Every finding on record at Citrus Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 3 of 5 units. Findings include: 1) During an observation on 5/12/2025 at 10:27 AM, Resident #55 was lying in bed. On top of the resident's nightstand, there were two clear vials of Budesonide Inhalation Suspension next to the nebulizer machine (Photographic evidence obtained). During an interview on 5/12/2025 at 10:27 AM, Resident #55 stated, Sometimes I do not want to do the treatment and the nurse will leave it there. No one is going to drink it. The nurse that is here is not the one who left it there. Review of Resident #55's physician order dated 3/9/2025 read, Budesonide Inhalation Suspension 0.25 MG/2 ML [0.25 milligrams per 2 milliliters] (Budesonide Inhalation), 2 ml inhale orally two times a day for respiratory failure. Review of Resident #55's physician orders did not show an order for medication self-administration. During an interview on 5/12/2025 at 1:54 PM, Staff D, Licensed Practical Nurse (LPN), stated, The nurse before me must have left it in the room. [Resident #55's name] will refuse her treatment at times. The nurse should not have left the medication in the room. I have not seen an order for self-administration of medication for [Resident #55's name]. During an interview on 5/14/2025 at 3:27 PM, the Director of Nursing (DON) stated, Residents must have an evaluation for medication self-administration before they are able to self-administer their own medication. [Resident #55's name] does not have that evaluation at this time. Even after the evaluation, the residents will be given a lock box and medication should be stored in a secure manner. Medication should not be left unattended. 50695 2) During an observation on 5/12/2025 at 1:25 PM, there were two medication cups on Resident #19's overbed table with a pale, yellow cream in each cup. During an interview on 5/12/2025 at 1:25 PM, Resident #19 stated, It's an anti-itch cream. I put on a rash in my groin. It's prescription, but I don't know if there is a doctor's order for me to apply it. Review of Resident #19's physician order dated 4/29/2025 read, Nystatin Ointment 100000 UNIT/GM [unit per gram]: Apply to groin topically two times a day for yeast infection for 14 Days. During an observation on 5/13/2025 at 1:31 PM, Resident #19 was sitting on the edge of her bed, speaking on her cellular phone. There was a medication cup sitting on her overbed table with 5 pills in it. During an interview on 5/13/2025 at 1:31 PM, Resident #19 stated that the nurse usually waited for her to take her pills, but that he left the medications because she was talking on the phone. Review of Resident #19's physician order dated 3/24/2025 read, Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa), Give 2 tablets by mouth two times a day for Parkinson's for a total of 7 tablets daily. Review of Resident #19's physician order dated 10/4/2022 read, Gabapentin Capsule 300 MG, Give 3 capsule by mouth three times a day for neuropathy. During an interview on 5/13/2025 at approximately 1:45 PM, Staff A, Registered Nurse (RN), stated he believed Resident #19 was on an anti-fungal cream and that he believed it was administered around 6:00 AM. He further stated that he did leave medications in a cup in Resident #19's room because she was talking on the phone and did not want to take the medications at that time. He stated that he told her what the medications were, which were 3 Gabapentin pills and 2 Carbidopa-Levodopa pills. During an interview on 5/13/2025 at approximately 2:30 PM, the DON stated that for residents to self-administer medications, there would have to be an evaluation to ensure they could safely administer their own medications, and that if the medications were to be left in the resident's room, there would need to be a lock box in which to secure the medications. She further stated that the evaluation and lock box requirements would apply to all medications including topical medications, such as Nystatin topical cream. Review of Resident #19's records revealed no evaluation for self-administration of medications. 40559 3) During an observation while conducting the tour of the nourishment area on the 400 hall in Memory Care Unit on 5/13/2025 at 2:11 PM, there was one pain relieving gel container on a shelf in an unlocked kitchen area cabinet accessible to residents of the memory care unit. During an interview on 5/13/2025 at 2:13 PM, the Certified Dietary Manager stated that the medications should be in a locked cabinet and not accessible to residents in the nourishment area. During an interview on 5/13/2025 at 2:25 PM, the DON stated that all medications should be stored in a locked area not accessible to residents and not in the cabinet in the memory care unit. Review of the facility policy and procedure titled Medication/Biological Storage with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedure: 1. Medications, drugs and biological shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary.

Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the residents' status for 3 of 7 residents reviewed for nutrition (Resident #13, #65, and #69), and 1 of 6 residents reviewed for hospice services (Resident #349). Findings include: 1) Review of Resident #65's physician order dated 4/16/2025 read, CCHO [Consistent Carbohydrate Diet] diet, Pureed texture, Nectar Thick consistency. Review of Resident #65's significant change in status Minimum Data Set (MDS) assessment dated [DATE] showed no mechanically alerted diet under Section K- Swallowing/Nutritional Status. During an interview on 5/15/2025 at 12:40 PM, the MDS Coordinator Registered Nurse (RN) stated, [Resident #65's name] MDS has to be corrected. [Resident #65's name] was a pureed diet, which would be a mechanically altered diet. Normally, we do not do Section K on the MDS that would be the Registered Dietician, but I need to correct it. 2) Review of Resident #69's physician order dated 12/24/2024 read, Regular diet, Mechanical Soft texture, Thin consistency. Review of Resident #69's quarterly MDS assessment dated [DATE] showed no mechanically alerted diet under Section K- Swallowing/Nutritional Status. During an interview on 5/15/2025 at 12:32 PM, the MDS Coordinator RN stated, [Resident #69's name] MDS will have to be corrected due to having a diet order of mechanically soft, starting on 12/24/2024. 3) Review of Resident #13's Weight Summary showed the resident weighed 157 pounds on 2/19/2025 and weighed 165.4 pounds on 1/20/2025, which is a 5.1% weight loss. Review of Resident #13's quarterly MDS dated [DATE] showed it documented No or unknown under Loss of 5% or [NAME] in the last month or loss of 10% or more in the last 6 months section under Section K- Swallowing/Nutritional Status. During an interview on 5/15/2025 at 12:46 PM, the MDS Coordinator RN stated, [Resident #13's name] did have weight loss for the look back period. The MDS will have to be corrected. Review of the facility policy and procedure titled MDS Assessments with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to complete MDS assessments in accordance with the RAI [Resident Assessment Instrument] manual guidelines. Procedures: 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews. 51447 4) Review of Resident #349's physician order dated 4/25/2025 read, Admit to [hospice name]. Review of Resident #349's admission MDS assessment dated [DATE] showed the resident was not under hospice care under Section O- Special Treatments, Procedures, and Programs. During an interview on 5/12/2025 at 12:25 PM, Staff J, Licensed Practical Nurse (LPN), stated, The section was incorrectly documented and should be checked yes. During an interview on 5/15/2025 at 2:20 PM, the Director of Nursing (DON) stated, My expectations are that the information included in a resident's MDS would be filled out accurately.

Based on observation, interview, and record review, the facility failed to revise the residents' care plans to meet the current needs of the residents for 1 of 11 residents reviewed for enhanced barrier precautions (Resident #56) and 1 of 2 residents reviewed for dialysis services (Resident #15). Findings include: 1) Review of Resident #56's care plan on 5/12/2025 at 12:00 PM read, Focus: [Resident #56' name] is at risk for infection and enhanced barrier precautions (EBP) are indicated due to: positive COVID-19 virus. Date Initiated: 12/09/2025. During an observation on 5/12/2025 at 9:36 AM, Resident #56 was sitting in her wheelchair in her room watching television. There was no enhanced barrier precaution signage on her door. During an interview on 5/12/2025 at 12:25 PM, the Minimum Data Set (MDS) Coordinator stated that the care plan focus of EBP for COVID-19 was initiated on 12/9/2024. It should have been resolved after the resident was no longer contagious for the virus. Review of the facility policy and procedure titled Comprehensive Assessments and Care Plans with the last review date of 1/20/2025 read, Standard: It will be the standard of this facility to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services] . Guidelines . 10. The plan of care reviewed and revised by interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 52506 2) Review of Resident #15's admission record showed the resident was most recently admitted on [DATE] with diagnoses including dependence on renal dialysis with onset date of 3/17/2025. Review of Resident #15's physician order dated 3/26/2025 read, Dialysis Center Information- Name: [Name, address and phone number of local end-stage renal disease (ESRD) facility] M-W-F [Monday, Wednesday, Friday] 11:30 [11:30 AM]. Review of Resident #15's physician order dated 3/26/2025 read, Remove pressure dressing after return from dialysis M-W-F 11:30. Review of Resident #15's physician order dated 3/26/2025 read, Do not use the access site left arm to take blood samples, administer IV fluids, or give injections. Review of Resident #15's care plan dated 3/25/2025 read, Focus: [Resident #15's name] has potential for complications related to hemodialysis for treatment of ESRD. Shunt site is located: L [left] subclavian, Receives dialysis on: M-W-F 11:30 . Interventions . Perform dressing change to dialysis site per MD [Medical Doctor] order . Labs as ordered- Do not obtain BP [blood pressure] reading from shunted arm . do not obtain blood draws from shunt site . monitor for bruit and thrill at shunt site. Review of Resident #15's treatment administration record for May 2025 revealed no record of checks for bruit and thrill at shunt site. During an interview on 5/15/2025 at 3:24 PM, the Director of Nursing stated, The orders need to be updated. He [Resident #15] uses a CVC [Central Venous Catheter]. During an interview on 5/15/2025 at 3:36 PM, Resident #15 stated a CVC placed in his left groin area was used for dialysis.

Based on record review and interview, the facility failed to ensure residents received services according to professional standar of practice for 1 of 5 residents reviewed for unnecessary medications (Resident #151). Findings include: Review of Resident #151's physician order dated 4/28/2025 read, Voltaren Arthritis Pain External Gel 1% (Diclofenac Sodium (Topical)), Apply to affected areas. The order had no dosage or specific area for application of the medication. During an interview on 5/13/2025 at 3:11 PM, the Director of Nursing (DON) stated that Voltaren order did not have dosage or area to be applied. She stated her expectation was that orders had a dosage and location of application. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 5. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's physician or the facility's Medical Director for further instructions.

Based on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by physician for 2 of 7 residents reviewed for medication administration (Residents #29, and #55), and failed to ensure enteral tube dressing was changed for 1 of 1 resident reviewed for enteral feeding (Resident #349). Findings include: 1) During an observation on 5/14/2025 at 2:35 PM, Staff F, Registered Nurse (RN), entered Resident #29's room, performed hand hygiene, and donned gloves and a gown. Staff F disconnected the IV (intravenous) tubing from Resident #29's needleless connector. Staff F used an alcohol wipe to sanitize the needleless connector and flushed the needleless connector with 5 ml (milliliters) of normal saline. Staff F removed her personal protective equipment, preformed hand hygiene, and exited the room. Staff F did not follow with 5 milliliters of Heparin solution. Review of Resident #29's physician order dated 5/7/2025 read, Normal Saline Flush Solution (Sodium Chloride Flush) use 10 cc [milliliters] intravenously two times a day for Prophylaxis, Flush central venous catheter with 5 ml NS [normal saline] before and after medication administration. Then follow with 5 ml Heparin Solution, 10 u/ml [units per milliliter]. During an interview on 5/15/2025 at 9:11 AM, Staff F, RN, stated, I did not know [Resident #29's name] had an order for Heparin flush. I am used to seeing the orders separated. During an interview on 5/15/2025 at 10:33 AM, the Director of Nursing (DON) stated, Normally we just use normal saline flushes, not heparin. If a nurse is confused by the order, they should ask me, the unit manager, or reach out to the doctor. Nurses need to follow physician orders. Review of the facility policy and procedure titled IV Infusions with the last review date of 1/20/2025 read, Policy: It is the policy of this facility to provide administration of intravenous fluids, medications and electrolytes for the purpose of hydration and management of infections or other medical conditions. Procedure .3. Assemble the equipment and supplies needed such as . Saline or heparin for flush, if appropriate . 6. Administer IV medications or fluids per physician orders. 2) Review of Resident #55's physician order dated 3/16/2025 read, Acetaminophen Tablet 325 MG [milligrams], Give 2 tablets by mouth every 4 hours as needed for Mild Pain, level 1-3 Not to exceed 3 gm [gram]/ 3000 mg in 24 hours. Review of Resident #55's Medication Administration Record (MAR) for May 2025 for administration of Acetaminophen Tablet 325 mg showed the resident received the medication on 5/3/2025 at 8:51 PM for a pain level of 5, on 5/5/2025 at 7:07 AM for a pain level of 4, and on 5/6/2025 at 7:01 AM for a pian level of 6. Review of Resident #55' MAR for April 2025 for administration of Acetaminophen Tablet 325 mg showed the resident received the medication on 4/9/2025 at 10:08 AM for a pain level of 6 and at 9:33 PM for a pian level of 5, on 4/12/2025 at 7:44 PM for a pain level of 5, on 4/13/2025 at 11:45 AM for a pain level of 5, and on 4/17/2025 at 8:38 AM for a pain level of 8. During an interview on 5/14/2025 at 9:28 AM, Staff D, Licensed Practical Nurse (LPN), stated, I normally give her [Resident #55] what she ask for. I really never paid attention to the parameters for the Tylenol. During an interview on 5/15/2025 at 11:09 AM, the DON stated, I would expect nurses to talk to the resident and see what their pain level is on the pain scale and give medication accordingly. If they decline the medication, they should document and contact the provider and find out what works best for the resident. Review of the facility policy and procedure titled Pain Screening and Management with the last review date of 1/20/2025 read, Procedure . 4. Administer pain medications according to physician's orders and resident request for PRN [as needed] medications. Review of the facility policy and procedure titled Medication Administration with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 3. Medications should be administered in a timely manner and in accordance with the physician's orders. 3) During an observation on 5/14/2025 at 8:24 AM, Staff E, LPN, administered medication to Resident #349 via gastric tube (G-tube). The split gauze around the gastric tube was dated 5/11/2025 and had staff initials written with black marker. During an interview on 5/14/2025 at 8:55 AM, Staff E, LPN, stated, [Resident #349's name] gauze is dated 5/11/2025. The gauze should be changed daily. Normally the wound care nurse does the dressing change. Review of Resident #349's physician order dated 4/25/2025 read, Wound Care to G-tube site: Cleanse with wound wash, pat dry and place split gauze around tube, tape to secure in place every day shift for maintenance. During an interview on 5/14/2025 at 11:21 AM, the DON stated, [Resident #349's name] gauze should be changed daily according to the orders. During an interview on 5/15/2025 at 9:03 AM, Staff G, LPN, stated, The wound care nurse is the one who does the dressing change. We are responsible for checking it off on the TAR [Treatment Administration Record], but if the wound care nurse does not communicate with me that he has not done the dressing change, I take it as it was completed. During an interview on 5/15/2025 at 9:59 AM, the Wound Care Nurse stated, I can do the dressing change, but I thought the nurses do the gastric tube dressing changes. If the nurse sees the dressing change is not done, she could come to me and ask me or change the dressing. During an interview on 5/15/2025 at 10:27 AM, the DON stated, Anything wound or skin related, the Wound Care nurse is responsible for. He [the Wound Care Nurse] has his own laptop. He is the one who should be checking off the entries of wound care. Whoever did the dressing change should be checking off the care. The nurses should check their TAR and if the dressing is still showing, they should check to see if the dressing is done and if not, they should do it. Review of the facility policy and procedure titled Enteral Tube Feeding with the last review date of 1/20/2025 read, Procedure . 13. Provide cleaning and dressing changes as ordered to enteral tube feeding sites (i.e. gastrostomy or jejunostomy).

Based on observation, interview, and record review, the facility failed to keep resident environment free of accident hazards. Findings include: During an observation on 5/12/2025 at 10:17 AM, Resident #89 was sitting in bed. There was one oxygen cylinder in the right corner of the room, which was not secured on a stand (Photographic evidence obtained). Review of Resident #89's physician order dated 4/23/2025 read, Administer oxygen 2-4 L/Min [liters per minute] via NC [nasal cannula]. Humidification PRN [as needed] as needed Every shift monitor skin behind ears, necks, and face every shift for irritation or breakdown and apply tube padding PRN. During an interview on 5/14/2025 at 3:35 PM, the Director of Nursing (DON) stated, Oxygen cylinders must be secured on the cart and should not be stored loose in a resident room. There is a risk the cylinder can fall. We secure the oxygen cylinder for safety. Review of the facility policy and procedure titled Standards and Guidelines: Compressed gases and Oxygen usage with the last review date of 1/20/2025 read, Guidelines: Personnel concerned with the use and transport of compressed gas shall be trained in the proper handling of cylinders, cylinder trucks and supports, and cylinder-valve protection caps. All cylinder storage areas outside and inside, shall be protected from extremes of heat and cold from access by unauthorized individuals. Procedure: General Standards: Cylinders must be secured at all times so they cannot fall. Oxygen Use . Procedure: Be sure cylinders are secure on rack and never hang anything on cylinder Store oxygen cylinders upright and secured.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents #12 and #19). Findings include: Review of Resident #12's physician order dated 4/24/2025 read, Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium), Give 1 tablet by mouth one time a day for GERD [Gastroesophageal Reflux Disease] . Order Status: Active. Review of Resident #12's Medication Regimen Review (MRR) showed the consultant pharmacist's recommendation dated 8/6/2024 that read, This patient is currently receiving a PPI [Proton Pump Inhibitors] for > [more than] 12 weeks, Due to the updated F757, Unnecessary Medication Tag, the use of the PPI should be periodically reviewed and the necessity for continuation documented as well as monitoring done for any adverse consequences. The current order is: Protonix 40 mg [milligram] po [by mouth] Q AM [every morning] (05/24). Reduce dose to: Protonix 20 mg po Q QM. The physician's response read, No change. The form did not include the rationale\ for declining the recommendation. Review of Resident #12's MRR showed the consultant pharmacist's recommendation dated 3/4/2025 read, This patient is currently receiving a PPI for > 12 weeks, Due to the updated F757, Unnecessary Medication Tag, the use of the PPI should be periodically reviewed and the necessity for continuation documented as well as monitoring done for any adverse consequences. The current order is: Protonix 40 mg po Q AM . This resident's PPI therapy has been re-evaluated and is appropriate for the continued use; dose reduction is contraindicated and the benefit of use outweighs the risks; Continue PPI therapy for [No length of time was written in the blank] months; Continued use of any PPI therapy requires diagnosis and supportive documentation in the progress note or below: The form did not include the rationale for declining the recommendation. The form was signed by the Advanced Registered Nurse Practitioner (ARNP) #2 and dated 4/2/25. Review of Resident #19's physician order dated 9/2/2022 read, Trazodone HCl Tablet 100 MG, Give 1 tablet by mouth at bedtime for depression and insomnia at bedtime . Order Status: Active. Review of Resident #19's physician order dated 11/18/2022 read, Sertraline HCl Tablet 50 MG, Give 1 tablet by mouth one time a day for Depression . Order Status: Active. Review of Resident #19's physician order dated 4/21/2024 read, Meclizine HCl Oral Tablet Chewable 25 MG (Meclizine HCl), Give 1 tablet by mouth every 12 hours as needed for c/o [chief complaint] dizziness . Order Status: Active. Review of Resident #19's physician order dated 4/8/2025 read, Perphenazine Oral Tablet 8 MG (Perphenazine), Give 1 tablet by mouth every 12 hours for delusions, hallucinations, mood swings, agitation related to Paranoid Schizophrenia . Order Status: Active. Review of Resident #19's MRR showed the consultant pharmacist's recommendation dated 7/15/2024 read, Meclizine PRN [as needed]. Per CMS [Centers for Medicare and Medicaid Services] guidelines, recommend reassessment of after 14 day PRN use. Response: No change at this time after assessment: risk vs benefit [No information was documented on the provided line]. Review of Resident #19's MRR showed the consultant pharmacist's recommendation dated 3/4/2025 read, Medication(s): Perphenazine 8 mg po q 12 H (2/23) + Trazodone 100 mg po HS [bedtime] (9/22) + Sertraline 50 mg QD [every day] (11/22). Federal guidelines state psychotropic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year, then annually thereafter, when used to manage behavior, stabilize mood or treat psych disorder. Could we attempt a dose reduction at this time to verify this resident is on the lowest possible dose? If not, please indicate response below: Response . The drug, dose, duration and indications are clinically appropriate; further reductions are contraindicated due to: [no further information was documented]. The form was signed by ARNP #2 and dated 4/2/25. Review of Resident #19's MRR showed the consultant pharmacist's recommendation dated 3/4/2025 read, Meclizine PRN. Per CMS guidelines, recommend reassessment of after 14 day PRN use. Response: No change at this time after assessment: risk vs benefit [No information was documented on the provided line]. The form was signed by ARNP #2 and dated 4/2/25. Review of Resident #19's Progress Notes for July 2024, March 2025, and April 2025 revealed no physician progress notes addressing the use of Meclizine or the dizziness for which it had been prescribed. During an interview on 5/14/2025 at 8:35 AM, the Director of Nursing (DON) stated that she managed the MRRs. She stated that if the provider marked one of the provided responses, they go with it and do not request clarification or additional information. During an interview on 5/15/2025 at 2:33 PM, the ARNP #2 stated, I recently learned that if we [prescribing providers] deny or change the recommendations from the pharmacist [during the medication regimen review process], we have to give an explanation. If we agree, we don't have to do anything else. I was not initially educated about what the expectation was. Review of the facility policy and procedure titled Pharmacist Recommendations issued on 4/1/2022 and last reviewed on 1/20/2025 read, Policy: It will be the policy of this facility to provide pharmacist services to meet the needs of the residents through monthly regimen review (MRR) and properly addressing recommendations per federal and state guidelines. Procedure . 2. The pharmacists must report any irregularities to the attending physician or Licensed Independent Practitioner (LIP) and the facility's medical director and director of nursing, and these reports must be acted upon as soon as reasonably able, but prior to the following month's MRR . (iii) The attending physician/LIP must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it.

Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 1 resident reviewed for enteral feeding (Resident #349) and 1 of 6 residents reviewed of 5 residents reviewed for immunizations (Resident #29). Findings include: 1) During an observation on 5/14/2025 at 8:24 AM, Staff E, Licensed Practical Nurse (LPN), administered medication to Resident #349 via gastric tube (G-tube). The split gauze around the gastric tube was dated 5/11/2025 and had staff initials written with black marker. During an interview on 5/14/2025 at 8:55 AM, Staff E, LPN, stated, [Resident #349's name] gauze is dated 5/11/2025. The gauze should be changed daily. Normally the wound care nurse does the dressing change. Review of Resident #349's physician order dated 4/25/2025 read, Wound Care to G-tube site: Cleanse with wound wash, pat dry and place split gauze around tube, tape to secure in place every day shift for maintenance. Review of Resident #349's Treatment Administration Record (TAR) for May 2025 showed split gauze was changed on 5/12/2025 and 5/14/2025 during the day shift. During an interview on 5/15/2025 at 9:03 AM, Staff G, LPN, stated, The wound care nurse is the one who does the dressing change. We are responsible for checking it off on the TAR, but if the wound care nurse does not communicate with me that he has not done the dressing change, I take it as it was completed. During an interview on 5/15/2025 at 9:59 AM, the Wound Care Nurse stated, I can do the dressing change, but I thought the nurses do the gastric tube dressing changes. If the nurse sees the dressing change is not done, she could come to me and ask me or change the dressing. During an interview on 5/15/2025 at 10:27 AM, the Director of Nursing (DON) stated, Anything wound or skin related, the Wound Care nurse is responsible for. He [the Wound Care Nurse] has his own laptop. He is the one who should be checking off the entries of wound care. Whoever did the dressing change should be checking off the care. Review of the facility policy and procedure titled Wound Care with the last review date of 1/20/2025 read, Procedure . 10. Document in the clinical record when treatment are performed. Review of the facility policy and procedure titled Charting and Documentation with the last review date of 1/20/2025 read, Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. Observations, medications administered, services performed, etc., should be documented in the resident's clinical record. 3. Entries into the clinical record should be made by the appropriate staff members. 50695 2) Review of Resident #29's immunization record showed the resident received Influenza vaccine on 8/7/2024 and refused Pneumococcal vaccine on 10/22/2023. Review of Resident #29's Medication Administration Record (MAR) for August 2024 revealed documentation of the completion of the order for Afluria Quadrivalent Suspension Prefilled Syringe 0.5 ml [milliliter] (Influenza Vac Split Quad), Inject 0.5 milliliter intramuscularly one time only for immunization for 1 day document consent and administration in immunizations tab of the chart. Start Date: 08/07/2024 1429 [2:29 PM.] Review of Resident #29's Informed Consent for Influenza Vaccine showed the resident did not give the facility permission to administer an Influenza vaccination. The form was signed by Resident #29, and witnessed by the Director of Nursing (DON), and dated 8/7/2024. Review of Resident #29's medical records showed no Informed Consent for Pneumococcal Vaccine indicating that the resident declined the vaccination. During an interview on 5/15/2025 at approximately 9:30 AM, the DON stated that the process was to begin educating residents about the Flu shot in the summer and obtaining consent from the residents who were interested in receiving the vaccine. She stated that they ordered vaccines based on the number of signed consents they received, and that they typically began administering the influenza vaccines a few days after obtaining consent, when the ordered vaccines arrived from the pharmacy. During an interview on 5/15/2025 at approximately 10:20 AM, the DON stated that the expectation was that if a resident changed their mind regarding a vaccine, where they had initially signed a declination but decided they did want the vaccine, that the nurse would have the resident sign a new form indicating they gave consent for the vaccine. During an interview on 5/15/2025 at approximately 12:10 PM, the DON stated that they were not able to locate a declination form for the pneumonia vaccine for Resident #29, even though it was documented as having been refused, and that the expectation was that the resident would sign a declination form and that it would be uploaded into his medical record. Review of the facility policy and procedure titled Influenza (FLU) Vaccination: Residents issued on 4/1/2022 and last reviewed on 1/20/2025 read, Policy: The Advisory committee on immunization practices (ACIP) recommends vaccinating persons who are at high risk for serious complications from influenza, including residents of nursing homes. Procedure . 4. Informed consent in the form of a written signature by the resident/resident representative, will serve as verification of receipt of the VIS [Vaccination Information Sheet]/education regarding benefits and potential side effects of the immunization. Review of the facility policy and procedure titled Resident Pneumonia Vaccination issued on 4/1/2022 and last reviewed on 1/20/2025 read, Policy: It is the policy of this facility that residents will be offered the Pneumococcal vaccine to aid in preventing pneumococcal infections (e.g., pneumonia). Procedure . 4. Residents/representatives have the right to refuse vaccination. If refused, appropriate entries will be documented in the resident's clinical record.

Based on observation, interview, and record review, the facility failed to ensure staff followed infection control standards for 1 of 1 resident reviewed for enteral feeding (Resident #349), and for 1 of 5 residents reviewed for wound care and intravenous therapy (Resident #29) to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 5/14/2025 at 8:24 AM, Staff E, Licensed Practical Nurse (LPN), administered medication to Resident #349 via gastric tube, using a flush syringe. Staff E finished the enteral medication administration and placed the flush syringe back in a clear bag without rinsing the syringe. There was white residual in the syringe. Staff E exited the room and returned to the medication cart (Photographic evidence obtained). During an interview on 5/14/2025 at 8:55 AM, Staff E, LPN, stated, For [Resident #349's name], I did not flush the syringe. Normally I would get a new one (flush syringe). It is easier. During an interview on 5/14/2025 at 11:21 AM, the Director of Nursing (DON) stated, The staff should rinse the flush syringe once they are finished using them. The syringes are changed every 24 hours. Review of the facility policy and procedure titled Medication Administration via Enteral Feeding Tube with the last review date of 1/20/2025 read, Procedure . 10. Clean the syringe with warm water and place in cover or plastic bag. 2) During an observation on 5/14/2025 at 1:10 PM, Staff F, Registered Nurse (RN), entered Resident #29's room without performing hand hygiene. Staff F donned gloves, but did not put on a gown. There was an enhanced barrier precautions signage posted outside of Resident #29's room door. Staff F accommodated the IV (intravenous) pole. Without changing gloves or performing hand hygiene, Staff F connected IV tubing to the medication. Staff F sanitized the needleless connector and connected the IV tubing to the connector and started the IV pump. Staff F removed her gloves and exited the room. During an interview on 3/14/2025 at 1:35 PM, Staff F, RN, stated, I should have done hand hygiene and put on a gown since I was dealing with an IV. Review of Resident #29's physician order dated 3/29/2024 read, Enhanced Barrier Precautions-Wound every shift for precautions. Review of Resident #29's physician order dated 5/6/2025 read, Type of IV infusion: Ceftriaxone Sodium Solution Reconstitute 2 GM [gram] IV until 6/3/25. During an interview on 5/15/2025 at 2:50 PM, the DON stated, Nurses should perform hand hygiene and don a gown and gloves. Nurses should get all supplies ready and wash hands again and then put gloves on to connect tubing, prime the IV tubing, scrub the hub and connect the IV tubing to the hub. Remove all PPE [Personal Protective Equipment] and perform hand hygiene before exiting the room. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to the use of own and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug resistant organisms Procedure . 4. For residents for whom EBP are indicated, EBP is employed when performing the following High-contact resident care activities- a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. H. Wound care: any skin opening requiring a dressing. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 1/20/2025 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . c. Before preparing and handling medications . e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites) . g. Before handling clean or soiled dressings, gauze pads, etc. k. After handling used dressings, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the residents; m. After removing gloves. 50695 3) During an observation on 5/14/2025 at 9:19 AM, Staff C, RN, gathered wound care supplies for Resident #29. Staff C removed bandage scissors from his pants pocket and cut the wound dressing and calcium alginate. Staff C removed the dressings from Resident #29's left lower leg and foot and right lower leg, using the bandage scissors to cut away the external gauze portion of the dressings. Without removing his gloves or performing hand hygiene, Staff C then used the prescribed cleanser on three wounds on Resident #29's left lower leg and patted them dry with gauze. Staff C removed the remaining dressing from Resident #29's right lower leg, and without removing his gloves or performing hand hygiene, applied the prescribed cleanser and patted it dry with gauze. During an interview on 5/14/2025 at approximately 9:35 AM, Staff C, RN, stated that he did not believe it was necessary to remove his gloves and perform hand hygiene between removing Resident #29's dressing and applying the prescribed cleanser, because the wound was considered dirty until after he applied the cleanser. During an interview on 5/14/2025 at 11:25 AM, the DON stated that the expectation for wound care was for the nurse, after taking off an old soiled dressing, to remove their gloves, perform hand hygiene, and don clean gloves before applying a cleansing agent, and again after applying the cleansing agent before applying the clean dressing. During an interview on 5/15/2025 at 3:45 PM, the DON stated that nurses should not store scissors in their pockets and they should keep them in the treatment cart. The DON also stated that scissors should be cleaned, at least with an alcohol wipe, before and after use, during wound care. Review of the facility policy and procedure titled Wound Care with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. Procedure . 7. Wound care treatment should maintain proper technique, as is indicated by the type of wound and physician orders. Review of the facility's Wound Care Nurse Competency Test for Infection Control read, Procedure . Cleansed hands as appropriate during procedure. Changed gloves as appropriate . Scissors are cleaned before and after use and are not stored in employee's pockets.

Based on interview, observation, and record review, the facility failed to ensure call light cords and buttons were placed within resident's reach while they were in bed for 1 of 8 residents reviewed (Resident #40). Findings include: During an interview on 5/12/2025 at approximately 10:30 AM, Resident #40 stated that she did not have a call light, and that she had been instructed just to call out (verbally) if she needed assistance. During an observation on 5/12/2025 at 2:48 PM, Resident #40's call light was on the resident's bedside table (Photographic evidence obtained). During an observation on 5/13/2025 at 9:00 AM, Resident #40's call light was inside the drawer of the resident's bedside table (Photographic evidence obtained). During an observation on 5/13/2025 at 1:35 PM, Resident #40's call light was clipped to the handle/drawer pull of the resident's bedside table (Photographic evidence obtained). During an interview on 5/13/2025 at 1:35 PM, Resident #40 stated, I did not put my call light on the bedside table. I am not supposed to get out of bed on my own. During an interview on 5/13/2025 at 1:40 PM, Staff A, Registered Nurse (RN), stated, [Resident #40's name] does use her call light and is usually able to state what her needs are. [Resident #40's name] call light should not be clipped to her bedside table because she will not be able to reach it, and she does not get out of bed without assistance. During an interview on 5/13/2025 at 1:55 PM, Staff B, Certified Nursing Assistant (CNA), stated that she clipped Resident #40's call light to the drawer pull on her bedside table when she was providing peri-care. During an interview on 5/13/2025 at 3:40 PM, the Director of Nursing (DON) stated, Call lights need to be placed within residents' reach. She [Resident #40] is a Hoyer lift; she would not be able to put her call light on or in her bedside table and she would not be able to reach it there. Review of Resident #40's care plan showed a focus initiated on 3/8/2025 indicating that Resident #40 was at risk for falls and/or fall related injury with the intervention to keep call light within reach. Review of the facility policy and procedure titled Call Lights with the last review date of 1/20/2025 read, Policy: It will be the policy of this facility to respond to the resident's requests and needs via notification with the call light system. Procedure . 4. When the resident is in bed or confined to a chair, the call light should be within easy reach of the resident. 5. Some residents may not be able to use their call light or may have visitors that may have move belongings, including the call light. Staff should check these residents regularly.

Based on observation, interview, and record review, the facility failed to ensure food was properly and safely stored, covered and labeled in the areas of the kitchen coolers and freezers and failed to ensure the equipment and storage containers were kept in a clean condition. Findings include: During a walk-through tour of the kitchen on 2/19/2024 at 9:08 AM with the Certified Dietary Manager (CDM), there were 102 unlabeled and undated large and small bowls filled with food items in the walk-in cooler and numerous boxes with flaps open exposing food items including veggie burgers and waffles in walk-in freezer. The can opener had food debris on it. During an interview on 2/19/2024 at 9:12 AM, the CDM confirmed that the 102 bowls contained gelatin and they should have identifying labels and dates. The CDM stated that all boxes in the freezer should be closed to protect the food from freezer burn and as a cover for the food contents.The CDM verified the can opener was dirty with food debris and should have been washed on the previous night shift. During an observation on 2/20/2024 at 6:05 AM, Staff A, Dietary Aide, was getting prepared to place fruit cocktail from the dented cans in dessert bowls. During an interview on 2/20/2024 at 6:10 AM, Staff A, Dietary Aide, stated that she should not be using dented cans of food. During an observation on 2/20/2024 at 6:15 AM, there was a partially-open drawer under the toaster. The drawer contained clean cooking utensils. There were breadcrumbs and bread ties in the drawer. During an interview on 2/20/2024 at 6:15 AM, the CDM stated the drawer should not have been opened to allow debris to fall onto the clean utensils. Review of the facility policy and procedures titled Food Receiving and Storage with the last review date of 1/4/2024 reads, Policy Interpretation and Implementation . 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration in 6 of 12 observations for medication administration. Findings include: During an observation on 2/22/2024 at 8:45 AM, Staff G, Registered Nurse (RN), prepared medications for Resident #73. Staff G entered Resident #73's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:50 AM, Staff G prepared medications for Resident #54. Staff G entered Resident #54's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:52 AM, Staff G prepared medications for Resident #59. Staff G entered Resident #59's room and administered the medications. Staff G exited the room and returned to the medication cart. At 8:55 AM, Staff G entered Resident #72's room to obtain the resident's blood pressure prior to administering the resident's medications. Staff G exited the room after obtaining the resident's blood pressure and returned to the medication cart. Staff G prepared the resident's medications, entered Resident #72's room and administered the resident's medications. Staff G did not perform hand hygiene during observation of medication administration process. During an interview on 2/22/2024 at 9:15 AM, Staff G, Registered Nurse (RN), stated, I didn't think I had to do it [hand hygiene] when I left the room and walked straight to the med cart, so I didn't. During an interview on 2/22/2024 at 12:15 PM, the Director of Nursing (DON) stated, They should perform hand hygiene if their hands are visibly soiled, after they take gloves off, when they are pulling medications. 41334 2. During an observation on 2/22/2024 at 6:00 AM, Staff D, Licensed Practical Nurse (LPN), prepared medications for Resident #88. Staff D entered Resident #88's room and administered the medications. Staff D exited Resident #88's room and returned to the medication. At 6:08 AM, Staff D prepared medications for Resident #30. Staff D entered Resident #30's room and administered the medications. Staff D removed the straw with her ungloved hand and placed her right index finger over the tip of the straw and asked the resident to open her mouth and dropped water from the straw into the resident's mouth. Staff D then placed the straw back in the cup and the resident took several sips of water from the tip of straw that Staff D had her finger on. Staff D exited Resident #30's room and returned to the medication cart. At 6:11 AM, Staff D prepared medications for Resident #71. Staff D assembled all supplies for blood glucose check. While outside of the room, Staff D donned gloves without performing hand hygiene, removed the alcohol pad from the packet and placed the alcohol swab within her gloved hand. Staff D entered Resident #71's room with gloves on and administered the oral medication. Staff D then took the alcohol swab, cleaned Resident #71's finger in one sweep with the alcohol swab. Staff D did not wait for the finger to dry and obtained the blood sample for the accucheck. Staff D doffed her gloves, exited the resident's room, returned to medication cart, and began preparing medications for another resident. Staff D did not perform hand hygiene during observation of medication administration process. During an interview on 2/22/2024 at 6:18 AM, Staff D, LPN, stated, I should have used hand sanitizer before I poured my meds [medications]. We should either wash our hands or use sanitizer before and after we put on gloves. I should have waited to put on my gloves and opened the alcohol swab until I was in the room. During an observation on 2/22/2024 at 6:20 AM, Staff E, LPN, donned gloves and cleaned an accucheck machine and placed the accucheck machine in a plastic cup. With the same gloves on, Staff E prepared Resident #4's oral medications, entered the resident's room, and administered the oral medications. Staff E doffed her gloves and returned to the medication cart. Staff E assembled all accucheck supplies, donned gloves and returned to Resident #4's bedside. Staff E performed the accucheck, doffed her gloves, and exited the resident's room. Staff E returned to the medication cart and prepared insulin. Staff E donned gloves and entered Resident #4's room. Staff E administered the insulin to the resident, doffed her gloves and returned to the medication cart and began preparing medications for another resident. Staff E did not perform hand hygiene during observation of medication administration process. During an interview on 2/22/2024 at 6:35 AM, Staff E, LPN, stated, I should have used hand sanitizer and changed my gloves. During an interview on 2/22/2024 at 11:15 AM, the Director of Nursing (DON) stated, I expect all staff to use hand sanitizer when our policies state they should. Review of the facility policy and procedures titled Hand Hygiene with the last review date of 1/24/2024 read, Policy: This facility considers hand hygiene the primary means to prevent the spread of infection. Procedure . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors . 5. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations . b. Before and after direct contact with residents; c. Before preparing or handling medications . f. Before donning sterile gloves . l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; m. After removing gloves . 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. 7. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on record review and interview, the facility failed to ensure residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were reviewed for level II pre-admission screening and resident review (PASARR) for 1 of 4 reviewed residents, Residents #41. Findings include: Review of Resident #41's admission record revealed the resident was admitted on [DATE] with the diagnoses to include unspecified dementia, cognitive communication deficient, paranoid schizophrenia (with onset date of 9/29/2023), generalized anxiety disorder (with onset date of 5/26/2023), bipolar disorder (with onset date of 3/10/2023), and major depressive disorder (with onset date of 12/30/2022). Review of Resident #41's medical records revealed a Level I PASRR completed on 12/30/2022 that listed anxiety disorder and depressive disorder as diagnoses and indicated that the resident may be admitted to a nursing facility due to no diagnosis or suspicion of serious mental illness or intellectual disability that required to level II PASRR evaluation. Further review revealed no Level II PASRR. Review of psych note dated 12/22/2023 for Resident #41 read, [Resident #41's name] is an [AGE] year-old male with schizophrenia, mood disorder, anxiety, dementia, and a history of depression. Staff reported that the patient is combative. Continued medications of Aricept for dementia, Sertraline for depression and Divalproex for mood disorder. During an interview on 2/20/2024 at 2:30 PM, the Director of Nursing (DON) stated that a new PASSAR should have been completed for Resident #41 and was not.

Based on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status to prevent weight loss for 1 of 6 reviewed residents, Resident #660. Findings include: During an interview on 2/19/2024 at 10:11 AM, Resident #660 stated, I have lost weight and do not always receive foods I request on my tray. During an observation on 2/20/2024 at 12:20 PM, Resident #660 was eating lunch with only bites taken from his plate. During an interview on 2/20/2024 at 12:21 PM, Resident #660 stated lunch was not a favorite meal, and he did not get the bowl of soup he requested. Review of Resident #660's records showed the resident weighed 148 lbs (pounds) on 11/22/2023, 147.5 lbs on 11/24/2023, 146.5 lbs on 11/27/2023, 141 lbs on 12/20/2023, 138.0 lbs on 1/1/24 and, 135 lbs on 2/1/2024, which is a -8.78 % loss. Review of Resident #660's dietary note authored by the Registered Dietician (RD) dated 11/28/2023 read, At risk for weight loss and malnutrition. RD to monitor. Review of Resident #660's care plan dated 11/22/2023 showed nutritional focus to provide diet as ordered and honor food preferences. During an interview on 2/20/2024 at 2:20 PM, the RD confirmed that she had not charted or had interventions in place for Resident #660 to prevent further weight loss and there should have been interventions of fortified foods, updating food preferences, or supplements added for more caloric intake.

Based on observation, interview, and record review, the facility failed to administer oxygen per physician orders and according to professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #55 and #64. Findings include: Review of Resident #64's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD), and multiple subsegmental pulmonary emboli without acute cor pulmonale. Review of Resident #64's physician order dated 6/26/2022 reads, May apply O2 [oxygen] @ [at] 2 LPM [liters per minute] via nasal cannula prn [as needed] for respiratory distress. During an observation on 2/19/2024 at 10:50 AM, Resident #64 was sitting in a wheelchair, receiving oxygen via nasal cannula. The oxygen concentrator was set at 3 liters per minute and was across the room and out of the resident's reach. During an interview on 2/19/2024 at 10:50 AM, Resident #64 stated, I pretty much use my oxygen all the time, but I can take it off to go outside. I do not change the amount. I just take off my cannula and leave it on the bed until I come back in. During an observation on 2/20/2024 at 8:52 AM, Resident #64 was sitting in a wheelchair, receiving oxygen via nasal cannula with the oxygen concentrator set at 3 liters per minute. During an observation on 2/22/2024 at 6:40 AM, Resident #64 was in bed, receiving oxygen via nasal cannula with the oxygen concentrator set at 3 liters per minute. During an interview on 2/22/2024 at 6:40 AM, Staff E, Licensed Practical Nurse (LPN), stated, All oxygen should be checked when we do meds. I think she will adjust the oxygen sometimes; she will take herself on and off. 2. Review of Resident #55's admission record showed the resident was admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease, acute diastolic congestive heart failure, paroxysmal atrial fibrillation (an irregular heartbeat), and atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Review of Resident #55's physician order dated 3/14/2023 reads, Continuous O2 at 2 L/MIN [liters/minute] via N/C [nasal cannula] q [every] shift, every day for COPD. During an observation on 2/20/2024 at 10:45 AM, Resident#55 was in bed, receiving oxygen at 3 liters per minute via nasal cannula through concentrator. During an interview on 2/20/2024 at 10:45 AM, Resident #55 stated, I don't change the oxygen. The nurses do that. During an observation on 2/22/2024 at 6:05 AM, Resident #55 was in bed, receiving oxygen at 3 liters per minute via nasal cannula through concentrator. During an observation on 2/22/2024 at 10:26 AM, Resident #55 was in bed, receiving oxygen at 3 liters per minute via nasal cannula. During an interview on 2/22/2024 at 10:27 AM, Staff F, LPN, confirmed that oxygen was running at 3 liters per minute for Resident #55. Staff F stated, The oxygen should be checked when we give medications. I didn't today. I should have. It is not at the ordered amount. During an interview on 2/22/2024 11:01 AM, the Director of Nursing (DON) stated, We need to verify oxygen is correct daily. We should be following the orders. Review of the facility policy and procedures titled, Oxygen Administration with the last approval date of 1/24/2024 reads, Policy: It is the policy of this facility to provide guidelines for safe oxygen administration. Procedure . 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter as is ordered by the physician or required to provide for the needs of the resident.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards. Findings include: 1. During an observation on 2/19/2024 at 10:20 AM, there were Orajel tooth ache cream, Afrin Nasal Spray, and Prednisolone Acetate on Resident' #48's bedside table (Photographic evidence obtained). Review of Resident #48's records revealed no physician order or care plan related to self-administration of medications. During an interview on 2/20/2024 at 10:30 AM, Staff B, RN (Registered Nurse), stated, Those medications should not have been left at [Resident #48's name] bedside. 2. During an observation on 2/19/2022 at 10 AM, there was Spiriva Respimat 2.5 mcg/actuation inhaler on Resident #712's bedside table (Photographic evidence obtained). During an interview on 2/19/2024 at 10:05 AM, Resident #712 stated, I use that when I need it. Review of Resident #712's records revealed no physician order or care planned intervention related to self-administration of medications. During an interview on 2/20/2024 at 10:35 AM, Staff B, RN, stated, That is a prescription medication and should not have been left in [Resident #712's name] room. During an interview on 2/21/2024 at 9:50 AM, the Director of Nursing stated, My expectation is that medications should never be left at the bedside. 44571 3. During an observation on 2/19/2024 at 12:16 PM, there was a bottle of nasal spray at Resident #40's bedside on the tray table. During an observation on 2/19/2024 at 12:41 PM, accompanied with the Assistant Social Services Director (ASSD), there was one bottle of nasal spray at Resident #40's bedside. During an interview on 2/19/2024 at 12:45 PM, the ASSD stated meds were not supposed to be at bedside. During an interview on 2/20/2024 at 1:10 PM, the Director of Nursing (DON) stated her expectation was for no medications to be at bedside and if found should be removed immediately. 41334 4. During an observation of Medication Cart #2 on 2/19/2024 at 9:06 AM, with Staff C, Licensed Practical Nurse (LPN), there was one unlabeled white pill in a clear plastic bag in the narcotic drawer. During an interview on 2/19/2024 at 6:10 AM, Staff C, LPN, stated, Oh that is Tylenol #3. I went to administer it to [Resident #94's name] and she had her Oxycodone at her bedside, so I didn't want to give her both at the same time. During an interview on 2/19/2024 at 9:23 AM, the DON stated, Medications should never be left at the bedside. Narcotics should not be returned to the narcotic drawer if a resident refuses them. They should be destroyed with 2 nurses. Review of the facility policy and procedures tilted Medication/Biological Storage with the last review date of 1/24/2024 read, Policy: It will be the policy of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Procedures . 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems.

Based on record review and interview, the facility failed to ensure medical records were accurate and complete for 1 of 3 residents reviewed for insulin administration, Resident #93, and for 1 of 3 residents reviewed for changes in condition, Resident #108. Findings include: 1. Review of Resident #93's admission record revealed the resident was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes mellitus with diabetic neuropathy, acute on chronic systolic (congestive) heart failure and atherosclerotic heart disease of the native coronary artery with angina pectoris (chest pain). Review of Resident #93's physician order dated 11/17/2023 reads, Humalog Kwikpen Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Lispro) inject as per sliding scale if: 0-59= Notify provider, 60-150= 0, 151-200= 2, 201-250= 4, 251-300= 6, 301-350= 8, 351-400= 10, 401-999= 10 Notify MD [Medical Doctor], subcutaneously before meals and at bedtime for DM2 [diabetes mellitus type 2]. Review of Resident #93's Medication Administration Record (MAR) for December 2023 showed no blood sugar level documented on 12/23/2023 at 6:30 AM, and on 12/25/2023 at 6:30 AM. Review of Resident #93's MAR for January 2024 showed no blood sugar level documented on 1/16/2024 at 9:00 PM, with the code 4 (vitals outside parameters for administration). Review of Resident #93's MAR for February 2024 showed a blood sugar level of 411 documented on 2/5/2024 at 6:30 AM, and a blood sugar level of 410 documented on 2/18/2023 at 6:30 AM, with the code 10. Review of the nursing progress notes for Resident #93 from 12/23/2023 through 2/18/2024 revealed no progress notes related to holding insulin and physician notification of elevated blood sugars. During an interview on 2/22/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and get orders to hold the insulin. I spoke to the nurses with the elevated blood sugars and they notified the ARNP [Advanced Registered Nurse Practitioner]. They just failed to document this. They should have documented it. Review of the facility policy and procedures titled Medication Administration with the last review date of 1/24/2024 reads, Policy: It will be the policy of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication or refusals of medication by the resident. Procedure . 9. The individual administering the medication must initial the resident's MAR on the appropriate line and date for that specific day when administering the next resident's medication . 14. When medications are administered, the individual administering the medication must record in the resident's medical record/MAR. 2. Review of the admission record for Resident #108 revealed the resident was recently admitted to the facility on [DATE] with the diagnoses including cerebral infarction (stroke), hyperlipidemia (high cholesterol), paroxysmal atrial fibrillation (an irregular heart beat), essential primary hypertension, anemia, major depressive disorder, osteoarthritis, heart failure, unspecified dementia, and anxiety disorder. Review of Resident #108's nursing progress note dated 11/30/2024 at 10:30 PM read, Aides approached this writer to come evaluate patient. Upon entering the patient room, patient observed to have minimal amount of vomit/spit coming out of right side of mouth, shallow breathing and was not responding to verbal or sternal rub stimulation. Call placed to [Advanced Practice Registered Nurse's name] with [Medical Doctor's name] and order to send patient to ER for further evaluation and treatment given. Patient transferred and wife [Resident #108's Representative's name] notified. Review of Resident #108's nursing progress note dated 12/1/2023 at 7:15 AM read, This writer called [hospital name] and spoke with RN [Registered Nurse] in PCU [Progressive Care Unit]. Patient admitted for A Fib [atrial fibrillation] with RVR [rapid ventricular rate] and aspiration. Review of Resident #108's SBAR (Situation, Background, Assessment, Response) Communication Form dated 11/30/2023 at 10:28 PM read, Vital Signs B/P [blood pressure]: 140/72, pulse 82, RR [respiratory rate]: 18.0, Temp [temperature]: 97.3, Pulse Oximetry (if indicated): 96.0%. Review of the nursing Progress Note with an effective date of 11/30/2023 at 10:17 PM showed the vital signs recorded on the SBAR were completed on 11/30/2023 for the BP at 1:11 PM, Pulse at 1:13 PM, RR at 1:14 PM, Temp at 1:12 PM, and the Pulse Oximetry at 1:14 PM. The vital sign values were present 9 hours and 14 minutes prior to the resident being sent to the hospital which did provide for inaccurate assessment for when the resident suffered a change in condition. During an interview on 2/21/2024 at 2:15 PM the Director of Nursing (DON) stated, There are no vital signs documented for this resident when he went to the hospital. We should have vital signs documented for him, a heart rate, temperature, and accucheck if needed. A neurological assessment should be done when they have an altered mental status. It is our policy to document accurately what is happening with the residents. Review of the facility policy and procedures titled Change in Condition with the last review date of 1/24/2024 reads, Procedure . 2. When a change is noted, gather pertinent data such as vital signs, weights and other clinical observations. Review of the facility policy and procedures titled Charting and Documentation with the last review date of 1/24/2024 reads, Policy: It is the policy of this facility that services provided to the resident, or any changes in resident's medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1. observations, medications administered, services performed, etc., should be documented in the resident's clinical records. 2. Incidents, accidents, or changes in the resident's condition should be recorded in the clinical record.

Based on record review and interview, the facility failed to ensure resident rights for advanced directives were honored by failing to follow physician's order to Do Not Resuscitate (DNR) when the resident was found unresponsive and absent of vital signs for 1 of 3 residents, Resident #1. The facility failed to ensure resident rights were honored when the resident was found unresponsive and absent of vital signs by initiating CPR (Cardiopulmonary Resuscitation) for a resident with a Do Not Resuscitate Order. The facility failure to honor Resident #1's advanced directives resulted in likely serious harm to Resident #1. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE] and was removed on February 1, 2023 after the facility submitted an acceptable removal plan. Findings include: Review of the admission record for Resident #1 revealed the resident was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure with hypoxia (low oxygen level in the blood), other speech and language deficits following cerebrovascular accident (a stroke), idiopathic peripheral autonomic neuropathy, cerebral infarction (a stroke) due to occlusion (blockage) or stenosis narrowing) of small artery, other sequalae of cerebral infarction, presence of cerebrospinal fluid drainage device (a shunt that drains fluid from the brain), pneumonia due to Coronavirus 2019, sepsis (an overwhelming infection), unspecified protein calorie malnutrition, essential (primary) hypertension, hyperlipidemia (high cholesterol), unspecified dementia, dysphagia, idiopathic normal pressure hydrocephalus (a brain disorder where excess spinal fluid accumulates in the brain), anemia in chronic disease, and history of malignant neoplasm (cancer) of the skin. Review of the Medical Certificate for Medicaid Long Term Services and Patient Transfer form provided to the facility by the sending hospital dated [DATE], under Section H, read, Advance Care Planning: DO NOT Resuscitate (DNR). Review of the Admission Assessment completed by Staff A, LPN (Licensed Practical Nurse), dated [DATE], read, Section 1: Admission details. Code Status: Full Code. Review of the Narrative Note dated [DATE] at 12:44 PM read, Type: Social Service Note. Narrative Note: [Resident #1's name] does have a wife in the community who is active with his care in the facility. We did discuss advanced directives. Review of the physician's order dated [DATE] at 11:36 AM read, DNR. Review of the Order Summary Report read, DNR. Communication Method: Verbal. Order Status: Active. Order Date: [DATE]. FULL CODE. Communication Method: Phone. Order Status: Active. Order Date: [DATE]. Review of the form titled State of Florida Department of Health Do Not Resuscitate Order (Florida Department of Health, Form 1869) dated [DATE] revealed the form was signed by Resident #1's representative on [DATE] and the physician on [DATE]. Review of the Electronic Medical Record (EMR) showed Resident #1's vital signs on [DATE] at 8:01 AM as a temperature of 97.6 degrees Fahrenheit and an SPO2 [oxygen saturation] of 92% on room air. Review of the Code Blue [Code for staff response to cardiac arrest] Documentation form for Resident #1 dated [DATE] at 8:50 to 9:16 AM read, Could not obtain VS [vital signs] started CPR Time CPR Started: 8:50. Periodic notes: Time: 8:50 am, absence of VS. EMT [Emergency Medical Technician] arrival time 9:16 Fire Rescue arrived first. Time resident expired 09:25 AM. Review of the nursing progress note for Resident #1 dated [DATE] at 11:00 AM authored by the Director of Nursing (DON) read, Nurse while making rounds start of shift noticed that he was with congestion. He was alert vital signs ,d+[DATE] [Blood pressure, mmHg], 97 pulse [beats per minute], respirations 19 [breaths per minute], on two-liter nasal cannula [flexible tube that is placed under the nose] with an O2 [oxygen] sat [saturation] at 92%. He was alert at his normal baseline. Was able to give meds had a residual of 20 CC [cubic centimeters]. Due to his congestion nurse did put his tube feed on hold. She left message with nurse practitioner [name of practitioner] about his condition and waiting on call back for further direction. CNA [Certified Nursing Assistant] alerted me the nurse that he appeared not to be breathing at approximately 8:50 this AM, looked in PCC [Point Click Care- electronic medical record software] resident was entered a full code, immediately started CPR due to the absence of vital signs, 911 called, continued CPR until EMS [Emergency Medical Services] arrived at approximately 9:16 AM and called the code. Review of the handwritten statement authored by Staff B, LPN dated [DATE] read, On Monday [DATE] I came onto the floor and got report at 0700 [7:00 AM] from night nurse [name]. In report [Nurses name] reported to me that [Resident #1's name] was off sounding, very congested and had been coughing. He told me that he contacted the on call night doctor but left a voicemail and hadn't heard back. At 0720 [7:20 AM] I went in to check on [Resident #1's name]. At the time [Resident #1's name] was alert, talking and when asked had no c/o [complaint of] shortness of breath or chest pain. He did sound very congested and was coughing on and off at times. I took his vital signs b/p [blood pressure] ,d+[DATE] [mmHg] HR [heart rate] 87, 19 [breaths per minute] resp and temp [respirations and temperature] of 97.9 [degrees Fahrenheit]. I notified MD [Medical Doctor] by texting the PA [Physician Assistant] for [Doctor's name]. She responded back at a later time. [CNA's name] reported to me that [Resident #1's name] was not breathing. I ran down to his room found he had no pulse or respirations. I went back to the nurse's station logged into PCC to his profile to check code status. He was listed as full code. I ran back down to his room yelling code blue [CNA's name] grabbed the crash cart and [CNA's name] paged overhead code blue. I stopped his tube feeding laid him flat and began chest compressions with relief came into room. [LPN's name] did breaths with Ambu bag [self-inflating bag resuscitator] while [LPN's name], and myself rotated doing compressions EMS arrived on scene approx. 0915 [9:15 AM] and took over breaths and chest compressions. [DON's name] came into room with the DNR showed it to EMS who called time of death and stopped compressions. Review of Resident #1's care plan read, Focus: [Resident #1's name] has expressed the following wishes regarding code status and has the following advanced directives in place: DNR, DPOA [Durable Power of Attorney] for health care and finances, Health Care Surrogate. Date Initiated: [DATE]. Goal: Resident's wishes regarding code status and advanced directives will be followed by staff. During an interview via telephone on [DATE] at 10:15 AM, Resident #1's spouse stated, He was a do not resuscitate in the hospital and I thought that he was always a do not resuscitate while he was there. I know they wanted me to sign a paper and I did. I did not want to prolong his suffering and he had a living will that stated he did not want any life prolonging measures at all. I can't understand why they would have done CPR, that is not what he wanted and it is not what I wanted. I thought that my husband was a DNR from the time he got to the nursing home. During an interview on [DATE] at 12:30 PM, the Assistant Administrator stated, I was notified immediately after the event that we had performed CPR on a DNR resident. We immediately began an investigation and did the required reporting. I do agree that we should have recognized that staff may not know what to do if there is incorrect paperwork. Apparently his yellow DNR form was not appropriately filled out and we did not have his wife's POA paperwork in the facility, so we waited for her to come and provide this before we made him a DNR. We should have reviewed our own policies and determined what to do. This resident was without the correct advance directive plan for three days and once we had this [the advanced directive], he was provided CPR and shouldn't have been. The investigation revealed that the order was entered incorrectly and did not populate the new advance directive for DNR in PCC. Since that time, we completed a root cause analysis, and implemented a performance improvement plan. I am monitoring the plan and it will be brought to QAPI [Quality Assurance Performance Improvement] monthly. During an interview on [DATE] at 12:45 PM, the Director of Nursing stated, I was on the day that Resident #1 coded. I found his DNR paperwork and provided this to EMS and they stopped the code. His DNR form was in a book at the nurses' station. I immediately began to look into why this happened. First, when the resident arrived staff did not verify with the POA the code status and did not review the transfer form. On admission staff did not follow our policies, they did not look at all the hospital documentation or know that they could still get an order for the DNR without the POA paperwork when the resident couldn't speak on his own behalf. Social Services did realize there was a DNR form provided but it was not correctly filled out and they were unaware of our ability to have two nurses document and get the physician's order. Once the resident's [Resident #1) wife provided the POA paperwork we obtained the order, and it was not correctly entered into PCC and the full code order was not discontinued. The day of the code blue the nurse that had obtained the DNR order just didn't remember and went to PCC to check, and he [the resident] was still listed as a full code. I interviewed all staff involved, and completed an investigation. We did an ad hoc QAPI that day, conducted a root cause analysis and formulated a performance improvement plan. We have conducted the training on advance directives, abuse and neglect, proper order entry so the correct order comes on the patients' profile. We immediately began a facility wide audit to determine that all residents had the correct advance directives and code status and have reviewed all new admissions daily. During an interview on [DATE] at 1:00 PM, Staff A, LPN, stated, I did not call or ask his wife if he was a DNR when I did his admission. I did not look at any of his paperwork like the transfer form, [from the hospital], just the discharge medication reconciliation form, that's all. I should have spoken to his wife. I was not aware that two nurses could get the form signed verbally and we could get an order for the DNR from the doctor. I should have reviewed all the admission paperwork. During an interview conducted via telephone on [DATE] at 1:30 PM, Staff B, LPN stated, I did get the order for Resident #1 on Friday, and I did get a DNR order. I did not remember that I got a DNR order when he coded three days later. I started CPR. I guess that I did not enter the order in the right spot and so it didn't show up as an order and I didn't discontinue the full code order and I should have. The Director of Nursing came in when the paramedics were here and showed them the DNR form, the yellow form, and they stopped and called the code. During an interview on [DATE] at 1:45 PM, the Social Service Director stated, I obtained his [Resident #1] paperwork for his POA. He did come to the facility with a DNR form, but it was not properly filled out and we did not have his POA paperwork, so I told his wife we could not honor the DNR until she gave us proof that she was his POA. I did interview him, but he was not really able to talk to me. His wife couldn't come because she was sick. Once she came on the 27th, I made sure that the staff knew to get an order for the DNR since she signed the yellow form. I was not aware that our policies state two nurses could obtain verbal consent and sign the form until the POA was able to. I have received the training now. During an interview on [DATE] at 2:15 PM, the Medical Director stated, I do expect staff to follow a resident or resident representative's wishes for code status. We should not perform CPR when residents do not wish for these measures. Once we identified this, we worked and found two to three weak links, the first being portal training on how to enter the right orders in the right ways so that we had the most up to date information available to all the staff. Next, we have created a manual system to prevent reoccurrences in the future so at all times we have two systems to make sure we are doing the right thing for the residents. The possible complications of CPR would include fractured ribs and a fractured sternum and would be considered traumatic should he have survived. Review of the policy and procedure titled Determination of Code Status issued in ,d+[DATE] read, Policy: The residents' code status will be determined by a physician's order and/or validly executed State of Florida DNR order form (Florida Department of Health Do Not Resuscitate form #DH 1896) and/or documented evidence of resident wishes being in place. Procedure: 1. Upon Admission the nurse completing the admission assessment will ascertain resident's desired code status (full code or DNR). In the event the resident is incapacitated or unable to communicate their wishes regarding code status, reasonable efforts will be made to contact the designated responsible party or surrogate decision maker to ascertain the resident's desired code status. 2. Upon Determination of resident/responsible party wishes, the nurse will document those wishes in the admission nursing assessment. 3. If the resident/responsible party elects a DNR, the resident and/or responsible party will sign and date the State of Florida DNR form available at: State of Florida form 1896 do not resuscitate order form. This can be done in person, via fax or scanned e-mail for resident representative not present. 4. The nurse will contact the attending physician and obtain an order for full code or DNR per resident or responsible party wishes. In the event of a DNR order given via telephone, two nurses shall witness and note such a verbal/telephone order using the State of Florida Do Not Resuscitate order form by writing and cosigning the verbal/telephone order at the bottom of the form, including the date and time the order was obtained. 6. Upon receipt of either verbal, telephone, or direct order for code status the nurse noting such order shall enter the order status into the electronic health record and validate that such order can be visualized in the record, the EMAR, and the point of care kiosk. The nurse shall check that any prior advance directive orders which exist are discontinued at the same time the new order is being entered. 7. The electronic record (including electronic chart, point of care kiosk, or EMAR) will serve as the primary source of validation of code status should a resident be found unresponsive. 9. When a DNRO [Do Not Resuscitate Order] is executed it will be made part of the medical record by being scanned into the EHR [electronic health record] under the documents section of the electronic health record. 10. A code status binder will be maintained at each nurses' station. Copies of state of the Florida DNR order forms, documentation of verbal wishes of resident, and/or physician orders shall be printed out and maintained in such binder. 12. Any resident without a signed State of Florida DNR order form, or without a physicians DNR order, or without documented verbal wishes of a desire for withholding of resuscitative measures, will be a Full code. Review of the policy and procedure titled Code Blue and CPR issued in ,d+[DATE] read, Policy: This facility will honor the resident/resident representative wishes regarding either the provision while withholding of cardiopulmonary resuscitation (CPR), to any resident requiring such care prior to the arrival of emergency medical personnel in accordance with related physician orders, such as DNR's, and the resident's advanced directives. In the event a resident experiences cardiac arrest (cessation of pulse and/or respirations). CPR will be provided in the absence of a valid physician's orders for do not resuscitate (DNR), a state of Florida DNR order form (#DH1896) or documented verbal wishes indicating otherwise which are pending physician order. Once emergency responders arrive, emergency responders will take control of the resuscitative effort and direct all related activities until either the resuscitative effort is ceased, or the resident is transported to an emergency center. Procedure: 5. A staff member other than the one who is evaluating the resident and preparing to provide emergency care must promptly check current code status by checking the code status section of the EHR (electronic health record), EMAR [electronic medication administration record] or point of care kiosk. At that point provision or withholding of resuscitative efforts may begin. Additional CPR certified personnel when present, may assist with management of the physical efforts in resuscitation as directed by the Licensed nurse in command. Review of the policy and procedure titled, Advanced Directives issued in ,d+[DATE] read, Policy: It will be the policy of this facility that the resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive and participate in advanced care planning. Advance Directives/Advance Care planning designations will be respected in accordance with state law and facility policy. The facility submitted an acceptable Immediate Jeopardy removal plan, and the immediate jeopardy was removed. The facility's non-compliance was corrected on February 1, 2023. The facility conducted an Ad Hoc QA meeting to review of the removal plan. On [DATE], the facility conducted a house-wide full chart review of 103 of 103 resident records and systems review for DNR/advance directives, physician orders pertaining to code status/advance directives, DNRO forms scanned in records. The facility provided training on advance directives to 30 of 30 licensed nurses on [DATE]. The facility provided abuse, neglect, and advanced directive training to 119 of 122 total facility staff. The facility conducted three mock codes/drills to ensure staff understood the location of the advance directives book and the documentation of code status in the electronic medical record with a total of 24 of 30 licensed nurses. The facility started validation of the code orders in care profile as per physician order for newly admitted residents by conducting daily audits through Advance Directives Compliance Tracking Tool on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility conducted advance directive monitoring audits of 10 residents per facility unit, which includes monitoring DNR/full code status in PCC, physician order for DNR, care plans for DNR, and implementation of admission information regarding DNR, on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents reviewed for changes in condition, Resident #29 and #42, resulting in the residents having to be treated by IV (intravenous) antibiotic therapy due to infection. Delay in notifying the physician of a wound, critical labs, and resident change in condition due to infection can result in the spread of the infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start [MEDICATION(S)] pending wound culture results. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: [MEDICATION(S)] <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For [CONDITION(S)] wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the [MEDICATION(S)] covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV [MEDICATION(S)] sooner had I been notified. I would have discontinued the [MEDICATION(S)] on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had [CONDITION(S)], but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, [MEDICATION(S)] trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, [MEDICATION(S)] trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [[MEDICATION(S)] trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose [MEDICATION(S)], I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical [MEDICATION(S)] trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the [MEDICATION(S)] dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The [MEDICATION(S)] is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell . I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell . I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

Based on observation, interview, and record review, the facility failed to ensure residents were free from medical neglect when they did not immediately consult with the resident's physician and notify the residents' representatives when there was a change of condition for 2 of 2 residents, Residents #29 and #42, resulting in a delay of care. Delay in notifying the physician of a wound, critical labs, or resident change in condition can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start [MEDICATION(S)] pending wound culture results. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: [MEDICATION(S)] <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For [CONDITION(S)] wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the [MEDICATION(S)] covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV [MEDICATION(S)] sooner had I been notified. I would have discontinued the [MEDICATION(S)] on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had [CONDITION(S)], but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, [MEDICATION(S)] trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, [MEDICATION(S)] trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [[MEDICATION(S)] trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose [MEDICATION(S)], I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical [MEDICATION(S)] trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the [MEDICATION(S)] dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The [MEDICATION(S)] is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled Abuse and Protection and Response Policy approval date of 1/27/2022 reads, Policy: Abuse as hereafter defined, will not be tolerated by anyone, including staff, patients, volunteers, family members or legal guardian, friends, or other individuals. The health center Administrator is responsible for assuring that patient safety, including freedom from risk of abuse holds the highest priority. Definitions: Neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor/supervise the delivery of patient care and services to assure that care is provided as needed by the resident. Identification: Policy: Any patient event that is reported to any staff by patient family, other staff or any other person will be considered as possible abuse if it meets any of the following criteria: d. Any complaint of deprivation by an individual caregiver of goods and services necessary to maintain physical, mental, and psychological well-being to include toileting issues. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell . I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell . I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

Based on observation, interview, and record review the facility administration failed to administer the facility in a manner that enables it to attain and maintain the highest practicable physical well-being of each resident and to prevent medical neglect when the facility failed to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings include: Review of the job description for the Administrator with an effective date of 1/17/2022 reads, Purpose of your job position: The primary purpose of your position is to direct the day-to day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure the highest degree of quality care can be provided to our residents at all times. Delegation of Authority: As administrator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Duties and responsibilities: Administrative functions: Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities in accordance with guidelines issued by the VP (Vice President) of operations. Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the facility. Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice. Ensure that all employees, residents, visitors, and the general public follow the facility's established policies and procedures. Review of the job description for the Director of Nursing Services dated 9/9/2021 reads, Purpose of your job position: The primary purpose of your position is to plan. organize, develop, and direct the overall operation of our nursing service department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility and as may be directed by the administrator to ensure the highest degree of quality care is maintained at all times. Duties and responsibilities, Administrative functions: Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities. Develop methods for coordination of nursing services with other resident services to ensure continuity of the resident's total regime of care, develop, implement, and maintain an ongoing quality assurance program for the nursing services department, perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc. as necessary and monitor the facility's QI (quality improvement) QM (quality management) and survey reports. Assist in developing plans of actions to correct potential or identified problem areas. 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start [MEDICATION(S)] pending wound culture results. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: [MEDICATION(S)] <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For [CONDITION(S)] wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the [MEDICATION(S)] covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV [MEDICATION(S)] sooner had I been notified. I would have discontinued the [MEDICATION(S)] on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had [CONDITION(S)], but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, [MEDICATION(S)] trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, [MEDICATION(S)] trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [[MEDICATION(S)] trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose [MEDICATION(S)], I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical [MEDICATION(S)] trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the [MEDICATION(S)] dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The [MEDICATION(S)] is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell . I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell . I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI [Quality Assurance and Performance Improvement] when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. During an interview on 9/16/2022 at 9:05 AM the Administrator stated, I am ultimately responsible for the running of the facility, but the Director of Nursing is responsible for all the clinical operations. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

Based on observation, interview, and record review the facility failed to utilize the Quality Assessment and Process Improvement (QAPI) process when the administrative staff failed to investigate, develop, and implement appropriate plans of correction to identify and correct quality deficiencies of the facility failing to notify the physician of critical laboratory results, wound culture results and wound care needs resulting in a delay in care and treatment for 2 of 2 residents, Residents #29 and #42. Delay in wound care treatment can result in the spread of infection into the deeper tissues of the body, the infection can travel through the blood to other parts of the body and could become life threatening. Findings Include: 1. Review of the admission record documented Resident #29 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Tissue Analytics (TA) wound care note for Resident #29 dated 8/29/2022 reads, Sacral wound 1.97 cm [centimeters] x 3.33 cm x 0.20 cm cleanse with n/s [normal saline] Med Honey, calcium alginate cover with bordered gauze, daily. In house acquired 8/23/22, Recommendation: obtain wound culture d/t [due to] increased deterioration. Recommend start [MEDICATION(S)] pending wound culture results. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start med [medication] after wound is cultured for 7 days. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Critical result called to [Director of Nursing's (DON) name] on 9/2/2022 11:42 AM by [Laboratory technician's name]. Results were read back to caller. Site: Coccyx. Result: Heavy growth Gram Positive Cocci: Staphylococcus Aureus (isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Review of the nursing progress note for Resident #29 dated 9/2/22 at 1307 (1:07 PM) reads, ARNP [Advanced Registered Nurse Practitioner] aware of coccyx culture, awaiting final results and sensitivity for further evaluation of tx [treatment] plan. Review of the lab results report for Resident #29 dated 8/30/2022 titled Wound culture 1 reads, Report information: Collection date: 8/30/2022 02:30 [AM]; Received date: 8/30/2022 14:51 [2:51 PM]; Report date: 9/3/2022 10:08 [AM]. Final Report: Result: Heavy growth normal skin flora, heavy growth gram positive cocci. staphylococcus aureus (Isolate 1) This isolate is [CONDITION(S)] Resistant ([CONDITION(S)]). Moderate growth gram negative rods. Morganella Morganii spp morganii (Isolate 2), Proteus mirabilis (Isolate 3) Pseudomonas aeruginosa (Isolate 4). Sensitivity Analysis: [MEDICATION(S)] <=1 S for isolate 1. [Susceptible] There was no sensitivity analysis documented for additional isolates 2, 3 and 4. [A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection]. Review of the medical record for Resident #29 does not document the physician or Advanced Practice Registered Nurse (APRN) were notified of the final culture report dated 9/3/2022 through 9/7/2022. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . For [CONDITION(S)] wounds for 10 days in 0.9% NSS [normal saline solution] 100 ml [milliliters]. Review of the document from The IV Company for Resident #29 dated 9/8/2022 reads, Consultation: Reason for consultation: Midline; reason for insertion: drugs. Post insertion data -line removal: Line insertion: Midline Insertion site: left, attempts: 1; Cephalic, blood return: positive; internal length 15; arm circumference: 33. Comments: Midline left cephalic. No complications. Time in 1333 [1:33 PM], Time out: 1353 [1:53 PM]. During an interview on 9/14/2022 at 8:05 AM, the Director of Nursing (DON) stated, I did not call the nurse practitioner with the critical lab result of the wound. I gave it to the nurse. I don't see that the critical lab result was called. The lab result should have been called. I'm not sure why it wasn't. There is no progress note and no change of condition done. We failed this resident [Resident #29]. We did not do what we should have for the resident. I did not make sure that the staff called the practitioner. I was not aware that the final culture results weren't called. We should have called the results to the nurse practitioner. During an interview on 9/14/2022 at 10:38 AM, the Advanced Practice Registered Nurse (APRN) stated, I was not notified of any critical lab results. I saw the full wound culture report the day that I ordered the midline and antibiotics because the [MEDICATION(S)] covered everything that was present in the coccyx wound culture. I believe I was notified that the culture report was back on 9/7/2022. I would have changed the antibiotics to IV [MEDICATION(S)] sooner had I been notified. I would have discontinued the [MEDICATION(S)] on 9/3/2022 because it did not cover the other organisms. I would say this was a delay in care. He [Resident #29] definitely could have worsened without appropriate treatment and the appropriate antibiotics for his wound. I expect that all labs will be called so we can provide care that is appropriate for any given infection. During an interview on 9/15/2022 at 10:35 AM Staff F, Registered Nurse (RN) stated, I did speak with [APRN's name] on September 2, to let her know that the coccyx wound culture had [CONDITION(S)], but the rest of the culture was not available. I was not on the next several days and did not call the culture reports. There is no documentation that anyone called the doctor or the practitioner. They should have. I finally called [APRN's name] and she came in and ordered the midline and the antibiotics. Review of the lab results report for Resident #29 dated 9/11/2022 reads, [MEDICATION(S)] trough result: 5.4 mcg [micrograms]/ml [milliliter]. Critical lab result called to [Staff name] on 9/11/2022 1:40 PM by [Laboratory staff name]. Results were read back to caller. [Aiming for a level of < 1 mcg/mL approximately 6 hours prior to the next dose ensure there is a drug-free window in order to minimize drug accumulation within proximal tubules/major component of the kidney]. Review of the medical record for Resident #29 does not document the physician, pharmacist or APRN were notified of the critical laboratory result. Review of the lab results report for Resident #29 dated 9/12/2022 reads, [MEDICATION(S)] trough result: 2.6 mcg/ml. Critical lab result called to [Staff name] on 9/13/2022 at 11:47 AM by [Laboratory Staff name]. Results were read back to caller. Review of the medical record does not document the physician, pharmacist or APRN were notified of the critical laboratory result. During an interview on 9/15/2022 at 11:15 AM the Medical Director stated I understand that the culture reports were not called to the physician or mid-level. I told them that there were two different areas, and they are independent of one another, and no one should wait for another culture of a different area to come back. This is a breach of protocol and this needs to be improved. We have much space for improvement and training and education needs to be done for the staff. We need to reach a better-quality matrix for the residents, and I think we will. All critical lab reports should be called to the physicians. During an interview on 9/15/2022 at 3:10 PM the DON stated, It does not look like we have called these results [[MEDICATION(S)] trough results] to the pharmacist or the nurse practitioner. They are critical results and should be called immediately. We usually have a doctor's order to have pharmacy dose [MEDICATION(S)], I don't know why we don't. I see there were two critical results and neither of them were called when they should have been. During a telephone interview on 9/16/2022 at 9:22 AM the pharmacist stated, We were not informed of the critical [MEDICATION(S)] trough that was completed on 9/11/2022. We did attempt to contact the facility multiple times and have notes to indicate that multiple messages were left requesting that the nursing staff call us back and they did not. I see a note that we spoke to [Staff O, Licensed Practical Nurse's name] on 9/13/2022, we recommended that the [MEDICATION(S)] dose get reduced to 80 mg twice a day and a repeat peak and trough be completed after the second dose. We are having a hard time maintaining communication with the nurses. The [MEDICATION(S)] is currently on hold until we get another peak and trough and then we will decide further dosing. The potential side effects would be damage to the eight cranial nerves which would have an effect on hearing, causing possible hearing loss and nephrotoxicity [a rapid decline in kidney function due to toxic effects of medications]. During an interview on 9/15/2022 at 1:25 PM the Director of Nursing stated, I should have reviewed and brought both concerns to QAPI when we did not complete the skin assessments and when we needed to get midlines and antibiotics. We should have completed full house skin sweeps and identified any other concerns. Absolutely we should have investigated these and brought them to QAPI. We failed the residents, and we can do much better. Review of the policy and procedure titled Quality Assurance and Performance Improvement Program the last approval date of 12/7/2022 reads, Policy Statement: The facility shall develop, implement, and maintain an ongoing facility wide quality assurance and performance improvement program that builds on the quality assessment and assurance program to actively pursue quality of care and quality of life goals. Policy interpretation and implementation the primary purpose of the quality assurance and performance improvement plan is to establish data- driven, facility wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five strategic elements: 3. feedback, data systems and monitoring. A. Systems are in place to monitor care and services. B. Systems are designed to incorporate feedback from caregivers, residence, family, and staff as appropriate. C. Care processes and outcomes are monitored using performance indicators. These performance indicators are measured against quality benchmarks and targets that the facility has established. D. Adverse events are tracked, monitored, and investigated as they occur. E. Action plans are implemented to prevent recurrence of adverse events. QAPI action steps: 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include a. clinical outcomes: pressure ulcers, infections, medication use, pain, falls, etc. 14. Set measurable goals for improvement that may include percentage of reductions (or increases) from the measured baseline of a particular goal. 16. Recognizing patterns in systems of care that can be associated with quality problems. 17. Prioritizing identified quality issues based on risk of harm and frequency of occurrence and determining which will become the focus of PIPS [Performance Improvement Plans].18. Planning, conducting and documenting PIPS.19. Conducting root cause analysis to identify the issues that contribute to recognized problems. 20. Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provides significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. Review of the policy and procedure titled ANE (Abuse, Neglect and Exploitation) and Investigations issue date of 4/1/2022 reads Policy: It will be the policy of this facility honor resident rights and address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint not required to treat the residents symptoms in accordance with federal law. It will be the policy of this facility to ensure that all alleged violations of federal or state laws, which include mistreatment, neglect, abuse (verbal mental physical or sexual, injuries of undetermined source, involuntary seclusion, corporal punishment, misappropriation of resident property or funds or use of physical or chemical restraint) not in accordance with regulation to treat residents' symptoms will be reported immediately to the administrator/DNS abuse coordinator designee. Appropriate agencies will be notified in accordance with existing laws. Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 3. Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facilities designated abuse contact person as well as numbers for state agencies. This will be done through resident council, family council, in service training, one to one if indicated, information posted in the facility. The facility environment will be monitored to prevent any additional ANE through: Monitoring staff actions while caring for residents. The facility will monitor reported events to determine if any pattern, trend, or frequency exists to attempt to minimize the occurrence or injury. All events will be addressed at the monthly Quality Assurance Performance Improvement (QAPI) meeting. Review of the policy and procedure titled, Lab and Diagnostic Results - Clinical Protocol with an approval date of 1/27/2022 reads, Review by Nursing: 1. When test reports are reported to the facility, a nurse will first review the results. a. If staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. 2. Before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information and be prepared to discuss the following (to the extent that such information is available): c. Why the lab and diagnostic tests were obtained (for example, as a routine screening or follow up); to assess a condition change or recent onset of signs and symptoms, or to monitor a serum medication level; d. How test results may relate to the individual's current condition and treatment. 3. A nurse will identify the urgency of communicating, with the Attending Physician based on physician request, seriousness of any abnormality, and the individual's current condition. 4. A nurse will try to determine whether the test was done: b. To assess a condition change or recent onset of signs and symptoms. Identifying situations that warrant immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: Whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); Whether the resident/patients' clinical status is unclear or he/she has signs of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for physician notification: 1. A physician can be notified by phone, fax voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff) b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification. Review of the policy and procedure titled Change in Condition issued on 4/1/2022 reads Policy: It will be the policy of this facility to notify the physician, family, resident, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the residents wishes and physician orders. Procedure: 2. When a change is noted, gather pertinent data such as vital signs, weights, and other clinical observations. 4. When significant changes in skin condition or weight are noted it is appropriate to contact the physician and responsible party/resident representative if applicable to notify them and receive orders such as consultations, root cause analysis or implementation of further monitoring. 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. 2. Record review of the admission record documented Resident #42 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress note for Resident #42 dated 8/24/2022 at 5:49 AM authored by Staff E, Licensed Practical Nurse (LPN) reads This nurse heard noise come from pt. [patient] room. Entered pt. room visualized pt. on hands and knees at the side of the bed. Blood noted on floor, small amount of bleeding noted in right hairline, small bleeding area noted to right elbow. Assisted pt. back to bed. Bleeding to hairline stopped and steristrips applied. Bleeding area to right elbow cleansed and steristrips applied and dressing applied. Pt. denies any pain at this time. No other areas of discoloration noted at this time, ROM [range of motion] WNL [within normal limits], Vitals WNL. Neuro checks started. Left message for [Medical Doctor's name] on call service to notify, left message for Daughter [name]. Pt. resting comfortably in bed, bed in low position, call light and bedside table with fluids within reach. Review of the medical record for Resident #42 revealed no evidence of change in condition documentation, skin assessments or nursing progress notes indicating the physician or nurse practitioner were notified and wound care orders obtained. Review of the nursing progress note for Resident #42 dated 9/6/2022 at 10:45 PM reads, Swelling and redness noted to right elbow some serosanguinous discharge noted. No odor. This nurse dressed site until further evaluation. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 6:14 AM reads, Noted that skin tear from previous fall is reddened, painful and warm to touch, with serosanguinous drainage. Call placed to [APRN's name] to notify, awaiting call back with any new orders. Dressing orders clarified and dressing in place CDI [clean, dry and intact]. Review of the Nursing Progress note for Resident #42 dated 9/7/2022 at 11:25 AM reads, Skin tear from previous fall right elbow, red, warm, and tender. ARNP did a wound culture, cleaned, and applied new dressing awaiting orders. Review of the treatment administration record for the month of August revealed no evidence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record for the month of September documented treatment to the right elbow skin tear began on 9/7/2022. There were no other orders related to care for the right elbow skin tear. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of The IV Company document for Resident #42 dated 9/8/2022 reads Consultation: Reason for consultation: Midline: reason for insertion: drugs. Post insertion data - line removal: Line insertion: Midline Insertion site: left, attempts: 1; Basilic, blood return: positive; internal length 15; arm circumference: 32. Comments: Midline left basilic. No complications. Time in 1228 [12:28 PM], Time out: 1307 [1:07 PM]. Review of the lab results report for Resident #42 dated 9/13/2022 reads, Final Report: Microbiology report. Site: elbow right; Result: Staphylococcus aureus (isolate 1). During an interview on 9/13/2022 at 1:45 PM the DON stated, I see that there were no treatment orders in place for [Resident #42's name], after her fall. I do not see any provider notification or request for wound care orders for her skin tear. I see the culture and that she needed to have a midline and antibiotics for the infection of the skin tear. We should have asked for treatment orders, and we did not. I could see that you might consider that we did not provide her the proper care and it was part of the reason she needed the midline and antibiotics. I don't see any notes or a change of condition form in the chart where we notified the doctor or nurse practitioner until the arm was red and swollen. During an interview on 9/14/22 at 7:48 AM Resident #42 stated, I was having a lot of pain in my arm after I fell . I kept telling them, but they weren't listening. Finally, someone did and that's when they got the wound culture. No one would look at it when I asked and told them how much it was hurting me. They did not change the dressing on it at all. During an interview on 9/14/22 at 8:59 AM Staff E, Licensed Practical Nurse (LPN), stated, I did find her [Resident #42] on the floor. I heard a thud and found her on her knees on the floor. She had a skin tear and had a cut on her forehead. I assessed her and cleaned her forehead and right elbow. I was able to close the wound on her elbow with steristrips directly after she fell . I think I left a message for the nurse practitioner, but don't recall that she called back. We should follow up when a resident has any injuries and see if the practitioner wants any type of skin care done. I did not obtain any orders to treat her skin tear and I probably should have, but I did provide immediate treatment to her wounds. I did an assessment. I probably should have called the nurse practitioner back before I went off shift. During a telephone interview conducted on 9/14/2022 at 10:25 AM the APRN stated, I do not think that I was notified of the patient's fall until 9/6/2022 late in the evening, a nurse notified me that she had a red and draining arm from the skin tear. I gave orders for treatment and saw her the next day when I took a wound culture. I was not called and asked for any wound treatments prior to that time. I absolutely feel that the wound became infected due to a lack of wound care and that she would not have required additional treatments had she been provided daily wound care. I do feel this was a delay in treatment and caused a need for additional, more invasive treatments. I expect that staff will inform me of any changes in patient condition. All skin concerns should be addressed, and we should be called. During an interview conducted on 9/14/2022 at 2:10 PM the Regional Nurse Consultant stated, We have not provided change of condition notification to the providers for [Resident #42 and #29's names]. We were notified of the critical lab results for [Resident #29's name]. We did notify the provider. There is a note in the chart, but when the final culture was back, we did not call the provider. I don't see that there was information about whether the additional sensitivities were sensitive to the oral antibiotic he [Resident #29] was on. We should have called. There is no excuse that I could give you for why they weren't notified. [Resident #42's name] was not provided any wound care after the skin tear. We should have notified the physician or nurse practitioner and we should have gotten orders for wound care. I can't give you any clear reason why this was not done. She did have a need for a midline and antibiotics because the wound became infected. We did not do what we should have. Review of the policy and procedure titled Wound Care issue date of 4/1/2022 reads, Policy: It is the policy of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Skin will be assessed/evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. 11. Document the progression of the wound being treated. Such observations should include items size, staging (if applicable), odors, exudate, tunneling, etiology, etc. 12. Contact the physician for additional order changes as is appropriate or to notify of skin condition changes or refusals of care. The Immediate Jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan. The survey team verified the facility's actions for removal of immediacy to prevent the likelihood of harm and/or possible death: Residents #29 and #42 were assessed for skin impairments and their physicians were notified on 9/13/2022. Ad Hoc QAPI [Quality Assurance Performance Improvement] was held on 9/13/2022 attended by Medical Director, Administrator, Director of Nursing, Infection Preventionist, and Social Services Director to implement a performance improvement plan. The facility has conducted root cause analysis on 9/14/2022 for delay in treatment and neglect. The facility completed skin assessments on 93 residents for any wound concerns and obtained orders for three additional residents identified with concerns. On 9/14/2022, the Administrator and Director of Nursing were educated by the Regional Director of Clinical Operations on the components of administration to include monitoring of facility systems during administrative/clinical stand up and standdown to identify areas that may rise to the level of investigating ANEMMI. By 9/16/2022, the facility trained 28 of 28 licensed nursing staff on change in condition, skin and wound care and abuse and neglect, which was verified through staff interviews.

Based on observation, interview, record review, and review of CDC (Centers for Disease Control and Prevention) guidelines, the facility failed to implement an infection prevention and control program to follow infection control precautions to prevent three residents (Residents #1, #2, #3) from potential exposure to COVID-19 (Coronavirus Disease 2019), a highly contagious and potentially deadly virus for people over [AGE] years of age, by failing to implement transmission-based precautions. The facility failed to follow the policies and procedures to ensure required personal protective equipment was used and failed to ensure hand hygiene was performed before and after resident contact. Individuals who are [AGE] years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing and might require intensive care for the treatment of [REDACTED]. COVID-19 infection can lead to death. COVID-19 is a new disease, caused by a new coronavirus that has not previously been seen in humans. As a result of the deficient practice related to transmission-based precautions, 3 residents with whom the Advance Practice Registered Nurse came in contact with on February 24, 2021 of a total of 22 residents to whom the Advance Practice Registered Nurse provides services, were at risk for developing a communicable disease (COVID-19). Findings: On 02/24/2021 at 9:56 AM, signage was observed posted on Resident #1's room door, reading, N95 Required. Stop Stop. DROPLET PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. On 02/24/2021 at 9:57 AM, Staff A, APRN (Advanced Practice Registered Nurse), was observed entering Resident #1's room. Staff A was wearing an N95 respirator. Staff A did not don a face shield or goggles, gloves or a gown. The APRN was observed in the resident's room having a conversation with the resident. At 9:59 AM, Staff A exited Resident #1's room, and proceeded down the hallway to Resident #2's room. Staff A did not perform hand hygiene after exiting Resident #1's room. At 10:00 AM, Staff A entered Resident #2's room, did not perform hand hygiene and was observed having a conversation with Resident #2. Staff A exited Resident #2's room and proceeded to Resident #3's room. Staff A did not perform hand hygiene after exiting Resident #2's room. At 10:01 AM, Staff A entered Resident #3's room, did not perform hand hygiene. Staff A stood in close proximity to Resident #3. Staff A picked up Resident #3's television remote control from the floor, adjusted Resident #3's call bell receptable, and repositioned the Resident's pillow. Staff A then exited Resident #3's room. Staff A did not perform hand hygiene after exiting Resident #3's room and proceeded to walk up the hall. During an interview on 02/24/2021 at 10:08 AM, Staff A, APRN, stated he had seen the signage posted on Resident #1's room door. He stated he was not wearing eye protection and did not wash his hands prior to entering Resident #1's room. He confirmed he had not performed hand hygiene after he exited Resident #1's room. He confirmed he had not washed or sanitized his hands before entering or after exiting Resident #2's room and Resident #3's room. During an interview on 02/24/2021 at 10:36 AM, the Infection Preventionist stated face shields were available in the facility. She stated individuals working in the facility should complete hand hygiene as they move from one room to another. There was hand sanitizer available outside of the residents' rooms. Staff A should have come out of Resident #1's designated droplet precautions room and used hand sanitizer immediately and then wash his hands. The facility expectation was individuals complete hand hygiene before going into residents' rooms. There was risk of exposure if a staff member entered a room without the proper personal protective equipment. She stated even though an individual was not symptomatic, the individual could still pass the COVID-19 virus. The failure to complete hand hygiene and wear proper personal protective equipment could result in a potential outbreak of infection. Staff A had committed a prevention infraction that could lead to the spread of the COVID-19 virus. She added the facility had provided education to providers in the past that required the provider staff to wear full personal protection. She clarified that providers included the nurse practitioners that come into the facility to provide services. During an interview on 02/24/2021 at 11:10 AM, the Administrator stated Resident #1 had been placed on droplet precautions because of exposure to an employee who had worked with Resident #1 and who had tested positive for COVID-19 on 02/17/2021. She stated Staff A's failure to follow infection prevention and control practices by failing to wear proper personal protective equipment and complete hand hygiene was completely unacceptable. Staff A's failure to follow infection prevention and control practices by failing to wear proper personal protective equipment and complete hand hygiene had the potential to endanger residents because an infection could spread from one resident to the next resident. During an interview on 02/25/2021 at 12:15 PM, the Medical Director (MD) stated, I have been the Medical Director for the last [AGE] years. I have discussed and spoken with the APRN (Staff A's name). He has been coming here for the last two years. When asked the expectations of the practitioners related to infection control guidelines, the MD stated, I expect them to follow all the rules of the facility and all the competencies. I have trained him on the COVID infection control protocol and guidelines. He knows the guidelines and I expected that he should have washed his hands and applied the necessary PPE. I am terminating him. I provide education every month regarding COVID. We train all of our employees to follow the CDC guidelines and the OSHA (Occupational Safety and Health Administration) protocols. Review of the facility's In-Service Attendance Record titled PPE Vendors, dated 12/08/2020, read, All vendors to include MD, PA (Physician Assistant), ARNP (Advanced Registered Nurse Practitioner) . must be in full PPE to include gloves, gown, mask and face shield while rounding in facility seeing patients. The in-service record documented Staff A's signature. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions (Last Reviewed: 11/18/2020) read, Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation: Droplet Precautions: 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets {larger than 5 microns in size} that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning). 2. Residents on droplet precautions will be placed in a private room if possible. a. When a private room is not available, residents may share a room with a resident infected with the same microorganism or with limited risk factors. b. When a private room is not available and cohorting is not achievable, a curtain will be used and a distance of at least 3 feet of space will be maintained between the infected resident and his or her roommate. c. Special air handling and ventilation are unnecessary and the door to the room may remain open. 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. Review of the facility policy titled Handwashing/Hand Hygiene (Reviewed: 11/18/2020) read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . k. After handling used dressings or contaminated equipment, etc. l. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident, . n. Before and after entering isolation precaution settings. Review of Resident #1's clinical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's physician's order dated 02/18/2021 read, Follow droplet precautions. Review of Resident #1's facility medical record revealed the resident was last identified as COVID-19 positive on 09/04/2020. Record review of Resident #2's clinical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #3's clinical record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an undated COVID-19 test log provided by the facility showed a total of 113 facility residents had tested positive since 06/24/2020 and a total of 90 facility staff had tested positive since 06/26/20. Review of the CDC Guideline titled Preparing for COVID-19 in Nursing Homes, dated November 20, 2020 (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html), read, Residents with known or suspected COVID-19 should be cared for using all recommended PPE (Personal Protective Equipment), which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. --------------------------------------------------------------------------------------------------------------------- The scope and severity of the deficiency was lowered to D, with no actual harm with more than minimal harm that is not immediate to residents as evidenced by the facility's performance improvement plan: 1. The facility removed the APRN from the facility and tested him for COVID-19 and notified the physician, with whom the APRN worked, on 02/24/2021, 2. The facility placed the residents, with whom the APRN had contact, on isolation precautions for possible exposure to COVID-19 and notified the families of the residents involved in the incident for the need to place the residents in precautionary isolation on 2/24/2021. 3. The facility tested 76 of 84 residents for COVID-19 using a rapid test following the infection control infractions. The 76 residents had negative results for COVID-19. 4. The facility started education of the staff related to hand hygiene and the use of personal protective equipment on 2/24/2021. At the time of exit, the facility provided education to 24 of 24 licensed nurses, 36 of 59 CNAs (Certified Nursing Assistants), 8 of 11 housekeepers, 18 of 19 therapists, 8 of 9 dietary staff, and 21 external providers to include MDs, APRNs, PICC (Peripherally Inserted Central Catheter) line insertion technicians, radiology technicians, podiatry and hospice workers. It was posted that the staff who have not completed the required training are not to start work on the floor until the training is completed.