Every finding on record at Beaufont Health and Rehabilitation Center

Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #1) in a survey sample of 2 residents resulting in harm for Resident #1. The findings included: For Resident #1, the facility staff failed to assess and monitor the Resident's respiratory status and intervene with appropriate measures prior to the death of the Resident who was suffering labored breathing & respiratory difficulty. No other tracheostomy Residents were residing in the facility at the time of survey so could not be added to the sample. Resident #1 was a discharged Resident so a closed record review was conducted. The Resident was originally admitted to the facility from the hospital on [DATE] with diagnoses including; Acute Osteomyelitis to the right shoulder (primary diagnosis) and a history of Laryngeal cancer with total laryngectomy surgical removal in 1987, anemia, diabetes, hypertension, dementia without behavior disorder, and hospice was ordered on [DATE] with comfort measures and a Do not resuscitate (DNR) order. Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of [DATE]. Resident #1 was coded with mild cognitive impairment. Resident #1 required substantial assistance to complete dependence on staff members for activities of daily living. On [DATE] Resident #1's former room mate (Resident #2) was interviewed and found to be alert, and oriented to person, place, time, and situation. The Resident described the friendship that had occurred between herself, Resident #1, and the family of Resident #1 during their time as room mates. She stated that Resident #1's husband brought food to her every day. Resident #2 was asked if suctioning and oxygen were in the room that they shared, and she stated no, she never used oxygen, and she had never seen suctioning completed for Resident #2, and that no machine was kept in the room. She stated that Resident #1's husband would clean her neck stoma everyday, and further stated that the Resident would at times have a partially clogged stoma which gurgled and staff would clean it, but she never saw or heard suctioning. On [DATE] LPN A, and LPN B (Licensed Practical Nurses) were interviewed at the nursing station beginning approximately at 11:45 AM. Both nurses stated they had received training in the care of patients with tracheostomys and stomas, suctioning, administration of oxygen by way of nasal cannulas, masks, emergency CPR, ambu bags, and tracheostomy stoma masks for oxygen delivery, and were able to verbalize the situational uses and applications. Those interviews continue below; LPN A stated that she had cared for Resident #1, and Resident #2 and stated that Resident #1 had been alert and interactive and at times could even be combative when she didn't want anyone bothering her. LPN A went on to say both Residents were good cognitively. LPN A was asked if she was working on the day that Resident #1 expired, and she stated she was not caring for Resident #1 that day. When asked what she would do if she had noted that Resident #1 was in Respiratory distress, she stated she would have suctioned Resident #1 if she needed it. LPN B stated she had recently moved to that unit from the other unit and had not known Resident #1. LPN B was asked what she would do if she encountered a Resident with a stoma having respiratory difficulty. LPN B stated she would take vital signs, assess the Resident's oxygen saturation, and suction the Resident if they needed it. LPN B was asked to show the surveyor the suction machine that she would use at 12:05 PM and she proceeded to the Crash Cart showed the surveyor the device. The surveyor asked her to demonstrate how the device worked, and she gathered the supplies (tubing and suction catheter) and proceeded to the nursing station to plug in the suction machine for a demonstration. The tubing was attached to the canister through ports in the top which was not secured to the canister and the machine did not provide suction. The nurse removed the canister and found the top was not the correct fit for the canister, and proceeded to the supply room to find another top. In the supply room several tops were tried on the canister, and finally the correctly fitting top was applied and returned to the machine which now provided suction at 12:15 PM. LPN A was asked the same question separately from LPN B and she gave a similar answer to LPN B at 12:20 PM. At 12:25 PM Employee A was interviewed in the supply room. She was in charge of supplies on the unit and was found in the supply room placing newly received supplies on the many shelving units. She was asked if Tracheostomy oxygen masks were available on the unit and stated yes. The oxygen delivery neck masks specifically designed for stomas were located in a unopened box of 50 which she stated had arrived in August, and I had not placed them on the shelving units yet. She was asked if there were any open tracheostomy masks and she stated no. When asked how many of these masks were typically used in a month she stated we haven't had a trach since (name) Resident #1. She was asked if they were used for Resident #1, and she stated no, she didn't use oxygen, but we could borrow them from a sister facility if we didn't have any on hand, and needed them. On [DATE] at 12:45 PM the spouse of Resident #1 was contacted via telephone and interviewed. He stated that the nurses don't know what they are doing, she had that stoma for over [AGE] years and we know it has to be suctioned and cleaned, we did that at home every day, I told them that. He went on to state that the day before she died I told them her stoma needed to be suctioned. The next day around lunchtime before I got there, they called me and told me she was having trouble breathing. He went on to say that upon his arrival around 12:30 PM or 12:45 PM he found Resident #1 with a nasal cannula on her face infusing oxygen, and the Resident had very labored crackly breathing, and no one was in the room with her. The spouse went on to say that Resident #1 only breathed through her stoma and not through her nose, he yelled for help and took the nasal piece off of her nose and placed it over her stoma, but it didn't do any good, she passed away a few minutes after I got there. The spouse went on to say I was panicked and not thinking, I had a pocket knife, I could have cut the 2 nose prongs off and just put the tube in her stoma but I wasn't thinking. Review of physician's orders revealed that the Resident had no oxygen orders, and no suctioning orders. The only order for care of the stoma documented; Stoma, cleanse with normal saline using a lightly damp gauze sponge daily and as needed, Ordered on [DATE]. Review of physician and nursing progress notes revealed the following; Prior to [DATE] there is no indication of problems breathing, other than physician notes stating that the Resident's stoma was uncovered and she had told them that her stoma needed to stay open for her to breathe. This was recorded by physicians multiple times in the progress notes. On [DATE] at 7:35 PM, the call bell was depressed in Resident #1's room and nursing arrived to find the Resident had used a Q-tip to unclog her own stoma and it was stuck in the stoma. The nurse removed the Q-tip and cleaned the stoma. No other notes were documented after [DATE] until the day of [DATE]. On [DATE] the nursing notes documented the following At 12:53 PM, Called to room by LPN and CNA (Certified Nursing Assistant), resident was presenting with a low blood pressure, elevated respirations, and low oxygen saturation of 88% on room air. Resident is not responding to any verbal or tactile stimuli at this time. Hospice (name) notified and resident spouse notified of resident's current clinical state. Resident placed on 2 liters of oxygen via nasal cannula to bring oxygen saturation to 94%. Hospice has dispatched a nurse to come out and evaluate Resident. Will continue to monitor. No further assessment nor monitoring were documented. No assessment was completed for respiratory rate, rhythm or labor, shallow or purse lip breathing, nasal flaring, audible breath sounds, retractions or accessory muscle use, pallor or cyanosis of skin or mucus membranes. No breath sounds were assessed, which could have alerted to mucus or fluid in the lungs, and or stridor which would indicate an obstruction, such as a mucus plug in the trachea. Please refer to the National Institutes of Health (NIH) for further respiratory assessment protocols and standards. References from the National Institutes of health revealed that after a total laryngectomy surgery the Patient can no longer breath using the nose or mouth, rather a stoma (surgical hole) placed in the anterior neck is the only way for the Patient to breath. It is further noted that mucus will collect in the trachea and stoma as it no longer can be expectorated through the mouth, and must be removed by way of suctioning the trachea and cleansing the stoma. At 1:12 PM, progress notes documented Resident has expired. Pronounced at 1:06 PM, Hospice and RP (responsible party/spouse) have been notified. Awaiting hospice. At 1:20 PM, the Director of nursing (DON) wrote Resident was observed unresponsive, upon assessment, there were no signs of respiration or pulse. Resident was cold to touch, pupils were fixed. Resident was pronounced 1:06 PM, husband and son were at bedside. Hospice was notified. MD (doctor) had been notified. The Director of Nursing (DON) was the Registered Nurse who Pronounced the Resident expired, however, according to statements made by the Administrator and the Assistant Director of Nursing (ADON) the DON was not involved in care prior to the death. At 2:57 PM, (wrong name) funeral home arrived at 2:56 PM and accepted body. Family at bedside. At 8:21 PM, Ate 25% or less for two or more meals in the day. resident expired. The last entry indicated that the Resident did consume some part of breakfast, and or lunch, on the day she expired as the document did not state the Resident ate 0. The notes do not describe the spouse arriving prior to the death of the Resident nor the interaction with staff during that time when staff were called to the room by him yelling. There is also no description of lung sounds, no apparent attempt to suction the Resident, as the staff were aware that the Resident did experience mucus plugs and would attempt to remove them herself. There was no apparent recognition by the LPN providing care that the nasal cannula oxygen was not infusing oxygen to the Resident's lungs as it was not applied to the stoma by way of a tracheostomy mask. The oxygen saturation documented at 12:53 PM by the LPN would not have been consistent with applying a nasal cannula to the Resident, as the nasal passages no longer communicated with, and supplied oxygen to the lungs after a total laryngectomy. The 12:53 PM note would have been consistent with the spouses account that staff were called to the room by him yelling and the Resident died shortly after that and was pronounced at 1:06 PM, 13 minutes later. Review of the Resident's care plan revealed a focus for a weight loss plan which described crusting and scabbing at stoma site, and a focus for infection control enhanced barrier precautions related to open stoma. These were the only entries in the care plan regarding the Resident's airway. No care plan interventions for cleaning, assessing nor suctioning and oxygen use were derived for the Resident's airway maintenance. There was no individualized nor measurable care care plan for the Resident's airway. Review of hospice notes revealed that the DON at the facility pronounced death, and they were not onsite during the incident. On [DATE] at 2:00 PM, the Administrator was interviewed and stated unfortunately the nurse who was here that day and involved in the Resident's care is on vacation and can't be reached for interview. He further stated he remembered the Resident and her spouse and stated he understood there were problems with the situation. On [DATE], at 2:30 PM, the Administrator and ADON were made aware of the lack of respiratory assessments, suctioning and appropriate oxygen administration leading to harm for Resident #1. They were informed that supplies were in house for appropriate treatment of respiratory care, and the nurses who were interviewed were knowledgeable on respiratory assessments and knew appropriate interventions for this particular scenario, however, in this incident those standards were not followed, and care planning for this individual was insufficient. They stated they knew things had not happened in this situation appropriately and would begin retraining of all nursing staff immediately, and that they had nothing further to provide.

Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide a comprehensive care plan for respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #1) in a survey sample of 2 residents. The findings included: For Resident #1, the facility staff failed to assess and monitor the Resident's respiratory status and intervene with appropriate measures prior to the death of the Resident who was suffering labored breathing & respiratory difficulty. No other tracheostomy Residents were residing in the facility at the time of survey so could not be added to the sample. Resident #1 was a discharged Resident so a closed record review was conducted. The Resident was originally admitted to the facility from the hospital on [DATE] with diagnoses including; Acute Osteomyelitis to the right shoulder (primary diagnosis) and a history of Laryngeal cancer with total laryngectomy surgical removal in 1987, anemia, diabetes, hypertension, dementia without behavior disorder, and hospice was ordered on [DATE] with comfort measures and a Do not resuscitate (DNR) order. Resident #1's most recent Minimum Data Set (MDS) assessment was an admission assessment with an Assessment Reference Date (ARD) of [DATE]. Resident #1 was coded with mild cognitive impairment. Resident #1 required substantial assistance to complete dependence on staff members for activities of daily living. On [DATE] Resident #1's former room mate (Resident #2) was interviewed and found to be alert, and oriented to person, place, time, and situation. The Resident described the friendship that had occurred between herself, Resident #1, and the family of Resident #1 during their time as room mates. She stated that Resident #1's husband brought food to her every day. Resident #2 was asked if suctioning and oxygen were in the room that they shared, and she stated no, she never used oxygen, and she had never seen suctioning completed for Resident #2, and that no machine was kept in the room. She stated that Resident #1's husband would clean her neck stoma everyday, and further stated that the Resident would at times have a partially clogged stoma which gurgled and staff would clean it, but she never saw or heard suctioning. On [DATE] LPN A, and LPN B (Licensed Practical Nurses) were interviewed at the nursing station beginning approximately at 11:45 AM. Both nurses stated they had received training in the care of patients with tracheostomys and stomas, suctioning, administration of oxygen by way of nasal cannulas, masks, emergency CPR, ambu bags, and tracheostomy stoma masks for oxygen delivery, and were able to verbalize the situational uses and applications. Those interviews continue below; LPN A stated that she had cared for Resident #1, and Resident #2 and stated that Resident #1 had been alert and interactive and at times could even be combative when she didn't want anyone bothering her. LPN A went on to say both Residents were good cognitively. LPN A was asked if she was working on the day that Resident #1 expired, and she stated she was not caring for Resident #1 that day. When asked what she would do if she had noted that Resident #1 was in Respiratory distress, she stated she would have suctioned Resident #1 if she needed it. LPN B stated she had recently moved to that unit from the other unit and had not known Resident #1. LPN B was asked what she would do if she encountered a Resident with a stoma having respiratory difficulty. LPN B stated she would take vital signs, assess the Resident's oxygen saturation, and suction the Resident if they needed it. LPN B was asked to show the surveyor the suction machine that she would use at 12:05 PM and she proceeded to the Crash Cart showed the surveyor the device. The surveyor asked her to demonstrate how the device worked, and she gathered the supplies (tubing and suction catheter) and proceeded to the nursing station to plug in the suction machine for a demonstration. The tubing was attached to the canister through ports in the top which was not secured to the canister and the machine did not provide suction. The nurse removed the canister and found the top was not the correct fit for the canister, and proceeded to the supply room to find another top. In the supply room several tops were tried on the canister, and finally the correctly fitting top was applied and returned to the machine which now provided suction at 12:15 PM. LPN A was asked the same question separately from LPN B and she gave a similar answer to LPN B at 12:20 PM. At 12:25 PM Employee A was interviewed in the supply room. She was in charge of supplies on the unit and was found in the supply room placing newly received supplies on the many shelving units. She was asked if Tracheostomy oxygen masks were available on the unit and stated yes. The oxygen delivery neck masks specifically designed for stomas were located in a unopened box of 50 which she stated had arrived in August, and I had not placed them on the shelving units yet. She was asked if there were any open tracheostomy masks and she stated no. When asked how many of these masks were typically used in a month she stated we haven't had a trach since (name) Resident #1. She was asked if they were used for Resident #1, and she stated no, she didn't use oxygen, but we could borrow them from a sister facility if we didn't have any on hand, and needed them. On [DATE] at 12:45 PM the spouse of Resident #1 was contacted via telephone and interviewed. He stated that the nurses don't know what they are doing, she had that stoma for over [AGE] years and we know it has to be suctioned and cleaned, we did that at home every day, I told them that. He went on to state that the day before she died I told them her stoma needed to be suctioned. The next day around lunchtime before I got there, they called me and told me she was having trouble breathing. He went on to say that upon his arrival around 12:30 PM or 12:45 PM he found Resident #1 with a nasal cannula on her face infusing oxygen, and the Resident had very labored crackly breathing, and no one was in the room with her. The spouse went on to say that Resident #1 only breathed through her stoma and not through her nose, he yelled for help and took the nasal piece off of her nose and placed it over her stoma, but it didn't do any good, she passed away a few minutes after I got there. The spouse went on to say I was panicked and not thinking, I had a pocket knife, I could have cut the 2 nose prongs off and just put the tube in her stoma but I wasn't thinking. Review of physician's orders revealed that the Resident had no oxygen orders, and no suctioning orders. The only order for care of the stoma documented; Stoma, cleanse with normal saline using a lightly damp gauze sponge daily and as needed, Ordered on [DATE]. Review of physician and nursing progress notes revealed the following; Prior to [DATE] there is no indication of problems breathing, other than physician notes stating that the Resident's stoma was uncovered and she had told them that her stoma needed to stay open for her to breathe. This was recorded by physicians multiple times in the progress notes. On [DATE] at 7:35 PM, the call bell was depressed in Resident #1's room and nursing arrived to find the Resident had used a Q-tip to unclog her own stoma and it was stuck in the stoma. The nurse removed the Q-tip and cleaned the stoma. No other notes were documented after [DATE] until the day of [DATE]. On [DATE] the nursing notes documented the following At 12:53 PM, Called to room by LPN and CNA (Certified Nursing Assistant), resident was presenting with a low blood pressure, elevated respirations, and low oxygen saturation of 88% on room air. Resident is not responding to any verbal or tactile stimuli at this time. Hospice (name) notified and resident spouse notified of resident's current clinical state. Resident placed on 2 liters of oxygen via nasal cannula to bring oxygen saturation to 94%. Hospice has dispatched a nurse to come out and evaluate Resident. Will continue to monitor. No further assessment nor monitoring were documented. No assessment was completed for respiratory rate, rhythm or labor, shallow or purse lip breathing, nasal flaring, audible breath sounds, retractions or accessory muscle use, pallor or cyanosis of skin or mucus membranes. No breath sounds were assessed, which could have alerted to mucus or fluid in the lungs, and or stridor which would indicate an obstruction, such as a mucus plug in the trachea. Please refer to the National Institutes of Health (NIH) for further respiratory assessment protocols and standards. References from the National Institutes of health revealed that after a total laryngectomy surgery the Patient can no longer breath using the nose or mouth, rather a stoma (surgical hole) placed in the anterior neck is the only way for the Patient to breath. It is further noted that mucus will collect in the trachea and stoma as it no longer can be expectorated through the mouth, and must be removed by way of suctioning the trachea and cleansing the stoma. At 1:12 PM, progress notes documented Resident has expired. Pronounced at 1:06 PM, Hospice and RP (responsible party/spouse) have been notified. Awaiting hospice. At 1:20 PM, the Director of nursing (DON) wrote Resident was observed unresponsive, upon assessment, there were no signs of respiration or pulse. Resident was cold to touch, pupils were fixed. Resident was pronounced 1:06 PM, husband and son were at bedside. Hospice was notified. MD (doctor) had been notified. The Director of Nursing (DON) was the Registered Nurse who Pronounced the Resident expired, however, according to statements made by the Administrator and the Assistant Director of Nursing (ADON) the DON was not involved in care prior to the death. At 2:57 PM, (wrong name) funeral home arrived at 2:56 PM and accepted body. Family at bedside. At 8:21 PM, Ate 25% or less for two or more meals in the day. resident expired. The last entry indicated that the Resident did consume some part of breakfast, and or lunch, on the day she expired as the document did not state the Resident ate 0. The notes do not describe the spouse arriving prior to the death of the Resident nor the interaction with staff during that time when staff were called to the room by him yelling. There is also no description of lung sounds, no apparent attempt to suction the Resident, as the staff were aware that the Resident did experience mucus plugs and would attempt to remove them herself. There was no apparent recognition by the LPN providing care that the nasal cannula oxygen was not infusing oxygen to the Resident's lungs as it was not applied to the stoma by way of a tracheostomy mask. The oxygen saturation documented at 12:53 PM by the LPN would not have been consistent with applying a nasal cannula to the Resident, as the nasal passages no longer communicated with, and supplied oxygen to the lungs after a total laryngectomy. The 12:53 PM note would have been consistent with the spouses account that staff were called to the room by him yelling and the Resident died shortly after that and was pronounced at 1:06 PM, 13 minutes later. Review of the Resident's care plan revealed a focus for a weight loss plan which described crusting and scabbing at stoma site, and a focus for infection control enhanced barrier precautions related to open stoma. These were the only entries in the care plan regarding the Resident's airway. No care plan interventions for cleaning, assessing nor suctioning and oxygen use were derived for the Resident's airway maintenance. There was no individualized nor measurable care care plan for the Resident's airway. Review of hospice notes revealed that the DON at the facility pronounced death, and they were not onsite during the incident. On [DATE] at 2:00 PM, the Administrator was interviewed and stated unfortunately the nurse who was here that day and involved in the Resident's care is on vacation and can't be reached for interview. He further stated he remembered the Resident and her spouse and stated he understood there were problems with the situation. On [DATE], at 2:30 PM, the Administrator and ADON were made aware of the lack of respiratory assessments, suctioning and appropriate oxygen administration leading to harm for Resident #1. They were informed that supplies were in house for appropriate treatment of respiratory care, and the nurses who were interviewed were knowledgeable on respiratory assessments and knew appropriate interventions for this particular scenario, however, in this incident those standards were not followed, and care planning for this individual was insufficient. They stated they knew things had not happened in this situation appropriately and would begin retraining of all nursing staff immediately, and that they had nothing further to provide.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication administration in nursing practice for two Residents (Resident # 6 and #37) in a survey sample of 50 Residents. The findings included: For Resident # 6, the facility staff failed to administer medications and treatments on several dates as ordered by the physician Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. The MDS coded Resident # 6 as requiring extensive to total staff assistance with Activities of Daily Living. Resident # 6 was coded as incontinent of bowel and bladder. Review of the clinical record was conducted 5/7/2024-5/14/2024. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for March 2024 and April 2024, and revealed the absence of nursing signatures indicating the treatments were not completed on 9 occasions. Those dates were as follows: Med Plus 2.0 two times a day for Supplement -Order Date-10/17/2023 scheduled at 9:00 a.m. and 6:00 p.m. Not administered on 3/12/2024 at 6 p.m., 3/13/2024 at 6 p.m. and 3/18/2024 at 6 p.m. Tramadol HCl Oral Tablet 50 MG (milligrams) Give 1 tablet by mouth every 6 hours for pain -Order Date-12/06/2023 0829 scheduled 12 midnight, 6:00 a.m., 12 noon and 6:00 p.m. Not administered on 3/12/2024 at 6 p.m., 3/13/2024 at 6 p.m. and 3/18/2024 at 6 p.m. Santyl External Ointment 250 UNIT/GM (gram) (Collagenase) Apply to Left Buttock topically every night shift for Unstageable -Order Date-01/29/2024 0910. Not administerd on 3/5/2024 on night shift. WOUND CARE- Right ischium: Cleanse with soap & water, pat dry then apply collagen particles & xeroform, cover with bordered foam every day shift for Abrasion -Order Date- 03/07/2024 1257. Not administered 3/17/2024, 3/22/2024, 3/24/2024, 3/28/2024, and 3/29/2024 WOUND CARE - Right buttocks: Cleanse with soap and water, apply zinc leave ota (open to air) three times a day for incontinence TID and PRN (as needed) -Order Date- 02/05/2024 0941. Not administered 3/2/2024 at 9 p.m., 3/6/2024 at 9 p.m., and 3/6 /2024 at 2 p.m. Nursing medication administration notes did not indicate why the treatments were not completed, and why medications were omitted. Nurses on the nursing unit were asked about blanks in documentation and the responses were if it's not documented, it's not done. There were valid Physician orders for the medications and treatments that were omitted. The nursing facility stated Mosby's as their nursing standard. Mosby's stated all medications must be administered by the physician's order. Guidance for nursing standards for the administration of medication provided by Fundamentals of Nursing, 7th Edition, Mosby's/ [NAME]-[NAME], p. 705 stated Professional standards, such as the American Nurses Association's Nursing Scope and Standards of Nursing Practice of (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. Resident 6's care plan was reviewed and revealed a care plan that instructed to administer medications and treatments as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medications had been omitted, nor that the doctor was made aware of the omissions. On 5/10/2024 at 10:20 a.m., an interview was conducted with Licensed Practical Nurse D who stated the expectation was for nurses to administer medications and treatments as ordered by the physician. She stated that nurses should document immediately after administration of medications and treatments. Also, LPN-D stated that if the space was empty it would appear that it was not done. On 5/14/2024, during the end of day debriefing with all surveyors, the Administrator and Director of Nursing were made aware of the failure of staff to administer medications as ordered. The Director of Nursing stated the expectation was for the staff to administer medications and treatments as ordered by the physician. No further information was provided. 2. For Resident #37, the facility staff failed to administer the proper dose of Lovenox as ordered by the physician on 05/06/2024. Resident #37 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to, urinary tract infection (UTI), bacteremia, extended spectrum beta lactamase (ESBL), history of deep vein thrombosis (DVT), diabetes, malignant neoplasm of the prostate, chronic kidney disease and abnormal gait. The most recent MDS (minimum data set) was a quarterly assessment with an (ARD) assessment reference date of 04/06/2024 was reviewed and revealed a (BIMS) Brief Interview for Mental Status score of 15 out of 15 which indicated no cognitive impairment . On 05/07/2024, a medication administration observation with LPN (Licensed Practical Nurse) #B, revealed that Resident #37's dosage for Lovenox was changed by the physician on 05/05/2024 from 40 mg (milligrams) to 90 mg subcutaneously to start on 05/06/2024. The box of Lovenox injections observed on hand for Resident #37 on the medication cart was 40 mg/ml (milligrams per milliliter). The medication administration record (MAR) documented that the Lovenox 100mg/ml 0.9 ml was administered to Resident #37 on 05/06/2024 at 9 a.m. and 5 p.m ., but only Lovenox 40mg/ml was on the medication cart for Resident #37. The Unit Manager was notified of the dosage change and that the new dosage of Lovenox for Resident #37 was not on the med cart. The Unit Manager, returned with an unopened supply of Lovenox 100mg/ml that had been delivered and stored in the wrong medication cart overnight on 05/05/24 but, not identified or administered. An interview was conducted on 05/07/2024 with Resident #37 who stated that he received his Lovenox injection twice on 05/06/2024. Resident stated he was aware that his Lovenox dosages changes. An interview was conducted with LPN #D on 05/07/2024 at approximately 2:00 p.m. who stated she was informed of the medication error, that Resident #37 received Lovenox 40mg/ml twice on 05/06/204 instead of the new dosage of 100 mg/ml .9ml dosage by LPN #B. LPN #D stated that she had informed and assessed Resident #37 for adverse effects and had notified the physician The 05/07/2024 progress note revealed: Spoke with resident today in regards his Lovenox injection. Resident was receiving 40ml Lovenox injections BID. The order was changed to Lovenox injection 100ml BID to start on 05/06/2024. Instead of receiving the 100 ml resident received the old dosage of the 40ml at 9 a.m. and 5 p.m. Resident has shown no adverse effects of the administration of this medication. Resident is alert and oriented and ho changes from baseline. Residents is his own RP and MD had been made aware of the error as well. Med error plan of correction in place. Will continue to monitor resident. [SIC] On 05/06/2024, Resident #37's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Lovenox injection solution prefilled syringe 40 MG/ML (Enoxaparin Sodium) inject 0.4ml two times a day for History of DVT discharge (d/c) date 05/05/2024 -Lovenox injection solution prefilled syringe 100 MG/ML (Enoxaparin Sodium) inject 0.9 ml subcutaneously two times a day for History of DVT Order date 05/05/2024 1009 During the end of day debriefing on 05/08/2024, the Administrator and Regional Nurse Consultant were informed of findings during med pass 05/07/2024. On 05/08/2024 the Pharmacy Delivery Manifest was requested and revealed Enoxaparin /Lovenox 100 mg/ml syringes 10 was delivered to the east wing on 05/05/2024 at 11:03 p.m. During the end of day debriefing on 05/13/2024, the Administrator, Regional Nurse Consultant and Director of nursing were informed of the findings. No further information was provided.

On 5/14/24 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. Based on observations, resident interviews, staff interviews, family interview, and clinical record review, the facility staff failed to inform, educate, formulate, and document information concerning the right to have an advanced directive for 2 of 50 residents in the survey sample, Resident #106, and Resident #55. The findings include: 1. On admission the facility staff failed to inform and educate Resident #106 about advanced directives. The facility staff failed to assist in helping the resident to formulate an advanced directive if she would have wanted one. The facility staff failed to document in the progress notes any interaction to support that they provided any of the above to Resident #106. The facility failed to document that the resident refused any advance directive services if that would have been her decision. Resident #106 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/26/24 coded the Resident #106 as completing the Brief Interview for Mental Status (BIMS) and scoring 15 which indicated the resident was cognitively intact. Resident #106's personal centered care plan created on 1/23/24 had an updated entry dated 3/24/24 that read, the resident has an advanced directive of full code. There was no documentation in the resident's medical record that supports a conversation with the resident to come to that decision. An interview was conducted with Resident #106 and Family Member (FM) #1 on 5/7/24 at approximately 11:45 AM. They both denied having any conversation with any facility staff on Advanced Directives. An interview was conducted with the Director of Social Work on 5/7/24 at approximately 1:00 PM, who shared that advanced directives should be initiated by the admitting nurse. She said advance directive questions were included in the admission process and could be found in the resident's medical record under documents and should be titled admission packet. The Director of Social Work looked in Resident #106 medical records and shared that she could not find the advanced directive documents from the resident's admission process. An interview was conducted with the Administrator on 5/13/24 at approximately 4:00 PM, who shared the facilities policy on advanced directive, as well as the facility's protocol Medical Facilities of America (MFA) policies governing the implementation of self-determination rights. The administrator said that this document should be under documents in the resident record and any conversations had about advanced directives should be documented in progress notes. Resident #106 medical record was reviewed. There were no progress notes supporting the resident received any information on advanced directives. The resident's admission packets dated 12/19/23 and 1/17/24 were reviewed and the policy on advanced directive, as well as the facility's protocol/policies governing the implementation of self-determination rights were not found. There was no admission packet for the resident's most recent admission of 2/6/24. The facility's policy titled Advanced Directives, effective 1/6/20 read, . Social Work and Discharge Planning staff will assist with requests for information regarding Advance Directives upon patient's admission to the Center and throughout the patient's stay to allow each patient an opportunity to plan in advance for medical treatment . The facility's protocol/policies governing the implementation of self-determination rights is a document that the Administrator, Regional Nurse Consultant, and Director of Social Work should have been used on admission, completed, and placed in the resident's medical record. This form has check boxes for the resident to make as proof of receiving the document, being educated verbally as well as being given written information on advanced directives, being offered assistance to formulate an advanced directive, and a place to refuse wanting an advance directive. This could not be found in Resident #106's medical record by the Director of Social Services. An advance directive, sometimes called a living will, is a written document that tells your healthcare providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself. This information is important if you become unconscious or otherwise too sick to make your wishes known. (https://www.hopkinsmedicine.org/patient-care/patients-visitors/advance-directives) On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing, and Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 40711 2. For Resident #55 the facility staff failed to formulate an advance directive. Resident #55 was originally admitted to the facility on [DATE] after an acute care hospital stay. The current diagnoses included essential hypertension. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/26/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of a possible 15. This indicated Resident #55 cognitive abilities for daily decision making were severely impaired. In sectionGG(functional abilities and goals) the resident was coded as requiring set-up help with eating and oral hygiene, requiring partial/moderate assistance with toileting hygiene and personal hygiene and substantial/maximal assistance with bathing/showering. A review of the Resident's clinical record revealed no advanced directive was available. An interview was conducted on 05/14/24 at approximately 9:57 AM., with the Social Worker (SW). The SW said that the Advanced Directed was not available in the medical chart. The SW also said that the advance directive should have been offered to the resident during admission. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse Consultant. The administrator said that the admissions coordinator would discuss the advanced directive and provide education.

Based on observation, family interview, staff interview, clinical record review, a review of facility documents, the facility's staff failed to notify family of an abnormal lab and transfer to a local hospital for 1 of 50 (Resident #172), a closed record resident. The findings included: Resident #172 was originally admitted to the facility 05/27/2022 and discharged on [DATE]. The current diagnoses included but was not limited to acute kidney failure. The entry Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 06/02/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #172 cognitive abilities for daily decision making were moderately impaired. The Discharge Minimum Data Set (MDS) assessment with an assessment reference date of 6/02/22 coded resident discharged with return anticipated. In sectionGG(Physical functioning) the resident was coded as requiring set-up help with eating, oral hygiene. Dependent on staff for oral hygiene and toileting hygiene. The care plan read that Resident #172 was at risk for nutritional problems related recent hospitalization , revised on 5/31/22. The goal for the resident was that the resident would avoid significant weight change through next review. An intervention for Resident #172 was labs as ordered. A review of the facility data report indicated Resident #172 was discharged and transferred to a short-term general hospital for inpatient care on 6/2/22 at 4:00 PM. A review of a Nurse Practitioner (NP) note dated on 6/02/22 at 12:18 PM., read that Resident #172 had an abnormal Creatinine Level. The note indicated, We have discussed these lab results and what it might mean and why it needs to be worked up in an in-patient setting. He needs to be sent to the hospital for deeper work up given the increase. On 5/07/24 at approximately 10:30 AM., a phone interview was conducted with Family Member (FM) #2 concerning the above issue. FM #2 said that the facility staff did not notify her of a change in condition concerning abnormal labs nor was she informed of Resident #172's transfer to the local hospital until a relative called the facility and was informed that resident was sent to the hospital. On 5/10/24 an interview was conducted at 11:09 AM., with Administrative Staff (D) concerning Resident #172. Administrative Staff (D) said that normally a transfer and a change of condition form would be completed, but no form is available in the resident's chart. On 05/14/24 at 9:51 AM., an interview was conducted with Licensed Practical Nurse (LPN) (L), concerning hospitalization s. LPN (L) said that normally if a resident is being admitted to the hospital a Change of Condition form is completed, the responsible party and physician should be notified. On 5/14/24 at approximately 3:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Regional Nurse Consultant. The Regional Nurse Consultant said that STAT (now) labs could have been done at the facility and the family member should have been called about the labs and hospital transfer.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide a written copy of the bed hold policy to the responsible party when two Residents were transferred to the hospital (Resident #176, and #172) in a survey sample of 50 Residents. The findings included: 1. For Resident # 176, the facility staff failed to provide a written copy of the bed hold policy to the responsible party when transferred to hospital on 01/02/2023. Resident # 176 was admitted to the facility in October 2021 with diagnoses that included but were not limited to: unspecified dementia, fracture of the left knee, prosthetic knee joint, diastolic congestive heart failure, repeated falls, chronic obstructive pulmonary disease, dysphagia, diabetes mellitus, cerebral infarction and asthma. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 10/18/2022. The MDS coded Resident # 176 with severe cognitive impairment. Resident # 176 required extensive assistance of one to two staff persons with ADLs (activities of daily living). Functional status for activities of daily living were coded as requiring extensive to total assistance of one to two staff persons. The MDS coded Resident # 176 as frequently incontinent of bowel and always incontinent of bladder. Review of the closed clinical record was conducted 5/7/2024-5/14/2024. Review of the Progress Notes revealed documentation that Resident # 176 was transferred to the hospital on 1/2/2023 due to altered mental status. The note stated that the transfer was at the family's request. The physician wrote the following excerpt under the assessment and plan: ASSESSMENT/PLAN: -Lethargy - she is not at her regular baseline nothing by report to explain this. BP and BS stable. Oxygen levels 90% but weaker pulses. Will send to the ER for further evaluation - family prefers this over attempted in house work up .Full report given to EMS (Emergency Medical Service). On 05/10/2024 at 9:50 a.m., a copy of the written bed hold policy notification was requested. The Administrator stated he would check with the Social Worker. A copy of the facility policy regarding resident transfers was requested and received. On 05/10/2024 at 10:00 a.m., a copy of the bed hold policy was requested from the the Social Worker who stated Nursing does the bed holds. On 5/10/2024 at 10:30 a.m., an interview was conducted with Licensed Practical Nurse D who stated there was no noted documentation of a bed hold policy being given to Resident # 176's Responsible Party. A copy of facility policy regarding resident transfers was requested. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) Hospital Transfer Form dated 1/2/2023 revealed Resident # 176 was transferred to the hospital 1/2/2023 at 9:40 a.m. for Altered Mental Status. The most recent pain level was a 5 out of 10 at 1/2/2023 at 05:57. The code status for Resident # 176 was DNR (Do Not Resuscitate). Usual mental status was listed as alert, disoriented, but cannot follow simple instructions. Under wounds was listed: bruising and hematomas to the face s/p (status post) fall and wound to buttock. A copy of the resident Acute Transfer Document checklist form was reviewed. The form listed Copies of Documents to be sent with Resident/Patient (check all that apply). Nothing was checked on the form. Documents Recommended to Accompany Resident/Patient: Resident- seven items were listed from which to choose. Under the section entitled Send these Documents if available, there were 7 items listed from which to choose. Under the section entitled Emergency Department, there was a statement that read Please ensure that these documents are forwarded to the hospital unit if this resident/patient is admitted . EMT Signature (optional) Transport Team Signature (optional) The form was not signed nor completed by facility staff members. It only had Resident # 176's name typed on the form. On 05/14/2024 at approximately during the end of day debriefing, the Administrator and DON (Director of Nursing) were notified of findings. There was no documentation of the responsible party receiving a written bed hold policy when Resident # 176 was transferred to the hospital. No further information was provided. 40711 2. For Resident #172, the facility staff failed to provide Resident #172 or resident's representative a copy of the bed hold policy when discharged and admitted to the hospital on 6/02/22. Resident #172 was originally admitted to the nursing facility on 5/27/22. The current diagnoses included; Acute Kidney Failure. The entry Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 06/02/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #172 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Physical functioning) the resident was coded as requiring set-up help with eating, oral hygiene. Dependent with oral hygiene and toileting hygiene. The care plan read that resident #172 was at risk for nutritional problems related recent hospitalization (revised on 5/31/22). The goal for the resident was to avoid significant weight change through next review. An intervention for Resident #172 was labs as ordered. The Discharge Minimum Data Set (MDS) assessment with an assessment reference date of 6/02/2022 coded resident as being discharged with return anticipated. A review of the medical record revealed no bed hold was offered. A review of a Nurse Practitioner note dated on 6/02/22 at 12:18 PM., read that Resident #172 had an abnormal Creatinine Level. We have discussed these lab results and what it might mean and why it needs to be worked up in an in-patient setting. He needs to be sent to the hospital for deeper work up given the increase. According to the Resident Representative she was not notified by the facility staff that Resident #172 was being transferred to the hospital. On 5/14/24 at 9:51 AM., with Licensed Practical Nurse (LPN) (L), concerning hospitalization s. LPN (L) said that normally if a resident is being admitted to the hospital, a bed hold should be offered to the resident or resident representative. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse 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, facility record review, and clinical record review, the facility staff failed to develop and implement a comprehensive care plan for two Residents (Resident #40, and #179) in a survey sample of 50 Residents. The findings included: 1. For Resident #40, the facility staff failed to care plan oxygen saturation and titration of oxygen administration to meet the needs of the Resident. Resident #40 was originally admitted to the facility on [DATE]. The Resident went out to the hospital on 3-19-24 with acute hypoxia, and returned on 4-10-24 to the facility with diagnoses including; Acute and chronic respiratory failure with hypoxia, muscle weakness, chronic obstructive pulmonary disease (COPD), acute pulmonary edema, morbid obesity, asthma, iron deficiency anemia, diabetes, and shortness of breath. Resident #40's most recent Minimum Data Set (MDS) assessment was a discharge assessment with an Assessment Reference Date (ARD) of 4-29-24. Resident #40 was Alert and oriented to person, place, time and situation indicating no cognitive impairment according to staff documentation, and interview by the surveyor. Resident #40 required extensive assistance from staff members for activities of daily living. On 5-6-24 at 2:15 PM, Resident #40 was interviewed via telephone. The Resident stated that her oxygen concentrator while she was a Resident in the facility could provide only 5 liters of oxygen, and that was insufficient for her needs. She further stated that the staff did not check her oxygen saturation (SPo2) levels regularly, that it was hit and miss which meant they could not see, and didn't know when I needed more oxygen. She went on to state that the nurses don't know what they are doing, the doctor wants me to be on 10 liters when I get short of breath, but they don't do it, and the Administrator said I was using too many portable tanks. Review of physician's orders revealed that the following oxygen orders were documented; Ordered 2-13-24, discontinued 2-13-24, O2 at 4 liters per minute via nasal cannula continuous. Ordered 2-13-24, discontinued 3-23-24, O2 at 5 liters per minute via nasal cannula continuous. Ordered 4-10-24, discontinued 4-30-24, O2 at 6 liters per minute via nasal cannula, may titrate as needed to maintain O2 SATs (SPO2) above 90% continuous. Review of the Vital signs record, and physician/nursing progress notes revealed the following; On 3-15-24 the physician evaluated the Resident for increased oxygen demands, patient up to 10 liters via nasal cannula, and a chest x-ray was ordered by the physician. The doctor also ordered Bumetanide 4 milligrams twice per day medication for 5 days. On 3-16-24 the Registered Nurse Practitioner evaluated the Resident documenting a follow up visit due to shortness of breath, and ordered continuous O2 (oxygen) via nasal cannula titrate up to 10 liters with humidity to maintain SATs (SPO2) greater than 93%. Continue Bumetanide for 7 days 4 milligrams twice per day. It is important to mention that a normal SPO2 is 95-100%. (10 liters per minute was never appeared in the physician orders as a limit for titration.) On 3-18-24 a nursing progress note documented that staff spoke with a tech from (business name with unknown initials) who was assigned to obtain the chest x-ray. This is the only note from 3-16-24 to 3-19-24 when the Resident was sent out to the hospital. On 3-19-24 at 6:00 AM no chest x-ray had been completed, and the Resident's SPO2 was at 66%. At 8:56 AM the physician was notified and ordered the Resident to be sent to the emergency room immediately. On 4-10-24 the Resident returned to the facility with an SPO2 of 93%, on 6 liters of oxygen via nasal cannula. Physician progress notes revealed that humidified oxygen should be continued and titrated to 10 liters per minute to maintain SPO2 at 88-92% as needed and for intermittent acute hypoxia, and bumetanide decreased to 1 milligram twice per day. On 4-11-24 at 2:22 AM the nurse documented Resident oxygen levels at 80%, complaints of shortness of breath due to a malfunctioning concentrator per Resident. O2 at 6 liters via nasal cannula, unlabored breathing, not in distress and comfortable. Wants oxygen to be increased to 10 liters per minute. Educated on the 6 liters ordered by the doctor .Resident not receptive to caregivers suggestions to promote her health Resident turned oxygen to 10 liters. On 4-11-24 at 4:58 AM O2 at 6 liters, not in distress according to nursing notes. On 4-11-24 at 11:59 PM the doctor visited the Resident and saw her sitting in a wheelchair with oxygen infusing at 8 liters per minute from an oxygen tank. The doctor documented that the Resident complained that her 5 liter concentrator was not working well. On 4-14-24 at 11:59 PM the Nurse practitioner again documents that the Resident feels that the oxygen concentrator is defective. On 4-15-24 at 8:38 PM the Resident complained to nursing that she was short of breath, nursing documented SPO2 at 79% on the concentrator, and then went up to 87% when placed on the portable oxygen tank. On 4-21-24 at 3:22 PM a nursing note documented Patient alert and oriented continues to wear O2 at 10 on her concentrator against medical advice. On 4-22-24 at 8:48 PM nursing notes documented In chair on 6 liters of oxygen via nasal cannula with no complaints . On 4-29-24 the Resident complained of shortness of breath and was sent to the hospital via ambulance and did not return. Review of the care plan (dated 2-15-24) revealed: The resident is at risk for respiratory complications, secondary to COPD, supplementary oxygen requirement. As interventions, the nurses were directed to provide: Administer nebulizer treatments as ordered, administer oxygen as ordered, Bipap/Cpap as ordered, assess oxygen saturation as needed, provide education on oxygen therapy. None of the care plan interventions were measurable and none of the SPO2 daily monitoring or titration of oxygen to meet the physician ordered oxygenation percentage was ever included in the care plan for nursing to follow. Those assessments were sporadic and from the 4-10-24 readmission until final discharge on 4-29-24, they only occurred on 9 of 20 days. The chest x-ray was never completed, and no record of it was in the clinical record. It was discontinued on 5-18-24 as completed, however, there was no record found in the clinical record by nursing staff nor by surveyors. No order was documented for Oxygen saturation assessments daily to monitor for hypoxia in order to titrate the oxygen to 10 liters per minute as was ordered in the physician progress notes on 3-16-24, and again on 4-10-24 to maintain the Resident's oxygenation between 88% and 92%. The Resident continued to complain that the oxygen concentrator was not working properly, and nursing staff counseled the Resident not to increase oxygen to 10 liters on 4-11-24, and 4-21-24 which the doctor had prescribed, with staff seemingly unaware of the order. On 5-9-24 at approximately at 10:00 AM, LPN (licensed practical nurse) anonymous was interviewed about the resident. The nurse was afraid of retaliation and stated she did not want to be identified. She stated, I told them the patient was not getting enough oxygen, and we should keep her on the tanks, but I was told by administration that she was using too many tanks and she had to be on the concentrator. I didn't know she was supposed to have her SATs checked like that and her oxygen increased, or I would have done it anyway. The facility Oxygen use policy was reviewed and revealed: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's orders and in accordance with standards of practice. Monitor and record saturation levels and vital signs as indicated, or by provider's order. Document oxygen delivery flow rate, method of delivery, date and time, saturation levels if indicated, in the electronic medical record. Document oxygen saturation level/and or vital signs in the electronic medical record as indicated, and any unusual findings and follow-up interventions including provider and responsible party notification. On 5-9-24, at 12:00 PM, and on 5-10-24 at 12:00 PM, the Administrator and Corporate RN were made aware of the lack of respiratory assessments and oxygen administration for Resident #40. They stated they had nothing further to provide. 2. For Resident #179, the facility staff failed to complete a care plan for Intravenous (IV) antibiotics after an infection from a status post knee replacement with acute hospitalization follow up for the post operative infection. Resident #179, was admitted to the facility on [DATE] at 6:30 PM, and discharged on [DATE] after 8:00 AM. Diagnoses included; After care following joint replacement surgery, infection due to right knee internal prosthetic, hypertension, hyperthyroidism, obesity, and gastroesophageal reflux disease (GERD). Resident #179's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-29-24 was coded as a discharge assessment. Resident #179 was coded as having no cognitive impairment. Resident #179 was also coded as requiring supervision or limited dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders were reviewed and revealed an order for antibiotics. The order was for the following; 1-16-24 Penicillin G Potassium 20,000,000 units use 4 milliunit IV every 4 hours, start 1-16-24. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for January 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 9 added to it indicating the antibiotic was not administered on 9 of 79 occasions. Those follow; 1-16-24 - 8:00 AM, 12:00 PM, 4:00 PM 1-17-24 - 4:00 AM 1-18-24 - 4:00 PM 1-24-24 - 12:00 PM 1-27-24 - 8:00 AM, 12:00 PM, 4:00 PM Nursing medication administration notes do not indicate why the antibiotics were not administered as ordered, and why they were omitted. Only one nursing orders administration note existed in the clinical record completed by LPN J which documented medication not available, MD (doctor), RP (responsible party), nursing managers are aware medication has been stat ordered, on 1-16-24 at 6:53 PM. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov; Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. Resident #179's care plan was reviewed and revealed no care plan for IV antibiotic infusions for an active infection. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable omitted, nor that the doctor was made aware of the omissions. Interviews conducted on 5-8-24, and 5-9-24 with nursing staff on both units revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 on the medication administration record (MAR), that the medication was not administered. On 5-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 5-13-24 at approximately 4:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in unavailable and omitted Antibiotics as ordered. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a discharge summary for 1 Resident (Resident # 176) in the survey sample of 50 residents. Findings included: For Resident # 176, the facility staff failed to complete a discharge summary after the a transfer to the hospital on 01/02/2023. Resident # 176 was admitted to the facility in October 2021 with diagnoses that included but were not limited to: unspecified dementia, fracture of the left knee, prosthetic knee joint, diastolic congestive heart failure, repeated falls, chronic obstructive pulmonary disease, dysphagia, diabetes mellitus, cerebral infarction and asthma. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 10/18/2022. The MDS coded Resident # 176 with severe cognitive impairment. Resident # 176 required extensive assistance of one to two staff persons with ADLs (activities of daily living). Functional status for activities of daily living were coded as requiring extensive to total assistance of one to two staff persons. The MDS coded Resident # 176 as frequently incontinent of bowel and always incontinent of bladder. Review of the closed clinical record was conducted 5/7/2024-5/14/2024. Review of the progress notes revealed documentation that Resident # 176 was transferred to the hospital on 01/02/2023. Further review of the progress notes and other sections of the clinical record revealed no documentation of a Discharge Summary. Resident # 176 did not return to the facility. During the end of day debriefing on 5/10/2024, the Administrator and Regional Nurse Consultant were informed of the findings. A copy of the Discharge Summary and the facility's policy was requested. Review of the Facility's policy entitled Discharge Summary revealed the statement A Discharge Summary must be completed by the physician for every discharge unless the Center is using the continuous chart procedure and the patient has been readmitted within thirty days. During the end of the day debriefing on 5/13/2024, the Administrator, Regional Nurse Consultant and Director of Nursing were informed of the findings of no discharge summary for Resident # 176. A copy of the Discharge Summary was not presented to the surveyor prior to survey exit. No further information was provided.

Based on staff interview, and clinical record review, the facility failed to provide care and services necessary to maintain good grooming for one resident (Resident # 6) in a survey sample of 50 residents. Findings included: For Resident # 6, the facility staff failed to provide grooming/nail care resulting in fingernails over 1/2 inch long on contracted hands. Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. The MDS coded Resident # 6 as requiring extensive to total staff assistance with Activities of Daily Living. Resident # 6 was coded as incontinent of bowel and bladder. Review of the clinical record was conducted 5/7/2024-5/14/2024. Review of the ADL documentation report for April 2024 and May 2024 revealed no documentation of nail care for Resident # 6. On 5/7/2024 at 10:30 a.m., Resident # 6 was observed lying in bed with contractures of both hands. The fingernails on both hands were very long at over a half an inch over the tip of the fingers. On 5/7/2024 at 1:15 p.m., Resident # 6 was observed sitting in a Geri-Chair at the nurses station. The fingernails were observed to be long and almost touching the palm of the hands. On 5/7/2024 at 2:44 p.m., an interview was conducted with CNA (Certified Nursing Assistant)-C who stated the residents should receive assistance as needed for activities of daily living. CNA-C stated staff should document the care provided. On 5/8/2024 at 2:33 p.m., an interview was conducted with CNA-B who stated the facility expected ADL care to be provided for residents and documentation should be done every shift. CNA-B stated sometimes Resident # 6 refused to allow the staff to provide care. When asked what the CNA should do if a resident refused care, CNA-B stated the nurse should be informed. On 5/8/2024 at 2:49 p.m., an interview was conducted with the Wound Care Nurse who stated the facility staff was expected to provide ADL care including incontinence care and nail care. The Wound care nurse stated whenever any resident refused any care, that should be documented, and the nurse should be notified. She stated that blanks in the documentation would indicate that it was not done. The Wound Care nurse stated that she was new in her position but that she administered treatments daily as ordered by the physician when she was on duty. She stated that she made rounds with the wound care nurse practitioner once a week and documented the assessments. She stated the nurses were expected to administer treatments as ordered by the physician. Nurses were expected to notify her of any new wounds discovered during the assessments or during skin checks by the CNAs. The Wound Care nurse stated that long fingernails on a contracted hand was a risk for development of a pressure wound in the palm of the hand. She stated the fingernails should be kept short and devices placed in the contracted hands to prevent the development of pressure wound. She stated she would check to see if Resident # 6 had a referral to Occupational therapy to address the contractures. On 5/8/2024 at 4:45 p.m., an interview was conducted with LPN (Licensed Practical Nurse)-B who stated the expectation was for staff members to provide care to the residents and to document the assistance provided. LPN-B stated that if residents refused to allow staff to provide care, the staff were expected to immediately report the refusal to the nurse. On 5/13/2024 during the end of day meeting, the Administrator, Director of Nursing and Corporate Nurse Consultant were informed of the findings. No further information was provided.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to provide treatment and services for pressure wounds for two Residents (Residents # 6 & # 87) in a survey sample of 50 Residents. 2. For Resident #87, the facility staff failed to administer wound care according to physician orders. The Findings Included: 1. For Resident #6, the facility staff failed to provide nail care to reduce the risk of development of new pressure wounds in the palms of the hands and failed to consistently provide treatments for pressure wound care per physician orders. Resident # 6 was admitted to the facility in April 2024 with diagnoses that included but were not limited to: Dementia, contractures and sepsis. Resident #6's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 04/12/2024 was a quarterly assessment. The MDS coded Resident # 6 with a BIMS (Brief Interview for Mental Status) score of 10 out of 15, indicating moderate cognitive impairment. The MDS coded Resident # 6 as requiring extensive to total staff assistance with Activities of Daily Living. Resident # 6 was coded as incontinent of bowel and bladder. Review of the clinical record was conducted 5/7/2024-5/14/2024. Review of the ADL documentation report for April 2024 and May 2024 revealed no documentation of nail care for Resident # 6. On 5/7/2024 at 10:30 a.m., Resident # 6 was observed lying in bed with contractures of both hands. The fingernails on both hands were very long at over a half an inch over the tip of the fingers. On 5/7/2024 at 1:15 p.m., Resident # 6 was observed sitting in a Geri-Chair at the nurses station. The fingernails were observed to be long and almost touching the palms of the hands. Review of Resident # 6's Progress notes and care plan revealed the resident occasionally refused care. There was no consistent documentation of attempts to encourage Resident # 6 to allow the staff to provide care to include nail care. There were interventions to treat and decrease the risk of pressure wounds. The facility policy for Documentation of Wound Treatments was reviewed and revealed the following excerpt: Wound treatments are documented at the time of each treatment . The Resident's care plan was reviewed and indicated the Resident would There was a care plan for wounds for Resident # 6. Physician's orders were reviewed and valid for the dates and times wound care was omitted. Staff nurse and CNA interviews were conducted during the course of the survey on all units. Those interviews indicated that the expectation for incontinence rounds was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNAs (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. The nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent the wounds worsening. The nursing staff stated all skin assessments were in the computerized record, and they had no paper assessments. Interviews were conducted with the facility staff members: On 5/7/2024 at 11:15 a.m., an interview was conducted with CNA (Certified Nursing Assistant)-E who stated residents should be turned and repositioned every two hours to help prevent pressure ulcers. CNA-E stated pillows and wedges should be used to help keep pressure off of the bony areas. CNA-E stated they look at the skin when giving baths or showers and during incontinence care. CNA-E stated any areas noted should be immediately reported to the charge nurse. CNA-E stated the Rehab Department frequently gave inservices about ways to prevent or reduce the risk of pressure wounds. On 5/8/2024 at 2:24 p.m., an interview was conducted with Licensed Practical Nurse C who stated the facility had a wound care nurse who performed dressing changes daily, a wound care nurse practitioner who examined residents once a week along with the wound care nurse. On 5/8/2024 at 2:49 p.m., during observations of Resident # 6's wounds, an interview was conducted with the Wound Care Nurse who stated the facility staff was expected to provide ADL care including nail care. When asked if Resident # 6's fingernails were properly groomed or too long, she stated the fingernails were very long at over one quarter to a half inch long and that both hands were contracted. The Wound Care nurse stated that long fingernails on a contracted hand was a risk for development of a pressure wound in the palm of the hand. She stated the fingernails should be kept short and devices placed in the contracted hands to prevent the development of pressure wound. She stated she would check to see if Resident # 6 had a referral to Occupational therapy to address the contractures. The Wound care nurse stated whenever any resident refused any care, that should be documented, and the nurse should be notified. She stated that blanks in the documentation would indicate that it was not done. The Wound Care nurse stated that she was new in her position but that she administered treatments daily as ordered by the physician when she was on duty. She stated that she made rounds with the wound care nurse practitioner once a week and documented the assessments. She stated the nurses were expected to administer treatments as ordered by the physician. Nurses were expected to notify her of any new wounds discovered during the assessments or during skin checks by the CNAs. CNA-B was in the room helping to hold Resident # 6 on the side for observation of the pressure wounds on the buttocks. On 5/8/2024 at 3:01 p.m., an interview was conducted with CNA-B stated Resident # 6 often refused care. CNA-B was asked if the refusals were documented each time. CNA-B stated we are supposed to document any time they refuse and notify the nurse. On 5/8/2024 at 4:10 p.m., Resident # 6 was observed lying in bed. Fingernails had been trimmed. On 5/8/2024 at 4:35 p.m., an interview was conducted with the Unit Manager who stated Resident # 6 often refused care. The Unit Manager stated the staff should document all refusals and staff should try differing attempts to encourage the resident to allow care to be provided. She stated maybe different times or a different person would be helpful. The Unit Manager stated Resident # 6 allowed the staff to cut the fingernails after the surveyor discussed concerns with the staff members. The Unit Manager stated a referral would be made to the Rehab department to assist with reducing the risk of developing a wound in the palm of the hand. On 5/8/2024 at 4:45 p.m., an interview was conducted with the Rehab Director who stated Resident # 6 had been in the therapy case load for the contracture of the hand. The Rehab Director provided documentation of a problem of inconsistent wear of palm roll/hand hygiene issues during the period of 12/19/2023-1/17/2024. The Rehab Director stated Resident # 6 was being seen currently (at the time of survey) for knee contractures. Interventions were in place to reduce the risk of pressure wounds of the knees and ankles. On 5/9/2024 at 11:20 a.m., Resident # 6 was observed with fingernails trimmed and palm rolls in each hand. Review of the clinical record revealed physician and nursing progress notes regarding the risk for pressure wounds with plans and interventions to treat and decrease the risk of the development of new wounds. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for March 2024 and April 2024, and revealed the absence of nursing signatures indicating the treatments were not completed on 9 occasions. Those dates were as follows: Santyl External Ointment 250 UNIT/GM (gram) (Collagenase) Apply to Left Buttock topically every night shift for Unstageable -Order Date-01/29/2024 0910 -D/C Date- 03/25/2024 1203 not administered on 3/5/2024 on night shift WOUND CARE- Right ischium: Cleanse with soap & water, pat dry then apply collagen particles &xeroform, cover with bordered foam. every day shift for Abrasion -Order Date- 03/07/2024 1257 -D/C Date- 03/29/2024 1528 not administered 3/17/2024, 3/22/2024, 3/24/2024, 3/28/2024, and 3/29/2024 WOUND CARE - Right buttocks: Cleanse with soap and water, apply zinc leave ota (open to air) three times a day for incontinence TID and PRN (as needed) -Order Date- 02/05/2024 0941 -D/C Date- 03/07/2024 1257 not administered 3/2/2024 at 9 p.m., 3/6/2024 at 9 p.m., and 3/6 /2024 at 2 p.m. On 5/13/2024 and 5/14/2024 during the end of day debriefing, the Administrator, and DON (Director of Nursing) were notified that the facility failed to provide care and services for pressure ulcers. Copies of inservices conducted with nursing staff were presented by the Unit Manager and Rehab Director No further information was provided by the facility. 40711 2. For Resident #87, the facility staff failed to administer wound care according to physician orders. Resident #87 was originally admitted to the facility 03/08/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included diabetes mellitus. The Care Plan dated 3/09/24 read that Resident #87 has chronic wound and pressure ulcers to the sacrum, left and right leg. The goal for Resident #87 the resident was that pressure ulcers/skin impairments would not develop thru the review period (3/11/24). The interventions for Resident #87 would be to keep the skin clean and dry and to assess the resident for skin breakdown. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/12/24 coded the resident as completing a Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #87 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goal) the resident was coded as independent with eating, oral hygiene, requiring dependence with toileting hygiene, showers/bathing and personal hygiene. In Section M (Skin Conditions) the resided is coded as having 5 stage 3 pressure ulcers with all 5 being present on admission. According to the March 2024 and April 2024 Treatment Administration Record (TAR) wound care treatments were missed on the following dates: Left posterior leg, stage 3: 3/17/24, 3/22/24, 3/27/24. Right posterior leg, stage 3: 3/17/24. Sacrum stage 3: 3/17/24. Right anterior leg: 3/17/24 and 3/20/24. Current Physician Order Summary (POS) for May 2024 read: Right anterior lower leg, cleanse with wound cleanse, xeroform and cover with border gauze daily, every night shift (Order date- 05/07/2024). Right lateral ankle, cleanse with wound cleanse, xeroform and cover with border gauze daily every night shift (Order date- 05/07/2024). Sacrum wound Stage 3, cleanse with wound cleanser, Honey fiber, bordered gauze. Day shift (Start 3/12/24). A skin and wound note dated 5/6/2024 at 10:46 AM., read right lateral ankle Skin Tear/Laceration. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Xeroform to base of the wound. 3. secure with Bordered gauze 4. change Daily. On 5/08/24 at approximately 3:40 PM., a wound care observation was conducted with the wound care nurse (WCN) for Resident #87. The WCN was observed removing a bordered gauze dressing dated 5/06/24 from Resident #87's Right lateral ankle. The wound care nurse said that the night shift nurse should have changed the dressing last night (5/07/24) but they didn't. On 5/14/2024 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Corporate Nurse Consultant. The corporate nurse consultant said that wound care should have been done.

Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to provide respiratory care and services to maintain the highest practicable wellbeing for one resident, (Resident #40) in a survey sample of 50 residents, . The findings included: For Resident #40, the facility staff failed to assess and monitor the Resident's oxygen saturation and titrate oxygen administration to meet the needs of the Resident. Further, oxygen treatment orders were unclear, not followed, and not care planned for nursing staff guidance. Resident #40 was originally admitted to the facility on [DATE]. The Resident went out to the hospital on 3-19-24 with acute hypoxia, and returned on 4-10-24 to the facility with diagnoses including; Acute and chronic respiratory failure with hypoxia, muscle weakness, chronic obstructive pulmonary disease (COPD), acute pulmonary edema, morbid obesity, asthma, iron deficiency anemia, diabetes, and shortness of breath. Resident #40's most recent Minimum Data Set (MDS) assessment was a discharge assessment with an Assessment Reference Date (ARD) of 4-29-24. Resident #40 was Alert and oriented to person, place, time and situation indicating no cognitive impairment according to staff documentation, and interview by the surveyor. Resident #40 required extensive assistance from staff members for activities of daily living. On 5-6-24 at 2:15 PM, Resident #40 was interviewed via telephone. The Resident stated that her oxygen concentrator while she was a Resident in the facility could provide only 5 liters of oxygen, and that was insufficient for her needs. She further stated that the staff did not check her oxygen saturation (SPo2) levels regularly, that it was hit and miss which meant they could not see, and didn't know when I needed more oxygen. She went on to state that the nurses don't know what they are doing, the doctor wants me to be on 10 liters when I get short of breath, but they don't do it, and the Administrator said I was using too many portable tanks. Review of physician's orders revealed that the following oxygen orders were documented; Ordered 2-13-24, discontinued 2-13-24, O2 at 4 liters per minute via nasal cannula continuous. Ordered 2-13-24, discontinued 3-23-24, O2 at 5 liters per minute via nasal cannula continuous. Ordered 4-10-24, discontinued 4-30-24, O2 at 6 liters per minute via nasal cannula, may titrate as needed to maintain O2 SATs (SPO2) above 90% continuous. Review of the Vital signs record, and physician/nursing progress notes revealed the following; On 3-15-24 the physician evaluated the Resident for increased oxygen demands, patient up to 10 liters via nasal cannula, and a chest x-ray was ordered by the physician. The doctor also ordered Bumetanide 4 milligrams twice per day medication for 5 days. On 3-16-24 the Registered Nurse Practitioner evaluated the Resident documenting a follow up visit due to shortness of breath, and ordered continuous O2 (oxygen) via nasal cannula titrate up to 10 liters with humidity to maintain SATs (SPO2) greater than 93%. Continue Bumetanide for 7 days 4 milligrams twice per day. It is important to mention that a normal SPO2 is 95-100%. (10 liters per minute was never appeared in the physician orders as a limit for titration.) On 3-18-24 a nursing progress note documented that staff spoke with a tech from (business name with unknown initials) who was assigned to obtain the chest x-ray. This is the only note from 3-16-24 to 3-19-24 when the Resident was sent out to the hospital. On 3-19-24 at 6:00 AM no chest x-ray had been completed, and the Resident's SPO2 was at 66%. At 8:56 AM the physician was notified and ordered the Resident to be sent to the emergency room immediately. On 4-10-24 the Resident returned to the facility with an SPO2 of 93%, on 6 liters of oxygen via nasal cannula. Physician progress notes revealed that humidified oxygen should be continued and titrated to 10 liters per minute to maintain SPO2 at 88-92% as needed and for intermittent acute hypoxia, and bumetanide decreased to 1 milligram twice per day. On 4-11-24 at 2:22 AM the nurse documented Resident oxygen levels at 80%, complaints of shortness of breath due to a malfunctioning concentrator per Resident. O2 at 6 liters via nasal cannula, unlabored breathing, not in distress and comfortable. Wants oxygen to be increased to 10 liters per minute. Educated on the 6 liters ordered by the doctor .Resident not receptive to caregivers suggestions to promote her health Resident turned oxygen to 10 liters. On 4-11-24 at 4:58 AM O2 at 6 liters, not in distress according to nursing notes. On 4-11-24 at 11:59 PM the doctor visited the Resident and saw her sitting in a wheelchair with oxygen infusing at 8 liters per minute from an oxygen tank. The doctor documented that the Resident complained that her 5 liter concentrator was not working well. On 4-14-24 at 11:59 PM the Nurse practitioner again documents that the Resident feels that the oxygen concentrator is defective. On 4-15-24 at 8:38 PM the Resident complained to nursing that she was short of breath, nursing documented SPO2 at 79% on the concentrator, and then went up to 87% when placed on the portable oxygen tank. On 4-21-24 at 3:22 PM a nursing note documented Patient alert and oriented continues to wear O2 at 10 on her concentrator against medical advice. On 4-22-24 at 8:48 PM nursing notes documented In chair on 6 liters of oxygen via nasal cannula with no complaints . On 4-29-24 the Resident complained of shortness of breath and was sent to the hospital via ambulance and did not return. Review of the care plan (dated 2-15-24) revealed: The resident is at risk for respiratory complications, secondary to COPD, supplementary oxygen requirement. As interventions, the nurses were directed to provide: Administer nebulizer treatments as ordered, administer oxygen as ordered, Bipap/Cpap as ordered, assess oxygen saturation as needed, provide education on oxygen therapy. None of the care plan interventions were measurable and none of the SPO2 daily monitoring or titration of oxygen to meet the physician ordered oxygenation percentage was ever included in the care plan for nursing to follow. Those assessments were sporadic and from the 4-10-24 readmission until final discharge on 4-29-24, they only occurred on 9 of 20 days. The chest x-ray was never completed, and no record of it was in the clinical record. It was discontinued on 5-18-24 as completed, however, there was no record found in the clinical record by nursing staff nor by surveyors. No order was documented for Oxygen saturation assessments daily to monitor for hypoxia in order to titrate the oxygen to 10 liters per minute as was ordered in the physician progress notes on 3-16-24, and again on 4-10-24 to maintain the Resident's oxygenation between 88% and 92%. The Resident continued to complain that the oxygen concentrator was not working properly, and nursing staff counseled the Resident not to increase oxygen to 10 liters on 4-11-24, and 4-21-24 which the doctor had prescribed, with staff seemingly unaware of the order. On 5-9-24 at approximately at 10:00 AM, LPN (licensed practical nurse) anonymous was interviewed about the resident. The nurse was afraid of retaliation and stated she did not want to be identified. She stated, I told them the patient was not getting enough oxygen, and we should keep her on the tanks, but I was told by administration that she was using too many tanks and she had to be on the concentrator. I didn't know she was supposed to have her SATs checked like that and her oxygen increased, or I would have done it anyway. The facility Oxygen use policy was reviewed and revealed: Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per provider's orders and in accordance with standards of practice. Monitor and record saturation levels and vital signs as indicated, or by provider's order. Document oxygen delivery flow rate, method of delivery, date and time, saturation levels if indicated, in the electronic medical record. Document oxygen saturation level/and or vital signs in the electronic medical record as indicated, and any unusual findings and follow-up interventions including provider and responsible party notification. On 5-9-24, at 12:00 PM, and on 5-10-24 at 12:00 PM, the Administrator and Corporate RN were made aware of the lack of respiratory assessments and oxygen administration for Resident #40. They stated they had nothing further to provide.

Based in information obtained during the sufficient and competent nurse staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents. The findings included; During the nursing staff review from June 2022 through May 2024. The facility staff was unable to verify RN coverage for at least 8 consecutive days on the following dates for eleven (11) days: 7/03/23, 7/04/23, 7/05/23, 7/08/23,7/16/23, 8/05/23, 8/06/23, 9/09/23, 9/10/23, 10/15/23, and 10/22/23. The above dates were verified by the scheduling coordinator on 5/14/24 at approximately 11:30 AM. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse Consultant. The administrator said that coverage should have been provided.

Based on Staff interview, clinical record review, and facility document review, the facility failed to provide medications as ordered by a physician for one (Resident #179) in a survey sample of 50 residents. The findings included: 1. For Resident #179, Intravenous (IV) Antibiotics were unavailable during an acute post operative infection. Resident #179, was admitted to the facility on [DATE] at 6:30 PM, and discharged on [DATE] after 8:00 AM. Diagnoses included; After care following joint replacement surgery, infection due to right knee internal prosthetic, hypertension, hyperthyroidism, obesity, and gastroesophageal reflux disease (GERD). Resident #179's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-29-24 was coded as a discharge assessment. Resident #179 was coded as having no cognitive impairment. Resident #179 was also coded as requiring supervision or limited dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders were reviewed and revealed an order for antibiotics. The order was for the following; 1-16-24 Penicillin G Potassium 20,000,000 units use 4 milliunit IV every 4 hours, start 1-16-24. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for January 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 9 added to it indicating the antibiotic was not administered on 9 of 79 occasions. Those following doses included: 1-16-24 - 8:00 AM, 12:00 PM, 4:00 PM 1-17-24 - 4:00 AM 1-18-24 - 4:00 PM 1-24-24 - 12:00 PM 1-27-24 - 8:00 AM, 12:00 PM, 4:00 PM Nursing medication administration notes do not indicate why the antibiotics were not administered as ordered, and why they were omitted. Only one nursing orders administration note existed in the clinical record completed by LPN J which documented medication not available, MD (doctor), RP (responsible party), nursing managers are aware medication has been stat ordered, on 1-16-24 at 6:53 PM. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov: Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. Resident #179's care plan was reviewed and revealed no care plan for IV antibiotic infusions for an active infection. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable, omitted, nor that the doctor was made aware of the omissions. Interviews conducted on 5-8-24, and 5-9-24 with nursing staff on both units revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 on the medication administration record (MAR), that the medication was not administered. On 5-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 5-13-24 at approximately 4:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in unavailable and omitted Antibiotics as ordered. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for one Resident (Residents #179) in a survey sample of 50 Residents. The findings included: For Resident #179, the facility staff failed to administer Intravenous (IV) antibiotics after an infection from a status post knee replacement with acute hospitalization follow up for the post operative infection. Resident #179, was admitted to the facility on [DATE] at 6:30 PM, and discharged on [DATE] after 8:00 AM. Diagnoses included; After care following joint replacement surgery, infection due to right knee internal prosthetic, hypertension, hyperthyroidism, obesity, and gastroesophageal reflux disease (GERD). Resident #179's most recent MDS (minimum data set) with an ARD (assessment reference date) of 1-29-24 was coded as a discharge assessment. Resident #179 was coded as having no cognitive impairment. Resident #179 was also coded as requiring supervision or limited dependence on one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident's physician orders were reviewed and revealed an order for antibiotics. The order was for the following; 1-16-24 Penicillin G Potassium 20,000,000 units use 4 milliunit IV every 4 hours, start 1-16-24. The Medication and Treatment Administration Record (MAR/TAR) was reviewed for January 2024, and revealed the absence of nursing signatures on some occasions, and a signature with the number 9 added to it indicating the antibiotic was not administered on 9 of 79 occasions. Those follow; 1-16-24 - 8:00 AM, 12:00 PM, 4:00 PM 1-17-24 - 4:00 AM 1-18-24 - 4:00 PM 1-24-24 - 12:00 PM 1-27-24 - 8:00 AM, 12:00 PM, 4:00 PM Nursing medication administration notes do not indicate why the antibiotics were not administered as ordered, and why they were omitted. Only one nursing orders administration note existed in the clinical record completed by LPN J which documented medication not available, MD (doctor), RP (responsible party), nursing managers are aware medication has been stat ordered, on 1-16-24 at 6:53 PM. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov: Antibiotics must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses. Do not discontinue this medication without seeking a doctor's help. Stopping Antibiotics increases the likelihood of MDRO's (multi drug resistant organisms) such as Methycillin Resistant Staphyloccocus Aureus (MRSA), and can result in rebound infections which can be life threatening. Resident #179's care plan was reviewed and revealed no care plan for IV antibiotic infusions for an active infection. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been unavailable omitted, nor that the doctor was made aware of the omissions. Interviews conducted on 5-8-24, and 5-9-24 with nursing staff on both units revealed that the expectation for all medications is that they are available and administered per physician's order. They were in agreement that if there was a hole (no signature), or a 9 on the medication administration record (MAR), that the medication was not administered. On 5-10-24 at 11:00 a.m., the Director of Nursing (DON) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 5-13-24 at approximately 4:30 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in unavailable and omitted Antibiotics as ordered. No further information was provided.

Based on information obtained during resident group interview and staff interviews the facility staff failed to assist 3 residents (#17, #1, and #27) to exercise their right to vote in the November 2023 general election in the survey sample of 50 residents. The findings included: 1. The facility failed to remind and assist Resident #17, to vote in the November 2023 general election. Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus without complications, muscle weakness, and constipation. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #17's cognitive abilities for daily decision making were intact. On 5/7/24 at approximately 1:00 PM, an interview was conducted with the Resident Council group. During this interview Resident #17 stated he didn't get to vote in the November 2023 election, and it was his desire to vote. The resident stated that no one talked about the upcoming election or asked if he wanted or needed assistance to obtain an absentee ballot. 2. The facility failed to remind and assist Resident #1, to vote in the November 2023 general election. Resident # 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, muscle weakness, type 2 diabetes mellitus without complications, and hyperlipidemia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/4/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were intact. On 5/7/24 at approximately 1:00 PM, an interview was conducted with the Resident Council group. During this interview Resident #1 stated she didn't get to vote in the November 2023 election, and it was her desire to vote. The resident stated that no one talked about the upcoming election or asked if she wanted or needed assistance to participate in the November 2023 election. 3. The facility failed to remind and assist Resident #27, to vote in the November 2023 general election. Resident #27 was originally admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, acquired absence of right leg above knee, acquired absence of left leg above knee, and major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact. On 5/7/24 at approximately 1:00 PM, an interview was conducted with the Resident Council group. During this interview Resident #27 stated he didn't get to vote in the November 2023 election, and he would have liked to vote. The resident stated that no one talked about the upcoming election or asked if he wanted or needed assistance to obtain an absentee ballot. An interview was conducted with the Activities Director on 5/14/24 at 12:55 PM. The Activities Director stated that the residents did not have an opportunity to vote in the November 2023 general election and it is her duty to manage all voting activities. The Activities Director also stated going forward she would ensure all activities related to voting are carried out. An interview was conducted with the Administrator on 5/14/24 at 1:05 PM. The Administrator stated that he understands the importance of residents voting however he cannot produce any evidence that residents had the opportunity to vote in the November 2023 general election. On 5/14/24 at approximately 3:45 PM, a final interview was conducted with the Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing. 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 staff interview, clinical record review, and review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a discharge and admission to a local hospital for 3 of 50 residents (Residents #101, #172, and #176 ) in the survey sample. The findings included: 1. Resident #101 was originally admitted to the facility 11/7/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included metabolic encephalopathy, muscle weakness, cognitive communication deficit, and dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/25/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #101's cognitive abilities for daily decision making were moderately impaired. A review of Resident #101's nurses note dated 1/20/24 at 10:28 AM read patient was sent to emergency room at the local hospital due to altered mental status. The nurses note further read that the patient representative was notified of this transfer. An interview was conducted with the Director of Social Work on 5/13/24 at 3:05 PM. The Director of Social Work stated that she does not have evidence that notification was sent to the Ombudsman of the reason for transfer/discharge to hospital for Resident #101 on 1/20/24. The Director of Social Work further stated that during the month of January 2024 she thought that another individual was sending the notification's however compliance was not achieved. On 5/14/24 at approximately 3:45 PM, a final interview was conducted with the Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing. 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. 40711 2. For Resident #172, a closed record resident, the facility staff failed to send a notice to a representative of the Ombudsman office for Resident #172's discharge to the hospital. Resident #172 was originally admitted to the facility 05/27/2022 and discharged on [DATE]. The current diagnoses included acute kidney failure. A review of the clinical records indicated this resident was admitted to the hospital on 06/02/22. The entry Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 06/02/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #172 cognitive abilities for daily decision making were moderately impaired. The Discharge Minimum Data Set (MDS) assessment with an assessment reference date of 6/02/22 coded resident as being discharged with return anticipated. In sectionGG(Physical functioning) the resident was coded as requiring set-up help with eating, oral hygiene. Dependent with oral hygiene and toileting hygiene. The care plan read that resident #172 was at risk for nutritional problems related recent hospitalization (revised on 5/31/22). The goal for the resident to avoid significant weight change through next review. An intervention for Resident #172 was labs as ordered. On 5/14/24 at approximately 9:57 AM., the Social Worker (SW) presented a binder with Ombudsman notifications. The Ombudsman notifications were reviewed from June 2022 through August 2022. No Ombudsman notifications were uncovered for Resident #172. A review of a Nurse Practitioner note dated on 6/02/22 at 12:18 PM., read that Resident #172 had an abnormal Creatinine Level. We have discussed these lab results and what it might mean and why it needs to be worked up in an in-patient setting. He needs to be sent to the hospital for deeper work up given the increase. On 5/10/24 an interview was conducted at 11:09 AM., with Administrative Staff (D) concerning Resident #172. Administrative Staff (D) said that normally a transfer and a change of condition form would be completed, but no form is available in the resident's chart. On 05/14/24 at 9:51 AM., with Licensed Practical Nurse (LPN) (L), concerning hospitalization s. LPN (L) said that normally if a resident is being admitted to the hospital, a medication list is sent, a bed hold policy, if resident has a Do Not Resuscitate (DNR) order (a copy is sent), Change of Condition (CIC) form, a transfer form and care plan including notice to the local Ombudsman. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 34894 3. For Resident # 176, the facility staff failed to notify the Ombudsman when transferred to hospital on 01/02/23. Resident # 176 was admitted to the facility in October 2021 with diagnoses that included but were not limited to: unspecified dementia, fracture of the left knee, prosthetic knee joint, diastolic congestive heart failure, repeated falls, chronic obstructive pulmonary disease, dysphagia, diabetes mellitus, cerebral infarction and asthma. The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 10/18/22. The MDS coded Resident # 176 with severe cognitive impairment. Resident # 176 required extensive assistance of one to two staff persons with ADLs (activities of daily living). Functional status for activities of daily living were coded as requiring extensive to total assistance of one to two staff persons. The MDS coded Resident # 176 as frequently incontinent of bowel and always incontinent of bladder. Review of the closed clinical record was conducted 5/7/24-5/14/24. Review of the Progress Notes revealed documentation that Resident # 176 was transferred to the hospital on 1/2/2023 due to altered mental status. The note stated that the transfer was at the family's request. On 05/10/2024 at 9:50 a.m., a copy of the ombudsman notification was requested. The Administrator stated he would check with the Social Worker. A copy of the facility policy regarding resident transfers was requested and received. On 05/10/2024 at approximately 12:00 p.m., an interview was conducted with the Social Services Director. She stated the notices were sent to the Ombudsman monthly. Review of the Ombudsman notifications revealed no notice of Resident # 176 being transferred from the facility. On 05/14/24 during the end of day debriefing,, the Administrator and DON (Director of Nursing) were notified of findings of the Ombudsman not being notified. No further information was provided.

Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the resident's care plan to include their goals after being transferred to the hospital for 1 of 50 residents (Resident #172), a closed record sample in the survey sample. The findings included: Resident #172 was originally admitted to the facility 05/27/2022 and discharged on [DATE]. The current diagnoses included acute kidney failure. The entry Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 06/02/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #172 cognitive abilities for daily decision making were moderately impaired. The Discharge Minimum Data Set (MDS) assessment with an assessment reference date of 6/02/22 coded resident as being discharged with return anticipated. In sectionGG(Physical functioning) the resident was coded as requiring set-up help with eating, oral hygiene. Dependent with oral hygiene and toileting hygiene. The care plan read that Resident #172 was at risk for nutritional problems related recent hospitalization , revised on 5/31/22. The goal for the resident was to avoid significant weight change through next review. An intervention for Resident #172 was labs as ordered. A review of the facility data report indicated Resident #172 was discharged and transferred to a short-term general hospital for inpatient care on 6/2/22 at 4:00 PM. The document was created on 6/03/22 at 9:47 AM., to local hospital. A review of a Nurse Practitioner (NP) note dated on 6/02/22 at 12:18 PM., read that Resident #172 had an abnormal Creatinine Level. The note indicated, We have discussed these lab results and what it might mean and why it needs to be worked up in an in-patient setting. He needs to be sent to the hospital for deeper work up given the increase. On 5/10/24 an interview was conducted at 11:09 AM., with Administrative Staff (D) concerning Resident #172. Administrative Staff (D) said that normally a transfer and a change of condition form would be completed, but no form is available in the resident's chart. On 05/14/24 at 9:51 AM., and interview was conducted with Licensed Practical Nurse (LPN) (L), concerning hospitalization s. LPN (L) said that normally if a resident is being admitted to the hospital, a medication list is sent, a bed hold policy, if resident has a Do Not Resuscitate (DNR) order (a copy is sent), Change of Condition (CIC) form, a transfer form and care plan. On 5/14/24 at approximately 3:30 p.m., the above findings were reviewed with the Administrator, Director of Nursing and Regional Nurse 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, clinical record review, and facility document review, the facility failed to prevent significant medication errors regarding 4 medications for two Residents, (Resident #29 & #259) in a sample of 46 residents. The findings included; 1. For Resident #29, the Resident was given two doses of an anticoagulant significant drug, instead of the single dose ordered by the physician. Resident #29 was admitted to the facility on [DATE]. The Resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On Monday 5-23-22 at 8:00 a.m., during the Medication administration pour and pass observations with LPN (G), Resident #29's medications were observed while being prepared for administration, and was observed receiving those medications. The Resident was observed receiving 16 total medications to include the following medications of concern; [MEDICATION(S)] 5 milligrams (mg), and [MEDICATION(S)] 7.5 mg. both given for a total of 12.5 mg given by LPN (G). After medication pour and pass observations were completed, a review of Resident #29's clinical record was conducted. This review revealed the following excerpts from the physician's orders: Ordered 5-13-22, [MEDICATION(S)] Sodium 5mg tablet one every day on Tuesday, Friday, and Sunday. Ordered 5-13-22, [MEDICATION(S)] Sodium 7.5mg tablet one every day on Monday, Wednesday, Thursday, and Saturday. Resident #29 had received a double dose of the blood thinning medication in error. The LPN, Director of Nursing, and Administrator were made aware immediately. The Resident was not exhibiting signs of bleeding at that time. On 5-23-22, during the end of day debriefing, the Administrator and DON (Director of Nursing) were notified of the issue, both stated they had nothing further to provide. 2a. For Resident #259, the facility staff failed to administer a physician ordered intravenous antibiotic on four occasions. On 5/22/22 and 5/23/22, a clinical record review was conducted of Resident #259's closed electronic health record. Review of the physician orders revealed an order dated 1/6/22, that read, [MEDICATION(S)] Solution Reconstituted 500 MG Use 500 mg intravenously every 6 hours for pelvic abscesses. Resident #259's medication administration record (MAR) revealed that on 1/14/22, 1/15/22, 1/19/22, and 1/24/22, she had not been administered [MEDICATION(S)] [an antibiotic] as ordered by the physician. The progress notes were reviewed and no indication was noted of the antibiotic being administered, the doctor being notified or any orders to alter the previously scheduled treatment/medication order(s). On 5/23/22 at 1:46 PM, an interview was conducted with LPN B. LPN B stated that medications are given within an hour of the scheduled time and documented on the MAR. LPN B was asked what it means if the MAR is blank, she said, If blank it wasn't given. LPN B went on to say in such an instance she would document in the nursing notes why the medication was not given. LPN B was asked to explain the risk of missing doses of IV antibiotics. LPN B said, It wouldn't be complaint and would have to start the therapy again. On 5/23/22 at 2:25 PM, an interview was conducted with the nurse practitioner (NP). The NP said she recalled Resident #259 very well as she was a clinically complex case. The NP said she recalled talking to the surgeon regarding Resident #259 on several occasions to assist with treatment decisions. During the interview, the NP stated she recalled the daughter of Resident #259 expressing concern of Resident #259 missing doses of the IV antibiotic. The NP said, The Resident and daughter weren't aware of the labs and stop dates you have to have with antibiotics, so I would order treatment for 4-6 weeks, then try to stop it. The stop date was in place and then I would re-initiate it. So it wasn't that she actually missed doses, it was due to the start and stop dates. Further review of the clinical record was conducted following the above interview with the Nurse Practitioner. This additional review revealed that the order for [MEDICATION(S)] given on 1/6/22, had no stop date indicated. It was not discontinued until 2/14/22, when treatment was changed to an oral antibiotic in preparation for her to discharge home. On 5/24/22 at 10:15 AM, an additional interview was conducted with the nurse practitioner. The NP was made aware that based on the clinical record, Resident #259 had missed 4 doses of her IV antibiotics in January. The NP said she was not aware of this. When asked what the possible risks are when such antibiotics are missed she said, Well 2 things come to mind. 1. Whatever we are treating has the ability to come back and second, it could develop a resistance. On 5/24/22 at 10:46 AM, an interview was conducted with LPN E. LPN E was asked about medication administration and documentation of such. LPN E said medication administration is documented on the medication administration record. When asked what blanks would mean, she stated she had never encountered that. On 5/24/22 at 11:06 AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that the administration of medications is recorded on the MAR and is documented immediately following the administration. The DON was reviewed the MAR for Resident #259 and confirmed the findings of the IV antibiotic not being recorded as being administered on 1/14/22, 1/15/22, 1/19/22, and 1/24/22. When asked what the blanks indicated, the DON said, I see there is not a signature, it appears that there is a missed signature. When asked if this would indicate the medication was not given, the DON said, It appears the medication was here since the dose prior and the dosed after that one was administered so it appears that it wasn't signed off. The DON was asked if there was evidence anywhere else that the antibiotics were given as ordered. The DON said without talking to the nurse that was working at that time she had no way of knowing. 2b. For Resident #259, the facility staff administered medications six hours late. When the second dose of medications was administered 5-6 hours later, this had the potential to cause adverse outcomes due to insufficient time having lapsed between doses of antihypertensive medications and anticoagulants being administered. During a clinical record review of Resident #259's electronic health record it was noted that on 12/21/21 the resident was transferred to ER via EMS [emergency medical services]. Further review revealed no further notes to indicate when Resident #259 returned to the facility. Hospital records from the ER visit that were scanned into the record and were reviewed. This revealed that Resident #259 was diagnosed with an [CONDITION(S)] flutter and treated with bolus IV [MEDICATION(S)] [antiarrhythmic medication] [[MEDICATION(S)] is a calcium channel blocker. It works by relaxing the muscles of your heart and blood vessels. [MEDICATION(S)] is used to treat hypertension (high blood pressure), [CONDITION(S)] (chest pain), and certain heart rhythm disorders.] Review of the medication administration records revealed that Resident #259's medications scheduled for 9 AM on 12/21/21, included but were not limited to: [MEDICATION(S)] Tablet 5 MG [blood thinner] and [MEDICATION(S)] [antihypertensive/blood pressure medication]. These two medications as well as other medications scheduled for administration at 9 AM, were signed off as being administered at 4:10 PM. Resident #259 was scheduled to receive a second dose of the same medications, [MEDICATION(S)] and [MEDICATION(S)] again at 9 PM, each day. On 12/21/21, her 9 PM, dose of medications was noted to have been administered at 9:50 PM. This was only five hours and 40 minutes since her last administration. On 5/24/22 at 10:15 AM, an interview was conducted with the nurse practitioner (NP). The NP was asked to explain the timing of medications ordered to be given twice daily. The NP said, When medications are ordered morning and night it is 9 AM and 9 PM, if they are ordered BID [twice a day] it is typically 9 AM and 5 PM. It depends on who puts the order in. The NP was asked about anticoagulants and blood pressure medications, she said, I like to spread it out every 12 hours. The NP was asked, what are the risk of getting consecutive doses of those two medications too close together? She said, With [MEDICATION(S)] it is concerning because they are getting a larger dose all at once and the next 12 hours they would be at an increased risk for bleeding. The other could make the blood pressure drop too low and at would be at risk for a [CONDITION(S)] event. The NP was told of the medications given to Resident #259 on 12/21/21. The NP was asked what the process is when a Resident is sent to the emergency room and returns with regards to the medications they may have missed while away from the facility. The NP said, When they come back it would be communicated and if I recall she came back midafternoon. I would not assume we would give the 9 AM, medication late. The instructions we get from the hospital aren't always complete and since we don't always know what they were administered in the hospital I would pick up where we are, so she wouldn't get medications that were not administered in her absence until the next scheduled dose. The NP was made aware that Resident #259 was treated in the hospital with IV [MEDICATION(S)] and then administered her 9 AM, scheduled medications at 4:10 PM, and again at 9:50 PM, which included but were not limited to: [MEDICATION(S)] and [MEDICATION(S)]. The NP said, Yeah, that is something, I would have told them to resume her evening dose of medications and not go back and administer the morning dose. The NP agreed that this could have caused significant problems for Resident #259. She concurred with the Survey team's concern and said, If I had given those orders it would have been more like around noon, I would not have agreed to them being given at 4 PM. On 5/24/22 at 10:46 AM, an interview was conducted with LPN E. LPN E was asked to explain what happens if a Resident is out of the facility at their scheduled time for medications to be administered. LPN E said, You would document resident is away from the facility and let the MD [medical doctor] or NP know. You have to notify the doctor that the Resident is back and find out what they want to do. You wouldn't go back and administer the medications that were missed because you don't know what they got while in the hospital. LPN E was asked what the risk is if blood thinner and blood pressure medication doses are given too close together. LPN E said, It will make the blood too think and the can bleed more easily and that is something you definitely don't want to do with blood thinner. With blood pressure medications the first dose is still working if you give the second dose too soon, it can drop their blood pressure too low, they can get dizzy or may pass out altogether, have a [CONDITION(S)] episode, or breathing problems. It is very dangerous. On 5/24/22 at 11:06 AM, an interview was conducted with the Director of Nursing. The DON was asked to explain the process if a Resident misses a dose of medication or it is given late. The DON said, The physician should be notified and will give orders on what to do. When asked what is done in the event the Resident is out of the facility at the scheduled administration of medication time. The DON said, We can put the meds on hold and administer when they return but we check with the doctor to what they want to do. The DON was made aware of the above concerns regarding Resident #259's medications on 12/21/21. On 5/24/22 at approximately 3 PM, the Director of Nursing notified Surveyor F that she had looked and Resident #259's discharge paperwork from the hospital was signed at 11:37 AM. She said the facility is just down the street from the hospital so the Resident was likely in the facility around noon. When asked if she had any evidence of what time the Resident returned she said no. When asked to provide evidence of where the doctor or nurse practitioner was notified and gave orders to administer the medications at 4:10 PM, she indicated there was not such documentation. Review of the facility policy titled, Administration Procedures for All Medications was conducted. This policy read, .III. 5 Rights (at a minimum) at a minimum, review the 5 rights at each of the steps of medication administration . IV. Administration .7. After administration, return to cart, replace medication container, and document administration in the MAR or TAR . Additional Guidance from Lippincott's Nursing Center, read, Rights of Medication Administration: 1. Right patient .2. Right medication .3. Right dose . 4. Right route . 5. Right time: check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation: Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.7. Right reason: Confirm the rationale for the ordered medication 8. Right response .Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania. Accessed online at: www.nursingcenter.com. On 5/24/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided. Complaint related deficiency.

Based on staff interview, facility documentation review, and clinical record review and in the course of a complaint investigation, the facility staff failed to provide multiple care and services in accordance with professional standards and according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1a. For Resident #259 the facility staff failed to provide medications timely. On 5/22/22 and 5/23/22, a closed clinical record review was conducted. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/23/22, the facility staff provided Surveyor F with a listing of medication administration times for several specific days. Review of these documents revealed the following: * On 12/21/21, medications scheduled to be administered at 9 AM, were not administered until 4:10 PM. * On 1/8/22, medications scheduled to be administered at 9 AM, were administered at 11:25 AM, medications scheduled for 9 PM, were administered at 11:43 PM. * On 1/21/22, medications scheduled to be administered at 9 AM, were administered at 12:14 PM. * On 1/23/22, medications scheduled to be administered at 9 PM, were administered at 11:46 PM. * On 1/24/22, medications scheduled to be administered at 9 AM, were administered at 10:49 AM. A review of the progress notes for Resident #259 was conducted, with attention to the above dates of when medications were administered late. There were no notes to indicate the doctor or nurse practitioner were notified of medications not being given on time, nor that they agreed to or ordered for the medications to be administered later. On 5/23/22 at 1:46 PM, an interview was conducted with LPN B. When asked to explain when medications are to be given, LPN B said, An hour before and an hour after scheduled. On 5/23/22 at 2:25 PM, an interview was conducted with Employee E, the nurse practitioner. When asked about the administration of medications, the nurse practitioner said meds are to be given within an hour of the time ordered to be given. On 5/23/22 at 10:15 AM, an additional interview was conducted with Employee E, the nurse practitioner (NP). The NP was asked about the importance of and risks to Residents if medications are not given on time with sufficient time between doses. The NP said, It is concerning because they are getting a larger dose all at once if they are given too close together. On 5/24/22 at 10:46 AM, an interview was conducted with LPN E. LPN E was asked to explain the timeframe of when medications are to given. LPN E said, Times are attached to the medications and you have an hour before and an hour after to administer. LPN E said, the administration of medications and treatments get documented on the MAR and TAR (treatment administration records). On 5/24/22 at 11:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated, We have 4 med passes, 9 AM, 12 noon, 5 PM, and 9 PM. Medications are to be given within the hour before and the hour after. The DON was asked why it is important the medications be given on time. She said, Residents have different medications and illnesses, which determines why need to get medications on time. The DON was asked what the process is if a Resident misses a dose or medications are given late, she said, The physician should be notified and will give orders. When asked where the communication with the doctor would be located, the DON said, We have a book at the nurses station they use to communicate to the provider and it gets documented in the Resident's progress notes. During this interview, the DON was made aware that Resident #259 had multiple instances of medications not being administered timely. On 5/24/22 at approximately 3 PM, the Director of Nursing identified Lippincott as the facilities' professional standards of nursing practice followed. A review was conducted of the facility policy titled, Administration Procedures for All Medications. This policy read, .III. 5 Rights (at a minimum). At a minimum, review the 5 rights at each of the steps of medication administration . According to Lippincott Nursing Procedures, Eighth Edition, Chapter 2, Standards of Care, Ethical and Legal Issues, on page 17 read, Common Departures from the Standards of Nursing Care. Claims most frequently made against professional nurses include failure to make appropriate assessments, follow physician orders, follow appropriate nursing measures, communicate information about the patient, follow facility policy and procedures, document appropriate information in the medical record, and follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional Guidance from Lippincott's Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration: 1. Right patient .2. Right medication .3. Right dose . 4. Right route . 5. Right time: check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation: Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.7. Right reason: Confirm the rationale for the ordered medication 8. Right response . Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania. Accessed online at: www.nursingcenter.com. On 5/24/22, during an end of day meeting the facility Administrator and DON were made aware of the above findings. No further information was provided. 1b. For Resident #259, the facility staff failed to provide wound care treatments as ordered by the physician. On 5/22/22 and 5/23/22, a closed clinical record review was conducted. The physician orders, treatment administration records (TAR's), and progress notes were reviewed for Resident #259's entire stay at the facility, which was from November 2021, through February 2022. The review revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order remained active until Resident #259's discharge on 2/19/22. There was also a progress note from the nurse practitioner on 11/30/21, that read, .with the ongoing concern for another fistula development from abscess to the midline wound, will start IV antibiotics, dc po [discontinue by mouth antibiotics] when PICC [Percutaneously Inserted Central Catheter, is a medical device that is placed into a vein to allow access to the bloodstream] in place. Review of the TAR's for December, January and February revealed a total of 35 occurrences of wound care not being documented as provided. Specifically, December had 6 occasions/shifts where the wound treatment was blank. January had 20 occurrences that were blank, with no documentation and February had 9 occasions with no evidence of wound treatments being provided. On 5/23/22 at 1:46 PM, an interview was conducted with LPN B. LPN B stated if there is a blank it means it was not given, if I didn't give a medication or perform a treatment I would put the reason in the nursing notes. On 5/24/22 at 10:46 AM, an interview was conducted with LPN E. LPN E was asked where she documents when wound treatments are performed. LPN E said, In PCC [electronic computer system] on the TAR. When asked what a blank means, LPN E said, I've never come across that. LPN E was asked why is it important to perform wound treatments as ordered by the physician. LPN E said, Because you don't want it to get infected and it is to help with the healing process. On 5/24/22 at 11:06 AM, AN interview was conducted with the Director of Nursing (DON). The DON was asked where treatments are documented and she said, On the TAR. When asked why it is important to do treatments as ordered by the physician, she said, Wounds can deteriorate or get infections, it is important to make sure they are done. The DON was asked to observe the TAR for Resident #259 and confirmed the observation of blanks as previously noted. When the DON was asked what the blank would indicate she said, It appears it was not documented. The DON said she could not confirm or deny if the treatment was performed based on the documentation. The DON further confirmed that she does expect staff to document immediately following the treatment. On 5/24/22 at approximately 3 PM, the Director of Nursing identified Lippincott as the facilities' professional standards of nursing practice followed. The facility policy regarding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Lippincott Nursing Procedures, Eighth Edition, Chapter 2, Standards of Care, Ethical and Legal Issues, on page 17 read, Common Departures from the Standards of Nursing Care. Claims most frequently made against professional nurses include failure to make appropriate assessments, follow physician orders, follow appropriate nursing measures, communicate information about the patient, follow facility policy and procedures, document appropriate information in the medical record, and follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/24/22, during an end of day meeting with the facility Administrator and Director of Nursing, they were made aware of the above findings. No further information was provided. Complaint Related Deficiency. 2) For Resident #159 medications were not given. A review of Resident #159's clinical record was conducted. This review revealed the Resident did not receive the following medications on 8-9-21. [MEDICATION(S)] 2 milligrams (mg) every day at bedtime (9:00 p.m.) for [MEDICATION(S)] [CONDITION(S)] drug. [MEDICATION(S)] 100 mg 4 times per day (9:00 p.m.) for [CONDITION(S)]. [MEDICATION(S)] 0.5 mg 4 times per day (9:00 p.m.) for anxiety. Dantroline 25 mg 4 times per day (9:00 p.m.) for muscle relaxation. Tylenol extra strength 500 mg 2 tablets every 8 hours for pain. There was no documentation of the facility staff using medication from the Stat box. There were valid Physicians Orders for the medications. On 5-23-22 at 1:37 PM, an interview was conducted with the LPN administering drugs on the unit. The LPN stated, if meds (medications) are not available, staff are to try to get them out of the (in-house stock of medications), if they can't they are to call the pharmacy and physician. The DON (Director of Nursing confirmed the process for reordering medications, which she said, there are several options, and you can press the reorder button in the computer or call the pharmacy. When asked when meds are to be ordered, the DON said, When meds get down to a 7 day supply we will go ahead and order them to prevent them from running out, we have a back up pharmacy that can deliver meds as well. On 5-23-22, during the end of day debriefing, the Administrator and DON (Director of Nursing) were notified of the issue, both stated they had nothing further to provide.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 5 Residents, Residents #106, #69, #62, #104, and #310, in a sample of 8 Residents reviewed for new admission COVID-19 testing. The findings included: For Residents #106, #69, #62, #104, and #310, the facility staff failed to conduct COVID-19 testing upon their admission to the facility. On 5/23/22, a clinical record review was conducted and revealed no evidence of any COVID-19 testing for the previously referenced Residents. On 5/23/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, all new admits are tested [for COVID-19] within 5-7 days after their admission to our facility, we rely on the first [COVID-19] test to be conducted by the hospital sending them to us, we don't accept them unless they have been tested before their arrival here. The IP verified the findings for the previously referenced Residents, however was unable to provide any evidence of COVID-19 testing being performed after admission to the facility. The IP reviewed a copy of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and confirmed it was utilized in facility's COVID-19 policies and practices. The IP was asked to review page 4 of the previously referenced CDC document, subheading, Testing, item 3, which read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection; immediately and, if negative, again 5-7 days after their admission. Following her review, the IP stated, I thought I could use the test from the hospital. The Director of Nursing was also in attendance during the interview and confirmed the facility policy and CDC guidance for COVID-19 testing of newly admitted residents. Review of the facility's policy related to COVID-19 testing for newly admitted residents was conducted and was found to be in accordance with current CDC guidance. On 5/23/22, during the end of day meeting, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were provided goods and services to treat existing pressure areas and prevent the development of new pressure areas, for 4 Residents (#1, #2, #5, and #6) in a survey sample of 6 Residents. This resulted in physical harm for Resident #1. The findings included: 1. For Resident # 1, the facility staff failed to provide treatment and services that would promote healing and prevent new 3 pressure areas from forming. This is harm. Resident # 1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident # 1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/23/2020 coded Resident # 1 with a BIMS (Brief Interview of Mental Status) score of 8 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #1 requiring total dependence, on staff, for Activities of Daily Living. A clinical record review was conducted and it was found that on 1/13/2020 on admission to the facility Resident # 1 had an admission assessment, a Braden Scale assessment and conducted by LPN H. The Braden Scale score on admission was 10 indicating that the Resident is at HIGH RISK for development of pressure ulcers. A review of the Progress Notes dated 1/13/2020 revealed that LPN H documented that Resident #1 was admitted with a pressure ulcer to her sacrum measuring 1.5 cm (centimeters) x 0.5 cm X 0.2 cm. She also states bilateral lower limbs starting to contract. A review of Resident #1's baseline care plan read as follows: Focus -Resident has an actual skin impairment (stage III to sacrum) - Date initiated 1-14-20 Created on 1-14-20 Revision on 1-30-20. Goal - Residents wound will improve through next review-Date initiated 1-14-20- Created on 1-14-20 Revision 1-30-20. Interventions - Keep skin clean and dry - Date initiated 1-14-20- Created on 1-14-20. Pericare with incontinence episodes - Date initiated 1-14-20- Created on 1-14-20. Weekly skin assessments - Date initiated 1-14-20- Created on 1-14-20. A review of the care plan revealed that the care plan was updated on 1/30/20 was as follows: Treatment as ordered - date initiated - 1/30/20 - created on 1/30/20 Turning and positioning - Q 2 hrs. as tolerated 1/30/20 created on 1/30/20 On 1/14/2020 a progress note written by the Nurse Practitioner (NP) describes the sacral wound as Unstageable sacral wound 100% covered in slough yellow- the periwound is moist with scattered breaks in the skin due to the moisture. The NP also documented Sacral ulcer-skin prep the periskin and apply [MEDICATION NAME] to the wound itself cover with Allevyn. A review of clinical record revealed the NP order dated 1/14/2020 was not implemented as written. The Skin prep was omitted from the order. Excerpts from the Wound Care Doctor's notes from the 2/3/20 are as follows: Initial wound Evaluation & Management Summary Focused wound exam (site 1) - Stage 4 Pressure wound Sacrum Etiology - Pressure - Wound Size - 1.2 x 0.5 x 0.1 - Thick adherent devitalized necrotic tissue 75% Granulation tissue - 25%. Surgical excisional debridement procedure Indication for procedure- Remove Necrotic Tissue and Establish the Margins of Viable Tissue Procedure Note: The wound was cleansed with normal saline anesthesia was achieved using topical [MEDICATION NAME]. Then with a clean surgical technique a size 15 blade was used to surgically excise necrotic muscle and surrounding facial fibers were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Dressing treatment plan - Primary dressing -[MEDICATION NAME] dressing apply every three days for 30 days. Plan of care reviewed and addressed - OFF LOAD WOUND Reposition per facility protocol. (emphasis added) There was no record of any intervention to off load the wound. A review of the clinical record revealed that Resident #1's sacral wound deteriorated and required surgical debridement by the wound doctor on 2/3/20, 2/10/20, 2/17/20, 2/24/20 and 3/2/20. Excerpts from the Wound Care Doctor's notes from the 2/3/20 are as follows: Focused wound exam (Site 2) wound of left elbow - Wound size 1 x 1 x not measurable Dressing treatment plan-Primary dressing- Hydrogel gel w/silver apply three times a week for 30 days. Secondary dressing - dry protective dressing apply three times per week for 30 days. A review of the physician orders [REDACTED]. Nurses Progress notes do not document date (Site II - Elbow wound) was found or notification of development of second wound to the Resident Representative as the Resident was not her own responsible party. On 2/7/20 at 6:01 PM progress notes read: CNA reported an area to resident's right hip during am care. Upon entering room and open area was observed to resident's right hip. Area was cleansed with NS (Normal Saline). , applied Santyl to eschar area with surrounding slough 80% of wound bed is beefy red. No foul odor noted. Continue tx as ordered. Continue to turn and position Q 2 hrs. (Every 2 hours). (NP name redacted) notified. (RP name redacted) notified. Resident #1 Right hip pressure area required surgical debridement on 2/10/20, 2/17/20, 2/24/20 and 3/2/20. In addition, on 2/10/20 the wound doctor gave the following orders which were also not implemented. Dressing/ Treatment Plan Discontinue Hydrogel gel w/silver Add- [MEDICATION NAME] Add - Calcium Alginate and continue dry protective dressing. [MEDICATION NAME] (lab) On 2/17/20, the wound doctor gave new orders for [MEDICATION NAME] with calcium alginate and dry dressing. However, a review of the physicians order sheet and the treatment administration record revealed the new orders were not on the physicians order sheet or the treatment administration record. On 4/21/20 at approximately 1:30 PM an interview was conducted with the NP who stated As a general rule when the wound doctor is consulted I step back and let him make the treatment decisions. When asked about her expectations for interventions for pressure wounds prevention and treatment, she stated she would expect an air mattress. When asked if she had ordered an air mattress on admission for Resident #1 she said Well that is usually an order I give verbally. 4/21/20 at approximately 2:00 PM an interview was conducted with wound doctor. When asked his expectations were for interventions for sacral and hip pressure areas he stated that I would expect an air mattress for someone with a sacral wound. When asked if he ordered an air mattress he stated he was not certain. His Physician note read: Support Surface Bed- Group 1, Chair - Pressure Reduction, Feet -Pillow. When asked what the term Group 1 refers to he stated It's a regular mattress, a Group 2 refers to an air mattress. On 4/21/20 at approximately 2:25 PM, an interview was conducted with the Director of Nursing (DON) who stated anyone with a stage 3 or worse sacral ulcer and comorbidities like poor nutrition and limited mobility should have an air mattress. On 4/24/20 during the end of day conference the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #2, an unstageable wound on the left heel was found by the facility staff on 02/08/2020. The facility staff failed to provide pressure-reducing interventions at that time. On 02/12/2020, the NP was made aware of the wound and ordered a Podus boot which was not implemented until 04/20/2020. Resident #2, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent MDS with an ARD of 4/2/20 coded as a Quarterly assessment coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 indicating no cognitive impairment. Resident is her own responsible party and makes all her own decisions. She has her right leg amputated below the knee has just gotten her prosthesis and is working with physical therapy on walking. She still uses a wheel chair for mobility. On 4/20/20 Resident #2's clinical record was reviewed. The review found that on 2/8/20, Employee J (former DON) discovered Resident #2 had an unstageable left heel wound found during a skin assessment. The progress notes did not document notification of physician or NP, therefore no treatments were ordered. A review of the progress notes shows that the wound is not mentioned until 2/12/20 at 8:15 PM. excerpts of the Nurse Practitioner's notes read: Chief Complaint: Left heel wound Patient was seen in Physical therapy today and staff found a wound to the left posterior heel. Skin warm and dry, Left heel open red/purple superficial appearance with surrounding blistered skin. 1. [MEDICATION NAME] paint twice daily. PODUS boot in place, will follow for risk of further breakdown. On 4/20/20, an observation was made of Resident #2 lying in bed feet not on a pillow no PODUS boot on. An interview was conducted with LPN B who stated No she doesn't wear any boot she puts a pillow under her foot sometimes. On 4/21/20 at 9:35 AM, an interview was conducted with Resident #2 and she stated I don't wear a boot at night I just put a pillow under my foot . On 4/21/20 at 9:45 AM, an interview was conducted with the Unit manager RN B who stated Resident #2 has a boot she wears at night to protect her heel. On 4/21/20 around 12:00 noon, an interview was conducted with the DON. When asked when the wound on Resident #2 was discovered she stated that she was new to the facility and from what she knew the wound had been found on 2/8/20 by the former DON who did not document on it properly. When asked what her expectation was for documenting wounds she stated, It is my expectation that the nurse who finds it should measure and stage it notify the MD and or RP (Responsible Party), update the care plan and put some interventions in place and document all you have done in the nurses notes. When asked was she aware there was no order for a Podus boot and nothing in the care plan about it she stated that she was aware now and she would get it fixed. On 4/24/20, during the end of day conference the Administrator was made aware of the concerns and no further information was provided. 3. For Resident #5, the facility staff failed to assess and treat in timely fashion an unstageable sacral pressure wound present on admission (09/17/2019). Also, the facility staff failed to turn on the air mattress on 04/21/2020. Resident #5 had a Stage 4 sacral wound and was observed lying supine on his air mattress which was off (unplugged from the wall) and partially deflated. Resident #5, a [AGE] year old male, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #5's most recent Minimum Data Set with an Assessment Reference Date of 04/01/2020 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 13 out of possible 15 indicative of intact cognition. Functional status for bed mobility, transfers, dressing, and personal hygiene were coded as requiring extensive assistance from staff. Current number of Stage 4 pressure ulcers was coded as 1 meaning one. Number of these Stage 4 pressure wounds that were present on admission/reentry was coded as 1 meaning one. Bowel continence was coded as always incontinent. The physician's orders [REDACTED]. An order entry dated 09/22/2019 documented, Clean sacral wound with normal saline apply allevyn patch every day shift for wound care. An order entry dated 09/24/2019 documented, Clean sacral wound with normal saline, apply santyl (enzymatic [MEDICATION NAME] agent), saline moistened gauze, dry gauze and cover with ABD (dressing) every day shift for wound care. An active order dated 01/23/2020 documented, Wound consult with (physician name). An active order dated 04/13/2020 documented, Clean sacrum area with NS (normal saline), pat dry apply medi-honey and dry dressing daily every day shift. The first Wound treatment orders were entered 4 days after admission. There were no orders for an air mattress. A document titled, PCC (electronic health record software name) Skin & Wound - Total Body Skin assessment dated [DATE] at 1:30 PM documented the following sub-headers and selections under Section 1 titled, Skin Assessment: Turgor: good elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: normal New wounds: 1 There was no further information about wound location, description, measurements, treatments, or pressure-reducing interventions in place in this document. A document titled, Braden Scale For Predicting Pressure Sore Risk dated 09/17/2019 documented a score of 17 in the header of the assessment. In Section 7 titled, Scoring, an excerpt documented, The Score and Category will appear in the header of this assessment as per the scoring below .AT RISK 15-18. The progress notes on 09/17/2019 were reviewed. A noted dated 09/17/2019 at 1:30 PM documented, An Admission Assessment has been completed. See the Assessment for details. The resident arrived from the hospital. The reason for the admission per the resident/POA (power of attorney) is . The entry was electronically signed by a registered nurse and a licensed practical nurse. The new wound documented on the skin assessment was not addressed in any nursing progress notes dated 09/17/2019. Excerpts of a progress note written by the nurse practitioner, Employee G, dated 09/18/2019 at 3:19 PM documented the following narratives under the selected headers: Interval History: (Resident #5) was admitted to rehab s/p (status [REDACTED]. ROS (review of systems) SKIN: Turgor normal; cap refill<3 sec (less than 3 seconds); no cyanosis; warm; dry, clean stump incision with staples in tact (sic) on the left. A sacral wound was not addressed in the progress note. An excerpt of a medical admission note written by the medical director dated 09/19/2019 at 7:27 PM under the sub-header titled, Skin documented, Turgor normal; cap refill <3sec (less than 3 seconds); no cyanosis; warm; dry. A sacral wound was not addressed in the admission note. An excerpt of a medical note written by the nurse practitioner dated 09/20/2019 at 7:54 PM under the sub-header titled, Skin documented, Turgor normal; cap refill <3sec (less than 3 seconds); no cyanosis; warm; dry, clean stump incision with staples in tact (sic) on the left. A sacral wound was not addressed in the note. An excerpt of a nurse's note written by LPN G dated 09/21/2020 at 10:05 PM documented, Wound care provided to sacrum wound and surgical wound. This note did not define what the wound care was; it did not contain a description of the wound, measurements, treatments, dressing, or pressure-reducing measures. There were no orders for sacral wound care on 09/21/2019. A document titled, PCC (electronic health record software name) Skin & Wound - Total Body Skin assessment dated [DATE] at 3:00 PM entered by LPN G, documented the following sub-headers and selections under Section 1 titled, Skin Assessment: Turgor: good elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: normal New wounds: 0 An excerpt of a medical note written by the nurse practitioner dated 09/24/2019 at 1:50 PM under the sub-header titled, Skin documented, Turgor normal; cap refill <3sec (less than 3 seconds); no cyanosis; warm; dry, sacral unstageable wound covered in slough-some pink discoloration around the ulcer itself. Under the header, Assessment/Plan Section 2, it was documented, Unstageable sacral ulcer-begin santyl dressings, may be able to debrid (sic) it next week. He needs an air mattress. An excerpt of a dietary note dated 09/25/2019 at 1:19 PM under the header Skin documented, Unstageable pressure ulcer to sacrum 3.8 x 2.6 .per 9/24/19 Skin & Wound Evaluation. The most recent wound care evaluation via telemedicine evaluation by the wound care physician was dated 04/20/2020. The following sub-headers and input were documented under the header, Focused Wound Exam Stage 4 Pressure Wound Sacrum: Wound size: 3 x 2.3 x 0.3 cm (centimeters) Undermining: 4.4 cm at 12 o'clock Exudate: moderate serous Thick adherent devitalized necrotic tissue: 15% Granulation tissue: 85% Wound progress: improved Primary dressing: leptospermum honey apply once daily for 23 days Secondary dressing: foam with border apply once daily for 23 days; alginate calcium apply once daily for 23 days Recommendations: Off-load wound; reposition per facility protocol. On 04/21/2020 at approximately 2:00 PM, a telephone interview with the wound care physician, Employee F, was conducted. Employee F confirmed documentation on his most recent visit. When asked about his expectation for pressure-reducing measures, Employee F stated he expects an air mattress on Resident #5's bed and something to reduce pressure when (Resident #5) is up in his chair. On 04/21/2020 at 2:45 PM, Licensed Practical Nurse B (LPN B) verified she was the nurse caring for Resident #5. When asked if Resident #5 was cognitively able to make his needs known, LPN B stated, Yes. On 04/21/2020 at approximately 2:50 PM, Resident #5 was observed in his bed, awake, lying supine with the head of the bed slightly elevated. When asked when he first arrived to the facility, Resident #5 stated, Some months ago. Resident #5 was unable to state what month he arrived. When asked if he had a wound, Resident #5 stated he had a wound on his back. When asked if staff were caring for the wound and doing dressing changes, Resident #5 stated that when he first arrived they didn't change it like they were supposed to. Resident #5 also stated that he had to tell the doctor they weren't changing the dressing when he first arrived but they're getting better at it now. This surveyor also observed that the air mattress was off and partially deflated. The mattress appeared to be approximately 4 inches thick. On 04/21/2020 at approximately 2:55 PM, an interview with LPN B was conducted. When asked what the current treatment was for Resident #5's sacral wound, LPN B referred to the electronic health record and stated the treatment is [MEDICATION NAME] and a dry dressing daily. When asked how long he had the wound, LPN B stated she didn't know but she has been working at the facility for 6 weeks and it has been improving. On 04/21/2020 at approximately 3:00 PM, LPN B entered Resident #5's room with this surveyor to observe the sacral wound. This surveyor again observed that the air mattress was off and partially deflated. LPN B peeled back the dressing (dated 04/20/2020) to reveal the sacral wound. There was granulation tissue in the majority of the wound bed and no odor or purulent drainage was observed. After the wound observation, LPN B and this surveyor exited the room. When asked why the air mattress was off, LPN B stated that she saw it was off this morning. LPN B also so stated that she checked the orders and didn't see air mattress ordered, so she just left it off. When asked why he was on an air mattress, LPN B stated that (Resident #5's) wound used to be worse but now it is better and his dressing provides cushioning. LPN B stated that she will find out if he needs an air mattress or not. On 04/21/2020 at approximately 3:10 PM, an interview with LPN C (the nurse who makes rounds with the wound doctor), was conducted. When asked if Resident #5 had orders for an air mattress, LPN C stated that (Resident #5) is on an air mattress and it should be in the orders. When asked if an air mattress should ever be turned off, LPN C stated the air mattress should always be on, otherwise it will deflate down to the metal frame. LPN C and this surveyor then entered Resident #5's room to observe the air mattress. LPN C tried to turn the unit on but was unable to do so. LPN C then looked at the cord and stated, It came unplugged. LPN C then plugged it into the wall and turned the unit on. LPN C pushed down on the mattress and stated that she could not feel the metal frame with her fingers while pushing down on the mattress. Resident #5 stated, I feel it coming up now. On 04/21/2020 at 5:50 PM, an interview with the unit manager, Registered Nurse B (RN B), was conducted. When asked if the meaning of new wound on the total body skin assessment dated on 09/17/2019 was in reference to the left AKA incision or a pressure wound, RN B stated, We don't know what that means. RN B stated that she tried to find clarification in the chart but was unable to determine the meaning. RN B also stated that Resident #5 was admitted with an unstageable sacral pressure ulcer. When asked about what would be expected on the admission skin assessment if a pressure wound was present on admission, RN B stated she would expect to see a description of the wound and, I would stage it, put in some form of treatment, and put it on the care plan. When asked about the importance of performing skin assessments on admission, RN B stated it's important to make sure (residents) are getting appropriate care and treatment so no harm comes to the patient. RN B also stated that it's important to identify it (wound) quickly so can address it and turn things around and heal it. On 04/22/2019 at 8:57 AM, RN B provided a document titled, Richmond Market PCI Live for DQMDD. RN B verified this document was an excerpt from the Discharge Summary dated 09/16/2019 at 9:36 AM. Under the header, Category, it was documented Wound Healing Care Notes. Under the header, Assessment, it was documented, Coccyx - moist, black, now unstageable pressure ulcer, no drainage, odor, or induration noted. Periwound skin intact, delayed blanching red. Under the header, Recommendations, it was documented, Coccyx/sacrum - clean with comfort shield wipes, then with normal saline moisten gauze, allow to air dry, then cover with allevyn lift border. Change Q3DAYS and PRN soiled (change every 3 days and as needed when soiled). On 04/22/2020 at approximately 9:05 AM, Resident #5 was observed lying in bed, awake, leaning to his right side, and the head of the bed slightly elevated. The air mattress unit was on and the air mattress appeared to be approximately 10 inches thick. On the morning of 04/23/2019, the administrator provided an invoice for an air mattress for Resident #5 dated 10/10/2019. An expense log for the air mattress was also provided with a start bill date of 10/10/2019 up to current. The facility staff provided a copy of their Policy Number 3201 titled, General Wound Care/Dressing Changes. In Section 1, it was documented, Notify the physician and obtain orders for treatment(s) and dressing changes. In their Policy Number 2402 titled, Pressure Ulcer Monitoring & Documentation in Section 1, it was documented, A licensed nurse will assess patients for the presence of pressure ulcers/injuries; if a pressure ulcer/injury is present, the nurse will evaluate for complications. In their facility Policy Number 202 titled, Patient admitted , under the header, Procedure an excerpt of Section 14 documented, Complete the following assessments: Skin Assessment, Braden Scale for Prediction of Pressure Sore Risk . Section 15 documented, Document any unusual findings and follow-up interventions including notification of physician and responsible party in progress notes. In summary, Resident #5 was admitted to the facility with an unstageable sacral wound. The sacral wound was not described, measured, staged, treated, or documented in the nursing admission skin assessment. The wound was not addressed in the admission note by the nurse practitioner or the medical director. The first sacral wound treatment was ordered 4 days after admission. A nurse practitioner progress note 7 days after admission first documented about the sacral wound and indicated (Resident #5) needed an air mattress. An air mattress was not ordered and facility documentation provided by the administrator showed that Resident #5 was provided an air mattress 23 days after he was admitted with an unstageable sacral wound. Also, the facility staff failed to turn on the air mattress on 04/21/2020. Resident #5 had a Stage 4 sacral wound and was observed lying supine on his air mattress which was off (unplugged from the wall) and partially deflated. On 04/24/2020 by the end of survey, the administrator and DON had no further information or documentation to offer. 4. For Resident #6, the facility staff failed to promote wound healing and treat left heel wound present on admission until 3 days after admission. Resident #6, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6's most recent Minimum Data Set with an Assessment Reference Date of 03/27/2020 was coded as a quarterly review. The Brief Interview for Mental Status was coded as 99 meaning the interview could not be completed. Cognitive Skills for Daily Decision-Making were coded as moderately impaired - decisions poor; cues/supervision required. Functional status for bed mobility, transfers, eating, dressing, and personal hygiene were coded as requiring extensive assistance from staff. Number of Stage 4 pressure ulcers were coded as 1 meaning one. Number of these Stage 4 pressure ulcers that were present upon admission/reentry was coded as 1 meaning one. Number of Unstageable pressure ulcers with suspected deep tissue injury in evolution was coded as 1 meaning one. The physician's orders [REDACTED]. Every day shift for pressure ulcer. An order dated 12/16/2019 documented, Heel lift while in bed every shift for pressure ulcer. However, the physician's orders [REDACTED]. The Treatment Administration Record for December 2019 was reviewed. An entry dated 12/16/2019 at 3:30 PM titled, Heel lift while in bed every shift for pressure ulcer was signed off as administered initially on the night shift of 12/16/2019, three days after Resident #6 was admitted to the facility. The Medication Administration Record [REDACTED]. Every day shift for pressure ulcer was signed off as administered initially on 12/17/2019, four days after Resident #6 was admitted to the facility. The admission skin assessment was reviewed. A document titled, (electronic software name) Skin & Wound - Total Body Skin assessment dated [DATE] at 5:13 PM documented the following headers and selections: Turgor: good elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: normal New wounds: 2 Description, location, measurements, treatments, or interventions were not documented in this assessment. The progress notes for December 2019 were reviewed. A nursing Skin/Wound note dated 12/13/2019 at 5:13 PM documented, Skin assessment completed. Findings: Turgor: good elasticity Skin color: normal for ethnic group Temperature: warm (normal) Moisture: normal Condition: normal New wounds: 2 Left heel ulcer yellowSacral heel ulcer healing stage 2 (sic). There was no further description, measurements, treatment, or pressure-reducing intervention addressed in this narrative note. A nursing admission summary written by an LPN dated 12/13/2019 at 5:13 PM documented, An admission assessment has been completed. See the assessment for details. The Resident arrived from hospital. The reason for the admission per resident/POA (power of attorney) is Weakness special care needs. A document titled, Admission assessment dated [DATE] at 5:13 PM was reviewed. The form did not have a header for skin assessment. An excerpt of the discharge summary titled, (hospital name) Discharge Summary dated 12/13/2019 at 11:06 AM under the header, Hospital Course documented, Left heel decub (decubitus) staph capitis infection. An excerpt of the physician's progress note titled, Physician's Admission Medical Care Plan dated 12/14/2019 at 6:31 AM under the header, Skin documented, Turgor normal; cap refill<3 sec (capillary refill less than 3 seconds); no cyanosis, warm; dry, left heel with dressing. Under the header, Assessment of acute and chronic conditions, it was documented, .left heel ulcer - wound care. An excerpt of the nurse practitioner note dated 12/16/2019 at 3:28 PM under the header, Skin documented, .left heel with black center, there is soft tissue around the edge, tender. An excerpt under the header, Assessment/Plan documented, Left heel ulcer - wound care, heel lift and consider an air mattress. A skin/wound note written by an RN dated 12/19/2019 at 2:21 PM documented, Patient admitted on [DATE] from the hospital with 2 pressure wounds #1- 3 x 5cm Unstageable pressure ulcer to left heel. Wound covered 100% with eschar tissue, scant amount of drainage noted on reassessment with mild [DIAGNOSES REDACTED] periwound and area is tender to touch. #2 - 1.5 x 1 cm stage 1 pressure area to R ankle. Bunny boots to both feet and floated as ordered. On 04/21/2020 at approximately 6:10 PM, Licensed Practical Nurse C was interviewed. LPN C (the nurse that rounds with the wound care physician) verified she was the nurse caring for Resident #6. When asked how long Resident #6 had the wounds, LPN C stated, Forever and a day. LPN C and this surveyor entered Resident #6's room for a wound observation. Resident #6's heels were floated and there was a kling outer wrap dressing dated 04/21/2020 to the left foot. LPN C unwrapped the dressing. The medial left heel wound bed was covered with eschar/necrotic tissue. LPN C stated that the wound is improving. The wound care evaluations by the wound care physician with dates ranging 01/24/2020 through 04/20/2020 were reviewed. The most recent wound care evaluation by the wound physician was dated 04/20/2020. Under the header, Focused Wound Exam (Site 1) Stage 4 Pressure Wound of the Left Medial Heel, the following sub-headers and input were documented: Wound size: 4 x 4.3 x not measurable cm Thick adherent black necrotic tissue (eschar): 90% Thick adherent devitalized necrotic tissue: 10% Wound progress: improved On 04/22/2020 at 1:10 PM, an interview with the unit manager, Registered Nurse B (RN B) was conducted. When asked about the expectation for initiating treatment and interventions for pressure wounds present on admission, RN B stated that it should be

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to maintain a hazard free environment on East unit resulting in immediate jeopardy and substandard quality of care. Also, for Resident #3 and #26, the facility staff failed to ensure an environment free of chemical hazards, which was not immediate jeopardy. The Administration was informed on 10-31-16 at 8:15 p.m. of the immediate jeopardy situation. After the removal of the immediate jeopardy situation, on 10-31-16 at 9:05 p.m., the scope and severity level of the deficiency was lowered to a level 2 pattern. 1. The main supply room on East unit was held open with a wooden wedge propping the door. The contents in the room included Dakin's solution, hydrogen peroxide, isopropyl alcohol, UTI (urinary tract infection) stat solution, razors, staple removal kits, fingerstick blood sugar lancets, and syringes with needles attached. 2. For Residents # 3, the facility staff failed to maintain an environment free from chemical hazards as a bottle of Clorox Clean-up Disinfectant Cleaner with Bleach was found in the bathroom on initial tour of the facility on 10/31/2016 at 6:35 PM 3. For Residents # 26, the facility staff failed to maintain an environment free from chemical hazards as a bottle of Clorox Clean-up Disinfectant Cleaner with Bleach was found in the bathroom on initial tour of the facility on 10/31/2016 at 6:35 PM The findings included; On 10-31-16 at 6:15 p.m. surveyors entered the facility, and at 6:30 p.m. began initial tour. It was noted that the main supply room adjacent to the nursing station on the East nursing unit was open. The door was propped open with a wooden wedge, and several residents were wheeling in wheel chairs independently around the station and in the hallways and also, visitors were observed walking in the hallway near the open door. Three residents were spoken with, by surveyors, and two of the three were able to communicate verbally and appeared to be oriented to person and place. The third was confused, and repeatedly asked where am I, where should I be , while wandering aimlessly in the hallway in a wheel chair. Two Licensed Practical Nurses (LPN's), and 2 Certified Nursing Assistants (CNA's) were seen at the nursing station at various times, and in and out of the supply room , however, they did not stay at the nursing station. They continued up and down the 3 hallways of the unit assisting residents in their rooms, leaving the supply room open and unattended. Tour was completed on this 30 bed unit at 7:30 p.m. At 7:30 p.m. it was noted that the door to the supply room remained open, and the room was assessed by 4 surveyors. The room contained the following items that were open and available to residents and visitors, without staff present to observe who may obtain them: 1. Dakin's solution - (4) 240 milliliter bottles, one of which was open. 2. Hydrogen peroxide -(8) 240 milliliter bottles, one of which was open. 3. Isopropyl Alcohol - (8) 240 milliliter bottles, one of which was open. 4. UTI Stat - (1) bottle 480 milliliters, a cranberry supplement to prevent urinary tract infections. 5. Shaving razors - greater than 60 in a box. 6. Syringes with needles on them - cases of thousands. 7. Staple remover kits - plastic bin of greater than 100. 8. Finger stick blood sugar lancets - cases of thousands. Immediate Jeopardy Summary: At 7:45 p.m. the survey team met and reviewed the evidence. The team concluded that the hazardous situation had harm potential for the residents immediately if no action was taken. The staff was aware of the propped, open door to the supply room, and the room's contents were well known to staff. The door had remained open for the observed 1.25 hours without the staff intervening, and correcting the problem. At this time, the team decided an immediate jeopardy (IJ) situation existed. At 7:54 p.m., a call was placed to the Long term Care Supervisors for the Virginia Department of Health (VDH) Office of Licensure and Certification (OLC) to notify them of the IJ situation. 8:06 p.m., the supervisors agreed with the IJ findings. 8:12 p.m., the door to the supply room remained open, a wheel chair was pushed through the door of the supply room, fitting easily. 8:15 p.m., the Administrator was informed that the team needed to meet with her regarding an important matter immediately. 8:19 p.m., the Facility staff was informed of the IJ. This consisted of the Administrator, Director of Nursing (DON), and the Corporate Nurse Executive (Corp RN). The DON stated there is a lock on that door, it is supposed to be locked. A 5 point Plan of Correction (POC) was requested by the team, to make safe, the area. 8:28 p.m., the supply room door was noted to be closed and locked. 8:32 p.m., the Corporate RN provided the first POC. The POC was not accepted due to lack of auditing to monitor and measure sustained corrective action. 8:40 p.m. the Corporate RN provided a second POC. The POC was not accepted because it stated All staff would be educated, and it was explained to her that lifting the IJ sanction would not occur until the POC could be completed. Education of all staff could not be completed immediately. 8:45 p.m. a third POC was presented by the Corporate RN. The third POC was not accepted, as it stated an audit would be conducted, however, no auditing tool was presented. 8:56 p.m. a fourth POC was presented by the Corporate RN. The fourth POC was not accepted, as the plan stated 100% of the staff would be educated by 11-1-16, (the following day). Then the Corporate RN stated that she recognized there was no way for all of the staff to be educated in 24 hours. On 10-31-16 at 9:05 p.m., the final revision to the facility Plan of Correction was accepted. The Administration was then informed that the facility was considered in Sub-standard Quality of Care, due to the nature of the accident, hazard potential, posed to the resident population, by the immediate jeopardy situation. It was explained that this finding would extend the survey investigative process. The Administrator, DON, and Corporate RN, stated understanding. The accepted Plan of Correction consisted of the following points: 1. Central Supply room door unlocked, items not secure. Door immediately locked. 2. All Residents are at risk. 3. Education will be provided by SDC (Staff Development Coordinator) or designee to all staff in house at current time, and 100% of oncoming staff, education will be completed every day. 4. SDC (Staff Development Coordinator) or designee will monitor the central supply door three times each shift to maintain compliance and document on the central supply security tool. 5. Date of Compliance 10/31/16. On 10-31-16 at 9:15 p.m. interviews were conducted separately on East unit with the 3 Licensed Practical Nurses (LPN's) working on the unit. Those nurses were (LPN) A, B, and D. Each of them were asked if the supply room door should be closed and locked. LPN A, and LPN D both stated the door should remain closed, and locked at all times, however, LPN B stated she did not know if the door should be closed and locked, and she would check with her supervisor to get the answer. They were each asked who had opened the door, and each answered that the door had been open since they entered the building at change of shift at 3:00 p.m. that day. On 10-31-16 at 9:30 p.m. Resident #5 was interviewed. Resident #5 was one of the residents seen in the hallway outside of the supply room. The Resident stated he could not remember if he had seen the supply room door open other days, but did state that the supply room door had been open most of that evening on 10-31-16. ****The surveyors were on site for 3 days, and verified that the implementation of the above Plan of Correction was performed before the IJ was abated, and continued to be practiced during the course of survey. Audit sheets for monitoring the security of the supply room, and education for all staff entering each day was provided to surveyors, each day to prove continued compliance. 2. For Resident # 3, the facility staff failed to maintain an environment free from chemical hazards as a bottle of Clorox Clean-up Disinfectant Cleaner with Bleach was found in the bathroom on initial tour of the facility on 10/31/2016 at 6:35 PM. Resident # 3, a [AGE] year old female, was admitted to the facility on [DATE],with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was an Admission assessment with an Assessment Reference Date (ARD) of 10/11/2016. The MDS coded Resident # 3 with a BIMS (Brief Interview for Mental Status) of 15/15 indicating no cognitive impairment; the resident required extensive assistance of two staff persons with activities of daily living except required supervision and set up only for eating. Resident # 3 was coded as always continent of bowel and occasionally incontinent of bladder. 3. For Resident # 26, the facility staff failed to maintain an environment free from chemical hazards as a bottle of Clorox Clean-up Disinfectant Cleaner with Bleach was found in the bathroom on initial tour of the facility on 10/31/2016 at 6:35 PM. Resident # 26, a [AGE] year old female, was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was an Admission assessment with an Assessment Reference Date (ARD) of 10/11/2016. The MDS coded Resident # 26 with a BIMS (Brief Interview for Mental Status) of 12/15 indicating moderate cognitive impairment; the resident required extensive to total assistance of one to two staff persons with activities of daily living except required supervision and assistance of one staff person for eating. Resident # 26 was coded as always continent of bowel and occasionally incontinent of bladder. On 10/31/2016 at 6:35 PM during initial tour of the facility, Resident # 3 was observed sitting in her wheelchair watching television. Resident # 3 was alert and stated she was doing fine. Resident # 3 resided in the first bed and closer to the bathroom. Resident # 3 had a roommate who was in the second bed by the window (Resident # 26). The privacy curtain between the two was pulled to the end of the bed for Resident # 26. The surveyor greeted Resident # 26 who was observed lying in bed with the television off. Resident # 26 was alert and stated she was doing fine. After greeting both residents, the surveyor looked in the bathroom of the room Resident # 3 and # 26 shared. A bottle of Clorox Clean-Up Disinfectant Cleaner with Bleach was observed in the bathroom on top of the paper towel dispenser located next to the sink. On 10/31/2016 at 7:20 PM, the surveyor returned to the room that Resident # 3 and #26 shared and observed the bottle of Clorox Clean-Up was no longer in the bathroom. Resident # 3 was still sitting in her wheelchair in her room watching television. Resident # 26 was still behind the privacy curtain with her television off. On 10/31/2016 at 7:22 PM, 5 staff members were asked who removed the bottle of Clorox Clean-Up. The staff members stated they did not see the disinfectant in the bathroom of Resident # 3. Staff members: LPN (Licensed Practical Nurse) A charge nurse, LPN D, charge nurse, LPN B, CNA (Certified Nursing Assistant) D, and CNA-E were asked if they removed the Clorox Clean-up bottle out of Resident # 3's bathroom. All stated they had not seen the bottle of disinfectant. When asked if any more staff members were working on that unit, one staff member stated another CNA was working on that unit and identified CNA-A as the CNA assigned to work with the residents in Resident # 3's room. On 10/31/2016 at 7:25 PM, the Director of Nursing was informed that a bottle of Clorox Clean-up was observed in the bathroom of Resident # 3 and Resident # 26 and the bottle was no longer there. The DON stated the housekeeping staff use it and must have left it but that she did not know who removed it. On 10/31/2016 at 7:30 PM, an interview was conducted with Resident # 3 who stated she did not know who took the bottle of Clorox Clean-up out of the room but she had seen a couple of staff members come out of the bathroom after the surveyor left. On 10/31/2016 at 7:40 PM, CNA-A was interviewed while she was straightening the bed in another room on the other hallway on the unit. CNA-A stated she did not remove any Clorox Clean-up bottle from any room. CNA-A stated she had not seen any bottle of Clorox Clean-up. On 10/31/2016 at 9:15 PM, the Corporate Consultant (Admin C) was informed that the surveyor wanted to know who removed the bottle of Clorox Clean-up from the bathroom that Residents # 3 and # 26 shared and wanted to see the bottle along with photocopies of the front and back of the bottle. On 10/31/2016 at 9:18 PM, the Director of Nursing came to the conference room where surveyors were convened, presented the bottle of Clorox Clean-Up and stated the LPN(Licensed Practical Nurse) who was working as a Certified Nursing Assistant that shift had removed the bottle of disinfectant from the resident's bathroom. The Director of Nursing identified the nurse as LPN B and stated she was not sure why the staff did not admit who had removed the Clorox Clean-up earlier when the surveyors asked several times prior. The surveyor requested photocopies of the front and back of the bottle. The DON immediately returned with the bottle of disinfectant along with the requested photocopies of the front and back of the bottle. On 10/31/2016 at 9:24 PM, an interview was conducted with LPN B who stated she saw the bottle of Clorox Clean-Up in the resident's bathroom when she was checking everything once she heard the inspectors were in the facility. LPN B stated she removed the bottle and put it in the Central Supply office where it was normally kept. LPN B stated she often use it to clean counters. LPN B did not answer when asked why she did not admit to removing the cleaner from the bathroom when asked by surveyors earlier. During the end of day debriefing on 11/1/2016 at 5 PM, the Administrator, Director of Nursing, Corporate Nurse Consultant (Admin C) and Corporate Nurse Consultant (Admin D) were informed of the findings. When asked why Clorox Clean-up bottles were in the facility, the Director of Nursing stated the housekeeping staff use the disinfectant cleaner. On 11/2/2016 at 9:30 AM, an interview was conducted with the Housekeeping Director (Other C) who stated that she was working late on the day the surveyors came into the facility (10/31/2016). Other C stated she and the other staff were rushing to make sure everything was tidy when she heard the surveyors were in the facility. Other C stated she was the one who accidentally left the bottle of Clorox Clean-up in Resident # 3's room. Other C stated the housekeeping staff use the Clorox Clean-up to clean up blood spills and urine spills on the floor in the bathroom. Other C was very apologetic and stated the housekeeping staff should not leave the disinfectant in any of the residents' rooms. Other C stated the cleaner was approved to be used at the facility and stated she had a copy of the MSDS (Material Safety Data Sheet) for Clorox Clean-up Disinfectant Cleaner with Bleach. Other C presented a copy of the MSDS sheet for Clorox Clean-up. Review of the MSDS revealed a 10 page document dated January 5, 2015 which read: On Page 1 of 10 Under Hazards Identification: Classification: This chemical is considered hazardous by the 2012 OSHA (Occupational Safety Hazard Association) Communication Standard (29 CFR 1910.1200) On Page 2 of 10: Under Warning: Causes mild skin irritation Causes serious eye irritation. Under Hazards not otherwise classified (HNOC): The following medical conditions may be aggravated by exposure to high concentrations of vapor or mist: heart conditions or chronic respiratory problems such as asthma, emphysema, or obstructive lung disease. On Page 4 of 10 Under Accidental Release Measures: Personal Precautions: Avoid Contact with eyes, skin and clothing. Use personal protective equipment as required. During the end of day debriefing on 11/2/2016 at approximately 1:15 PM, the facility Administrator, Director of Nursing, Corporate Consultants (Admin C and Admin D) were informed of the findings. No further information was provided.

Based on staff interview, facility documentation, hospital documentation, clinical record review, and in the course of a complaint investigation, the facility staff failed, for one resident (Resident #20) in a survey sample of 26 residents, to identify a right heel pressure ulcer that was found at eschar, resulting in harm. The facility staff failed to provide interventions to prevent pressure ulcer wounds to Resident #20 ' s heels from her date of admission, 4/9/14, through 4/15/14. On 4/16/14, the facility identified a pressure wound to Resident #20 ' s left heel. Treatment to the left heel was initiated and orders to elevate both heels were implemented. On 5/2/14, Resident #20 was admitted to the hospital at which time, the hospital physician identified a right heel wound at eschar, resulting in harm for Resident #20. The findings included: Resident #20, a female, was admitted to the facility on [DATE], discharged to the hospital on [DATE], readmitted after hospitalization on [DATE] and discharged from the facility on 5/25/14. Her [DIAGNOSES REDACTED]. Resident #20's admission MDS (minimum data set) with an ARD (assessment reference date) of 4/17/14 revealed a BIMS (Brief Interview for Mental Status) score of 13 out of 15, cognitively intact. She was coded as requiring extensive assistance of one to two staff members to perform her activities of daily living. Resident #20 was coded as being at risk for developing pressure ulcers and as having no unhealed pressure ulcers at Stage 1 or higher. On 10/21/15 at 4:00 p.m., a review of Resident #20's electronic clinical record and a small packet of copied documentation were provided by the director of nursing (DON). The DON stated, I think her original clinical record was sent to the lawyer. A review of the available information including the nursing notes and care plans revealed the following documentation: Admission Care Plan dated 4/10/14 - Skin Care/Incontinence. Resident will not develop skin breakdown over the next review. Approaches: Pressure reduction surface to bed and chair and Use lotion and moisture barrier. Care Pan dated 4/16/14 - Under Evaluation - Pt. has a some serosangeneous drainage from her left heel. RP (responsible party) notified. Initiated tx (treatment) clean with ns (normal saline), [MEDICATION NAME] and dry dressing. Nursing admission note, dated 4/10/14 - She is a [AGE] year old African American female who was admitted to the facility for long term from a nursing home, she is alert and oriented x 3, no trouble with swallowing on a regular diet, lung sounds clear in all her lung fields, bowel sounds present in all 4 quads, skin warm to touch, skin turgor brisk return, cap refill < (less than) 3 secs (seconds), she has some [DIAGNOSES REDACTED] on her sacral area, pedal pulses present bilaterally, she has some dry skin on her feet, with some swelling in her LE (lower extremity) bilaterally, vitals T (temperature) 97.1 R. (respirations) 19, P (pulse) 76, B/P (blood pressure) 134/77, no acute distress. Nursing Note dated 4/16/14 - Pt (patient) is alert and oriented x 2 all her pm meds tolerated well, pt has extensive assist x 1 with feeding, pt. is has soft left heel, skin preped (prepped) it this shift, pt has some serosangeneous drainage from her left heel rp (responsible party) notified initiated tx (treatment) clean with ns (normal saline), [MEDICATION NAME] and dry dressing, pt heels floated this shift, vitals T 98.1, R 18, P 80, B/P 127/77, no acute distress. Review of the clinical record did not reveal a physician order for [REDACTED]. Review of the Treatment Administration Record revealed Resident #20 received the treatment to clean the left heel with normal saline, [MEDICATION NAME] and dry dressing on 4/17, 4/18, 4/19, 4/20, 4/21/14. Physician Order Sheet dated 4/9/14 - 5/1/14 revealed the following pressure ulcer orders - a.) 4/17/14 - Float Heels bilateral every shift (day, eve, night) wound healing. b.) 4/21/14 - Left Heel dry dressing ns (normal saline) Santyl ointment left heel evening shift (eve) wound healing. Hospital Wound Consultation dated 5/2/14 - Integument: Sacral area measuring 5 x 6 cm (centimeters) with scattered partial thickness skin loss of 30%, yellow crusting and 70% pink wound bed. Also, with areas that appear to be hypergranulated. Right lateral heel pressure wound that is unstageable with black eschar measuring 4 x 6.5 cm. Left heel unstageable pressure ulcer measuring 6.8 x 6.3 cm, 50% black eschar, 30% is yellow and 20% pink. According to National Pressure Ulcer Advisory Panel's (NPUAP) Updated Pressure Ulcer Staging System: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. NPUAP defines pressure ulcer stages as follows: Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Unstageable pressure ulcer: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed Review of the clinical record revealed no measurements or staging of any of Resident #20's pressure ulcers from her admission date of [DATE] through her transfer to the hospital on [DATE]. A review of the clinical record that was available did not identify Resident #20's left heel as having a wound. On 10/22/15 at 8:15 a.m., another request for the Resident#20's complete clinical record was made. The DON stated, I can't locate the rest of her clinical record, the clinical nurse, Admin D, is trying to locate it. Follow-up requests for Resident #20's complete clinical record were made again at 9:10 a.m., 11:40 a.m., 2:20 p.m. and 2:45 p.m. Admin D provided a copy of some wound assessment sheets from Resident #20's nursing home from which she was admitted . Admin final response regarding Resident #20's complete clinical record was, We just don't have it. On 10/22/15 at 5:30 p.m., the administration was informed of the hospital wound assessments and the right heel identified at eschar, resulting harm for Resident #20. No additional information was provided at this time. On 10/22/15 at 6:15 p.m., the administration was informed of the facility staff's failure to prevent, assess, and monitor, Resident #20's pressure wounds, resulting in harm with regard to the right heel wound identified on the hospital admission at eschar. No additional information was furnished at the end of survey. On 10/26/15 the facility contacted the Office of Certification and Licensure and submitted, in it's entirety, according to the administrator, a copy of Resident #20's closed clinical record. Information specific to Resident #20's pressure ulcers which was not available during the survey period included the Physician's Admission History and Physical and the Initial Admission Nursing Skin Assessment. 1. The Physician Admission assessment dated [DATE] read, Dermatology/Integumentary: [MEDICAL CONDITION]/Ulcers Pressure Ulcers: No. Skin: no rashes, [MEDICAL CONDITION], no pressure ulcers. Positive for chronic stasis changes bilateral lower extremities (LE), skin rough, dry and hyperpigmented. 1+ non pitting LE [MEDICAL CONDITION], taught. 2. Nursing Admission Skin Assessment form dated 4/9/14 identified a red area to the buttock by way of a circle around the buttock of a small anatomical human figure. Resident #20 was marked on this form as having no sensory impairment, usually dry, chairfast, very limited mobility, potential for friction and excellent nutrition intake. Also included with the closed record was a facility prepared 'Timeline For Resident's Clinical Presentation/Events and Course/Pathway'. This timeline outlined the following dates of Resident #20's pressure ulcers development: 1. 4/9/14 - Initial Admission -noted Redness to Sacrum. 2. 4/16/14 - Open wound to the left heel with presenting Serosanguineous drainage. 3. 5/17/14 - Readmission - Bilateral Buttock Wounds [MEDICAL CONDITION] and 5 x 5 x 0.1, Bilateral Heels 6 x 3.5 x 0.1 and 3 x 4 x 0.1. A review of the additional information provided by the facility on 10/26/15, further confirmed: 1. the facility ' s awareness of Resident #20's potential for pressure ulcers and the facility staff's lack of preventive interventions. Physician orders from Resident #20 ' s prior facility revealed orders to apply skin prep to both of Resident #20 ' s heels. There were no physician orders to continue skin prep to her heels when admitted to the facility on [DATE]. 2. Resident #20's admission MDS RAI with an assessment date of 4/17/14 did not reflect the pressure ulcer that was identified on 4/16/14. 3. the Comprehensive Care plan dated 4/10/14 did not include interventions for the prevention of pressure to Resident #20 ' s heels until 4/16/14, considering the facility ' s awareness of the Resident ' s high risk for pressure ulcer development to her heels. (i.e. impaired mobility, pressure ulcer history and lower leg extremity [MEDICAL CONDITION]) 4. interventions to float Resident #20 heels were not implemented until after the development and identification of the left pressure ulcer on 4/16/14. 5. the facility staff failed to assess and monitor Resident #20's heels as evidenced by the lack of staging and wound tracking documentation for the left heel wound identified on 4/16/14. Weekly skin assessments between 4/14/14 and 5/1/14 did not reflect any existing pressure wounds to the heels. 6. the clinical record did not identify a right heel wound that was noted on Resident #20's admission hospital records on 5/2/14 as unstageable with black eschar measuring 4 x 6.5 cm. The clinical record did not reveal any documentation of a wound to the right heel between Resident #20 ' s admission on 4/9/14 through her transfer to the hospital on [DATE]. 7. no wound identification, documentation or assessment of the right wound appeared in the clinical record until it was identified in the hospital wound admission consultation on 5/2/14 at eschar, resulting in harm for Resident #20 COMPLAINT DEFICIENCY

Based on observation, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure timely and appropriate pressure ulcer prevention and treatment for [REDACTED].#1, and #7) in a survey sample of 27 Residents. 1. For Resident #4, the staff failed to perform appropriate skin assessments resulting in the identification of a pressure ulcer that was unstageable at discovery with harm and failed to perform clean technique for wound care per physician's orders; 2. The facility staff failed for Resident #1 to inform the physician and then modify the plan of care for a sacral pressure wound which was not healing. The sacral wound failed to show evidence of healing with 8 consecutive weeks of treatment with Dakin's solution. The physician was not notified of lack of healing, or the need to change the plan of care. The nurse failed to ensure appropriate measures were used to prevent wound contamination -the nurse picked up a trash can after washing her hands, and pulled her scissors out of her pocket without cleaning. 3. For Resident #7, the facility staff failed to prevent a pressure ulcer on the left heel. The pressure ulcer was first discovered at a stage 2. The findings included: 1. For Resident #4, the staff failed to perform appropriate skin assessments resulting in the identification of a pressure ulcer that was unstageable at discovery with harm and failed to perform sanitary and wound care per physician's orders; Resident #4, a female, was admitted to the facility 10/3/12. Her [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10/10/12 was coded as an admission assessment. Resident #4 was coded as having short term memory deficits and required minimal help in making daily life decisions. Resident #4 was also coded as requiring one person physical assistance with her activities of daily living including transferring, bed mobility, bathing, dressing, and toileting. While Resident #4 was coded as being at risk for the development of a pressure ulcer, no pressure ulcer had been coded on the admission MDS. Review of Resident #4's clincial record revealed Resident #4 had no pressure ulcers upon admission. The admission nursing assessment completed 10/4/12 at 4:45 p.m. included, "Skin assessment was done with dark area noted to left lower leg, bursie (sp) to left knee old surgical scars to abdomin and healed stage 2 wound to sacaral (sp) area and buttocks." Weekly skin assessments completed on 10/5/12, 10/9/12, 10/16/12, 10/23/12, 10/30/12, 11/6/12, and 11/13/12 revealed no pressure area on Resident #4's right hip. Upon review of the physician's order for wound care to her left buttock, treatment was also ordered for Resident #4's right hip. Resident #4's clinical record was thoroughly reviewed for an assessment of a wound on the right hip. Review of the wound care assessments, revealed an unstageable pressure ulcer was identified on Resident #4's right hip. Documentation did reveal Resident #4 was identified as having developed a Stage II pressure ulcer on her left buttock and treatment was instituted. On 11/15/12 a wound was identified as an unstageable pressure ulcer which was observed on Resident #4's right hip. On "ULCER AND WOUND RECORD" an area 2.6 cm x 1.2 cm with no depth was documented as unstageable. According to the NPUAP (National Pressure Ulcer Advisory Panel) the definition of a Stage II pressure ulcer is: "Stage II:Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.Further description:Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal [MEDICAL CONDITION], maceration, or excoriation.*Bruising indicates suspected deep tissue injury". Resident #4 was observed during wound care, 11/28/12 beginning at 4 p.m. LPN A was observed performing wound care with the assistance of the staff development coordinator. While preparing her supplies to perform wound care, a nurse came to Resident #4's bedroom door, LPN A reached in her uniform pocket and retrieved a set of keys. LPN A handed the keys to the nurse at the door. LPN A then continued to prepare for performing wound care. LPN A performed wound care to a Stage II pressure ulcer on Resident #4's left buttock. LPN A cleaned the wound with dermal wound cleaner, dried the area with a 4 x 4. She applied Santyl, an autolytic medication that would chemically debride the wound. After applying the Santyl, LPN A applied 4 x 4s, and taped the dressing in place. LPN A wrote the date and her initials on a separate 4 x 4 and put it on the dressing. LPN A taped the dated 4 x 4 in place. The staff development coordinator advised LPN A to date and initial the dressing on the tape, LPN A removed the dated 4 x 4 and reached in her pocket, with gloved hands and retrieved a marker. LPN A proceeded to date a piece of tape, apply it to the dressing, and put the marker back in her pocket with gloved hands. The staff development coordinator stated the pressure ulcer was staged as a II. Review of the physician's orders revealed the wound care should be, "11/15/12 santyl ointment clean area to left buttocks and right hip with ns (normal saline), apply santyl ointment, and apply dry dsg (dressing) daily day shift. A thorough review of the clincial record revealed no order to clean the wound with dermal wound cleaner. Review of the contents of "Dermal Wound Cleanser" revealed the solution is considered "First Aid Antiseptic". The ingredients in the solution were Benzethonium chloride 0.13%, [MEDICATION NAME] alcohol, citric acid, [MEDICATION NAME] EDTA, [MEDICATION NAME], polyquaternium-10, polysorbate 20, sodium [MEDICATION NAME], and water. Guidance for use of the solution was for "first to help reduce the risk of infection in minor cuts, scrapes, and burns, for washing small superficial wounds, and aides in the removal of foreign materials such as dirt and debris." LPN A was unable to be interviewed. The DON stated the expectation was for the staff to follow physician's orders, 11/30/12 at 4 p.m. Guidance for sanitary practice during wound care was provided by www.cdc.gov, "Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets. Also, guidance was provided in "Fundamentals of Nursing 7th Edition, p. 652, Use your critical thinking skills to prevent an infection from developing or spreading. Implement procedures to minimize the numbers and kinds of organisms that could be possibly transmitted. Eliminating reservoirs of infection, controlling portals of exit and entry, and avoiding actions that transmit microorganisms prevent bacteria from finding a new site to grow. Proper use of sterile supplies, barrier precautions, standard precautions, transmission -based precautions and proper hand hygiene are examples of methods to control the spread of microorganisms." NPUAP defines an unstageable pressure ulcer as: "Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed." Documentation on the wound record revealed the wound base was granulating. Granulation is defined by www.medicaldictionary.thefreedictionary.com as, "the new tissue formed in repair of wounds of soft tissue, consisting of connective tissue cells and ingrowing young vessels. It ultimately forms the cicatrix." Wound care was instituted and continued wound assessment by the facility staff assessed the wound as a pressure ulcer. When observed 11/28/12 at 4:10 p.m., the wound on the right hip was approximately 2 inches in length and 1 inch in width. The depth was approximately 1/2 inch with a pink granular wound bed. No redness, odor, or [MEDICAL CONDITION] was noted. Minimal serous drainage was noted on the old dressing. The staff develop coordinator related that the wound was staged as a Stage II pressure ulcer. Review of Resident #4's clinical record revealed no documentation within the nurse's notes to indicate the development of an unstageable pressure ulcer until 11/20/12, "11-20-12 08:32 AM Late entry, 11/15/12 Unstageable wound to R hip. New order was obtained to cleanse with NS, apply Santyl and cover with dry dressing. MD and RP notified." RN A, the nurse that wrote the note on 11/20/12 was interviewed, 11/29/12 at 9:50 a.m. In light of the definition of an unstageable wound having slough or eschar in the wound base, how was the wound base granular. RN A stated, "I looked at the wound that day (11/15/12) and the wound bed was covered with slough. I couldn't see the wound bed." RN A said she, the DON, and the Santyl representative viewed the wound at the same time, and all saw the same thing, "wound bed was covered by slough, couldn't see the wound bed." RN A was unaware of how the wound bed could have granulation tissue as documented by the LPN on the wound tracking. The DON stated 11/29/12 at 1:18 p.m., RN A must have misspoken when she stated the wound bed was unable to be visualized. The DON stated the area was a skin tear that Resident #4 experienced when she fell that same day. Documentation was evident that Resident #4 had a fall on 11/15/12, "Resident heard by cna yelling out for help. Resident observed on floor, sitting on buttocks...Old scab removed off of right hip..." Review of the facility's policy for the treatment of [REDACTED]. "Appearance: Category 1: Skin tear without tissue loss. The [MEDICATION NAME] flap either completely covers the dermis or covers the dermis to within 1 mm (milllimeter) of the wound margin, skin edges can be realigned to the normal anatomical position. Category 2: Skin tear with partial thickness tissue loss, skin edges cannot be realigned to the normal anatomical position. Category 3: Skin tear with complete tissue loss, skin flap is completely absent. General Management Guidelines: Control bleeding as indicated. Clean wound with normal saline or per physician orders. Gently pat dry surrounding skin. Approximate skin flap id flap is viable by gently easing the flap backing into place; if flap is difficult to align, consider using a moistened Q-tip to gently align the edges. Select appropriate dressing: Calcium Alginates-may assist with control of bleeding Soft silicone or silicone impregnated dressing-to facilitate flap security & non traumatic removal. Foam or fiber dressings-assist with drainage management. Antimicrobial dressing-aid in infection control. Adhesive dressing-best avoided when per-wound skin is fragile Tubular or roller bandages-to secure dressing or provide additional protection." Additionally, another reference provided by the facility, MEDICAL FACILITIES OF AMERICA CLINICAL PRACTICE QUICK REFERENCE GUIDE" advocated the use of a "Hydrogel dressing ie: Flexigel, Kling for protection" for the treatment of [REDACTED]. www.santyl.com provided the following recommendations for the use Santyl" "[MEDICATION NAME] SANTYL? Ointment is a prescription medicine for certain kinds of wounds, including chronic dermal ulcers (such as pressure, diabetic, and venous stasis ulcers) or severely burned areas. Wounds like these often contain skin or other tissue that is no longer living and must be removed. Sometimes the body can naturally shed this nonliving tissue, as in the case of a scab. In many cases, though, the tissue cannot be shed naturally, and that may cause a delay in healing or an infection. Be sure to follow all your healthcare provider's instructions about using SANTYL? Ointment. You will usually be instructed to apply it once a day, or more frequently if your wound dressings become soiled. [MEDICATION NAME] SANTYL? Ointment is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas. Occasional slight transient [DIAGNOSES REDACTED] has been noted in surrounding tissue when applied outside the wound. One case of systemic hypersensitivity has been reported after 1 year of treatment with [MEDICATION NAME] and cortisone. Use of [MEDICATION NAME] SANTYL? Ointment should be terminated when debridement is complete and granulation tissue is well established. [MEDICATION NAME] SANTYL? Ointment is a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP. The enzyme [MEDICATION NAME] is derived from the fermentation by ,[MEDICAL CONDITION]. histolyticum. It possesses the unique ability to digest collagen in necrotic tissue." No documentation was available by the manufacturer for the use of Santyl on skin tears. Review of the facility policy "Skin Assessment" revealed: "1. A licensed nurse will ensure that the skin risk assessment is done upon admission, and quarterly thereafter. 2. A skin assessment will also be completed upon re-entry to the Center. 3. The weekly skin assessment will be completed thereafter. 4. Care plan specific interventions will be developed based on skin risk assessment outcomes and individual resident needs." RN A stated 11/29/12 at 9:50 a.m., the CNAs were responsible for assessing their Residents skin daily during bathing and at any other observation of an area, such as with peri care or toileting. CNA B, the staff member caring for Resident #4, said 11/29/12 at 9:25 a.m., she had been caring for Resident #4 for the last week. She stated the previous CNA that cared for Resident #4 was no longer with the facility. CNA B stated she checked Resident #4's skin every day when she assisted her with her bath, and checked the perineal area whenever she assisted her with her incontinent brief. CNA A, a CNA that also cared for Resident #4, said at the same time, she checked her Residents skin the same as CNA B did. Both staff members stated that if there was anything unusual they would notify the nurse immediately. Neither CNA could respond if Resident #4 had any areas on her right hip prior to the development of the unstageable pressure ulcer on 11/15/12. Guidance provided by NPUAP revealed that only pressure ulcers should be staged, "Integrated into the staging system is an assumption that the ulcer is due to pressure, hence other etiologies of wounds are not only inaccurately classified as pressure ulcers, but the understanding of their etiology is imperative for the prescription and choice of treatments. Also, same source, "The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Note the phrase "the base of the ulcer" is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover' and should not be removed." The demonstrator, DON, and staff present were advised of the failure of the staff to detect the presence of skin damage until an unstageable pressure ulcer developed, resulting in harm for Resident #4, 11/30/12 at 4 p.m. 2. The facility staff failed for Resident #1) to modify the plan of care for a sacral pressure wound failed to heal timely. The nurse failed to ensure appropriate measures to prevent wound contamination. The sacral wound failed to show evidence of healing with 8 consecutive weeks of treatment with Dakin's solution. The physician was not notified of lack of healing, or the need to change the plan of care. The nurse picked up a trash can after washing her hands, and pulled her scissors out of her pocket without cleaning. Resident #1, a [AGE] year old, was admitted to the facility 9/7/10. [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 10/19/12 was coded as a quarterly assessment. Resident #1 was coded as having short and long term memory deficits, and requiring supervision with daily decision making. Resident #1 was also coded as requiring total assistance with activities of daily living. Resident #1 was coded as having a stage 4 pressure ulcer and a suprapubic catheter. The NPUAP (national pressure ulcer advisory panel describes a stage 4 pressure ulcer as "full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present and often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable." On 11/29/12 at 11:15 AM, wound care was observed. The resident was face down on the bed with dressings in place over the wound. RN (registered nurse) C removed the soiled dressings and left the room. Resident #1's wounds were left exposed as well as her lower extremities and buttocks. There was a gap in the curtain and the door was open. Approximately 5 minutes later, LPN (licensed practical nurse) C entered the room and washed her hands. She then picked up the trash can by the sink and moved it near the bed. Scissors and a pen were removed from the LPN's pocket. Gloves were applied, and the wound was cleaned with NS (normal saline). The wound bed was clean, without slough or eschar and the surrounding tissue was clear. There were no signs of infection. Undermining was present. The latest wound measurements done on 11/23/12 described the wound as being 6.5 cm (centimeters) in length, 3.6 cm in width and 1.5 cm depth, which was consistent with observation. LPN (C) was questioned if the wound was getting better. She stated, "I am not usually on this hall." An interview with the the facility's nurse consultant revealed the following, "We don't have a wound care nurse, the nurse's do their own measurements." Review of the sacral wound measurements from 2/9/12 until present revealed the following measurements. There was no change in the treatment or notification to the physician of the need for a change in the plan of care: 2/9/12: 5.5 cm x 2.5 x 1 cm, treated with Dakin's solution 2/16/12: 6.8 x 4.8 x 1, treated with Dakin's solution 2/23/12 6.6 x 4.6 no depth recorded, treated with Dakin's solution 3/1/12 6.2 x 2.5 x 1, treated with Dakin's solution 3/9/12 5.8 x 2.3 x 1, treated with Dakin's solution 3/15/12 6.5 x 3.2 x 1, treated with Dakin's solution 3/24/12 6.2 x 3.0 x 1, treated with Dakin's solution 4/5/12 5.8 x 2 x 1, treated with Dakin's solution 4/12/12 5.2 x 2 x 1 treated with Dakin's solution According to the NPUAP, "Topical antiseptics such as providone iodine, Dakin ' s solution, or acetic acid that are properly diluted may be used for a limited time to control the bacterial burden, clean the ulcer, and reduce surrounding inflammation. Once the wound is clean, these products should be discontinued, as they can be damaging to healthy tissue". "Stage I and II pressure ulcers should show evidence of healing within 1-2 weeks, and Stage III and IV ulcers should show evidence of healing within 2-4 weeks. This means that if after 2 weeks of treatment, no healing is detected, then the wound, the patient, and the plan of care need to be reevaluated." On 11/30/12 at approximately 10:00 AM, the facility nurse consultant stated, "She came from the hospital with the orders for the Dakin's. She had been seen by the wound clinic there." There were no follow ups with the wound care clinic. On 11/30/12 at approximately 1:00 PM, the Administrator and DON (director of nursing) were notified of above findings. 3. For Resident #7, the facility staff failed to prevent a pressure ulcer on the left heel. The pressure ulcer was first discovered at a stage 2 on 9/13/12 and the ulcer was healed, according to the documentation, on or before 11/28/12. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 09/10/2012 coded Resident #7 with short-term memory problems and severely impaired cognitive skills for daily decision-making. In addition, the Minimum Data Set coded Resident #7 requiring total dependence, on staff, for Activities of Daily Living care and incontinent of bowel and bladder. A review of Resident #7 ' s clinical record was conducted during the survey. The review showed a care plan dated 06/30/2012. The care plan read that Resident #7 was at risk for skin breakdown and the following intervention were to be used: a pressure reduction surface to the bed, weekly skin assessments, be turned and positioned as needed, and heels floated while in bed. The review showed a document titled, " Weekly Skin Assessments. " The review showed skin assessments were done on 06/14/2012, 06/21/2012, and then no skin assessments were done until 09/27/2012. According to the wounds sheet when the facility first started tracking the wound (09/13/2012) it measured 0.4 x .04 x blank centimeters (the depth was left blank). On 09/20/2012, it was 0.4 x 0.4 x 0.3. On both dates, the wound bed was described as [MEDICATION NAME] and the peri-wound was described as intact. The next change occurred on 10/08/2012 when the wound was described as 2 x 1.5 x 0. The wound bed had 10% eschar and 90% granulation. The peri-wound was red and inflamed. The wound sheets then showed that the wound improved on 11/01/2012 it measured 0.5 x 0.5 x 0 with [MEDICATION NAME] and intact peri-wound. It was healed by 11/28/2012. The review showed a document titled " Ulcer and Wound Record " that read that Resident #7 was discovered with a pressure ulcer on the heel on 09/13/2012. A nursing note dated 11/28/2012 read that the pressure ulcer on Resident #7 ' s heel had healed. An interview was conducted with the Director of Nursing on 11/29/2012 at approximately 10:50 a.m. The Director of Nursing stated that the pressure ulcer was discovered at a stage 2. (There are 4 stages for pressure ulcers, which increase in severity from a stage 1 to a stage 4. A stage 2 pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.) The facility administration was informed of the findings during a briefing on 11/30/2012 at approximately 1:45 p.m. The facility did not present any further information about the findings. Complaint deficiency.