Every finding on record at Clay Healthcare Center

Based on observation, policy review, Centers for Disease Control and Prevention (CDC) review and staff interview, the facility failed to ensure that drugs and biologicals used were labeled in accordance with currently accepted professional principles, including appropriate accessory and cautionary instructions, and the expiration date when applicable. This had the potential to affect more than an isolated number of residents. Facility census: 54. Findings included: a) On 08/11/26 at 11:44 AM, a Tubersol/Tuberculin Purified Protein Derivative (PPD) injectable vial was observed in the medication storage refrigerator. Date opened written on the vial/box was 07/07/26. Interview with Nurse #65 LPN confirmed Tubersol/Tubeculin PPD injectable vial was dated as opened on 07/07/26 and said that was beyond the 30 day policy. A review of the facility policy titled Storage of Medications effective September 2025 Policy #4.1 stated, Certain medications or package types, such as IV solutions, multiple dose injectable vials, require both an opened date and an expriation date, which may be shorter than the manufacturer's expiration date to insure medication purity and potency. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expration date unless the medication is in a multi-dose vial When the orginial seal of a manufactuer's contanienr or vial is itially broken, the nurse shall label the medication witht the date opened and the new date of expiration. The facility may use stickers that include notationl lines for the date opened and the expriation date. The expriation date of the vial or container will be 30 days unless the manurfactuer recommends another date or regulations/guildenss reqauire different dating According to the Centers for Disease Control and Prevention, an opened multidose vial of PPD is good for 30 days after its initial puncture, even if there is still solution left.

Based on record review, and staff interviews, the facility neglected to provide the amount of assistance and supervision needed to prevent a resident from aspiration. On 05/22/25 at 6:00PM, the state agency notified the facility of the finding of past-noncompliance Immediate Jeopardy (IJ) that began on 03/19/25 and ended on 03/24/25. The deficient practices caused actual harm to Resident #16. The facility's neglect of the resident created a case of physical harm. The resident required transfer to the emergency room for evaluation and had to undergo medical testing. Resident identifier: #16. Facility census: 53. Findings included: a) Resident #16 Medical Record Review (MRR) revealed Resident #16 had resided in the facility since 2018. He did not have the capacity to make medical decisions. According to the Minimum Data Set (MDS) the resident's Brief Interview for Mental Status (BIMS) score was 3, indicating cognitive impairment. The resident had diagnoses of Neurocognitive Disorder with Lewy Bodies Disease, Aphasia following cerebrovascular disease, Dysphagia , Major Depressive Disorder, Recurrent, Visual Hallucinations, Dysphagia Oral Phase, Anxiety Disorder, Need for Assistance with Personal Care, Dementia, Parkinson's Disease with Dyskinesia, with Fluctuations, and Cognitive Communication Deficit. On 03/20/25 at 12:46 AM, the facility submitted a facility reported incident (FRI) to the state agency. The report revealed the following: On 03/19/25 at 12:15 PM in the dining room, Resident #16 was found drooling, not breathing, and was cyanotic (blue). This was reportedly observed by Activities Leader (AL) #72. AL #72 immediately notified nursing staff. The Heimlich Maneuver with finger sweep was performed by Licensed Practical Nurse (LPN) #54 without success. After moving the resident to the hallway, Licensed Practical Nurse (LPN) #53 performed the Heimlich Maneuver and finger sweeps again without success, 911 was called. Resident #16 was transferred to his room where RN #88 performed another finger sweep and suctioned the resident with partial success. The resident was transferred to a local emergency department. Resident #16 was found to have aspiration pneumonia and a thoracic aortic aneurysm. The family declined any further interventions. The resident was transferred to the facility with antibiotics and hospice level of care. An investigation was initiated. The five (5) day follow-up investigation contained the following additional information: It had been determined there was a system failure for which the facility had taken immediate action to address. Witness statements were obtained and interviews were conducted with all staff involved in the serving of residents in the facility on the day of the incident. The facility's plan of correction initiated 03/20/25 was as follows: On 03/20/25, the Director of Nursing (DON) started an in service with all staff on level of assistance with meals, types of diets, ensuring the resident is receiving appropriate assistance, ensuring resident meal on tray matches ordered diet consistency and awareness that meal tickets are no longer printing highlighted or in red. On 03/20/25, the Activities Supervisor started an in service with all activities staff on requirements for resident's requiring assistance and allowing clinical staff to set these residents up with meals as they are prepared to assist them with their meal. On 03/20/24, The Certified Dietary Manager(CDM) started an in service with all dietary staff on ensuring that the food served matches diet order on meal ticket. As of 03/24/25, staff in services were completed. To prevent other residents who require assistance with full assist feeding, either the RN, LPN or NA that takes the tray to the resident, will be the person who will assist and/or feed the resident until the meal is completed. New CNA and Nursing employees orientation will include instruction upon meal delivery process to include diet texture and full assist definition by the DON or designee. Clinical staff also will receive follow up competency check off sheet through Relias training. On 03/20/25, The DON completed audits of all diets in the system to ensure they matched and reviewed with the CDM to ensure meal tickets also reflected. The CDM is monitored texture modification of food daily for two weeks. The CDM conducted tray line audits two times a week for four weeks. Starting 03/20/2025,The DON and ADON will be performing audits twice a week on the floor to ensure diet orders match the food texture served and those who require assistance with eating are receiving the appropriate level of care. On 3/20/25,The DON will be reviewing audit weekly with the CDM. A review of the Emergency Department (ED) Information/Report revealed the resident presented on 03/19/25 to the emergency department with a chief complaint of aspiration of turkey. The resident was hypoxemic and was. His oxygen saturation was 67%. The ED noted, He must have passed the bolus on down somewhere because his O2 sats picked up to 90. The resident was diagnosed as having Aspiration Pneumonia. The residents' family elected not to have aggressive measures taken to remove the turkey that was stuck in his right mainstream bronchus. He was discharged back to the nursing home with antibiotics and hospice care. The facility provided evidence of pre-incident training for Nurse Aide (NA) #72. The NA had received training on feeding assistance, tray/ticket breakdown and I information and tray pass services. On 03/24/25, a corrective action form was completed for NA #71. She was disciplined with a verbal warning for performance/policy violation for serving a tray to a full feed assist resident and not providing the correct level of assistance not validating that the resident's meal consistency matched the meal ticket. A review of the facility definition/policy of neglect revealed the following: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical, and emotional needs and concerns of the residents. It is the intent of this facility to prevent the abuse, mistreatment, or neglect of residents or the misappropriation of their property, corporal punishment and/or involuntary seclusion and to provide guidance to direct staff to manage any concerns or allegations of abuse, neglect, or misappropriation of their property. In the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. Neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that necessary to avoid physical harm, pain, mental anguish, or emotional distress. WV code 9-6-1 defines neglect as the unreasonable failure by a caregiver to provide the care necessary to assure the physical safety or health of an incapacitated adult; or provide the care necessary to assure physical safety or health of and incapacitated adult; or unlawful expenditure or willful dissipation of the funds or other assets owned or paid to, or for the benefit of, an incapacitated adult or resident. The facility's updated Meals Policy Inservice dated February 2025 gave the following procedures and instructions: It is the responsibility of nursing staff when passing trays to verify that residents' meals are accurate according to what is on the meal ticket. Nursing staff must also ensure that residents are receiving the appropriate textured foods and level of assistance with meals. Trays are not to be set in front of a full feed assist resident unless a clinical staff is present and ready to feed. Clinical staff providing full feed assist are to remain with the resident from the time the tray is dropped off until the meal is completed. Clinical staff providing full assistance to residents during meals are to provide observation, cueing, and assistance to ensure appropriate bite size, rate of feeding, and use of liquid wash. On 07/02/24 Resident #16 was referred to Speech Therapy (ST) due to new onset of coughing/choking during oral intake indicating the need for ST to assess/evaluate least restrictive oral intake, analyze oral/pharyngeal function, develop and instruct in compensatory strategies, teach/instruct in environmental modifications and instruct family/staff in compensation techniques. The risk factors included Due to documented physical impairments and associated functional deficits, the resident was at risk for aspiration. It was recommended that the resident have supervision for oral intake. It was recommended that he have rate modifications and bolus size modifications upright posture during and upright posture for 30 minutes after meals. It was noted that staff and caregivers would be provided training regarding diet texture and positioning to enhance safety On 09/19/24 the resident was referred to Speech Therapy again for a dysphagia evaluation due to concerns of silent aspiration. The following risk factors were discussed Due to the documented physical impairments and associated functional deficits, the patient is at risk for aspiration, further decline in function, increased dependency upon caregiver, pneumonia and weight loss. The resident and primary caregivers were trained and instructed on safe swallowing, bolus size reduction, upright positioning and alternating solids and liquids. When the resident was given a cup to hold himself, he was described as not utilizing rate mod requiring max verbal cues. He was recommended to have close supervision for oral intake, full feeding assistance and to be in the dining room for lunch and dinner. A medical record review revealed the resident was on a speech therapy caseload at the time of the choking incident. On 03/20/25 due to the change in the resident's medical condition, he was discharged from Speech Therapy. A Speech Therapy final evaluation was on 03/20/25. Medical Record Review (MRR) revealed that on 03/20/25 Resident was discharged from Speech Therapy to Hospice. The MRR revealed on 10/04/24 the resident had an order for a regular diet dysphagia advanced texture with thin liquids and a raised lip plate with all meals. He was also supposed to have fortified foods with meals and was considered to need full feeding assistance related to his dysphagia. The resident's care plan review revealed a care plan dated 12/27/24 that said the resident was dependent in the area of eating with the helper doing all the effort. Nurse Aide (NA) # 71 was interviewed via phone on 05/22/25 at 11:00 AM. She stated she did take Resident #16 his tray and noticed the meat was not totally ground up but was in longer strips. She said she cut the turkey into smaller pieces and stated she would have fed him, if she had not been assigned to Resident #36 that day. She did not remember which staff told her to feed Resident #36. While feeding Resident #36, she stated she was not able to see Resident #16's face because his back was to her at the table. She stated she was told previously that Resident #16 was ok to eat on his own, unsupervised in the dining room where he could sit upright but was a full feed assist if he was fed in his room. NA #71 stated she did not remember full feed training before the incident but was trained 2 days afterward. She stated, We are trying so hard to feed all full feed assists. NA #71 said she felt there was not enough staff. During an interview with Activities Leader #71 on 05/22/25 at 10:00AM, she stated she did not feed the residents, and she was not the one who checked Resident #16's tray, but she did check tray tickets to make sure everything was right on the tray and to make sure the residents receive the correct meal according to their meal ticket. On the day of the incident, after she checked tray tickets, she walked around to check to see if anyone needed her help when she approached Resident #16. She said he was not breathing and was choking on a piece of turkey. She said she saw it hanging out of his mouth. His face and lips were blue. She stated that was when she screamed for help. She stated she had training to check the tickets and check the meal prior to the incident in the dining room and had since been re-trained within two (2) days after the incident. On 05/22/25 at 2:30PM, in an interview with NA #23, she explained one process of full feed assist, that she had helped Resident #16 with eating. She stated she had been in-serviced after the choking incident. The Regional Operations Coordinator (ROC) was interviewed on 5/21/25 at 3:00 PM. She stated there was a meal service system failure as Resident #16 was to have ground meat and was a full feed assist, but the turkey was not completely ground. The ROC said, Resident #16's tray was set up by the NA who cut the meat into smaller pieces, then left him to eat without supervision instead of being fed by a staff member. In an interview with Speech Therapy (ST) on 05/22/25 at approximately 2:00 PM, she stated that Resident #16 had been seen by ST at different times since admission. ST stated Resident #16 had issues with wanting to bolus (a soft , rounded mass of chewed food or liquid that is ready to be swallowed) food and drink and therefore recommended he be a full feed assist.

Based on observation, medical record review and staff interviews, the facility failed to maintain an effective infection control program. Failed to complete hand hygiene after removing gloves and did not re-glove when providing care for a resident who was on enhanced barrier precautions (EBP). In addition, ten (10) Personnel Protection Equipment (PPE) Storage Bins were sitting directly on the hallway floor. Three (3) wheelchairs were found with cracked arm rests and could not be sanitized. A Nurse Aide (NA) did not perform hand hygiene prior to feeding a resident. These failed practices had the potential to affect more than a limited number of residents. Resident identifiers: #15, #16, and #30. Facility census: 53. Findings included: a) Resident #15 On 05/19/25 at 11:35 AM, an observation revealed NA's #64 and #24 performed Foley catheter care for Resident #15. Resident #15 was on EBP for the Foley catheter. NA #64 and #24 completed catheter care per policy and then removed gloves. They did not perform hand hygiene nor put on a new set of gloves as they pulled up the pajama bottoms, straightened linens, etc. When asked if they normally take off contaminated gloves and complete their task with no gloves both stated No. Both stated that they were nervous, and both agreed that they change gloves after catheter care and put on new gloves to finish providing care. On 05/19/25 at 2:19 PM a random opportunity for discovery found PPE Storage Bins were sitting directly on the floor outside of resident rooms who were on EBP. There were ten (10) storage boxes throughout the building. An interview with the Regional Operations Coordinator Registered Nurse (ROCRN) #87 on 05/19/25 at approximately 10:00 AM revealed the ROCRN said no when asked if the PPE storage bins were to be sitting on the floor. c) Resident #16 On 5/13/24 at 2:20PM, during an observation of Resident #16's room, it was observed that his wheelchair had cracks around the edges of arm pads exposing inner padding. After leaving Resident #16's room, observation revealed an extra wheel chair sitting at the end of the 100 hallway was discovered to have a small round hole in the seat with exposed padding. An observation of Resident #16s lunch tray delivered at 12:00 PM revealed the Assistant Director of Nursing took Resident # 16s tray to his room and asked for assistance with his positioning. She raised his bed up via buttons and assisted with repositioning him in bed then touched his bedside table to adjust height to accommodate for feeding him. She then began to feed him without changing her gloves nor washing her hands. On 05/13/25 at 12:10PM, during an interview with the ADON regarding hand hygiene, she acknowledged she did not wash her hands and change her gloves between adjusting the bedside table and bed height and positioning the resident before feeding him. d) Resident #30 During an observation of Resident # 30's room on 5/19/25 at 12:20 PM, it was observed that his wheelchair had a crack in the top of the chair back with exposed inner padding. In an interview with the ADON on 5/13/25 at 2:30PM, she acknowledged Resident #16's w/chair and stated it needed to be removed. She also acknowledged the hole in the cushion on the wheelchair in the hall and stated it was just an extra chair but did agree that it would be used for a resident when/if needed. On 5/19/25 at 12:30 PM, During an interview with The Regional Operations Coordinator. She acknowledged the crack in the top of the chair back on Resident # 30's wheelchair and stated it would be taken care of.

Based upon record review, staff interview and resident interviews, the facility failed to maintain an accurate medical record. This was found to be true for two (2) of seventeen (17) records reviewed during the annual survey process. Resident identifiers: #50 and #51. Facility census: 53 Findings included: a) Resident #50 A Bed safety evaluation completed on 05/02/25, marked no for floor mats. Resident #50 ' s orders and care plan have one floor mat documented on the right side of bed. A visual observation of the resident's room on 05/22/25 during the morning hours, found a floor mat on the right side of the bed. The floor mat intervention was implemented following a post fall of the resident on 04/28/25, according to the resident's care plan. This was reviewed with the Regional Operations Manager on 05/20/25 in the afternoon, who said she would check into it. b) Resident #51 West Virginia POST form was completed on 02/14/25 for Resident #51. Resident's gender was identified as a Female. MDS screening upon admission, under Section A Demographics, showed the resident was a male. This discrepancy was reviewed with the Director of Social Services on 05/20/25 in the afternoon. The Director of Social Services had no comment to make when the error was pointed out.

Based on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident's room. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 53. Findings include: a) Resident #19 During facility entrance on 05/13/25 at 2:03 PM, an observation in room [ROOM NUMBER] revealed Resident #19 was sitting up on the side of her bed. She asked for assistance to find her call button. She stated she needed to get some help for her roommate. Upon checking around, the call button was found on the floor under the bed and out of the resident's reach. On 05/13/25 at 2:13PM, in an interview with CNA #24 she acknowledged the call button was not within reach of the resident and stated that sometimes residents knock them off the bed. She then placed the call button back on the bed without securing it. On 5/13/25 at 2:30PM during an interview with the DON, she acknowledged she had been made aware of the call light not being within Resident #19's reach.

Based upon record review and staff interview, the facility failed to update the Pre admission Screening and Resident Review (PASARR) when the resident was diagnosed with Major Depressive disorder. This was found to be true for one (1) resident of the four (4) reviewed during the annual survey process. Resident identifier #53. Facility census: 53 Findings included: a) Resident #53 Record review revealed Resident #53 had a diagnosis of Major Depression dated 01/28/25. A new PASARR should have been updated with diagnosis of Major depressive disorder following diagnosis received on 01/28/25 Resident #53 had a Care Plan developed on 01/28/25 for major depressive disorder. The PASARR and resident diagnoses were reviewed with the Director of Social Services on 05/20/25 in the afternoon. She agreed the PASARR should have been updated.

Based on record review and staff interview, the facility failed to have a diagnosis of depression for the order of an antidepressant medication. This was true for one (1) of seventeen (17) residents reviewed during this annual survey process. Resident identifier # 258. Facility census: 53 Findings included: a) Resident #258 The medical record revealed the resident had an order for Duloxetine 60 milligrams (1 capsule by mouth at bedtime) for depression. This order was had an active date of 05/08/25. A review of the Medication Administration Record (MAR) revealed the Duloxetine 60 mg had been discontinued on 05/18/25. A review of the care plan revealed the resident used an antidepressant related to depression. This was dated 05/14/25. A pharmacy review revealed that the physician did not want to attempt a gradual dose reduction on the Duloxetine because the resident had recently started the antidepressant. This finding was reviewed with the Regional Operations Manager on 05/20/25 late in the afternoon.

Based on record review and staff interview, the facility was unable to provide evidence that the attending physician reviewed any irregularities identified by the pharmacist and either accepted or rejected the recommendations. This was true for two (2) of five (5) residents reviewed under the Unnecessary Medications pathway in the Long-Term Care Survey Process. Resident identifiers: #30 and #52. Facility census: 53 Findings included: a) Resident #30: On 05/17/25 10:58 AM, during Medication Regimen Review two pharmacist reviews dated 01/24/25 and 02/04/25 were located. The facility could not provide the pharmacist consult report that contained the recommendations they made nor the Physician response to those recommendations. In an interview with the Regional Director of Operations Coordinator (RDOC) on 03/17/2025 at 11:50PM, she stated she was not able to provide the pharmacist recommendations nor the physician response for recommendations dated on 01/20/25, and 02/04/25. b) Resident #52: On 05/19/25 at 12:10PM during review of the Medication Regimen Review for 01/28/25, the facility could not provide the pharmacist consult report nor the physician response to the pharmacist recommendations. On 05/19/25 at approximately 1:35PM the RDOC stated she was unable to provide the physician response and signatures for the pharmacist recommendations.

Based on observation and staff interviews, the facility failed to store food in accordance with professional standards for food service safety. This was a random opportunity for discovery with the ability to affect a multiple number of residents. Facility census: 53. Findings include: a) On 05/13/25 at 9:40AM, during the kitchen initial visit, employee personal items such a purse, keys, and a jacket were observed on a chair in the kitchen pantry room. In an interview with the Corporate District Manager at 9:50AM on 5/13/25, he acknowledged the personal staff items on the chair in the pantry, stating staff had been using this corner for personal items. On 5/14/25 at 3:35PM, during an interview with the Corporate District Manager, he stated personal items were no longer allowed to be stored in the kitchen pantry room.

Based on observation and staff interviews, the facility failed to ensure disposal of garbage and refuse was properly contained in the kitchen pantry and in dumpsters with lids closed or covered. This was a random opportunity for discovery with the possibility of affecting multiple residents. Facility census: 53. Findings included: a) On 05/13/25 at 9:30 AM, it was observed in the dish room that a trash receptacle lid at the hand washing station was blocked by a box sitting on top. This blocked staff's ability to dry hands without contamination. In an interview with The Corporate District Manager on 05/13/25 at 9:32AM, he acknowledged the box sitting on the top of the trash receptacle was blocking the ability to dry hands without contamination and removed the box stating it should not have been there. On 05/13/25 at approximately 10:35 AM, it was observed that the dumpster lid was left open while not in use. During an interview on 05/13/25 at 10:40 AM, with the Assistant Director of Nursing (ADON), she acknowledged the dumpster lid was not in use but the lid was left open.

Based on policy review, medical record review and staff interview, the pharmacist failed to identify an incomplete order for risperidone (atypical antipsychotic with no indication for use). In addition the Medication Regimen Review (MRR) policy lacks specific time frames for the different steps in the review process. This is true for one (1) of five (5) reviewed for unnecessary medications. The policy has the potential to affect all residents in the facility. Resident identifier: #36. Facility census: 55. Findings included: a) MRR Policy The facility's MRR policy # NS 1218-01 lacks time frames for the different steps in the process when an irregularity is identified. The policy was reviewed with the Regional Director of Clinical Operations (RDCO) #105 during an interview on 11/01/23 at 12:34 PM. The RDCO confirmed the policy lacks time frames for the different steps in the review process. b) Resident (R) #36 Review of the physician orders on 11/01/23, revealed the following order written on 01/17/23: Risperidone oral tablet 1 milligram (mg). Give 1 mg by mouth two times a day. The order lacks an indication/diagnosis for use or administration. The MRRs were completed monthly by the pharmacist form 01/30/23 through 10/12/23. The pharmacist failed to identify the incomplete order for Risperidone during each of these reviews. On 11/01/23 at 11:51 AM the Regional Director of Clinical Operations (RDCO) #100 confirmed the Risperidone order for R#36 lacked a diagnosis or indication for administration. RDCO #100 acknowledged the pharmacist failed to identify the incompete order during monthly MRR.

Based on the pharmacy services agreement, medical record review and staff interview, the facility failed to ensure routine and emergency medications were available to meet the residents' needs. Paxlovid was not available to treat a Covid positive resident and Tylenol with Codeine was not available to treat a resident's pain after a fall. This is true for one (1) of one (1) reviewed for Covid and one (1) of three (3) residents reviewed for falls. Resident identifiers: R#43 and R#2. Facility census: 55. Findings included: a) Resident (R) #43 A review of the medical record on 10/31/23, found R #43 was Covid positive on 10/27/23. The Nurse Practitioner (NP) prescribed Paxlovid. The order written on 10/27/23 stated: Paxlovid 300/100 oral therapy Pack 20 x 150 milligrams (mg) and 10 x 200 mg. Give one dose by mouth two times a day for Covid 19 for 5 Administrations. Give 300 mg nirmatrelvir and 100 mg ritonavir with each dose. The medication administration record (MAR) is coded with a 9 for administration on 10/27/23 at 9:00 PM and 10/28/23 at 9:00 PM. The code 9 refers the reader to the progress notes. The progress notes state the prescribed Paxlovid was unavailable. On 10/29/23 at 9:00 PM the MAR is coded with a 5 indicating the medication was on hold and for the reader to review the nurse's notes. The progress note written at 8:30 PM on 10/29/23 states the Paxlovid was unavailable. On 10/30/23 at 8:59 AM the Paxlovid order was discontinued because it was never obtained from the facility pharmacy. During an interview on 10/31/23 at 12:00 PM, Regional Directors of Clinical Operations (RDCO) #100 and #105 confirmed the Paxlovid was never obtained from the facility's contracted pharmacy. RDCO #100 confirmed the facility and the contracting pharmacy did not attempt to obtain the Paxlovid from another source. b) Resident (R) #2 The facility's Pharmacy Services Agreement signed 08/21/23, states the pharmacy will deliver to the facility any prescriptions and supplies at least daily, Monday through Saturday, with additional deliveries if emergencies arise. Review of the medical record on 10/31/23, revealed an order written on 10/09/23 at 10:00 PM for Tylenol with Codeine #3 one (1) tablet three (3) times a day for pain for 15 days. The medication administration record (MAR) notes the medication was not available to be administered until 10/10/23 at 12:00 PM. The NP wrote on 10/10/2023 at 7:41 AM, the resident in visible discomfort, is restless and uncomfortable. He is struggling to sit upright. He has a new order for Tylenol with Codeine but the pharmacy did not deliver due to holiday. Ordered Tramadol 50 mg x one dose until medication can be obtained. On 11/01/23 the facility's Cubex medication tower inventory sheet was reviewed. Tylenol with Codeine #3 is not stocked and readily available for administration for resident's pain. The above findings were reviewed with Regional Directors of Clinical Operations (RDCO) #100 and #105 on 11/01/23 at 11:00 AM. RDCO #105 confirmed Tylenol with Codeine #3 is not stocked in the facility's Cubex and the prescribed pain medication was not delivered and available for administration until 10/10/23 at 12:00 PM.

Based on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan, developed and implemented, with specific interventions of care to address the resident's medical, physical, mental, and psychosocial needs for three (3) of 18 sample residents reviewed. Resident #28's and Resident #104's care plan failed to address specific non-pharmacological approaches to anxiety. Resident #34's care plan failed to have specific Hospice approaches addressed. Resident identifiers: Resident #34, #104 and #28. Facility census: 55. Findings included: a) Resident #28 A record review, for Resident #28, on 11/01/23, revealed a care plan focus area of anxiety medications related to anxiety, with an intervention to encourage the resident to voice feelings and discuss coping skills A discussion of coping skills did not provide for specific direction for staff to assist the resident to alleviate the anxiety. An interview, with the Director of Nursing (DON), on 11/01/23 at 9:13 AM, confirmed the interventions were not written in a manner that was specific to the resident. The DON added there should have been more specific approaches to provide a distraction when the behavior was noted which should have included positioning with pillows and providing music. b) Resident #104 A record review, for Resident #104, on 11/01/23, revealed a care plan focus area of anxiety medications related to anxiety, with an intervention to encourage the resident to voice feelings and discuss coping skills. There was no specific non-pharmacological approach to assist the resident with the identified anxiety focus area. Discussion of coping skills did not provide for specific direction. An interview, with Registered Nurse (RN) #100, on 11/01/23 at 11:25 AM, verified the care plan to discuss coping skills was a generic approach and Resident #104's care plan should have reflected more resident specific modalities to assist the resident with the focus concern of anxiety. RN #100 stated further, during the interview, the care plan would have to be corrected to reflect this. c) Resident #34 Upon a record review on 10/31/23 at 7:58 AM a record review of Resident #34's Hospice care plan created on 04/11/23 had no mention of the days of the week or time when Hospice services were to occur. They only mention on the care plan for Resident #34 for when Hospice services were to occur read Nurse to visit 1 to 2 times per week and Nurse Aide (NA) to visit 2 to 3 times per week. Upon a record review on 10/31/23 at 8:00 AM of Resident #34's care plan had no mention of when Hospice services were to occur. During and interview on 10/31/23 at 9:36 AM with Licensed Practical Nurse (LPN) #84 stated, Hospice typically comes Tuesday and Friday. They just check in with us. We just know they are coming when they get here. Then stated, They don't sign in and out, that I know of. During and interview on 10/31/23 at 10:00 AM the Minimum Data Set (MDS) Coordinator stated, Times and days are not in the care plan. 49465

Based on record review and staff interview, the facility failed to complete a new PASARR (Pre-Admission Screening) with a new diagnosis. This is true for one )1) of one (1) reviewed for PASARR. Resident identifier: #36. Facility census: 55. Findings included: a) Resident (R) #36 Review of the medical record on 10/30/23 revealed R #36 was diagnosed with schizophrenia in 2023. The annual Minimum Data Assessment with an Assessment Reference Date of 08/03/23 was coded as yes under section I 6000 acknowledging the diagnosis of schizophrenia under the psychiatric/mood disorder. The most recent PASARR dated 10/18/22 was marked as none for mental illness including schizophrenia under section 30. During an interview on 11/01/23 at 8:00 AM, Social Worker #70 confirmed R#36's most recent PASARR is dated 10/18/22. At 8:30 AM on 11/01/23, Regional Director of Clinical Services (RDCS) #100 reported R#2's diagnosis of schizophrenia was dated 1/23/23. The RDCS confirmed the PASARR should have been completed after the new diagnosis of schizophrenia.

Based on policy review, record review, and staff interview, the facility failed to ensure that all alleged violations involving abuse were reported. This was true for one (1) of (2) residents reviewed under the abuse pathway. Resident identifier: #19 . Facility census: 55. Findings included: a) Resident #19 Record review, on 11/01/23 at 9:00 AM, of Resident #19's nursing progress note written on 10/06/23 by the Assistant Director of Nursing (ADON) revealed Resident #19 had filed a grievance. The note read: Resident filed a grievance stating a gray-haired nurse was rude to her. The ADON went on to question the resident further about this. When the ADON asked about the Gray-haired nurse, Resident #19 said, You leave her alone. This person is a Nurse Aide (NA) who provides her care. The ADON investigated further and talked with staff on the floor. All staff stated that the resident gets upset when they attempt to empty the catheter bag. She prefers to empty it herself into the trash. All staff stated that they are not hateful to her, but she gets agitated when anyone attempts to help her. The ADON explained this to a family member. Once explained, the family member had no further issues. Review of the Abuse and Neglect Tracking Log revealed no mention of the grievance being filed/ and no record of the suspected verbal abuse being reported. During an interview, on 11/01/23 9:00 AM, with the social worker, she was asked about the nurse's progress note. She stated, I did not know about it. This resident is this way sometimes, no it was not reported. Record review, on 11/01/23 at 9:15 AM, of the Policy titled Abuse, Neglect, and Misappropriation revealed mental abuse was defined on page 4 as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse may be considers a type of mental abuse. The policy goes on to read on page 11 section V that An event may not be perceived by staff to constitute abuse neglect or misappropriation of resident property; however, if a resident , family member or visitor perceives an event to be abuse, neglect or misappropriation , the facility must report the event. Record review, on 11/01/23 at 9:30 AM, of Resident #19's care plan revealed no mention of Resident #19 making false allegations. Resident #19 had a BIMS of 11. On 11/01/23 at 11:00 AM the Administrator handed a grievance form to the surveyor and stated, This was found behind the nurses station. Record review, on 11/01/23 at 9:35 AM, revealed the grievance had not been signed by a grievance officer or the Administrator. The grievance had witness statements but had no mention of anybody witnessing/not witnessing the staff member being hateful to Resident #19 and some statements talked about how hateful the resident is. Upon record review on 11/01/23 at 10:00 AM of the facilities Abuse and Neglect Tracking Log for September and October had no record of the suspected abuse being reported.

Based on observation and staff interview, the facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure a wall in a resident room was in good repair. Room identifier: 117. Resident identifier: #255. Facility census: 55. Findings included: a) room [ROOM NUMBER] / Resident #255 On 10/30/23 at 1:21 PM observation revealed the wall behind Resident #244's bed was in disrepair. There was an approximate 4 x 2 rectangular scrape/scratch as well as an approximate 2 x 2 rectangular scrape/scratch immediately noticeable to the right of Resident #255's bed. Additionally, there was an approximate 7- 8 scrape/scratch close to the baseboard on the right side of resident's bed. The scrapes had removed the wall paint and left the white drywall exposed. To the left of Resident #255's headboard, there were four (4) round, circular scrapes/scratches approximately the size of a pencil. During an interview, on 10/31/23 at 9:15 AM, the Social Worker confirmed the wall was in disrepair and not very homelike. The Social Worker went on to state the resident residing in the room before Resident #255 was a male resident and she believed the marks were from when he had been in the room. The Social Worker said it must have been an oversight that repairs to the wall were not completed before Resident #255 moved in.

Based on observation and staff interview, the facility failed to respect residents' right to personal privacy and confidentiality of the medical record. This was a random opportunity for discovery. The failed practice was true for three (3) of 18 sample residents. Resident identifiers: #254, #38, and #34. Facility census: 55. Findings included: a) Resident #254 An in-room observation, on 11/01/23 at 12:29 PM, revealed a print pink sheet of paper pinned to Resident #254's board. The paper had writing on it in a landscape format which read, [Name of Hospice Care Agency] for body mind and spirit. The paper form went on to outline, [First Name of hospice agency staff] will visit me on: and then had a notation that Resident #254 would be visited on 11/01/23 from 11:00 AM - 1:00 PM and would receive social visit, would receive a bed bath, hair would be washed, and clothes would be organized. Additionally, it was noted that Resident #254 would be visited on 11/03/23 sometime between the hours of 11:00 - 3:00 PM. During an interview on 11/01/23 at 1:02 PM, the Administrator confirmed the posting in the room made it readily evident that Resident #254 was receiving hospice services, was a violation of resident's right to privacy, and immediately removed the form from room. b) Resident #38 An in-room observation, on 11/01/23 at 12:33 PM, revealed a print pink sheet of paper pinned to Resident #38's board. The paper had writing on it in a landscape format which read, [Name of Hospice Care Agency] for body mind and spirit. The paper form went on to outline, [First Name of hospice agency staff] will visit me on: and then had a notation that Resident #38 would be visited on 10/25/23 from 11:00 AM - 1:00 PM. Additionally, it was noted that Resident #38 would be visited on 10/27/23 sometime in the AM hours and would receive a social visit as well as a shower. During an interview on 11/01/23 at 1:04 PM, the Administrator confirmed the posting in room made it readily evident that Resident #254 was receiving hospice services, was a violation of resident's right to privacy, and immediately removed the form from room. c) Resident #34 Upon observation on 11/01/23 at 12:45 PM of Resident #34's room, a bright pink piece of paper sign said (Name of Hospice Agency) for body, mind, and spirit at the top. The middle stated the workers name and then had the schedule with initials on it below. Upon interview on 11/01/23 at 1:00 PM with the Administrator who walked into the room with the surveyor and stated, That is a Hospice form, I guess they put that up there. I will be having a talk with them. I don't know why they would put that up there. She took the signs down from the Bulletin board. 49465

Based on observation and staff interview, the facility failed to ensure call lights were within reach for residents who had the ability to utilize them to request help. This was true for one (1) of two (2) residents reviewed under the environment pathway. Resident identifier: #16. Facility census: 55. Findings included: a) Resident #16 a) An observation on 10/30/23 at 1:20 PM of Resident #16 revealed the call light was a touch light call pad and was not in reach of Resident #16. The resident was lying in bed. The touch pad call light was on the nightstand. During an observation, on 10/30/23 at 3:30 PM, Resident #16 revealed the call light was not in reach of resident that was lying in bed. The touch pad call light was on the nightstand. During a review, on 10/31/23 at 9:00 AM, of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADLs). The care plan mentioned the resident had a Cognitive Deficit and the care plan indicated the staff needed to place the call light within reach. Observation, on 10/31/23 at 1:30 PM, revealed the call light was not in reach of the resident. The resident had just been put back in bed after lunch. The touch pad call light was on the nightstand. During an interview, on 10/31/23 at 2:30 PM, with Licensed Practical Nurse (LPN) #69, the LPN stated, She definitely can use her call light and she does. During an observation, on 11/02/23 at 10:00 AM, Resident #16 was lying in bed, the call light was not in reach. The touch pad call light was sitting on the nightstand. During an interview, on 11/02/23 at 10:30 AM, with Nurse Aide (NA) #86, the NA stated, No her call light is not in reach, she must of put it over there. Employee #86 then put touch pad call light Resident #16 bed within reach.

Based on record review and staff interview, the facility failed to revise a resident's comprehensive care plan based on an identified change in the residents care that was no longer applicable to the plan of care for one (1) of 18 sampled residents reviewed. Resident #28 no longer was receiving oxygen therapy, however, the focus problem with goals and approaches were continued to be included on the the current care plan. Resident identifier: Resident #28. Census: 55. Findings included: a) Resident #28 A record review, on 11/01/23 found current orders contained no order for oxygen therapy. Further review of the record showed the resident had received oxygen therapy, however, the order for oxygen had been discontinued on 09/16/23. A review of the current care plan revision, that was dated 10/12/23, showed a focus area of oxygen therapy with oxygen to be provided at two (2) Liters per minute remained on the care care plan. An interview with the Director of Nursing ( DON), on 11/01/23 at 9:13 AM, confirmed after review of the orders, the order had been discontinued on 09/16/23 and the resident no longer was ordered oxygen. During the interview, on 11/01/23 at 9:13 AM, the DON, confined the care plan reviewed and revised on 10/12/23 did not reflect the discontinuation of the oxygen therapy and should have been revised to reflect the resident no longer having a current order for the oxygen therapy.

Based on observations, record review, and staff interview, the facility failed to provide an activity program that meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was found true for two (2) of (18) residents reviewed during the long-term care survey process. Resident identifiers: #8 and #19. Facility census: 55. Findings included: a) Resident #8 An observation on 10/30/23 at 2:00 PM revealed no stimulation on in Resident #8's room. Resident #8 was fidgeting in bed and repeating staff that was in the hallway. An observation on 10/30/23 at 3:00 PM revealed no stimulation on in Resident #8's room. Resident #8 was lying in bed gripping her blanket. An observation on 10/31/23 at 7:45 AM revealed Resident #8 was in the dining room for morning activities. Resident #8 was placed with her back to everyone else in the room. An observation on 10/31/23 at 8:40 AM Resident #8 was in dining room for scheduled coffee and news activity. The resident was placed with her back to the activity and was not served a drink at this time. An observation on 10/31/23 at 9:40 AM Resident #8 was in dining room for the scheduled activity, Parachute Pop. The resident was placed with her back to the activity while others were playing the scheduled game. An observation on 10/31/23 at 10:10 AM Resident #8 was in the dining room for the scheduled activity, Coloring TV/Paper plate spider craft. The resident was not assisted to do activity or given any supplies. Resident #8's back was placed to everyone else in the room. An observation on 10/31/23 at 11:00 AM Resident #8 was in the dining room for the scheduled activity, Halloween Trivia. The resident was placed with her back to the rest of the room. Upon record review on 10/31/23 at 1:00 PM of Resident #8's Minimum Data Set (MDS) Section B revealed for vision was marked 4-Severely impaired-no vision or sees only light, color, or shapes; eyes do not appear to follow objects. Upon record review on 10/31/23 at 1:00 PM Resident #8's admission activity preference interview reveals that she enjoys the company of others in small settings, enjoys attending facility parties and events, and that resident is blind and requires assistance from staff to participate in activities and social stimulation. Upon record review on 10/31/23 at 1:50 PM of Resident #8's activity care plan has no mention of the residents blindness and interventions for blindness as related to activities. During an interview on 10/31/23 at 2:00 PM with the Activity Assistant #25 stated, I worked morning activities today. Resident #8 was in my activity? I didn't know that. During an interview on 10/31/23 at 2:15 PM with Nurse Aide (NA) #72 which was assigned to the resident today stated, The Resident has been in activities from breakfast until after lunch today. Upon record review on 10/31/23 at 10:26 AM of Activity Preference interview dated 05/19/23 reads as follows: Resident #8 requires assistance getting to and from activities. She requires assistance from staff for Activities of Daily Living (ADL)'s. Resident #8 is blind and requires assistance from staff to participate in activities and social stimulation. b) Resident #19 Upon an interview on 10/30/23 at 1:00 PM with Resident #19 who has a Brief Interview for Mental Status (BIMS) of 11 when asked if she enjoyed the activities that was offered in the facility Resident #19 stated, I do when I know what is going on, most of the time I don't know what is going on. An observation on 10/30/23 at 1:00 PM of Resident #19's room an an activity calendar for the month of October was on Resident #19's bulletin board. The calendar font looked to be standard size 12. During an interview on 10/30/23 at 1:00 PM surveyor pointed out the October Activity Calendar to Resident #19 and she stated, Well I cant see that thing.' Resident noted to have her glasses on. . Upon and observation on 10/30/23 2:00 PM of Resident #19 she was lying in bed. TV was turned on by her. She was not in attendance of the 2:00 scheduled bingo. Upon an interview on 10/30/23 at 2:00 PM with Resident #19 she stated, I did not know we was having bingo Upon and observation on 10/31/23 at 10:00 AM of Resident #19 she was lying in bed. TV was turned on by her. Upon and interview on 10/31/23 at 1:30 PM with Resident #19 surveyor asked if she was going to the Halloween party. Resident #19 stated, I didn't know we was having a Halloween party. In an interview with the Actiity Director (AD) on 10/31/23 at 1:00 PM, when asked how residents with visual problems knew what activities were offered for the day, the AD stated I give them a one page calendar for the entire month. No large print calendar was observed in Resident #19's room. Upon a record review on 10/31/23 at 2:30 PM of Resident #19 admission MDS revealed under section F that it is very important for resident to do things with groups of people. Upon a record review on 10/31/23 at 2:30 PM of Resident #19 Admission Activity Preference revealed that Resident #19 is big in the church, enjoys playing bingo, enjoys arts and crafts, cooking and gardening. It also reveled that resident is a people person. Loves being around people and likes to socialize. Upon a record review on 10/31/23 at 2:30 PM of Resident #19 Activity Participation Record from 10/16/23-10/31/23 revealed that Resident #19 has only participated in one group activity. Upon a record review on 10/31/23 at 2:35 PM of Resident #19 care plan revealed that resident #19 is self directed for activities in and out of room daily. Under interventions it reads resident #19 loves being around people and in social settings.

Based on observation, medical record review, and staff interview, the facility failed to provide services to ensure one (1) of three (3) residents reviewed for nutritional status maintained, to the extent possible, acceptable parameters of nutritional status. The resident had four (4) recorded significant/severe weight losses which were identified, but not addressed by the facility. This was harm to the resident, as the resident's continual unaddressed weight losses resulted in a loss of 9.75% of the resident's total body weight in forty-six (46) days. Resident identifier: #41. Facility census: 58. Findings include: a) Resident #41 Observation of Resident #41, during the lunch meal on 09/27/15 at 11:45 a.m., revealed a family member was assisting the resident to eat. The resident ate very slowly and ate very small bites of food. Review of medical records, beginning at 2:00 p.m. on 09/29/15, revealed Resident #41 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's weight records revealed a continual weight loss since admission: 1. On 06/18/15, the resident's admission weight was eighty-two (82) pounds. 2. On 06/25/15, the resident weighed seventy-nine (79) pounds, a 3.65% weight loss in seven (7) days. A significant weight loss is a loss of 5% in 30 days. 3. On 07/05/15, the resident had lost down to seventy-five (75) pounds. This was a 5.06% severe weight loss in ten (10) days, since 06/25/15. In the sixteen (16) days since admission on 06/18/15, the resident experienced a loss of 8.53% of her total body weight. 4. On 08/03/15, the resident lost another 1.33% between 07/05/15 to 08/03/15. The weight was seventy-four (74) pounds. Between 06/16/15 and 08/03/15 the resident experienced a severe weight loss of 9.75% in forty-six (46) days. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 06/25/15, revealed the care area assessment (CAA) for nutrition triggered an actual condition to care plan due to a body mass index (BMI) of 17.7. Continued review of the medical records revealed a dietary progress note, dated 06/25/15, recommending a 2 oz (two ounces) MedPass (supplement) twice a day to increase intake. Weekly weight meeting notes indicated the facility was aware of the weight losses; however, no interventions to address the weight losses were established. The facility was weighing the resident, but took no action as the weight losses were identified: 1. 06/23/15, Patient has had a decrease in weight of 3.2 lbs. since admission. 2. 07/02/15, . down 9.5% in a week, will continue to monitor weights weekly. 3. 07/09/15, Resident has had an increase in weight of 4.4%. 4. 07/16/15 , Patient has had a decrease in weight of 1.3%. None of the weight meeting notes included knowledge of the dietary progress note dated 06/25/15, to start 2 oz of MedPass twice a day to increase intake. Continued review of medical records revealed a dietary progress note with a date of 09/10/15, with another recommendation to start 2 oz MedPass twice a day. The Med Pass supplement nutritional content information was obtained from the administrator on 09/30/15 at 8:30 a.m. One (1) ounce of MedPass would have provided sixty (60) calories and 2.5 grams of protein. The dietary recommendation for MedPass would have provided Resident #41 two-hundred and forty (240) additional calories and ten (10) additional grams of protein each day. On 09/29/2015 at 3:41 p.m., an interview with Dietary Supervisor #46 revealed the dietary department did not receive an order for [REDACTED]. Review of physician's orders [REDACTED]. At 4:44 p.m. on 09/29/15, the administrator stated she reviewed the records and could see evidence of weight meeting discussions, but could not find evidence the facility made any changes related to Resident #41's dietary concerns until 09/15/15.

Based on review of medical records, observations, review of the "Weekly Skin Check Report of Pressure Areas", review of the facility policies and procedures, and staff interview, the facility had failed to ensure residents did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable; and failed to ensure a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. This resulted in actual harm to two (2) residents. Two (2) of three (3) residents, who were reviewed for the pressure ulcer care area in the Stage II sample of thirty-seven (37), were found to have developed unstageable pressure ulcers while in the facility. One (1) resident developed a pressure area on his left heel and had another area on the anterior aspect of his foot / ankle area that was thought to be related to pressure. Another resident developed an area of deep tissue injury on her buttock that developed in-house. Additionally, during the observation of treatments, breaches on infection control practices were noted. Resident identifiers: #32 and #10. Facility census: 57. Findings include: a) Resident #32 Medical record review revealed this [AGE] year old male was re-admitted to the facility on [DATE]. A Medicare 14-Day minimum data set assessment (MDS), with an assessment reference date (ARD) of [DATE], noted that no pressure ulcers were present. A comprehensive significant change in status MDS with an ARD of [DATE] also noted no pressure ulcers were present. Review of the list of MDS assessments completed for this resident found he had not been discharged to an acute care facility for at least for at least three (3) months. Review of the resident's medical record found a pressure ulcer was first noted on the resident's left heel on [DATE]. - A copy of the "Weekly Skin Check Report of Pressure Areas" was provided upon request. The resident was first listed on the report dated [DATE], with the area on his left outer heel being identified as unstageable measuring 1.5 cm x 1.0 cm with "thin black eschar". The resident was discharged to the hospital on [DATE] and returned on [DATE]. A report dated [DATE] noted the area was unstageable, measured 2.2 cm x 2.5 cm, had thin yellow drainage, and had worsened in the hospital. On [DATE], the area remained unstageable, measured 2.0 cm x 2.0 cm, and had no drainage. On [DATE], the area remained unstageable, measured 2.0 cm x 3.4 cm, and had no drainage. On [DATE], the report indicated the stage remained the same, measured 2.4 cm x 3.4 cm, and there was no drainage. On [DATE], the stage was unchanged, it measured 2.3 cm x 3.3 cm, and it had no drainage. The resident was discharged to the hospital on [DATE] and returned on [DATE]. On [DATE], the wound measured 2.0 cm x 3.4 cm but was otherwise unchanged. It was noted he had been readmitted from the hospital. On [DATE], the area remained unstageable, measured 2.0 cm x 3.4 cm, and the assessor noted, "No redness around wound bed." On [DATE], the report remained the same as the previous week for stage and measurements. On [DATE], the wound measured 3.0 cm x 3.0 cm and had no drainage. On [DATE], the report noted the area measured 3.0 cm x 3.0 cm and had no drainage, but it had "soft black eschar". On [DATE], the report was the same except the tissue was described as "Dry Black Eschar". On [DATE], the measurements and stage remained the same, there was no drainage, and the wound was again noted to have "Dry Black Eschar". Also noted was: "Red / Pink around wound started on Keflex [DATE]." On [DATE], the area measured 2.2 cm x 3.0 cm. It continued to have no drainage. The assessor noted: "Dry Black Eschar. 0.5 cm pink around." On [DATE], the area measured 2.5 cm x 3.2 cm with no drainage. The nurse noted: "Dark Black - loose @ (at) edges." The most recent report, dated [DATE], noted the area remained unstageable, measured 2.5 cm x 3.0 cm, had scant purulent drainage with no odor, the peri wound area was dark pink, and a new order for antibiotics had been written. Recent progress notes were reviewed and found the following: - Wound assessment [DATE]: First observed on [DATE] - left heel unstageable 2.2 x 3.0 Wound bed necrotic tissue No drainage or odor. Cleanse with Saf-clens, pat dry, apply dry dressing. "Periwound area pink 0.5 cm around wound. Slight improvement in length of wound. (Necrotic tissue (eschar) is dead or devitalized tissue that is hard of soft in texture; usually black, brown, or tan in color, and may appear scab-like.) - Wound assessment [DATE]: First observed on [DATE] - left heel unstageable 2.5 x 3.2 Wound bed necrotic tissue Moderate amount of drainage - purulent, necrotic tissue. No odor. Cleanse with Saf-clens, pat dry, apply dry dressing - first ordered [DATE] "Wound bed black yellow eschar soft. Periwound bright pink. Moderate amount of purulent drainage. No odor. Denies pain with cleansing." - Wound assessment [DATE]: First observed on [DATE] - left heel unstageable 2.5 x 3.0 Wound bed necrotic tissue Scant purulent drainage, no odor. Cleanse with Saf-clens, pat dry, apply dry dressing. "Wound bed necrotic, edges pale yellow, scant amount of purulent tan drainage, no odor. Periwound dark pink and inflamed. Dr. (Name) notified. New orders received for antibiotic. New orders received for antibiotic by mouth. " - The resident's minimum data set (MDS) assessments were reviewed for [DATE] through [DATE]. The first assessment coded with a pressure ulcer was a quarterly MDS with an ARD of [DATE]. The prior assessments had identified he was at risk for developing pressure ulcers, but none were noted to have developed. - At the time the pressure ulcer developed, the resident had lost 9 pounds (#) between [DATE] and [DATE] (when the pressure ulcer was first noted). The ARDs and weights were as follows: [DATE] - 185#; [DATE] - 182#; [DATE] - 183# (this was a significant change in condition assessment); [DATE] - 176# (in the hospital [DATE] to [DATE]); [DATE] - 176#; [DATE] - 176#; [DATE] - 172#; [DATE] - 172# (in the hospital [DATE] to [DATE]); [DATE] - 172#; [DATE] - 164#; [DATE] - 159#; [DATE] - 160#. - No pressure ulcers were listed on the resident's MDS assessments with ARDs of [DATE], [DATE], [DATE], [DATE], and [DATE]. The MDS assessments of [DATE], [DATE], [DATE], [DATE], and [DATE] all noted the size of the unstageable pressure ulcer was 2 cm long x 3 cm wide. The tissue type was listed as "Necrotic" for all of these but the [DATE] assessment. (According to MDS coding definitions "Necrotic tissue (Eschar) - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin.") The MDS of [DATE] noted the area measured 2 cm x 2 cm. The assessments for [DATE] and [DATE] noted the area measured 3 cm x 3 cm with necrotic tissue as the most severe tissue type. All of the MDS assessments, with the exception of the discharge assessment of [DATE], indicated this resident required extensive assistance for bed mobility. - On [DATE] at 9:53 a.m., a licensed practical nurse (LPN - Employee #2) was observed changing the dressing on the resident's left heel. During this procedure, the nurse placed items directly on the resident's overbed table without benefit of a barrier for all items. These supplies were returned to the cart after completion of the dressing change. This created a potential for transfer of microorganisms from Resident #32 to others. The nurse washed her hands at the appropriate times, but she did not wash them for a sufficient length of time. She also handled the paper towels after turning off the water or turned it off with her bare hands. The nurse removed a pair of scissors from her pocket to cut off the old dressing on the resident's left foot. The scissors were then placed on a paper towel on the overbed table. At the end of the procedure, she used the scissors to cut Medfix, and later put them back in her pocket. The scissors were not cleaned / sanitized at any point during the procedure. This created a potential for transfer of microorganisms from the nurse's pocket, to the resident's wound, to the resident's table, to the Medfix and potentially other resident, and to the nurses' pocket which also might result in transfer of organisms to other resident's. The left heel area was [DIAGNOSES REDACTED]tous around the eschar. He was receiving an antibiotic for infection in the wound. During the observation of the treatment to the resident's left lateral heel, it was noted he had an eschar-covered area on the anterior aspect of his foot / ankle. The nurse was asked what had happened to cause the wound. She said they thought it was from the code alert bracelet. (This would involve pressure and should have been avoidable and / or identified at an earlier stage.) After completion of the treatment, the resident's medical record was reviewed. The most recent order for the area on top of the foot, dated [DATE], was: "Cleanse top Left foot with Saf-Clens, pat dry, apply non adherent pad and affix with hypo fix tape. Change daily." The nurse had removed and reapplied plain 4 x 4 to the area. She had had to use the Saf-Clens to moisten the 4 x 4 as it had adhered to the wound. - The director of nursing (DON) was interviewed about the resident's pressure ulcer development on at 9:40 a.m. on [DATE]. When asked for any information that would demonstrate the resident's pressure ulcer was clinically unavoidable, she stated she would have to check the resident's medical record. She later reported she had not found anything. -- b) Resident #10 This resident was identified in Stage I of the QIS survey as having developed a pressure ulcer in the first thirty (30) days following admission to the nursing home. She also was found to have been admitted with one (1) or more pressure ulcers. Review of the resident's medical record found she was admitted to the facility on [DATE] and discharged to home on [DATE]. Prior to admission to the facility, she had fallen at home. She had gone to the hospital where she was diagnosed as having a urinary tract infection. The H&P noted under "Skin" stated: "[MEDICATION NAME] (R) Buttock when ______ / _____ unstageable so far." The [DATE] computer-generated orders included: "Cleanse buttocks with soap and water, apply [MEDICATION NAME] ointment every shift for 14 days." (She had a urinary catheter at that time.) She was noted to not be eating well. The medication [MEDICATION NAME] was ordered on [DATE] for appetite stimulation. The [DATE] computer-generated orders included: "Posy boot to right heel when in bed. Cleanse right heel with Saf Clens, pat dry, apply dressing daily." Hand written onto the computer-generated orders were "Cleanse (L) (left) buttock /c (with) Saf Clens, apply [MEDICATION NAME] q (every) 3 days May change PRN (as needed) Check placement of drsg (dressing) q shift" & "Cleanse (R) buttock /c Saf Clens, apply [MEDICATION NAME] q 3 days May change PRN Check placement of drsg q shift." Other orders for wound care included: - On [DATE] (admission orders [REDACTED]. buttocks. ..." - On [DATE] - "D/C (discontinue) tx (treatment) to (R) (right) buttock - Resolved. Cleanse buttocks /c soap & water apply [MEDICATION NAME] ointment every shift x 14 days" - On [DATE] - "Med-Pass 2.0 120 ml po three times a day D/T (due to) wt. loss" - On [DATE] - "2) [MEDICATION NAME] 400 mg i (1) po (by mouth) BID (twice daily) for appetite stimulation d/t wt loss" - On [DATE] - "Posy boot to (R) heel when in bed Cleanse (R) heel /c Saf-Clens, pat dry & apply dry dressing daily. ..." - On [DATE] - "Cleanse (L) buttock- /c Saf-Clens, apply [MEDICATION NAME] every 3 days May change dressing to (L) buttock PRN Check placement of dressing to (L) buttock every shift" and "Cleanse (R) buttock /c Saf Clens, apply [MEDICATION NAME] every 3 days May change dressing to (R) buttock PRN Check placement of dressing to (R) buttock every shift" - On [DATE] - "D/C [MEDICATION NAME] Vitamin C 500 mg po daily x 90 days Zinc 220 mg po daily x 90 days Pro-mod 30 ml po BID x 90 days Promote wound healing." - On [DATE] - "Cleanse bilateral buttocks /c soap and water and apply [MEDICATION NAME] Q shift x 14 days." - Review of the daily skilled nursing entries found the following: - On [DATE] at 4:00 p.m. - "Resident /c blister to bilateral buttocks, New orders received to cleanse /c Saf-clens, apply [MEDICATION NAME] every 3 days & PRN." - On [DATE] at 11:10 a.m. - "Resident /c open areas on bilateral buttocks (R) - measures 9.0cm x 7.0cm redness /c open area 5.0cm x 3.0cm x 0.1cm /c areas of suspected deep tissue injury @ (up arrow) portion of open area. (L) measures 5.5 cm x 4.5 cm redness /c open area 4.0cm x 0.1cm /c areas of suspected deep tissue injury. New orders for Vitamin C, Zinc, & Pro mod. ..." - On [DATE] (Weekly Medicare Meeting) -"... (Resident #10) receives treatment to (L) buttock and (R) buttock for pressure sores. ..." - On [DATE] at 1:30 p.m. (Weekly Medicare Meeting) - "... Resident /c stage II pressure ulcers to buttocks. Improved in size this week, granulation tissue present." - On [DATE] - "... Two deep tissue injuries to bilateral buttocks. Both presenting as Stage II (R) (right) buttock 1.3cm x 1.0 cm x 0.1 cm /c (with) 100% granulation tissue present. (L) (left) buttock 2.5cm x 1.2cm x 0.1cm /c 100% granulation tissue. [MEDICATION NAME] applied every 3 days. Blister to heel reabsorbed - continue to monitor daily." - On [DATE] (Weekly Medicare Meeting) - The resident was noted to have excoriation to her buttocks. She was identified as being incontinent of bowel and bladder. (The Foley indwelling urinary catheter was noted to have been removed on [DATE].) - On [DATE] - The right heel and left buttock dressings were noted to be changed. "Area to (R) buttock 1.5 x 0.5 wound bed is purple/red /c small amt of yellow slough. Area to (R) buttock measures 1.0 x 0.6 wound bed is dark pink (symbol for no) drainage or odor noted. ..." - Review of the resident's MDS assessments found the following: - The admission plus Medicare 5-day assessment, with an ARD of [DATE], indicated in Section S the resident was admitted with a pressure ulcer on her right buttock. Section M of the MDS identified she was at risk of developing a pressure ulcer and she had one (1) pressure ulcer at a Stage I or higher. Item M0300F1 indicated she had an unstageable pressure ulcer present on admission measuring 1.5 cm x 0.5 cm. The tissue type for the most advanced stage was 4 - necrotic. - The 14-day assessment, with an ARD of [DATE], indicated the resident did not have any pressure ulcers. Item M0800 (worsening in pressure ulcer status) was blank. Item M0900A (healed pressure ulcers) indicated there had been a pressure ulcer on the prior assessment. Item M0900D indicated one (1) Stage IV pressure ulcer had healed. - The 30-day assessment, with an ARD of [DATE], again noted the resident had a pressure ulcer at a Stage 1 or higher. It listed two (2) Stage II ulcers with the date of the oldest Stage II as [DATE]. Item M0300B was coded "0" indicating these had NOT been present on admission. Granulation tissue was coded in M0700 as the tissue type of the most advanced type stage. (The presence of granulation tissue would indicate a Stage III or Stage IV pressure ulcer.) Item M0800 ("Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment (OBRA, PPS, or Discharge). If no current pressure ulcer at a given stage, enter 0.") was coded as "2". - The end of therapy and discharge with return not anticipated assessment, with an ARD of [DATE], indicated the resident had two (2) Stage II pressure ulcers that were not present on admission. The oldest was dated [DATE]. (Note: This was the same date the nurse documented the presence of slough - see excerpts of nursing progress notes in the preceding findings.) Granulation tissue was again coded for the tissue type of the most advanced stage, although the most advanced stage was coded a Stage II. Item M0900A was coded "Yes" for ulcers were present on the last assessment. Item M0900D for healed Stage 4 pressure ulcers was coded "2". - The MDS assessments with ARDs of [DATE], [DATE], [DATE], and [DATE], indicated the resident was totally dependent for bed mobility. - The resident's pressure ulcer development was discussed with the DON on [DATE]. The DON said the resident had been on all of the right supplements. She also commented that the resident's son could get her to eat, but he could not be there all of the time. The resident's admission weight on [DATE] was 172.9#. She had lost weight and her [DATE] weight was 151.8#. The DON said the resident would refuse to eat and that, although she had lost weight, she was still above her ideal body weight. It was discussed that the resident did have pressure ulcers upon admission. Those areas had healed. The resident's buttocks had become excoriated, and she subsequently developed Stage II areas. Those areas then developed the purple spots indicative of deep tissue injury, according to the DON. The DON said the resident had been noncompliant in participating in activities of daily living (ADLs); however, there was no evidence found in the nursing notes to indicate the resident refused to be turned. The DON said the resident had been dying. She said the resident had died not too long after she went home; however, nothing was found in the resident's medical record regarding terminal or end-stage illnesses. The physician had noted the resident was stable for discharge. .

Based on medical record review, staff interview, and resident interview, the facility failed to ensure a resident received care and services to assist the resident in maintaining her highest practicable level of well-being. Tests to determine the anticoagulant effect of [MEDICATION NAME] were not done in a timely manner. Nearly a month after lab tests had been ordered, a test was done - the results of which were found to be significantly elevated. The resident developed a nose bleed which did not respond to Vitamin K injections. She was subsequently sent to the hospital for treatment, which included insertion of nasal tampons and administration of fresh frozen plasma (FFP). Resident identifier: #34. Facility census: 57. Findings include: a) Resident #34 Review of Resident #34's medical record found she had been on [MEDICATION NAME] (a blood thinner). On 06/30/11, it was noted her PT/INR (laboratory tests to determine how much the [MEDICATION NAME] had affected her bleeding times) were elevated. Her PT ([MEDICATION NAME]) was 42.3 (the mean normal is 12.6), and her INR was 8.7 (reference range is 2.0 - 3.0). (INR: International normalized ratio, a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Homeostasis for reporting the results of blood coagulation (clotting) tests. All results are standardized using the international sensitivity index for the particular [MEDICAL CONDITION] reagent and instrument combination utilized to perform the test. (http://www.medterms.com/script/main/art.asp?articlekey=9185)) She had developed a nose bleed at this time. She was noted to have received two (2) injections of Vitamin K in an attempt to reverse the blood thinning effects of the [MEDICATION NAME]. After the second injection did not cause the bleeding to stop, the resident was sent to the hospital for evaluation and further treatment. The nursing entries (typed as written) for this acute episode on 06/30/11 were: - 12:23 p.m. - "Resident refused to eat her lunch ,then wanted ice for Pepsi." - 3:30 p.m. - "Lab calls this nurse with critical PT/INR of 42.3/8.7" - 3:45 p.m. - "Doctor on call notified of PT/INR Receive new order Vitamin K PO (by mouth) 2.5 mg times one dose now." - 3:50 p.m. - "Dr. (Name) notified of by mouth Vitamin K availability. Receive order to discontinue [MEDICATION NAME] 5.5 mg. Dr. (Name) states 'Will call back.'" - 5:03 p.m. - "Dr. (Name) call this facility. Receives order Vitamin K 5 mg Intramuscular times one dose now. Re-check PT/INR in morning." - 5:10 p.m. - "Vitamin K 5 mg per doctor order administered at this time to resident's left ventro-gluteal area. Resident tloerated well." - 8:30 p.m. - "Dr. (Name) notified of slow results of earlier Vitamin K order. Receive new order Vitamin K 5 mg Intramuscular times one dose now and CBC in morning." - 8:35 p.m. - "Vitamin K 5 mg Intramuscular administered at this time per doctor's order to right ventro-gluteal area. Resident tolerated well." - 10:09 p.m. - "Resident's vital signs B/P 94/52 Temperature 95.7 Pulse 94 Respirations 28 Pulse oximeter 86% DR notified at this time. Receive order Transport resident to (Name) Emergency Department." - 9:30 p.m. - "Medical Power of Attorney notified of Resident's status." - 10:21 p.m. - "Medical Power of attorney notified of doctor order to transport." - 10:22 p.m. - "MPOA request's (Name) Hospital." The resident left the facility at 11:00 p.m. She returned at 4:36 a.m. on 07/01/11 with packings in nose. It was noted there was a moderate amount of bleeding. The packings were to be removed the next shift. -- In an interview on 07/27/11 at 2:42 p.m., Employee #22 (the nurse who had cared for the resident on 06/30/11) said she had been mainly concerned about the resident's vital signs. She had called the doctor, and received an order for [REDACTED]. A second order for Vitamin K had been received. After about an hour, it did not seem like the Vitamin K was working, so she had them check the vital signs again and called the doctor. That time, the doctor said to send her out to the hospital. She thought the resident was "pretty low on her LOC (level of consciousness)." -- The resident was interviewed at 1:25 p.m. on 07/26/11. She said she had had nose bleeds three (3) times, but this last had been the worst. She said she had had two (2) nose bleeds while here and one (1) at another nursing home. She said her shirt had been covered with blood when this happened. The resident said she was on a blood thinner when this happened, but she was not anymore. She said they had given her two (2) shots and it did not help so they had sent her to the hospital. At the hospital, they had put some things in her nose to stop the bleeding (she made a face as she spoke of this). She said "he" had two (2) needles in her arm. As she spoke about the needles, she gestured with each hand as though sticking something in the opposite arm. As she made this gesture, she became animated and grimaced. The resident related "he" had wanted her to stay, but she said she had told him she wanted to come back to the nursing home. "He" (according to the resident) said he had to do something with the needles, then she could go home. She said she had spots of blood down her shirt when tried to quantify the bleeding. On 07/27/11 at 9:30 a.m., the resident was interviewed again. The resident was asked about her nose (as she was documented as putting her finger in her nose causing very minor bleeding). She said they were putting some white stuff in her nose that helped - kept if from hurting. She said the doctor had told her her nose was a problem. She again said she had had nose bleeds three (3) times, but that last time was the only time she had had to go to the hospital. She again talked about the needles in her arms and repeated the same gestures she had made on 07/26/11. -- Record review revealed there was no physician's order for routine INRs. A nurse would contact the physician with the results of the test, and the physician would order a dosage change for the [MEDICATION NAME], if indicated. If the dosage changed or the physician wanted to recheck the INR, he or she would order another INR to be completed. -- The lab section of the resident's record was reviewed. The most recent PT/INR studies were as follows ((L) = low; (H) = high): (Date of lab - PT - INR - any notations made on the lab results) 04/05/11 - 15.3 - 1.4 (L) 04/13/11 - 13.8 - 1.2 (L) 04/18/11 - 16.2 - 1.6 (L) 05/03/11 - 16.5 - 1.6 (L) - "On 4/18 INR 1.6 on 5.5 [MEDICATION NAME] 6 mg [MEDICATION NAME] Repeat PT/INR on 5/11/11" (On 05/04/11, the physician order a PT/INR to be done on 05/11/11. The results of the 05/11/11 labs were not found.) 05/23/11 - 30.6 - 4.7 (H) - "6 mg now hold [MEDICATION NAME] to recheck tomorrow 05/24/11" 05/24/11 - 27.0 - 3.7 (H) - "Hold [MEDICATION NAME] tonight PT INR 05/25/11" 05/25/11 - 23.2 - 2.8 - "Start 5 mg repeat INR Tuesday" 05/31/11 - 14.6 - 1.4 (L) (On 06/01/11, the physician ordered a PT/INR to be done in three (3) days (on 06/04/11). The results of the 06/04/11 labs were not found.) 06/30/11 - 42.3 - 8.7 (H) (This elevated INR was well above previous results for which the physician had ordered the [MEDICATION NAME] held.) -- On the afternoon of 07/27/11, Employee #63 (a registered nurse - RN) was asked where additional lab reports might be found. She said she would check the resident's thinned records. Some of the missing reports were found and copies provided. At approximately 11:45 a.m. on 07/27/11, the director of nursing (DON) was informed that the resident had not had an INR between 05/31/11 and 06/30/11. On the morning of 07/28/11, the DON was asked to try to locate the reports for INRs that were to have been done on 05/11/11 and 06/04/11. She later reported the studies had not been done. -- Review of Resident #34's hospital records for 06/30/11 noted the following. - The "Emergency Provider Record" noted the time seen was 1700 (5:00 p.m.). Under "onset / duration" was written: "continuous epistaxis x 8 hr. . . ." Under the past history, "previous nosebleeds" and "occasionally" were circled. Her general appearance was noted as "mild / moderate distress head atraumatic, sinus non-tender NOSE - nml (normal) inspection, dried blood, fresh clots, R & L (right and left) were circled. Active bleeding R/L & mod (moderate) were circled." Her INR was noted to be 9.68. The clinical impression was: "Epistaxis - anterior - [MEDICATION NAME] Toxicity". The hospital documentation included a nursing assessment which noted the chief complaint was a nose bleed, elevated PT/PTT. Her blood pressures were charted every ten (10) minutes with the lowest recorded as 71/60. It was noted she had been given total of 10 mg Vitamin K IM at the nursing home. Her skin was listed as pale. Bleeding was noted of the right nares and her tongue had dried blood. The lab studies at the hospital were: 06/30/11 at 23:30: - WBC - 22.1 (reference range of 4.8 - 10.8) - PT - 48.9 - Critical high (reference range of 10.8 - 13.6) - INR - 9.63 - Critical high (reference range of 2.00 - 3.50) 07/01/11 at 3:15: - APTT - 51.6 - Critical high (reference range of 20.8 - 33.7) - [MEDICATION NAME] - 20.3 - High - INR - 2.19 While at the hospital, she was given 250 ml of normal saline [MEDICATION NAME], and 10 ml of 1% [MEDICATION NAME] with epi ([MEDICATION NAME]). Nasal tampons were inserted, and she was given two (2) units of fresh frozen plasma (used at times to help the blood coagulate). -- A hospital record from 02/19/11 noted the resident had been sent to the hospital for altered mental status and shortness of breath. Her labs included an INR of 6.56 (high). The assessment and plan included: "2. Supratherapeutic INR - unclear if this is from an improper medication dosage of due to another medication interaction. At this time no medication interactions can be found documented that would cause this. At this time we will hold her [MEDICATION NAME] doses and avoid other medications that could exacerbate her [MEDICATION NAME] therapy. We will check a daily PT and INR and monitor. At this time there is no indication of any active or subclinical bleeding, however, we will continue to monitor and give vitamin K if needed." -- The PT/INR ordered on [DATE] to be done on 05/11/11 could not be located. When the lab was performed on 05/23/11, the INR was high and the [MEDICATION NAME] had to be held. The resident did not have an INR done from 05/31/11 until 06/30/11. The facility had failed to obtain an INR ordered on [DATE], to be done in three (3) days (06/04/11). The physician needed the results of the test to determine whether the dosage of [MEDICATION NAME] needed to be adjusted. Therefore, the [MEDICATION NAME] was not titered as had previously been done. Her INR became significantly elevated resulting in bleeding that did not respond satisfactorily to Vitamin K injections. Although the INR might have become elevated despite the lack of INRs and dosage adjustment, it would have lessened the chance of such a significant elevation. On 06/30/11, the resident developed a nose bleed. Based on what was learned through interviews with staff, the bleeding persisted for more than eight (8) hours. During this time, the physician was notified and ordered an injection of Vitamin K (used to reverse the effects of [MEDICATION NAME] ([MEDICATION NAME])). The resident continued to have a nose bleed. A second injection of Vitamin K was ordered and administered. The nose bleed continued and there was a concern about the resident's vital signs. She was transferred to the emergency room for further evaluation and treatment. In the emergency room , her nose was packed and she was given two (2) units of fresh frozen plasma (FFP). An INR done in the emergency room was 9.3. (Note: This resident was known to pick at her nose, and this may have caused the bleeding to occur initially, but it would not have been the cause of the bleeding to persist for hours.) (See also citation at F502.) .