Every finding on record at Cedar View Rehabilitation and Healthcare Center

Based on observation, record review and interview the facility failed to ensure for 3 out of 3 sampled residents (#49, #23 and #65), out of 6 applicable residents, in a total sample of 21 residents, that professional standards of practice were provided for the treatment related to urinary catheter output. Specifically, for Resident #49, #23 and #65 the facility failed to implement the physician's order to measure each resident's urinary output. Findings include: 1. Resident #49 was readmitted to the facility in August 2024 and has diagnoses that include hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side and neuromuscular dysfunction of bladder unspecified. Review of the Minimum Data Set (MDS) assessment, dated 8/31/24, indicated Resident #49 scored an 11 out of 15 on the Brief Interview of Mental Status indicating he/she has a moderately intact cognition, has an indwelling catheter and is dependent on staff for toileting. During an observation and interview on 1/22/25 at 2:11 P.M., Resident #49 was in his/her bed. A urinary catheter collection bag was hanging on the side of the bed in a privacy cover. Resident #49 said he/she required care and has been at the facility since 2019. Review of Resident #49's physician's orders indicated the following: -Measure urinary out every shift document output in mls [milliliters], active 9/4/2024. Review of the Treatment Administration Record dated November 2024 indicated the following: -Day 11/22/24, 11/26/24 did not have measured or recorded output. -Evening 11/6/24, 11/16/24 did not have measured or recorded output. -Night 11/4/24, 11/11/24, 11/13/24, 11/19/24 did not have measured or recorded output. -A total of 8 sifts out of 90 shifts failed to have measured and recorded output for Resident #49. Review of the Treatment Administration Record dated December 2024 indicated the following: -Day 12/17/24 did not have measured or recorded output . -Evening 12/2/24, 12/8/24, did not have measured or recorded output. -Night 12/6/24, 12/13/24, 12/19/24, 12/20/24, 12/28/24, 12/30/24, 12/31/24 did not have measured or recorded output . -A total of ten shifts out of 93 shifts failed to have measured and recorded output for Resident #49. Review of the Treatment Administration Record dated January 2025 (1/1/25-1/22/25) indicated the following: -Day 1/3/25, 1/7/25, 1/10/25, did not have measured or recorded output. -Evening 1/17/25, did not have measured or recorded output. -Night 1/8/25, 1/13/25, 1/18/25, did not have measured or recorded output. -A total of seven shifts out of sixty-six shifts failed to have measured and recorded output for Resident #49 During an interview on 1/23/25 at 1:12 P.M., Certified Nursing Assistant (CNA) #1 said Resident #49 has a catheter. CNA #1 said the CNAs empty the catheter and report the amount to the nurse. During an interview on 1/23/25 at 1:14 P.M., Nurse #4 said Resident #49 has a urinary catheter. Nurse #4 said the purpose of having the output measurement is to make sure the Resident is not experiencing any urinary retention. Nurse #4 said the CNA staff are to report to the nurses the amount each shift. Nurse #4 said the CNA staff leave quickly at the end of a shift and do not always report to the nurse the output. Nurse #4 said the Nurse is responsible to document in the medical record the amount of output each shift. 2. Resident #23 was admitted to the facility in December 2024 and has diagnoses that include but are not limited to paraplegia and neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/16/24, indicated Resident #23 scored a 15 out of 15 on the brief interview of Mental Status exam indicating that the Resident is cognitively intact. Further review of the MDS indicated Resident #23 had a urinary indwelling catheter. During an observation on 1/23/25 at 12:54 P.M., Resident #23 was observed resting in his/her bed. A urinary collection bag was hanging on his/her right side of the bed. Review of the physician's order indicated the following: -order: Measure Urinary Output every shift for foley document output in mls (milliliters) dated as active 12/11/2024. Review of the November 2024 Treatment Administration Record (TAR) indicated the following: Measure Urinary Output every shift document in mls start date 7/15/2024 DC date 11/25/2024. -Day: 11/1/24, 11/9/24, 11/15/24, 11/20/24, 11/21/24 and 11/23/24 did not have measured or recorded output. -Evening: 11/1/24, 11/2/24, 11/3/24 11/8/24, 11/9/24, 11/15/24, 11/17/24, 11/19/24, 11/23/24 did not have measured or recorded output. -Night: 11/3/24, 11/20/24 and 11/22/24 did not have measured or recorded output. -Review of the November 2024 TAR indicated a total of 17 shifts out of 75 shifts failed to have documented urinary output for Resident #23. Review of December 2024 TAR indicated the following: Measure Urinary Output every shift for foley document output in: mls start date 12/11/24 -Day 12/12/24, 12/14/24, 12/15/24, 12/17/24, 12/19/24, 12/20/24, 12/22/24, 12/26/24, did not have measured or recorded output. -Evening: 12/14/24, 12/15/24, 12/20/24, 12/27/24, 12/28/24, 12/29/24, 12/31/24 did not have measured or recorded output. -Night: 12/18/24, 12/23/24. 12/28/24 did not have measured or recorded output. -Review of the December 2024 TAR indicated that a total of 19 shifts out of 63 shifts failed to have documented urinary output for Resident #23. Review of the January 2025 TAR indicated the following: Measure Urinary Output every shift for foley document output in: mls start date 12/11/24 -Day: 1/5/25, 1/8/25, 1/10/25, 1/11/25 1/15/25, 1/17/25, 1/21/25 did not have measured or recorded output. -Evening: 1/1/25, 1/3,25, 1/14/25, 1/15/25, 1/16/25, 1/17/25 did not have measured or recorded output. -Review of the January 2024 TAR indicated 15 shifts out of 44 day and evening shifts failed to have documented urinary output on Resident #23. During an interview on 1/24/25 at 9:38 A.M., Nurse #1 said that the Certified Nurses aids (CNAs) generally empty the urinary catheters and should let the nurse know the amount that is drained. Sometimes they do not let us know so we cannot document it, but it should be documented per physician's orders. 46339 3. Resident #65 was admitted to the facility in September 2023 with diagnoses including urinary retention. Review of Resident #65's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact. The MDS further indicated the Resident had a urinary catheter (a tube used to remove urine directly from the bladder). On 1/22/25 at 8:59 A.M., the Resident was observed lying in his/her bed foley catheter observed draining and in a privacy bag. On 1/23/25 at 9:28 A.M., the Resident was observed lying in his/her bed, foley catheter observed draining and in a privacy bag. Review of the physician order dated 9/30/23 indicated the following: -Measure urinary output every shift document output in mls (milliliter). Review of a care plan date initiated 12/27/23 with a focus of indwelling urinary catheter related to urinary retention. Had the following intervention: Monitor/record/report as needed signs and symptoms of UTI (urinary tract infection), pain burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior change in eating patterns. Review of the Treatment Administration Record (TAR) indicated on the following months there were incomplete documentation for urinary output: During the month of November 2024- there were seven undocumented shifts without urinary output. During the month of December 2024- there were ten undocumented shifts without urinary output. During the month of January 2025- there were seven undocumented shifts without urinary output. During an interview on 1/23/25 at 12:50 PM., Unit Manager #1 said physician orders should be followed as ordered and urinary output should be documented following the physician's orders. During an interview on 1/24/25 at 10:25 A.M., the Director of Nursing said nursing should follow physician order and document output as per the orders.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for one Resident (#85) out of a total sample of 21 residents. Specifically, for Resident #85 the facility failed to develop a fall risk care plan. Findings include: Review of facility policy titled Care Plans, Comprehensive Person- Centered, dated as revised March 2022, indicated the following: -A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -A comprehensive, person centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment, and no more than 21 days after admission. Resident # 85 was admitted to the facility in November 2024 with diagnoses that include hemiplegia (paralysis to one side of the body) and hemiparesis (weakness to one entire side of the body) following cerebral infarction affecting left dominant side. Review of Resident #85's most recent comprehensive Minimum Data Set Assessment (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 9 out of 15 indicating that the Resident has moderate cognitive impairment. Further the MDS indicated that the Resident is dependent with activities of daily living (ADLs) and transfers. Review of the discharge referral from hospital, dated 11/27/24, indicated the following: -Precautions/Restrictions: Fall Precautions, Left Hemiparesis. Review of Resident #85's Admission/Readmission Evaluation Packet, dated 1/7/25 indicated a fall risk score of 20, indicating that the resident is at high risk for falls. Review of Resident #85's nursing progress note, dated 1/18/25 indicated the following: Pt [patient] s/p [status post] fall at 5pm. Pt was found on floor by wheelchair and assisted back to bed via hoyer lift [a mechanical lift used to transfer residents from one place to another].[sic] Review of Resident #85's fall risk assessment completed on 1/18/25 indicated a fall risk score of 22, indicating that the Resident is at high risk for falls. Review of Resident #85's active care plan indicated a risk for falls care plan, initiated on 1/22/25, four days after sustaining a fall in the facility, and 15 days after being assessed as having a fall score of 20 and being at high risk for falls. Review of Resident #85's resolved plan of care that indicated a focus indicating that Resident #85 is at risk for falls related to impaired mobility, dated as initiated on 11/29/24 and resolved on 1/22/25. The incomplete care plan failed to indicate a measurable goal or any interventions to prevent falls in the facility. During an interview on 1/23/25 at 11:53 A.M., Nurse #1 said that a resident with a cerebral infarction and hemiplegia would be at risk for falls and should probably have a fall care plan in place with interventions to prevent falls. He said Resident #85 is at risk for falls. During an interview on 1/23/25 at 12:11 P.M., the Director of Nursing said Resident #85 is at risk for falls and should have had a complete and comprehensive falls care plan with interventions in place but did not.

Based on observation, record review and interview the facility failed to ensure for one Resident (#146), out of a total sample of 21 residents that a physical therapy evaluation was completed timely. Findings include: Resident #146 was admitted to the facility in January 2025 and has diagnoses that include but are not limited to muscle wasting and atrophy and acute systolic (congestive) heart failure. Review of Resident #146's Minimum Data Set assessment dated [DATE] indicated he/she scored a 14 out of 15 on the Brief Interview for Mental Status exam, indicating his/her as having intact cognition. During an observation and interview on 1/22/25 at 11:17 A.M., Resident #146 was resting in bed. Resident #146 said he/she was admitted to the facility in early January 2025, after being in the hospital for CHF (congested heart failure). Resident #146 said he/she needed to have therapy to walk again. Resident #146 said he/she has both physical therapy and occupational therapy, but they have been inconsistent. Review of Resident #146's physician's orders indicated the following: PT (physical therapy)-Screen, Evaluate, and Treat as indicated, dated 1/4/25. Review of Resident #146's Physical Therapy Evaluation and Plan of Treatment, dated with a certification period of 1/8/2025-2/8/2025 indicated treatment approaches may include, therapeutic exercises, neuromuscular reeducation, gait training therapy, manual therapy techniques, group therapeutic procedures, Physical therapy evaluation: moderate complexity, Therapeutic activities, Wheelchair management training. Frequency 5 time(s)/week Duration 4 weeks. Review of the Physical Therapy and Evaluation and Treatment Plan indicated the evaluation was completed on day five after Resident #146 was admitted to the facility. Review of progress notes in Resident #146's medical record from 1/4/25 through 1/8/25 failed to indicate any refusal or documented obstacles impacting the physical therapy evaluation. During an interview on 1/23/25 at 9:24 A.M., the Director of Rehabilitation (DOR) said the physical therapy staff aim to evaluate a resident within 24 hours of admission. The DOR said following the Medicare guidelines a PT evaluation and treatment plan must be completed by day three of admission and that day one is the admitted . The DOR said Resident #146 was admitted for skilled rehabilitation. The DOR said Resident #146 was scheduled to be evaluated by physical therapy on 1/6/25 and that she is unsure what happened and is just now looking into it. The DOR said Resident #146 should have been evaluated by physical therapy by day three of admission.

Based on observation, record review and interview the facility failed to ensure accuracy of the medical record for one Resident (#24) out of a total sample of 21 residents. Specifically: For Resident #24 the facility failed to ensure accurate documentation for a hand roll. Resident #24 was admitted to the facility in November 2016 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side. Review of Resident #24's Minimum Data set (MDS) assessment, dated 10/24/24, indicated the Resident scored a 13 out of a total possible 15 on the Brief Interview for Mental Status indicating he/she was cognitively intact. The MDS further indicated impairment on one side to the upper extremity. On 1/22/25 at 8:18 A.M., the surveyor observed Resident #24 sitting in his/her room, left hand clenched in a fist, the surveyor observed a hand roll sitting on the bedside table. On 1/23/25 at 9:26 A.M., the surveyor observed Resident #24 sitting in his/her room . The Resident did not have the hand roll on. On 1/23/25 at 12:38 P.M., the surveyor observed Resident #24 sitting in his/her room, the Resident did not have the handroll on. Resident #24 said he/she only wears the splint at night. Review of the physician order dated 11/20/20 indicated the following: Left hand roll, remove during care check skin integrity every shift. Review of the care plan focus: Activity of Daily Living (ADL) care performance deficit date initiated: 3/18/2019 had the following interventions: Left hand roll, remove during care-check skin integrity. Review of the January 2025 Treatment Administration Record (TAR) indicated staff documented that the Resident had been wearing the hand roll continuously throughout the three shifts. During an interview on 1/23/25 at 12:40 P.M., Nurse #5 said the Resident wore the hand roll all the time. During an interview on 1/23/25 at 2:52 P.M., Unit Manager #1 said the Resident only wears the hand roll at nighttime, and staff should document accurately if Resident is not wearing the hand roll. During an interview on 1/24/25 at 10:25 A.M., the Director of Nursing said the Resident has been wearing the splint only at night and had worked with occupational therapy to put the hand roll on and take it off. She said the staff should document accurately if the Resident is not utilizing the hand roll.

Based on observation, record review and interview the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for one Resident (#22), out of a total sample of 21 residents. Specifically, for Resident #22 the MDS dated [DATE] indicated Resident #22 had a gradual dose reduction (GDR) of his/her antipsychotic medication administered on a routine basis dated 11/11/24. Review of the physician's orders failed to indicate a GDR was implemented therefore the MDS assessment failed to be accurate. Findings include: Resident #22 was admitted to the facility in September 2024 and has diagnoses that include major depressive disorder with recurrent severe psychotic symptoms. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #22 scored a 12 out of 15 on the Brief Interview for Mental Status exam indicating that he/she as having moderately intact cognition. Further review of MDS indicated Resident #22 is administered an antipsychotic medication on a routine basis and was coded that a gradual dose reduction of the antipsychotic medication was completed and documented on 11/11/24. Review of Resident #22's medical record failed to indicate documentation of a gradual dose reduction. Review of the physician's orders indicated the following order: -Seroquel (an antipsychotic medication) oral tablet 50 mg (milligrams) (Quetiapine Fumarate) (generic name) Give 50 mg by mouth at bedtime for anxiety. Start date 9/23/24. Review of the December 2024 Medication Administration Record (MAR) indicated Resident #22 was administered Seroquel 50 mg. Further review of the MAR failed to indicate that the dose of Seroquel was reduced, which conflicts with the MDS dated [DATE]. During an interview on 1/23/25 at 8:40 A.M., Unit Manager #1 said Resident #22 did not have a gradual dose reduction of the Seroquel in November 2024. During an interview on 1/23/25 at 9:49 A.M., MDS Nurse #1 reviewed Resident #22's orders and said he did not see a dose reduction in the Seroquel. MDS Nurse #1 said he would need to look into it further. During an interview on 1/23/25 at 11:50 A.M., MDS Nurse #1 said the coding of the MDS dated [DATE] that Resident #22 had a gradual dose reduction of the antipsychotic medication (Seroquel) was a data entry error and that there was no medication change or reduction of the antipsychotic medication.

Based on observations, interviews and policy review, the facility failed to ensure staff stored drugs and biologicals in accordance with State and Federal laws. Specifically, the facility failed to: 1.) ensure treatment carts were locked and secured on two of two units, 2.) ensure medications were stored in locked compartments on one of two nursing units, 3.) ensure the medication cart keys were not left unattended on one of four medication carts, and 4.) ensure one of two medication storage rooms were locked when unattended. Findings include: Review of the facility policy titled, Medication Labeling and Storage, dated as revised February 2023, indicated, the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if opened or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 1.) The facility failed to ensure treatment carts were locked and secured on two of two units. On 2/15/24 at 6:52 A.M., the surveyor observed one treatment cart unlocked and unattended in the hallway on the East unit. The treatment cart contained prescription ointments and creams. No staff were present at the treatment cart. Two residents and one housekeeping staff member were observed in the hall near the treatment cart. On 2/15/24 at 7:00 A.M., the surveyor observed a treatment cart unlocked and unattended in the hallway on the [NAME] unit. The treatment cart contained prescription ointments and creams. No staff were present at the medication cart. During an interview on 2/15/24 at 7:10 A.M., Nurse #1 said treatment carts should be locked when unattended. During an interview on 2/20/24 at 8:18 A.M., Unit Manager #1 said treatment carts should be locked when unattended. During an interview on 2/20/24 at 8:52 A.M., the Director of Nursing said treatment carts must be kept locked when not in use. 2.) The facility failed to ensure medications were stored in locked compartments on one of two nursing units. On 2/15/24 at 6:52 A.M., the surveyor observed two cards of medications left unattended, on the East high side medication cart including: -one blister packs of warfarin tabs 7.5 milligrams (medication for blood clot prevention) -one blister pack of metoprolol (medication for blood pressure) During an interview on 2/15/24 at 7:12 A.M., Nurse #1 said medication packs should not be stored on top of medication carts and should not be left unattended. During an interview on 2/20/24 at 8:52 A.M., the Director of Nursing said the medications should not be kept on top of the medication cart and must be locked in the medication cart. 3.) The facility failed to ensure the medication cart keys were not left unattended on one of four medication carts. On 2/15/24 at 6:52 A.M., and 2/15/24 at 7:05 A.M., the surveyor observed key rings with keys to the medication cart and treatment cart placed inside the narcotic book, located on top of the East medication cart. Two residents and one housekeeping staff member were observed in the hall near the medication cart. During an interview on 2/15/24 at 7:10 A.M., Nurse #1 said keys to the medication and treatment cart should not be left on the medication cart and should be always kept with the nurse. During an interview on 2/20/24 at 8:52 A.M., the Director of Nursing said keys to the medication and treatment cart should not be placed on top of the medication cart. 4.) The facility failed to ensure one of two medication storage rooms were locked when unattended. On 2/15/24 at 6:52 A.M., the surveyor observed the East side medication room door propped open with an intravenous (IV) kit. The IV kit contained bags of IV fluids, needles, and venous access device equipment. Two residents and one housekeeping staff member were observed in the hall. During an interview on 2/20/24 at 8:18 A.M., Unit Manager #1 said the medication room should not be unlocked and should not be propped open with any equipment. During an interview on 2/20/24 at 8:52 A.M., the Director of Nursing said the medication room must be locked.

Based on observation, record review and interview the facility failed to ensure specialized rehabilitative services were provided timely for one Resident (#30), out a total sample of 20 residents. Specifically, for Resident #30 when on 11/2/23 his/her diet was downgraded while waiting on the fabrication of dentures, the facility failed to ensure Speech Language Pathology (SLP) screened/assessed Resident #30 after he/she received the new dentures on 12/19/23, resulting in Resident #30 not being screened/assessed for 63 days after he/she received new dentures. Findings include: Review of the facility's policy titled 'Speech Therapy', dated May 2013 indicated the purpose of this procedure is to identify, assess and treat speech and language problems including swallowing disorders. Further review of the policy indicated; General Guidelines 1. Speech therapists treat stroke survivors and other brain injury survivors who experience impaired ability to swallow or have difficulty expressing thought or understanding language. These residents may experience d. Dysphagia-difficulty in chewing or swallowing. 2. The speech therapist works with other rehabilitation and medical professionals and families to provide a comprehensive evaluation and treatment plan for residents with any of the problems listed in paragraph (1) above. Resident #30 was admitted to the facility in February 2015 and has diagnoses that include adult failure to thrive, dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat). Review of the comprehensive Minimum Data Set (MDS) assessment, dated 8/31/23, indicated in section L that Resident #30 had no natural teeth or tooth fragments. Edentulous (lacking teeth). Review of the MDS assessment, dated 11/29/23, indicated Resident #30 scored a 10 out of 15 on the Brief Interview for Mental Status exam, indicating he/she is moderately cognitive impaired. Further review of the MDS indicated that Resident #30 was seen by Speech Therapy on 11/2/23. During an interview on 2/15/24 at 11:42 A.M., Resident #30 said he/she did not like his/her meals. Resident #30 said he/she does not need a soft diet and is waiting for his/her meals to be changed because he/she got new teeth in December. Review of Resident #30's medical record indicated the following physician's order summary: -ST (speech therapy) screen, evaluate and treat as indicated, dated 6/21/21 -Regular diet, mechanical soft texture, thin consistency dated 11/2/23. Review of Resident #30's medical record indicated in a document from the dentist, dated 12/19/23, full upper and lower denture insertion, adjustment. Pt (patient) pleased and comfortable, followed treatment well. RN (registered nurse) informed. Review of the Speech Therapy Evaluation and Plan of Treatment, dated 11/2/23, indicated' Pt (patient) referred for clinical bedside swallow exam d/t (due to) difficulty with mastication (chewing) d/t awaiting new dentures. Assessment Summary: Oral dysphagia WFL (within functional limits) with mech. (mechanical) soft diet. Rec (recommend) upgrade to regular when dentures fitted. During an interview on 2/20/24 at 9:03 A.M., the Speech Language Pathologist (SLP) said she was not informed by nursing that Resident #30's dentures came in. The SLP said Resident #30 was placed on a soft diet because he/she was edentulous, and the plan was to screen Resident #30 after he/she received his/her new dentures. The SLP said when a screen request is made for speech therapy, the resident would be screened/or evaluated within a few days. During an interview on 2/21/24 at 7:40 A.M., CNA #3 said Resident #30 eats independently with set up. CNA #3 said Resident #30 got new dentures over a month ago. During an interview on 2/21/24 at 7:45 A.M., Nurse #2 said for a resident to have an upgraded diet, the dietitian will be involved, or rehabilitation staff would screen and fill out a form with their recommendation. Nurse #2 said he did not know why Resident #30 was on a mechanical soft diet and was not familiar with Resident #30's teeth or dentures. During an interview on 2/21/24 at 7:51 A.M., Unit Manager #2 said speech therapy would need to screen a resident for a diet upgrade. Unit Manager #2 said she did not know if Resident #30 was screened by speech after receiving his/her new dentures. During an interview on 2/21/24 at 8:11 A.M., the Director of Nursing said diet texture changes would need to be assessed by the speech therapy, with a few exceptions. The DON said Resident #30 should have been screened by the SLP after receiving his/her new dentures.

Based on observations, policy review, record review and interviews the facility failed to ensure a resident who required respiratory care (continuous oxygen) received care consistent with professional standard of practice for one Resident (#344) out of a total sample of 20 Residents. Specifically, for Resident #344, nursing administered continuous oxygen without a physician's order. Findings include: Review of the facility policy titled, Oxygen Administration, dated October 2010, indicated: 1. Verify that there is a physician's order for this procedure. Review the physicians' orders or facility protocol for oxygen administration. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: -The date and time the procedure was performed -The name and title of the individual who performed the procedure. -The rate of oxygen flow, route, and rationale. -The frequency and duration of the treatment. Resident #344 was admitted to the facility in February 2024 with diagnoses including chronic obstructive pulmonary disease, respiratory failure, and aortic venous thrombus (condition affecting the heart). Review of the Minimum Data Set (MDS) assessment, dated 2/15/24, indicated Resident #344 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated he/she was cognitively intact. Further review of the MDS indicated the use of oxygen therapy. On 2/15/24 at 7:59 A.M., the surveyor observed Resident #344 in his/her bed. He/she was receiving oxygen via nasal cannula at 2.5 liters per minute. Resident #344 said he/she wears oxygen at his/her home and oxygen is not new. On 2/15/24 at 10:18 A.M., the surveyor observed Resident #344 in his/her bed. He/she was receiving oxygen via nasal cannula at 2.5 liters per minute. Review of the nurse practitioner (NP) health status note, dated 2/14/24, indicated acute and chronic respiratory failure with hypoxia, newly diagnosed congestive heart failure. Patient with history of COPD, on 3 L to 4 L of home oxygen. He/she presented to the emergency room with increased shortness of breath. He/she reports shortness of breath is improving. Currently 99% on 2 Liters. Advised to maintain oxygen (O2) saturation 88 to 92% if possible. Do not exceed 2 Liters unless O2 saturation is less than 88%. Review of the plan of care, dated 2/15/24, failed to include the use of oxygen. Review of the physician's orders, dated 2/15/24, failed to include an order to administer continuous oxygen. Review of the medical record indicated the following documented use of oxygen: 2/15/24 at 12:58 P.M. 96 % (Oxygen via Nasal Cannula) 2/15/24 at 12:53 P.M. 96 % (Oxygen via Nasal Cannula) 2/15/24 at 6:17A.M. 92 % (Oxygen via Nasal Cannula) 2/15/24 at 12:10 A.M. 92 % (Oxygen via Nasal Cannula) 2/15/24 at 12:09 A.M. 92 % (Oxygen via Nasal Cannula) During an interview on 2/16/24 at 6:59 A.M., Certified Nursing Assistant (CNA) #1 said Resident #344 uses oxygen. During an interview on 2/16/24 at 7:04 A.M., Unit Manager #1 said Resident #344 should have an order for oxygen and orders for oxygen use must be followed. During an interview on 2/16/24 at 10:01 A.M., the Director of Nurses (DON) said Residents on oxygen are required to have an order in place for settings, for cleaning and changing the tubing. The DON said she expects the policy to be followed.

Based on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication was limited to 14 days and the physician's order included the duration for the PRN order, for one Resident (#27) out of a total sample of 20 residents. Findings include: Review of the facility's policy entitled, 'Psychotropic Medication Use', dated July 2022 indicated the following: 11. Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the record. (1) For psychotropic medications that are NOT antipsychotic: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. Resident #27 was admitted to the facility in October 2023 and has diagnoses that include atrial fibrillation, chronic pain, and anxiety disorder. Review of Resident #27's Minimum Data Set (MDS) assessment, dated 1/18/24, indicated Resident #27 scored a 15 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition and in section N0415 High-Risk Drug Classes, Resident #27 was administered antianxiety medication. Review of Resident #27's physician's orders indicated the following: -Xanax (a psychotropic medication used to treat anxiety) Oral Tablet 0.5 milligrams (mg) (Alprazolam), give 0.5 mg by mouth as needed for anxiety 3x/day, dated 10/19/23. Further review of the physician's order for the as needed antianxiety medication failed to include the duration of the PRN order, as required. Review of the Medication Administration Record (MAR), dated 2/1/24 through 2/20/24, indicated 18 doses of the PRN Xanax were administered to Resident #27. Review of the Nurse Practitioner notes in Resident #27's medical record dated 10/18/23, 10/26/23, 11/3/23, 12/29/23 and 1/2/24 failed to include an end date or duration for the use of the PRN antianxiety medication. During an interview on 2/20/24 at 1:09 P.M., Unit Manager #2 said PRN psychotropic medications should be reviewed after the first 14 days, then would require an evaluation by the nurse practitioner or physician, and if continued would require a stop date. During an interview on 2/20/24 at 1:45 P.M., Nursing Supervisor #1, who was caring for Resident #27, said the Resident was admitted to the facility with a Xanax order, and is being administered the PRN regularly as needed at Resident #27's request for anxiety. Nursing Supervisor #1 reviewed the physician's order and said it did not have an end date. During an interview on 2/20/24 at 2:44 P.M. the Director of Nursing (DON) said psychotropic medication used PRN needs to be reevaluated after 14 days. The DON said the Nurse Practitioner did not want to make changes to Resident #27's PRN psychotropic medications and should have put a duration or end date on the PRN Xanax order.

Based on observations and interviews, the facility failed to wear Person Protective Equipment (PPE) appropriately to prevent the potential spread of infection on 2 out of 2 units. Findings include: On 1/23/23 at 9:03 A.M., a Certified Nursing Assistant was observed eating in the main dining room near the kitchen. She was not wearing a mask and there were residents in the dining room eating. On 1/23/23 at 11:17 A.M., a nurse was observed sitting at the nurses' station on the East Unit with her mask around her chin, not covering her nose or mouth. During an interview on 1/24/22 at approximately 11:00 A.M., the Director of Nursing said staff should all be wearing masks in patient areas and it was unacceptable that these staff had not been. 46339 2. During an observation on 1/23/23 at 7:53 A.M., the surveyor observed House Keeper #1 with her mask below her nose speaking to staff in resident care area. During an interview on 1/23/23 at 7:54 A.M., House Keeper #1 said she is not supposed to have the mask down and that it should cover her mouth and nose. During an interview on 1/24/22 at approximately 11:00 A.M., the Director of Nursing said staff should all be wearing masks in patient areas and it was unacceptable that these staff had not been.

Based on record review, interview and observation the facility failed to ensure proper respiratory practices were followed for nebulizer masks and tubing for 4 Residents ( #9, #23, #291 and #292) out of a sample of 20 Residents. Findings include: Review of the facility`s policy titled ' Administering Medications through a Small Volume (Handheld) Nebulizer' version 1.1 (H5MAPR0303) indicated the following: *Purpose: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident`s airway. *Steps and procedure -21. When equipment is completely dry, store in plastic bag with resident`s name and that date on it. 1. Resident #9 was admitted to the facility in October of 2016 with diagnoses that included dementia, respiratory disorder and pneumonia. Review of Resident #9's Physician Orders, dated 1/17/23, indicated Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML, 3 ml inhale orally every 4 hours as needed for SOB or Wheezing for 5 Days via nebulizer and 3 ml inhale orally four times a day for SOB or Wheezing for 5 Days via nebulizer. During an observation on 1/22/23 from 8:31 A.M. till 10:00 A.M., the surveyor observed Resident #9's unbagged nebulizer mask and tubing, on top of personal items, on top of the night stand. Review of Resident #9's Medication Administration Record (MAR), indicated on 1/21/23 at 5:00 P.M. and 9:00 P.M., and on 1/22/23 at 9:00 A.M., that Ipratropium-Albuterol Solution was administered via nebulizer to Resident #9. During an interview on 1/23/23 at 1:01 P.M., the Director of Nursing said nebulizers should be stored in plastic respiratory bag when not in use. 46339 2. Resident #23 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), asthma and heart failure. Review of Resident #23 Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23 was cognitively intact and scored a 14 out of 15 on the Brief Interview of Mental Status (BIMS) exam. During an observation on 1/22/23 at 9:25 A.M., the surveyor observed Resident #23`s nebulizer equipment laying on the nightstand, not bagged. Review of Resident #23`s medical record indicated, a physician's order: pratropium, dated 1/17/2023, Albuterol Inhalation Solution 0.5-2.5 (3) MG/3 ML (Ipratropium-Albuterol), 3 ml inhale orally via nebulizer three times a day related to asthma for 5 Days. Review of Resident #23`s Medication Administration Record (MAR) indicated, on 1/22/23 at 9:00 A.M. and 1:00 P.M., that Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ 3 ML was administered via nebulizer to Resident #23. During an interview on 1/23/23 at 1:01 P.M., the Director of Nursing said nebulizer equipments should be stored in plastic respiratory bags when not in use. 3. Resident #291 was admitted to the facility in January 2023 with a diagnoses including acute respiratory failure with hypoxia, Pneumonia, Acute bronchospasm and Covid. Review of Resident #291`s Minimum Data Set (MDS) assessment, dated 1/12/23, revealed Resident #291 was cognitively intact as evidenced by a score of 15 out of a possible 15 on the Brief Interview of Mental Status (BIMS). The MDS further indicated the Resident did not have any behaviors and did not reject care. During an observation and interview on 1/22/23 at 10:13 A.M., the surveyor observed Resident #291 laying in his/her bed. Nebulizer equipment was observed on the nightstand, not bagged. Resident #291 said staff use the nebulizer to administer breathing treatments to him/her. During an observation on 1/23/23 at 11:52 A.M., the surveyor observed Resident #291 laying in his/her bed, the nebulizer equipment was observed on the nightstand, not bagged. Review of Resident #291`s medical record indicated the following: Physician order, dated 1/10/2023, for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML 3 ml inhale orally four times a day for respiratory failure. During an interview on 1/23/23 at 1:01 P.M., the Director of Nursing said nebulizer breathing equipment should be stored in a plastic respiratory bag when not in use. 4. Resident #292 was admitted to the facility in January 2023 with diagnoses including lobar pneumonia and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #292 Minimum Data Set (MDS) assessment, dated 1/11/23, revealed Resident #292 was cognitively intact and scored a 15 out of 15 on the Brief Interview of Mental Status (BIMS) exam. During an observation on 1/22/23 at 7:17 A.M., the surveyor observed Resident #292`s nebulizer mask on the floor, not bagged. Review of Resident #292 Medication Administration Record indicated, on 1/22/23 at 9:00 A.M., nursing administered Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/ 3 ML via nebulizer to Resident #292. During an interview on 1/23/23 at 1:01 P.M., the Director of Nursing said nebulizer breathing equipment should be stored in a plastic respiratory bag when not in use.

Based on observations, record review and interview, the facility failed to 1) develop a care plan for dementia for 1 Resident (#56) and 2) failed to implement a physician's order for weekly weights for 1 Resident (#49) out of a total sample of 20 residents. Findings include: 1. Resident #56 was admitted to the facility in October 2021 with diagnoses including dementia. Review of Resident #56's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated the Resident had a Brief Interview for Mental Status score of 9 out a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #56 requires extensive assistance from staff for all self-care tasks. Review of Resident #56's interdisciplinary care plans failed to indicate a dementia care plan was developed. During an interview on 1/23/23 at 1:24 P.M., the Director of Nursing said she would expect a care plan to be in place for all diagnoses, including dementia to ensure staff know how to care for the residents. 43846 2. Resident #49 was admitted to the facility in October of 2022 with diagnoses that included unspecified protein-calorie malnutrition, dysphagia (difficulty chewing and swallowing) and cerebral infarction. Review of Resident #49's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status score of 5 out of a possible 15, indicating severe cognitive impairment. Review of Resident #49's Physician Orders, dated 10/27/22, indicated Weights Weekly on Thursdays. Review of Resident #49's Nutritional Problem Care Plan, dated 11/2/22, indicated to obtain weights at ordered intervals. Review of Resident #49's weights failed to indicate a weight was obtained on 11/3/22, 11/24/22, 12/1/22, 12/15/22, 12/19/22, 1/12/23. Review of Resident #49's clinical progress notes failed to indicate that Resident #49 refused to be weighed. During an interview on 1/23/23 at 12:57 P.M., the Registered Dietitian (RD) said she would expect that the weekly weight would be obtained weekly. The RD acknowledged there were many weeks where Resident #49 was not weighed and she could not say why. During an interview on 1/23/23 at 1:05 P.M., Nurse #1 said Resident #49 has an order for weekly weights on Thursdays and it is the expectation that the Certified Nursing Assistants (CNAs) obtain the weight on the day shift on Thursdays. During an interview on 1/24/23 at 10:08 A.M., the Director of Nursing said she expects the nursing staff to follow the doctors order and obtain the weekly weight and document it in the medical record.

Based on observations, record reviews and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for three Residents (#56, #49, and #81) out of a total sample of 20 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, undated, indicated the following: *Residents who are able to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. *Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) 1. Resident #56 was admitted to the facility in October 2021 with diagnoses including macular degeneration. Review of Resident #56's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 has a Brief Interview for Mental Status score of 9 out a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #56 requires extensive assistance from staff for all self-care tasks. During an observation on 1/22/23 at 7:30 A.M., Resident #56 was observed in the dining room with significantly greasy hair. During an interview on 1/23/23 at 10:14 A.M., Resident #56 said he/she would like to have regular showers and does not get them. Resident #56's hair was slicked back and was significantly greasy. Review of Resident #56's activity of daily living care plan last revised 10/21/21, indicated the following: *I (Resident #56) require staff to assist me with bathing. Dependent at times. Review of the Documentation Survey Report for the months of August 2022 to January 2023 indicated the following: *Resident #56 has received 5 showers in the last 6 months with no showers provided in September, October or December. *During the last 6 months, there have been 56 days where Resident #56 has had ADL care only once a day. *During the last 6 months, there have been 19 days that failed to document Resident #56 had any ADL care. During an interview on 1/23/23 at approximately 11:00 A.M., Certified Nursing Assistant (CNA) #2 said all residents in the facility are supposed to receive showers at least once a week. CNA #2 said Resident #56 does not refuse care and should be given regular showers. During an interview on 1/23/23 at 1:44 P.M., the Director of Nursing said all residents should have both morning and evening ADL care and showers twice a week. The Director of Nursing reviewed the Documentation Survey Report with the surveyor and confirmed there was no documentation that this was occurring for Resident #56. 43846 2. Resident #49 was admitted to the facility in October of 2022 with diagnoses that included unspecified protein-calorie malnutrition, dysphagia (difficulty chewing and swallowing) and cerebral infarction. Review of Resident #49's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status (BIMs) exam score of 5 out of a possible 15, indicating severe cognitive impairment. The MDS further indicated Resident #49 required extensive one person physical assistance for eating. During an observation on 1/22/23 at 8:13 A.M., the surveyor observed Resident #49 in bed with his/her breakfast tray eating breakfast. No staff were present to supervise or assist Resident #49. During an observation on 1/23/23 from 8:27 A.M. to 8:36 A.M., the surveyor observed Resident #49 in the dining room with his/her breakfast tray eating alone. Resident #49 was noted only to eat about 25%. During an observation on 1/23/23 from 12:20 P.M. to 12:25 P.M., the surveyor observed Resident #49 in the dining room with his/her lunch tray eating alone. Review of Resident #49's Activity of Daily Living (ADL) Care Plan, dated 11/3/22, indicated EATING: I require hands-on assistance for eating and drinking. Review of Resident #49's Care Card, dated 1/23/22, indicated that Resident #49 required hands-on assistance for eating and drinking. During an interview and review of Resident #49's Care Card on 1/23/23 at 12:31 P.M., Certified Nurse Aide #1 said she would look at the care card to know what assist level a resident would need and acknowledged Resident #49 requires assist with eating. During an interview on 1/23/23 at 12:35 P.M., Unit Manager #1 said that Resident #49 requires assist with eating. During an interview on 1/24/23 at 10:45 A.M., Regional Nurse #2 said she edited the ADL care plan yesterday, after the surveyor brought up the concern regarding Resident #49's assist with meals. Regional Nurse #2 acknowledged modifying the care plan on 1/23/23 to indicate assistance needs with eating fluctuates. 46339 3. Resident #81 was admitted to the facility in October 2022 with diagnoses including legal blindness, right below knee amputation and muscle atrophy. Review of Resident #81's Minimum Data Set (MDS) assessment, dated 10/24/22, revealed Resident #81 was cognitively intact as evidenced by a score of 15 out of 15 on the Brief Interview of Mental Status (BIMS) exam. The MDS further indicated Resident #81 required total dependence of 2 person physical assist for bathing and did not have behaviors or reject care. During an observation and interview on 1/22/23 at 10:30 A.M., Resident #81 was observed laying in his/her bed with greasy hair. Resident #81 said he/she had not had a shower since October 2022 and does not like how his/her hair looks and feels. Review of Resident #81's Activity of Daily Living (ADL) care plan last initiated 10/21/22, indicated the following: * I (Resident #81) require 1 staff to assist with bathing. Review of the Documentation Survey report for the months of October 2022 to January 2023 indicated the following: * Resident #81 had received 3 showers in the last 4 months with no showers provided in October, December and January. *During the last 4 months, there were 17 days when Resident #81 had ADL care only once a day. *During the last 4 months, there have been 2 days that failed to document Resident #81 had any ADL care. During an interview on 1/24/23 at 8:48 A.M., Certified Nursing Assistant (CNA) #3 said Resident #81 refuses to have showers and nursing was aware. During an interview on 1/24/23 at 9:08 A.M., Nurse #1 said she was unaware Resident #81 has refused showers and that if he/she had it would be documented in the nurse's progress notes. Nurse #1 verified there was no documentation regarding refusals. During an interview on 1/23/23 at 1:44 P.M., the Director of Nursing said all residents should have both morning and evening ADL care and showers twice a week.

Based on record review and interview, the facility failed to implement a recommendation from the optometrist for one Resident (#56) out of a total sample of 20 residents. Findings include: Resident #56 was admitted to the facility in October 2021 with diagnoses including macular degeneration. Review of Resident #56's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 has a Brief Interview for Mental Status score of 9 out a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #56 requires extensive assistance from staff for all self-care tasks. Review of the eye exam report, dated 8/19/22, indicated the following: Assessment: 1. Macular degeneration, dry; Both eyes; intermediate dry stage 2. Dry eye; Both eyes 3. Pseudophakia 4. Hyperopic astigmatism and presbyopia; Both eyes Recs: 1. New Medication Order: PreserVision AREDS 2 Soft Gel, 1 Capsule, PO, twice daily for indefinitely; Follow-Up: 5-6 Months; please start 2 AREDS supplements after clearing w/ pcp (primary care physician) 2. Monitor; continue ATs prn (as needed) 3. Monitor 4. New distance vision Rx (prescription) Review of Resident #56's physician orders and notes failed to indicate the physician was notified of the recommendation for a new medication to treat macular degeneration or that the recommendation was implemented. During interviews on 1/23/23 at 10:15 A.M., and 1/23/23 at 12:27 P.M., Unit Manager #2 said visit reports from the Optometrist are faxed to her and she is responsible to review the recommendations and relay any recommendations to the resident's physician. The surveyor asked the Director of Nursing to provide documentation that the recommendation was relayed to the physician and/or if they were implemented. This documentation was never provided to the surveyor by the end of survey.

Based on interview and record review the facility failed to ensure there was a Physician's Order for a treatment being performed to a stage 2 pressure ulcer for one Resident (#54) out of a sample of 20 Residents. Findings include: Resident #54 was admitted to the facility in December of 2022 with diagnoses that included type 2 diabetes and chronic kidney disease stage 3. Review of Resident #54's Nursing Progress Note, dated 1/18/23 indicated While CNA (Certified Nurse Aide) was attending the Pt in the toilet she called me to assess his/her buttocks . There was another spot on coccyx area smaller with no depth. Review of Resident #54's Nursing Progress Note, dated 1/20/23 indicated Resident has another stage 2 wound on the sacral region, 2 cm in diameter. cleaned with normal saline and covered with boarder dressing. Review of Resident #54's January 2023 Physician Orders failed to indicate a treatment order for the pressure injury on the sacral area. During an interview on 1/23/23 at 12:38 P.M., Unit Manager #1 and Regional Nurse #1 acknowledged that there was not a doctors order for the sacral wound that was found on 1/18/23 and said that there should be.

Based on observation, interview and record review the facility failed to ensure weekly weights were obtained, as indicated by the At Risk Team that was following one Resident (#65) for weight loss, out of a total 20 sampled residents. Findings include: The facility policy titled Weight Assessment and Intervention, undated, indicated the following: * Resident weights are monitored for undesirable or unintended weight loss or gain. * Any weight change of 5% or more since the last weight assessment is retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Resident #65 was admitted to the facility in February 2022 and had diagnoses that included dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/20/22, revealed on the Brief Interview for Mental Status (BIMS) exam Resident #65 scored a 3 out of a possible 15 indicating severely impaired cognition. The MDS further indicated Resident #65 had no behaviors. During a record review the following was indicated: * Resident #65 was discussed by the facility's At Risk team, on 11/22/22, and the team initiated an intervention of obtaining weekly weights for Resident #65, due to a significant weight loss *Review of the record indicates the following weights were obtained for Resident #65 following the At Risk meeting on 11/22/22: 11/21/22 130 pounds (lbs) 12/13/22 127.4 lbs 12/20/22 123.8 lbs 1/16/23 121.2 lbs * A Physician's order was obtained for weekly weights on 12/5/22, 2 weeks after the intervention had been developed by the risk team. * Resident #65's medical record failed to indicate weekly weights were obtained on 12/5/22, 12/27/22, 1/2/23, or 1/9/23. During that time, Resident #65 experienced a consistent downward trend in his/her weight, which led to a significant weight loss of 6.77% on 1/16/23. The record also failed to indicate Resident #65 refused weights. * Resident #65 had a nutrition care plan, initiated 10/13/22, with a current intervention obtain weights at ordered intervals. During an interview with the facility's Registered Dietitian (RD) on 1/24/23 at 9:39 A.M., she said that: * Resident #65 was being followed by the facility's At Risk team, and that the team had initiated weekly weights on 11/22/22, following a hospitalization where Resident #65 experienced a significant weight loss. * Following the 11/22/22 meeting, nursing staff were expected to obtain an order from the Physician for weekly weights for Resident #65, and she could not say why that was not done until 12/5/22. * She was not aware that the weights were not being obtained consistently, and were not obtained between 12/20/22 and 1/16/23. *Following meeting with the surveyors on 1/23/23 she had requested Resident #65 be re-weighed, and that this identified an even further weights loss, of the Resident down to 120 pounds. The said she initiated as intervention at that time, but would have done so sooner if she had been aware of the continued weight loss. During an interview with the Director of Nursing (DON) on 1/24/23 at 10:08 A.M., she said if a resident has an order for weekly weights she would expect them to be done. As well, she said that she would expect nursing to obtain an order sooner than two weeks, following an At Risk meeting. The DON indicated that if a Resident refused to have a weight obtained this should be documented on the Medication Administration Record or in a nurses note. For Resident #65 there was no indication he/she refused to have weights obtained.

Based on record review and interview, the facility failed to follow recommendations for a Gradual Dose Reduction (GDR) to ensure one Resident (#56) was free from unnecessary psychotropic medications out of a total sample of 20 residents. Findings include: Resident #56 was admitted to the facility in October 2021 with diagnoses including bipolar disorder, anxiety, and major depression. Review of Resident #56's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #56 has a Brief Interview for Mental Status score of 9 out a possible 15 which indicates he/she has moderate cognitive impairment. The MDS also indicates Resident #56 requires extensive assistance from staff for all self-care tasks. Review of the facility policy titled, Psychotropic Medication Use, undated, indicated the following: * Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. Review of Resident #56's physician orders indicated the following: * Clonazepan (an anti-anxiety medication) tablet 1 MG (milligram) *Controlled Drug*. Give 1 tablet by mouth three times a day for Anxiety. Review of Resident #56's anti-anxiety medication care plan last revised on 12/14/22 indicated the following: * Consult with physician to consider dosage reduction when clinically appropriate. Review of a psychiatric note dated 5/19/22 indicated the following: * Recommend discontinuing Clonazepam orders. Recommend Clonazepam 1 MG twice daily at 0800 and 1400 for anxiety. Recommend Clonazepam .5 MG p.o. (by mouth) nightly for anxiety/insomnia. Review of Resident #56's physician orders and notes failed to indicate the physician was made aware of this recommendation or that the recommendation was followed. Review of the psychiatric note dated 7/28/22 indicated the following: * Recommend discontinuing Klonopin (another name for Clonazepam) orders. Recommend Klonopin 1 MG twice daily at 0800 and 1200 and .5 MG p.o. (by mouth) nightly at 2000 per GDR recommendations. Review of Resident #56's physician orders and notes failed to indicate the physician was made aware of this recommendation or that the recommendation was followed. During an interview on 1/23/23 at 12:27 P.M., Unit Manager #2 said she was responsible for ensuring recommendations made by the psychiatric nurse practitioner were relayed to the physician. Unit Manager #2 said the psychiatric nurse practitioner often made recommendations in the notes but never verbally told her about the recommendations made. Unit Manager #2 said she did not know about the recommendation to lower Resident #56's medications and they were not implemented.

Based on observation, interview, and policy review the facility failed to 1) ensure medications with shortened expirations dates after being opened were labeled with open dates, which would indicate the date they would expire, in 2 out of 2 medication carts and 1 of 1 medication rooms and 2) failed to ensure medications were stored securely on 1 of 2 resident care units. Findings include: Review of facility policy titled 'Administering medications' version 2.1(H5MAPL0028), indicated the following: *Policy heading: Medications are administered in a safe and timely manner, and as prescribed. *Policy Interpretation and Implementation: -The expiration/beyond use date on the medication label is checked prior to administering. when opening a multi-dose container, the date opened is recorded on the container. *During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. Review of facility policy titled Medication Storage, dated August 2021, indicated the following: *Policy Interpretation and implementation. -*15. Discontinued or expired medications will be destroyed within 30 days, or if unopened and properly labeled, returned to the pharmacy for credit, if allowable. 1. The facility failed to ensure medications were labeled with open dates and failed to ensure outdated medications were not available for administration. During an observation of the east wing high side medication cart on 1/22/23 at 9:30 A.M., the following medications were observed without open dates: - saline nasal spray, opened and undated, therefore unable to determine an expiration date. Manufacturer instruction indicates to discard the bottle after 30 days of opening. -4 packages of ipratropium Bromide and albuterol sulfate ( an inhaled medication to treat breathing conditions) 0.5 mg/ 3 mg/ ml (milligrams/milliliter) open and undated, therefore therefore unable to determine an expiration date. manufacturer instructions indicated once removed from foil pouch individual vials should be used within one week. -Fluticasone-salmeterol (an inhaled medication to treat breathing conditions) 100 mcg/ 50 mcg (micrograms) open and undated, therefore unable to determine an expiration date. Manufacture instructions to discard 30 days after the foil pouch is opened. -2 bottles of fluticasone nasal spray (nasal spray contain steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine the expiration date. Manufacture instructions to discard after using 120 sprays. -1 bottle of liquid Acetaminophen 160 mg/ml had an expired date of 12/22 During an observation of the east wing low side medication cart on 1/22/23 at 9:50 A.M., the following medications were without open dates: -2 bottles of fluticasone nasal spray (nasal spray contain steroid used to treat allergies) 50 mcg (micrograms) open and undated, therefore unable to determine an expiration date. Manufacture instructions to discard after using 120 sprays. -4 packages of ipratropium Bromide and albuterol sulfate (an inhaled medication to treat breathing conditions) 0.5 mg/ 3 mg/ ml (milligrams/milliliter) open and undated, therefore therefore unable to determine an expiration date. Manufacturer instructions indicate once removed from foil pouch individual vials should be used within one week. During an observation of the east wing medication room refrigerator on 1/22/23 at 9:45 A.M., the following medication were open and undated: -1 pen insulin lantus (medication to treat diabetes) open and without date, therefore unable to determine the expiration date. Manufacture instructions indicate to discard 28 days from opened date. During an interview on 1/22/23 at 9:40 A.M., Nurse #2 acknowledged the unlabeled/undated and expired medications. During an interview on 1/22/23 at 9:55 A.M., Nurse #3 acknowledged the unlabeled/undated medications. During an interview on 1/23/23 at 1.46 P.M., the Director of Nursing said there should be no expired medications in the medication carts and that medications requiring dates when opened should be labeled and dated. 41456 2. On 1/22/23 at 6:45 A.M., the medication cart on the West Unit was observed to be unlocked. Nurse #4 was in a resident room on the other side of the hallway. During an interview on 1/22/23 at 6:49 A.M., Nurse #4 said the medication cart should be locked at all times.

Based on record review and interview the facility failed to ensure a Physician's order was in place for hospice services for one Resident (#13) out of a total sample of 20 Residents. Finding include: Resident #13 was admitted to the facility in April of 2018 with diagnoses that included dementia, chronic kidney disease stage 3, anxiety and hypertension. Review of Resident #13's Hospice Care Plan, dated 6/24/22, indicated Resident #13 was receiving Hospice services. Review of Resident #13's Progress Note, dated 3/21/22, indicated admitted on to hospice services with [NAME] Hospice effective today 3/21/22. Review of Resident #13's Nurse Practitioner Note, dated 12/20/22, indicated Continue on hospice no signs of pain, continues with baseline confusion. Review of Resident #13's Physician Orders failed to indicate an order for Hospice services. During an interview on 1/23/23 at 12:23 P.M., Unit Manager #2 said there should be a doctors order when someone goes onto hospice. The Unit Manager acknowledged that there was not an active order for hospice and said someone must have discontinued it.

Based on observation, interview and record review the facility staff failed to ensure a transfer or discharge notice was provided prior to a hospital transfer for one Resident (discharged Resident #1) out of 1 applicable residents. Findings include: 1. discharged Resident #1 was admitted to the facility in December 2022. Review of the medical record indicated discharged Resident #1 was transferred to the hospital 24 hours after admission secondary to behaviors. The facility was unable to produce documentation that the notice of transfer/discharge was provided to discharged Resident #1 prior to being transferred to the hospital. During an interview on 1/24/23 at 11:00 A.M., the Director of Nursing said the notice of transfer/discharge should be provided to any resident being transferred to the hospital.

Based on observation, record review and interview the facility failed to 1) prevent the development of a pressure ulcer after a contracture developed and 2) appropriately assess a pressure ulcer according to facility policy for 2 Residents (#23 and #57) out of a total sample of 25 residents. Findings include: The facility policy titled Pressure Ulcers/Skin Breakdown--Clinical Protocol, undated, indicated the following: * The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcers. * Assessment and Recognition: The nurse shall describe and document/report the following: -Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. - Pain Assessment - Resident mobility status - Current treatments, including support surfaces, and - All active diagnosis 1. Resident #23 was admitted to the facility in November 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 5/27/21, indicated that on the Brief Interview for Mental Status (BIMS) exam Resident #23 scored a 4 out of a possible 15, indicating severely impaired cognition. The MDS further indicated that Resident #23 was totally dependent on staff for care and had no behaviors. During an observation on 7/27/21 at 8:32 A.M., Resident #23 was in bed sleeping with his/her right hand on his/her chest. Resident #23's right hand and wrist appeared to be contracted with his/her fingers pushing into his/her palm. Review of Resident #23's medical record on 7/28/21 at 8:27 A.M., the following was indicated: * A weekly skin check, dated 7/26/21, indicated that Resident #23 had no skin impairments. * A nurse practitioner's progress note, dated 7/15/21, did not indicate there were any open areas. * A Skilled Nursing Assessment, dated 7/14/21, did not indicate that Resident #23 had any skin issues. During an interview with Certified Nursing Assistant (CNA) #1 on 7/28/21 at 9:32 A.M., she said that she regularly cared for Resident #23. She said that Resident #23 required total assistance from staff for all aspects of his/her care and that Resident #23 never refused care. CNA #1 said that for weeks Resident #23 could no longer open her hands and that she had told the Nurse Unit Manager (UM) that morning that she thought that Resident #23's right hand was more difficult to open. CNA#1 did not indicate Resident #23 had an open areas or skin issues nor could she explain why she did not report the worsening condition of Resident #23's hand sooner. During an interview on 7/28/21 at 9:55 A.M., the surveyor and UM#1 observed Resident #23 together and UM#1 said Resident #23's hands appeared to be more contracted and that she would make a referral to rehabilitation to screen him/her. She did not indicate any concerns with Resident #23's skin. During an interview on 7/28/21 at 11:41 A.M., Occupational Therapist (OT) #1 said that she had just received a referral to screen the Resident for worsening hand contractures. The surveyor and OT#1 observed the Resident together, and upon opening Resident #23's hand, OT#1 discovered an open area in his/her palm. OT#1 said that staff had not reported any skin breakdown when they made the referral but said that based on the appearance of the wound (the wound was nickel sized with, an apparent open blistered skin injury. There was dry white colored and hardened skin on the skin injury edges and the injury area was dry and pink in color) it did not appear new. Review of Resident #23's clinical record failed to indicate a care plan to address a pressure ulcer of the right palm for Resident #23. During a follow-up interview with UM#1 on 7/28/21 at 12:02 P.M., she said she was unaware that Resident #23 had an open area on his/her palm and that she would have expected the CNA to observe that during care. She said that CNA#1 reported to her that morning that Resident #23's hand was tighter but never mentioned an open area. During an interview with the Assistant Director of Nursing (ADON) on 7/28/21 at 12:06 P.M., she said that she was also the wound nurse in the facility and did weekly wound rounds. The ADON said that she was unaware that Resident #23 had any skin issues on his/her hand. She said that any resident that has any type of skin issue or wounds would be followed by her. The ADON said that she would have expected the CNA to identify an open area during routine care and then report it to the UM who would notify the physician, responsible party and complete an incident report. During an interview with the DON on 7/30/21 at 8:39 A.M., she said she had seen the wound on Resident #23's hand after learning about it from the ADON. The DON said that while it appeared like the blister was freshly open, she observed the injury was dry and pink in color with the dry white and hardened edges, indicating it was not a new wound. She said she would expect the area to be identified during daily ADL care and reported at that time, which did not occur. 2. Resident # 57 was admitted in March 2021 with [CONDITION(S)], metastasis to the neck, and failure to thrive. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated that Resident #57 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. The MDS also indicated Resident #57 required a two person assist with bed mobility and grooming. Review of the care plan, dated 3/25/21, indicated that Resident #57 was at risk for pressure ulcers and to monitor, document, and report any changes. Review of the Nurse Practitioner note, dated 3/26/21, indicated that Resident #57 was admitted with an unspecified wound to the right ear, requiring a 7-day course of antibiotics, which was to be completed on 3/31/21. Review of the nursing weekly skin checks, dated 3/25/21, 4/4/2021, 4/11/2021, 4/18/2021, 4/25/2021, and 5/2/2021, did not indicate any skin impairment to the right ear, including description, location, stage, or measurements. Review of the nursing daily skilled pathway documentation did not indicate a skin integrity issue from 3/27/21-5/10/21. Review of the weekly skin check, dated 5/9/2021, indicated a pressure injury to Resident #57's right ear. It also indicated the skin impairment was not new. There was no staging, description, or measurements documented of the identified pressure injury. Review of the wound consult, dated 5/13/21, indicated Resident #57 had a Stage IV pressure wound to the right ear with 10% necrotic tissue requiring a surgical excisional debridement procedure. During an interview on 7/28/21 at 1:28 P.M., Unit Manager #2 said skin checks are done on admission and weekly. Unit Manager #2 acknowledged that the skin impairment should have been noted and documented on the nursing evaluation that was completed on 3/25/2021. An interview on 7/30/21 at 10:21 A.M. with Nurse #2 indicated that new skin issues should be documented on an interim skin assessment and reported to the supervisor. Nurse #2 said that Resident #57 frequently laid on his right side, where the pressure ulcer of the ear was located, due to a large tumor on the left side of his/her neck. Nurse #2 cannot recall if she initially found the pressure ulcer.

Based on observation, record review and interview, the facility failed to prevent a decline in range of motion (ROM) resulting in new bilateral hand and wrist contractures for one Resident (#23) out of a total 25 sampled. Findings include: The facility policy titled Resident Mobility and Range of Motion, undated, indicated the following: *Residents will not experience an avoidable reduction in range of motion (ROM). *Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. * Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility and unless reduction in mobility is unavoidable. Resident #23 was admitted to the facility in November 2020 and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 5/27/21, indicated that on the Brief Interview for Mental Status exam Resident #23 scored a 4 out of a possible 15 indicating severely impaired cognition. The MDS further indicated that Resident #23 was totally dependent on staff for care. Review of section G of the MDS indicated no functional limitations in range of motion for Resident #23. During an observation on 7/27/21 at 8:32 A.M., Resident #23 was in bed sleeping with his/her right hand on his/her chest. The surveyor observed Resident #23's wrist and hand to be bent in a flexed position and his/her fingers to be pressing into the palm. Resident #23's left arm was underneath his/her covers and not visible. During an interview with Certified Nursing Assistant (CNA) #1 on 7/28/21 at 9:32 A.M., she said that she regularly cared for Resident #23 and that Resident #23 required total assistance from staff for all aspects of his/her care and never refused care. CNA#1 said she could not remember exactly when Resident's #23's hands became worse but she knew that Resident #23 used to be able to hold a spoon to feed him/herself and now he/she couldn't even open his/her hands to hold a napkin. During an interview on 7/28/21 at 9:55 A.M., the surveyor and UM#1 observed Resident #23 together UM#1 attempted to open both of Resident #23's hands but was unable to do so without Resident #23 grimacing, and she said both of Resident #23's hands appeared to be more contracted and that she would make a referral to rehabilitation to screen him/her. During an interview with the Director of Rehab (DOR) on 7/28/21 at 9:59 A.M., she said the following: * Once a week she, the nurse unit managers and MDS Director do functional rounds. These rounds consist of discussing if any resident in the facility has had a decline in status. The DOR said that she does not keep minutes for these meetings; * All residents are screened once a quarter for changes in their status; * Resident #23 was last screened on 5/10/21 for her once a quarter screening but she could not locate a copy of the screen; She said at no other time since rehabilitation discharge on 4/28/21 had Resident #23 been discussed for status declines. *According to her documentation, Resident #23 had been seen for a right elbow contracture only. During an interview on 7/28/21 at 11:41 A.M., Occupational Therapist (OT) #1 said that she had just received a referral to screen the resident for worsening hand contractures. The surveyor and OT#1 observed the Resident together and OT#1 said that Resident #23 had new bilateral hand and wrist contractures. Review of Resident #23's physician and nurse practitioner progress notes from June to present failed to indicate they were notified of a developing contracture to Resident #23's bilateral hands and wrists. Review of Resident #23's clinical record failed to indicate that Resident #23 had any therapy consults since 4/28/21. Further review of Resident #23's clinical record failed to indicate any additional services or treatments were provided for the decrease in ROM to his/her bilateral hands and wrists. Review of Resident #23's clinical record failed to indicate a care plan to address range of motion concerns for Resident #23's new bilateral hand and wrist contractures. During an interview with the Director of Nursing (DON) on 7/29/21 at 9:23 A.M., she said that if a CNA notices a resident has a decline in his/her ROM they should inform the nurse UM and the UM will initiate a referral for a rehabilitation screen. During a follow-up interview with OT #1 on 7/29/21 at 11:58 A.M., she provided the surveyor with a copy of the OT evaluation she completed the day prior. She said that Resident #23 has new bilateral hand and wrist contractures and has been placed on occupational therapy to address the four new contractures.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she received care and services consistent with professional standards of practice, when after obtaining a physicians order on 12/24/20 to collect a urine sample for a suspected urinary tract infection (UTI), which included nursing could collect the urine sample via straight catheter, the urine sample was not obtained until three days later, on 12/27/20, the same day Resident #1 was transferred and admitted to the Hospital with [CONDITION(S)] (a life threatening complication of an infection). Findings include: Resident #1 was admitted to the Facility in December 2020, for short term rehabilitation after hospitalization for acute hypoxic [CONDITION(S)] related to aspiration pneumonia and [CONDITION(S)] obstruction due to food impaction. Resident #1's medical history included Stage 3 [CONDITION(S)], chronic [CONDITION(S)], severe [CONDITION(S)] dysmotility which required dilatation in the past, and [CONDITION(S)] (multi-system connective tissue disorder). Review of the Nurse Practitioner Progress Note, dated 12/23/20, indicated that prior to Resident #1's initial transfer and admission at Facility, his/her white blood cell count was normal upon hospital discharge. The Note indicated that due to Resident #1's ongoing leukocytosis (white blood cell count is above normal, can be indicative of an underlying infection) will obtain a urine culture. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/07/21 at 11:16 A.M., Family Member #1 said on 12/25/20, he called the Facility to check on Resident #1's condition, spoke to a nurse and said he was told they had already obtained a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Family Member #1 said he called the Facility on 12/27/20, spoke to the Case Manager and asked if they had the results of Resident #1's UA C&S and said he was told a urine sample for Resident #1 had not been sent out to the laboratory yet. Review of Resident #1's Treatment Administration Record (TAR), dated 12/24/20 through 12/27/20, indicated nursing documentation related to obtaining his/her urine sample was as follows: - 12/24/20 on both the day and evening shift, indicated obtained, as evidenced by a check mark - 12/25/20 on the day shift, indicated obtained, as evidenced by a check mark - 12/26/20 day and night left blank, evening shift coded as #7, sleeping ( all which would indicate not obtained) - 12/27/20 urine sample indicated as obtained, as evidenced by a check mark During an interview on 04/07/21 at 11:39 A.M., the Unit Manager said that a urine sample for Resident #1's UA C&S was obtained on 12/26/20, and that the results were not received by the Facility until after Resident #1 had already been transferred and admitted to the Hospital. However, review of Resident #1's TAR, indicated there was no documentation to support nursing obtained a urine sampled on 12/26/20, as evidenced by the day shift was left blank, evening shift was coded with #7 for sleeping, and the night shift entry was blank, which conflicted with what was told to Family Member #1 by staff. Review of Resident #1's medical record indicated his/her urine sample was obtained by nursing on 12/27/20, the same day he/she was transferred and admitted to the Hospital for [CONDITION(S)]. During an interview on 04/07/21 at 10:51 A.M., the Case Manager said nursing staff did not obtain urine samples for Resident #1 on 12/24/20, 12/25/20 or 12/26/20 and that documentation on the TAR related to obtaining Resident #1's urine sample was inaccurate. The Case Manager said she told Family Member #1 on 12/27/20 that they had just obtained the urine sample, but it had not been sent out to the laboratory for analysis yet. Review of the TridentCare, laboratory report, dated 12/28/20, related to Resident #1's UA indicated the specimen was collected on 12/27/20, findings were abnormal and the C&S was pending. Further review of Resident #1 medical record indicated there were no other laboratory report results related to UA C&S dated prior to 12/28/20. Review of Resident #1's medical record, indicated there was no documentation to support nursing notified Resident #1's physician of the delay in obtaining his/her urine for the UA C&S. Review of Resident #1's physician and nurse practitioner progress notes, dated 12/24/20 through 12/27/20, indicated there was not documentation to support they were notified of a problem or delay in obtaining Resident #1's urine sample. Review of the Hospital Laboratory Report for Resident #1, dated 12/31/20, indicated his/her urine culture's colony count was greater than 100,000 CFU/ml and the organism found was [CONDITION(S)] pneumonia (bacterium that normally lives inside human intestines). Review of the Hospital Infectious Disease Consult, dated 01/04/21, indicated that Resident #1 urinalysis was indicative of an active infection versus colonization.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who require fluids via intravenous (IV) infusion for hydration, the Facility failed to ensure nursing followed professional standards of practice for maintaining and documenting the use of an IV, when there was no documentation to support that after his/her initial IV was placed, that the site or location of his/her IV site was changed by nursing, and there was no documentation, including a physician's order, to indicate why the IV was discontinued on 12/25/20 and not changed, as ordered. Resident #1 experienced a change in condition, required transfer to the Hospital Emergency Department on 12/27/20 for evaluation and was admitted for [CONDITION(S)] (a life threatening complication of an infection). Findings include: Review of the Facility Policy titled, Assessment of the Patient Receiving IV Therapy, dated 08/2016, indicated the following: -Residents receiving infusion therapy will be monitored at established intervals based on prescribed therapy, and age and condition of resident and type of IV catheter. -Parameters to be monitored include, but not limited to, the insertion site. -Assess the catheter insertion site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Review of Infusion Nurses Society, Infusion Therapy Standards of Practice, Journal of Infusion Nursing 2016, indicated the following: -When the short peripheral catheter, midline catheter, or Peripherally Inserted Central Catheter (PICC) is removed, monitor the vascular access site for 48 hours to detect post infusion phlebitis (inflammation of a vein) symptoms include redness, warmth and pain in the affected area. -Signs and symptoms of complications with or without infusion through the catheter include, but are not limited to; Infections (Cellulitis, common and potentially serious bacterial skin infection, where bacteria enters the skin) (Septicemia/[CONDITION(S)], a life-threatening complication of an infection, chemical released in the bloodstream to fight an infection trigger inflammation throughout the body). Review of Infusion Nurse Resource, dated February 2013, indicated repeated puncture of the same vein will result in damage to the vein lining resulting in phlebitis (inflammation) and [CONDITION(S)] (hardening) of the vein. Blood flow will not be as good if this happens and can be a problem depending on what you will be receiving. Review of the Facility's SNF/NF to Hospital Transfer Form for Resident #1, dated 12/27/20, indicated information that included his/her diagnoses, vital signs, activity of daily living status, cognitive status, code status, that he/she required oxygen, was on an anti-coagulant medication, was a fall risk and had swallowing difficulties. Upon further review of the SNF/NF to Hospital Transfer Form, indicated there was no documentation to support why Resident #1 was being transferred to the Hospital on 12/27/20, and there was no documentation related to his/her recent need for IV hydration or that he/she had an IV. Review of the Ambulance Company, Patient Care Report, dated 12/27/20, indicated Emergency Medical Services (EMS) were dispatched to the Facility for Resident #1, who required transport to the Hospital Emergency Department. The Report indicated, nursing reported Resident #1 had a decline in status and that Resident #1 requested to be transferred to the hospital. The Report indicated Resident #1 was asleep, awakened to verbal stimuli, and felt hot to the touch. The Report indicated after rolling up Resident #1's sleeve to start an IV, EMS noticed what looked like an old IV line site in left anti-cubital (area on arm where the bones of the upper arm connect to the bones of the forearm) that was swollen, hot, red and pustule (small blister or pimple on skin containing pus). The Report indicated Resident #1's tympanic (via the ear) temperature was 101.0 (normal range 97.0 - 99.0) Fahrenheit. Review of the Hospital Emergency Department Note, dated 12/27/20, indicated Resident #1 had a superficial thrombophlebitis (condition in which a blood clot in a vein causes inflammation and pain) that there was an area of [CONDITION(S)] (reddening of the skin, as result of an injury) and warm in the proximal left upper extremity. The Note indicated Resident #1 was admitted to the Hospital with [CONDITION(S)] with several potential sources of infection. The Note indicated Resident #1's white blood cell count was 22,000 (normal range 4,000 - 11, 000) which was indicative of an infection. Review of the Hospital Infectious Disease Consult, dated 01/04/21, indicated that Resident #1 had blood cultures times two, that grew MSSA (methicillin-susceptible Staphylococcus aureus, infection caused by a bacteria commonly found on the skin). The Consult indicated the likely source was Resident #1's left arm soft tissue infection, which may have been associated with a previous infected intravenous site with septic thrombophlebitis. Resident #1 was admitted to the Facility in December 2020, for short term rehabilitation after hospitalization for acute hypoxic [CONDITION(S)] related to aspiration pneumonia and [CONDITION(S)] obstruction due to food impaction. Resident #1's medical history included Stage 3 chronic kidney disease, chronic [CONDITION(S)], severe [CONDITION(S)] dysmotility which required dilatation in the past, and [CONDITION(S)] (multi-system connective tissue disorder). Review of the Access RN, Procedure Note of Vascular Access Device Insertion, dated 12/16/20, indicated a Peripheral IV was placed in Resident 1's left anti-cubital. During an interview on 04/07/21 at 11:39 A.M., the Unit Manager said the Facility's process is to change the IV, including moving the site, every three days and as needed, unless they have an order to extend it. The Unit Manager said she was unaware of any issues with Resident #1's IV site. Review of Resident #1's Physician's orders related to the placement and maintenance of his/her peripheral IV line, dated 12/16/20, with a discontinued date of 01/07/21, indicated nursing to complete the following: A) IV (peripheral) change IV site every 72 hours (one time a day every three days) and as needed. If dwell (to remain) must be extended, document reason, maximum dwell not to exceed 7 days. B) Assess all IV sites for unusual redness. drainage, skin irritation at the site, patient confusion and patient diaphoresis, observe for tenderness or induration (inflammation, hardened mass) when gently palpating the vein pathway above the IV site every shift, document in progress notes. C) - IV, Assess that the IV catheter is secured well and does not slide around in the vein or become dislodged, the dressing is adhered with no moisture accumulation underneath it, every shift. Review of Resident #1's Medication Administration Record (MAR) dated 12/16/20 through 12/27/20, indicated nursing documentation related to step A of the physician order was as follows: - 12/19/20, the IV site was documented changed as ordered, as evidenced by a check mark, however the location of the new IV site was not indicated on the MAR. - 12/22/20, the IV site was documented changed as ordered, as evidenced by a check mark, however the location of the new IV site was not indicated on the MAR. - 12/25/20, the IV site was documented changed as ordered, as evidenced by a check mark, however the location of the new IV site was not indicated on the MAR. Review of Resident #1's MAR, dated 12/25/20, indicated nursing documented that the IV site was changed as evidenced by a check mark in the box for 12/25/20, and there was no documentation to support that the IV was discontinued. During an interview on 04/07/21 at 11:39 A.M., the Unit Manager said Resident #1's peripheral IV was discontinued on 12/25/20, and was not changed on 12/25/20 as indicated on the MAR. However, documentation on the MAR, dated 12/25/20 through 12/27/20, related to step B, conflicts with the Unit Manager's interview, where she said Resident #1's IV was discontinued on 12/25/20. Review of Resident #1's MAR. dated 12/16/20 through 12/27/20, indicated nursing documentation related to step C of the physician order was as follows: - 12/16/20 through 12/27/20, nursing documented a total of 32 entries which consisted of just a check mark which indicated administered. However, documentation on the MAR, dated 12/25/20 through 12/27/20, related to step C, conflicts with the Unit Manager's interview, where she said Resident #1's IV was discontinued on 12/25/20. Review of Resident #1's Nurse Progress Notes, dated 12/18/20 through 12/27/20, indicated there was no nursing documentation related to his/her IV site, including where the actual IV site was changed to on 12/19/20, 12/22/20 or 12/25/20. Review of Resident #1's Physician's orders, dated 12/25/20, indicated there was no documentation to support an order was obtained by nursing to discontinue the IV, or that the physician was notified. Review of Resident #1's Nurse Progress Notes, dated 12/18/20 through 12/27/20, indicated there was no nursing documentation or reference in a nursing progress note related to his/her IV site, the location of where IV was placed, or of any assessments completed by nursing. At the time of the survey, other than the pre-populated Electronic Medical Record (EMR) documentation on Resident #1's MAR and Treatment Administration Record (TAR), the Facility was unable to provide any documentation to support the IV site was changed, specifically where it was rotated to, and nursing assessments of the IV site. Review of written witness statements, provide by the Facility, from nurses who documented that they changed Resident #1's IV site, indicated the statements only served to acknowledge that nursing changed IV site as ordered, however, there was no documentation in the written statements to support where the IV site was changed to or located, by nursing.

Based on record review and interview, the Facility staff failed to provide adequate supervision and assistance during care for 1 Resident, (#1), out of a total of 24 sampled Residents, resulting in a fall with injury. Findings include: Resident #1 was admitted to the Facility in (YEAR) with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, dated dated [DATE] indicated he/she is cognitively impaired and requires assistance with bathing, dressing and positioning. Review of Resident #1's clinical record indicated that on 3/6/19, Resident #1 was being repositioned by CNA #1 while receiving a bed bath. Resident #1 then fell out of bed and sustained a right femur fracture. Review of Resident #1's Activities of Daily Living care plan indicated the following: I require 2 person assist for bed mobility, initiated 1/13/2017 Review of the Facility's incident investigation for Resident #1's fall included 3 witness statements indicating that Resident #1 was being repositioned at the time of the fall. On 3/21/19 at 11:03 A.M., the Surveyor interviewed CNA #1. CNA #1 said that she was caring for Resident #1 on the day of the fall. She said that she had seen other staff give Resident #1 a bath alone and thought she could do it. She said that she did not ask for assistance and that Resident #1 fell out of bed while she was turning him/her over. CNA #1 said that Resident #1 had always needed assistance of 2 staff for positioning. On 3/21/19 at 11:30 A.M., the Surveyor reviewed the above with the Director of Nursing and the Administrator. In response to the inicident, the Facility's plan of correction was implemented by admitting the resident to the emergency roiagnom on the day of the incident. The facility reviewed and updated care plans and Kardex's, (a form utilized by Facility's to indicate the level of assistance residents need for care) for all residents as needed, to assure care requirements and number of caregivers was documented. Nursing staff were educated on care plans, Kardex, and bed mobility during care. The Director of Nursing completed random audits of resident care to ensure the Facility is in compliance with the implementation of required assistance during care. The results of the audit were brought to the Facility's Quality Assurance Performance Improvement monthly meetings until consistent compliance was met. The Facility alleged compliance by 3/11/19. At the time of this survey, there was no deficient practice identified in this area.

Based on observation, interview and record review the facility failed to notify the physician of a pain assessment indicating that 1 resident (#281), out of a total sample of 29 residents, was having uncontrolled pain. Findings include: Resident #281 was admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. Review of the clinical record indicated that prior to admission Resident #281 was on [MEDICATION NAME] for chronic pain which was discontinued after an accidental overdose. On 1/9/18 at 10:49 A.M., the Surveyor observed Resident #281 lying in bed, with postural guarding and facial grimacing, which are non-verbal indicators of pain. Resident #281 said that he/she had bilateral leg pain 10/10 and had requested pain medication from Nurse #1. Nurse #1 was immediately notified and was in the process of preparing [MEDICATION NAME], the prescribed pain medication. On 1/10/18 at 9:00 A.M., Surveyor observed Resident #281 lying in bed he/she state that their pain was 9/10 in both legs. Resident #281 was medicated with [MEDICATION NAME] with no effect. During an interview with the Unit Manager (UM) #2 on 1/10/18 at 10:20 A.M., she said that Resident #281 was requesting [MEDICATION NAME] to be restarted, but the physician would not prescribe it. When asked if the current pain management orders were effective she said she would do a pain assessment. Review of the nurses note of 1/10/18 indicates that the pain management had little effect, a call was placed to the Nurse Practitioner and a new order was obtained for [MEDICATION NAME] (a short acting pain medication) 5 milligrams (mg) every 4 hours as needed, continue to monitor pain and notify physician and nurse practisioner if pain management is ineffective. Review of the nurses notes on 1/12/17 and 1/13/17, indicated that [MEDICATION NAME] 5mg was administered as prescribed and was not effective. On 1/15/18 a new pain assessment was completed and indicated that Resident #281 continued to have pain rated 5-6 despite the new medication changes and nursing to refer to primary physician to explore options of increasing medications. Review of the nurses note of 1/16/18 indicates that Resident #281 continued to complain of pain 10/10 stating pain medication only lasts 2 hours and is not effective. The clinical record failed to indicate that the physician or nurse practisioner was notified that the pain management was not effective. During an interview with UM #2 on 1/17/18 at 12:22 P.M., she said that the physian would be in to see Resident #281 the next day (1/18/18), 8 days after the pain medication adjustment, which contained an order to notify MD and NP if ineffective, and 3 days after a pain assessment indicated medications were ineffective and to refer pain management to the primary physician. Review of the nurses note of 1/17/18 at 5:48 P.M., indicated that a pain assessment was done and Resident #281 contined to report pain 8/10. The physician and nurse practisioner were notified and new orders obtained for [MEDICATION NAME] (a long acting pain medication) 10 mg every 12 hours and for a pain clinic consult. The facility failed to promptly notify the physician that the pain management for Resident #281 was ineffective for adequate pain control for 7 days from 1/10/18 through 1/17/18. Refer to cite F 697

Based on observation, interview and record review the facility failed to ensure that pain management was effective for 2 Residents, (Resident #281) with a [DIAGNOSES REDACTED].#48) during a stage 4 pressure ulcer dressing change, in a total sample of 29 residents. Findings include: 1. For Resident #281 the facility failed to ensure that pain management was effective. Resident #281 admitted to the facility in 12/2017 with [DIAGNOSES REDACTED]. Review of the clinical record indicated that Resident #281 was previously on [MEDICATION NAME] which was discontinued status [REDACTED]. On 1/9/18 at 10:49 A.M., Surveyor observed Resident #281 lying in bed, with postural guarding and facial grimacing which are non-verbal indicators of pain. Resident #281 said that he/she had bilateral leg pain with an intensity of 10/10 and had requested pain medication from Nurse #1. Nurse #1 was immediately notified and was in the process of preparing the prescribed pain medication. On 1/10/18 at 9:00 A.M., Surveyor observed Resident #281 lying in bed and said that his/her pain was 9/10 in both legs. Resident #281 was medicated with [MEDICATION NAME] with no effect. During an interview with the Unit Manager (UM) #2 on 1/10/18 at 10:20 A.M., she said that Resident #281 was requesting [MEDICATION NAME] to be restarted, but the physician would not prescribe it. When asked if the current pain management orders were effective she said she would do a pain assessment. Review of the nurses note of 1/10/18 indicates that the pain management had little effect and a call was placed to the Nurse Practitioner and a new order was obtained for [MEDICATION NAME] (a short acting pain medication) 5 milligrams (mg) every 4 hours as needed, continue to monitor pain and notify physician and nurse practitioner if pain management is ineffective. Review of the nurses notes on 1/12/17 and 1/13/17, indicated that [MEDICATION NAME] 5mg was administered as prescribed and was not effective. On 1/15/18 a new pain assessment was completed and indicated that Resident #281 continued to have pain rated 5-6/10 despite the new medication changes and nursing was to refer Resident #281 to primary physician to explore options of increasing medications. Review of the nurses note of 1/16/18 indicates that Resident #281 continued to complain of pain at an intensity of 10/10, stating pain medication only lasts 2 hours and is not effective. The clinical record failed to indicate that the physician or the nurse practisioner was notified that the pain management interventions were not effective for until 1/17/18, and resident continued to report ineffective pain control to nursing staff for 7 days. During an interview with UM #2 on 1/17/18 at 12:22 P.M., she said that the physician would be in to see Resident #281 the next day, 3 days after the pain assessment indicated to refer pain management to the primary physician. Review of the nurses note of 1/17/18 at 5:48 P.M., indicated that a pain assessment was done and Resident #281 continued to report pain intensity of 8/10. The physician and nurse practitioner were notified and new orders obtained for [MEDICATION NAME] (a long acting pain medication) 10 mg every 12 hours and for a pain clinic consult. 2. For Resident #48 the facility failed to ensure that pain was managed during the dressing change of stage 4 pressure sores on both the left and right heels. Resident #48 was admitted to the facility in 7/2017 with [DIAGNOSES REDACTED]. Resident #48 has stage 4 wounds to both heels and is followed by a wound care specialist. On 1/10/18 at 3:37 P.M., surveyor observed Nurse #1 change the dressings on both the left and right heels of Resident #48. Nurse #1 began to cleanse the wound on the left heel and the Surveyor observed Resident #48 grimace, flinch and say ouch don't do that so hard. Nurse #1 apologized that Resident #48 was in pain and said I know it hurts, but only one more time. Nurse #1 proceeded to cleanse the wound on the right heel and the Surveyor observed Resident #48 continue to grimace, flinch and say ouch. During an interview with Nurse #1 immediately after the dressing observation, she said that it was the first time that she had done the dressing change for Resident #48. She said she had given Resident #48 Tylenol 650 mg approximately 15 minutes before the dressing change, but she should have waited longer and that Tylenol might not be a strong enough pain medication. She further said she should have stopped when Resident #48 said ouch. During an interview with the Director of Nurses on 1/17/18 at 8:08 A.M., she said that pain medication should be given 30 minutes prior to a dressing change to give it time to work and the nurse should have stopped when Resident #48 said she was in pain. Review of the nurses notes for 1/17/18 indicate that a new order was obtained to medicate Resident #48 with [MEDICATION NAME] 50 mg 30 minutes prior to dressing change.

Based on record review and interview the Facility failed for one of three residents (Resident #1)to ensure they received proper care following the insertion of a urinary catheter into a new gastrostomy tube site. The nurse who inserted the urinary catheter inserted it without first obtaining an order to do so, and was without documented competency or skills validation in accordance with Facility policy. Over the course of approximately 14 hours after re-insertion, Resident #1 had abdominal pain, difficulty urinating, restlessness and anxiety. Resident #1 was transferred to the Hospital at the insistence of the Guardian where it was determined Resident #1 required emergent surgical intervention and the catheter was found "free floating in the peritoneum rather than in the stomach"; had a perforation; had 1 to 2 liters of purulent fluids in the peritoneal space; and required ventilatory support. The findings included: The physician orders [REDACTED].#1 had a PEG (percutaneous endoscopic gastrostomy tube, which is defined as a tube passed into the stomach through the abdominal wall and used to provide a means of feeding when oral intake is not adequate) inserted and returned to the Facility the same day. The post sedation and procedure instructions, dated 11/18/10, indicated that Resident #1 received medication for sedation. The instructions included that general muscle pain and pain at the operative site were included in the most common complaints post-procedure and that any prolonged symptoms should be reported to the physician and a telephone number was provided. The instructions indicated that, "In case of emergency and you are unable to go to your physician, please go to the nearest Emergency Department or call the Hospital's Emergency Department..." The telephone number was provided. The Facility policy indicated nurses were not to re-insert [DEVICE]s that were in place for less than three months and licensed nurses must have completed an education program with skills validation. The policy indicated a physician may choose to write an order for [REDACTED]. The nurse's note, dated 11/20/10, indicated that during the 11 PM to 7 AM shift, Resident #1 was restless and at 4 AM, Resident #1 pulled the PEG out and threw it in the hallway. The note indicated that a pressure dressing was applied immediately and that there was a moderate amount of frank bleeding noted with small blood clots. The note indicated Foley catheter (type of urinary catheter) was inserted into the stoma, in place of the PEG tube and placement was checked. There was no indication that Nurse #1 obtained a physician's orders [REDACTED]. The note indicated that the nurse practitioner was called at 4:30 AM but did not respond and was recalled again at 6:30 AM. There was no indication that when the nurse practitioner did not immediately respond, that the Director of Nurses, Physician, or Medical Director was immediately contacted. The note indicated that the covering nurse practitioner contacted the Facility at 6:40 AM and was informed that Resident #1 had pulled out the [DEVICE], that at Foley was re-inserted, and that at 6:30 AM the feedings were restarted. The note indicated that the covering nurse practitioner instructed the nurse to continue medications and feedings as ordered and to follow-up with the nurse practitioner on Monday (11/22/10). The Staff Development Coordinator (SDC) was interviewed at 12:50 PM on 11/30/10. The SDC said that nurses were not supposed to re-insert or change a [DEVICE] without documented competencies. The SDC said that Nurse #1 did not have competencies or any documentation with skills validation on re-insertion of a [DEVICE] and therefore should not have re-inserted the tube. The SDC said that in addition, there was no order for the re-insertion at the time Nurse #1 inserted the Foley. Nurse #1 was interviewed at 2:30 PM on 11/30/10 and at approximately 12:40 PM on 1/19/11. Nurse #1 said that at 4 AM on 11/20/10, when Nurse #1 attempted to flush Resident #1's gastrostomy tube, Resident #1 ripped both the PEG and the syringe out of the body and threw them into the hallway. Nurse #1 said that the balloon and wafer (used to help keep tube in place) were still intact. Nurse #1 said that Resident #1 had no complaints or indication of pain when assessed on 11/20/10 prior to the tube being forcibly removed by Resident #1. Nurse #1 said that there was a moderate amount of bleeding from the insertion site and dressing was applied over the area. Nurse #1 said that the nurse practitioner was informed the tube had been inserted on 11/18/10, that there was frank bleeding from the site, and that placement had been confirmed. Nurse #1 said that the nurse practitioner informed Nurse #1 that it was "okay" to use the tube. Nurse #1 said that Nurse #1 did not feel right about using the tube, despite the nurse practitioner's orders, but started the feeding at 6:45 AM. This was not consistent with one copy of the nurse 's note provided to the Surveyor, which indicated the feedings were started prior to the nurse practitioner's call. Nurse #1 said that Nurse #1 did not call the physician who inserted the tube, the Director of Nurses, or the Medical Director to discuss Resident #1's care or concerns about using the tube despite it being traumatically removed by Resident #1. Nurse #1 said that Nurse #1 had no documented competencies on re-insertion of a [DEVICE] and only learned after 11/20/10 that nurse's were not allowed to reinsert a [DEVICE] on a resident who had to tube for less that three months. The 11/20/10 note for 7 AM to 3 PM indicated that at 7 AM Resident #1 was noted to be having increased pain, moaning and groaning and was restless. The note indicated at 7:30 AM Resident #1's Physician was contacted and ordered narcotic pain medication and anti-anxiety medication for Resident #1. Nurse #2 was interviewed at 10:30 AM on 1/7/10. Nurse #2 said that Resident #1 was assessed shortly after starting the shift. Nurse #2 said that when Nurse #2 entered Resident #1's room, the tube feeding was running and Resident #1 appeared uncomfortable. Nurse #2 said that Resident #1 was moaning and groaning and when asked if Resident #1 had pain, told Nurse #2 yes. Nurse #2 said that Nurse #2 pressed around the [DEVICE] insertion site and Resident #1's abdomen Resident #1 made facial grimaces, moaned, groaned, and appeared anxious. Nurse #2 said that the Physician was called regarding Resident #1's complaints of pain. Nurse #2 said that the Physician was told that Resident #1 needed something immediately for pain and anxiety to make Resident #1 more comfortable, but did not specifically state Resident #1 had abdominal pain. Nurse #2 said that the Physician was informed that the [DEVICE] was newly inserted and had been replaced with a Foley catheter. The nurse's note, dated 11/20/10, at 12:30 PM indicated that Resident #1 had not urinated and the nurse practitioner was notified. Nurse #2 said that at 12 PM the Physician's Assistant was notified that Resident #1 was unable to urinate and a catheter was inserted. Physician Assistant #2 was interviewed at 3:18 PM on 1/11/10 and at 12:45 PM on 1/13/10. Physician Assistant #2 said that the nurse called specifically to report that Resident #1 had not urinated and that Resident #1 had a distended abdomen. Physician Assistant #2 said that at no time was any concern expressed by the nursing staff about the [DEVICE]. Nurse #3 was interviewed by at 8:30 AM and 10 AM on 1/11/10. Nurse #3 said that between 7:30 and 7:45 AM, Nurse #2 and Nurse #3 assessed Resident #1. Nurse #3 said that when assessed, Resident #1 had facial grimacing and was restless which was different from Resident #1's normal self, and Nurse #3 interpreted Resident #1's actions has non-verbal indicators of pain. Physician Assistant #2 said that a second call was received by a Facility nurse at 3:13 PM on 11/20/10 to report Resident #1 appeared dry. Physician Assistant #2 said that orders were given to increase the water being administered in the tube for Resident #1 in response to the nurse calling and reporting that they thought Resident #1 appeared "dry." The Physician Assistant #2 said that the nurse also informed Physician Assistant #2 that the machine for the [DEVICE] was beeping but the staff thought it was due to a malfunctioning machine and planned to change the machine. The 11/20/10 note indicated that at 5 PM Resident #1's family member was in and requested that Resident #1 be transferred to the Hospital for evaluation of the [DEVICE] and restlessness, and Resident #1 was transferred to the Hospital. Guardian was interviewed at 3:55 PM on approximately 12/17/10. The Guardian said that the Facility nurse did inform the Guardian that Resident #1 pulled out the [DEVICE], but told the Guardian words to the effect of, "not to worry" and that Resident #1 was stable. The Guardian said that couple of hours later (after 3 PM), when the Guardian visited, Resident #1 was screaming in what appeared to be pain and was restless. The Guardian said that the Guardian approached the nurses' station a few times to express concern about Resident #1, and after waiting 30 minutes, went to the nurses' station and informed the nurse that the Guardian wanted Resident #1 transferred to the hospital for an evaluation. The ambulance report, dated 11/20/10, indicated Resident #1 left the Facility at 5:40 PM and arrived at the Hospital at 6:06 PM. The triage nurse report, dated 11/20/10 indicated Resident #1 was evaluated within minutes and was noted to have an elevated blood pressure, fever, and indication of pain. The physician's emergency department assessment, dated 11/20/10, indicated it was completed at 6:45 PM, and Resident #1 was noted to be restless, not voiding and the chief complaint was a question of abdominal pain. The treating emergency department physician documented that Resident #1 had decreased bowel sounds, distended abdomen, abdominal tenderness and guarding (all abnormal assessment findings and indicative of possible life-threatening change in condition). The operative report, dated 11/20/10, indicated that during surgery, the surgeon was able to visualize a Foley catheter was noted to be just, "free floating in the peritoneal cavity (and) was not in the stomach." The operative report indicated that there was approximately one to two liters of purulent material in the cavity which was drained out, in addition to repair of a hole in Resident #1's stomach. The operative report indicated Resident #1 was intubated and admitted to the intensive care unit.

Based on record review, interviews, and observation for one of three sampled residents (Resident #1), the Facility failed to ensure the Facility policy for gastrostomy tube re-insertion was followed. On 11/20/10 Resident #1's newly inserted gastrostomy tube ([DEVICE]) was traumatically removed and Nurse #1, who did not have the documented competencies to re-insert the [DEVICE], inserted a Foley catheter (brand name of a urinary catheter) in its place and restarted the feeding. This was not consistent with Facility policy, which indicated staff were not to re-insert [DEVICE]s that were in place for less than three months and licensed nurses must have completed an education program with skills validation. The tube was later found free floating in the peritoneum (The serous membrane that lines the walls of the abdominal cavity and folds inward to enclose the viscera). Findings included: The Facility policy on Gastrostomy Tube Change and Reinsertion, dated April 2005, indicated that [DEVICE]s were changed/reinserted, per physician's orders [REDACTED]. The policy indicated a licensed nurse performed the procedure only after attending an educational program for licensed nurses with skills validation and as permitted by state nurse practice act. The policy indicated a physician may choose to write an order for [REDACTED]. Review of Resident #1's physician's orders [REDACTED].#1 to have a gastrostomy tube placed. The nurse's note and short referral form, both dated 11/18/10, indicated that Resident #1 was transferred to the Hospital for a scheduled [DEVICE] placement and returned to the facility on [DATE]. The post sedation and procedure instruction form, dated 11/18/10, indicated that Resident #1 had a normal esophagogastroduodenoscopy (a diagnostic procedure in which a tube is inserted through the mouth which allows visualization the upper part of the gastrointestinal tract up to the duodenum) with PEG (percutaneous endoscopic gastrostomy) tube is passed into the stomach through the abdominal wall and used to provide a means of feeding when oral intake is not adequate). The post sedation and procedure instructions indicated that the staff could use the PEG for medications at any time; and for feedings after mid-night tonight (11/19/10) per nutritionist recommendations. The instructions indicated that general muscle pain and pain at the operative site were included in the most common complaints post-procedure and that any prolonged symptoms should be reported to the physician and a telephone number was provided. The instructions indicated that, "In case of emergency and you are unable to go to your physician, please go to the nearest Emergency Department or call the Hospital's Emergency Department..." The telephone number was provided. The nurse's note, dated 11/20/10, that at 4 AM, Resident #1 pulled the PEG out a threw it into the hall. The note indicated that a pressure dressing was applied immediately and that there was a moderate amount of frank bleeding noted with small blood clots. The note indicated a 20 french Foley catheter was inserted into the stoma (opening into the abdominal wall), in place of the PEG and placement was checked. The note indicated that placement was checked in "all four quadrants" and that there was no residual found prior to Resident #1 removing the PEG. The note indicated that Nurse #1 re-inserted a Foley into the new [DEVICE] site, without there being a physician's orders [REDACTED]. The note indicated that the nurse practitioner was called at 4:30 AM but did not respond and was recalled again at 6:30 AM. There was no indication Nurse #1 immediately called the Director of Nurses, Medical Director, or Physician when Nurse #1 did not receive a response from the 4 AM call. The nurse's note indicated that the covering nurse practitioner contacted the Facility at 6:40 AM and was informed that Resident #1 had pulled out the [DEVICE], and that at Foley catheter was inserted. The note indicated that at 6:30 AM the feedings were restarted at 55 cubic centimeters per hour. The note indicated that the covering nurse practitioner instructed the nurse to continue medications and feedings as ordered and to follow-up with the nurse practitioner on Monday (11/22/10). Review of the physician order [REDACTED].#1 was transferred to the emergency department for evaluation of the [DEVICE] and restlessness at the request of Resident #1's Guardian. The hospital operative report, dated 11/20/10, indicated Resident #1 required surgical intervention after arrival to the Hospital. The operative report indicated that once the abdominal cavity was opened the surgeon documented that a Foley catheter was noted to be just, "free floating in the peritoneum, was not in the stomach." The operative report indicated that there was approximately one to two liters of purulent (abnormal finding and indicative of infection) material in the cavity which was drained out, in addition to a hole in Resident #1's stomach which was "controlled." The operative report indicated Resident #1 was intubated (tube inserted in the airway for the purpose of assisted ventilation) and admitted to the intensive care unit. The Hospital discharge summary, dated 12/17/10, indicated that Resident #1 was admitted from the Facility with a suspected abdominal source infection/sepsis related to PEG placement. The record indicated that Resident #1 had an emergent laparotomy (defined as a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity) and debridement (removal of dead or infected tissue) with replacement of the [DEVICE]. The record indicated that subsequently, Resident #1 required ventilatory support and intensive care as a result of the infection. Nurse #1's personnel and educational records were reviewed on 11/30/10. There was no documentation to indicate Nurse #1 had received education or skills validation on re-inserting a [DEVICE] and there were no competencies regarding re-insertion of a [DEVICE]. Nurse #1 was interviewed at 2:30 PM on 11/30/10. Nurse #1 said that Nurse #1 had reinserted [DEVICE]s prior to working at the Facility, but had not received recent re-education on reinserting a [DEVICE], had not completed skills validation or competencies. Nurse #1 said that at 4 AM on 11/20/10, after Resident #1 traumatically removed the new [DEVICE], Nurse #1 inserted a Foley catheter into the stoma. Nurse #1 said that Nurse #1 only learned that nurses were not to re-insert a [DEVICE] on a newly placed PEG after 11/20/10, when Resident #1 was admitted to the Hospital. The Staff Development Coordinator was interviewed at 12:50 PM on 11/30/10. The Staff Development Coordinator said that nurses were not supposed to re-insert or change a [DEVICE] without documented competencies and an order from a physician. The Staff Development Coordinator said that Nurse #1 did not have competencies or any documentation with skills validation on re-insertion of a [DEVICE] and therefore should not have re-inserted the tube; and obtained an order after inserting a Foley into the stoma.