9-13-19 The Resident consumed 26-50% both meals 9-14-19 The Resident consumed 26-50% breakfast, and 75-100% at lunch 9-15-19 The Resident consumed nothing both meals 9-16-19 The Resident consumed 26-50% for breakfast, nothing for lunch During this 16 day period from 9-1-19 through 9-16-19, nine different staff members signed the meal consumption record, only 3 of which delivered the meal to the Resident consistently more than one day in the 16 days. The Resident's weight record was requested and revealed that from 7-3-19 until the time of survey on 9-16-19, the Resident had lost 23.4 pounds of weight in less than 12 weeks. Those weights follow: 4-15-19 - On admit 122.4 lbs (pounds) 4-23-19 - 119.2 5-1-19 - 115.2 - weight loss of 7 pounds after admission for 2 weeks. 5-22-19 - 120.2 - weight gain of 5 pounds and stabilizes after 3 more weeks. 6-25-19 - diet modified to ground texture begun, and significant weight loss begins. 6-26-19 - 119.0 7-3-19 - 119.0 7-24-19 - 117.0 7-31-19 - 117.0 8-26-19 - 108.0 9-1-19 - 103.0 9-9-19 - 101.8 9-11-19 - diet modified to pureed texture begun after significant weight loss of 17.2 pounds from 7-3-19 to 9-9-19. 9-16-19 - 95.6 - significant weight loss increased in less than 12 weeks to 23.4 pounds, equaling 20% of the Resident's entire body weight, and 26.8 pounds, since admission. On 9-16-19 at 3:00 p.m., an interview was conducted with the Director of Nursing (DON), and Unit manager RN (registered nurse) D, by surveyors in the conference room. They stated we want to have a care plan meeting with him and his family, wife, son or brother, that is our next step with him I am aware he is loosing weight. They were asked why it had taken 5 months to get a plan going, and they stated At first his family was bringing in food that he was eating, he doesn't like the pureed texture or the nectar thick liquids. Therapy had been working with him, and he had a FEES study on 9-10-19 that he failed. They were asked why the physician had not talked with the Resident himself and decide a course of action? They stated We discussed the doctor talking to him (the Resident), and we didn't have a social worker as Employee O has been gone about a month and a half ago, and he has lost weight since that. The DON stated I see we need to make a decision and talk to him to see if he wants a peg tube because he doesn't like the pureed texture to maintain his BMI (Body Mass Index). The DON and unit manager continued with, Speech therapy did a swallowing eval, and he didn't do well. They were asked when that occurred as no therapy notes were found in the clinical record. She stated, I don't know, I will get those for you. The family brings in McDonalds, and that he eats. She was asked if he had ever aspirated or been hospitalized , or treated for [REDACTED]. They were asked why the Resident was not being fed by staff who thought he was independent, when his MDS showed he needed extensive assistance from staff to eat since the 7-12-19 MDS which included a seven day look back to 7-5-19. They responded He should be fed. On 9-16-19 at 3:15 p.m., Employee E, the speech language pathologist (ST/SLP) entered the interview in progress in the conference room with surveyors, and with the unit manager and DON. She stated he was on ground meat with pureed solids and the Resident didn't like it so the family requested an upgrade so he would eat, and then the FEES study was ordered on 9-10-19. I asked if there was no problem, or outcome with the regular diet that the family brought in that the Resident did eat, why the change. She stated he needs positioning and encouragement to not aspirate, he is at risk for silent aspiration. She continued he wasn't really eating the ground texture, or anything off of the pureed tray but pudding, oatmeal, and cream of wheat, and that's why the FEES study was done. A bedside swallowing evaluation was done by another speech therapist who was full time here. I am not typically treating most of the time. Her last day was weeks ago, I don't remember how many, we have a new one starting today. Between the last one and this one we have had PRN (as needed) staff and I have been helping treat as well. She was asked if she had assessed or treated Resident #37, and she stated no. The ST notes were again requested. The FEES (Dysphagia systems test) study was requested at 3:15 p.m., during the interview with Employee E, and received at 4:00 p.m. The study documented no diagnoses linked to dysphagia, and documented that the Resident took his medications whole. The document describes the Potential risks to the Resident, and documents that the Resident is at Potential risk for aspiration. Any and all ST notes from Resident #37's time of admission to today were requested again. On 9-16-19 at 4:00 p.m., the Registered Dietician (RD), and Assistant Director of Nursing (ADON) were interviewed by surveyors in the conference room. The current RD stated there had been a lot of turnover in the department and there had been one RD from (MONTH) to may 2019, and then travel and consultant RD's had come in as needed until mid (MONTH) 2019 during his significant weight loss, and she herself (employee G) started work in the facility in mid august, and had been there just under a month. Physician's progress notes were reviewed and indicated no weights on the assessments conducted by the physicians. The area in the form for weight were all left blank. There is no indication that the physician's were aware of the significant weight loss from 6-25-10 to 8-29-19. A review of the physician's orders [REDACTED]. They revealed the following timeline of interventions; 4-15-19 - admission regular diet with thin liquids. - weight 122.4. 4-16-19 - ST, OT (occupational therapy), PT (physical therapy) all evaluate and treat as necessary order entered. 5-2-19 - 2 Cal supplement 120 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m. - weight 115.2. 6-25-19 - Weight 119.0, which had rebounded from initial admission loss, proving the Resident had no difficulty gaining weight back (for the 2 months and 10 days since admission) while eating a regular diet, and taking a small amount of supplement. During this time there were no problems associated with aspiration. 6-25-19 The diet change to dysphagia ground diet with thin liquids, which the Resident did not like. No other interventions occurred to prevent significant weight loss from 5-2-19 until 8-28-19 when the new RD arrived, and the significant weight loss had already occurred. - weight 108.0 (14.4 pound (10%) weight loss since admission, and an 11 pound weight loss in 2 months.) 7-25-19 through 7-29-19 the Resident had symptoms of illness, and had laboratory blood tests drawn. As a result of those tests it was revealed that the Resident had become dehydrated. Resident #37 then was ordered to receive IV (intravenous) normal saline fluids for dehydration. The infusion was started initially through a peripheral IV in his left wrist, however, the IV was not positioned well and had to be removed, and the staff was unable to replace it, so a specialist nurse was brought in to insert a mid line PICC (peripherally inserted central line catheter) to infuse the fluids. 7-26-19 - physician's orders [REDACTED]. Resident recently ended PT, OT, and ST services. Will continue to monitor for further decline and have therapy screen as needed. 8-27-19 - RD progress note revealed Weight not stable, Spoke with Resident who says that he doesn't like the ordered texture of his food. He reports that he feels like he's lost weight and does feel hungry throughout the day and at bedtime. He is agreeable to drinking 2 cal and trying snacks between meals and at bedtime Orders are then initiated and follow below. 8-29-19 - 2 Cal supplement increased to 240 ml (milliliters) drink twice per day at 8:00 a.m., and 5:00 p.m., magic cup twice per day with lunch and supper, yogurt and apple sauce between meals and at bedtime, were all started - weight 108.0. 9-3-19 - Resident lab test resulted for pre-[MEDICATION NAME] (measures recent dietary intake). Pro-stat protein supplement for wound healing was ordered. 9-9-19 - FEES study (Dysphagia systems test) completed. - weight 101.8. 9-11-19 - Diet changed to pureed with nectar thickened liquids, increase to 2 cal supplement to 3 times per day, and med pass liquid supplement was added for 60 ml three times per day. 9-16-19 - at the time of survey weight was - 95.6. The Resident's diet card was requested from the kitchen and stated the pureed diet with nectar thickened liquids was being served. No mention of the supplement (2 cal supplement 240 ml (milliliters) three times per day, was on the tray card. On 9-17-19 at 12:32 p.m., the physician was called on the telephone and asked for an interview. He stated he would come to the facility and look at the chart and let surveyors know about Resident #37. The physician arrived and stated he had looked at the chart, and said the Resident is severely malnourished and doesn't like the texture of the diet. He stated We had speech look at the patient, and they said he isn't able to eat regular food. The family said no to a PEG (Per Endoscopic Gastrostomy) tube, there is nothing else to do. The doctor was asked why was speech therapy was consulted, if the Resident had no signs of aspiration, was not hospitalized or ever suffered from any respiratory illness associated with aspiration, and had been here in the facility for 5 months. He stated that the family was concerned. The doctor was asked why the family was allowed to make decisions for a Resident, who was alert and oriented, could make his needs known, and was his own Responsible Party (RP). The Resident had not been deemed incompetent, and had the right to make his own decisions. The doctor responded I was not aware of that, and if we let him eat whatever he wants, that's how we get sued. On 9-17-19 at 5:00 p.m., a Summary Report of Meeting document for the last 2 days of staff huddle meetings was presented to surveyors by the DON. The document described the subject of the meetings to be in regard to Passing trays at meal times, assisting feeders, documenting on amounts eaten. and was signed by those in attendance. This was evidence of training begun by the facility to rectify deficient practice in the meal delivery and assistance system. The comprehensive care plan was reviewed in it's entirety and revealed the following interventions for the weight loss and pressure sore. There were no interventions for hydration, and it was simply placed in with the nutrition (weight loss) hydration plan below; (Weight loss) F[NAME]US: (name) Resident #37 has the potential for nutrition/hydration imbalance related to hypertension, [MEDICAL CONDITIONS], history of [MEDICAL CONDITION], [DIAGNOSES REDACTED]. initiated on 4-19-19, revised on 5-5-19, 6-25-19, and 9-13-19. GOAL: Resident will remain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through review date. INTERVENTIONS: (all created and initiated on 4-19-19 immediately after admission) Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered, honoring resident preferences. Monitor intake and record every meal. RD to monitor and follow up per protocol. Weigh per facility protocol. (initiated 6-25-19) No hot liquids for safety. No changes were made to any interventions after the Resident suffered a significant weight loss. The significant weight loss was not care planned, none of the interventions that were initiated for the weight loss were care planned, none of the supplements were care planned, none of the diet changes were care planned, and the need of the Resident to be fed by extensive assistance of staff was not care planned. Most goals are not measurable, and the Residents preferences were not honored. There was no Hydration care plan initiated, even after the Resident suffered from dehydration requiring IV fluid infusions on 7-25-19. On 9-17-19 at 5:00 p.m., the DON was again asked for ST notes, and none were supplied. At that time, the facility Administrator and Director of nursing were made aware of findings at the end of day meeting. The facility stated they had no further information to provide. 2. For Resident #28, the facility failed to ensure that he was offered adequate hydration. Resident #28 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #28's diagnoses included Diabetes Mellitus Type 2, Muscle Weakness, and Hypertension. The Minimum Data Set, which was an Admission Assessment with an Assessment Reference Date of 4/22/19 was reviewed. Resident #28 was coded with a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment. He was also coded as requiring set up assistance with meals, and being able to ambulate independently with his wheelchair. On 9/16/19 a review was conducted of Resident #28's clinical record, revealing the following diet order: 4/22/19. Renal diet. Regular texture, Large Portions, Sandwich 3 times a day at meals. On 9/15/19 at 1:40 P.M. an interview was conducted with Resident #28 in his room. His lunch had not been served. He stated that he wanted some apple juice, or something other than water to drink. Other than water there were no beverages in his room. He further stated that the dining room was closed all day on weekends. He complained that his food was late on a daily basis. He had not received an additional beverage to drink because the food tray was always late, and the facility did not ensure that preferred sources of hydration was available between meals. On 9/16/19 at approximately 5:00 P.M., an interview was conducted with the Director of Nursing (DON Employee B). When asked why Resident #28 was unable to receive other sources of hydration, the DON said that the facility had a hydration cart that passed out ice. No further information was received. 3. For Resident #31, the facility staff failed to recognize and evaluate a 8.06% weight loss over a 4-day period. Resident #31, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, dysphagia, and diabetes. Resident #31's most recent Minimum Data Set with an Assessment Reference Date of 07/15/2019 was coded as a quarterly assessment. Functional status for eating was coded as requiring a one-person physical assist and supervision (oversight, encouragement, or cueing) during meals. On 09/16/2019, the clinical record was reviewed. According to the weight summary, Resident #31 weighed 172 pounds on admission (02/09/2019), 177 pounds on 06/26/2019, 171.2 pounds on 08/28/2019 and 157.4 pounds on 09/01/2019 which indicated an 8.06% weight loss over a 4-day timeframe. An active physician's orders [REDACTED]. MONITOR FOR SIZE AND RATE DURING INTAKE for [MEDICAL CONDITION] (sic). Aphagia refers to the inability or refusal to swallow. There were no orders for protein/carbohydrate/ high-caloric supplements or fortified foods. The progress notes from 08/01/2019 through 09/09/2019 were reviewed. There were no notes by any service addressing the weight loss documented in the weight summary on 09/01/2019. The care plan was reviewed. A focus entitled (Resident #31) has the potential for nutrition/hydration imbalance r/t (related to) dementia, DM2 (diabetes mellitus 2), dysphagia dx (diagnosis), need for mechanically altered texture diet. A goal associated with this focus initiated on 02/18/2019 and revised on 09/16/2019 documented (Resident #31) will maintain adequate nutritional status as evidenced by maintaining weight with no significant weight changes through the review date. Interventions associated with this focus are as follows: Administer medications as ordered. Monitor/document for side effects and effectiveness. Provide/serve diet as ordered and per resident preference. Monitor intake and record q (every) meal. RD (registered dietitian) to monitor and f/u (follow up) per protocol Weigh per facility protocol. The interventions did not include monitoring for size and rate during intake as indicated in the physician's orders [REDACTED]. There was not a focus on the care plan for an actual significant weight loss. On 09/16/2019 at 4:30 PM, an interview with Licensed Practical Nurse F (LPN F) was conducted. When asked about the process when a resident presents with weight loss, she stated, I would re-weigh. She then stated that if it was true weight loss, she would notify the physician, the dietician, and the responsible party. When asked how much weight loss constitutes notifying the physician, she stated, Five to ten pounds. On 09/17/2019 at 10;23 AM, this surveyor observed a restorative aide that routinely weighs residents weigh Resident #31 via wheelchair on the scale and his weight was 158.8 pounds indicative of an overall 7.24% weight loss since 08/28/2019. On 09/17/2019 at 1:34 PM, the medical director was asked if he was aware of Resident #31's significant weight loss. He stated, We discuss it every week in meeting so yes, I think so. When told there were no provider progress notes addressing it, the medical director stated, I will look at it then I have to look at it and exactly the reason, he was doing so well and all of a sudden .I will definitely look at him and get back to you. On 09/17/2019 at 2:45 PM, an interview with Employee G, a registered dietician, was conducted. When asked if she was aware of Resident #31's significant weight loss, she stated she was aware. She went on to explain her process of obtaining a printout of all the residents and their weights. She stated she highlights the residents that need to be re-weighed but Resident #31 was not on the list. Employee G stated, I talked to the nurse about that today. Employee G also stated that she will put in new recommendations for him. When asked what the recommendations would be, she stated that Resident #31 likes milk and ice cream so I was going to add both of those. She stated she would also add juice to the breakfast meal and stated that his wife and daughter bring him snacks as well. The facility staff provided a copy of their policy entitled, Resident Weight. In Section 2 entitled, Weight Procedure it was documented in Part (c) Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, reweigh resident to verify weight. In Section 6 entitled, Reweight Parameters it was documented, a) A plus/minus of 5 pounds of weight in one week will result in: i) reweight within 24 hours(1) validation with nurse for accurate weight (2) notify IDT (interdisciplinary team)/doctor/family, if indicated. On 09/17/2019 at approximately 7:00 PM, the administrator and DON had no further information or documentation to offer.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed, for 3 residents (Resident #9, Resident #59 and Resident #13) of the survey sample of 38 residents, to provide adequate supervision to prevent accidents. On 3/20/18 at 6:13 P.M. Immediate Jeopardy was called due to residents being burned by hot coffee. Prior to the survey, there was no Hot Liquid Assessments done for residents. There were no interventions put in place to prevent burn injury from hot liquids. 1. For Resident #9, the facility staff failed to provide adequate supervision to prevent a burn injury from hot liquid, resulting in harm. 2. For Resident #59, the facility staff failed to ensure that 2 persons provided extensive physical assistance during a transfer, resulting in a spiral fracture of her lower leg, resulting in harm. 3. Resident #13 sustained multiple large fluid filled blisters on his thigh after spilling hot coffee on himself, resulting in harm. 4. The facility staff failed to ensure that an unattended medication cart was locked. The Findings included: 1. For Resident #9, the facility staff failed to provide adequate supervision to prevent a burn injury from hot liquid. Resident #9 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #9's [DIAGNOSES REDACTED]. Resident #9 was cognitively intact with a Brief Interview of Mental Status score of 15, indicating no cognitive impairment, Mobility Impairment, Range of Motion Limitations, History of Cardiovascular Accident with left [MEDICAL CONDITIONS], multiple cardiac problems deficit related to Generalized Weakness, Poor Endurance, Impaired Balance and Motor Control secondary to Above the Knee Amputation. On 3/20/18, a review was conducted of Resident #9's clinical record. On 3/7/18, Resident #9 was given a cup of hot coffee in his room without a lid on it. He put cream into the coffee, then accidentally hit the cup with his elbow, spilling it onto his abdomen and sustaining a burn on his abdomen. Resident #9's care plan read, Increased risk for nutrition/hydration imbalance related to history of Mental Illness, diuretic use, Hypertension, Chronic Heart Failure, Major [MEDICAL CONDITION], and Chronic Obstructive [MEDICAL CONDITION] Disorder. Provide assistance as meals as needed. Resident #9's clinical record contained the following Skin Assessment, 3/2/18. new non-pressure area. first observed 3/2/18. Site Abdomen 4 cm L x 1.5 cm open area. Burn. Color open area. Exudate type: none. Odor: no. Infection: no. Current treatment orders: clean area with normal Saline and apply nonstick drsg (dressing) with Alocane and border drsg every shift until healed. Pain Assessment: Pain associated with non pressure wound - yes. Resident #9's clinical record contained an Initial Evaluation Wound Treatment. It read, 3/13/18 Burn wound on abdomen Size 0.8 x 1.1 x Not Measurable MC. Surface area 0.88 CM. Dried [MEDICATION NAME] exudate (scab). Additional information: mostly heated burn. Treatment: Skin prep apply 1 x daily for 30 days. Foam apply 1x daily x 30 days. Resident #9's signed physician's orders [REDACTED]. Gel 4%. Apply to abdomen topically three times a day for burn. Clean area with normal saline then apply Alocane Emergency Burn Gel with non stick drsg with cling until area healed. 3/8/18. Daily wound [MEDICAL CONDITION] stomach. Document abnormalities in progress notes. Document level of pain at wound site. According to the Medication Administration Record, [REDACTED].M. until 3/8/18 at 8:00 A.M. After Resident #9 sustained a burn injury on 3/2/18, his care plan had not been updated to include interventions to prevent further burns. After the IJ was called, The Hot Liquids Evaluation recommended using lids on hot coffee as of 3/20/17. As of the last day of the survey on 3/29/18, the care plan had not been revised to include burn injury prevention. Prior to the survey, there was no Hot Liquid Assessment done either before or after the burn. There was no intervention put in place to prevent another burn injury. On 3/20/18 at 1:15 P.M , a coffee carafe was observed on a tray at both units. Cups and lids were available on the tray. On 3/20/18 at 4:58 P.M., a coffee carafe was observed on a tray at both units. Cups and lids were available on the tray. Licensed Practical Nurse D on Unit 2 stated that the dinner carafe had been delivered. She stated that the other carafe at the nursing station was the lunch carafe and needed to be picked up. On 3/20/18, at 5:15 P.M. an observation was made of the dinner meal. A Resident, who was put into the sample and identified as Resident #24 was holding a cup coffee in his hand. There was no top on the cup and steam was observed rising from the cup. He gave permission to have the Dietary Manager take the temperature, which was 141.6 degrees. Resident #24 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #24's [DIAGNOSES REDACTED]. On 3/26/18 at 10:40 A.M. Resident # 24 was observed ambulating in the hallway in his wheelchair. Resident stated, I have nothing to do. They took away my coffee. DON stated the he used to go to get his own coffee. 3/26/18 4:40 P.M. Interviewed Regional Nurse. She stated, He is used to get his own coffee at the Nurse's station. Now, the Activities person gives out the coffee. On 3/20/18 at 12:30 P.M., an interview was conducted with the dietary Manager. She described the coffee service process. Coffee is sent in an Curtis Airpot, it holds the temperature for 8 hours. We put it on a tray along with empty cups and a stack of lids. Whoever serves the coffee should put lids on the cups, if the resident needs one. The Dietary Manager was unable to state which residents needed lids as a safety measure. On 3/20/18 a review was conducted of facility documentation. According to the monthly menus submitted by the Dietary Manager, Hot Coffee and Hot Tea were served at every meal, including breakfast, lunch, and dinner. The Dietary Manager submitted a copy of the Manufacturer's Instructions for the Wilbur Curtis D500 Generation 3 Airpot Brewer. According to the manufacturer's instructions for the brew temperature was factory pre-set to 200 degrees. The coffee is brewed directly into the Airpot, which are delivered to the dining room and nurse's stations, and are accessible by staff and residents. On 3/20/18 at 5:53 P.M. on Unit 1, and Unit 2, there were large carafes of hot coffee on top of both nurses' stations. The coffee was accessible to any resident who walked by, or who wanted to drink coffee. Upon request by the surveyor, the Dietary Manager obtained a measurement of the temperature of the coffee on Unit 1. At 5:53 P.M., the temperature was 161.6 degrees. In addition, the Dietary Manager measured the temperature in the carafe on Unit 2. The temperature was 151.0 degrees at 5:54 P.M. On 3/20/18 at 6:05 P.M., an interview was conducted with the Regional Nurse. She stated that the facility did not have a Hot Liquid Assessment tool. She stated that if a resident had a decline in their ability to feed themselves they could be assessed by therapy. The Director of Nursing stated that the facility had not done any Hot Liquid Assessments on any of the residents. On 3/20/18 at 6:13 P.M. Immediate Jeopardy was called. The facility Administrator (Administration A), and Director of Nursing (Administration B) were informed immediately. The Immediate Jeopardy was abated on 3/20/18 at 9:09 P.M. The facility submitted the following Abatement Plan: Battlefield Park Plan of Correction Findings: Facility did not prevent recurrence of hot liquid injury. 1. Identified residents have been evaluated by Nurse Manager for ability to safely handle hot liquids. The plan of care will be revised as indicated. Residents have current treatment plans in place. 2. Current residents will be evaluated by nursing to ensure safety and ability to handle hot liquids. Plan of care will be reviewed and revised as indicated. Residents identified at risk for handling hot liquids will be evaluated to determine need for alternative interventions. The facility has removed potential hot liquid accessibility. Nursing will complete skin assessments on all residents within facility to ensure no [MEDICAL CONDITION]. Social Service Department will interview interviewable residents to ensure they have had no issues with hot liquids. 3. Facility nursing will evaluate ability to handle hot liquids upon admission, quarterly, and with change of condition. All facility staff will be educated prior to working on the process for evaluating resident's safety and ability to handle hot liquids, and the proper temperature to serve hot liquids. Dietary will continue to monitor hot liquid temperatures before each meal to ensure the hot liquids are not served above 135 degrees at point of service with log sign off. 4. Director of Nursing or designee will audit 10 residents per week to ensure hot liquid safety assessments have been completed x 4 weeks, and 5 residents per week x 3 weeks, with results found brought to QAPI (Quality Committee). Administrator or designee will audit hot liquid temperature logs once daily x 4 weeks and will bring results found to QAPI. 5. Corrective Action will be completed by 11:59 pm on (MONTH) 20, (YEAR). On (MONTH) 20, (YEAR) the facility Administrator (Administration A) and Director of Nursing (Administration B) were notified of the findings. The facility subsequently submitted a Hot Liquid Assessment of Resident #9, which indicated that he was At Risk for handling hot liquids due to his Contractures - Fingers, hand wrist , elbow, shoulder of non-dominant side, Strength - Weakness, paresis, paralysis of upper extremity. Intervention: resident to drink hot liquids with lid on cup, resident to be evaluated by therapy, resident to be educated by staff preparing coffee for him. In addition, Hot Liquid Assessments were submitted for all other residents. The facility staff received inservice training that covered the following: No resident can have any hot liquid until properly assessed by a nurse. If they are a new admission they are not given hot liquids until assessment is completed. All hot liquids must be under 135 degrees with log signed off and covered with a lid. On 3/23/18 at 9:25 A.M., an interview was conducted with Licensed Practical Nurse E. When asked if she had received training regarding hot liquids, she stated, Yes. The residents need to be assessed upon admission, annually, quarterly, and after a change in condition. The temperature of any hot liquids should not exceed 135 degrees. On 3/23/18 at 9:20 A.M., an interview was conducted with Certified Nursing Assistant I. When asked if she had received training regarding hot liquids, she stated, Yes. Everybody has been assessed. Everybody has to have a lid on their cups. Coffee is served not hotter than 135 degrees. On 3/23/18 at 9:30 A.M., Certified Nursing Assistant C (CNA C) was interviewed. When asked if she had received training regarding the service of hot liquids, CNA C stated yes. When asked what she was instructed to do, she stated that coffee could not be served over 135 degrees and coffee cups needed to have lids on them. On 3/23/18 at 9:31 A.M. Licensed Practical Nurse F (LPN F) was interviewed. When asked if she had received training about hot liquids, LPN F stated yes. She said that residents were assessed to see if they were safe to handle hot liquids. She stated that the white lids were to be used when serving hot liquids and hot liquids needed to be below 135 degrees. 2. For Resident #59, the facility staff failed to provide adequate supervision to prevent an improper transfer, resulting in a spiral [MEDICAL CONDITION] left leg and resulting in harm. Resident #59 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #59's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 11/3/17, coded Resident # 59 as having a Brief Interview of Mental Status Score of 15, indicating no cognitive impairment, and as requiring the extensive physical assistance of at least 2 persons for transfers. On 3/21/18 a review was conducted of Resident #59's clinical record, revealing a care plan initiated on 7/11/17. The care plan did not address the residents' requirement per MDS Assessment on 11/3/17 for the extensive physical assistance of at least two persons for transfers, until 1/21/18, which was the month following her spiral fracture injury. It read, 1/21/18. Risk for falls r/t (related to) gait/balance problems. Tibial Plateau Fracture of LLE (left lower extremity) and fracture of right ankle. Requires assistance with mobility and transfers, medication side effects, pain control. Interventions. Resident transfers with hoyer lift 2 person assist. On 3/21/18 at 4:45 P.M. an observation was conducted of Resident #59. The head of her bed was elevated, and she was watching television, while wearing headphones. She stated that she was ok, and denied having any concerns. She was wearing a nightgown. On 3/22/18 at 10:15 A.M. another observation was made of Resident #59. Licensed Practical Nurse C (LPN C) was present, and stated, She is supposed to have a pillow under her left leg and assistive rails on both sides. Resident #57's heels were not floated. Both heels were directly on her bed. LPN C was asked to state what the physician's orders [REDACTED]. She then stated, The order says to float both heels. It is to relieve pressure and [MEDICAL CONDITION] to avoid pressure sores from her heels. She has a pressure sore on the underside of her left calf. LPN C did not ensure that Resident #59's heels were floated after reading the physician's orders [REDACTED]. On 3/22/18 at 10:25 A.M., the Regional Nurse (Administration C) was asked to accompany the surveyor into Resident #59's room. The Regional Nurse stated, Her heels are not floated. It's important for pressure wound prevention. On 3/21/18 a review was conducted of facility documentation. The facility sent the resident for a left leg fracture which was discovered by x-ray. The facility reported to the hospital that resident had been complaining of pain; there was no indication that resident had fallen or the fracture was a result of an injury. The x-ray performed at the hospital indicated the resident had a spiral [MEDICAL CONDITION] tibia and a chest x-ray. The reporter indicated that a spiral fracture would mean that there was some force used and not the result of a fall. On 3/21/18 a review was conducted of Resident #59's clinical record, revealing that on her original admission date of [DATE], she had a [DIAGNOSES REDACTED]. That injury occurred at her home prior to her admission to the facility. The clinical record also contained two Radiology Reports. 1.) 12/12/17. Results: There is an acute appearing non-displaced oblique [MEDICAL CONDITION] shaft of the tibia. A small plantar spur is present. No other fracture. Conclusion: Acute appearing non-displaced [MEDICAL CONDITION] tibia. 2) 12/28/17. Results: There is a hairline nondisplaced obliquely oriented distal tibial shaft fracture best visualized on the lateral examination. The fracture appears recent. In addition, there is a healing/healed [MEDICAL CONDITION] tibia and the fibula neck. No dislocation. There is bone demineralization. Vascular calcifications identified. Conclusion: Headline nondisplaced [MEDICAL CONDITION] tibial shaft best visualized on the lateral examination. ANKLE AP and LAT 2V, Left. The hospital Assessment/Plan read: admitted [DATE]. (Resident #59) is a [AGE] year -old female with: 1. [MEDICAL CONDITION] on [MEDICAL TREATMENT] 2. Acute ischemia of the right frontal lobe, small focus right occipital lobe in right Middle cerebral artery territory. [MEDICAL CONDITION]. 3. Hypertension with hypertensive [MEDICAL CONDITION] 4. Chronic [MEDICAL CONDITION] 5. Left eye [MEDICAL CONDITION] 6. Diabetes mellitus 7. Spiral [MEDICAL CONDITION] left tibial Diaphysis 8. Functional [MEDICAL CONDITION] 9.[MEDICAL CONDITION](Cardio Vascular Accident) 10. History of [MEDICAL CONDITION] Lower leg pain-swelling. Pneumonia, Unspecified organism. medications: [REDACTED]. Resident #59's clinical record contained a re-admission progress note signed by her physician at the facility. It read, 1/19/18. Pt. (patient) readmitted from Hospital. Patient admitted /discharge diagnoses. Acute ischemic left frontal lobe small form related to history of small vessel ischemic disease. Hx. (history) Hypertension, A-Fib ([MEDICAL CONDITION]) L eye [MEDICAL CONDITION], diabetes mellitus, spiral [MEDICAL CONDITION] diaphysis, End Stage [MEDICAL CONDITION] on [MEDICAL TREATMENT],[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) Infection, History of Breast CA (Cancer), Patient is legally Blind. Patient discharged in stable condition [MEDICAL CONDITION], or [MEDICATION NAME]. Patient was seen by infectious disease. Patient doing well. No chest pain no shortness of breath, eating and drinking well, vital signs are stable, heart irregular, lungs good air entry, abdomen soft non tender, extremities no [MEDICAL CONDITION]. Assessment - Continue current medication. Medication reviewed and hospital record reviewed. A review of facility documentation revealed a Corrective Action Report dated 1/5/18. It read, (Certified Nursing Assistant - CNA G) Current counseling step: Written. Violation of Safety Standards. Description of incident: CNA G performed an improper transfer on a resident (Resident #59) resulting in an injury by not using a gait belt. The facility Administrator submitted the following written Investigation timeline: 12/11/17 evening shift - Resident requested to return to bed from wheelchair. CNA G transferred resident. CNA interview and re-enactment of transfer does not reveal that anything unusual occurred during the transfer. CNA G transferred the resident by herself. Patient complained of discomfort when CNA G was positioning her feet on pillows. CNA G reported this discomfort to the nurse. 12/12/17 at 0456 A.M. resident reported to nurse supervisor that earlier on 12/11/17 while being lifted from her wheelchair to the bed, she felt as though her left foot was twisted behind her and she felt a pop. After assessing her foot, it was noted that her foot was swollen and warm to the touch with positive pedal pulse bilaterally. Resident was unable to lift or move her left foot. MD was notified and a new order was received for a 2 view x-ray of the left foot, and to delay [MEDICAL TREATMENT] until x-ray is completed. On 12/12/17 at 1017 LPN (incorrectly reported) reported that the x-ray report revealed no fracture or dislocation to the left lower extremity, this information was called to the MD and report was noted and filed in the chart. 12/12/17 at 1020 AM Resident c/o (complained of) pain in left lower extremity 5/10 Tylenol 325 given and was effective. 12/12/17 at 1020 AM Resident c/o pain in left lower extremity 5/10, [MEDICATION NAME] 50 mg was given and shown to be effective 12/13/17 - 12/28/17 No other c/o pain were noted and no pain medications were administered until 12/28/17. 12/28/17 While pharmacy and the facility Assistant Director of Nursing (Administration I) were looking at resident lab information it was noted that there was an x-ray report from 12/12/17 at 0849 that resident had an oblique fracture non-displaced to the distal end of the tibia shaft on lower left extremity. MD was notified New order was received to send resident to (hospital) for evaluation and treat. 12/2917 Resident was admitted to the hospital with [REDACTED]. On 3/22/18 at approximately 4:00 P.M. the facility Administrator (Administration A) and Director of Nursing (Administration B) were notified of the findings. No further information was received. 3. Resident #13 sustained multiple large fluid filled blisters on his thigh after spilling hot coffee on himself, resulting in harm. Resident #13, a [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 12/28/17. Resident #13 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. He required extensive assistance with activities of daily living and was coded as 2/2 (limited assistance/ 1 person assist) for eating. Resident #13 was identified by the survey team to have [MEDICAL CONDITION] hot coffee. The investigation report was requested. The burn occurred on 12/31/17. The Incident Description read Resident alert & oriented was OOB (out of bed), sitting in his w/c (wheel chair). Stated that he spilled a cup of hot coffee on himself while eating his breakfast & now feeling a burring sensation. 2/person assist transferred resident back to bed, upon assessment observed multiple large fluid filled intact blisters on his right upper thigh distal to groin. Supervisor on duty DON (director of nursing), wound nurse, wound doctor per wound nurse & (doctor) were notified of the incident. New order for [MEDICATION NAME], to apply to affected area. No further c/o (complaint of) discomfort voiced, will continue to monitor, call bell within reach. Stated that he spilled a cup of hot coffee on himself while eating his breakfast & now feeling burring sensation. A Skin Grid Non-Pressure was initiated on 12/31/17. The wound is described as a burn to the front of the right thigh with large fluid filled blisters with periodic pain. Another form 'Skin Grid Pressure was initiated on 12/31/17. Impaired mobility and [MEDICAL CONDITION] were documented as risk factors. The wound was documented as a burn to the groin with pain present. Resident #13 was assessed by the wound care doctor on 1/9/18. The burn on the upper thigh measured 4 x 15 x 0.1 centimeters, with heavy serous drainage, 50% necrotic tissue and 50% granulation tissue. The wound was described as Large 2nd degree burn with blister roof ruptured but intact. This was removed sharply. The most current wound measurements were documented on 3/14/18. The wound measured 2.1 x 3.7 x 0.1 with moderate serosanguineous drainage. Resident #13 was interviewed on 3/28/18. When asked if was burned by hot coffee, he stated yes. When asked what happened, Resident #13 stated that he meant to pull the overbed table but instead pulled on the meal tray. He stated that tray tipped over and the coffee spilled onto his lap. An interview was conducted with the Administrator and Director of Nursing (DON) on 3/23/18 at 11:15 a.m. The Administrator was asked if a hot liquid assessment had been completed for Resident #13 prior to the burn, the Administrator stated no. She did provide a copy of the Hot Liquid Evaluation that was completed for Resident #13 as a result of the survey findings. The assessment dated [DATE] concluded Resident #13 was unsafe- unable to manage. When asked what the facility changed with regard to the service of hot beverages after Resident #13 was burned, the Administrator stated that she instructed the dietary and nursing staff to use lids for the coffee cups. On 3/23/18 at 9:10 a.m., the Dietary Manager (DM) was interviewed. When asked if she was aware that a resident was burned by hot coffee on 12/31/17, the DM stated that she was not aware. When asked if she was aware that a second person (Resident #9) was burned by hot coffee, the DM stated that she was aware of the second person. When asked if she was instructed to change anything regarding the service of hot coffee, the DM stated that she was asked to send lids to the units on the tray with the coffee pot. The DM stated that she had already been sending lids prior to the burn to the second resident. When asked what the usual temperature of the coffee served from the kitchen measured, the DM stated that she tried to keep it in the range of 145-150 degrees Fahrenheit. She stated that if it was higher than that range, she would put ice in the coffee pots. It was reviewed with the DM that on 3/20/18 the survey team had a concern that the coffee was served too hot and residents were burned as a result. The DM was asked if anything had changed with the coffee temperatures since 3/20/18. The DM stated that coffee now needs to be 135 degrees or below before it is sent out to the units for service. At the end of day meeting on 3/22/18, the Administrator and DON were notified of the concerns regarding Resident #13's burn. No further information was provided. 4. A medication cart was observed unlocked and unattended during medication pass. On 3/22/18 at 8:40 a.m., Licensed Practical Nurse C (LPN C) was working one of the medication carts. She was in a resident room administering medications to a resident in the bed near the door. The medication cart was pulled in front of the door frame with the drawer side facing the room. The cart was unlocked. A medication pour and pass observation was conducted with LPN C. She prepared and administered medications for two residents. She locked her cart on both occasions before entering the room. On 3/22/18 at 11:00 a.m., this surveyor stood in the hall waiting to ask LPN C a question. LPN C was in a resident room. The curtain was pulled and she was behind the curtain with the resident in the window bed. The cart was not within her vision. The cart was pulled close to the door frame with drawers facing the room. The cart was unlocked. At this time, there were two residents in wheelchairs within arms reach of the cart. There was a visitor standing next to the cart waiting to speak with LPN C. In addition, the housekeeping staff pulled one end of the cart about two feet from the door frame towards the hallway so that she could go in and out of the room. At the end of day meeting on 3/23/18, the Administrator and Director of Nursing were notified that the medication cart had been unlocked on two occasions. The facility policy titled Medication Administration was reviewed. The Procedure section read K. Do not leave medication cart unlocked.

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed, for 2 residents (Resident #68, Resident #70) of the survey sample of 38 residents, to prevent and identify pressure ulcers, resulting in harm. 1. For Resident #68, the facility staff failed to prevent the development of two stage three pressure ulcers, resulting in harm. 2. For Resident #70, the facility staff failed to prevent the development of an unstageable sacral pressure ulcers, resulting in harm. The Findings included: 1. For Resident #68, the facility staff failed to prevent the development of two stage three pressure ulcers, resulting in harm. Resident #68 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #68's [DIAGNOSES REDACTED].-Unspecified. The Minimum Data Set, which was an Admission Assessment with an Assessment Reference Date of 2/27/18, coded Resident #68 as Rarely/never being to understand or be understood by others. In addition, she was coded as requiring the extensive physical assistance of at least 2 persons for bed mobility and transfers. On 3/21/18 a review was conducted of Resident #68's clinical record, revealing the following nurse's Skin Assessments, and Physician Wound Consultation: Facility acquired pressure ulcer Date area First observed 3/11/18. House Acq. 1. Skin Grid Pressure . Left distal mid calf. Pressure. Length 1.2 Width 1.2 Depth 0.1 Stage 3 Distinct, outlined clearly visible, attached, even with wound base. Granulation tissue present. Pink wound bed. Exudate amount Moderate. Peri-wound appearance pink or normal for ethnic type. No tunneling present. No associated pain. 2. 3/11/18 House Acquired. Right Medial Knee. Pressure. length 1.3 Width 1.2 Depth 0.1 Stage 3. Distinct, outlined clearly visible, attached, even with wound base. Appearance Granulation present. Color of wound bed Pink. Exudate amount Moderate. Peri-wound appearance Pink of normal for ethnic type. No tunneling present. No pain associated. Wound Physician consultation 3/13/18. Wound Care Evaluation. Patient has a wound on her calf. She presents with a stage 3 pressure wound of the left , distal, medial calf of at least 1 days duration. There is moderate sero - sanguineous exudate. On 03/21/18 at 4:54 P.M., an observation was made of Resident #68 in her bed. Resident #68 did not have a pillow between her legs. Also, the Certified Nursing Assistant (CNA D) was present. She stated that she had worked with this resident for 6 months, and that the pillow that goes between the residents legs was missing. She stated that the only pillow she found was the small wedge pillow that goes on the resident's back on her right side. She described the missing pillow as being blue with 2 white straps that wrap around from the back of her legs to the front. She stated that the therapy department trained her on how to use the pillow that is missing. She stated that she had also been in the resident's room at about 3:30 P.M., and that the pillow was not in use by the resident, and not in her room. On 03/22/18 at 9:11 A.M., an observation was made of Resident #68 in bed. Resident #68 did not have a pillow between her legs. She had a wedge pillow on her upper left side above her waist. The Charge Nurse (LPN F) was present. She stated that there was no pillow between Resident #68's legs. The pillow goes between her legs to prevent skin breakdown because she's contracted and has limited mobility. The pillow keeps her bony prominences from rubbing together. I supervise the CNA's. When asked what the physician's orders [REDACTED]. Resident #68's signed Physician order [REDACTED]. 9/15/17 Turn and reposition Q 2 hours for pressure relief 3/16/18 float pillow between legs and knees at all times 3/23/18 float heels qs. On 3/31/18 a review was conducted of facility documentation, revealing a Pressure Ulcers/Wounds Acquired Log. It read, 2 new facility acquired pressure ulcers. 3/11/18 right medial knee stage 3 3/11/18 left distal calf stage 3. Resident #68's bathing record was reviewed, indicating that prior to the discovery of both stage 3 pressure ulcers, on 3/11/18, she hadn't been bathed since 3/9/18. Resident #60's care plan was reviewed. It read, Impaired skin integrity related to impaired mobility, incontinence of bowel and bladder. Receives tube feedings. Dependent upon staff for all aspects of mobility and toileting as evidence by right hip and left buttock wounds. Actual wounds to left medial leg and right medial knee .Nutritional and hydration support, place pillow between legs and knees at all times. Provide pressure reducing wheelchair cushion. Provide thorough skin care after incontinent episodes and apply barrier cream. Specialty mattress. Treatments as ordered. 03/26/18 02:11 PM Interview with the Director of Nursing (Administration B) The DON was asked to state her expectation regarding when the development of a pressure ulcer should be discovered by staff. She stated, As soon as redness is noted before it becomes a stage 1. On 3/22/18 at approximately 4:00 P.M. the facility Administrator (Administration A) and Director of Nursing (Administration B) were notified of the findings. No further information was received. 2. For Resident #70, the facility staff failed to prevent the development of an unstageable sacral pressure ulcers, resulting in harm. Resident #70 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #70's [DIAGNOSES REDACTED]. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 2/23/18, coded Resident #70 as being able to understand and be understood by others. He was also coded as requiring the extensive physical assistance of at least two people for bed mobility, and the extensive physical assistance on 1 person for transfers. Resident #70 was coded as having Functional Limitation in Range of motion on both sides. On 3/27/18 at 9:17 A.M. Resident #70 was observed resident sitting in his high back wheelchair eating breakfast. His bed had a specialty mattress - Micro Air 65 Alternating Pressure with Low Air Loss. According to Resident #70's signed physician order, A regular mattress was in place from 12/14/17 until 2/7/18, when it was changed to an Air Mattress after the development of an unstageable sacral pressure ulcer. On 03/27/18 at 5:09 P.M. a surveyor conducted an observation of the sacral would. It was healed as of 3/27/18. On 3/26/18 at 5:06 P.M., an Interview was conducted with the Regional Nurse (Administration C), and the wound nurse (LPN G). The Regional Nurse stated, I feel like they have been identifying the wounds. We consider the co morbidity. When a new wound is reported I look at it, also we let the wound doctor know about it so that she checks the next Tuesday. She stated that they do skin assessment upon admission and that the wound report contains all of the identified wounds. She further stated that LPN G does assessments every other weekend, and that LPN F works Monday thru Friday. The Regional Nurse was unable to state why Resident #70's sacral pressure ulcer was first identified after it had become unstageable. On 3/27/18 a review was conducted of Resident #70's clinical record, revealing a Skin Grid dated 1/4/18 which identified a new unstageable pressure ulcer on his sacrum. Measurements: 1.9 x 0.9 x 0.2 cm. Wound bed- Necrotic. The Wound Report documented a Diabetic wound on Resident #70 Right Dorsal Foot on 1/4/18, and a Deep Tissue Injury on his Right Heel on 2/6/18. Resident #70 care plan was reviewed. The care plan did not address Resident #70's need for assistance with turning and repositioning while in bed. He was also coded on the MDS as requiring the extensive physical assistance of at least two people for bed mobility. The care plan read, 2/8/18. Actual impairment to skin integrity related to Diabetes Mellitus, impaired mobility. Actual wound to top of R foot, left heel and sacral. Interventions: Bilateral heels are to be floated at all times while in bed. Placed a pillow folded in half under the calf of each leg. Elevate legs while in wheelchair, Multi podus boots (initiated on 3/9/18) applied at all times for pressure relief. Prior to the development of the pressure ulcers, Resident #70 had the following interventions in place: wheelchair cushion, regular mattress. In addition, prior Resident #70 had not received a Braden Risk Assessment prior to the development of his Sacral Pressure Ulcer, Deep Tissue Injury, or Diabetic Wound. On 3/22/18 at approximately 4:00 P.M. the facility Administrator (Administration A) and Director of Nursing (Administration B) were notified of the findings. No further information was received.

Based on observation, resident interview, staff interview, and clinical record review, and in the course of a complaint, the facility staff failed, for residents 3 residents (Resident #72, Resident #87, Resident #32) of the survey sample of 32 residents, to ensure the highest practicable well-being resulting in psychosocial harm for Resident # 72. 1. For Resident # 72, the facility staff failed to ensure care and services were received according to physicians orders resulting in psychosocial harm related to anxiety about medications being given by distracted nurses. The resident stated she was afraid. 2. For Resident # 87, the Facility staff failed to administer intravenous antibiotics as ordered by the physician. 3. For Resident # 32, the facility staff failed to provide medications as ordered by the physician. The medications which included antibiotics, aerosol for [MEDICAL CONDITION] and eye drops for [MEDICAL CONDITION] were listed as medication unavailable. The resident was on Hospice. The findings include: 1. For Resident # 72, the facility staff failed to ensure care and services were received according to physicians orders resulting in psychosocial harm related to anxiety about medications being given by distracted nurses. The resident stated she was afraid. Resident # 72, a female, was admitted to the facility 11/2/2015. Her [DIAGNOSES REDACTED]. Resident # 72's most recent MDS with an ARD of 2/21/2018 was coded as a quarterly assessment. Resident # 72's cognitive status (her ability to make every day life decisions and memory ability) was not coded. Dashes were entered in the areas of Section C 100 Should Brief Interview for Mental Status through C 1000 Cognitive Skill for Daily Decision Making. Resident # 72 was coded as needing supervision assistance of one staff member to perform her activities of daily living. Resident # 72 was coded as being able to hear, speak, understand, and be understood. On 3/28/2018 at 1:47 PM, Resident # 72 requested to talk with the surveyors about some things she had experienced living at the facility for the past 3 years. On 3/28/2018 at 1:50 PM, Resident # 72 came to the conference room with all of the surveyors. Resident # 72 stated she had deemed herself as the advocate for others. Resident # 72 stated she was happy to see things beginning to improve at the facility since new management was in place over the past few months. However, she was concerned that the nurses passing medications often had to be interrupted to take care of residents who wander or need other assistance. Resident # 72 stated she was afraid to take her medicine several times because the nurses were interrupted so often. Resident # 72 stated she often inquired about the medications presented to her because she was unsure if what was being given by the nurses was correct. Resident # 72 also stated she often had to wait for pain medication because the nurses were busy doing paperwork. She stated the nurses should be able to focus on their jobs and the residents. She stated the nurses often have too much to do that could be assigned to someone else. She stated that Unit Secretaries should do more paperwork which would allow the nurses to give pain medications when requested by residents and do other things for the residents. Resident # 72 stated a big problem at the facility was the high turnover of CNAs (Certified Nursing Assistants). Resident # 72 stated new CNAs come in, get overworked and quit and means more work for the nurses. She stated she also was upset that she had missed six appointments with doctors because of no transportation was available. Resident # 72 stated her appointments with specialists often take almost a year to schedule and it was upsetting to have to cancel appointments due to transportation. Resident # 72 stated she thought the current Administrator and Director of Nursing were making positive changes in the facility and things would get better with time. On 3/28/2018 at 2:25 PM, Review of the clinical record was conducted. Review of the Progress Notes revealed documentation of problems with medication orders and administration. On 2/12/2018 at 12:44 eMAR (electronic Medication Administration Note): [MEDICATION NAME] 1000 milligrams give one tablet by mouth two times a day for elevated glucose resident refused. On 2/13/2018 at 4:59 PM electronic Medication Administration Note: [MEDICATION NAME] 1000 milligrams give one tablet by mouth two times a day for elevated glucose Resident states she does not take this medication anymore. On 2/14/2018 at 12:25 AM Nurses Note: Resident returned from the dentist around 1645 (4:45 PM). She had a new order for [MEDICATION NAME] 250 milligrams by mouth but resident is allergic to medication. Attempted to contact MD/NP (Medical Doctor/Nurse Practitioner) but phone went to voice mail . On 2/14/2018 at 12:39 AM- doctor notified residents allergy to [MEDICATION NAME]. New order from [MEDICATION NAME] 500 milligrams by mouth three times a day for 7 days per Dr________. On 2/14/2018 at 8:03 AM orders were received from the doctor for antibiotics to be changed from [MEDICATION NAME] to [MEDICATION NAME] d/t (due to) allergy to [MEDICATION NAME]. On 2/14/2018 at 12:34 electronic Medication Administration Note: [MEDICATION NAME] 1000 milligrams give one tablet by mouth two times a day for elevated glucose resident refused. Review of the allergies [REDACTED]. Other allergies [REDACTED]. Review of Physicians Orders Summary Sheet with order status: active, completed, discontinued revealed no documentation of [MEDICATION NAME] orders. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The medication was scheduled to be administered at 9 AM and 5 PM each day. The medication was documented as administered by facility staff 36 times during the month. There was no documentation of [MEDICATION NAME] 1000 milligrams by mouth two times a day being discontinued. There was no noted documentation of the facility staff notifying the doctor that Resident # 72 was refusing to take [MEDICATION NAME] until 3/9.2018. The Nurses Note dated 3/9/2018 at 18:59 (6:59 PM) stated Dr._____ in facility Informed him of Residents refusal to take medication [MEDICATION NAME]. NO (New Order) received. Resident is her own RP (Responsible Party) made aware of NO (new order). The new order was not written in the Nurses Note. Further review of the Nurses Notes revealed Resident # 72 refused to take [MEDICATION NAME] 11 times at 9 AM and two times at 5 PM after 3/9/2018. Documentation revealed [MEDICATION NAME] was administered 7 times at 9 AM and 16 times at 5 PM after 3/9/2018. On 3/17/2018 at 5 PM, the documentation on the MAR indicated [REDACTED]. The Nurses Note dated 3/17/2018 at 5:19 PM stated [MEDICATION NAME] 1000 milligrams by mouth two times a day for elevated glucose Medication has been discontinued. The MAR indicated [REDACTED]. Resident # 72 continued to refuse the [MEDICATION NAME] at times but was administered the medication at other times throughout the rest of the month. Review of the Order Summary Report Printed on 3/29/2018 at 9:19 AM for Order Status: Active, Completed, Discontinued Order date range 9/28/2017-3/28/2018 revealed no documentation of any orders for [MEDICATION NAME] listed in the list of medications. Review of the Facility policy on Medication Administration effective 8/3/2010 and Revised 12/14/2017 on Page 1 of 7 stated Administer Medications only as prescribed by the provider On page 2 of 7 was written: f. Observe the five rights of in giving each medication: i. the right resident ii. the right time iii. the right medicine iv. the right dose v. the right route j. Full attention should be given during preparation of medications. i. Avoiding distractions is important for infection prevention and reducing errors. The facility cited Lippincott as the resource used for professional nursing standards. Guidance was given from Lippincott, Fundamentals of Nursing, which reads: To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to these rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation On 3/29/2018 at 8:40 AM, an interview was conducted with the Director of Nursing who stated medications should be administered as ordered by the physician and clarified if there were questions. The Director of Nursing stated the nurses should follow the five rights of medication administration at all times and verify the correct medication is being given. The Director of Nursing stated the nurses should not be interrupted repeatedly while giving medications so they can focus. The Director of Nursing stated the residents should feel confident that they are receiving the correct medications and should not miss appointments due to lack of transportation. No further information was provided. 2. For Resident # 87, the Facility staff failed to administer intravenous antibiotics as ordered by the physician. Resident # 87 was admitted to the facility on ,[DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident # 87's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 1/30/2018. The MDS coded Resident # 87 with a Brief Interview for Mental Status (BIMS) score not assessed. Resident # 87 required extensive assistance of one to two staff members with activities of daily living and always incontinent of bowel and bladder. Resident was admitted to the hospital on [DATE] and discharged on [DATE]. Review of the Hospital Discharge Summary revealed final [DIAGNOSES REDACTED]. ON Page 3 of 4 under Hospital Course was documented .patient have some pus drainage and blood drainage from these decubitus ulcers seen by the surgeon and plan to do the debridement but patient refused. Patient discharged back to nursing home on IV antibiotic. discuss with the patient and patient daughter this morning and if in case ulcer worse she will come back to the hospital for debridement. Also discussed about patient and going [MEDICAL CONDITION] with worsening sacral wound. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Missing doses were 3/2/2018 at 2 PM and 10 PM, 3/3/2018 at 6 AM and 2 PM, 3/5/2018 at 10 PM, 3/9/2018 at 10 PM, 3/10/2018 at 6 AM and 2 PM. Review of the Nurses Notes revealed documentation: 3/2/2018 at 5:43 PM of medication [MEDICATION NAME]-Tazobactam in Dex Solution 3-0.375 grams per 50 milliliters give 3.375 grams intravenously every 8 hours for ABSCESS for 6 weeks. Notified Pharmacy. Stated they will send ABT ( Antibiotic) to facility on next run. Notified MD (medical doctor). Stated to hold until arrival of medication. 3/3/2018 at 2:28 PM nurses note stated the IV (intravenous) antibiotics remain on hold. 3/5/2018 5:10 PM-Awaiting Pharmacy to send resident's IV ABT Tx. Notified provider stated to hold medication until arrive from pharmacy. 3/5/2018 at 5:16 PM eMAR (electronic medication administration record) Medication Administration Note: [MEDICATION NAME]-Tazobactam in Dex Solution 3-0.375 grams per 50 milliliters give 3.375 grams intravenously every 8 hours for ABSCESS for 6 weeks. Awaiting arrival from pharmacy. See nurse note. 3/5/2018 7:28 PM IV Antibiotic on hold per doctor . 3/9/2018 10:07 PM eMAR (electronic medication administration record) Medication Administration Note: [MEDICATION NAME]-Tazobactam in Dex Solution 3-0.375 grams per 50 milliliters give 3.375 grams intravenously every 8 hours for ABSCESS for 6 weeks. Awaiting refill from pharmacy. Coming on run 3/9/2018 10:16 PM Nurse Note: Doctor_________ aware of 2200 (10 PM) dose of ABT not available. 3/10/2018 7:01 AM eMAR (electronic medication administration record) Medication Administration Note: [MEDICATION NAME]-Tazobactam in Dex Solution 3-0.375 grams per 50 milliliters give 3.375 grams intravenously every 8 hours for ABSCESS for 6 weeks. Awaiting on order from pharmacy. 3/10/2018 3:04 PM eMAR (electronic medication administration record) Medication Administration Note: [MEDICATION NAME]-Tazobactam in Dex Solution 3-0.375 grams per 50 milliliters give 3.375 grams intravenously every 8 hours for ABSCESS for 6 weeks. Awaiting arrival from pharmacy. 3/10/2018 4:05 PM Resident remains on IV ABT r/t (related to)abscess to buttocks. Resident currently out of ABT Tx (treatment). Awaiting arrival from pharmacy. MD aware. Will resume ABT when they arrive from pharmacy. 3/10/2018 10:43 PM Nurses Note: Call was placed to Pharmacy to check status of delivery of IV ABT [MEDICATION NAME]. Pharmacy tech stated that [MEDICATION NAME] was delivered by Pharmacy to the wrong Facility and that it should be arriving shortly. [MEDICATION NAME] has not arrived as of 1045 (8:45 PM). MD is aware Further review of the Nurses Notes revealed Resident # 87 was medicated daily with [MEDICATION NAME] 50 milligrams by mouth for sacral pain and/or pain to buttocks. The pain was rated between 6-7 out of ten on a pain scale of 10 being the worst pain and with the follow up pain scale being rated between 0 and 2 on each day except 3/12/2018. On 3/12/2018 at 10:39 AM, Resident # 87 was administered [MEDICATION NAME] 50 milligrams for pain of 9 out of 10. On 3/12/2018 at 11:57 AM, the pain was rated a 7 out of 10. On 3/23/2018 at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who stated the facility had experienced difficulty with a previous Pharmacy and had recently changed to a different Pharmacy. The DON stated the new pharmacy was located in [NAME]land and made three regular runs to the facility each day. The DON stated the expectation was that medications should be available for administration as ordered by the physician. The DON stated the course of antibiotics should be administered without interruption. No further information was provided. 3. For Resident # 32, the facility staff failed to provide medications as ordered by the physician. The medications which included antibiotics, aerosol for [MEDICAL CONDITION] and eye drops for [MEDICAL CONDITION] were listed as medication unavailable. The resident was on Hospice. Resident # 32 was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] and 3/9/2018 with the [DIAGNOSES REDACTED]. Resident #32's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 1/30/2018. The MDS coded Resident # 32 with a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating severe cognitive impairment. Resident # 32 required extensive assistance of one to two staff members with activities of daily living except required total assistance of one staff person for bathing and always incontinent of bowel and Resident # 32 was coded to have an indwelling urinary catheter. Resident currently on Hospice. Review of the clinical record was conducted on 3/21/2018 at 2:30 PM. Review of the Progress Notes revealed documentation of an eMar (electronic Medication Administration Note) on 3/10/2018 at 3:25 PM which stated [MEDICATION NAME] tablet 25 milligrams give 2 tablet by mouth every 12 hours related to Essential Hypertension (110) hold for HR <60 (heart rate less than 60) Awaiting arrival from pharmacy. Further review of the Progress Notes revealed other documentation of medications not available from the pharmacy. On 11/4/2017 at 4:27 PM eMar (electronic Medication Administration Note) [MEDICATION NAME] Aerosol 200-5 micrograms per activation 2 puffs inhale orally two times a day for [MEDICAL CONDITION]. Med not available. On 11/4/2017 at 4:30 PM eMar (electronic Medication Administration Note) Dorzolamide HCL ([MEDICATION NAME]) Solution 2 % instill one drop in both eyes two times a day related to other specified [MEDICAL CONDITION]: Med not available On 11/4/2017 at 4:30 PM eMar (electronic Medication Administration Note) [MEDICATION NAME] Solution 0.5 % Instill one drop in right eye one time a day related to other specified [MEDICAL CONDITION]. Med not available. On 11/4/2017 at 10:10 PM eMar (electronic Medication Administration Note) [MEDICATION NAME] Solution Reconstituted 3.375 grams Use 3.375 milligrams intravenously every 12 hours [MEDICAL CONDITIONS] in wound for 14 days. Med has not been delivered On 11/5/2017 at 7:45 AM eMar (electronic Medication Administration Note) [MEDICATION NAME] in D5W Solution 500 milligrams intravenously every 24 hours [MEDICAL CONDITION] in wound for 14 days awaiting on pharm On 3/22/2018 at 9 AM, an interview was conducted with LPN (Licensed Practical Nurse) B who stated the staff should notify the Pharmacy when medications are not available. On 3/22/2018 at 2 PM, an interview was conducted with the Director of Nursing who stated the Pharmacy should have medications available for administration as per Physicians Orders. The Director of Nursing also stated the facility staff should check the First Dose medications to see if the missing medication is available in that supply. Review of the STAT box First Dose contents list revealed the Medication, [MEDICATION NAME] (Generic Name-[MEDICATION NAME]) 25 milligrams was available to the staff. During the end of day debriefing on 3/23/2018, the Facility Administrator, Director of Nursing and Corporate Nurse were informed of the findings. The Director of Nursing stated the Pharmacy should ensure medications were available for administration as ordered by the physician. No further information was provided.

Based on staff interview, facility documentation and clinical record review, the facility failed for one Resident (Resident #20) in a survey sample of 26 residents, to ensure a safe living environment, resulting in harm (facial fractures and lacerations requiring sutures). This was a past noncompliance. Resident #20 did not have his elevating leg rests as indicated for trunk instability. Resident #20 fell , causing facial fractures and two lacerations requiring sutures. The findings included: Resident #20, was initially admitted to the facility 2/26/15. [DIAGNOSES REDACTED]. Resident #20's most recent MDS (minimum data set) with an ARD (assessment reference date) of 6/4/16 was coded as a quarterly assessment. Resident #20 was coded as having short and long term memory deficits and required moderate assistance in making daily life decisions. Resident #20 was coded as needing extensive assistance of one to staff members to perform activities of daily living. Resident #20 no longer resided in the facility, so a closed record review was conducted. An FRI (facility reported incident) was sent to the OLC (office of licensure and certification) regarding a fall which occurred on 4/18/16. The resident was found on the floor, having sustained a fracture of the right orbit of the eye, maxillary bone and zygomatic arch of the face. In addition, the resident sustained [REDACTED]. The resident required pain medication after the fall. The leg rests were to maintain trunk stability as the resident leaned forward in his wheelchair. The resident's care plan dated (3-18-16) included the potential for falls, and included the intervention dated 4/19/16 for high back w/c with elevated leg rests to be on when resident up in chair. Prior to this intervention (3-18-16) was the intervention Assess that wheelchair is of appropriate size, assess need to have w/c locked/unlocked for safety, antitippers. In addition to his ADL's, the resident did not stand or ambulate and was total care for transfer, ambulation on unit and toileting. Information concerning the leg rests were to be on the wheelchair, and the legs elevated was not communicated to the nursing department from rehab. The rehab assessed and determined that the leg rests were neccessary to prevent falls. According to the facility investigation, this was the causative factor in the subsequent fall with fracture. A four point action plan was implemented to ensure that all communication between the departments is received and implemented in a timely manner. Review of the 4 point POC (plan of correction) dated 4/21/16 included the following: 1. The resident's care plan and care card were updated to indicate the need for footrests his wheelchair when up. The incident was reported to the state on 4/20/16 and an investigation was initiated. 2. All residents with therapy recommendations have the potential to be affected. 3. Therapy staff will be inserviced on the process of communicating any equipment or device needed for residents to the nursing department through the Clinical start up and stand down (daily meeting) process. The DOR (director of rehab) will ensure that she or a designee attends the clinical start up and stand down to provide that communication to the nursing department. 4. The DOR or designee will review therapy recommendations daily to ensure that all recommendations have been communicated to nursing. The DNS (director of nursing services) will review all orders during Clinical Start Up and Stand Down to ensure that all recommendations from therapy have been communicated and incorporated on to the care plans and care cards. 5. The AOC (allegation of compliance) date was May 18, 2016. The above POC was reviewed and had been implemented. On 2/15/17 at approximately 11:00 AM, the Administrator was asked if there any issues with therapy communication with nursing after the above incident. He stated, no. On 2/15/17 at 1:20 PM, the DOR (other D- a COTA- certified occupational therapy assistant) was interviewed. She stated, For any changes I do a nursing communication and take to unit manager. She also stated that these are reviewed in the daily Stand Up meeting. On 2/15/17 at approximately 2:00 PM, the DNS and Administrator were notified of above findings.

Based on observation, staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure one resident (Resident # 1) in a survey sample of 7 residents was free from safety hazards related to behaviors of lack of poor control and wandering into other residents rooms. For Resident #1, the facility staff failed to implement supervision to keep her safe and failed to develop or implement a care plan to manage her behaviors of wandering room to room resulting in an injury of unknown origin while in the Merry Walker. The resident sustained [REDACTED]. The facility was not able to ascertain how the injury occurred. Findings included: Resident # 1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 5/18/2015. The MDS coded Resident # 1 with cognitive status as moderately impaired; required extensive assistance with activities of daily living and always incontinent of bowel and bladder. On 8/4/2015, a review of the clinical record was conducted. Review of the Social Service Progress Note dated 5/28/2015 stated the resident is independent once she is in her Merry Walker. She rolls herself about the building and activity department has tried numerous attempts for different programs, but Resident # 1's attention span is very short. She wanders in the hallways and at times will wander into other residents rooms. She is easily redirected. She has a history of climbing into bed with another resident. This behavior has not been noted recently. At times she will reach out towards staff and will grab at whatever is accessible at that time. She has a history of rolling her merriwalker into other staff and residents and has to be redirected. She has no safety awareness for herself or others. She continues to have a Wanderguard bracelet. She is being followed by a psychiatrist with medication adjustments. It was also written that Resident # 1 does require assistance with ADLs (Activities of Daily Living) and monitoring for poor safety awareness and inappropriate behaviors as well as medication management. A Social Services Progress Note written on 7/24/2015 described discussion of the incident on 7/20/2015 with the Ombudsman. It was also documented that attempts were made regarding alternative placement at a locked unit but no beds were available at that time. There was a notation that Staff interventions will be kept in place to monitor resident ' s whereabouts and redirect resident from other residents as well as other resident ' s rooms. Social Services to remain available as needed. The Comprehensive care plan for Resident # 1 was reviewed. There was a notation under the focus area of altered communication that the resident is non-verbal, sometimes understands commands or questions from others. She will occasionally shake her head yes or no to answer questions. Her needs are rarely/never understood. There were several notations about the resident using a Merry Walker and wandering into other residents ' rooms. Under focus, Risk for falls: She has dementia and psychosis and her decision making and safety awareness are impaired. Resident uses a Merry Walker which is least restrictive device for safe independent ambulation. When in her Merry Walker, she tends to hover over others. Resident is starting to roll very fast in Merry Walker and rolls into other residents and staff and volunteers. The intervention of Merry Walker for unsteady gait, poor judgment/safety awareness was initiated 4/30/2015 according to the care plan. Focus: Risk for injury related to physical restraint due to use of Merry Walker Sometimes I demonstrate sexually inappropriate behaviors exhibited by: Inappropriate touching, Groping, Disrobing in public, climbed in bed with room mate. She has also been noted to wander in and out of other resident's rooms recently, picking up their water pitchers and trying to drink from them (7/2). She has been noted to strike out at others. sit on the floor and refuse to get up, and attempt to sit on others laps (7/16) Also walks up to other resident so close that her Merry Walker touches them and leans over top of their heads. Resident is easily redirected. (10/23) Doing better on current meds (medications). (1/18/15) No dates for the year was documented for the dates above except for 1/18/15. The goal was listed that the resident will interact with others appropriately during social and care situations or accept redirection without harming self or others over the next 90 days. The interventions listed were: As a diversion, offer me something else I like such as sitting in the hallway watching what others are doing. If I display inappropriate behavior, quietly attempt to re-direct, reminding me that the behavior is not appropriate. The Care Plan included headings Focus Category initiated 7/22/2015. My safety is at risk and there is a potential for abuse due to: Wandering into other resident rooms and reaching out to touch their body and personal items. The Interventions included: please re-direct me when I wander into other rooms or areas that are unsafe for me. Please remove me from potentially dangerous situations. Three separate instances of resident to resident altercations involving Resident #1 and three separate residents were reviewed. The other residents were identified and added to the survey sample as Resident # 2, Resident # 3 and Resident # 7. The incidents will be identified as: Incident # A involved Resident # 1 and Resident # 2, Incident # B involved Resident # 1 and Resident # 3 and Incident #C involved Resident #1 and Resident # 7. Incident #A-occurrence 7/20/2015: Resident # 2, a [AGE] year old male, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 5/12/15. The MDS coded Resident #2 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident was coded as independent or in need of supervision with one person assistance in activities of daily living except extensive help in dressing; and occasionally incontinent of bowel and bladder. On 7/20/2015, Resident # 1 was found with blood coming from her nose and mouth, sitting in the doorway of Resident # 2's room drenched with water. denied knowing what happened. Resident # 2 was not aware of what was going on or how (Resident # 1) sustained the injuries. Unit Manager on Wing 2 Registered Nurse (RN) A stated she saw Resident # 1 with blood coming from her nose and mouth and drenched in water. RN A stated Resident # 2 never exhibited any behaviors until that incident and there have been none involving him since that date. RN A stated the assumption is there was a behavior toward another resident. The assumption was based on the water and ice on the floor, water pitcher on the floor and track marks of water on the floor that led to Resident #2's room. RN A stated Resident # 2 denied any knowledge of what happened to Resident #1. RN A stated the roommate of Resident #2 is blind and his water pitcher was still on the nightstand. RN A stated the police were called and even they could not determine what happened. They said they could not say for sure and said it was speculation. Review of the Verification of Investigation report revealed the facility staff saw Resident # 1 sitting in the resident lounge at 5:40 p.m. and at 5:45 p.m., the staff saw Resident # 1 sitting in the door way of the room belonging to Resident # 2. The staff member pulled the merriwalker back, turned the resident around and noted blood on her face and that her hair and clothing were wet. The physician was in the facility during the incident, examined the resident at 5:50 PM and ordered an x ray of the face. 6:00 p.m. Resident # 2 was interviewed and stated he did not know what happened. The roommate was not interviewed at that time. 6:05 p.m. Other staff members were interviewed and stated they had not heard anything or saw anything unusual. 6:10 p.m. Responsible party was notified. 6:15 p.m. Police notified 6:20 p.m. Police arrived, saw resident, then interviewed Resident # 2, he stated again to police he did not know what happened. 6:25 p.m. Police spoke with resident in A bed (Resident # 2's roommate) who stated I don't know to questions 6:30 p.m. Resident lying in bed after eating dinner. 7:00 p.m. X-ray taken 8:00 p.m. X-ray results called back to facility Undisplaced fracture of nasal bones 8:10 p.m. MD (doctor) notified with new orders 8:15 p.m. Responsible party notified. The Director of Nursing (Admin B) documented: There is a 5 minute gap between 5:40 and 5:45 p.m. that is unaccounted for where resident was not visualized by staff . There were no residents in resident lounge when resident was sitting there. All residents were either in their rooms or in the dining area due to dinner time. Review of the care plan revealed a new entry written on 7/22/2015: Focus: My safety is at risk and there is a potential for abuse due to: Wandering into other resident rooms and reaching out to touch their body and personal items. Date initiated 7/22/2015 Goal: I will be kept safe and free from abuse through my next review Date initiated 7/22/2015 Target date 8/21/2015 Interventions: Please re-direct me when I wander into other rooms or areas that are unsafe for me and Please remove me for potentially dangerous situations, Date initiated: 7/22/2015 There were no other interventions written to keep the resident safe. On 8/4/15 at 2:30 p.m. an interview was conducted with the Director of Nursing (Admin B). The investigation surrounding the injury of unknown origin was reviewed. Facility documentation revealed an investigation was initiated on 7/20/15. Adult Protective Services, the Ombudsman, Resident's Representative, Attending Physician, the Police Department and the Office of Licensure of Certification were notified of the findings on 7/24/15. Staff interviews and resident interviews were conducted. The investigation was completed in a timely manner with the final report being sent to the OLC on 7/24/15. On 8/5/2015 at 11:40 a.m., an interview was conducted with Licensed Practical Nurse (LPN) C who stated a medication adjustment was done on 8/3/2015 where the medication Ativan was decreased because Resident # 1 became lethargic. LPN C stated the physician had ordered the medication Ativan for Resident # 1 on 7/30/2015. Admin C stated Activities Department does something with Resident # 1 everyday but that it was difficult because Resident # 1 has an attention span of about ten seconds. During the debriefing 8/5/2015 at 11:50 a.m., Admin (Administration) C stated she had documentation of one on one activities and Activity Behavior Tracking Sheets. Admin C stated she is trying everything to help this resident. On 8/5/2015 at approximately 3 p.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) B. The MDS Coordinator (RN B) stated the care plan did have interventions about the Merry Walker. The surveyor informed RN B that there were no parameters for instructing the staff of when, how often the restraint should be released. At 4:00 p.m., Admin C presented documentation of activities of one on one, small groups and Activity Behavior Tracking Sheets for January 2015-August 2015. The administrator presented a list of all of the incidents and accidents over the past 3 months involving Resident # 1. There were 6 incidents listed from 5/12/2015-7/20/2015. There were 4 falls and 2 incidents of resident to resident altercations reported since May 2015. The most resident incident of 7/29/2015 where Resident # 1 hit Resident # 3 was not listed. On 8/5/2015 at 4:00 p.m., the Administrator, Director of Nursing (DON) and Corporate Nurse (Admin E) requested a meeting with the surveyors regarding Resident #1. The three stated the facility had tried many things to keep Resident # 1 safe. The DON and Admin E stated interdisciplinary meetings have been held where the facility staff tried to brainstorm to find interventions that would be keep Resident # 1 safe and improve her cognition. The DON stated the facility had tried to find placement in a secure facility but no beds were available. The Administrator stated the facility staff looks out for Resident # 1 because she moves throughout the facility and everybody knows her. The Administrator stated he could not imagine Resident # 1 ever being the aggressor in a resident to resident altercation. The Administrator stated Resident # 1 is back on one on one supervision as of 1:30 p.m. today. There was no documentation that Resident #1 had one on one supervision except for planned or group activities. The surveyor observed a staff member sitting one on one with Resident # 1 at 2:45 p.m. During the end of day debrief, the facility staff was informed of the failure of staff to keep Resident # 1 safe from injury as evidenced by 7 documented incidents including 3 resident to resident altercations. Resident # 1 was the aggressor in one of the resident to resident altercations (on 7/29/2015). No other information was provided. The surveyor attempted to reach the Police Officer who responded to the incident via the telephone. The person who answered stated the officer was not in the office and allowed the surveyor to leave a message on the work voicemail. There was no return call from the Police Officer. An interview was conducted on 8/4/2015 with Resident # 2 who stated he is very familiar with Resident # 1 and that she always goes into other resident's rooms. Resident # 2 stated he remembered that day very well and did not know what happened to Resident #1. Resident # 2 stated he was behind the curtain sitting on the bed taking a bath when he saw the wheels of the Merry Walker from the bottom of the curtain. Resident # 2 said he then heard the nursing staff come to the room and wheel Resident # 1 out of the room. Resident # 2 stated then he heard the nursing staff talking loudly and asking what happened. Resident # 2 stated the nursing staff asked him what happened in the room but he told him he did not know because he was behind the curtain. Resident # 2 stated he did not know how the water pitcher and water got on the floor in his room. Resident # 2 stated that he is active in the Resident Council at the facility and would never hurt anybody. Resident # 2 stated he speaks up for the residents who can't do it for themselves. Resident # 2 stated a lot of the residents have gotten in trouble because of Resident # 1 and some have even had to be put on one on one because of that resident (Resident #1). Resident # 2 stated that Resident # 1 seems to like my room. She always comes in here. I scream out for help when she comes in because I do not want to get in trouble and end up on one on one. Resident # 2 stated a lot of residents are upset because of her. Resident # 2 stated the staff just let her roam around everywhere. Resident # 2 stated other residents are scared they will get in trouble because of this resident. Review of the comprehensive care plan for Resident # 2 revealed no documentation of aggression toward other residents. There was one focus area under activities where it was noted I enjoy helping others and am enjoying calling bingo and cards for residents. Resident has a desire to help out during programs. Incident # B-occurrence 7/29/2015: RN A informed the surveyor during tour that Resident #1 was involved in an incident with another resident one week ago. Resident # 3 was placed in the sample. Resident # 3, an [AGE] year old female, was admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 7/16/2015. The MDS coded Resident #3 with cognitive status as moderately impaired; required extensive assistance of one person with activities of daily living and always incontinent of bowel and bladder. Review of the Nurses Notes revealed an entry documented on 7/29/2015 at 17:15 (5:17 PM) Late Entry note, Resident #3 was in Wheelchair sitting in hall when Resident # 1 rolled up behind her and hit her in the back of the head with an open hand. Assessment was done-no redness, bruises or swelling noted to back of head. Resident # 1 was removed and returned to Wing 1. The doctor was notified. The Responsible Party was notified. Review of the care plan for Resident # 3 revealed an entry under the focus area of altered thought processes. Resident (Resident #3) has poor judgment and safety awareness. Resident has a history of chronic agitation with episodes of yelling, cursing and attempting to hit staff as well as episodes of wandering, refusing care . Resident has a history of being physically abusive to other residents, verbally abusive to roommate. Resident continues to wander in and out of areas and other residents rooms. It was also written that Resident #3 was not easily redirected. Review of the care plan for Resident # 1 revealed no new interventions after the resident to resident altercation on 7/29/2015. Incident # C-occurrence 5/25/2015: Resident # 7, a[AGE] year old female, was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 7/1/2015. The MDS coded Resident # 7 with a BIMS (Brief Interview for Mental Status) of 3/15 indicating severe cognitive impairment; the resident was coded as in need of extensive assistance of one person with activities of daily living; and incontinent of bowel and bladder. On 5/25/2015, Resident #7 was ambulating around the facility unassisted as her norm; was not agitated at the time. While walking, Resident # 7 came into the same area of the facility as Resident # 1. Resident # 1 accidentally bumped into Resident # 7 with her Merry Walker. Resident # 7 turned and struck Resident # 1 on the right side of her face. Residents were separated. The Doctor and responsible parties of both residents were notified. Resident # 7 stated She hit me and I hit her back. Resident # 1 was noted with bruising to right side of face and swollen lip. Resident #7 was placed on close supervision, attempts to place a staff member for one-one monitoring was unsuccessful it caused the resident to become more and more agitated. Close supervision was done until Resident #7 went to bed. Review of the Care plan for Resident # 1 revealed no new interventions for safety after the incident on 5/25/2015. Review of the Progress Notes revealed a Restraint Meeting was held on 6/4/2015: resident was reviewed by the committee for continuous use of the Merry Walker; due to safety awareness and poor judgment in which resident constantly stand and often noted getting into other resident's bed. She is hard to re-direct at times due to [DIAGNOSES REDACTED]. Committee recommends continued use of Merry Walker at this time. On 8/5/2015 at 11:30 a.m., Resident # 1 was observed walking in the Merry Walker in the hallway on Wing 2. A Wanderguard bracelet was on the right ankle. The Activities Coordinator, Admin C, was walking beside Resident # 1 and redirected her when she turned the Merry Walker toward any other residents rooms. Resident # 1 walked short distances then sat down in the Merry Walker. Resident # 1 observed trying to enter other residents rooms. Admin C redirected her and told her to stay in the pathway. Resident # 1 walked 12 steps briskly, stopped and tried to turn around. Admin C redirected her. Resident #1 walked 5 steps briskly, sat down in the Merry Walker for approximately 2 seconds, stood, walked 6 steps, sat down for a couple of seconds, walked 6 steps, sat down, walked 8 steps, sat down, walked 5 steps, sat down and continued along the hallway until she was directed toward her own room by Admin C. The surveyor observed that Resident # 1 sat for a few seconds each time before standing to walk again. It was also observed that Resident # 1 did not steer away from others in the hallways. Resident # 1 almost bumped into other residents sitting in the hallways but was redirected by Admin C. The surveyor asked why Admin C was walking with Resident # 1. Admin C stated she was trying to give the resident some exercise. Admin C also stated we have been trying anything to keep her occupied and increase her cognition. Admin C stated Activities Department does something with Resident # 1 everyday but that it was difficult because Resident # 1 has an attention span of about a ten seconds. During the debriefing at 11:50 p.m., Admin C stated she had documentation of one on one activities and Activity Behavior Tracking Sheets. Admin C stated she is trying everything to help this resident. At 4:00 p.m., Admin C presented documentation of activities one on one, small groups and Activity Behavior Tracking Sheets for January 2015-August 2015. The administrator presented a list of all of the incidents and accidents over the past 3 months involving Resident # 1. There were 6 incidents listed from 5/12/2015-7/20/2015. There were 4 falls and 2 incidents of resident to resident altercations reported since May 2015. The most recent resident to resident altercation of 7/29/2015 where Resident # 1 hit Resident # 3 was not listed. Review of the care plan revealed documentation of risk for falls related to limited mobility and use of anti-psychotic and anti-depressant medications. Resident requires limited assistance with transfers and bed mobility. Resident will throw herself to the floor intentionally at times. She has dementia and psychosis and her decision making and safety awareness are impaired. Resident takes off socks and put them on her hands. Resident uses a merrywalker which is the least restrictive device for safe independent ambulation. When in her merry walker she tends to hover over others. Resident is starting to roll very fast in merry walker and rolls into other residents and staff and volunteers. Fall in room (6/3/2015) Slid from bed to floor (6/11/2015) Date initiated 5/21/2015 The new interventions were: Get resident out of bed when restless. Date initiated 5/28/2015 Floor mats beside bed while in bed. Date initiated 6/13/2015 Review of the Progress Notes revealed a note written by the Director of Nursing on 7/23/2015 that documented the Interdisciplinary team (IDT) met to update plan of care and to discuss interventions to be put into place for resident. When resident is up all staff is to constantly monitor residents location and to redirect her from other residents ' rooms. MD (doctor) in this afternoon to evaluate and/or adjust medications as needed. Alternative placement was also discussed and to be followed up on by Social Services. Progress Note 7/23/2015, doctor in to see resident. New orders for labwork, increase Zyprexa to 10 milligrams every morning, increase Exelon to 6 milligrams every 12 hours and change Lisinopril to once a day. 7/24/2015 Progress Note: Order for Remeron clarified, new order to discontinue Remeron, start Seroquel 25 milligrams one tablet three times per day and Seroquel 75 milligrams at bedtime. 8/3/2015: New order to decrease Ativan to 0.5 milligrams every 8 hours due to drowsiness. There were several notations of the Resident # 1 ambulating in her Merry Walker and wandering into other resident ' s rooms before and after the resident to resident altercations. There was also notation that the resident was easily redirected. On 8/5/2015 at 11:40 a.m., an interview was conducted with Licensed Practical Nurse (LPN) C who stated a medication adjustment was done on 8/3/2015 where the medication, Ativan, was decreased because Resident # 1 became lethargic. LPN C stated the physician had ordered the medication Ativan for Resident # 1 on 7/30/2015. On 8/5/2015 at approximately 3 p.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, Registered Nurse (RN) B. The MDS Coordinator (RN B) stated the care plan did have interventions about the Merry Walker. The surveyor informed RN B that there were no parameters for instructing the staff of when, how often the restraint should be released. On 8/5/2015 at 4:00 p.m., the Administrator, Director of Nursing (DON) and Corporate Nurse (Admin E) requested a meeting with the surveyors regarding Resident #1. The three stated the facility had tried many things to keep Resident # 1 safe. The DON and Admin E stated interdisciplinary meetings have been held where the facility staff tried to brainstorm to find interventions that would be keep Resident # 1 safe and improve her cognition. The DON stated the facility had tried to find placement in a secure facility but no beds were available. The Administrator stated the facility staff looks out for Resident # 1 because she moves throughout the facility and everybody knows her. The Administrator stated he could not imagine Resident # 1 ever being the aggressor in a resident to resident altercation. The Administrator stated Resident # 1 is back on one on one supervision as of 1:30 p.m. today. The surveyor observed a staff member sitting one on one with Resident # 1 at 2:45 p.m. During the end of day debrief, the facility staff was informed of the failure of staff to keep Resident # 1 safe from injury as evidenced by 7 documented incidents including 3 resident to resident altercations. Resident # 1 was the aggressor in one of the resident to resident altercations (the most recent altercation on 7/29/2015.) No other information was provided. The facility failed to keep Resident #1 safe, the resident received a nasal bone fracture while ambulating within a merriwalker. This is a harm deficiency.

Based on staff interview, facility documentation review, closed clinical record review, as Resident #101 had expired, and in the course of a complaint investigation, facility staff failed to ensure sufficient fluid intake to maintain proper hydration and health resulting in harm for 1 resident (Resident #101) in the survey sample of 16 residents. Facility staff failed to obtain Intravenous (IV) access and to administer IV Normal Saline solution timely, as ordered by the doctor on [DATE]. The IV access was not obtained until [DATE] and the Resident did not receive any IV (intravenous) fluids until 6:01 p.m.on [DATE], contributing to already diagnosed dehydration. Resident #101 experienced [MEDICAL CONDITION] [DATE] at 10:36 p.m., was sent to the hospital at 11:00 p.m. on [DATE] and was pronounced dead at 11:09 p.m.. The Findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, 'start when IV access is obtained'. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON (Director of Nursing) were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review, as Resident #101 had expired, and in the course of a complaint investigation, facility staff failed to obtain an IV (intravenous access) timely, resulting in harm for 1 resident (Resident #101) in the survey sample of 16 residents. Facility staff failed to obtain IV (intravenous) access timely, and to provide IV fluids and antibiotics per the doctors orders on [DATE], resulting in harm. Resident #101 began receiving the medication and fluids on [DATE], and experienced [MEDICAL CONDITION], was sent to the emergency room where Resident #101 was pronounced dead. The Findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, BUN (blood urea nitrogen) was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility document review, closed clinical record review, as Resident #101 was expired, and in the course of a complaint investigation, the facility staff failed to ensure one resident was free from significant medication errors (Resident #101) resulting in harm, from the survey sample of 16 residents. For Resident #101, the IV (intravenous) antibiotic medication [MEDICATION NAME] for pneumonia treatment, and IV normal saline medication fluids for dehydration were ordered on [DATE]. Administration of the antibiotic and fluids did not begin until 3 days later on [DATE] just hours before the Resident suffered [MEDICAL CONDITION], was sent to the hospital and pronounced dead. The findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review as Resident #101 was expired, and in the course of a complaint investigation, the facility staff did not notify the physician of the failure to obtain IV access timely, as ordered for one (Resident #101) in the survey sample of 16 residents. For Resident #101, the facility staff failed to notify the physician that timely IV (intravenous) access was not obtained for the administration of IV fluids and IV antibiotic. The physician ordered IV fluids and IV antibiotic on [DATE]. The physician was not informed of the failure to obtain IV access. A PICC (peripherally inserted central line catheter) line was placed on [DATE]. The findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was informed on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT (immediately) on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36 milligrams/deciliter, and Creatinine was high at 1.62 milligrams/deciliter. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON (Director of Nursing) were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review, as Resident #101 had expired, and in the course of a complaint investigation, facility staff failed to ensure sufficient fluid intake to maintain proper hydration and health resulting in harm for 1 resident (Resident #101) in the survey sample of 16 residents. Facility staff failed to obtain Intravenous (IV) access and to administer IV Normal Saline solution timely, as ordered by the doctor on [DATE]. The IV access was not obtained until [DATE] and the Resident did not receive any IV (intravenous) fluids until 6:01 p.m.on [DATE], contributing to already diagnosed dehydration. Resident #101 experienced [MEDICAL CONDITION] [DATE] at 10:36 p.m., was sent to the hospital at 11:00 p.m. on [DATE] and was pronounced dead at 11:09 p.m.. The Findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, 'start when IV access is obtained'. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON (Director of Nursing) were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility document review, closed clinical record review, as Resident #101 was expired, and in the course of a complaint investigation, the facility staff failed to ensure one resident was free from significant medication errors (Resident #101) resulting in harm, from the survey sample of 16 residents. For Resident #101, the IV (intravenous) antibiotic medication [MEDICATION NAME] for pneumonia treatment, and IV normal saline medication fluids for dehydration were ordered on [DATE]. Administration of the antibiotic and fluids did not begin until 3 days later on [DATE] just hours before the Resident suffered [MEDICAL CONDITION], was sent to the hospital and pronounced dead. The findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review as Resident #101 was expired, and in the course of a complaint investigation, the facility staff did not notify the physician of the failure to obtain IV access timely, as ordered for one (Resident #101) in the survey sample of 16 residents. For Resident #101, the facility staff failed to notify the physician that timely IV (intravenous) access was not obtained for the administration of IV fluids and IV antibiotic. The physician ordered IV fluids and IV antibiotic on [DATE]. The physician was not informed of the failure to obtain IV access. A PICC (peripherally inserted central line catheter) line was placed on [DATE]. The findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was informed on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT (immediately) on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36 milligrams/deciliter, and Creatinine was high at 1.62 milligrams/deciliter. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON (Director of Nursing) were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

2. For Resident #113, the facility staff failed to administer Resident #113' s [MEDICATION NAME] (a medication for hypertension) on [DATE] and [DATE]. Resident #113 was admitted to the facility on [DATE] and readmitted after hospitalization on [DATE]. [DIAGNOSES REDACTED]. Resident #113's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #113 with short and long term memory problems and severely impaired cognition. In addition, the Minimum Data Set coded Resident #113 as requiring total assistance from staff for her Activities of Daily Living care. A review of Resident #113's clinical record was conducted during the survey. The review showed a physician order [REDACTED]. Monitor B/P (blood pressure), give prn (as needed) [MEDICATION NAME] for SBP (systolic blood pressure) > (greater than) 150; hold for SBP < (less than) 100 - Notify MD (Medical Doctor). PEG is a percutaneous endoscopic gastrostomy tube, which is a plastic flexible tube, surgically inserted through the abdominal wall into the stomach. A review of Resident #113 's EMAR (Electronic Medication Administration Record) was conducted during the survey. The review showed that Resident #113 was not administered [MEDICATION NAME] at 5 p.m. on [DATE] and [DATE]. Documentation on the EMAR for both missed doses read, "3-Hold/See Nurse Notes." A review of the eMAR-Medication Administration nurse's notes for [DATE], 19:05 (7:05 p.m.) read, "BP ,[DATE]". The eMAR-Medication Administration nurse's notes dated [DATE], 16:23 (4:23 p.m.) read, "B/P ,[DATE]." There was no evidence of a SBP < 100. On [DATE] at 1:30 p.m. an interview was conducted with the unit manager, LPN (Licensed Practical Nurse) B. After reviewing Resident #113's clinical record, LPN B stated, "I don't know why she (LPN E) did not administer the medication. The medication should have been given." The director of nursing cited Lippincott as the facility's professional nursing reference. "Fundamentals of Nursing, 7th Edition" by Potter-Perry, provided nursing guidance for medication administration. Page 336 read, "The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients." The facility administration was informed of the findings during a briefing on [DATE] at approximately 3:50 p.m. The facility did not present any further information or explanation about the findings. Based on staff interview, facility documentation review, closed clinical record review as Resident #101 was expired, and in the course of a complaint investigation, the facility staff failed to follow the professional standards of nursing for medication administration for 2 residents (Resident #101, and #113) resulting in harm for Resident #101, of 16 residents in the survey sample 1. For Resident #101, the facility staff failed to administer and document medications and treatments as ordered resulting in harm. The physician ordered IV fluids and IV antibiotic on [DATE]. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. 2. For Resident #113, the facility staff failed to administer Resident #113' s [MEDICATION NAME] (a medication for hypertension) on [DATE] and [DATE]. The Findings Included: 1. Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas the following: a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was given the information on [DATE] at 11:26 p.m., and made aware of the test results. No new orders were given. The chest x-ray results read, "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to say the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware. No response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE], and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, Blood Pressure normal rates are less than ,[DATE]. Systolic 120/ Diastolic 80. On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were again at 24 per minute. The nursing notes read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes read the Resident returned to the facility at 5:45 p.m. and the doctor was made aware of the venous doppler not being completed with the reason stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE], and showed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC (complete blood count), CMP (comprehensive metabolic panel), repeat CXR (chest XRay), and a CT (computed tomography) of the chest to be done at the hospital. The nursing progress notes revealed that the doctor was not made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. http://www.mayoclinic.org/tests-procedures/complete-blood-count/basics/results/prc- 088 normal range of WBC according to the above is 3XXX,[DATE].5 billion cells/liter On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained elevated at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page, and on [DATE] at 4:40 p.m. The doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (Licensed Practical Nurse) (C) and RN (Registered Nurse) (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review, as Resident #101 had expired, and in the course of a complaint investigation, facility staff failed to obtain an IV (intravenous access) timely, resulting in harm for 1 resident (Resident #101) in the survey sample of 16 residents. Facility staff failed to obtain IV (intravenous) access timely, and to provide IV fluids and antibiotics per the doctors orders on [DATE], resulting in harm. Resident #101 began receiving the medication and fluids on [DATE], and experienced [MEDICAL CONDITION], was sent to the emergency room where Resident #101 was pronounced dead. The Findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, BUN (blood urea nitrogen) was significantly high at 36, and Creatinine was high at 1.62. Reference range for lab results as documented was normal ,[DATE] milligrams/deciliter (mg/dl) and Creatinine norms were XXX,[DATE].40 mg/dl. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency. Based on staff interview, facility documentation review, closed clinical record review, as Resident #101 had expired, and in the course of a complaint investigation, facility staff failed to ensure proper treatment and care of an IV (intravenous access) resulting in harm for 1 resident (Resident #101) in the survey sample of 16 residents. Facility staff failed to obtain IV (intravenous) access and provide IV fluids and antibiotics per the doctors orders on [DATE], resulting in harm. Resident #101 began receiving the medication and fluids on [DATE], and experienced [MEDICAL CONDITION], was sent to the emergency room where Resident #101 was pronounced dead. The Findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS also coded as problem areas as a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. Review of hospital discharge information that was received by the facility upon admission revealed laboratory and diagnostic tests dated [DATE] and are listed below; White blood cell count (CBC) high at 12.2 (normal range is 3.20 to 9.58) Sodium, Potassium, and Chloride normal Blood urea nitrogen (BUN) high at 38 (normal range is ,[DATE]) Creatinine (Creat) high at 2.03 (normal range is 0.5 to 1.4) A Chest x-ray exam was also included and dated [DATE] which denoted that "Hypoinflated lungs with partial bilateral lower lung atelectasis (collapse); superimposed infection or aspiration is difficult to exclude." Vital signs on [DATE] at 3:37 p.m. the day before discharge and while in the hospital included; Blood pressure of ,[DATE], pulse of 59, respirations of 16, no fever, and oxygen saturation of 100%. The Resident was not receiving oxygen. These readings were the Resident's baseline and varied little while hospitalized . While hospitalized Resident #101 was evaluated by a Nephrology (kidney) doctor on [DATE], and [DATE], who documented in progress notes that the Resident's creatinine had risen prompting the consultation because of dye used for diagnostic tests, and that the Resident had poor urine output. The resident was ordered to have strict I&O (oral fluid intake and urine output) measurements. The Resident had a Foley catheter to drain urine from the bladder, and was placed on IV fluids to include normal saline at 50 ml (milliliters) per hour. Resident #101 had no abnormal lung sounds and no respiratory difficulty and was not receiving oxygen. The Resident was taking [MEDICATION NAME] (fluid removal drug) at home, however, this was discontinued in the hospital. Resident #101's urine output had improved during the hospital stay from [DATE] to [DATE], and was documented as 800 ml from [DATE] to [DATE] and 1200 ml from [DATE] to [DATE] in the nephrology progress notes. Resident #101 was initially hospitalized for [REDACTED]. Resident #101 was also seen by the vascular surgeon after surgery for [REDACTED]. was removed, as improvement was seen and the IV fluids were no longer necessary. Discharge instructions from the hospital revealed "call 911 do not drive yourself to the hospital for sudden onset of shortness of breath, if significant bleeding develops or swelling occurs, if you have a stroke." On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and stated that the lung sounds were clear. The document further read the Resident has a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however it did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes describe the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was spoken to on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read, "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read that the Resident was now confused, which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware. No response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was elevated to ,[DATE], and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE]. On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was elevated at ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes stated the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was elevated at ,[DATE], and respirations were back up to 24 per minute. The nursing notes read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note stated that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and read, "no significant pericardial effusion", and the diagnostic report had a hand written note on it which read the nursing staff made the facility doctor aware of the findings on [DATE] and the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes revealed the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm. The doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks. The surgically i

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to safely store an E cylinder in one resident's (Resident#19's) room out of 25 residents in the survey sample. One E cylinder of oxygen was stored unsecured in Resident #19's room. The findings included: Resident #19 was initially admitted to the facility 1/10/11. The [DIAGNOSES REDACTED]. Resident #19's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1/6/14 was coded as a quarterly assessment. Resident #19 was coded as having a BIMS (Brief Interview of Mental Status) score of 9, moderate impaired cognition. He was coded as requiring extensive to total dependence on staff for his activities of daily living. Resident #19 was coded as having ROM (range of motion) impairment to his upper and lower extremities. On 4/3/14 at 9:00 a.m., Resident #19 was observed in his room, in his bed. Resident #19 did not speak during this observation, but he was very cooperative of all requests to inspect his arms and hands. Resident #19 was unable to raise his left arm and hand. After observing and talking with Resident #19, an E cylinder of oxygen with a regulator in place was observed sitting upright on the floor in between two large clothing wardrobes and positioned beside a wheel chair. The cylinder was not secured to any safety device or storage holder. On 4/3/14 at 9:05 a.m. LPN (licensed practical nurse) B was asked to enter the room and was shown the unsecured E cylinder. The regulator on the E cylinder indicated the tank was close to empty. LPN B stated, "The resident's roommate went out to have a procedure and someone left it there. It should be in a cart." LPN B immediately removed the tank from the room. The DON (director of nursing) provided the facility's policy for "OXYGEN SAFETY" that included: "-All cylinder tanks must be secured in a stand or to the wall of the storage room." Additionally, guidance was provided by Joint Commission at www.jointcommission. org, "It may be impractical for some organizations to have piped nonflammable medical gases, so they may provide these gases in freestanding cylinders of various sizes. All freestanding cylinders must be stored in a rack, a cart, or another enclosure to protect them. Unsecured cylinders could fall, breaking the valve and possibly resulting in a rapid release of the gas, propelling the cylinder and turning it into a dangerous projectile." On 4/3/14 at 2:30 p.m. the administrator and director of nursing were advised of the failure of the staff to ensure an oxygen cylinder was stored in a secure manner.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to follow professional standards of nursing for medication administration for seven Residents (Residents' #6, #17, #7, #13, #12, #21, and #24) in a survey sample of 25 Residents. 1. For Resident #6, the facility staff failed to document medications as having been administered on 3/9/14; 2. For Resident #17, the facility staff failed to document medications as having been administered on 3/9/14; 3. For Resident # 7, the facility staff failed to document medications as having been administered; 4. For Resident # 13, the facility staff failed to document medications as having been administered; 5. For Resident #12, the facility staff failed to administer Resident #12 ' s [MEDICATION NAME] (a medication for dementia), [MEDICATION NAME] (an antipsychotic), Bactrim (an antibiotic), [MEDICATION NAME] (a laxative), [MEDICATION NAME] (a medication for Hypertension), [MEDICATION NAME] (a medication for diabetes), and Glucerna 1.2 (a nutritional formula) on 03/09/2014. In addition, the facility staff failed to obtain blood pressure readings on 03/09/2014 (day and evening shift), 03/13/2014 (day shift), 03/21/2014 (night shift), 03/24/2014 (day shift), and 03/28/2014 (evening shift). 6. For Resident #21, the facility staff failed to administer Resident #21 ' s [MEDICATION NAME] (for neuralgia) and [MEDICATION NAME] (for muscle spasms) on 03/14/2014. 7. For Resident #24, the facility staff failed to administer Resident #21 ' s [MEDICATION NAME] (a medication for difficult urination) on 03/12/2014. The findings included: 1. For Resident #6, the facility staff failed to document medications as having been administered on 3/9/14. Resident #6, a female, was initially admitted to the facility 3/6/09 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 2/3/14 was coded as a quarterly assessment. Resident #6 was coded as having no memory deficits and was able to make her own daily life decisions. Resident #6 was also coded as needing extensive to total assistance with all of her activities of daily living. Review of Resident #6's clinical record also revealed the following medications were not documented as having been administered on the days indicated: [MEDICATION NAME] 12.5 mg (milligram) Every 12 hours ([MEDICAL CONDITION]): 3/9/14 at 9 p.m. [MEDICATION NAME] 600 mg every 12 hours (cough): 3/9/14 at 9 p.m. [MEDICATION NAME] 600 mg every 12 hours (urinary tract infection): 3/9/14 at 9 p.m. Valid physician's orders [REDACTED]. When interviewed, the DON (Director of Nursing) stated 4/3/14 at 2:30 p.m., if the medications were not documented, they were not given. The DON also stated staff should document the medications as soon as they are administered. Review of the facility's policy entitled "Medication Administration General Guidelines" included: "4. The resident's MAR/TAR (treatment administration record) is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log." The administrator and DON (director of nursing) were informed of the failure of the staff to document medications as having been administered to Resident #6 on 3/9/14, 4/3/14 at 2:30 p.m. 2. For Resident #17, the facility staff failed to document medications as having been administered on 3/9/14. Resident #17, a female, was initially admitted to the facility 5/28/08 and readmitted after a hospitalization [DATE]. Her [DIAGNOSES REDACTED]. Resident #17's most recent MDS with an ARD of 1/2/14 was coded as a quarterly assessment. She was coded as having short and long term memory deficits and required moderate assistance in making daily life decisions. Resident #17 was coded as needing extensive assistance of one staff member to perform her activities of daily living. Review of Resident #17's clinical record revealed no documentation the following medications were administered on the days and times indicated: [MEDICATION NAME] P 0.1% Instill 1 drop in right eye two times a day (open angle [MEDICAL CONDITION]); 3/9/14 at 5 p.m. [MEDICATION NAME] 1% 1 drop in right eye twice daily (open angle [MEDICAL CONDITION]): 3/9/14 at 5 p.m. Sodium [MEDICATION NAME] tablet 650 mg 1 tablet two times a day: 3/9/14 at 5 p.m. Pain assess every shift: 3/3/14 on night shift, 3/9/14 on evening shift Valid physician's orders [REDACTED]. The administrator and DON were informed of the failure of the staff to document the above mentioned medications as having been administered, 4/3/14 at 2:30 p.m. 3. For Resident # 7, the facility staff failed to document medications as having been administered. Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 1/28/14. The MDS coded Resident #7 as being cognitively intact; requiring extensive assistance from staff for transfers, dressing, toileting and hygiene; requiring set up only for eating; and incontinent of bowel and bladder. Review of the MARs (medication administration record) revealed the following medications were not documented as having been administered: "[MEDICATION NAME] 10 mg (dementia) - 1/21/14 [MEDICATION NAME] 30 mg (depression) - 1/21/14 [MEDICATION NAME] 25 mg ([MEDICAL CONDITION]) - 1/5/14, 11/20/14, and 1/21/14 [MEDICATION NAME] Nebulizer ([MEDICAL CONDITION]) - 1/21/14" On 4/2/14 at 5:20 p.m., the unit manager, RN A, was questioned about the medications that were not documented as having been administered. RN (registered nurse) A stated, "They should have documented they gave the medications." Review of the facility's policy entitled Medication Administration, under Documentation read, "The individual who administers the medication dose, records the administration on the resident's MAR following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication." "Fundamentals of Nursing, 7th Edition" by Potter-Perry, provided nursing guidance for medication administration. Page 336 read, "The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients." Page 709 read, "After administering the medication, indicate which medications were given on the client's (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care." The DON (Director of Nursing) cited Lippincott as the facility's reference for professional nursing standards. On 4/3/14 at approximately 2:30 p.m., the administrator and the director of nursing were notified of findings. 4. For Resident # 13, the facility staff failed to document medications as having been administered Resident #13 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 2/4/14. The MDS coded Resident #13 as being severely cognitively impaired with a BIMS (Brief Interview of Mental Status) score of 5. Resident #13 was coded as requiring extensive assistance from staff for transfers, dressing, toileting, hygiene, and eating. He was coded incontinent of bowel and bladder. Review of the February 2014 MARs (medication administration record) revealed the following medications that were not documented as having been administered: "[MEDICATION NAME] 25 mcg ([MEDICAL CONDITION]) - 2/8/14. [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg ([MEDICAL CONDITION]) - 2/2/14. [MEDICATION NAME] 300 mg (nerve pain) - 2/2/14." On 4/2/14 at 5:20 p.m., the unit manager, RN A was questioned about the omissions in documentation. She stated, "They should have documented they gave the medications." Review of the facility's policy entitled Medication Administration, under Documentation, read, "The individual who administers the medication dose, records the administration on the resident's MAR following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. "Fundamentals of Nursing, 7th Edition" by Potter-Perry, provided nursing guidance for medication administration. Page 336 read, "The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients." Page 709 read, "After administering the medication, indicate which medications were given on the client's (Medication Administration Record) per agency policy to verify that the medication was given as ordered. Record medication administration as soon as medications are given to client. Inaccurate documentation of medications, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about client care." The DON cited Lippincott as the facility reference for professional nursing standards. On 4/3/14 at approximately 2:30 p.m., the DON and Administrator were notified of findings. 5. For Resident #12, the facility staff failed to administer Resident #12 ' s [MEDICATION NAME] (a medication for dementia), [MEDICATION NAME] (an antipsychotic), Bactrim (an antibiotic), [MEDICATION NAME] (a laxative), [MEDICATION NAME] (a medication for Hypertension), [MEDICATION NAME] (a medication for diabetes), and Glucerna 1.2 (a nutritional formula) on 03/09/2014. In addition, the facility staff failed to obtain blood pressure readings on 03/09/2014 (day and evening shift), 03/13/2014 (day shift), 03/21/2014 (night shift), 03/24/2014 (day shift), and 03/28/2014 (evening shift). Resident #12 was admitted to the facility on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #12 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 01/24/2014 coded Resident #12 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision-making. In addition, the Minimum Data Set coded Resident #12 requiring total dependence, on staff, for Activities of Daily Living care. A review of Resident #12 ' s clinical record was conducted during the survey. The review showed a physician order [REDACTED].#12 was to get 10 milligrams of [MEDICATION NAME] daily. The review showed a physician order [REDACTED].#12 was to get 12.5 milligrams of [MEDICATION NAME] at bedtime. The review showed a physician order [REDACTED].#12 was to get 800/160 milligrams of Bactrim DS two times a day. The review showed a physician order [REDACTED].#12 was to get 10 grams of [MEDICATION NAME] two times a day. The review showed a physician order [REDACTED].#12 was to get 25 milligrams of [MEDICATION NAME] two times a day. The review showed a physician order [REDACTED].#12 was to get 20 units of [MEDICATION NAME] two times a day. The review showed a physician order [REDACTED].#12 was to get 1 can of Glucerna 1.5 five times a day. The review showed a physician order [REDACTED].#12 was to have blood pressure readings taken every shift. A review of Resident #12 ' s Medication Administration Record [REDACTED]. In addition, the Medication Administration Record [REDACTED]. The facility administration was informed of the findings during a briefing on 04/03/2014 at approximately 2:25 p.m. During the briefing, the Director of Nursing stated that medications should be signed off when given. The facility did not present any further information about the findings. 6. For Resident #21, the facility staff failed to administer Resident #21 ' s [MEDICATION NAME] (for neuralgia) and [MEDICATION NAME] (for muscle spasms) on 03/14/2014. Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #21 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/20/2013 coded Resident #21 with short-term memory problems, long-term memory problems, and with moderately impaired cognitive skills for daily decision-making. In addition, the Minimum Data Set coded Resident #21 requiring extensive assistance for Activities of Daily Living care. A review of Resident #21 ' s clinical record was conducted during the survey. The review showed a physician order [REDACTED].#21 was to get 5 milligrams of [MEDICATION NAME] two times a day. The review showed a physician order [REDACTED].#21 was to get 10 milligrams of [MEDICATION NAME] every 8 hours. A review of Resident #21 ' s Medication Administration Record [REDACTED]. The facility administration was informed of the findings during a briefing on 04/03/2014 at approximately 2:25 p.m. During the briefing, the Director of Nursing stated that medications should be signed off when given. The facility did not present any further information about the findings. 7. For Resident #24, the facility staff failed to administer Resident #24 ' s [MEDICATION NAME] (a medication for difficult urination) on 03/12/2014. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #24 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/14/2014 coded Resident #24 with no cognitive impairment. In addition, the Minimum Data Set coded Resident #24 requiring limited assistance for Activities of Daily Living care. A review of Resident #24 ' s clinical record was conducted during the survey. The review showed a physician order [REDACTED].#24 was to get 0.4 milligrams of [MEDICATION NAME] in the evening. A review of Resident #24 ' s Medication Administration Record [REDACTED]. The facility administration was informed of the findings during a briefing on 04/03/2014 at approximately 2:25 p.m. During the briefing, the Director of Nursing stated that medications should be signed off when given. The facility did not present any further information about the findings.

Based on staff interview, facility documentation review, closed clinical record review as Resident #101 was expired, and in the course of a complaint investigation, the facility staff did not notify the physician of the failure to obtain IV access timely, as ordered for one (Resident #101) in the survey sample of 16 residents. For Resident #101, the facility staff failed to notify the physician that timely IV (intravenous) access was not obtained for the administration of IV fluids and IV antibiotic. The physician ordered IV fluids and IV antibiotic on [DATE]. The physician was not informed of the failure to obtain IV access. A PICC (peripherally inserted central line catheter) line was placed on [DATE]. The findings included: Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and be understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was informed on [DATE] at 11:26 p.m., and made aware of the test results and did not give any new orders. The chest x-ray results read There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]. The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to read the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware, no response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE] millimeters of mercury, and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, B/P norms are less than ,[DATE] millimeters of mercury (mm/Hg). On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were back up to 24 per minute. The nursing notes go on to read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated no significant pericardial effusion, and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form dehydration in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New STAT (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT (immediately) on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes stated that the Resident returned to the facility at 5:45 p.m. and that the doctor was made aware of the venous doppler not being completed. The reason for this was stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE]. The labs revealed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC, CMP, repeat CXR, and a CT (computed tomography) of the chest to be done at the hospital. At no time do the nursing progress notes reveal that the doctor was made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained high at 21.68, Bun was significantly high at 36 milligrams/deciliter, and Creatinine was high at 1.62 milligrams/deciliter. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page. On [DATE] at 4:40 p.m. the doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot which had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (C) and RN (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated no. RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to stick the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on Inserting a Peripheral IV Catheter stated INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained. Facility policy on Medication Administration read, Medications are administered as prescribed, and in accordance with written orders of the prescriber, and if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified. Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. Guidance for nursing standards for the administration of medication was provided by Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. On [DATE] at 4:00 p.m. the Administrator and DON (Director of Nursing) were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency.

Based on staff interview, facility documentation review, closed clinical record review as Resident #101 was expired, and in the course of a complaint investigation, the facility staff failed to follow the professional standards of nursing for medication administration for 2 residents (Resident #101, and #113) resulting in harm for Resident #101, of 16 residents in the survey sample 1. For Resident #101, the facility staff failed to administer and document medications and treatments as ordered resulting in harm. The physician ordered IV fluids and IV antibiotic on [DATE]. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. 2. For Resident #113, the facility staff failed to administer Resident #113' s [MEDICATION NAME] (a medication for hypertension) on [DATE] and [DATE]. The Findings Included: 1. Resident #101 was admitted to the facility on [DATE]. Resident #101's [DIAGNOSES REDACTED]. It is notable to mention that the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), which was an Admission 5 day Assessment, with an Assessment Reference Date (ARD) of [DATE], coded Resident #101 as being able to understand and understood by others. Resident #101 was coded as needing extensive assistance of 1 to 2 staff members for all activities of daily living with the exceptions of being totally dependent for Bathing, and requiring a 1 person limited physical assistance with eating. The MDS assessment also coded as problem areas the following: a poor appetite for ,[DATE] days during the preceding week, shortness of breath, complaints of difficulty or pain with swallowing, a mechanically altered diet, full dentures, 2 venous or arterial ulcers, nutrition or hydration interventions to manage skin problems, pressure ulcers, pneumonia, indwelling Foley urinary catheter and incontinence of bowel. On [DATE] Resident #101 was admitted to the facility and an admission assessment was completed by nursing staff at 5:00 p.m. The assessment revealed Resident #101 was experiencing shortness of breath and required oxygen, and read that the lung sounds were clear. The document further read the Resident had a need for temporary exact measurement of urine output. The document denoted no nutritional or dehydration risk. Review of the Care Plan for Resident #101 dated [DATE] revealed interventions for pressure and venous ulcers, however did not include nutrition or hydration program to manage skin care problems. The Resident was placed on a mechanically altered soft diet, and daily dietary intake was to be monitored to include all food and beverages. There was further documentation that rehab was to be notified for possible assessment. On [DATE] the Speech Therapist evaluated the Resident and the doctor ordered speech therapy to see the Resident 5 times per week for treatment of [REDACTED]. The nursing progress notes and lab results were reviewed and documentation follows: On [DATE] at 11:51 p.m. 400 ml (milliters) of clear yellow urine output, the doctor had written new admission orders [REDACTED]. On [DATE] at 5:47 a.m. the notes described the Foley catheter draining amber colored urine, no amount was given, and at 4:30 p.m. the Resident had to be fed by staff. That evening nursing notes revealed at 8:24 p.m. the doctor was in to evaluate the Resident and ordered multiple laboratory blood tests, an echocardiogram (ECHO) of the heart, an electrocardiogram (EKG) of the heart, and a chest x-ray. On [DATE] at 2:44 p.m. the doctor was paged by nursing staff to report the results of the lab and diagnostic test results. The doctor was given the information on [DATE] at 11:26 p.m., and made aware of the test results. No new orders were given. The chest x-ray results read, "There are findings of early pneumonia in each lower lung field. The heart is normal. There is no evidence of [MEDICAL CONDITIONS]." The CBC (complete blood count) revealed white blood cells count (WBC's) decreased from the time of hospitalization , at 10.6. The note went on to say the Resident was now confused which was a new finding. On [DATE] at 3:38 a.m. the Resident's urine was described as clear yellow. On [DATE] at 3:10 p.m. the Resident was complaining of pain to the penis and nursing staff called and made the Resident's son and doctor aware. No response was given by the doctor. On [DATE] at 7:13 p.m. Resident #101's urine was tea colored and only 200 ml of output was listed for the shift, the blood pressure (BP) reading was ,[DATE], and respirations had increased to 24 per minute. Normal urine output is 800 ml to 2000 ml per day according to http://www.nlm.nih.gov/medlineplus/ency/article/ 5.htm Also, according to the website: http://www.hopkinsmedicine.org/healthlibrary/conditions/cardiovascular_diseases/vital_signs_body_temperature_pulse_rate_respiration_rate_blood_pressure_85,P / normal respirations at rest are 12 to 16 breaths per minute. And same website, Blood Pressure normal rates are less than ,[DATE]. Systolic 120/ Diastolic 80. On [DATE] at 5:29 a.m. urine output was only 200 ml no color described, the BP was ,[DATE] and respirations remained at 24 per minute. On [DATE] at 3:32 p.m. urine output was described as yellowing and 350 ml for the shift, the BP was elevated at ,[DATE], with respirations at 20 per minute. On [DATE] at 10:26 p.m. and 10:31 p.m. nursing notes read the Resident refused dinner but did consume ,[DATE] bowl of chicken noodle soup and complained of difficulty swallowing and that the food had no taste. The Resident's BP was ,[DATE], and respirations were again at 24 per minute. The nursing notes read that the Resident's urine was tea colored, the nursing staff would continue to monitor food intake, the son was made aware, and that the doctor had been paged. No response from the doctor was received and the note read that the 7:00 a.m. to 3:00 p.m. shift would follow up with trying to contact the doctor in the morning. On [DATE] at 1:00 p.m. results of the echocardiogram completed on [DATE], was received by the facility, and stated "no significant pericardial effusion", and the diagnostic report had a hand written note on it which stated the nursing staff made the facility doctor aware of the findings on [DATE] and that the doctor issued no new orders. On [DATE] at 2:56 p.m. the facility nursing staff LPN(*****) faxed a request to the hospital for a PICC (peripherally inserted central line catheter) insertion procedure to be done and stated on the form "dehydration" in the blank area which was provided on the form asking for most recent BUN/Creatinine labs: denoting staff knowledge of dehydration at this time. On [DATE] at 5:47 p.m. nursing notes revealed the doctor was notified of the difficulty swallowing and that the Resident was experiencing pain to the penis and tea colored urine. New "STAT" (obtain immediately) orders were received from the doctor for; Complete blood count (CBC), Basic metabolic profile (BMP), chest x-ray (CXR), and IV normal saline to infuse at 75 ml per hour for 72 hours, start when IV access is obtained. On [DATE] at 5:59 p.m. nursing notes reveal the Resident was congested, short of breath, coughing, and that lung sounds in the left upper lobe congested, and diminished. The doctor was notified and ordered IV antibiotic medication [MEDICATION NAME] 3.75 mg (milligrams) IV every 8 hours for 10 days duration when IV access obtained. On [DATE] at 11:05 p.m., the doctor was made aware of the chest x-ray results and [MEDICAL CONDITION] (swelling) to the Resident's left arm, and the doctor ordered a one time dose of [MEDICATION NAME] 40 mg (milligrams), and a venous doppler study in the morning. At 11:42 p.m. the doctor was notified of the speech therapist recommendation for Resident #101's diet to be downgraded to pureed texture secondary to difficulty with chewing, swallowing, refusal to eat, risk for weight loss, [MEDICAL CONDITION], and new onset altered mental status, and urine output was 200 ml for this shift. On [DATE] at 3:19 p.m. nursing notes revealed that Resident #101 was sent out for a 1:00 p.m. follow up appointment with the vascular surgeon who wrote in a progress note, to follow up in 4 weeks, the surgically implanted stent was open (patent) and toe wounds were stable. The facility doctor was paged by nursing staff to report the lab results ordered STAT on [DATE], and he did not return the call. On [DATE] at 11:35 p.m. nursing notes read the Resident returned to the facility at 5:45 p.m. and the doctor was made aware of the venous doppler not being completed with the reason stated that the Resident was out to the follow up appointment with the vascular surgeon. However, the vascular doppler could have been completed while the Resident was at the vascular surgery appointment, but the vascular surgeon was not made aware of the need by the facility. The nursing notes further describe the left arm as still swollen and warm to touch. The facility doctor was also made aware of the labs ordered STAT the previous day which were faxed to the facility at 7:14 p.m. on [DATE], and showed a high WBC (indication of infection) of 26.48. By this time greater than 24 hours had elapsed from the results being received by the facility and the report of them to the doctor. As a result of the report, the doctor ordered a one time dose of the antibiotic [MEDICATION NAME] 2 gm (grams) IM (intramuscular) by injection. The doctor also ordered a CBC (complete blood count), CMP (comprehensive metabolic panel), repeat CXR (chest XRay), and a CT (computed tomography) of the chest to be done at the hospital. The nursing progress notes revealed that the doctor was not made aware that IV access had not been obtained, and the IV fluids and the IV antibiotics to treat the pneumonia and dehydration were not being given as ordered on [DATE]. http://www.mayoclinic.org/tests-procedures/complete-blood-count/basics/results/prc- 088 normal range of WBC according to the above is 3XXX,[DATE].5 billion cells/liter On [DATE] at 4:11 a.m. nursing notes described Resident #101's urine as cloudy and 380 ml output for the shift. On [DATE] at 8:00 a.m. CBC and BMP labs were again obtained and the results were received at the facility at 10:29 a.m. WBC's remained elevated at 21.68, Bun was significantly high at 36, and Creatinine was high at 1.62. The doctor was not paged until 2:55 p.m. and again at 11:22 p.m., and no call back was received from the doctor until greater that 24 hours after the 1st page, and on [DATE] at 4:40 p.m. The doctor issued new orders for Tylenol for pain, and to change the normal saline IV infusion to 50 ml per hour for 72 more hours. The nursing note does not reveal that the doctor was made aware that the previous antibiotic and fluids infusion orders issued [DATE] were not carried out. On [DATE] at 11:20 a.m. nursing notes revealed that the Resident went out to the hospital for an appointment at 10:30 a.m. for PICC (peripherally inserted central line catheter) to administer IV antibiotics and fluids through, and the Resident's son accompanied the Resident. On [DATE] at 2:55 p.m. a nursing note describing a change in condition was written and stated that the Resident was feeling tired, down, and had a poor appetite. On [DATE] at 11:18 p.m., and 11:22 p.m., nursing notes stated the Resident returned to the facility with a PICC line at 5:28 p.m.. The procedure report which was faxed to the facility at 12:42 p.m. described the procedure and the [DIAGNOSES REDACTED]. No drainage was seen by nursing, according to this note. On [DATE] at 4:40 p.m. the nursing notes revealed that the IV antibiotic was started, missing 2 further doses between the time of PICC insertion and this treatment start time, as the antibiotic order was for every 8 hours and the Resident could have received this medication at 10:00 p.m. on [DATE], and 6:00 a.m. on [DATE]. No restrictions were placed on using the PICC line after it was inserted, and it could have been accessed immediately upon return to the facility the previous day. The IV fluids order was changed, and decreased from Normal Saline infusion at 75 ml per hour to 50 ml per hour for 72 more hours. This order does not reveal that the doctor was aware that the Resident had not received the previous IV fluids, ordered [DATE]. On [DATE] at 5:01 p.m. the venous doppler of the left arm was completed and the doctor was made aware with no new orders issued. On [DATE] at 11:03 p.m. the nursing note described the Resident with congestion and cough continued, with added nasal drainage. Resident #101 refused dinner, but consumed 240 ml of milk, and only sips of water and tea, and the IV fluids and antibiotic were both now infusing. On [DATE] at 11:53 p.m. a further nursing note read at 10:36 p.m. the Resident was noted to be unresponsive and without pulse, BP, and respirations, with new [DIAGNOSES REDACTED]. The gangrene in 2nd and 3rd toes of the right foot had been diagnosed prior to admission to the hospital. The Resident was a full code and CPR (cardio [MEDICAL CONDITION] resuscitation) was initiated, and 911 called. The Resident was transported to the emergency room at the hospital at 11:00 p.m. and documents revealed that the Resident was pronounced expired at 11:09 p.m. due to [MEDICAL CONDITION]. The CT of the chest was never completed. Review of doctors orders and the Medication Administration Record [REDACTED]. On [DATE] the new order for IV normal saline at 50 ml per hour was placed on the MAR indicated [REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident was found without vital signs on [DATE] at 10:36 p.m. Urinary output was documented almost every shift on the MAR indicated [REDACTED]. They were as follows; ([DATE]) = 900 ml for 2 of three shifts ([DATE])= 1100 ml for 3 of 3 shifts ([DATE])= 1300 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 590 ml for 3 of 3 shifts ([DATE])= 400 ml for 3 of 3 shifts ([DATE])= 680 ml for 3 of 3 shifts ([DATE])= 550 ml for 3 of 3 shifts ([DATE])= 100 ml for 3 of 3 shifts On [DATE] for 7am-3pm shift there was no documentation of output on the MAR, or nursing notes. On [DATE] at 2:50 p.m. Interviews were conducted in the conference room of the facility with all surveyors present and with LPN (Licensed Practical Nurse) (C) and RN (Registered Nurse) (A). LPN (C) stated she received the IV fluids and medication orders on [DATE] from the doctor and scheduled the hospital to put in a PICC line on [DATE], but the Resident had other appointments scheduled. They could not get the PICC line done, so she rescheduled the PICC line insertion to be done on [DATE], and the Resident got the fluids and antibiotics on [DATE]. When asked if a regular non-emergent previously scheduled follow up appointment with the vascular surgeon was as important as treating dehydration and pneumonia, LPN (C) stated "no". RN (Registered Nurse) (A) was asked why the IV was not started on [DATE] when the doctor's order was received. She responded that she tried to "stick" the Resident, (and was unable to remember if it was one attempt or two) and was unable to get an IV started. She then stated she called the Director of Nursing (DON) RN, and he attempted once to get the IV started and was unsuccessful, so they called the doctor and requested a PICC line be instilled in the hospital, and the doctor agreed. RN (A) stated the reason for the IV orders was the Resident needed to be hydrated, and that death can occur from dehydration. RN (A) was asked what nurses do if they were unable to get IV access. She stated they try to get the resident out to the hospital to get a PICC line, and if they are really sick they are sent out to the emergency room to get one. It is notable to mention that no documentation of IV access attempts appeared in the nursing notes. On [DATE] at 3:05 p.m. The DON was interviewed in the conference room of the facility with all surveyors present and stated that if the staff were unable to get IV access the doctor would be called. Then if not able to get the doctor, the medical director would be called, and if that failed, the Resident would be sent out 911 for treatment in the emergency room . The DON was also aware that these steps did not occur for Resident #101. On [DATE] at 3:20 p.m. the treating doctor was called and interviewed via speaker phone from the conference room in the facility with all surveyors present. The doctor stated he was not aware that Resident #101 had not received the IV fluids and Antibiotic ordered [DATE], and further stated the reason he ordered them was because of the Residents poor intake and labs. The doctor also stated the PICC line should have been put in more quickly because there are mobile services, and emergency room s, and multiple ways to get it done quickly, and the same day it is ordered. Facility policy on "Inserting a Peripheral IV Catheter" stated "INS standards recommend no nurse attempt a venipuncture more than twice. If facility staff is unsuccessful after 3 total attempts, expert assistance should be obtained." Facility policy on "Medication Administration" read, "Medications are administered as prescribed, and in accordance with written orders of the prescriber," and "if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is not in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN (as needed) documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified." Expert assistance was not obtained on [DATE] after staff was unable to acquire IV access. No documentation of the antibiotic [MEDICATION NAME] appeared on the MAR until [DATE] at 10:00 p.m., and no documentation of the physician being notified of the missing doses of antibiotic and fluids existed. The facility used Lippincott and Mosby as a nursing standards reference. Potty and Perry are the educators and authors that provide text to the Mosby Company. Mosby publishes the information. Fundamentals of Nursing, 6th Edition, Potter-Perry, p. 419, provides the following guidance regarding physicians' orders, " Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients. " Guidance for nursing standards for the administration of medication was provided by "Fundamentals of Nursing, 7th Edition, Potter-Perry, p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation." On [DATE] at 4:00 p.m. the Administrator and DON were made aware of findings at the end of day debriefing. The administrator and DON were offered the time they needed to produce further evidence regarding this report of harm level deficiencies, and they exited the conference room. On [DATE] at 4:30 p.m. the Administrator and DON had reviewed the evidence and documents surveyors had copies of, and reentered the conference room and announced they had no further evidence to submit. Harm level deficiency. Complaint deficiency. 2. For Resident #113, the facility staff failed to administer Resident #113' s [MEDICATION NAME] (a medication for hypertension) on [DATE] and [DATE]. Resident #113 was admitted to the facility on [DATE] and readmitted after hospitalization on [DATE]. [DIAGNOSES REDACTED]. Resident #113's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #113 with short and long term memory problems and severely impaired cognition. In addition, the Minimum Data Set coded Resident #113 as requiring total assistance from staff for her Activities of Daily Living care. A review of Resident #113's clinical record was conducted during the survey. The review showed a physician order [REDACTED]. Monitor B/P (blood pressure), give prn (as needed) [MEDICATION NAME] for SBP (systolic blood pressure) > (greater than) 150; hold for SBP < (less than) 100 - Notify MD (Medical Doctor). PEG is a percutaneous endoscopic gastrostomy tube, which is a plastic flexible tube, surgically inserted through the abdominal wall into the stomach. A review of Resident #113 's EMAR (Electronic Medication Administration Record) was conducted during the survey. The review showed that Resident #113 was not administered [MEDICATION NAME] at 5 p.m. on [DATE] and [DATE]. Documentation on the EMAR for both missed doses read, "3-Hold/See Nurse Notes." A review of the eMAR-Medication Administration nurse's notes for [DATE], 19:05 (7:05 p.m.) read, "BP ,[DATE]". The eMAR-Medication Administration nurse's notes dated [DATE], 16:23 (4:23 p.m.) read, "B/P ,[DATE]." There was no evidence of a SBP < 100. On [DATE] at 1:30 p.m. an interview was conducted with the unit manager, LPN (Licensed Practical Nurse) B. After reviewing Resident #113's clinical record, LPN B stated, "I don't know why she (LPN E) did not administer the medication. The medication should have been given." The director of nursing cited Lippincott as the facility's professional nursing reference. "Fundamentals of Nursing, 7th Edition" by Potter-Perry, provided nursing guidance for medication administration. Page 336 read, "The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients." The facility administration was informed of the findings during a briefing on [DATE] at approximately 3:50 p.m. The facility did not present any further information or explanation about the findings.