Every finding on record at Colonial Health & Rehab Center, LLC

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain residents' highest level of well-being for eight of 35 residents in the survey sample, Residents #5, #138, #139, #63, #32, #48, #16, and #88. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for blood sugar checks and insulin (used to treat diabetes) when the resident was readmitted to the facility on [DATE] at 2:00 p.m. This resulted in harm: on [DATE] at approximately 1:15 a.m., R5's blood sugar was documented as 579 (1). The resident was transferred to the hospital, diagnosed with diabetic ketoacidosis (2) and required an insulin drip (insulin that is intravenously infused). R5 was admitted to the facility on [DATE] with a diagnosis of diabetes. A review of R5's clinical record revealed a nurse's note dated [DATE] that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on [DATE]. The hospital discharge medication list dated [DATE] documented, CONTINUE taking these medications: -Insulin Lispro 100 unit/mL (milliliter) insulin pen- two units beneath the skin Three Times Daily with Meals. If eats at least 50% of meal or drinks a supplement shake. -Insulin Lispro 100 unit/mL insulin pen- Inject ,d+[DATE] Units beneath the skin 4 Times a Day Before Meals & at Bedtime. Per sliding scale (based on the resident's blood sugars): ,d+[DATE]=1 unit ,d+[DATE]=2 units ,d+[DATE]=3 units Call & notify MD (Medical Doctor) if BG (Blood Glucose) > (greater than) 400. -LEVEMIR 100 unit/mL (3 mL) insulin pen- Inject 9 Units beneath the skin Every Night at Bedtime. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was readmitted on [DATE]. A review of R5's MAR (medication administration record) for [DATE] and [DATE] failed to reveal any medication orders. A nurse's note dated [DATE] at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals ,d+[DATE] (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated [DATE] at midnight ([DATE] into [DATE]) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on [DATE]. A nurse's note dated [DATE] at 10:58 p.m. (recorded as a late entry on [DATE]), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back. It was noted that the last time resident received insulin or glucose checks was on [DATE]. This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective. Blood glucose 579. Lispro and Levemir administered. 911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital discharge summary dated [DATE] documented, Per patient, since discharge (from the hospital on [DATE]) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .EMS reported BS (Blood Sugar) 600. The discharge summary further documented a diagnosis of diabetic ketoacidosis, and the resident was administered an insulin drip at the hospital. A facility synopsis of events dated [DATE] documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on [DATE] after an unrelated hospitalization . A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (emergency room ) for evaluation. The resident returned to the facility on [DATE] .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on [DATE] by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on [DATE] on another unit) documented, On Sunday [DATE] on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit [DATE] into [DATE]) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on [DATE]th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on [DATE]). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on [DATE] documented, On Monday [DATE], I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on [DATE] documented, On [DATE] at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on [DATE] at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on [DATE]) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On [DATE] at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5 stated she could not recall details and to refer to her note. RN #2 was not available for interview during the survey. A printed text message from LPN #6 (the nurse who sent R5 to the hospital on the night of [DATE]) to ASM (administrative staff member) #2 (the Director of Nursing) (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8), and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). Another printed text message from LPN #6 to ASM #2 (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). ASM #2, I have been waiting for a phone call from you. Since I haven't, I am going to write an incident report to my agency and I will report you to the VA (Virginia) board of nursing. The patient I sent to the hospital hadn't got her insulin for a day and a half because the dr (doctor) on call refused to verify the meds since (R5) didn't return to the facility while she was on call . LPN #6 was not available for interview during the survey. A statement signed by ASM #2 (the Director of Nursing) (no date) documented, On [DATE], 11 a.m. I called (name of nursing staff agency) to request (RN #1's) telephone number and reported Nurse's failure to initiate an admission nor verify medications to treat resident. Resident arrived at 2pm. Staffing agency, stated that they would contact Nurse and have her return my call. Upon return call, I inquired of the reason (RN #1- the nurse who cared for R5 when the resident was readmitted on [DATE]) did not initiate the admission process for the readmission. Nurse verbalized, she was extremely busy. 'I had to discharge a resident and was not sure of the process, and that the Unit Manager (who was on call and in the building) assisted her with printing discharge paperwork. 'I am not familiar with your version of (name of computer software), I use (name of computer software) at another facility, and however I am more familiar with (name of another computer software). I did ask (LPN #7) on the other unit, what I needed to do for the admission, and she told me the resident was a regular resident and all the medications for her were on the cart.' I went on to ask the Nurse had she received a discharge packet from the Medical transportation personnel, her response was, 'yes.' I continued by referencing her admission note and resident's script upon her return and inquired about the failure to call MD (medical doctor) for verification of orders. Nurse (RN #1) stated, she was unaware of the need to call since, she was told her medications were on the cart. I followed up by asking, Did you see a MAR (medication administration record) for the resident? 'No.' Did you ask the Unit Manager for assistance? 'No.' When you completed your assessment [sic] the resident and noted the script for Gabapentin (used to treat seizures and pain), why did you not input the new script? 'I continued to pass the other medications to the other residents.' Have you ever performed an admission? 'Yes, your system is different, and in (name of another computer system) after putting the resident in the system the admission assessments automatically populates [sic].' 'I informed the oncoming nurse that I had an admission but did not finish it and she said she would finish it, I offered to stay if she would walk me through the process, but she told me she would complete it.' Interviewed (LPN #5- the nurse who cared for R5 during the 7:00 p.m. to 7:00 a.m. shift [DATE] into [DATE]), via telephone. She verbalized she did inform the nurse that she would complete the admission, but initially was not aware of that the medications were not transcribed nor verified. (LPN #5), during her medication pass noted (R5) did not have a MAR, immediately after her medication pass, she made an attempt to call to verify orders, and after speaking with the On call Physician, who would not verify the orders. She texted the On Call Nurse. (LPN #5) was asked, why she did not call (name of the medical director) and she verbalized that she was not aware that she could since there was an On Call system in place. I educated (LPN #5), to call instead of text the On Call Nurse management team member or myself, and in cases of this importance (name of the medical director) can be called. (LPN #5) added that she did inform the oncoming Nurse to call to have the orders verified. However, the oncoming Nurse stated, 'I will not be doing that because it [sic] Mother's Day.' Called (name of nurse staffing agency), informed that of (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on [DATE]), failure to complete Medication Administration Record documentation, failure to follow up on a readmission, and failure to complete skilled documentation. Interviewed via telephone, (RN #2), stated she 'thought' she signed off her medications, 'I was constantly on the cart, tending to residents, answering questions for family members, and made attempts to control (R5's) pain since the resident only came back with gabapentin. They called in Tramadol (used to treat pain) to the pharmacy and it did not come in, then I got an order for Tylenol 1000 mg (milligrams) and gave it to resident.' I inquired of why the orders were not transcribed on the MAR nor documented in the system and was she aware that (R5's) medication were not verified? 'There was a lot going on and I planned to do it.' Why did you did [sic] not call the On call Nurse for assistance? 'I do not have anyone's number and like I said it was a lot going on.' (RN #2) was informed that there is a calendar at the desk with all On Call Nurses numbers attached. (RN #2) said she did not have time to look for anyone's numbers, but she did ask (LPN #7) for assistance. On [DATE] at 9:33 a.m., an interview was conducted with LPN #4 (the current unit manager). LPN #4 stated that when a resident is readmitted from the hospital, he or she returns with a package that contains a medication list and discharge instructions, and the admitting nurse should call the doctor to verify the medication list. LPN #4 stated sometimes the doctor changes medication orders and after medications have been verified, the nurse should put all orders into the computer system. LPN #4 stated that after orders are put into the computer system, they are transmitted to the pharmacy and transcribed onto a MAR. LPN #4 stated she would not stop in the middle of a medication pass to complete this process, but it should be done as soon as the resident arrives. LPN #4 stated, That's the first thing they should do because we need the meds. LPN #4 stated if the physician or nurse practitioner will not verify medications upon re-admission, the admitting nurse should call the medical director and inform the Director of Nursing. On [DATE] at 10:46 a.m., an interview was conducted with ASM #2 (the Director of Nursing). ASM #2 stated that when a resident is readmitted , the nurse should greet the resident, make sure the resident is comfortable, then go to the desk and open the packet of information and orders from the hospital. ASM #2 stated the nurse should enter/transcribe the orders into the queue in the computer system then verify the orders with the physician because the physician may want to change the orders. ASM #2 stated that after the orders are verified with the physician, the nurse should make the orders active in the computer system so the orders are activated onto the MAR and sent to the pharmacy. ASM #2 stated she was not made aware of the above incident regarding R5 until the resident was being sent back to the hospital on ([DATE] into [DATE]). ASM #2 stated it was the middle of the night and she received a phone call from R5's brother regarding the resident's pain. ASM #2 stated she could not recall if she was made aware of R5's blood sugar. ASM #5 stated that when R5 was readmitted to the facility on [DATE], the first nurse should have queued the medications in the computer system, called the physician to verify the medications, sent the medication orders to the pharmacy, and if the resident was in pain or required insulin, the nurse should have contacted the pharmacy and obtained medications from the box in the facility. ASM #2 stated that if the nurse didn't know what to do, she should have called the on-call nurse or ASM #2. ASM #2 stated that if the nurse practitioner refused to verify the medications, then the nurse should have notified her so she could have notified the medical director. On [DATE] at 11:23 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the responsibilities of the on-call physician or nurse practitioner are to take care of the patient, verify orders, and send the pharmacy an e-script (electronic prescription) if needed. In regard to the above incident involving R5, ASM #6 stated that if he recalled, there were errors on multiple sides. ASM #6 stated the orders should have been called in to the on-call nurse practitioner as soon as R5 arrived to the facility but it was the responsibility of the on-call nurse practitioner to verify orders and send e-scripts whenever called, regardless of the time. ASM #6 stated, It is our responsibility to make sure it happens with as little delay as possible. ASM #6 stated he should have been notified when the on-call nurse practitioner refused to verify R5's orders but he was not notified until the next day. ASM #6 stated the on-call nurse practitioner does not round at the facility and is only on-call for the group, but he escalated the incident to the chief medical officer because the patient actually came to some harm and had to go the emergency room for a lack of order verification and pain management. On [DATE] at 1:11 p.m. another interview was conducted with ASM #6. ASM #6 was made aware of the statement signed by LPN #8 on [DATE] that documented he (ASM #6) was notified on [DATE] at 8:38 a.m. ASM #6 stated he went back through his phone records. ASM #6 stated that during the morning on [DATE], LPN #8 made him aware that R5 was admitted at 2:00 p.m. on the previous day and the medications were not called to the on-call nurse practitioner until midnight and the nurse practitioner declined to verify the medications because she thought they should have been called to her earlier in the day. ASM #6 stated he told LPN #8 to call the on-call nurse practitioner back since it was not after 8:00 p.m., and if the nurse practitioner did not verify the medications, call him back. ASM #6 stated he was not notified again until R5 was sent to the hospital. On [DATE] at 1:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, New Admission/Readmission Process Policy documented, 6. Review of orders: a. Physician verification of orders noted b. Transmitted to pharmacy c. Transcribed to eMAR/eTAR (electronic medication administration record/electronic treatment administration record). References: (1) A blood sugar test measures the amount of a sugar called glucose in a sample of your blood. If you had a fasting blood glucose test, a level of 70 to 99 mg (milligrams)/dL (deciliter) is considered normal. If you had a random blood glucose test, a normal result depends on when you last ate. Most of the time, the blood glucose level will be 125 mg/dL or lower . (2) Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. This information was obtained from the website: https://medlineplus.gov/ency/article/000320.htm 27660 2. For Resident #138, the facility staff failed to administer medications per the physician orders. Resident #138 (R138) was admitted to the facility on [DATE] at 6:21 p.m. The physician orders were entered into the computer system on [DATE]. An interview was conducted with R138 on [DATE] at 5:06 p.m. R138 stated he got to the facility on [DATE] at 6:00 p.m. He didn't get any medications for over 12 hours. The physician orders dated [DATE], documented the following: Gabapentin capsule 300 mg (milligrams) (used to treat pain) (1); Administer 1 cap (capsule) by mouth three times a day. Dx (diagnosis) neuralgia and neuritis. Buspirone tablet 5 mg (used to treat anxiety) (2); administer 1 tab (tablet) by mouth three times a day, Dx - anxiety. Baclofen tablet 10 mg (used to treat anxiety) (3); administer 1 tab by mouth three times a day, DX - no listed. Review of the [DATE] MAR (medication administration record) documented the above orders. For the Gabapentin the first dose received was on [DATE] at 9:00 a.m. There was a blank for the dose on [DATE] at 9:00 p.m. For the Buspirone the first dose received was on [DATE] at 9:00 a.m. There was a blank for the dose on [DATE] at 9:00 p.m. For the Baclofen the first dose administered was on [DATE] at 9:00 a.m. There were blanks for the 9:00 p.m. dose on [DATE], [DATE] and [DATE]. Review of the contents of the Omnicell (emergency backup medication system) revealed Gabapentin, Buspirone, and Baclofen were in the system and available for administration. The baseline care plan dated, [DATE] documented in part, Approach: Behaviors: behavioral needs will be evaluated for impact on quality of life, safety and safety of others. Behavioral management plan will be addressed in needed with physician/NP (nurse practitioner) IDT (interdisciplinary team) and resident/resident representative .Approach: Pain: evaluation of pain will be performed routinely to address pain management needs. I will receive medication per physician/NP orders. Pain medication effectiveness will be documented and reported as needed. An interview was conducted with LPN (licensed practical nurse) #12 on [DATE] at 10:32 a.m. When asked how you obtain medications for a new admission or when medications are not on the medication cart, LPN #12 stated for the new admissions, you have to send them to the pharmacy and ask for the medications early, then it takes a bit for the medication to come. LPN #12 was asked if the nurses can cover any of the medications before they come from the pharmacy, LPN #12 stated you can get them from the Omnicell, including some narcotics. If it's a narcotic the pharmacy sends a code, and you need two nurses to pull it out. LPN #12 stated she was an agency nurse before coming as a permanent employee and had a code for the Omnicell, but it expired in two weeks and had to be renewed. She stated she currently did not have a code for the Omnicell. An interview was conducted with LPN #1 on [DATE] at 9:42 a.m. When asked how does a nurse evidence that they have administered a medication, LPN #1 stated, by signing it off on the MAR, if it's not documented it wasn't done. ASM (administrative staff member) #1, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on [DATE] at 5:13 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a694007.html. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688005.html. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688005.html. 3. For Resident #139 (R139), the facility staff failed to administer medications per the physician order. R139 was admitted to the facility on [DATE] at 5:09 p.m. The admission physician orders were dated [DATE] at the following times: 1:41 p.m. Amlodipine tablet 5 mg (used to treat high blood pressure and heart disease) (1); administer 1 tab by mouth once a day. 1:41 p.m. Bactrim DS (used to treat infections) (2) tablet ,d+[DATE] mg; administer 1 tab via gastric tube twice a day. 1:51 p.m. Finasteride (used to treat enlargement of the prostate) (3) once a day. 2:04 p.m. Magnesium Oxide tablet (supplement) 400 mg; administer 1 tab by mouth once a day. 2:33 p.m. Potassium Chloride tablet extended release 20 mEq (milliequivalent) (supplement); administer 1 tablet via gastric tube once a day. 2:10 p.m. Metoprolol tartrate (used to treat high blood pressure and heart disease) (4) tablet 25 mg; administer 1 tab by mouth twice a day. 2:37 p.m. Sodium Chloride 1,000 mg (supplement); administer 1000 mg via gastric tube three times a day. 2:38 p.m. Tamsulosin capsule 0.4 mg (used to treat enlarged prostate) (5); administer 1 capsule via gastric tube once a day. 2:44 p.m. Warfarin tablet (blood thinner) (6)1 mg, administer 6 tabs via gastric tube once a day. The [DATE] MAR documented the above orders. For the Amlodipine the first dose was administered on [DATE], two days after admission, missing one dose since admission. For the Bactrim DS, the first dose was administered on [DATE] at 6:00 p.m., missing two doses since admission. For the Finasteride, the first dose was administered on [DATE], two days after admission, missing one dose since admission. For the Magnesium Oxide, the first dose was administered on [DATE], two days after admission, missing one dose since admission. For the Potassium Chloride, the first dose was administered on [DATE], two days after admission, missing one dose since admission. For the Metoprolol tartrate. the first dose was administered on [DATE] at 9:00 p.m., missing two doses since admission. For the Sodium Chloride, the first dose was administered on [DATE] at 8:00 p.m., missing three doses since admission. For the Tamsulosin capsule, the first dose was administered on [DATE] at 9:00 a.m., missing one dose since admission. For the Warfarin tablets, the first dose was administered on [DATE] at 6:00 p.m. missing two doses since admission, the nurse documented for [DATE], waiting for RX (pharmacy) delivery. Review of the Omnicell system inventory, documented the above medications were all available in the emergency backup medication system and available for administration. An interview was conducted with LPN (licensed practical nurse) #12 on [DATE] at 10:32 a.m. When asked how you obtain medications for a new admission or when medications are not on the medication cart, LPN #12 stated for the new admissions, you have to send them to the pharmacy and ask for the medications early, then it takes a bit for the medication to come. LPN #12 was asked if the nurses can cover any of the medications before they come from the pharmacy, LPN #12 stated you can get them from the Omnicell, including some narcotics. If it's a narcotic the pharmacy sends a code, and you need two nurses to pull it out. LPN #12 stated she was an agency nurse before coming as a permanent employee and had a code for the Omnicell but it expired in two weeks and had to be renewed. She stated she currently did not have a code for the Omnicell. ASM (administrative staff member) #1, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on [DATE] at 5:13 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a692044.html/. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a684026.html. (3) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698016.html. (4) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682864.html. (5) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698012.html. (6) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682277.html. 42106 4 [TRUNCATED]

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician services for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the on-call nurse practitioner failed to verify medication orders when the resident was readmitted on [DATE]. This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. Also, the R5's blood sugar was documented as 579 (1), the resident was diagnosed with diabetic ketoacidosis (2), and the resident required an insulin drip (insulin that is intravenously infused). A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on [DATE]. The hospital discharge summary dated 5/11/24 documented a primary discharge diagnosis of bilateral distal femur fractures secondary to osteoporosis and a mechanical fall. The hospital discharge medication list documented, CONTINUE taking these medications: -gabapentin (used to treat seizures and pain) 400 mg (milligrams)- one capsule every eight hours for five days. -Insulin Lispro 100 unit/mL (milliliter) insulin pen- two units beneath the skin Three Times Daily with Meals. If eats at least 50% of meal or drinks a supplement shake. -Insulin Lispro 100 unit/mL insulin pen- Inject 0-3 Units beneath the skin 4 Times a Day Before Meals & at Bedtime. Per sliding scale (based on the resident's blood sugars): 250-350=1 unit 351-400=2 units 401-800=3 units Call & notify MD (Medical Doctor) if BG (Blood Glucose) > (greater than) 400. -LEVEMIR 100 unit/mL (3 mL) insulin pen- Inject 9 Units beneath the skin Every Night at Bedtime. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was readmitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/11/24 at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals 139/63 (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated 5/12/24 at midnight (5/11/24 into 5/12/24) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back. It was noted that the last time resident received insulin or glucose checks was on 05/08/2024. This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective. Blood glucose 579. Lispro and Levemir administered. 911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital discharge summary dated 5/17/24 documented, Per patient, since discharge (from the hospital on 5/11/24) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .EMS reported BS (Blood Sugar) 600. Started insulin drip per DKA (diabetic ketoacidosis) protocol and pain meds and admitted . A facility synopsis of events dated 5/22/24 documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on [DATE] after an unrelated hospitalization . A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (emergency room ) for evaluation. The resident returned to the facility on [DATE] .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on 5/15/24 by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on 5/12/24 on another unit) documented, On Sunday 5/12/24 on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit 5/12/24 into 5/13/24) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on May 12th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on 5/13/24 documented, On Monday 5/13/24, I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on 5/15/24 documented, On 5/12/24 at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on 5/12/24 at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On 9/17/24 at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5 stated she could not recall details and to refer to her note. RN #2 was not available for interview during the survey. A printed text message from LPN #6 (the nurse who sent R5 to the hospital on the night of 5/12/24) to ASM (administrative staff member) #2 (the Director of Nursing) (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). Another printed text message from LPN #6 to ASM #2 (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). ASM #2, I have been waiting for a phone call from you. Since I haven't, I am going to write an incident report to my agency and I will report you to the VA (Virginia) board of nursing. The patient I sent to the hospital hadn't got her insulin for a day and a half because the dr (doctor) on call refused to verify the meds since (R5) didn't return to the facility while she was on call . LPN #6 was not available for interview during the survey. A statement signed by ASM #2 (the Director of Nursing) (no date) documented, On 5/13/2024, 11 a.m. I called (name of nursing staff agency) to request (RN #1's) telephone number and reported Nurse's failure to initiate an admission nor verify medications to treat resident. Resident arrived at 2pm. Staffing agency, stated that they would contact Nurse and have her return my call. Upon return call, I inquired of the reason (RN #1- the nurse who cared for R5 when the resident was readmitted on [DATE]) did not initiate the admission process for the readmission. Nurse verbalized, she was extremely busy. 'I had to discharge a resident and was not sure of the process, and that the Unit Manager (who was on call and in the building) assisted her with printing discharge paperwork. 'I am not familiar with your version of (name of computer software), I use (name of computer software) at another facility, and however I am more familiar with (name of another computer software). I did ask (LPN #7) on the other unit, what I needed to do for the admission, and she told me the resident was a regular resident and all the medications for her were on the cart.' I went on to ask the Nurse had she received a discharge packet from the Medical transportation personnel, her response was, 'yes.' I continued by referencing her admission note and resident's script upon her return and inquired about the failure to call MD (medical doctor) for verification of orders. Nurse (RN #1) stated, she was unaware of the need to call since, she was told her medications were on the cart. I followed up by asking, Did you see a MAR (medication administration record) for the resident? 'No.' Did you ask the Unit Manager for assistance? 'No.' When you completed your assessment [sic] the resident and noted the script for Gabapentin (used to treat seizures and pain), why did you not input the new script? 'I continued to pass the other medications to the other residents.' Have you ever performed an admission? 'Yes, your system is different, and in (name of another computer system) after putting the resident in the system the admission assessments automatically populates [sic].' 'I informed the oncoming nurse that I had an admission but did not finish it and she said she would finish it, I offered to stay if she would walk me through the process, but she told me she would complete it.' Interviewed (LPN #5- the nurse who cared for R5 during the 7:00 p.m. to 7:00 a.m. shift 5/11/24 into 5/12/24), via telephone. She verbalized she did inform the nurse that she would complete the admission, but initially was not aware of that the medications were not transcribed nor verified. (LPN #5), during her medication pass noted (R5) did not have a MAR, immediately after her medication pass, she made an attempt to call to verify orders, and after speaking with the On call Physician, who would not verify the orders. She texted the On Call Nurse. (LPN #5) was asked, why she did not call (name of the medical director) and she verbalized that she was not aware that she could since there was an On Call system in place. I educated (LPN #5), to call instead of text the On Call Nurse management team member or myself, and in cases of this importance (name of the medical director) can be called. (LPN #5) added that she did inform the oncoming Nurse to call to have the orders verified. However, the oncoming Nurse stated, 'I will not be doing that because it [sic] Mother's Day.' Called (name of nurse staffing agency), informed that of (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24), failure to complete Medication Administration Record documentation, failure to follow up on a readmission, and failure to complete skilled documentation. Interviewed via telephone, (RN #2), stated she 'thought' she signed off her medications, 'I was constantly on the cart, tending to residents, answering questions for family members, and made attempts to control (R5's) pain since the resident only came back with gabapentin. They called in Tramadol (used to treat pain) to the pharmacy and it did not come in, then I got an order for Tylenol 1000 mg (milligrams) and gave it to resident.' I inquired of why the orders were not transcribed on the MAR nor documented in the system and was she aware that (R5's) medication were not verified? 'There was a lot going on and I planned to do it.' Why did you did [sic] not call the On call Nurse for assistance? 'I do not have anyone's number and like I said it was a lot going on.' (RN #2) was informed that there is a calendar at the desk with all On Call Nurses numbers attached. (RN #2) said she did not have time to look for anyone's numbers, but she did ask (LPN #7) for assistance. On 9/17/24 at 9:33 a.m., an interview was conducted with LPN #4 (the current unit manager). LPN #4 stated that when a resident is readmitted from the hospital, he or she returns with a package that contains a medication list and discharge instructions, and the admitting nurse should call the doctor to verify the medication list. LPN #4 stated sometimes the doctor changes medication orders and after medications have been verified, the nurse should put all orders into the computer system. LPN #4 stated that after orders are put into the computer system, they are transmitted to the pharmacy and transcribed onto a MAR. LPN #4 stated she would not stop in the middle of a medication pass to complete this process, but it should be done as soon as the resident arrives. LPN #4 stated, That's the first thing they should do because we need the meds. LPN #4 stated if the physician or nurse practitioner will not verify medications upon re-admission, the admitting nurse should call the medical director and inform the Director of Nursing. On 9/17/24 at 10:46 a.m., an interview was conducted with ASM #2 (the Director of Nursing). ASM #2 stated that when a resident is readmitted , the nurse should greet the resident, make sure the resident is comfortable, then go to the desk and open the packet of information and orders from the hospital. ASM #2 stated the nurse should enter/transcribe the orders into the queue in the computer system then verify the orders with the physician because the physician may want to change the orders. ASM #2 stated that after the orders are verified with the physician, the nurse should make the orders active in the computer system so the orders are activated onto the MAR and sent to the pharmacy. ASM #2 stated she was not made aware of the above incident regarding R5 until the resident was being sent back to the hospital on (5/12/24 into 5/13/24). ASM #2 stated it was the middle of the night and she received a phone call from R5's brother. ASM #2 stated the facility staff could not manage R5's pain. ASM #2 stated R5's brother said R5 was in significant pain and had not received any pain medications in over 24 hours. ASM #2 stated that at that point, all she could do was agree that pain medications should have been obtained for R5 then she called the facility staff to make sure they sent R5 to the hospital and documented a note. ASM #2 stated she could not recall what facility staff she talked to or if she was made aware of R5's blood sugar. ASM #5 stated that when R5 was readmitted to the facility on [DATE], the first nurse should have queued the medications in the computer system, called the physician to verify the medications, sent the medication orders to the pharmacy, and if the resident was in pain or required insulin, the nurse should have contacted the pharmacy and obtained medications from the box in the facility. ASM #2 stated that if the nurse didn't know what to do, she should have called the on-call nurse or ASM #2. ASM #2 stated that if the nurse practitioner refused to verify the medications, then the nurse should have notified her so she could have notified the medical director. On 9/17/24 at 11:23 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the responsibilities of the on-call physician or nurse practitioner are to take care of the patient, verify orders, and send the pharmacy an e-script (electronic prescription) if needed. In regard to the above incident involving R5, ASM #6 stated that if he recalled, there were errors on multiple sides. ASM #6 stated the orders should have been called in to the on-call nurse practitioner as soon as R5 arrived to the facility but it was the responsibility of the on-call nurse practitioner to verify orders and send e-scripts whenever called, regardless of the time. ASM #6 stated, It is our responsibility to make sure it happens with as little delay as possible. ASM #6 stated he should have been notified when the on-call nurse practitioner refused to verify R5's orders but he was not notified until the next day. ASM #6 stated the on-call nurse practitioner does not round at the facility and is only on-call for the group, but he escalated the incident to the chief medical officer because the patient actually came to some harm and had to go the emergency room for a lack of order verification and pain management. On 9/18/24 at 1:11 p.m. another interview was conducted with ASM #6. ASM #6 was made aware of the statement signed by LPN #8 on 5/13/24 that documented he (ASM #6) was notified on 5/12/24 at 8:38 a.m. ASM #6 stated he went back through his phone records. ASM #6 stated that during the morning on 5/12/24, LPN #8 made him aware that R5 was admitted at 2:00 p.m. on the previous day and the medications were not called to the on-call nurse practitioner until midnight and the nurse practitioner declined to verify the medications because she thought they should have been called to her earlier in the day. ASM #6 stated he told LPN #8 to call the on-call nurse practitioner back since it was not after 8:00 p.m., and if the nurse practitioner did not verify the medications, call him back. ASM #6 stated he was not notified again until R5 was sent to the hospital. On 9/17/24 at 1:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Physician/Provider Orders documented, ADMISSION ORDERS: All information received from the referring facility or agency shall be reviewed. 1. Transcribe all orders from the transfer form to the facility admission physician order form. 2. The attending physician shall review and confirm the orders. References: (1) A blood sugar test measures the amount of a sugar called glucose in a sample of your blood. If you had a fasting blood glucose test, a level of 70 to 99 mg (milligrams)/dL (deciliter) is considered normal. If you had a random blood glucose test, a normal result depends on when you last ate. Most of the time, the blood glucose level will be 125 mg/dL or lower . (2) Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. This information was obtained from the website: https://medlineplus.gov/ency/article/000320.htm

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement an effective pain management program for two of 35 residents in the survey sample, Residents #5 and #138. The findings include: 1. For Resident #5 (R5), the facility staff failed to obtain and verify physician orders for pain medications when the resident was readmitted to the facility at 2:00 p.m. on 5/11/24 with two broken femurs (thigh bones). This resulted in harm: on 5/13/24 at approximately 1:15 a.m., R5 was transferred to the hospital for inadequate pain control. A review of R5's clinical record revealed a nurse's note dated 6/5/24 that documented the resident sustained a fall and was transferred to the hospital. R5 was discharged from the hospital back to the facility on [DATE]. The hospital discharge summary dated 5/11/24 documented a primary discharge diagnosis of bilateral distal femur fractures secondary to osteoporosis and a mechanical fall. The hospital discharge medication list documented, CONTINUE taking these medications: gabapentin (used to treat seizures and pain) 400 mg (milligrams)- one capsule every eight hours for five days. Further review of R5's clinical record failed to reveal any physician's medication orders when the resident was readmitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/11/24 at 4:13 p.m. documented, Pt (Patient) returned from (name of hospital) at 1400 (2:00 p.m.) via stretcher. Received report from hospital. Pt is alert and oriented. Generalized bruising visible on face, scalp and both legs. Dried blood on face and scalp. Left side of hair line has 2 sutures. Bridge of nose with 3 sutures intact. Rt (Right) knee with honeycomb dressing bilaterally. Abrasion lower rt leg front. Left hip with Honeycomb dressing dry and intact. Petal pulse present bilaterally. Left side weaker than right, chronic issue. Lungs clear, abd (abdomen) soft with bowel sounds all 4 quads (quadrants). Pt has script for Neurontin (gabapentin) q (every) 8 hours prn (as needed) for pain. BS (Blood sugar) 132. Vitals 139/63 (blood pressure), 92 (pulse), 16 (respirations), 98 (temperature), 96% (oxygen level). A nurse's note dated 5/12/24 at midnight (5/11/24 into 5/12/24) documented, During hand off report, previous nurse reports to this nurse that patient arrived to facility at 1400 but she did not confirm orders with MD (Medical Doctor)/enter orders in MAR (medication administration record). Writer contacted (name of physician group) on call to confirm orders. Writer spoke with (name of a nurse practitioner). (Name of the nurse practitioner) refuses to confirm orders with nurse because patient came to facility at 1400. Writer attempted to explain to On call (name of nurse practitioner) that this nurse shift started at 1900 (7:00 p.m.) and this nurse just finished passing medication on unit and just needed to confirm the orders because previous nurse did not. (Name of nurse practitioner) states, 'I am not doing that. I am not approving medications after 8pm.' Due to (name of physician group) (name of nurse practitioner) refusing to confirm orders for patient, writer cannot enter patients [sic] orders/treatments into MAR at this time. Will endorse oncoming nurse. Will make management aware of clinical situation. An admission/readmission observation dated 5/12/24 at 2:59 a.m. documented R5 reported pain or hurting almost constantly over the last five days, the pain almost constantly made it hard to sleep, the pain almost constantly limited day-to-day activities, the pain was rated as an eight on a scale from zero to ten, and the intensity of the pain was severe. There were no nurses' notes documented in R5's clinical record during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24. R5's May 2024 MAR documented the resident's pain as a ten (on a scale from zero to ten) during the day shift on 5/12/24 and the resident's pain as an eight during the night shift on 5/12/24. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back .This nurse noted that the only pain medicine ordered is Tylenol 1000mg (milligrams). This nurse called nurse on 3West in (name of hospital) to get more information about resident's stay in the hospital. The only discharge papers were a list of medications. No Dx (diagnoses), tests, test results were noted. Nurse at (name of hospital) was not able to give any information since the resident had already been released. On call doctor was noted; on call doctor advised nurse to either administer Tylenol or send resident to the hospital if pain gets too intense. Resident's brother was noted and he drove to be at his sister's bedside at 0030 (12:30 a.m.). Tylenol was not effective. Resident was repositioned; ineffective .911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. A hospital discharge summary dated 5/17/24 documented, Per patient, since discharge (from the hospital on 5/11/24) was not able to get her insulin and noted increased pain on bilateral lower ext (extremities) .Started insulin drip per DKA (diabetic ketoacidosis) protocol and pain meds and admitted . A facility synopsis of events dated 5/22/24 documented, (R5's) brother, (name), called the DON (Director of Nursing) to inquire about prescribed medications and administration. Based upon this concern, the facility immediately started an internal investigation. The facility interviewed all nurses responsible for (R5's) care, the physician on-call upon the resident's return to the community and reviewed the resident's medical record. (R5) returned to the facility on [DATE] after an unrelated hospitalization . A review of the physician orders revealed medication errors regarding transcription of new orders upon return to the facility. Interviews of the nursing team members responsible for (R5's) care revealed unsuccessful attempts to verify the medications with the resident provider group via telephone upon return. Upon the orders being unsuccessfully verified (R5) to return to the ER (emergency room ) for evaluation. The resident returned to the facility on [DATE] .Based on the schedule, the nurses that would have completed her admission and or delivered medications. The nurses who assumed care for the resident were placed on a do not return list and are not allowed to work in the facility . The synopsis contained multiple statements by facility staff as documented below. A statement signed on 5/15/24 by RN (registered nurse) #3 (the nurse who worked the 7:00 a.m. to 7:00 p.m. shift on 5/12/24 on another unit) documented, On Sunday 5/12/24 on Day shift provider for (R5) called unit one inquiring about resident if she had returned from hospital. Updated provider that resident returned but did not have any pain medication. Provider reporting that they would escribe (electronically prescribe) pain medication to (name of pharmacy), did not specify what medication, dose, or frequency. RN #3 was available for interview during the survey. A statement signed by LPN (licensed practical nurse) #7 (the nurse who worked the 7:00 p.m. to 7:00 a.m. shift on another unit 5/12/24 into 5/13/24) (no signature date) documented, To Whom it may concern: I, (name of LPN #7) was approached by (LPN #6), regarding patient, (R5) on Unit 1 nurses station. (LPN #6) stated, '(R5) is having uncontrolled pain and she has no pain medications.' (LPN #6) continued, 'Oh! and her blood sugar is around 600.' This nurse then replied, 'Send her out.' (LPN #6) then replied, 'Well I gave her Levemir for her sugar.' I again stated, 'Send her out.' (LPN #6) walked to her computer to print off (R5's) paperwork for transfer. (R5's) brother was in her room. When (LPN #6) stated, 'She has only 1 or 2 medications, so I didn't print it off.' This nurse then went to computer and there were no medications under (R5's) orders. This nurse stated to EMTs (Emergency Medical Technicians) that patient 'does not have any medications on her orders.' This nurse stated, 'I don't know of any medications being administered, other than Levemir (LPN #6) gave her.' This nurse then left the room and the unit. Another statement signed by LPN #7 (no signature date) documented, To Whom it may concern: I, (name of LPN #7), had no interaction with nurse on unit 2, until 1020 PM on May 12th 2024. Said nurse on unit 2 (RN #2) approached the nurses station on unit 1 @ 1020 PM regarding her relief. On call nurse (LPN #8) was notified and there was no other interaction after 1030 PM.- Regarding (RN #2) (the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24). LPN #7 was not available for interview during the survey. A statement signed by LPN #8 (R5's unit manager) on 5/13/24 documented, On Monday 5/13/24, I came in to relieve the nurse (LPN #6) because she needed to leave by 630 am. (LPN #6) gave me report on the unit, she told me that she sent (R5) out because of the pain she was having. I asked her did she let anyone know. She stated no it was late it was 1 am. I then stated two residents went to the hospital on your watch, on call should have been called. I explained that and proceeded to take report. A statement signed by LPN #8 on 5/15/24 documented, On 5/12/24 at 12:32 am, nurse (LPN #5) text my phone to state the nurse during the day did not get the meds approved at 2 pm when the resident was admitted on 5.11.24. (LPN #5) stated she called (name of physician group) on call to get the meds verified but the on call (name of nurse practitioner) refused to verify the meds because she stated she doesn't verify meds after 8pm. Once I woke up to the text at 0738 (7:38 a.m.) I contacted (LPN #5) and she explained what she wrote in her text. I then called (name of medical director) explaining what happened, he stated this was not the first time on call has done this that he would be reaching out. Resident meds still needed to be verified, (name of medical director) stated to call on call and have them verify the meds. (Name of medical director) was contacted by me on 5/12/24 at 0838 (8:38 a.m.). This writer then called the building x (times) 4, no one answered. I then called the housekeeper supervisor to check all phones in the building because no one was picking up, she took phone to nurse. I told (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24) to place the orders in (name of computer system) because she stated to me that (RN #3), the nurse on unit one already verified the meds. (RN #2) stated she had one more resident to give meds to and she was going to put the orders in. LPN #8 was not available for interview during the survey. On 9/17/24 at 2:10 p.m., a telephone interview was conducted with LPN #5. LPN #5 stated she could not recall details and to refer to her note. RN #2 was not available for interview during the survey. A printed text message from LPN #6 (the nurse who sent R5 to the hospital on the night of 5/12/24) to ASM (administrative staff member) #2 (the Director of Nursing) (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). Another printed text message from LPN #6 to ASM #2 (no date) documented, Hello (ASM #2), I need to talk to you about last night. So much happened and I just came in trying to help. Seems like there are so many miscommunications about the events that took place. This morning I left the building feeling like the unit manager (LPN #8) and I were on the same page about how things went. Please call me at your earliest convenience. Thank you, (LPN #6). ASM #2, I have been waiting for a phone call from you. Since I haven't, I am going to write an incident report to my agency and I will report you to the VA (Virginia) board of nursing. The patient I sent to the hospital hadn't got her insulin for a day and a half because the dr (doctor) on call refused to verify the meds since (R5) didn't return to the facility while she was on call . LPN #6 was not available for interview during the survey. A statement signed by ASM #2 (the Director of Nursing) (no date) documented, On 5/13/2024, 11 a.m. I called (name of nursing staff agency) to request (RN #1's) telephone number and reported Nurse's failure to initiate an admission nor verify medications to treat resident. Resident arrived at 2pm. Staffing agency, stated that they would contact Nurse and have her return my call. Upon return call, I inquired of the reason (RN #1- the nurse who cared for R5 when the resident was readmitted on [DATE]) did not initiate the admission process for the readmission. Nurse verbalized, she was extremely busy. 'I had to discharge a resident and was not sure of the process, and that the Unit Manager (who was on call and in the building) assisted her with printing discharge paperwork. 'I am not familiar with your version of (name of computer software), I use (name of computer software) at another facility, and however I am more familiar with (name of another computer software). I did ask (LPN #7) on the other unit, what I needed to do for the admission, and she told me the resident was a regular resident and all the medications for her were on the cart.' I went on to ask the Nurse had she received a discharge packet from the Medical transportation personnel, her response was, 'yes.' I continued by referencing her admission note and resident's script upon her return and inquired about the failure to call MD (medical doctor) for verification of orders. Nurse (RN #1) stated, she was unaware of the need to call since, she was told her medications were on the cart. I followed up by asking, Did you see a MAR (medication administration record) for the resident? 'No.' Did you ask the Unit Manager for assistance? 'No.' When you completed your assessment [sic] the resident and noted the script for Gabapentin (used to treat seizures and pain), why did you not input the new script? 'I continued to pass the other medications to the other residents.' Have you ever performed an admission? 'Yes, your system is different, and in (name of another computer system) after putting the resident in the system the admission assessments automatically populates [sic].' 'I informed the oncoming nurse that I had an admission but did not finish it and she said she would finish it, I offered to stay if she would walk me through the process, but she told me she would complete it.' Interviewed (LPN #5- the nurse who cared for R5 during the 7:00 p.m. to 7:00 a.m. shift 5/11/24 into 5/12/24), via telephone. She verbalized she did inform the nurse that she would complete the admission, but initially was not aware of that the medications were not transcribed nor verified. (LPN #5), during her medication pass noted (R5) did not have a MAR, immediately after her medication pass, she made an attempt to call to verify orders, and after speaking with the On call Physician, who would not verify the orders. She texted the On Call Nurse. (LPN #5) was asked, why she did not call (name of the medical director) and she verbalized that she was not aware that she could since there was an On Call system in place. I educated (LPN #5), to call instead of text the On Call Nurse management team member or myself, and in cases of this importance (name of the medical director) can be called. (LPN #5) added that she did inform the oncoming Nurse to call to have the orders verified. However, the oncoming Nurse stated, 'I will not be doing that because it [sic] Mother's Day.' Called (name of nurse staffing agency), informed that of (RN #2- the nurse who cared for R5 during the 7:00 a.m. to 7:00 p.m. shift on 5/12/24), failure to complete Medication Administration Record documentation, failure to follow up on a readmission, and failure to complete skilled documentation. Interviewed via telephone, (RN #2), stated she 'thought' she signed off her medications, 'I was constantly on the cart, tending to residents, answering questions for family members, and made attempts to control (R5's) pain since the resident only came back with gabapentin. They called in Tramadol (used to treat pain) to the pharmacy and it did not come in, then I got an order for Tylenol 1000 mg (milligrams) and gave it to resident.' I inquired of why the orders were not transcribed on the MAR nor documented in the system and was she aware that (R5's) medication were not verified? 'There was a lot going on and I planned to do it.' Why did you did [sic] not call the On call Nurse for assistance? 'I do not have anyone's number and like I said it was a lot going on.' (RN #2) was informed that there is a calendar at the desk with all On Call Nurses numbers attached. (RN #2) said she did not have time to look for anyone's numbers, but she did ask (LPN #7) for assistance. On 9/17/24 at 9:33 a.m., an interview was conducted with LPN #4 (the current unit manager). LPN #4 stated that when a resident is readmitted from the hospital, he or she returns with a package that contains a medication list and discharge instructions, and the admitting nurse should call the doctor to verify the medication list. LPN #4 stated sometimes the doctor changes medication orders and after medications have been verified, the nurse should put all orders into the computer system. LPN #4 stated that after orders are put into the computer system, they are transmitted to the pharmacy and transcribed onto a MAR. LPN #4 stated she would not stop in the middle of a medication pass to complete this process, but it should be done as soon as the resident arrives. LPN #4 stated, That's the first thing they should do because we need the meds. LPN #4 stated if the physician or nurse practitioner will not verify medications upon re-admission, the admitting nurse should call the medical director and inform the Director of Nursing. On 9/17/24 at 10:46 a.m., an interview was conducted with ASM #2 (the Director of Nursing). ASM #2 stated that when a resident is readmitted , the nurse should greet the resident, make sure the resident is comfortable, then go to the desk and open the packet of information and orders from the hospital. ASM #2 stated the nurse should enter/transcribe the orders into the queue in the computer system then verify the orders with the physician because the physician may want to change the orders. ASM #2 stated that after the orders are verified with the physician, the nurse should make the orders active in the computer system so the orders are activated onto the MAR and sent to the pharmacy. ASM #2 stated she was not made aware of the above incident regarding R5 until the resident was being sent back to the hospital on (5/12/24 into 5/13/24). ASM #2 stated it was the middle of the night and she received a phone call from R5's brother. ASM #2 stated the facility staff could not manage R5's pain. ASM #2 stated R5's brother said R5 was in significant pain and had not received any pain medications in over 24 hours. ASM #2 stated that at that point, all she could do was agree that pain medications should have been obtained for R5 then she called the facility staff to make sure they sent R5 to the hospital and documented a note. ASM #5 stated that when R5 was readmitted to the facility on [DATE], the first nurse should have queued the medications in the computer system, called the physician to verify the medications, sent the medication orders to the pharmacy, and if the resident was in pain, the nurse should have contacted the pharmacy and obtained medications from the box in the facility. ASM #2 stated that if the nurse didn't know what to do, she should have called the on-call nurse or ASM #2. ASM #2 stated that if the nurse practitioner refused to verify the medications, then the nurse should have notified her so she could have notified the medical director. On 9/17/24 at 11:23 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the responsibilities of the on-call physician or nurse practitioner are to take care of the patient, verify orders, and send the pharmacy an e-script (electronic prescription) if needed. In regard to the above incident involving R5, ASM #6 stated that if he recalled, there were errors on multiple sides. ASM #6 stated the orders should have been called in to the on-call nurse practitioner as soon as R5 arrived to the facility but it was the responsibility of the on-call nurse practitioner to verify orders and send e-scripts whenever called, regardless of the time. ASM #6 stated, It is our responsibility to make sure it happens with as little delay as possible. ASM #6 stated he should have been notified when the on-call nurse practitioner refused to verify R5's orders but he was not notified until the next day. ASM #6 stated the on-call nurse practitioner does not round at the facility and is only on-call for the group, but he escalated the incident to the chief medical officer because the patient actually came to some harm and had to go the emergency room for a lack of order verification and pain management. On 9/18/24 at 1:11 p.m. another interview was conducted with ASM #6. ASM #6 was made aware of the statement signed by LPN #8 on 5/13/24 that documented he (ASM #6) was notified on 5/12/24 at 8:38 a.m. ASM #6 stated he went back through his phone records. ASM #6 stated that during the morning on 5/12/24, LPN #8 made him aware that R5 was admitted at 2:00 p.m. on the previous day and the medications were not called to the on-call nurse practitioner until midnight and the nurse practitioner declined to verify the medications because she thought they should have been called to her earlier in the day. ASM #6 stated he told LPN #8 to call the on-call nurse practitioner back since it was not after 8:00 p.m., and if the nurse practitioner did not verify the medications, call him back. ASM #6 stated he was not notified again until R5 was sent to the hospital. On 9/17/24 at 1:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Pain Management Protocol documented, It is the policy of this community to ensure any resident that is admitted to the facility is assessed for pain and/or the potential for pain in order for the resident to reach and maintain his/her highest practicable level of physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. 27660 2. For Resident #138 (R138), the facility staff failed to administer physician prescribed pain medications. The Brief Interview for Mental Status (BIMS) form dated, 9/12/24, the resident scored a 12 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. R138 was admitted to the facility on [DATE] at 6:21 p.m. An interview was conducted with R138 on 9/15/24 at 5:06 p.m. R138 stated he had pain upon admission, and they didn't give him his pain medications. It took a while to get his pain under control because he stated he got behind the curve with it. The physician orders dated 9/10/24, documented, Morphine tablet extended release; 15 mg (milligrams); 3 tabs (tablets) every 12 hours for malignant neoplasm of prostate. The September 2024 MAR (medication administration record) documented the above order. There were blanks on the MAR for 9/10/24 at 9:00 p.m., 9/11/24 at 9:00 p.m. and 9/12/24 at 9:00 p.m. The Controlled Medication Utilization Record documented the medication was received at the facility on 9/12/24. Review of the Omnicell (on site emergency medication system) inventory list failed to evidence the Morphine extended release was stocked in it. The Baseline Care plan dated 9/10/24, documented in part, Approach: Pain - evaluation of pain will be performed routinely to address pain management needs. I will receive pain medication per physician/NP (nurse practitioner) orders. Paim medication effectiveness will be documented and recorded as needed. An interview was conducted with LPN (licensed practical nurse) #12 on 9/17/24 at 10:32 a.m. When asked how you get narcotics for a new admission, LPN #12 stated if they don't have the medications here, there's the Omnicell. You need two nurses to get out narcotics and the pharmacy must give you a code to get into it. LPN #12 stated, when she gets report from the hospital, she asks them to medicate the resident for pain, if indicated, as transfers can be rough on the resident. LPN #12 further stated if you don't tell the pharmacy, you want them on the first run, then you don't get them until the night run. When asked about R138, LPN #12 stated she had done his admission, the narcotics should have come that night, unless there was an insurance delay. She stated someone had added (R138) to the system but can't transmit the orders to the pharmacy until the resident is actually in the building. ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/17/24 at 5:13 p.m. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to maintain a complete infection control program. The findings include: The facility staff failed to maintain infection control surveillance for December 2023 and February 2024 and incomplete tracking for March, April and May 2024. The infection control surveillance tracking was reviewed. There was nothing documented for December 2023 and February 2024, it was blank. The tracking logs for March, April and May 2024 had attached the Antibiotic Medications Reports only. There was no documentation of date symptoms started, culture results, or radiology reports. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 9/18/24 at 2:18 p.m. The above documents were reviewed with ASM #2. When asked about the December 2023 tracking, ASM #2 stated the book was given to the previous ADON (assistant director of nursing) to take care of. The documentation for March, April and May 2024 were reviewed. When asked if this was accurate documentation of surveillance of infections in the facility, ASM #2 stated, no. The facility policy, Infection Prevention and Control Program Policy, documented in part, POLICY: It is our policy to maintain an organized, effective facility-wide program designed to systematically prevent, identify, control and reduce the risk of acquiring and transmitting infections among employees, volunteers, visitors, and contract healthcare workers; to conduct surveillance of communicable disease and infectious outbreaks; and to monitor employee health. This program involves the intersection of many programs, policies and services within the facility and is designed to meet the intent of regulatory guidance .Particular focus of the program will be on conducting risk assessment, surveillance, reducing healthcare associated infections, limiting transmission of disease, immunization, promoting antibiotic stewardship, and reporting as necessary .The Infection Preventionist's responsibilities for infection prevention and control include, but may not be limited to: Conducts surveillance of staff and residents for facility-associated or community associated infections and/or communicable diseases. ASM #1, the interim administrator, and ASM #2 were made aware of the above findings on 9/18/24 at 3:00 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that written notification of a hospital transfer was provided to the resident representative and the Ombudsman for three of 35 residents in the survey sample; Residents #36, #9 and #11. The findings include: 1. For Resident #36, the facility staff failed to evidence that a written notice was provided to the resident representative and Ombudsman upon hospital transfers on 6/20/24, 7/6/24 and 7/18/24. A review of the clinical record revealed that the resident was transferred to the hospital for change in condition concerns on 6/20/24, 7/6/24 and 7/18/24. Further review failed to reveal any evidence of a written notice to the resident representative and Ombudsman for the above hospital transfers. On 9/17/24 at 2:18 PM, an interview was conducted with OSM #8 (Other Staff Member) the Director of Social Services and Admissions. He stated that for the above hospital transfers, he ran the wrong report when he was doing my hospital transfers report faxed to the Ombudsman. Regarding written notification to the resident representative, he stated that he does not send a written notice. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). She stated that nurses do not have a role in sending written notifications to the Ombudsman or resident representatives. The facility policy, Resident Discharge / Transfer Letter documented, .Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into the electronic chart with administrator/designee signature, with the certified receipt if applicable. For emergency transfers, one list can be sent to the Ombudsman at the end of month On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #9, the facility staff failed to evidence that a written notice was provided to the resident representative and Ombudsman upon hospital transfers on 6/8/24 and 6/13/24. A review of the clinical record revealed that the resident was transferred to the hospital for change in condition concerns on 6/8/24 and 6/13/24. Further review failed to reveal any evidence of a written notice to the resident representative and Ombudsman for the above hospital transfers. On 9/17/24 at 2:18 PM, an interview was conducted with OSM #8 (Other Staff Member) the Director of Social Services and Admissions. He stated that for the above hospital transfers, he ran the wrong report when he was doing my hospital transfers report faxed to the Ombudsman. Regarding written notification to the resident representative, he stated that he does not send a written notice. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). She stated that nurses do not have a role in sending written notifications to the Ombudsman or resident representatives. The facility policy, Resident Discharge / Transfer Letter documented, .Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into the electronic chart with administrator/designee signature, with the certified receipt if applicable. For emergency transfers, one list can be sent to the Ombudsman at the end of month On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #11, the facility staff failed to evidence that a written notice was provided to the resident representative and Ombudsman upon hospital transfers on 6/2/24. A review of the clinical record revealed that the resident was transferred to the hospital for change in condition concerns on 6/2/24. Further review failed to reveal any evidence of a written notice to the resident representative and Ombudsman for the above hospital transfers. On 9/17/24 at 2:18 PM, an interview was conducted with OSM #8 (Other Staff Member) the Director of Social Services and Admissions. He stated that for the above hospital transfers, he ran the wrong report when he was doing my hospital transfers report faxed to the Ombudsman. Regarding written notification to the resident representative, he stated that he does not send a written notice. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). She stated that nurses do not have a role in sending written notifications to the Ombudsman or resident representatives. The facility policy, Resident Discharge / Transfer Letter documented, .Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into the electronic chart with administrator/designee signature, with the certified receipt if applicable. For emergency transfers, one list can be sent to the Ombudsman at the end of month On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for four of 35 residents in the survey sample, Residents #42, #21, #138 and #11. The findings include: 1. For Resident #42 (R42), the facility staff failed to implement the comprehensive care plan to A) get the resident out of bed and B) provide tube feeding as ordered. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/24, the resident was assessed as being severely impaired for making daily decisions, not rejecting care, being dependent on staff for transfers and having a feeding tube. A) On 9/15/24 at 5:24 p.m., an observation was conducted of R42 in their room. R42 was observed in bed watching television with tube feeding observed hanging beside them on a feeding tube pump. At that time, an interview was conducted with R42 who was able to verbalize some words and use a communication board. R42 stated that they had the feeding tube for about six months and had problems with it recently. R42 stated that they liked to get up in their wheelchair every day and had not been up in five days. When asked if they had asked the staff to get them up, R42 nodded and stated, They won't get me up. On 9/16/24 at 8:22 a.m., R42 was observed in their room in bed. R42 stated again that they wanted to get out of bed in the wheelchair and had not been up in five days. A CNA (certified nursing assistant) in the hallway outside of R42's room was made aware of R42's request who stated that the CNA assigned to R42 was in the dining room at that time and they would be sure that R42 got out of bed as soon as she got back. Additional observations of R42 on 9/16/24 at 11:08 a.m., 12:36 p.m., and 3:15 p.m. revealed R42 remained in bed. At 12:36 p.m., R42 pointed at the clock and stated, See what time it is? They won't get me up. The comprehensive care plan for R42 documented in part, [Name of R42] has an ADL Self Care Performance Deficit r/t (related to) Activity Intolerance, Fatigue, Hemiplegia with right sided weakness, Musculoskeletal impairment - DJD (degenerative joint disease), right arm pain, neuropathy, respiratory failure . Date Initiated: 09/28/2021. Under Interventions it documented in part, .Resident's preference is to get out of bed before lunch. Encourage him to get up daily. Date Initiated: 09/29/2021 . Up daily by 11am if refuses place note in chart. Date Initiated: 09/26/2022 . Review of the ADL (activities of daily living) documentation for R42 for 9/16/24 under How did the resident transfer? documented Activity did not occur. Review of the ADL documentation for R42 documented R42 transferring last on 9/14/24. The progress notes for R42 failed to evidence documentation of refusal to get out of bed on 9/16/24. On 9/17/24 at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to provide them with the plan of care for the resident. She stated that the care plan should be implemented. She stated that all residents should be getting out of bed unless they did not want to. She stated that R42 got up at least four times a week and required a mechanical lift to get them up. She stated that R42 was alert and oriented and she was able to communicate with them and understand them. She stated that R42 also had a communication board to use if needed. She stated that R42 wanted to get up every day and she knew that he was up on Saturday because she had come to the facility for something. She stated that she was not aware that R42 had requested to get out of bed and not gotten up on 9/16/24. She stated that they had a lot of agency staff at the facility, and it was very hard to manipulate the staffing. On 9/17/24 at 11:25 a.m., an interview was conducted with CNA #5. CNA #5 stated that residents should be offered to get out of bed each day and if they refused, they reported it to the nurse. She stated that they encouraged the residents to get out of bed to help prevent bed sores and to socialize with other residents. B) The comprehensive care plan for R42 documented in part, Problem Start Date: 06/05/2024. Category: Nutritional Status. [Name of R42] is at increased nutrition/hydration risk r/t (related to) dx/pmhx (diagnoses/primary medical history) of hemiplegia & hemiparesis on R side . Enteral nutrition support via G (gastrostomy) Tube. Hx (history) of sig (significant) wt (weight) chnages [sic]. Under Interventions it documented in part, .Provide tube feed per order . The progress notes for R42 documented in part, 05/04/2024 16:09 (4:09 p.m.) This nurse notified by off going nurse peg tube is clogged. This nurse exhausted all efforts to unclog patients peg tube patient complains of 5/10 pain. Patient was apparently not connected to his tube feeding throughout the day. Patient is complaining of hunger pain. Called [Name of physician group] on-call and was given instructions to send patient out. Patient and emergency contact [Name of emergency contact] notified. Provider to be notified via on-call nurse. EMS (emergency medical services) notified. The eMAR (electronic medication administration record) dated 5/1/24-5/31/24 for R42 documented the resident receiving no tube feeding on day shift 5/3/24 or night shift 5/3/24. The eMAR documented R42 being out due to a clogged g tube on 5/4/24 at 6:00 p.m. Review of the clinical record for R42 failed to evidence documentation of why the resident did not receive feeding on 5/3/24, the physician being notified or an order to hold the tube feeding on 5/3/24. It further failed to evidence documentation of the feeding tube being clogged on day shift on 5/4/24 or notification of the physician of the feeding tube concerns until evening shift on 5/4/24. On 9/17/24 at 11:08 a.m., an interview was conducted with LPN #1. LPN #1 stated that the purpose of the care plan was to provide them with the plan of care for the resident. She stated that the care plan should be implemented. On 9/18/24 at 9:45 a.m., a follow-up interview was conducted with LPN #1. LPN #1 stated that if a residents feeding tube became clogged, they attempted to unclog the tube and if they were not successful, they called the doctor to see what they wanted them to do. She stated that they called the doctor right then because there could be an obstruction and the resident needed their medications and the feedings. On 9/18/24 at 12:06 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that they would expect nursing staff to have another staff member assist them if the feeding tube was clogged and if they were unsuccessful in opening the tube, they should call the physician right away to get further guidance. She stated that she would not expect the resident to go a day without feeding or until the next shift to have the tube unclogged. The facility policy Comprehensive Care Planning Policy revised 3/2/2021 documented in part, .All staff must be familiar with each resident's Care Plan and all approaches must be implemented . All direct care staff must always know, understand, and follow their Resident's Care Plan. If unable to implement any part of the plan, notify your Charge Nurse or MDS Coordinator, so that this can be documented, or the Care Plan changed if necessary. On 9/17/24 at 5:11 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern regarding not implementing the care plan to get R42 out of bed. On 9/18/24 at 2:59 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern regarding not implementing the care plan to provide tube feeding. No further information was provided prior to exit. 2. For Resident #21 (R21), the facility staff failed to implement the comprehensive care plan to obtain labs as ordered. The comprehensive care plan for R21 documented in part, Resident has potential for fluid deficit r/t (related to) diuretic use. Created Date: 6/26/2023. Under Interventions it documented in part, .Medications/labs per physician order. Created Date: 6/26/2023 . Review of the pharmacy consultation report for R21 dated 5/6/24 documented a recommendation to monitor labs (TSH- thyroid stimulating hormone) due to the use of the medication amiodarone on the next convenient lab day and every six months thereafter. The consultation report documented the physician review completed on 5/14/24 with the recommendations accepted and physician's order to check BMP, CBC, TSH (basic metabolic panel, complete blood count, TSH) next lab day. Review of the clinical record failed to evidence the laboratory tests completed or results of the BMP, CBC, or TSH. On 9/17/24 at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to provide them with the plan of care for the resident. She stated that the care plan should be implemented. On 9/18/24 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #1, the administrator for evidence of the BMP, CBC and TSH ordered by the physician on the 5/14/24 pharmacy consultation. On 9/18/24 at 2:02 p.m., ASM #2 stated that R21 had not had any labs since February of 2024, and they had received an order to have them drawn today. She stated that the process in May of 2024 was for the pharmacy to email the recommendations to her and she would print them out to put them in the folder for the physician who would review and then the former assistant director of nursing would enter orders and act on the recommendations based on the physician response. She stated that there was a new team now. On 9/18/24 at 2:59 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit. 27660 3. For Resident #138, the facility staff failed to implement the comprehensive care plan for treating a resident's pain and anxiety. The baseline care plan dated, 9/10/24 documented in part, Approach: Behaviors: behavioral needs will be evaluated for impact on quality of life, safety and safety of others. Behavioral management plan will be addressed in needed with physician/NP (nurse practitioner) IDT (interdisciplinary team) and resident/resident representative .Approach: Pain: evaluation of pain will be performed routinely to address pain management needs. I will receive medication per physician/NP orders. Pain medication effectiveness will be documented and reported as needed. An interview was conducted with R138 on 9/15/24 at 5:06 p.m. R138 stated he got to the facility on [DATE] at 6:00 p.m. He didn't get any medications for over 12 hours. The physician orders dated 9/10/24, documented the following: Gabapentin capsule 300 mg (milligrams) (used to treat pain) (1); Administer 1 cap (capsule) by mouth three times a day. Dx (diagnosis) neuralgia and neuritis. Buspirone tablet 5 mg (used to treat anxiety) (2); administer 1 tab (tablet) by mouth three times a day, Dx - anxiety. Baclofen tablet 10 mg (used to treat anxiety) (3); administer 1 tab by mouth three times a day, DX - no listed. Review of the September 2024 MAR (medication administration record) documented the above orders. For the Gabapentin the first dose received was on 9/11/24 at 9:00 a.m. There was a blank for the dose on 9/10/24 at 9:00 p.m. For the Buspirone the first dose received was on 9/11/24 at 9:00 a.m. There was a blank for the dose on 9/10/24 at 9:00 p.m. For the Baclofen the first dose administered was on 9/11/24 at 9:00 a.m. There were blanks for the 9:00 p.m. dose on 9/10/24, 9/11/24 and 9/12/24. Review of the contents of the Omnicell (emergency backup medication system) revealed Gabapentin, Buspirone, and Baclofen were in the system and available for administration. An interview was conducted with RN (registered nurse) #6 on 9/17/24 at 3:12 p.m. When asked what the purpose of the care plan and should it be followed, RN #6 stated the care plan is to give you a good idea of what the patient is here for, the plan of care in relations to physical therapy, occupational therapy and speech therapy, and the plan for discharge. RN #6 stated the care plan should be followed. ASM (administrative staff member) #1, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on 9/18/24 at 3:00 p.m. No further information was obtained prior to exit. 29125 4. For Resident #11, the facility staff failed to implement the comprehensive care plan for the administration of oxygen. On 9/15/24 at 4:59 PM, 9/16/24 at 11:20 AM, and 9/17/24 at 2:39 PM, Resident #11 was observed in bed, wearing a nasal cannula for oxygen and the oxygen concentrator was set at 2 liters per minute. A review of the clinical record revealed a physician's order dated 5/8/24 for oxygen at 4 liters per minute. A review of the comprehensive care plan revealed one dated 5/8/24 and revised 8/8/24, that documented, (Resident #11) requires oxygen therapy R/T (related to) COPD and emphysema. An intervention dated 8/28/24 documented, Administer oxygen at 4L (4 liters) via nasal cannula. Observed oxygen precautions. On 9/17/24 at 2:57 PM an interview was conducted with LPN #3 (Licensed Practical Nurse) who was the assigned to Resident #11. When asked about the oxygen rate vs the ordered rate, she stated that the order was not being followed. When asked if the care plan documented to administer oxygen at 4 liters and the resident was receiving 2 liters, was the care plan being followed, she stated that it was not. The facility policy, Comprehensive Care Planning documented, All staff must be familiar with each resident's Care Plan and all approaches must be implemented On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide oxygen related care and services for three of 35 residents in the survey sample; Residents #60, #11, and #42. The findings include: 1. For Resident #60, the facility staff failed to ensure an order was in place for the administration of oxygen. On 9/15/24 at 5:01 PM, Resident #60 was observed in bed, wearing a nasal cannula for oxygen and the oxygen concentrator was set at 3 liters per minute. On 9/16/24 at 11:19 AM, Resident #60 was observed in bed, wearing a nasal cannula for oxygen and the oxygen concentrator was set at 3.5 liters per minute. On 9/17/24 at 2:42 PM, Resident #60 was observed in bed, wearing a nasal cannula for oxygen and the oxygen concentrator was set at 3.5 liters per minute. A review of the clinical record failed to reveal any evidence of a physician's order for the use of oxygen. On 9/17/24 at 2:57 PM an interview was conducted with LPN #3 (Licensed Practical Nurse) who was the assigned to Resident #60. When asked about his order for oxygen, she reviewed the record and stated that she did not see any orders for it. She stated that there has to be a physician's order in place for oxygen. The facility policy, Oxygen Administration documented, Policy: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider Procedure: 1. Verify provider order . On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #11, the facility staff failed to administer oxygen at the physician ordered rate. On 9/15/24 at 4:59 PM, 9/16/24 at 11:20 AM, and 9/17/24 at 2:39 PM, Resident #11 was observed in bed, wearing a nasal cannula for oxygen and the oxygen concentrator was set at 2 liters per minute. A review of the clinical record revealed a physician's order dated 5/8/24 for oxygen at 4 liters per minute. On 9/17/24 at 2:57 PM an interview was conducted with LPN #3 (Licensed Practical Nurse) who was the assigned to Resident #11. When asked about the oxygen rate vs the ordered rate, she stated that the order was not being followed. A review of the comprehensive care plan revealed one dated 5/8/24 and revised 8/8/24, that documented, (Resident #11) requires oxygen therapy R/T (related to) COPD and emphysema. An intervention dated 8/28/24 documented, Administer oxygen at 4L (4 liters) via nasal cannula. Observed oxygen precautions. The facility policy, Oxygen Administration documented, Policy: Licensed clinicians with demonstrated competence will administer oxygen via the specified route as ordered by a provider Procedure: 1. Verify provider order . On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 42106 3. For Resident #42 (R42), the facility staff failed to store a nebulizer in a sanitary manner when not in use. On 9/15/24 at 5:24 p.m., an observation was conducted of R42 in their room. R42 was observed in bed watching television. A metal cart was observed beside R42 to the left side of the bed with a nebulizer machine on the top. A nebulizer mask was observed uncovered sitting on top of the cart on the metal surface. Additional observation of the nebulizer mask uncovered on the metal cart was made on 9/15/24 at 5:57 p.m. The physician orders for R42 documented in part, Start Date: 09/10/2024. Ipratropium-albuterol solution for nebulization 0.5mg-3mg (2.5mg base)/3ml three times a day . The order documented the medications to be given at 8:00 a.m., 2:00 p.m. and 8:00 p.m. The eMAR (electronic medication administration record) dated 9/1/24-9/30/24 for R42 documented the resident last receiving the ipratropium-albuterol nebulizer treatment on 9/15/24 at 2:00 p.m. and scheduled for the next dosage at 8:00 p.m. The comprehensive care plan for R42 documented in part, Problem Start Date: 07/26/2024. Category: Respiratory. [Name of R42] requires oxygen therapy R/T (related to) COPD (chronic obstructive pulmonary disease) and respiratory failure. Created: 07/31/2024. On 9/17/24 at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that nebulizer masks were supposed to be stored in a bag when they were not in use. She stated that the nebulizer masks and bags were supposed to be changed every Sunday and this was done for infection control purposes to keep them clean. She stated that they had a lot of agency staff at the facility, and it was very hard. The facility policy Nebulizer Administration Policy revised 8/10/23 documented in part, . Empty nebulizer cup, rinse with sterile water/sterile saline and air dry. Wipe mask with alcohol wipe and store the neb set in a plastic bag labeled with the patient's name when dried . On 9/17/24 at 5:11 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide pharmacy services for five of 35 residents in the survey sample and on one of two units, Residents #138, #63, #48, #16, #88 and Unit 2. The findings include: 1. For Resident #138, the facility staff failed to provide physician prescribed medications, Morphine Sulfate, in a timely manner. An interview was conducted with R138 on [DATE] at 5:06 p.m. R138 stated he got to the facility on [DATE] at 6:00 p.m. He didn't get any medications for over 12 hours. The physician order dated, [DATE] at 3:59 p.m. documented, Morphine tablet extended release; 15 mg (milligrams); administer 3 tabs (tablets) every 12 hours for malignant neoplasm of prostate. The [DATE] MAR (medication administration record) documented the above order. There were blanks on the MAR for the administration of the Morphine on [DATE], [DATE] and [DATE] at 9:00 p.m. The Controlled Medication Utilization Record documented the above physician order. The date the facility received the medication was documented as [DATE]. An interview was conducted with LPN (licensed practical nurse) #12 on [DATE] at 10:32 a.m. When asked how you obtain medications for a new admission or when medications are not on the medication cart, LPN #12 stated, for the new admissions, you have to send them to the pharmacy and ask for the medications early, then it takes a bit for the medication to come. LPN #12 was asked if the nurses can cover any of the medications before they come from the pharmacy, LPN #12 stated, you can get them from the Omnicell, including some narcotics. If it's a narcotic the pharmacy sends a code, and you need two nurses to pull it out. LPN #12 stated she was an agency nurse before coming as a permanent employee and had a code for the Omnicell, but it expired in two weeks and had to be renewed. She stated she currently did not have a code for the Omnicell. ASM (administrative staff member) #1, the interim administrator, and ASM #2, the director of nursing, were made aware of the above on [DATE] at 5:13 p.m. No further information was provided prior to exit. 42106 2. For Resident #63 (R63), the facility staff failed to ensure medications were available for administration as ordered by the physician on multiple dates in August and September of 2024. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], the resident scored 10 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was moderately impaired for making daily decisions. The assessment documented R63 receiving insulin injections. On [DATE] at 6:05 p.m., an interview was conducted with R63 in their room. R63 stated that they had concerns regarding the facility staff running out of their medications and they were missing doses of medications. R63 stated that they had missed medications because the nurses told them they were out. A review of R63's clinical record revealed the following physician's orders: - Humalog Mix ,d+[DATE](U-100) Insulin (insulin lispro protamin-lispro) suspension; 100 unit/ml (,d+[DATE]); amt: 20 units: subcutaneous once a morning. 0900. Order Date: [DATE]. A review of R63's [DATE] eMAR (electronic medication administration record) failed to evidence the humalog mix ,d+[DATE] insulin administered as ordered on [DATE], [DATE], [DATE], [DATE], and [DATE] for the 9:00 a.m. doses. The eMAR notes documented the reason for the medication not being administered on [DATE] being BLE (bilateral lower extremities) wrapped and [DATE] being Not administered: other comment: waiting for insulin syringe. The eMAR dates for [DATE] and [DATE] were observed to be blank. A review of R63's [DATE] eMAR failed to evidence the humalog mix ,d+[DATE] insulin administered as ordered on [DATE] and [DATE] for the 9:00 a.m. doses. The eMAR notes documented the reason for the medication not being administered on [DATE] being Not administered: other comment: was not given due to not having a log in. The [DATE] eMAR date was observed to be blank. Review of the clinical record failed to evidence documentation of notification of the pharmacy or the physician for the dates listed above. On [DATE] at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that medications were evidenced as given by the nurse signing off on the eMAR and if they were not given it was documented in the progress note why and that the physician was notified. She stated that if the medication was not available from the pharmacy the staff should contact the pharmacy and see if it could be sent over and notify the physician to see if an alternate was appropriate or held. She stated that there was an in-house medication stock that all staff should have access to. She stated that the director of nursing gave access to the agency staff to the in-house medication stock, and some had it and some did not. She stated that they had been working to get everyone access. She stated that if a standing order ran out the pharmacy was called, and they would either send the medication over stat or the staff would pull it from the in-house medication supply. She stated that the humalog ,d+[DATE] insulin for R63 was an insulin pen and was resident specific. She stated that this was not kept in the in-house medication supply and the nurse should call the pharmacy to have it sent over stat if they were out. LPN #1 stated that she could not say why the insulin was not administered due to the lower extremities being wrapped and thought that it may be a charting error. She stated that it was not a reason to hold the medication because there were multiple sites to administer insulin. On [DATE] at 3:19 p.m., an interview was conducted with RN (registered nurse) #6. RN #6 reviewed R63's eMAR notes and stated that they would not administer insulin in the lower extremities so them being wrapped would not be an excuse to not give the medication. He stated that if a medication was not available on the cart the staff were supposed to call the physician and the pharmacy to see if they could get an alternate. On [DATE] at 2:59 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit. 42183 3. The facility staff failed to provide pharmacy services by administering medications as ordered, specifically Insulin Lispro 100 units/milliliter and Insulin Lispro 100 units/milliliter, for Resident #48. Resident #48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage), hemiplegia, hemiparesis and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and set up for eating. A review of Section O-Special Treatments, Procedures and Programs: K1. Hospice care-coded 'no'. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: The resident is at risk for unstable blood glucose related to diabetes. INTERVENTIONS: Administer insulin as directed by the physician. A review of the physician orders dated [DATE] revealed Insulin Lispro 100 units/milliliter SQ, administer 3 units with meals, hold if blood sugar less than 120. A review of the physician orders dated [DATE] revealed, Amoxicillin-,d+[DATE] tablet, give 1 tablet twice a day x 10 days for UTI. A review of the August MAR (medication administration record) revealed, Insulin Lispro 100 units/milliliter not given on ,d+[DATE] at 5:00 PM-no insulin syringe. Amoxicillin-,d+[DATE] tablet not given on ,d+[DATE] at 8:00 AM-drug unavailable, ,d+[DATE] at 8:00 AM-drug unavailable and ,d+[DATE] 8:00 PM-drug unavailable. An interview was conducted on [DATE] at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. An interview was conducted on [DATE] at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. On [DATE] at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, there is no policy regarding pharmacy delivery. No further information was provided prior to exit. 4. The facility staff failed to provide pharmacy services by administering medications as ordered, specifically Revlimid capsule 5 mg po (milligram), for Resident #16. Resident #16 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: myelodispastic syndrome, seizures and paroxysmal atrial fibrillation. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and set up for eating. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: The resident has potential for pain. INTERVENTIONS: Administer pharmacological interventions as ordered by physician and monitor the effectiveness. A review of the physician orders dated [DATE] revealed Revlimid capsule 5 mg po, give 1 capsule daily for 21 days. Hold 7 days, repeat. A review of the September MAR (medication administration record) revealed, Revlimid capsule 5 mg po not given on ,d+[DATE] AM med pass, ,d+[DATE] AM med pass, ,d+[DATE] AM med pass, ,d+[DATE] AM med pass and ,d+[DATE] AM med pass. An interview was conducted on [DATE] at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. An interview was conducted on [DATE] at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. On [DATE] at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, there is no policy regarding pharmacy delivery. No further information was provided prior to exit. 5. The facility staff failed to provide pharmacy services by administering medications as ordered for Resident #88. Resident #88 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: respiratory failure, hypertension, diverticulitis and coronary artery disease. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of [DATE], coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as max assist for bed mobility, transfer, hygiene and set up for eating. Section O-Special Procedures: coded the resident for antibiotic, midline and isolation. A review of the comprehensive care plan dated [DATE] revealed, FOCUS: The resident has infection related to diverticulitis. Resident is on antibiotics for Pneumonia. INTERVENTIONS: Administer antibiotics/antiviral as ordered by the physician. A review of the physician orders dated [DATE] revealed Meropenem 1 gram intravenously every 8 hours for diverticulitis for 6 days. A review of the [DATE] MAR (medication administration record) revealed, Meropenem 1 gram IV not administered on ,d+[DATE] 6:00 AM, 2:00 PM and 10:00 PM; ,d+[DATE] 6:00 AM, 2:00 PM. An interview was conducted on [DATE] at 10:40 AM with LPN (licensed practical nurse) #12. When asked how medications are delivered, LPN #12 stated, there are two runs a day I believe. When asked when medications are delivered, LPN #12 stated, it should be either delivered on the next run or the next day at the latest. I am not sure of the cut off time to get medication orders in for the next run. When asked if there is an emergency drug supply, LPN #12 stated, yes, the Omnicell, we should get the medications from there if they are on the list. An interview was conducted on [DATE] at 8:50 AM with ASM (administrative staff member) #2, the director of nursing. When asked the process for medication delivery, ASM #2 stated, they deliver twice a day. If they are not delivered, the nurse should check the Omnicell and if it is there, give it. The OTC (over the counter) drugs are located in the top drawer of the medication cart. On [DATE] at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, there is no policy regarding pharmacy delivery. No further information was provided prior to exit. 31753 6. For unit two, the facility staff failed to evidence reconciliation of controlled substances during shift change on [DATE]. A review of the unit two, med cart two shift change controlled substance inventory count sheet failed to reveal a reconciliation of controlled substances on [DATE]. The nurses responsible for reconciliation of controlled substances on unit two on [DATE] were not available for interview during the survey. On [DATE] at 3:25 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated that during shift change, the on-coming and off-going nurses are supposed to count the controlled substances then sign the shift change controlled substance sheet to evidence the count was done. On [DATE] at 9:30 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. A facility PowerPoint presentation titled, Detection of Drug Diversion in a Long Term Care Facility documented, Keys to Prevention: Chain of custody procedures; Inventory & record keeping; Custody of keys from one authorized nurse to another, Chain of key custody recoded at each shift .CS (Controlled Substances) are counted by the on-coming with the Off-going nurse; both sign. No further information was presented prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure residents were free of unnecessary medications for one of 35 residents in the survey sample, Resident #39. The findings include: For Resident #39 (R39), the physician ordered furosemide (used to treat swelling) 20mg (milligrams)- one tablet two times a day and to administer an additional tablet if the resident presented with a weight gain greater than two pounds in one day. The facility staff failed to weigh the resident daily to determine if an additional tablet was needed. A review of R39's clinical record revealed a physician's order dated 7/20/24 for furosemide 20 mg- one tablet twice a day for congestive heart failure. The physician ordered special instructions documented to administer an additional one tablet for a weight gain greater than two pounds in one day. Further review of R39's clinical record failed to reveal any weights for 9/1/24 through 9/14/24. A facility document titled, Sept Monthly weights documented multiple residents' names and documented R39 refused a monthly weight but failed to reveal staff attempted to obtain daily weights. On 9/17/24 at 3:25 p.m., an interview was conducted with RN (registered nurse) #6. The above physician's order was reviewed with RN #6. RN #6 stated that R39 should receive an additional tablet of furosemide if the resident gains more than two pounds in one day. RN #6 stated that if a resident has that type of order, staff should obtain that person's weight during the morning every day to differentiate if there is an increase in weight. RN #6 stated the daily weights should be documented and a resident's refusal of a daily weight should be documented. On 9/17/24 at 9:30 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, and facility document review, it was determined the facility staff failed to serve food at a palatable temperature for five of 35 residents in the survey sample, Residents #21, #63, #46, #39 and #59. The findings include: On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/20/24, Resident #21 (R21) scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:14 p.m., an interview was conducted with R21. The resident stated the facility food was nasty and cold when it arrived. On the most recent MDS, a quarterly assessment with an ARD of 8/16/24, Resident #63 (R63) scored 10 out of 15 on the BIMS, indicating the resident was moderately impaired for making daily decisions. On 9/15/24 at 6:05 p.m., an interview was conducted with R63. The resident stated the facility food was often cold. On the most recent MDS, a quarterly assessment with an ARD of 7/24/24, Resident #46 (R46) scored 9 out of 15 on the BIMS, indicating the resident was moderately impaired for making daily decisions. On 9/15/24 at 5:33 p.m., an interview was conducted with R46 and their family member at the bedside. The resident stated that some of the facility food was cold when it was served, and the family member stated that R46 had lost weight due to the food being overcooked and inedible. On the most recent MDS, a quarterly assessment with an ARD of 7/9/24, Resident #39 (R39) scored 15 out of 15 on the BIMS, indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:02 p.m., an interview was conducted with R39. The resident stated the facility food was cold. On the most recent MDS, a quarterly assessment with an ARD of 8/14/24, Resident #59 (R59) scored 15 out of 15 on the BIMS, indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:12 p.m., an interview was conducted with R59. The resident stated the facility food was cold. On 9/16/24 during lunch service test trays were conducted. The test trays left the kitchen on 9/16/24 at 12:20 p.m. with the final food cart. The last resident tray was served at 12:35 p.m. The test tray was then tested . The temperatures of the food were as follows: - mechanical soft roasted red potatoes: 108.2. - regular roasted red potatoes: 102.3. - pureed seasoned greens: 104.8. The test tray was tasted by OSM (other staff member) #10 and the surveyors. When asked how the roasted potatoes and seasoned greens tasted regarding the temperature, OSM #10 stated that they were warm but could be warmer. OSM #10 stated that she would prefer the potatoes to be warmer. On 9/17/24 at 2:15 p.m., an interview was conducted with OSM #1, the regional dietician. OSM #1 stated that the kitchen staff utilized domes and bases, hot plates and steam tables to serve food at a palatable temperature. She stated that food temperatures had been a concern brought up recently in resident council and had been a focus for them. She stated that they had been doing test trays randomly and they were addressing resident concerns and were working to resolve temperature concerns. The facility policy, Food Temperatures Policy revised 8/28/2019, documented in part, . Hot food should be palatable at point of delivery . 5. Food should be transported as quickly as possible to maintain temperatures for delivery and service . On 9/17/24 at 5:11 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that all hospital transfer documentation requirements were implemented for three of 35 residents in the survey sample; Residents #36, #9 and #11. The findings include: 1. For Resident #36, the facility staff failed to evidence what, if any, documents were sent to the receiving facility upon a hospital transfer and/or ensure that the physician wrote a note regarding a hospital transfer. A review of the clinical record revealed the following: A. 6/20/24 - no evidence of what, if any, documents were sent: A nurse's note dated 6/20/24 documented, Resident assessed by PA (physician's assistant) and NP (nurse practitioner) and new orders given and noted to send to (hospital) for further eval (evaluation) for possible TIA/CVA (stroke) due to symptoms. Resident noted with delayed reaction during conversation Further review revealed no evidence of what, if any, documents were sent to the hospital, including contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters); transmission-based precautions; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident ' s comprehensive care plan goals; and all other information necessary to meet the resident ' s needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. B. 7/6/24 - no evidence of what, if any, documents sent, a nurse's note documenting the circumstances for the hospital transfer, and a physician's note regarding the transfer: A nurse's note dated 7/6/24 at 12:14 AM documented, Resident very confused and yelling denies pain. Attempted to calm him down but after staff left from the he will start yelling. Stayed with him for awhile. Ativan 1 mg (milligram) given with positive effects. Continues on Augmentin Resident resting comfortably awake but calm and cooperative, Will continue to monitor. The very next nurse's note was dated 7/6/24 at 10:38 PM and documented, Resident returned the facility from (hospital) at about 2120 (9:20 PM) received new orders to continue Augmentin 875/123 mg po (by mouth) twice a day. Foley was replaced from the hospital All HS (bedtime) meds given taking without difficulty. Will continue to monitor. There was nothing documented at the time of transfer to the hospital regarding the circumstances that necessitated the hospital transfer. In addition, there was no evidence of what, if any, documents were sent to the hospital, including contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters); transmission-based precautions; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident ' s comprehensive care plan goals; and all other information necessary to meet the resident ' s needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. Further review also failed to evidence any physician's note related to the hospital transfer, to include the specific resident needs the facility could not meet; the facility efforts to meet those needs; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. C. 7/18/24 - no evidence of a physician's note regarding the transfer: A nurse's note dated 7/18/24 documented, Resident experienced witnessed fall event as evidenced by resident was sitting in his wheelchair in the Community area and fell from w/c (wheelchair) at 2:00 p.m. Upon assessment, resident has an opened area under his right eye, two opened areas to his nose, one small, opened area to his forehead, and a laceration to his left middle finger. Resident transferred via lift and appropriate number of staff members back to wheelchair, then to bed. Areas cleansed and pressure applied. EMS (emergency medical services) called for transfer to ED (emergency department). EMS arrived at facility to transport resident and Face sheet, CCD, Transfer form, Care plan, Bed hold all sent with resident. Call placed to (hospice agency) and message left notifying them of fall with injury and transfer to ED. Further review failed to evidence any physician's note related to the hospital transfer, to include the specific resident needs the facility could not meet; the facility efforts to meet those needs; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. On 9/17/24 at 2:25 PM, ASM #1 (Administrative Staff Member) stated that they do not have any of the evidence requested. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked what documents are sent to the hospital, she stated that a facesheet and a medication list. When asked about the care plan, she stated not usually. When asked about a bed hold notice, she stated, You are supposed to provide a bed hold but each facility is different. When asked how does she evidence what is sent to the hospital, she stated it would be in a nurse's note. When asked about ensuring the physician writes a note about the hospital transfer, she stated, We notify the physician and they usually try interventions and we document what we did and that the provider was notified but she did not ensure that the provider writes a note. The facility policy, Resident Discharge / Transfer Letter provided by the facility did not address hospital transfer requirements related to required nursing and physician documentation regarding the resident's change in condition necessitating a hospital transfer and what documents are to be provided to the hospital. On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #9, the facility staff failed to evidence what, if any, documents were sent to the receiving facility upon a hospital transfer. A. 6/8/24 - no evidence of what, if any, documents were sent: A nurse's note dated 6/8/24 documented, Alerted by aid that resident had episode of vomiting, resident assessed and has a change in LOC (level of consciousness), elevated B/P (blood pressure) 188/103 Resident not responding appropriately to questions, EMS (emergency medical services) called. A second note dated 6/8/24 documented, Resident's emergency contact called and left voice mail to call back for update and status. A third nurse's note dated 6/8/24 documented, Author called (hospital) for update on resident. Resident being admitted for observations r/t (related to) stroke like symptoms. No other information present at this time. There were no further notes until 6/12/24 documenting the resident's readmission. There was no evidence of what, if any, documents were sent to the hospital, including contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters); transmission-based precautions; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident ' s comprehensive care plan goals; and all other information necessary to meet the resident ' s needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. B. 6/13/24 - no evidence of what, if any, documents were sent: A nurse's note dated 6/13/24 documented, Received resident in bed, alert and verbal. During AM (morning) med pass CNA (Certified Nursing Assistant) witnessed resident have two consecutive seizures approximately 90 seconds in duration 10 minutes apart. Resident was assessed and repositioned to prevent injury. Resident cold/dry to touch, Resident had drainage from both nostrils blood and mucous mixed. Resident sent to ED (emergency department) for further evaluation. On call provider and family notified. There were no further notes until 7/1/24 documenting the resident's readmission. There was no evidence of what, if any, documents were sent to the hospital, including contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters); transmission-based precautions; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident ' s comprehensive care plan goals; and all other information necessary to meet the resident ' s needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. On 9/17/24 at 2:25 PM, ASM #1 (Administrative Staff Member) stated that they do not have any of the evidence requested. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked what documents are sent to the hospital, she stated that a facesheet and a medication list. When asked about the care plan, she stated not usually. When asked about a bed hold notice, she stated, You are supposed to provide a bed hold but each facility is different. When asked how does she evidence what is sent to the hospital, she stated it would be in a nurse's note. The facility policy, Resident Discharge / Transfer Letter provided by the facility did not address hospital transfer requirements related to required nursing and physician documentation regarding the resident's change in condition necessitating a hospital transfer and what documents are to be provided to the hospital. On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #11, the facility staff failed to evidence what, if any, documents were sent to the receiving facility upon a hospital transfer and/or ensure that the physician wrote a note regarding a hospital transfer. A nurse's note dated 6/2/24 documented, Resident was complaining of pain peri suprapubic site. Morphine was given at 2103 (9:03 PM). (Hospice) nurse was called to exam site. Resident continued to call 911 (emergency number) x3 (three times). Informed resident nurse was coming to exam area. Resident continued to pull on the catheter. Hospice nursed arrived at 2130 (9:30 PM). Nurse tried changing the catheter, however, catheter was stuck from resident tugging at tube. Resident sent out to ER (emergency room ) by paramedics on stretcher at 2200 (10:00 PM). A nurse's note dated 6/3/24 documented, Resident arrived fromER on a stretcher with paramedics at 0205 (2:05 AM). Catheter was changed, resident is stable. There were no further notes on this hospital transfer. There was no evidence of what, if any, documents were sent to the hospital, including contact information of the practitioner who was responsible for the care of the resident; resident representative information, including contact information; advance directive information; all special instructions and/or precautions for ongoing care, as appropriate such as: treatments and devices (oxygen, implants, IVs, tubes/catheters); transmission-based precautions; special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions; the resident ' s comprehensive care plan goals; and all other information necessary to meet the resident ' s needs, which includes, but may not be limited to: resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. Further review failed to evidence any physician's note related to the hospital transfer, to include the specific resident needs the facility could not meet; the facility efforts to meet those needs; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. On 9/17/24 at 2:25 PM, ASM #1 (Administrative Staff Member) stated that they do not have any of the evidence requested. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked what documents are sent to the hospital, she stated that a facesheet and a medication list. When asked about the care plan, she stated not usually. When asked about a bed hold notice, she stated, You are supposed to provide a bed hold but each facility is different. When asked how does she evidence what is sent to the hospital, she stated it would be in a nurse's note. When asked about ensuring the physician writes a note about the hospital transfer, she stated, We notify the physician and they usually try interventions and we document what we did and that the provider was notified but she did not ensure that the provider writes a note. The facility policy, Resident Discharge / Transfer Letter provided by the facility did not address hospital transfer requirements related to required nursing and physician documentation regarding the resident's change in condition necessitating a hospital transfer and what documents are to be provided to the hospital. On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to promote dignity for one of 35 residents in the survey sample, Resident #137. The findings include: For Resident #137 (R137), the facility staff instructed the resident to pee in her pants, thus not providing dignified care. On 9/15/24 at 4:53 p.m. an interview was conducted with R137. R137 stated that the staff would not get her up from the bed until therapy had screened her. When asked how she was going to the bathroom, the staff told her to pee in her pant. R137 was asked how that made her feel, she stated it made her feel like an idiot and was embarrassed. A second interview was conducted with R137 on 9/16/24 at 8:44 a.m. When asked how her night was, she stated she was told to 'pee' in her diaper through the night as she hadn't been evaluated by therapy. When asked if she was offered the use of a bedpan, R137 stated no. The Admission assessment dated , 9/14/24 at 6:46 p.m. documented in part, Resident is alert, oriented, memory is intact, had clear organized thinking. The Continence and Retraining/Scheduled Toileting and Decision/Determination form dated 9/14/24 at 7:02 p.m. documented in part, Resident's mental status and communication - no problems. Physical condition/functioning - unable to walk to bathroom. What is resident's mental awareness of toileting needs - completely aware. Based on the review above, initiate 72 - hour bowel & bladder tracking/log - no tracking indicated; continent at present. An interview was conducted with CNA (certified nursing assistant) #2 on 9/17/24 at 3:00 p.m. When asked when a new admission comes, can you get them out of bed to use the restroom, CNA #2 stated you have to first check with the nurse to see what the discharge paperwork says. When asked if she's been told not to get a resident out of bed until therapy screens them, CNA #2 stated, no. CNA #2 was asked if she has or has ever told a resident to pee in their pants, CNA #2 stated, no. When asked how she thought that would make a resident feel, CNA #2 stated, lack of dignity. An interview was conducted with RN (registered nurses) #6 on 9/17/24 at 3;12 p.m. When asked when a new admission comes, how is it determined if a resident could get out of bed, RN #6 stated, he would see the resident first to see if they can get up and depending on what my report from the hospital said and my assessment he would determine if the resident could get up. When asked if the resident cannot get up how do they go to the bathroom, RN #6 stated, if they are continent, then a bedpan should be offered, if incontinent then changing their brief as needed. When asked if he has ever heard a staff member tell the resident to 'pee' in your pants, RN #6 stated, he hadn't witnessed that. RN #6 was asked how it would make a resident feel if they were told that, RN #6 stated it would make them feel bed, disappointed, if they could use a bed pan, they would feel belittled. The facility policy, Resident Rights Inservice, documented in part, The Nursing Home Reform Act established the following rights for nursing home residents: The right to be treated with dignity. ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/17/24 at 5:13 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility failed to implement their abuse policy for reporting an allegation of abuse within two hours after the allegation was made, for one of 35 residents in the survey sample, Resident #21 (R21). The findings include: For R21, the facility staff failed to implement their abuse policy by not reporting an allegation of abuse reported to staff on 7/1/24 until 7/2/24. The facility policy Virginia Resident Abuse Policy revised 10/03/2022 documented in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the DOH (department of health) immediately, but not later than 2 hours after the allegation is made . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/20/24, R21 scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:14 p.m., an interview was conducted with R21. R21 stated that they had recently filed a police report against another resident at the facility for threatening them. R21 stated that they had been in the hallway near the dining room and another resident [Name of Resident #64] had started arguing with them and threatened to kick her [expletive] and stab them. R21 stated that Resident #64 (R64) had threatened them and at first, they had not wanted to call the police but had changed their mind and called the police later to file a report. R21 stated that R64 was no longer allowed to come on the unit and resided on the other unit and they did not see each other anymore. R21 stated that they had reported this to the social worker who had called the police for the report. Review of R21's progress notes documented in part, - 07/01/2024 13:29 (1:29 p.m.) Resident reported being threatened over the weekend by another resident, grievance form filed and resident was asked if she wanted to press charges, resident said no, that she did not want the police involved. - 07/02/2024 15:00 (3:00 p.m.) Completed skin assessment resident's skin intact, no discolorations nor bruising noted. Able to make needs known. Shower was given this afternoon. - 07/03/2024 10:21 (10:21 a.m.) Resident was crying and clearly upset in the hallway and stated she would now like to press charges on another resident for a previous incident that occurred. See prior SS (social service) note. Non-emergency called and police report taken. A facility concern form dated 7/1/24 for R21 documented in part, .Describe concern using factual terms: resident stated that over the weekend she got into a verbal argument with another resident from unit 2. Resident stated she called APS (adult protective services) to report it and did not want to press criminal charges at this time. Individual(s) designated to take action on this concern: [Name of OSM (other staff member) #10, the director of social services/admissions coordinator] and admin. Date assigned: 7/1/24 . Review of the facility synopsis of event for R21 dated 7/2/24 documented in part, Report Date: July 2, 2024 . [Name of R21] reported another resident threatened to harm her, on an unknown day or time the past weekend. Head to toe assessment completed with no noted injuries. RP (responsible party) and MD (medical doctor) made aware. [Name of sheriff's office] contacted with report received. Final outcome to follow . The fax confirmation documented the report sent to the state agency on 7/2/24 at 3:05 p.m. On 9/17/24 at 11:32 a.m., an interview was conducted with OSM #10, the director of social services/admissions coordinator. OSM #10 stated that someone reported to him that R21 had reported R64 wandering over to the unit and threatening to stab them after they had gotten into a verbal altercation. He stated that he had completed the grievance form and reported it to the former administrator at that time. OSM #10 stated that they had spoken to R21 who did not want to file a police report at that time but then later decided to file a report after speaking with the family. He stated that he had contacted the non-emergency police number who had come out and taken the information. He stated that no one had witnessed the incident that R21 reported and R64 did not recall the incident. He stated that both residents were evaluated by psychiatric services and R64 had never had any threatening behaviors prior to that accusation and had not had any behavior issues since that incident. He stated that R21 had a history of attention seeking behaviors and other behaviors and they were unable to prove that it had happened. He stated that R64 wandered but did not exit seek and was confused but was not banned from coming on the unit but stayed away from R21. On 9/17/24 at 2:22 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that she did the investigation of the event between R21 and R64 initially reported on 7/2/24. She stated that the reporting time frame was two hours for an allegation of abuse. She stated that the allegation of abuse should have been reported on 7/1/24 when the resident reported it. On 9/18/24 at 10:43 a.m., ASM #5, the regional vice president of operations presented an action plan binder for the allegation of abuse reported by R21 on 7/1/24 and not reported until 7/2/24. She stated that they had implemented the plan after discovering that R21 had reported the allegation of abuse on 7/1/24 and it had not been reported until 7/2/24. Review of the action plan binder documented the concern form dated 7/1/24, facility synopsis of events dated 7/2/24, a resident risk tool completed 7/2/24, an investigation analysis, staff statements, a root cause analysis, staff and resident abuse audits and an ad hoc QAPI (quality assessment performance improvement) meeting regarding reporting abuse and timely reporting. The binder documented actions taken for R21 and R64, audits of five resident and five staff interviews weekly for four weeks, then monthly for two months to ensure there were no further issues with behaviors/abuse/neglect. The plan documented abuse policy education of current employees by telephone or in person dated 7/8/24. The plan documented an alleged date of compliance of 7/31/2024. Abuse education and training was reviewed and verified by multiple staff interviews. Implementation of the education was verified with additional resident interviews and observations. No current concerns were identified. On 9/18/24 at 2:59 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern recommended at past non-compliance. No further information was provided prior to exit. PAST NONCOMPLIANCE

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility failed to report an allegation of abuse in a timely manner for one of 35 residents in the survey sample, Resident #21 (R21). The findings include: For R21, the facility staff failed to report an allegation of abuse that was reported to staff on 7/1/24 until 7/2/24. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/20/24, R21 scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 9/15/24 at 5:14 p.m., an interview was conducted with R21. R21 stated that they had recently filed a police report against another resident at the facility for threatening them. R21 stated that they had been in the hallway near the dining room and another resident [Name of Resident #64] had started arguing with them and threatened to kick her [expletive] and stab them. R21 stated that Resident #64 (R64) had threatened them and at first, they had not wanted to call the police but had changed their mind and called the police later to file a report. R21 stated that R64 was no longer allowed to come on the unit and resided on the other unit and they did not see each other anymore. R21 stated that they had reported this to the social worker who had called the police for the report. Review of R21's progress notes documented in part, - 07/01/2024 13:29 (1:29 p.m.) Resident reported being threatened over the weekend by another resident, grievance form filed and resident was asked if she wanted to press charges, resident said no, that she did not want the police involved. - 07/02/2024 15:00 (3:00 p.m.) Completed skin assessment resident's skin intact, no discolorations nor bruising noted. Able to make needs known. Shower was given this afternoon. - 07/03/2024 10:21 (10:21 a.m.) Resident was crying and clearly upset in the hallway and stated she would now like to press charges on another resident for a previous incident that occurred. See prior SS (social service) note. Non-emergency called and police report taken. A facility concern form dated 7/1/24 for R21 documented in part, .Describe concern using factual terms: resident stated that over the weekend she got into a verbal argument with another resident from unit 2. Resident stated she called APS (adult protective services) to report it and did not want to press criminal charges at this time. Individual(s) designated to take action on this concern: [Name of OSM (other staff member) #10, the director of social services/admissions coordinator] and admin. Date assigned: 7/1/24 . Review of the facility synopsis of event for R21 dated 7/2/24 documented in part, Report Date: July 2, 2024 . [Name of R21] reported another resident threatened to harm her, on an unknown day or time the past weekend. Head to toe assessment completed with no noted injuries. RP (responsible party) and MD (medical doctor) made aware. [Name of sheriff's office] contacted with report received. Final outcome to follow . The fax confirmation documented the report sent to the state agency on 7/2/24 at 3:05 p.m. On 9/17/24 at 11:32 a.m., an interview was conducted with OSM #10, the director of social services/admissions coordinator. OSM #10 stated that someone reported to him that R21 had reported R64 wandering over to the unit and threatening to stab them after they had gotten into a verbal altercation. He stated that he had completed the grievance form and reported it to the former administrator at that time. OSM #10 stated that they had spoken to R21 who did not want to file a police report at that time but then later decided to file a report after speaking with the family. He stated that he had contacted the non-emergency police number who had come out and taken the information. He stated that no one had witnessed the incident that R21 reported and R64 did not recall the incident. He stated that both residents were evaluated by psychiatric services and R64 had never had any threatening behaviors prior to that accusation and had not had any behavior issues since that incident. He stated that R21 had a history of attention seeking behaviors and other behaviors and they were unable to prove that it had happened. He stated that R64 wandered but did not exit seek and was confused but was not banned from coming on the unit but stayed away from R21. On 9/17/24 at 2:22 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that she did the investigation of the event between R21 and R64 initially reported on 7/2/24. She stated that the reporting time frame was two hours for an allegation of abuse. She stated that the allegation of abuse should have been reported on 7/1/24 when the resident reported it. On 9/18/24 at 10:43 a.m., ASM #5, the regional vice president of operations presented an action plan binder for the allegation of abuse reported by R21 on 7/1/24 and not reported until 7/2/24. She stated that they had implemented the plan after discovering that R21 had reported the allegation of abuse on 7/1/24 and it had not been reported until 7/2/24. Review of the action plan binder documented the concern form dated 7/1/24, facility synopsis of events dated 7/2/24, a resident risk tool completed 7/2/24, an investigation analysis, staff statements, a root cause analysis, staff and resident abuse audits and an ad hoc QAPI (quality assessment performance improvement) meeting regarding reporting abuse and timely reporting. The binder documented actions taken for R21 and R64, audits of five resident and five staff interviews weekly for four weeks, then monthly for two months to ensure there were no further issues with behaviors/abuse/neglect. The plan documented abuse policy education of current employees by telephone or in person dated 7/8/24. The plan documented an alleged date of compliance of 7/31/2024. Abuse education and training was reviewed and verified by multiple staff interviews. Implementation of the education was verified with additional resident interviews and observations. No current concerns were identified. The facility policy Virginia Resident Abuse Policy revised 10/03/2022 documented in part, .Facility staff must immediately report all such allegations to the Administrator/Abuse Coordinator. The Administrator/Abuse Coordinator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy . If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the DOH (department of health) immediately, but not later than 2 hours after the allegation is made . On 9/18/24 at 2:59 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern recommended at past non-compliance. No further information was provided prior to exit. PAST NONCOMPLIANCE

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure admission orders were put in place to provide immediate care for one of 35 residents in the survey sample, Resident #139. The findings include: For Resident #139(R139), the resident was admitted on [DATE] at 5:09 p.m. The admission orders were not entered into the computer until 3/22/24, 20 hours after the resident was admitted . Review of the clinical record, failed to evidence a nursing admission assessment for 3/21/24. The Discharge documents from the hospital documented the following orders: Tylenol 650 mg (milligrams)/20 ml (milliliters) soln (solution): 20.3 ml by po/g-tube (by mouth/gastrostomy tube) every 4 hours as needed for fever - pain. - entered into the medical record on 3/22/24 at 1:45 p.m. Amlodipine 5 mg tablets: instill 1 tab (tablet) into tube once a day. Indications: high blood pressure. Entered into the medical record on 3/22/24 at 1:41 p.m. Finasteride 5 mg tab; take 1 tab by mouth once a day. Entered into the medical record on 3/22/24 at 1:51 p.m. Ipratropium-albuterol 0.5 mg-3 mg/3 ml Nebu (nebulizer): take 3 ml inhaled by mouth every 6 hours as needed. Entered into the medical record on 3/22/24. Lidocaine 4% patch; apply 1 patch as directed daily as needed for mild pain (pain score 1 - 3) moderate pain (pain score 4-6) severe pain (pain score 7-10). Entered into the medical record on 3/22/24. Magnesium oxide 400 mg; instill 2 tabs into tube once a day. Entered into the medical record on 3/22/24 at 2:04 p.m. Metoprolol 25 mg; instill 1 tab into tube twice a day. Entered into the medical record on 3/22/24 at 2:10 p.m. multivitamins - minerals- lutein tab: 1-tab po/g-tube route once a day. Entered into the medical record on 3/22/24 at 2:12 p.m. Omeprazole 2 mg/ml suspension; 10 ml by po/g-tube route once a day. Entered into the medical record on 3/22/24 at 7:22 p.m. Polyethylene glycol 17-gram packet; 1 packet by po/g-tube route once a day. Entered into the medical record on 3/22/24 at 2:30 p.m. Potassium Chloride ER 20 mEq (milliequivalent) tablet - take 1 tab by mouth once a day, indications: low potassium in the blood. Entered into the medical record on 3/22/24 at 2:33 p.m. Sodium chloride 1000 mg Tab - instill 1 tab into tube three times daily with meals. Entered into the medical record on 3/22/24 at 2:37 p.m. tamsulosin 0.4 mg caps; 1 cap by mouth daily after supper. Entered into the medical record on 3/22/24 at 2:38 p.m. TF (tube feeding) - Jevity 1.5 KCAL/ML Dose: 300 ml. Frequency: 4 times daily. Entered into the medical record on 3/22/24 at 2:41 p.m. Trimethoprim-sulfamethoxazole 160 - 800 mg tabs: 1 tab po/g-tube route twice a day for 180 days. Can be crushed. Entered into the medical record on 3/22/24 at 1:51 p.m. Warfarin 1 mg tabs; 6 tabs by po/g-tube route once a day. Entered into the medical record on 3/22/24 at 2:44 P.M. Discharge Procedure Orders: NPO TF only - nothing by mouth tube feeding only. Further review of the clinical record failed to evidence these orders were instituted and entered into the electronic medical record until 3/22/24. A request was made for documentation of care provided to R139 from 3/21/24 until 3/22/24 at approximately 1:00 p.m. A copy of the Vital Signs, documented the resident received a dinner tray, took in 240 ml of fluid, and ate 76-100% of his meal. An interview was conducted with LPN (licensed practical nurse) #12 on 9/17/24 at 10:32 a.m. When asked the process for a new admission and their admission orders, LPN #12 stated, most of the time we have the orders before the resident gets here. We can verify them with the physician, but we can't enter them into the computer until they are physically in the building. When asked how soon the orders should be entered into the computer, LPN #12 stated, as soon as you can. LPN #12 asked if the orders can wait 20 hours before they are entered into the computer, LPN #12 stated, no, the resident would need medications by then. The facility policy, New Admission/Readmission Process Policy, documented in part, 6. Review of orders: a. Physician verification of orders noted. b. Transmitted to pharmacy. c. Transcribed to eMAR/eTAR .14. Enteral feedings orders to contain the following: a. Route and Rate of solution[s] b. Amount to be infused, per shift and/or 24hr total. c. Flushes entered on eMAR. d. Checks for residuals. e. Verification of placement. f. HOB elevated 30-450 and/or as directed by physician. ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/17/24 at 5:13 p.m. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 35 residents in the survey sample, Resident #48 and Resident #58. The findings include: 1.The facility staff failed to complete an accurate MDS (minimum data set), a quarterly assessment for Resident #48. Resident #48 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ICH (intracranial hemorrhage), hemiplegia, hemiparesis and DM (diabetes mellitus). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/20/24, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as being dependent for bed mobility, transfer, hygiene and set up for eating. A review of Section O-Special Treatments, Procedures and Programs: K1. Hospice care-coded 'no'. A review of the comprehensive care plan dated 12/20/23 revealed, FOCUS: The resident is on hospice services. INTERVENTIONS: Contact hospice for changes in resident condition. A review of the physician orders dated 5/8/24, revealed Admit to hospice. An interview was conducted on 9/18/24 at 11:20 AM with RN #5 and RN #7, the MDS coordinators, when asked to review Resident #48's MDS for 7/20/24, Section O-hospice. RN #5 stated he is coded as a 'no', RN #7 stated, ''this will be modified now. When asked what standard is followed for MDS completion, RN #5 stated, the RAI (resident assessment instrument). On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the RAI (resident assessment instrument) MDS Section K100. Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs. O0100K, Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. No further information was provided prior to exit. 29125 2. For Resident #58, the facility staff failed to accurately code the MDS for the resident's smoking status. A review of the clinical record revealed a smoking assessment dated [DATE] that documented the resident intends to smoke, does not wish to quit, and was assessed as a safe smoker. Further review of the clinical record revealed a care plan dated 7/18/22 that documented, (Resident #58) is a smoker. At risk for health issues. This care plan included interventions dated 7/18/22 for Orient/review with resident smoking policy, times and places to smoke and Staff to complete smoking assessment to ensure safety. On 9/16/24 at approximately 8:00 AM, Resident #58 was observed outside smoking with others. A review of the annual MDS (Minimum Data Set) dated 2/24/24, revealed in section J1300 Current Tobacco Use that No was marked. On 9/17/24 at 2:49 PM, an interview was conducted with RN #7 (Registered Nurse) the MDS nurse. She stated that the MDS should have been coded as a smoker / tobacco user since they did the assessment and he smokes. She stated the MDS was not coded accurately. A review of the RAI Manual (Resident Assessment Instrument) dated October 2023, page 388, documented, The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for one of 35 residents in the survey sample, Resident #5. The findings include: For Resident #5 (R5), the facility staff failed to obtain a physician's order prior to administering insulin (used to treat diabetes) to the resident on 5/12/24. R5 was readmitted to the facility on [DATE]. A review of R5's clinical record failed to reveal any physician's medication orders when the resident was readmitted on [DATE]. A review of R5's MAR (medication administration record) for 5/11/24 and 5/12/24 failed to reveal any medication orders. A nurse's note dated 5/12/24 at 10:58 p.m. (recorded as a late entry on 5/13/24), documented, Received care of resident at 22:40 (10:40 p.m.) Resident had been released from the hospital a day before after falling face first on concrete. Resident states she is in a severe pain. This nurse looked at resident's MAR which was inadequately updated since resident has been back. It was noted that the last time resident received insulin or glucose checks was on 05/08/2024 .Blood glucose 579. Lispro (insulin) and Levemir (insulin) administered. 911 was called per brother's request. Resident was transferred to (name of hospital) at 0115 (1:15 a.m.) via stretcher. Resident has been admitted to the hospital unit. The nurse who documented the above note was not available for interview during the survey. On 9/18/24 at 8:28 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated nurses should have a physician's order to administer insulin because they would be practicing out of their scope if they did otherwise. On 9/18/24 at 3:25 p.m., ASM (administrative staff member) #1 (the interim administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility document titled, Skills Checklist 1: Oral Medication Administration documented, 3 Check Medication Record for order. No further information was presented prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review it was determined the facility staff failed to provide ADL (activities of daily living) care for three of 35 residents in the survey sample, Residents #33, 46, and #42. The findings include: 1. For Resident #33 (R33), the facility staff failed to provide oral care. An interview was conducted with R33 on 9/15/24 at 5:29 p.m. The resident was in bed. R33 stated she has to ask for help in brushing her teeth. She stated she had asked someone to assist her this afternoon but no one has responded. A second interview was conducted with R33 on 9/16/24 at 8:47 a.m. She stated she was never offered to brush her teeth after this writer left on 9/15/24. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 8/30/24, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section GG - Functional Abilities and Goals, the resident was coded as requiring set up or clean up assistance for oral hygiene, the resident completes the activity. Review of the ADL documentation from 9/9/24 through 9/16/24, the column for Personal Hygiene was blank. There was no documented evidence the resident received personal hygiene care. The comprehensive care plan dated, 1/30/23 documented in part, Focus: (R33) has ADL/self-care deficit related to hand assisted feeding with all meals. The Interventions documented in part, Assist with activities of daily living, dressing, grooming, toileting, oral care. An interview was conducted with CNA (certified nursing assistant) #2 on 9/17/24 at 3:00 p.m. When asked when a resident is offered to brush their teeth, CNA #2 stated, it should be daily. She stated if a resident wants it then you assist them. When asked if R33 asks for oral care, CNA #2 stated when she is assigned to the resident, she many times is in the bathroom, and I assist her in setting up and she brushes her teeth at the sink. CNA #2 was asked if the resident is in bed and wishes to brush her teeth, CNA #2 stated, she would set her up with the supplies on the over bed table and assist if needed. CNA #2 stated, she can do it herself, she just needs to be set up to do it. When asked where it is documented that oral care was provided, CNA #2 stated, in (name of electronic medical records system). The facility policy, Morning Care/AM Care. documented in part, Morning care will be offered each day to promote resident comfort, cleanliness, grooming, and general wellbeing. Residents who are capable of performing their own personal care are encouraged to do so but will be provided with setup assistance if needed . 4. Assist with/provide oral hygiene. Assist with dentures; clean and replace. The facility policy, Evening Care/PM Care, documented in part, Nursing staff will offer evening/PM care to residents to promote personal hygiene, comfort, relaxation and safety. Residents who are capable of performing their own care are encouraged to do so, with assistance as needed. PM care may be performed at the bedside or in the bathroom, according to resident preference .7. Assist resident with oral care. ASM (administrative staff member) #1, the interim administrator, and ASM #2, the director of nursing, were made aware of the above findings on 9/18/24 at 3:00 p.m. No further information was obtained prior to exit. 42183 2.The facility staff failed to provide evidence of incontinence care for dependent Resident #46. Resident #46 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: dementia, hypertension and CKD (chronic kidney disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/24/24, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as being dependent for toileting, bathing and hygiene. A review of the comprehensive care plan with a revision date of 2/16/24, revealed, FOCUS: The resident has a self-care deficit related to age related mobility. INTERVENTIONS: Resident requires 1 person assist for ADLs: toileting, hygiene, dressing and bathing. A review of the June-September 2024 ADL (activities of daily living) record revealed missing documentation for incontinence care/toileting on the following dates: 6/30, 7/7, 7/9, 7/13, 7/19, 7/26, 7/27, 8/2, 8/6, 8/7, 8/11, /8/15, 8/17, 8/20, 8/21, 8/22, 8/24, 8/29, 8/31, 9/2, 9/3, 9/4, 9/7 and 9/13. An interview was conducted on 9/16/24 at 6:50 AM with CNA (certified nursing assistant) #1. When asked the process for incontinence care, CNA #1 stated, we round every two to three hours and provide the incontinence care. When asked where the incontinence care would be evidenced, CNA #1 stated, we document it in the ADL record in Matrix. An interview was conducted on 9/17/24 at 11:15 AM with Resident #46. Resident #46 stated she had not been changed since night shift. I requested Resident #46 put on call light. LPN (licensed practical nurse) #1 entered the room. Resident #46 informed LPN #1 that she had not seen a CNA (certified nursing assistant) on day shift and she had not been changed. LPN #1 was interviewed by surveyor regarding expectations for incontinence care, LPN #1 stated, it should be done every two hours. At 11:35 AM, CNA #4 provided incontinence care for Resident #46. Adult depends was saturated but had not leaked onto sheets. CNA #4 stated, she is not my patient, but I am happy to take care of her. When asked the frequency of incontinence rounds, CNA #4 stated, it should be every 2-3 hours. On 9/18/24 at 3:00 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. According to the facility, no specific policy related to incontinence care is found. No further information was provided prior to exit. 42106 3. For Resident #42 (R42), the facility staff failed to get the resident out of bed per the resident's request. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/24, the resident was assessed as being severely impaired for making daily decisions, not rejecting care, being dependent on staff for transfers and having a feeding tube. On 9/15/24 at 5:24 p.m., an observation was conducted of R42 in their room. R42 was observed in bed watching television with tube feeding observed hanging beside them on a feeding tube pump. At that time, an interview was conducted with R42 who was able to verbalize some words and use a communication board. R42 stated that they had the feeding tube for about six months and had problems with it recently. R42 stated that they liked to get up in their wheelchair every day and had not been up in five days. When asked if they had asked the staff to get them up, R42 nodded and stated, They won't get me up. On 9/16/24 at 8:22 a.m., R42 was observed in their room in bed. R42 stated again that they wanted to get out of bed in the wheelchair and had not been up in five days. A CNA (certified nursing assistant) in the hallway outside of R42's room was made aware of R42's request who stated that the CNA assigned to R42 was in the dining room at that time and they would be sure that R42 got out of bed as soon as she got back. Additional observations of R42 on 9/16/24 at 11:08 a.m., 12:36 p.m., and 3:15 p.m. revealed R42 remained in bed. At 12:36 p.m., R42 pointed at the clock and stated, See what time it is? They won't get me up. Review of the ADL (activities of daily living) documentation for R42 for 9/16/24 under How did the resident transfer? documented Activity did not occur. Review of the ADL documentation for R42 documented R42 transferring last on 9/14/24. The progress notes for R42 failed to evidence documentation of refusal to get out of bed on 9/16/24. The comprehensive care plan for R42 documented in part, [Name of R42] has an ADL Self Care Performance Deficit r/t (related to) Activity Intolerance, Fatigue, Hemiplegia with right sided weakness, Musculoskeletal impairment - DJD (degenerative joint disease), right arm pain, neuropathy, respiratory failure . Date Initiated: 09/28/2021. Under Interventions it documented in part, .Resident's preference is to get out of bed before lunch. Encourage him to get up daily. Date Initiated: 09/29/2021 . Up daily by 11am if refuses place note in chart. Date Initiated: 09/26/2022 . On 9/17/24 at 11:08 a.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that all residents should be getting out of bed unless they did not want to. She stated that R42 got up at least four times a week and required a mechanical lift to get them up. She stated that R42 was alert and oriented and she was able to communicate with them and understand them. She stated that R42 also had a communication board to use if needed. She stated that R42 wanted to get up every day and she knew that he was up on Saturday because she had come to the facility for something. She stated that she was not aware that R42 had requested to get out of bed and not gotten up on 9/16/24. She stated that they had a lot of agency staff at the facility, and it was very hard to manipulate the staffing. On 9/17/24 at 11:25 a.m., an interview was conducted with CNA #5. CNA #5 stated that residents should be offered to get out of bed each day and if they refused, they reported it to the nurse. She stated that they encouraged the residents to get out of bed to help prevent bed sores and to socialize with other residents. The facility provided document Resident Rights Inservice documented in part, .All residents in long term care facilities have rights guaranteed to them under Federal and State law. The facility must promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights .Right to make independent choices. Make personal decisions, such as what to wear and how to spend free time. Reasonable accommodation of one's needs and preferences . On 9/17/24 at 5:11 p.m., ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence a written bed hold notice was provided to the resident and/or resident representative upon a hospital transfer for two of 35 residents in the survey sample; Residents #36 and #9. The findings include: 1. For Resident #36, the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or representative upon a hospital transfer. A nurse's note dated 6/20/24 documented, Resident assessed by PA (physician's assistant) and NP (nurse practitioner) and new orders given and noted to send to (hospital) for further eval (evaluation) for possible TIA/CVA (stroke) due to symptoms. Resident noted with delayed reaction during conversation The resident was readmitted on [DATE]. Further review failed to reveal any evidence that a written bed hold notice was provided. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked about sending a bed hold notice, she stated, You are supposed to provide a bed hold but each facility is different. When asked how does she evidence what is sent to the hospital, she stated it would be in a nurse's note. The facility policy, Resident Discharge / Transfer Letter documented, G. The resident or responsible party will receive a bed hold notice along with the discharge/transfer letter, when applicable. Bed Hold notices can be found in the electronic chart . On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #9, the facility staff failed to evidence that a written bed hold notice was provided to the resident and/or representative upon a hospital transfer. A nurse's note dated 6/8/24 documented, Alerted by aid that resident had episode of vomiting, resident assessed and has a change in LOC (level of consciousness), elevated B/P (blood pressure) 188/103 Resident not responding appropriately to questions, EMS (emergency medical services) called. The resident was readmitted on [DATE]. Further review failed to reveal any evidence that a written bed hold notice was provided. A nurse's note dated 6/13/24 documented, Received resident in bed, alert and verbal. During AM (morning) med pass CNA (Certified Nursing Assistant) witnessed resident have two consecutive seizures approximately 90 seconds in duration 10 minutes apart. Resident was assessed and repositioned to prevent injury. Resident cold/dry to touch, Resident had drainage from both nostrils blood and mucous mixed. Resident sent to ED (emergency department) for further evaluation. On call provider and family notified. The resident was readmitted on [DATE]. Further review failed to reveal any evidence that a written bed hold notice was provided. On 9/17/24 at 2:31 PM, an interview was conducted with LPN #10 (Licensed Practical Nurse). When asked about sending a bed hold notice, she stated, You are supposed to provide a bed hold but each facility is different. When asked how does she evidence what is sent to the hospital, she stated it would be in a nurse's note. The facility policy, Resident Discharge / Transfer Letter documented, G. The resident or responsible party will receive a bed hold notice along with the discharge/transfer letter, when applicable. Bed Hold notices can be found in the electronic chart . On 9/17/24 at 4:50 PM, ASM #1 (Administrative Staff Member) the Administrator, and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services for a feeding tube for two of 35 residents in the survey sample, Residents #139 and #42. The findings include: 1. For Resident #139, the facility staff failed to administer tube feedings per the physician orders and as documented, let the resident eat a meal tray upon admission to the facility, the resident was to be NPO (nothing by mouth). Resident #139 (R139), the resident was admitted on [DATE] at 5:09 p.m. The hospital discharge orders documented in part, TF (tube feeding) - Jevity 1.5 KCAL/ML (calories per milliliter) Dose: 300 ml. Frequency: 4 times daily. Discharge Procedure Orders: NPO TF only (nothing by mouth tube feeding only). Entered into the medical record on 3/22/24 at 2:41 p.m. The MAR (medication administration record) for March 2024, documented the above order. The resident did not receive any tube feedings on 3/21/24 at 8:00 p.m., 3/22/24 at 8:00 a.m. and 12:00 p.m. The ADL (activities of daily living) documentation, dated 3/21/24 at 7:55 p.m. documented, Fluids - 240 ml (milliliters); Dinner - 76-100%. This indicated the resident received a meal tray for dinner. There was no documentation for ADL care on 3/22/24 so it is unknown if the resident got a breakfast or lunch tray of food on 3/22/24. There was no nursing documentation related to care and condition of the resident on 3/21/24. An interview was conducted with LPN (licensed practical nurse) #12 on 9/17/24 at 10:32 a.m. When asked the process for a new admission and their admission orders, LPN #12 stated, most of the time we have the orders before the resident gets here. We can verify them with the physician, but we can't enter them into the computer until they are physically in the building. When asked how soon the orders should be entered into the computer, LPN #12 stated, as soon as you can. LPN #12 asked if the orders can wait 20 hours before they are entered into the computer, LPN #12 stated, no, the resident would need medications by then. When asked should the nurse and/or CNA (certified nursing assistant) verify the resident's diet before giving them a meal tray, LPN #12 stated, yes. The facility policy, New Admission/Readmission Process Policy, documented in part, 6. Review of orders: a. Physician verification of orders noted. b. Transmitted to pharmacy. c. Transcribed to eMAR/eTAR .14. Enteral feedings orders to contain the following: a. Route and Rate of solution[s] b Amount to be infused, per shift and/or 24hr total. c. Flushes entered on eMAR. d. Checks for residuals. e. Verification of placement. f. HOB elevated 30-450 and/or as directed by physician. ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing, were made aware of the above findings on 9/17/24 at 5:13 p.m. No further information was provided prior to exit. 42106 2. For Resident #42 (R42), the facility staff failed to address and notify the physician of feeding tube complications in a timely manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/13/24, the resident was assessed as being severely impaired for making daily decisions and having a feeding tube. On 9/15/24 at 5:24 p.m., an observation was conducted of R42 in their room. R42 was observed in bed watching television with tube feeding observed hanging beside them on a feeding tube pump. At that time, an interview was conducted with R42 who was able to verbalize some words and use a communication board. R42 stated that they had the feeding tube for about six months and had problems with it recently. The progress notes for R42 documented in part, 05/04/2024 16:09 (4:09 p.m.) This nurse notified by off going nurse peg (percutaneous endoscopic gastrostomy) tube is clogged. This nurse exhausted all efforts to unclog patients peg tube patient complains of 5/10 pain. Patient was apparently not connected to his tube feeding throughout the day. Patient is complaining of hunger pain. Called [Name of physician group] on-call and was given instructions to send patient out. Patient and emergency contact [Name of emergency contact] notified. Provider to be notified via on-call nurse. EMS (emergency medical services) notified. The eMAR (electronic medication administration record) dated 5/1/24-5/31/24 for R42 documented the resident receiving no tube feeding on day shift 5/3/24 or night shift 5/3/24. The eMAR documented R42 being out due to a clogged g-tube on 5/4/24 at 6:00 p.m. Review of the clinical record for R42 failed to evidence documentation of why the resident did not receive feeding on 5/3/24, the physician being notified or an order to hold the tube feeding on 5/3/24. It further failed to evidence documentation of the feeding tube being clogged on day shift on 5/4/24 or notification of the physician of the feeding tube concerns until evening shift on 5/4/24. The comprehensive care plan for R42 documented in part, Problem Start Date: 06/05/2024. Category: Nutritional Status. [Name of R42] is at increased nutrition/hydration risk r/t (related to) dx/pmhx (diagnoses/primary medical history) of hemiplegia & hemiparesis on R side . Enteral nutrition support via G (gastrostomy) Tube. Hx (history) of sig (significant) wt (weight) chnages [sic]. Under Interventions it documented in part, .Provide tube feed per order . Telephone interviews were attempted with the LPN's (licensed practical nurses) who worked with R42 on day and evening shift of 5/4/24 however the calls were not returned. The nurses who worked with R42 on 5/3/24 day and night shift no longer worked at the facility and could not be interviewed, this was verified by ASM (administrative staff member) #2, the director of nursing. On 9/18/24 at 9:45 a.m., an interview was conducted with LPN #1. LPN #1 stated that if a residents feeding tube became clogged, they attempted to unclog the tube and if they were not successful, they called the doctor to see what they wanted them to do. She stated that they called the doctor right then because there could be an obstruction and the resident needed their medications and the feedings. On 9/18/24 at 12:06 p.m., an interview was conducted with ASM #2, the director of nursing. ASM #2 stated that they would expect nursing staff to have another staff member assist them if the feeding tube was clogged and if they were unsuccessful in opening the tube, they should call the physician right away to get further guidance. She stated that she would not expect the resident to go a day without feeding or until the next shift to have the tube unclogged. The facility policy Enteral Feeding Tube[s] Policy revised 12/22/2023 documented in part, Nurses should monitor the condition of the tube with each use and inform the physician if the tube becomes unusable, leaks, or may need replacement . On 9/18/24 at 2:59 p.m., ASM #1, the interim administrator, ASM #2, the director of nursing, ASM #3, the regional director of clinical services, ASM #4, the administrator in training, and ASM #5, the regional vice president of operations were made aware of the concern. No further information was provided prior to exit.

Based on a complaint investigation, a closed medical record review, staff interviews and facility document review the facility staff failed to obtain and administer a physician ordered intravenous antibiotic to treat an infection which resulted in a rehospitalization for 1 of 4 residents in the survey sample, Resident #4. The facility staff failed to obtain and administer physician ordered intravenous (IV) antibiotic [MEDICATION(S)] every 8 hours (total of 10 misses doses) to treat Resident #4's Left Upper limb [CONDITION(S)], Bacteremia and [CONDITION(S)] Susceptible Staphylococcus Aureus Infection which resulted in a rehospitalization on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staphylococcus aureus (staph) is a germ found on people's skin. Staph can cause serious infections if it gets into the blood and can lead to [CONDITION(S)] or death (source obtained from https://www.cdc.gov). Bacteremia, in the strictest sense, refers to viable bacteria in the blood (source obtained from https://www.ncbi.nlm.nih.gov). Resident #4's most recent Minimum Data Set (MDS) was an Admission 5 Day/Discharge with an Assessment Reference Date (ARD) of 5/30/22. The Brief Interview for Mental Status was unable to be completed because the resident was coded as rarely/never understood. Under Section N Medications Resident #4 was coded as receiving 0 days of antibiotic therapy. Under Section O Special Treatments, Procedures and Programs the resident was coded as not receiving IV medications. Resident #4's Comprehensive Care Plan dated 5/27/22 was reviewed and is documented in part, as follows: Focus: Resident is on antibiotic therapy. Date initiated 5/30/22. Interventions: -Administer the full course of antibiotic as prescribed by physician. Date initiated 5/30/22. -Monitor resident response to therapy (decrease in signs and symptoms of infection). Date initiated 5/30/22. Focus: Resident is on intravenous therapy. Date initiated 5/30/22. Interventions: -Monitor skin at the IV site for redness, swelling, local warmth, tenderness. Date initiated 5/30/22. Resident #4's Hospital Discharge Summary dated 5/25/22 was reviewed. Under START taking these medications the orders indicated the resident was to receive [MEDICATION(S)] 2 grams intravenously every 8 hours for 23 days. Resident #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ([MEDICATION(S)]) injection is used to treat certain infections caused by bacteria including skin, bone, joint, genital, blood, heart valve, respiratory tract (including pneumonia), biliary tract, and urinary tract infections. [MEDICATION(S)] injection also may be used before, during, and sometimes for a brief period after surgery in order to prevent the patient from getting an infection. [MEDICATION(S)] injection is in a class of medications called cephalosporin antibiotics. It works by killing bacteria (source obtained from https://medlineplus.gov) Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #4. Resident #4 missed a total of 10 doses of IV antibiotic, [MEDICATION(S)]. Resident #4's Progress Notes were reviewed and are documented in part, as follows: 5/27/2022 12:49 p.m. Medication Administration Note Late Entry: Clarification; MD (Medical Doctor) put medication on hold until arrival from pharmacy. 5/27/2022 12:49 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM(grams) Use 2 gram intravenously every 8 hours for infection MD Orders to Hold. 5/27/2022 23:47 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 pump not in yet. 5/28/2022 16:34 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 MD on hold for pharmacy. 5/28/2022 16:38 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 MD on hold from pharmacy. 5/29/2022 12:33 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 md on hold pharmacy. 5/29/2022 18:43 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 order had not been faxed to pharmacy. Requested information sent via fax to (pharmacy phone number). 5/30/2022 01:27 a.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 Awaiting delivery from pharmacy. 5/30/2022 04:15 a.m. Nursing Note: Called (pharmacy name) about Resident's IV ABT [MEDICATION(S)] 2 grams. Spoke to (Name) in Richmond. (Name) stated that the ABT was not on the Residents profile and that it would have to be faxed over and would need to be followed up in the morning when the Pharmacy opens. I explained to her that the order had already been faxed twice on 5-27 and again on 5-29. Again she stated it was not on Residents profile and would need to followed up on in the morning. I re-faxed order to Omni for the third time and will have on-coming Nurse follow up later in the morning. 5/30/2022 09:05 a.m. Nursing Note: At shift report this writer was informed that (Resident #4's name) had a temp of 102.2 and it was also reported that she hadn't had her IV [MEDICATION(S)] that she needed since the 27th. The order was put in through the pharmacy and was checked upon a couple of times with on avail. When this writer went in to check on (Resident #4's name) her blood pressure (BP) was 96/55 and her O2 (oxygen) was 80%. This writer put O2 on her right away and called for the paramedics to take her to the hospital. Her POA (son) was informed as well as the MD. On 6/17/22 at 1:00 p.m. a phone interview was conducted with Pharmacy Account Manager, who is also a Pharmacist regarding Resident #4's IV [MEDICATION(S)]. The Pharmacist stated that on May 30th at 4 a.m. was the first time the IV [MEDICATION(S)] order was faxed over to the pharmacy from the facility. He stated for all IV and narcotic orders the facility is to fax over the script since these orders can be complicated and detailed, and the pharmacy fax machine prints a digital image of all faxes received with the date and time. On 6/17/22 at 3:40 p.m. an interview was conducted with Licensed Practical Nurse (LPN) #1 regarding Resident #4's IV [MEDICATION(S)]. LPN #1 stated she puts all the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] {Name of electronic medical record (emr)}. She stated she thought the orders went straight from the (Name of emr) to the pharmacy. She said she didn't know that she was supposed to fax the IV prescription over to the pharmacy as well, but knew now. On 6/16/22 at 5:10 p.m. a phone interview was on conducted with the previous Unit Manager LPN #2 regarding Resident #4's IV [MEDICATION(S)]. The Unit Manager stated that on Friday the 27th she was on the cart and in report she was told that Resident #4's [MEDICATION(S)] was not here yet. She stated she called the physician to inform him, and did not remember the name of the doctor that she called, but was told to hold the antibiotic. The Unit Manager said she did not have the 8 a.m. or 4 p.m. dose to give. The Unit Manager said to the oncoming nurse that she refaxed the order and the meds should be on the unit and here soon. She stated when she came back to work the following Monday, the resident was being sent out to the emergency room (ER) for evaluation. On 6/23/22 at 4:19 p.m. a phone interview was conducted with LPN #3 regarding Resident #4's 12 a.m. IV [MEDICATION(S)] dose on 5/28/22. LPN #3 stated she did not have the med to give and was waiting for the medication to be delivered from the pharmacy. She stated she did not call the doctor or the pharmacy because she thought it was on the way. On 6/16/22 at 5:29 p.m. a phone interview was conducted with LPN #4 who was Resident #4's nurse on 5/28/22 from 7 p.m. to 7 a.m. LPN #4 stated that she got the message in report that they were still waiting on the IV [MEDICATION(S)] to come from the pharmacy and was not told the medication was on hold. She stated medications usually are delivered from the pharmacy between 3 p.m. to 4 p.m., but did not show up during her shift. She said she did not call the physician because the resident was fine during her shift. On 6/17/22 at 8:37 a.m. a phone interview was conducted with LPN #5 who was Resident #4's nurse on 5/29/22 from 7 p.m. to 7 a.m. LPN #5 stated she did not have the IV [MEDICATION(S)] to administer. The LPN stated the pharmacy was called around 4 a.m. and it was determined the [MEDICATION(S)] was not on the resident's profile and it would need to be faxed over. The LPN stated that she refaxed the order for IV [MEDICATION(S)]. She said at the end of her shift the Certified Nursing Assistant (CNA) #1 obtained a temperature of 104 and took it again with a different thermometer to read 102.2 and Tylenol was administered for an elevated temperature. LPN #5 said the oncoming nurse (7 a.m. to 7 p.m.) sent the resident to the ER for evaluation. On 6/16/22 at 4:30 p.m. a phone interview was conducted with LPN #6 who was Resident #4's nurse on 5/30/22 from 7 a.m. to 7 p.m. LPN #6 stated besides the elevated temperature, she assessed Resident #4 to have dried blood on her mouth, a low oxygen saturation level of 80% (93-100=normal), and low blood pressure. She stated she informed the Unit Manager, LPN #2 of her assessment and the Emergency Medical Services (EMS/911) was called. She stated the Unit Manager was unaware that the IV [MEDICATION(S)] had not been sent to the facility to administer the resident. Resident #4's Emergency Department to Hospital-Admission record dated 5/30/22 was reviewed. Resident #4 arrived to the emergency department at 9:02 a.m. The record indicated that the resident presented from the nursing facility for evaluation of a fever and altered mental status. The resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)]: [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening medical emergency. [CONDITION(S)] happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to [CONDITION(S)] most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, [CONDITION(S)] can rapidly lead to tissue damage, organ failure, and death (source obtained from https://www.cdc.gov). On 6/17/22 at 1:53 p.m. a phone interview was conducted with the Medical Director who was also Resident #4's attending physician and the above information was shared. The Medical Director stated that he did not give the order to hold the IV [MEDICATION(S)]. He stated he checked his logged time stamped calls and that there were no calls concerning Resident #4 that the IV [MEDICATION(S)] was not available. He stated he would have called the pharmacy to send a STAT (now) order for the [MEDICATION(S)] or ordered a different IV antibiotic. On 6/17/22 at 10:32 p.m. a phone interview was conducted with the Administrator. The Administrator stated she found out on Tuesday the 31st from the Director of Nursing (DON) that the IV medication was missed and the resident had to be sent to the hospital. She stated she submitted a FRI (Facility Reported Incident) on 5/31/22 to the State survey and certification agency and started the investigation. She said she concluded that they failed to fax the IV antibiotic order to the pharmacy when she was admitted on [DATE] and notify the physician that the antibiotic was not available. The facility policy titled Missing Medication Policy last revised 6/4/21 was reviewed and is documented in part, as follows: Policy: Any medication(s) identified as missing will be promptly investigated. Procedure: 1. When a medication is identified as missing the issue is to be immediately communicated to the supervisor on duty, who will notify the Director of Nursing. The facility policy titled New Admission/Readmission Process Policy last revised 5/27/22 was reviewed and is documented in part, as follows: Policy: Admissions/readmissions will have required assessments/documents initiated promptly. Procedure: 6. Review of orders: b. Transmitted to pharmacy. On 6/23/22 at 4:30 p.m. a pre-exit debriefing was held with the Administrator and the Director of Nursing. The DON stated it was her expectation that the admitting nurse fax all of the orders over to the pharmacy after they were verified and if she was unsure what to do to have asked someone. She said that the next shift should have called the pharmacy and the doctor when the medication was not available to get further orders. She stated the nurses should have also made someone in administration aware of the situation. Upon entrance the facility provided a Quality Assessment and Performance Improvement Action Plan with a start date of 5/31/22. The allegation of compliance date was 6/8/22. The plan indicated the facility failed to obtain IV antibiotic from the pharmacy in a timely manner. The facility indicated all current and new residents have the potential to be affected by the deficient practice. A medication availability review was conducted on all current resident and will be conducted on all new admission for 30 days. The facility provided education to all licensed nurses (agency included) on the process for obtaining medications from the pharmacy, the Omnicell as well as communicating with the physician to discuss possible solutions if there will be a delay in obtaining medications. The facility staff was also educated on the abuse and neglect policy. The Unit Manager will complete medication available audits 5 times a week for 3 months as well as auditing all new admissions to ensure all medications have been delivered for 3 months. The facility also facility provided education to all licensed nurses (agency included) on notifying the physician of a missing medication and resident change of condition. Facility audits were reviewed with no issues identified. The facility nursing staff were interviewed on all units and verbalized training on the above stated issues and how they will respond hence forth. The facility conducted QAPI (Quality Assurance and Performance Improvement) meeting was held on 6/1/22 with all required attendees present. During the survey, no current residents were identified in the sample with the above deficient practice, and there were no residents that were identified as having the same issues since the facility's AOC date of 6/8/22. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on a complaint investigation, a closed medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 4 residents (Resident #4) in the survey sample were free from neglect by failing to obtain an intravenous antibiotic medication upon admission to treat an infection which resulted in rehospitalization . The facility staff neglected to obtain and administer physician ordered intravenous (IV) antibiotic [MEDICATION(S)] every 8 hours (total of 10 misses doses) to treat Resident #4's Left Upper limb [CONDITION(S)], Bacteremia and [CONDITION(S)] Susceptible Staphylococcus Aureus infection which resulted in a rehospitalization on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staphylococcus aureus (staph) is a germ found on people's skin. Staph can cause serious infections if it gets into the blood and can lead to [CONDITION(S)] or death (source obtained from https://www.cdc.gov). Bacteremia, in the strictest sense, refers to viable bacteria in the blood (source obtained from https://www.ncbi.nlm.nih.gov). Resident #4's most recent Minimum Data Set (MDS) was an Admission 5 Day/Discharge with an Assessment Reference Date (ARD) of 5/30/22. The Brief Interview for Mental Status was unable to be completed because the resident was coded as rarely/never understood. Under Section N Medications Resident #4 was coded as receiving 0 days of antibiotic therapy. Under Section O Special Treatments, Procedures and Programs the resident was coded as not receiving IV medications. Resident #4's Comprehensive Care Plan dated 5/27/22 was reviewed and is documented in part, as follows: Focus: Resident is on antibiotic therapy. Date initiated 5/30/22. Interventions: -Administer the full course of antibiotic as prescribed by physician. Date initiated 5/30/22. -Monitor resident response to therapy (decrease in signs and symptoms of infection). Date initiated 5/30/22. Focus: Resident is on intravenous therapy. Date initiated 5/30/22. Interventions: -Monitor skin at the IV site for redness, swelling, local warmth, tenderness. Date initiated 5/30/22. Resident #4's Hospital Discharge Summary dated 5/25/22 was reviewed. Under START taking these medications the orders indicated the resident was to receive [MEDICATION(S)] 2 grams intravenously every 8 hours for 23 days. Resident #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ([MEDICATION(S)]) injection is used to treat certain infections caused by bacteria including skin, bone, joint, genital, blood, heart valve, respiratory tract (including pneumonia), biliary tract, and urinary tract infections. [MEDICATION(S)] injection also may be used before, during, and sometimes for a brief period after surgery in order to prevent the patient from getting an infection. [MEDICATION(S)] injection is in a class of medications called cephalosporin antibiotics. It works by killing bacteria (source obtained from https://medlineplus.gov) Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #4. Resident #4 missed a total of 10 doses of IV antibiotic, [MEDICATION(S)]. Resident #4's Progress Notes were reviewed and are documented in part, as follows: 5/27/2022 12:49 p.m. Medication Administration Note Late Entry: Clarification; MD (Medical Doctor) put medication on hold until arrival from pharmacy. 5/27/2022 12:49 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM(grams) Use 2 gram intravenously every 8 hours for infection MD Orders to Hold. 5/27/2022 23:47 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 pump not in yet. 5/28/2022 16:34 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 MD on hold for pharmacy. 5/28/2022 16:38 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 MD on hold from pharmacy. 5/29/2022 12:33 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 md on hold pharmacy. 5/29/2022 18:43 p.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 order had not been faxed to pharmacy. Requested information sent via fax to (pharmacy phone number). 5/30/2022 01:27 a.m. Medication Administration Note: [MEDICATION(S)] Sodium Solution Reconstituted 2 GM Use 2 gram intravenously every 8 hours for infection until 06/17/2022 08:00 Awaiting delivery from pharmacy. 5/30/2022 04:15 a.m. Nursing Note: Called (pharmacy name) about Resident's IV ABT [MEDICATION(S)] 2 grams. Spoke to (Name) in Richmond. (Name) stated that the ABT was not on the Residents profile and that it would have to be faxed over and would need to be followed up in the morning when the Pharmacy opens. I explained to her that the order had already been faxed twice on 5-27 and again on 5-29. Again she stated it was not on Residents profile and would need to followed up on in the morning. I re-faxed order to Omni for the third time and will have on-coming Nurse follow up later in the morning. 5/30/2022 09:05 a.m. Nursing Note: At shift report this writer was informed that (Resident #4's name) had a temp of 102.2 and it was also reported that she hadn't had her IV [MEDICATION(S)] that she needed since the 27th. The order was put in through the pharmacy and was checked upon a couple of times with on avail. When this writer went in to check on (Resident #4's name) her blood pressure (BP) was 96/55 and her O2 (oxygen) was 80%. This writer put O2 on her right away and called for the paramedics to take her to the hospital. Her POA (son) was informed as well as the MD. On 6/17/22 at 1:00 p.m. a phone interview was conducted with Pharmacy Account Manager, who is also a Pharmacist regarding Resident #4's IV [MEDICATION(S)]. The Pharmacist stated that on May 30th at 4 a.m. was the first time the IV [MEDICATION(S)] order was faxed over to the pharmacy from the facility. He stated for all IV and narcotic orders the facility is to fax over the script since these orders can be complicated and detailed, and the pharmacy fax machine prints a digital image of all faxes received with the date and time. On 6/17/22 at 3:40 p.m. an interview was conducted with Licensed Practical Nurse (LPN) #1 regarding Resident #4's IV [MEDICATION(S)]. LPN #1 stated she puts all the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] {Name of electronic medical record (emr)}. She stated she thought the orders went straight from the (Name of emr) to the pharmacy. She said she didn't know that she was supposed to fax the IV prescription over to the pharmacy as well, but knew now. On 6/16/22 at 5:10 p.m. a phone interview was on conducted with the previous Unit Manager LPN #2 regarding Resident #4's IV [MEDICATION(S)]. The Unit Manager stated that on Friday the 27th she was on the cart and in report she was told that Resident #4's [MEDICATION(S)] was not here yet. She stated she called the physician to inform him, and did not remember the name of the doctor that she called, but was told to hold the antibiotic. The Unit Manager said she did not have the 8 a.m. or 4 p.m. dose to give. The Unit Manager said to the oncoming nurse that she refaxed the order and the meds should be on the unit and here soon. She stated when she came back to work the following Monday, the resident was being sent out to the emergency room (ER) for evaluation. On 6/23/22 at 4:19 p.m. a phone interview was conducted with LPN #3 regarding Resident #4's 12 a.m. IV [MEDICATION(S)] dose on 5/28/22. LPN #3 stated she did not have the med to give and was waiting for the medication to be delivered from the pharmacy. She stated she did not call the doctor or the pharmacy because she thought it was on the way. On 6/16/22 at 5:29 p.m. a phone interview was conducted with LPN #4 who was Resident #4's nurse on 5/28/22 from 7 p.m. to 7 a.m. LPN #4 stated that she got the message in report that they were still waiting on the IV [MEDICATION(S)] to come from the pharmacy and was not told the medication was on hold. She stated medications usually are delivered from the pharmacy between 3 p.m. to 4 p.m., but did not show up during her shift. She said she did not call the physician because the resident was fine during her shift. On 6/17/22 at 8:37 a.m. a phone interview was conducted with LPN #5 who was Resident #4's nurse on 5/29/22 from 7 p.m. to 7 a.m. LPN #5 stated she did not have the IV [MEDICATION(S)] to administer. The LPN stated the pharmacy was called around 4 a.m. and it was determined the [MEDICATION(S)] was not on the resident's profile and it would need to be faxed over. The LPN stated that she refaxed the order for IV [MEDICATION(S)]. She said at the end of her shift the Certified Nursing Assistant (CNA) #1 obtained a temperature of 104 and took it again with a different thermometer to read 102.2 and Tylenol was administered for an elevated temperature. LPN #5 said the oncoming nurse (7 a.m. to 7 p.m.) sent the resident to the ER for evaluation. On 6/16/22 at 4:30 p.m. a phone interview was conducted with LPN #6 who was Resident #4's nurse on 5/30/22 from 7 a.m. to 7 p.m. LPN #6 stated besides the elevated temperature, she assessed Resident #4 to have dried blood on her mouth, a low oxygen saturation level of 80% (93-100=normal), and low blood pressure. She stated she informed the Unit Manager, LPN #2 of her assessment and the Emergency Medical Services (EMS/911) was called. She stated the Unit Manager was unaware that the IV [MEDICATION(S)] had not been sent to the facility to administer the resident. Resident #4's Emergency Department to Hospital-Admission record dated 5/30/22 was reviewed. Resident #4 arrived to the emergency department at 9:02 a.m. The record indicated that the resident presented from the nursing facility for evaluation of a fever and altered mental status. The resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)]: [CONDITION(S)] is the body's extreme response to an infection. It is a life-threatening medical emergency. [CONDITION(S)] happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to [CONDITION(S)] most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, [CONDITION(S)] can rapidly lead to tissue damage, organ failure, and death (source obtained from https://www.cdc.gov). On 6/17/22 at 1:53 p.m. a phone interview was conducted with the Medical Director who was also Resident #4's attending physician and the above information was shared. The Medical Director stated that he did not give the order to hold the IV [MEDICATION(S)]. He stated he checked his logged time stamped calls and that there were no calls concerning Resident #4 that the IV [MEDICATION(S)] was not available. He stated he would have called the pharmacy to send a STAT (now) order for the [MEDICATION(S)] or ordered a different IV antibiotic. On 6/17/22 at 10:32 p.m. a phone interview was conducted with the Administrator. The Administrator stated she found out on Tuesday the 31st from the Director of Nursing (DON) that the IV medication was missed and the resident had to be sent to the hospital. She stated she submitted a FRI (Facility Reported Incident) on 5/31/22 to the State survey and certification agency and started the investigation. She said she concluded that they failed to fax the IV antibiotic order to the pharmacy when she was admitted on [DATE] and notify the physician that the antibiotic was not available. The facility policy titled Virginia Resident Abuse Policy last revised 5/26/21 was reviewed and is documented in part, as follows: Policy: This Facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. Neglect: The failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. On 6/23/22 at 4:30 p.m. a pre-exit debriefing was held with the Administrator and the Director of Nursing. The DON stated it was her expectation that the admitting nurse fax all of the orders over to the pharmacy after they were verified and if she was unsure what to do to have asked someone. She said that the next shift should have called the pharmacy and the doctor when the medication was not available to get further orders. She stated the nurses should have also made someone in administration aware of the situation. Upon entrance the facility provided a Quality Assessment and Performance Improvement Action Plan with a start date of 5/31/22. The allegation of compliance date was 6/8/22. The plan indicated the facility failed to obtain IV antibiotic from the pharmacy in a timely manner. The facility indicated all current and new residents have the potential to be affected by the deficient practice. A medication availability review was conducted on all current resident and will be conducted on all new admission for 30 days. The facility provided education to all licensed nurses (agency included) on the process for obtaining medications from the pharmacy, the Omnicell as well as communicating with the physician to discuss possible solutions if there will be a delay in obtaining medications. The facility staff was also educated on the abuse and neglect policy. The Unit Manager will complete medication available audits 5 times a week for 3 months as well as auditing all new admissions to ensure all medications have been delivered for 3 months. The facility also facility provided education to all licensed nurses (agency included) on notifying the physician of a missing medication and resident change of condition. Facility audits were reviewed with no issues identified. The facility nursing staff were interviewed on all units and verbalized training on the above stated issues and how they will respond hence forth. The facility conducted QAPI (Quality Assurance and Performance Improvement) meeting was held on 6/1/22 with all required attendees present. During the survey, no current residents were identified in the sample with the above deficient practice, and there were no residents that were identified as having the same issues since the facility's AOC date of 6/8/22. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #74. *Pressure Injury (ulcer) - A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. https://npuap.org/page/PressureInjuryStages. The findings included: Resident #35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #35's most recent MDS (Minimum Data Set Assessment) was a quarterly assessment with an ARD (assessment reference date) of 5/20/21. Resident #35 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status exam). Resident #35 was coded in Section M (Skin Conditions) as having a stage 4 (2) pressure ulcer. On 7/6/21 during an interview with Resident #35; Resident #35 had stated that he had come into the facility with a pressure ulcer but that he didn't feel that the facility was doing dressing changes like they should have been and that the wound had worsened. Review of Resident #35's facility admission note dated 12/9/20 documented in part, the following: Resident Arrival Date and Time: 12/09/2020 6:00 PM .Open area to coccyx present 1.5 X 2.5 cm (centimeters) x 0.1 cm .Braden: 13.0 (3). The next note dated 12/9/20 documented the following: Note Text: Wound type is pressure. Stage: 2 (4) Wound Location coccyx. Length (cm) 1.5, Width (cm) 2.5, Depth (cm) 0.1 Area is community acquired. Skin impairment was present on admission. 12/09/2020 Drainage type: Serosanguineous Drainage Small Drainage, Wound bed is Red No odor, Area is a new wound. Pain Level is 0 Family notified 12/10/2020 9:00 AM. Physician Aware: 12/10/21 .Treatment: (No treatment was documented). Review of a physician note dated 12/10/20 revealed that the physician was aware of Resident #35's wound to his sacral area. The following was documented: .new sacral lesion about 2 x 1 cm stage II it was noted by the staff . There was no evidence that orders for a treatment were obtained. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The following was documented: Treatment as follows: cleanse sacrum area with normal saline, apply skin barrier wipe to periwound area, apply Dermagel Hydrogel Sheet dressing, cover with gauze and tape or non-adherent dressing. Change every three days and prn (as needed). There was no evidence on the December 2020 TARs (Treatment Administration Record) or MARS (Medication Administration Record) that the 12/14/20 order was implemented. On 12/12/20 there was evidence that the primary physician had conducted a partial assessment on the sacral wound on 12/12/20. The following was documented in part, a sacral stage II skin breakdown about 1 x 2 cm with no secondary infection [CONDITION(S)] or tunneling . Description of the wound bed, periwound etc. was not mentioned in the above assessment. Review of a weekly wound assessment dated [DATE]; revealed that Resident #35's sacral wound had deteriorated. The following was documented: Wound Type: Pressure. Stage: Unstageable. Wound Location: sacrum. Length: 7 (cm) by Width (13 cm) Depth nonmeasure .was skin condition present upon admission? Yes .Drainage: Serous. Drainage Amount: Scant. Odor. None. Wound Bed appearance: necrotic .Odor: none. Peri wound appearance: Red .DRESSING TREATMENT PLAN. Primary Dressing(s) Dakin's solution (5) apply once daily. Santyl (6) apply once daily. Secondary Dressing(s) Gauze Island (w/bdr) apply once daily. Peri Wound Treatment Skin prep apply once daily .This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm. Review of the Resident #35's December 2020 MAR (Treatment Administration Record) revealed that this order was implemented on 12/17/20. Review of a note by the wound care physician dated 12/22/20 documented in part, the following: At the request of (Name of physician) a thorough wound care assessment and evaluation was performed today. He has an unstageable (due to necrosis) sacrum for at least 8 days in duration. There is light serous exudate .Wound Stage: 8.0 x 10.0 x Not Measurable cm. Periwound radius: Odor .Thick adherent black tissue: 50 % (percent) Thick adherent devitalized tissue: 20 % Granulation tissue: 20 % Skin: 10 % (percent). Wound progress: Deteriorated. Review of Resident #35's care plan dated 12/9/20 through 6/2/21 revealed a skin integrity care plan was not put into place until 12/30/21. The following was documented, in part: Resident has impaired skin integrity- Unstageable PU (pressure ulcer) to sacrum present on admission .administer treatments as ordered, Encourage (Name of Resident #35) to turn and reposition while in bed, monitor nutritional status. Consult dietician. Review of Resident #35's December 2020 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/8/21 at 10:00 a.m., an interview was conducted with LPN (Licensed practical nurse) #1, a nurse who worked with Resident #35 on occasion. When asked who was responsible for assessing a wound upon admission into the facility, LPN #1 stated that it was the floor nurse who was responsible for measuring the wound and providing a description of the wound. LPN #1 stated that LPNs could not stage but that an RN could stage a wound. LPN #1 stated that if the resident is not admitted with a treatment order on the hospital discharge instructions, it is up to the nurse to call the MD (medical doctor) for an order. LPN #1 was shown the admission note for Resident #35 on 12/9/21. LPN #1 was then shown the December 2020 POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 confirmed that she did not see that a treatment was put into place once his wound was identified upon admission as a stage two. When asked the consequence for not doing a dressing to an identified stage two ulcer, LPN #1 stated that the wound could get worse. LPN #1 was then shown that on 12/15/20 (Next weekly wound assessment) Resident # 35's wound had gotten bigger and was found to have necrotic tissue to the wound bed. LPN #1 stated, Yes, it looked like it had deteriorated. When asked what necrotic tissue was, LPN #1 stated that necrotic tissue was dead tissue that was black in color. LPN #1 stated that necrotic tissue has to be debrided in order for healing to occur. On 7/8/21 at 12:16 p.m., an interview was conducted with RN (Registered Nurse) #2, the unit manager for unit one and two. When asked if nursing staff were expected to assess and obtain a treatment order for a newly admitted resident who is admitted to the facility with an existing pressure ulcer, RN #2 stated, Yes, I expect the nurses to assess get a treatment order for that wound. When asked the consequence if an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what necrotic tissue meant to the wound bed, RN #2 stated that necrotic tissue was dead tissue. RN #2 stated that if necrotic tissue is in the wound bed, the wound will not heal until it has been removed. When asked if necrotic wounds are considered advanced stage wounds, RN #2 stated that they were. This writer had discussed the above findings with RN #2. RN #2 was asked to present any additional information regarding Resident #35's sacral wound. RN #2 was made aware that if this information was not found; this citation could lead to a serious scope and severity level. On 7/8/21 at 12:30 p.m., ASM #1, the Administrator was made aware of what was discussed with RN #2 and that documentation was needed to show that a treatment was put into place and implemented on 12/9/20 through 12/14/20 prior to the wound deteriorating. On 7/8/21 at approximately 3:00 p.m., RN #3, the MDS nurse presented Section M (Skin Conditions) of Resident #35's MDS assessment with an ARD date of 12/15/20. RN #3 stated that the look back period for this particular MDS was on 12/8/20 through 12/15/21. RN #3 stated that there had to have been an order in place if she had checked that Resident #35 was receiving dressings and ointments. The following was documented on this MDS and signed by the MDS nurse on 12/29/20: A. Resident has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device: Yes; B. Formal Assessment: Yes. C. Clinical Assessment: Yes M0210. Unhealed pressure Ulcers/Injuries: Yes. M0300. Current number of unhealed pressure ulcers/injuries: F1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: (1) .F2. Number of these unstageable pressure ulcers that were present upon admission or reentry: (1). Section F2 was inaccurate as it was documented in the clinical record that Resident #35 was admitted to the facility with a stage two ulcer. Further review of the Section M of Resident #35's MDS documented the following: .Application of nonsurgical dressing (with or without topical medications) other than to feet: Yes. H. Application of ointments medications other than to feet: Yes. There was no still no evidence that a treatment order was obtained and implemented after Resident #35 was admitted to the facility with a stage two pressure ulcer; AND there was no evidence that Resident #35 was receiving any type of ointment or barrier cream. On 7/8/21 at 3:15 p.m., a phone interview was conducted with the nurse who admitted Resident #35 on 12/9/20. She could not recall if Resident #35 had been admitted with a wound and if an order was obtained or not. On 7/8/21 at 4:00 p.m., ASM #1, the Administrator; ASM #3 and #4 the Corporate Nurses were made aware of the concern for harm. ASM #4 stated that they still could not find the treatment order for the stage II wound during 12/9/20 through 12/14/20 or a TAR showing that the order was implemented. ASM #4 stated that the orders and TAR were probably written on paper back when they were doing paper charting. ASM #4 stated that the 12/15/20 MDS however reflected that Resident #35 had an order in place because the MDS RN had signed and locked the MDS which indicated that all information on the MDS was accurate. This writer informed ASM #4 that the signature means that the section was completed, not that the information was accurate. On 7/8/21 at the exit conference held at 6:30 p.m., ASM #4 stated that she was still looking for TAR and order. This information could not be presented prior to exit. No further information was presented prior to exit. Facility Policy titled, Pressure Injury Prevention and Treatment Policy, documents the following: Resident's will be assessed for pressure injury risk on admission, quarterly, and with significant change of condition using the Braden Scale for Predicting Pressure Ulcer Risk. Wounds identified will be assessed initially and at least weekly thereafter, until closed. To include the following elements: Location and stage Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth and the presence, location and extent of any undermining or tunneling/[MEDICATION(S)] tract; Exudate, if present: type (such as purulent/serous), color, odor, and appropriate amount; Pain, if present: nature and frequency (e.g., whether episodic or continuous); Wound bed: Color and type of tissue/character including evidence of healing (e.g. granulation tissue, maceration) as appropriate; Appearance of surrounding tissue; Any evidence of infection If a PU (Pressure Ulcer)/Pressure Injury) fails to show some evidence of progress towards healing within 2-4 weeks, the area and the resident's overall clinical condition will be reassessed. B. Treatment: Pressure injuries identified will be documented and orders obtained from providers for treatment. C. Monitoring: At least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI will be documented. At a minimum, documentation will include the elements listed in Section A. D. Notification: The facility will notify family/resident representative[s] and the provider of any newly acquired or worsening pressure injuries and any changes in treatment[s]. (1) Unstageable pressure ulcer- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (2) Stage 4 pressure ulcer- Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (3) The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development .The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. This information is taken from the website https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN/ (4) Stage 2 pressure ulcer- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm. (5) Dakin's solution is used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores. This information was obtained from: https://www.webmd.com/drugs/2/drug- /dakins-solution/details. (6) Santyl- *SANTYL® Ointment is an FDA-approved active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level. This works to free the wound bed of microscopic cellular debris, allowing granulation to proceed and epithelialization to occur. (<http://www.santyl.com/about>) 2. Resident #74 was admitted to the facility on [DATE] and discharged to the hospital on 12/03/2020. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #74's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 11/26/2020 was coded with a BIMS (Brief Interview for Mental Status) score of 09 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #74 as requiring supervision with setup help only with eating, limited assistance of 1 with bed mobility, extensive assistance of 1 with transfer and personal hygiene and total dependence of 1 with bathing. On 07/06/2021 review of Resident #74's clinical record revealed the following: Admission Progress Note dated 11/20/2020 15:10 was reviewed and revealed the following: .has MASD (Moisture Associated Skin Damage) to the buttocks area with redness and excoriation, with an open area to the rt (Right) buttocks 0.5 x 1 x 0 MD (Medical Doctor) notified, moisture barrier cream applied . Braden: 13.0 Pressure / Non Pressure Skin Assessment Progress Note dated 11/20/2020 15:10 was reviewed and revealed and is documented in part, as follows: Note Text: Wound type is MASD Wound Location buttocks Length (cm) (Centimeter) 0.5 Width (cm) 1 Depth (cm) 0 Area is community acquired, no skin impairment was present on admission. 11/20/2020 Drainage type: No Drainage Wound bed appearance is Pink No odor Periwound appearance is Pink. Area is a new wound. Pain levels 0 11/20/2020 12:00 AM Treatment: moister [sic] barrier cream waiting on further orders from MD. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1. 11/20/20 Medications Treatments Wound MD eval (Evaluate) and treat. Review of orders did not evidence a treatment order for buttocks or sacrum. On 07/07/2021 requested copies of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for November 2020 and December 2020 and Braden scores for Resident #74. On 07/07/2021 requested copy of Resident #74's wound measurement from admission to discharge. Copy of Weekly Wound Assessment v1 - V5 was received. Review of assessment revealed the following: Effective Date: 11/20/2020 15:10 Admission: 11/20/2020 1. Wound Overview 1. Wound Type 10. Other; 1a. Other Wound Type MASD; 2. Wound Location: buttocks; 3. Length (cm) 0.5; 4. Width (cm) 1; 5. Depth (cm) 0; 6. Location Where Wound Was Acquired? 2. Community Acquired 2. Wound 1. Was the skin impairment present on admission 1? Yes; 3. Date Wound Identified 11/20/2020 6. Wound Bed Appearance 1. Pink; 8. Periwound Appearance 1. Pink; 10. Wound Status 1. New Wound; 4. Comments and Treatment 2a. Date and Time Physician Notified: 11/20/2020 00:00; 3. Treatment moister [sic] barrier cream; 4. Comments waiting on further orders from MD. On 07/07/2021 at 6:30 p.m., received copies of Resident #74's MAR and TAR for December 2020 from the Director of Nursing (DON). The Director of Nursing stated, We are still looking for November MAR and TAR. Resident #74's TAR received for the Month of December was reviewed on 07/07/2021 and revealed the following: Medications - [MEDICATION(S)] after each incont (Incontinent) episode. In the column under HOUR, Day, Night is documented. Resident #74's Admission / Readmission Evaluation - V 2 completed on 11/21/2020 was reviewed on 07/07/2021 and revealed the following: Skin Risk Score: 13 Skin Risk Category: Moderate risk. On 07/07/2021 review of Physician / PA (Physician Assistant) / NP (Nurse Practitioner) Progress Note dated 11/23/2021 14:19 in Resident #74's clinical record revealed the following: genitourinary: genitals unremarkable, there is some moisture associated skin damage with [CONDITION(S)] on most of the buttocks area it's completely covered with [MEDICATION(S)] there is some mild skin breakdown on the right buttocks it only appears to be about one or 2 cm but I could not get the [MEDICATION(S)] off at this time she said it was too uncomfortable and wish to just leave it on. Did not see any other [CONDITION(S)]. Review of Resident #74's Nursing Progress Note dated 11/24/2021 revealed and is documented in part, as follows: Note Text: Wound Doctor in to see patient today. MASD to bottom healing, no open areas just redness, barrier cream and [MEDICATION(S)] applied. Resident #74's Braden Scale Pressure Ulcer Risk Assessment with an Effective date of 11/27/2021 was reviewed on 07/07/2021 and revealed the following: Braden Score: 18 Braden Category: Low Risk. On 07/07/2021 Resident #74's Bi-Weekly Skin Check 1 with a date of 11/29/2021 was reviewed and revealed the following: 1. Does the resident have current Skin Issues 1. Yes Document current Skin Issues Site 53) Sacrum Description redness. On 07/07/2021 Resident #74's Bi-Weekly Skin Check 1 with a date of 12/2/2021 was reviewed and revealed the following: 1. Does the resident have current Skin Issues 1. Yes Document current Skin Issues Site 53) Sacrum Description redness. On 07/08/2021 at approximately 10:00 a.m., an interview was conducted with (Name of Doctor) Medical Doctor (MD) Other #6. When MD was told that surveyor had a couple questions for him regarding Resident #74, MD stated, I think I saw her maybe one time. When asked about Resident #74's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what the process for ordering resident medications is, MD stated, The nurse sends the orders from the discharge summary to the doctor, these are the medicines the hospital placed the patient on. If the doctor is not in the facility the staff would have to read the orders from the Discharge Summary over the telephone and not all medications are approved for different reasons. MD stated the last time he saw Resident #74 was December 2. MD stated, She had [MEDICATION(S)] on every time I saw her. When asked was [MEDICATION(S)] an acceptable treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . MD also stated, It keeps urine and poop off of the skin and it makes it slower for the skin to dry out. Review of Resident #74's clinical record for the period of 11/20/2020 through 11/30/2020 revealed documentation that staff applied barrier cream and /or [MEDICATION(S)] to resident on 11/20/2020, 11/23/2020 and 11/24/2020. There is no evidence that the resident was provided treatment to wounds consistently or had a wound treatment order during this time. On 07/08/2021 Resident #74's hospital records was reviewed and revealed the following: (Name of hospital) Emergency Department Time of Arrival: 12/03/20 0806 ED (Emergency Department) Provider Note Physical Exam Skin: Comments: Stage II decubitus ulcer in the sacral area this appears overall to be well - healed with some surrounding areas of [CONDITION(S)] and stage I ulceration.; Progress Notes by (Name of Nurse) RN (Registered Nurse), Other #7 at 12/4/2020 0203 Skin Image 5: Large area skin breakdown with several open areas. Non-blanching redness. Received patient from ED alert and oriented . Skin assessment completed, skin care provided. (Review of Skin Image Diagram indicates 5 is in the sacral region.) On 07/08/2021 at approximately 3:45 p.m., an interview was conducted with the Director of Nursing. When asked do you have any other wound measurements or Weekly Wound Assessments for Resident #74 buttocks or back, Director of Nursing stated, No. When asked do you have the MAR and TAR for November 2020, DON stated, We cannot find the MAR and TAR for November. When asked what is the MAR and TAR, DON stated, They are records to document what medications were administered and what treatments were given. When asked do you have the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked should the resident had a treatment ordered for her MASD and wound on her buttocks, DON stated, Yes. When asked what your expectations of nurses are when a resident has a wound, DON stated, See if treatment came over from the hospital and if it did not then to obtain a treatment order from the physician. When asked why should wounds and impaired skin integrity have a treatment, DON stated, to help promote healing. On 07/08/2021 at approximately 6:00 p.m. Administrator and Director of Nursing was informed of findings at pre-exit meeting. The facility did not present any further information about the finding. Complaint Deficiency

Based on a complaint investigation, a closed record review and staff interview, the facility staff failed to provide supervision to prevent a fall resulting in harm for one resident (Resident #105) of 5 residents in the survey sample. For Resident #105, the facility staff failed to provide supervision to prevent a fall with injury. The findings included: Resident #105 was admitted to the facility on [DATE] following a fall with fractures at home, with [DIAGNOSES REDACTED]. The facility staff failed to provide supervision to prevent a fall with injury. Resident #105 had a history of [REDACTED]. An Initial Minimum Data Set (MDS) coded this resident as having falls. A re-entry MDS dated [DATE] coded this resident as having falls. In the area of Cognitive Patterns-the resident was assessed to have a score of 14 for Brief Interview for Mental Status (BIMS)=intact cognition. In the area of Functional Status-Activities of Daily Living (ADL'S)-the resident was assessed in the area of bed mobility as a 4/2 requiring total dependence and support of one person physical assist; in the area for Toilet use this resident was assessed as a 4/2 requiring total dependence and support of one person physical assist; in the area of Personal Hygiene-the resident was assessed as a 3/2 requiring extensive assistance and support of one person physical assist. A care plan dated 11/21/18 included: Problem-(Resident #105) is at risk for decreased ROM (range of motion) and pain related to contractures. Goal-Resident to maintain LE/UE arm/prom within the 90 days. Interventions-left hand roll orthotic to be worn at all times except for hygiene and ROM. Problem-Self Care deficit-assistance required with bathing, hygiene, dressing, and grooming R/T (related to) muscle weakness. Goal-Will be odor free, dressed and out of bed daily over the next 90 day. Intervention-Shower use lifts devices mechanical lift. Total assist with dressing and undressing. Problem-(Resident #105) is at risk for Falls R/T muscle weakness and difficulty in walking. Goal-will demonstrate the ability to ambulate/transfer without fall related injuries. Interventions-bed in low position. Keep areas free of obstructions to reduce the risk of falls or injury. Problem-Toileting: Resident requires assistance. Goals-Resident will have toileting needs met with the assistance of 1-2 staff will be provided as needed. Interventions-Provide hygiene after voiding/BM to prevent skin breakdown. Apply moisture barriers. Select clothing that is easily removed. Change incontinence pad/brief. A Facility Incident Abstract Report Indicated: Event date-1/2/19 was reviewed and included: Event Description: CNA positioned resident in bed and stepped away to get brief when resident slid off bed. Special Analysis Fields: Event Type: fall-Event Detail-fell from bed. The clinical record was reviewed and included: Clinical note dated 1/2/19 at 9:31 P.M. included: Called to unit as resident had fall earlier in shift. Resident was in bed when I saw her, I saw her, alert, calm. Only c/o was left shoulder pain. No bruising or redness noted. Requesting X-ray of that shoulder. Doctor ok with x-ray. Mobile x in and obtained x ray. Called again to unit an hour later. Resident now has family member bedside and is c/o a headache along with the shoulder pain and requesting to go to ED. Paged doctor again, ok to send to ED. Transport contacted and will be here within the hour. Clinical note dated 1/2/19 at 11:30 P.M. included: Called by CNA in the room observed resident lying on her back on the floor by the bed. ROM initiated c/o left shoulder pain. Transferred to bed check due to c/o left shoulder no bruises or redness noted to the site. Called MD on physician ordered to have X-ray on left shoulder. Called brother and made aware the incident and explained what happened. Brother cane in and requested to be sent out resident to hospital for evaluation due to have a headache as what the resident to brother but when I was doing my assessment never c/o headache. On call MD made aware of the requests. The radiology report dated 1/2/19 at 10:44 PM included: Examination-Shoulder 1 view, left. Results: No acute fracture or dislocation. The osseous structures appear intact. Joint spaces are narrowed. Soft tissues are unremarkable. Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes. Limited single view. Recommend full exam for diagnostic evaluation. Hospital notes were obtained and included: Hospital emergency room Summary: Time of Arrival: 1/2/18 10:15 PM. Closed fracture of multiple ribs of left side, initial encounter. Closed displaced fracture of left clavicle, unspecified part of clavicle, initial encounter. Closed fracture of left elbow, initial encounter. Fall at nursing home, initial encounter.[MEDICAL CONDITION](cardiovascular accident). Vital Signs 1/2/19 at 2230 (10:30 P.M.) Temp 98.6, Heart Rate 103, Pulse 98, Resp 15, BP 160/82, spO2 95 %, weight 138 pounds. Assessment/Differential Diagnosis: [REDACTED]. Evaluation for injuries from fall from bed. Evaluate for head injury, [MEDICATION NAME] spine injury, shoulder contusion or fracture hip contusion or fracture. ED Course/Medical Decision Making: 11:38 PM, patient is still having significant pain. She does not want to return to the nursing home. Admit to the hospital for multiple rib fractures with concern for [MEDICAL CONDITION] deterioration and possible development of pneumonia. She will also need to have orthopedics evaluate her elbow fracture. Patient is a resident of the nursing facility. She was being turned and fell out of the bed onto the floor. She states she did hit her head she is complaining of pain in her head as well as her upper back area the left shoulder and her left leg and hip area. She has chronic deformities and contractures of her left upper and lower extremities. She has hx [MEDICAL CONDITION] residual deficits, left hand contractures, chronic bilateral leg weakness, per patient she has been bedridden for a long time, several years. No loss of consciousness. No chest pain or shortness of breath or abdominal pain. Final Results-XR : 1. Displaced left clavicular fracture. 2. Significant [MEDICAL CONDITION] change left shoulder. Elbow- Fractures of the distal left humerus as above. Chest:- Acute fractures at left ribs and left clavicle. Bony irregularity at the left elbow. Recommend elbow x-ray to determine if acute. A Hospital Discharge Summary dated 1/9/19 included: Principal problem: Multiple closed fractures of ribs of left side. Hospital Course: Resident #105 with past medical history of [REDACTED]. Patient was being turned and accidentally fell to the floor falling onto her left side. She has left sided deformities and contractures from her previous [MEDICAL CONDITION]. In the emergency room patient found to have multiple rib fractures on the left clavicular fracture and left humerus fracture. Further review of the facility clinical record included a Physical Therapy Discharge Summary dated 7/23/18 which included: Short Term Goal- Pt (patient) will demonstrate tolerance to progressive LLE (left lower extremity) splinting/positioning (progressing into L knee extension/hip IR and extension) . The pt's regular CNA staff will demonstrate competence and ability to setup LLE positioning device to facilitate prevention of a progressing contractures/promoting contractures reversal-will be displayed through in-service trg (training) and sign off. Previous (7/22/18)-Pt's 3 primary CNA'S have been trained in LLE positioning/contractures management w/use of bolster/positioning device. Will continue goal for cont'd trg and consistency until time of pt d/c (discharge) from therapy services. PT has not received pt w/LLE positioned over device as trained. Will communicate to nsg managers in attempt to increase adherence to contracture management program. Discharge: (7/23/18) Pt's 3 primary CNA's have been trained in LLE positioning/contractures management w/use of positioning device-demonstrating ability to setup independently. In service trg performed w/CNA's signing off. A OT Evaluation & Plan of Treatment dated: 6/19/18 indicated: Short Term Goal- Patient will safely wear a hand roll on left hand for up to 1 hour w/minimal s/s of redness, swelling, discomfort or pain. Long Term Goal: Patient will safely wear a resting hand splint on left hand for up to 4 hours w/minimal s/s of redness, swelling, discomfort or pain. Patient Goals: I would like some other kind of brace that helps my hand. A written statement by Certified Nursing Assistant #2 who was the staff providing care for Resident #105 during her fall indicated: To whom it may concern: I CNA #2 made sure Resident #105 was secured in the bed when I went to look for her depends which were missing out of the chair. I told her I'm going to get her a depends. I grab the depends off the cart. another staff ask why are you still here. I said I told Resident #105 I' am going to come back and change her. Next thing I know we heard some noise in the room less than 5 seconds we went into the room she was lying on her back. She didn't scream or holler. I saw the basket and puzzle inside the and she was on the floor. A written statement by CNA # 5 indicated: I CNA #5 was in the hallway assignment 1. doing rounds. Spoke to CNA #2 regarding being at work. CNA #2 stated she promise patient she would change brief before leaving. CNA #2 got brief off chart for patient. Two seconds after CNA #2 got brief we heard a loud noise. CNA #2 and I ran in the room and found patient on the floor on her back on the window side of room. Nurse was called into room. Nurse checked patient while on the floor and asked her several questions about her pain. Me and 3 other aids placed a blanket underneath patient and safely lift patient off floor. Nurse continued to asked patient about pain while checking her in bed. Patient complained that arm was hurting. A written statement by Licence Practical Nurse (LPN) #2 indicated: I was called by CNA in room [ROOM NUMBER] at about 7:10 P.M. on 1/2/19. Found resident lying on the floor on her back by the bed. I did ROM and c/o left shoulder transferred resident in bed. Re did ROM c/o left shoulder and left elbow pain. Called MD on call ordered x-ray. I called POA made aware of what happened. At about less than 30 minutes POA came in requesting to send resident out to ED called MD on call again and agreed to send out to ED. During a staff interview on 1/24/19 at 4:25 P.M. with CNA #2 she stated: I turn Resident #105 towards the window. I made sure her legs were secure. I left her in the room to go and get diapers. Not sure if resident had falls before. We were short of staff that day. Usually there are 6 CNA's on Unit 1. On that day there were 4. Later on there were 3. One staff left at 3:00 P.M. leaving 3 CNA's. I work from 7:00 A.M. until 7:00 P.M. CNA #2 explained: I left the room to get diapers and heard a loud noise. Found resident on the floor. Called nurse who came in assessed her, no pain. Bed was up in high position. Her bed is always up in high position. I had stayed over because I promised Resident #105 that I would come back and change her before I left for the day. During an interview on 1/25/19 at 2:35 P.M. with LPN #2 she stated: I normally turn her towards the window when giving care. I have two persons because she becomes unbalanced on her left side due to contractures of her left arm and left leg. During an interview on 1/25/19 at 2:45 P.M. with CNA #4 she stated: When I changed her, I have two persons. You can not leave her on side or she will tumble over due to her left leg is paralysis. She does not move on her own. During an interview on 1/28/19 at 11:42 A.M. via telephone with CNA #2 she explained: I took two diapers out and gave her a bath in the morning. I checked on her at 4:30 P.M. and she was dry. Between 6:30 P.M. and 6:45 P.M. I went back and she was wet. I secured her on her side and went looking for a diaper because the one I left earlier were gone. I went into the hallway to get a diaper. CNA #2 was asked if Resident #105 able to move on her own in bed? CNA #2 responded, no. CNA #2 was asked if Resident #105 had grab bars on her bed? CNA #2 responded, no. CNA #2 was asked if Resident #105 had side rails on her bed? CNA #2 responded, no. When asked about Resident #105 being secured on her side and which side was Resident #105 on, CNA#2 stated she left Resident #105 on her left side. When asked since Resident #105 can not hold on to anything on her left side for support why would you leave her on her left side unattended? CNA #2 stated I thought I could run to the hallway and get a diaper. I had no idea she would tumble out of bed. During an interview on 1/28/19 at 1:45 P.M. with the Administrator and Director of Nursing (DON) they indicated: CNA #2 had training to care for Resident #105. When asked if it was the same training that Physical Therapy had provided back in (MONTH) (YEAR) the Administrator stated, no. It was explained that staff are given an oral report of assignments. The plan of care is on electronic screen. The DON was asked to describe Resident #105's left side. The DON stated that Resident #105 had left side weakness due to a [MEDICAL CONDITION], she was contracted in her left hand and left leg. Resident #105 is not able to use her left side at all. Resident #105 is not able to move in bed at all if turned towards the window which is her left side. She did not have any type of assistive devices, pillows, grab bars, or side rails. When asked what happened to Resident #105 that caused her to fall out of bed. The DON stated, she was on the edge of the bed, gravity cause her left leg to pull her over the side of the bed and she fell . A Fall Risk Prevent Program last revised 09/28/17 Indicated: Purpose: The fall prevention program is designed to (1) establish a culture of awareness and implement fall prevention strategies to prevent falls, and (2) prevent patient and resident falls/falls with injury through appropriate assessment of fall risk and implementation of appropriate fall/injury prevention interventions. Definitions: Fall-A patient or resident fall is sudden, unintentional decent with a change in plain; with or without injury to the patient or resident, that results in the resident/or patient changing plain and coming to rest on the floor, on or against some other surface (e.g. a counter), on another person, or on an object. 2. Fall Risk Assessment, Care Plan and Interventions- A- Upon admission evaluate the resident for a potential risk to fall. All Fall Risk Assessments, Morse Scales, are to be completed within 24 hours following admission. E. Residents will be reassessed quarterly, annually, when a significant change occurs and after each fall. 4. Responsibilities and Education D. Team members: Communicating and identify residents at risk for fall and injury and developing interventions. Ensuring resident monitoring systems are in place and resident care plans are being followed. Complaint deficiency.

Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure 5 Residents (Residents #59, #78, #16, #55 and #129) of 36 residents in the survey sample remained free of potential accident hazards related to smoking. Immediate Jeopardy was identified on 5/31/18 at 5:45 PM. The Corrective Action Plan was approved and validated by the survey team on 6/1/18 and the Immediate Jeopardy (IJ) was officially lifted on 6/1/18 at 2:45 PM. 1. The facility staff failed to ensure Resident #59 remained free of potential accident hazards related to smoking by not performing a smoking assessment to assess if she was safe to smoke independently, failure to remove cigarette lighting materials from her room, failed to identify and remedy potential trip hazards on the facility grounds and failed to educate on potential safety hazards of smoking off campus without supervision. 2. The facility staff failed to assess Resident #78, who was identified as a smoker, for safe smoking practices who kept her lighter and cigarettes stored in her room. On 5/30/18, nursing staff was aware that the resident had smoked in her room. The facility staff did not safeguard resident #78 in the designated off campus smoking areas where environmental hazards were identified. The resident was allowed to come and go at anytime without signing out leave of absence (LOA), per their policy when residents go out of the building. All of the aforementioned issues contributed to a immediate jeopardy situation for Resident #78. 3. The facility staff failed to assess Resident #16, who was identified as a smoker, for safe smoking practices who kept her lighter and cigarettes stored in her room. The facility staff did not safeguard resident #16 in the designated off campus smoking areas where environmental hazards were identified. The resident was allowed to come and go at anytime without signing out leave of absence (LOA), per their policy when residents go out of the building. All of the aforementioned issues contributed to an immediate jeopardy situation for Resident #16. 4. The facility staff failed to complete a Resident Smoking Assessment and ensure that Resident #55 was free of potential smoking hazards related to routine medications, personal smoking paraphernalia and handicap accessible access while at the off facility grounds designed smoking area. 5. The facility staff failed to ensure the safety of Resident #129 who was a smoker by not completing a smoking an assessment prior to him smoking and smoking unsupervised. The findings included: 1. Resident #59 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #59's Annual Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date (ARD) of 5/12/18 scored Resident #59 with a Brief Interview for Mental Status (BIMS) score of a 15 of 15 indicating no cognition impairment. In addition the Annual MDS coded Resident #59 in: Section G0300 as: Not steady, but able to stabilize without staff assistance for moving from seated to standing position Not steady, but able to stabilize without staff assistance for walking Not steady, but able to stabilize without staff assistance for turning around Not steady, but able to stabilize without staff assistance for Moving on and off toilet Not steady, but able to stabilize without staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair) Section G0600 Mobility Devices: Walker (Front wheeled walker with slides on back two walker legs Wheelchair (Manual) Section G0110 Walking in Room: Independent Walking in corridor: Independent Locomotion on unit: Independent Locomotion off unit: Independent Eating: Supervision with 1 staff person assist Bathing: Total Dependence with 2 staff person assist Section J1300 Current Tobacco Use: No Section J1800: Any falls since admission/entry or reentry or prior assessment: No Section N0410 Medications Reviewed: The number of days the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days 7-Antipsychotic 7-Antianxiety 7-Antidepressant The current (5/16/18 to present) Comprehensive Person Centered Care Plan documented the following Focus areas: Focus: Refusal of Safety Measure. Flag Reflector for wheel chair as Resident smokes off facility grounds Goal: Resident will verbalize safety risks. Goal Date 7/25/18 Interventions: Educate Resident regarding safety risks Accept Resident's right to refuse Discus with Resident objections Ensure proper documentation in resident record Focus: Resident Smokes Goals: Resident will smoke only in designated smoking areas. Goal date 7/25/18 Interventions: Re-educate as needed to smoking area, can be non-compliant with smoking in designated area Check [MEDICAL CONDITION](clothing, fingers, skin); report to the nurse Focus: Transfers (to/from: bed chair wheelchair, standing position) - Resident requires assistance. Assistance varies from assessment to assessment Goal: Resident will complete transfers with the assistance of 1 person as needed. Goal date 5/16/18 Interventions: Place call bell/light within easy reach Remind Resident to call for assistance before moving from bed to chair and from chair to bed Focus: Resident has exhibited Wandering Behavior Goal: Current level of mobility will be maintained within a secure environment over the next 90 days. Goal date 7/25/18 Interventions: Assess potential physical causes for wandering Check location/whereabouts of Resident frequently on each shift Focus: Resident is receiving antipsychotic drugs on a regular basis related to [MEDICAL CONDITION], delusions Goal: Resident will not cause harm or injury to self or others over next 90 days. Goal date 7/25/18. Interventions: Remove from situation; allow time to calm down Remind that behavior is not appropriate Focus: [MEDICAL CONDITION] disorder Goal: Resident will be free of [MEDICAL CONDITION] activity and [MEDICAL CONDITION] related injury over next 90 days. Goal Date 7/25/18. Interventions: Should [MEDICAL CONDITION] occur assist resident to lying position and loosen any tight fitting clothes Focus: Restorative/Ambulation Goal: To promote residents ability to attain their maximum functional potential during the next 90 day review period. Goal Date 7/25/18. Interventions: Stay close to resident at all times when ambulating (walking) Focus: Actual Fall (2/13/18, 2/25/18, 3/1/18, and 6/5/18 Goal: Will be without injury due to falls over the next 90 days. Goal date 7/25/18. Interventions: Encourage resident not to push/pull carts while using walker Reinforce use of walker for independent ambulation Evaluate current medication usage related to complaints of hearing voices and increased anxiety Educated to not sit on other's laps 1/6/2016 Physical Therapy note documented the following: Gait training to normalize gait pattern Patient ambulated 200 feet, 600 feet using front wheeled walker with supervision Patient was able to maintain good positioning between self and from wheeled walker while performing cognitive task with no loss of balance Spoke with PA (power attorney) Recommended that patient can ambulate using front wheeled walker with supervision of staff Morse Fall Scales reviewed for the following dates: 6/23/17 Score 80: Risk level: 45 and higher is High Risk for falls 9/9/17 Score 80: Risk level: 45 and higher is High Risk for falls 3/1/18 Score 90: Risk level: 45 and higher is High Risk for falls 4/1/18 Score 90: Risk level: 45 and higher is High Risk for falls Review of Clinical Notes showed documentation of the following falls: 2/13/18 3:59 AM: The nurse was called to room by staff after a noise was heard at 2:45 AM. Resident was found sitting on her floor in front of the sink. Her wheel chair was by the door. Resident was noted to have increased anxiety and agitation. Resident verbalized to nurse that she was hearing voices. She stated that she was hearing her mother's voice, and it is asking her things, but she did not elaborate. Resident did become distressed and had trouble word finding when attempting to explain what the voice was telling her. 2/25/18 6:13 PM: Resident was attempting to sit on another patient's lap in front of the nurses station when resident was witnessed to have slid down the wall onto bottom. 3/1/18 5:00 PM: Resident in hallway pushing walker and pulling coffee cart when she lost her balance and sat on her buttocks. Denies pain or injury. Alert and verbal. Assisted to chair by Certified Nursing Assistants. 6/5/18 1:31 PM: Resident was in hallway and stood up to scratch leg with other foot and fell on buttocks. Fall was witnessed by staff. Assisted to chair. Denies any injury or pain. None of the above 4 falls resulted in injury or facility deficient practice. 6/5/18 10:15 AM, Physical Therapy note documented the following: Patient experience a fall on 6/3. Patient states I pulled my foot up to scratch it with my hand and fell backwards.Stated she was standing and she knows she shouldn't have. patient had walker available. Patient normal mode of mobility is Independent ambulation with front wheeled walker with sliders indoors, outdoors and thru door thresholds. Demonstrated her normal ataxic gait pattern and ability to stand with 1 hand on walker only. Walker in good working order. The Smoking Assessment completed on 5/31/18 at 8:37 PM documented the following: Directions: Residents who want to smoke independently are assessed on admission by the licensed nurse. Select the appropriate response. Does the resident have short-term memory loss? NO Does the resident have long-term memory loss? NO Does the resident have mobility and dexterity in both arms and hands? YES Can the resident display signs of safety awareness (i.e. safe lighting and extinguishing smoking materials)? YES Does the resident use oxygen? NO A member of the interdisciplinary Team, has assessed the resident's cognitive, physical and visual ability to carry out the responsibility of smoking in the facility smoking area and to be in possession of smoking materials Check one: Yes, is cognitively, physically and/or visually able to smoke with indirect supervision. An email provided to the surveyor dated 5/31/18 at 1:26 PM documented the following definition of supervision as used in therapy (PT, OT, ST): Patient performs the task independently, however, given distant supervision and/or verbal and/or visual cuing from a caregiver to initiate or complete at task, with or without adaptive equipment or devices. Resident #59 was observed on 5/29/18 at approximately 12:05 PM, sitting in a chair with her walker in front of her and a metal cart to her left, beside the water fountain by Unit 1's nursing station. Resident #59 was observed clean and well groomed. On 6/1/18 Resident #59 was observed ambulating with her front wheeled walker from the Unit 1 nursing station to her room for eye drop instillation at approximately 11:00 AM. Resident #59 was observed on 6/5/18 at approximately 10:15 AM Resident #59 with Physical Therapist standing at bedside. Resident #59 ambulated into the hall way using her front wheeled walker. The Physical Therapist #6 stated that she was performing a screening post fall of 6/4/18. On 5/31/18 at approximately 6:04 PM, the Director of Nursing stated that the Facility is not responsible for resident safety when they are on leave of absence (LOA) The Director of Nursing stated that they would not be responsible if the Resident were on LOA at the Walmart or the 7-Eleven store as the resident would be off of Facility property. The DON continued to state that Resident #59 was not a smoker upon her admission to the facility. The DON stated that Resident #59 became a smoker approximately 18-24 months ago On 5/31/18 at approximately 3:34 PM, Resident was interviewed while sitting on top of the telephone junction box and under the tree with the exposed elevated roots. Observed at the feet of Resident #59 were multiple extinguished cigarette butts on the ground (over 15). Resident #59 stated that she came to the smoking area four to five times a day to smoke. Resident #59 was not smoking at the time of this interview. Resident #59 was asked what difficulties she had getting to the off site smoking area. Resident #59 pointed to the curb and stated that it was difficult for her to get her walker over then curb and then go through the grass and gravel area. Resident #59 stated that she has recently been getting to her smoking area a different way and pointed to a portion from the driveway that led over a curb into a dirt area and into grass and had no gravel area to ambulate through. Resident #59 denied ever smoking in her room or in the facility. On 5/31/18 at approximately 4:00 PM, two surveyors walked with the Corporate Maintenance Director and the Facility Director using the path the Facility non-compliant smokers used to the offsite smoking area. The distance from the facility door to the offsite smoking area was measured to be 275 feet located behind tall shrubs and bushes blocking any view of the area from the Facility. The Corporate Maintenance Director admitted that the depression on the Facility Parking lot could be a potential place for a Resident to fall. He also admitted that the plastic bucket filled with paper and other debris could be a potential hazard in addition to the raised curbs, exposed elevated roots, Cox Cable junction box and 9 inch deep hole beside Cable junction box and Telephone junction box. Neither the Corporate or Facility Maintenance Director knew how the plastic bucket was placed in the offsite smoking area and neither knew how it was emptied. Both the Corporate and Facility Maintenance Directors stated that the offsite smoking area was owned by the City and that the Facility did not do anything to maintain the area. Both Maintenance Directors admitted that from the Facility, the non-compliant smokers could not be seen. Both of these Maintenance Directors stated that the residents had been assessed for safety of smoking and assessed to be able to keep their cigarettes and lighters with them in their rooms. The Maintenance Directors admitted that Facility staff employees would also smoke in the same area but were not considered staff to be observing the non-compliant smokers. While touring the offsite smoking area, the Cox Cable Junction box with existing hole beside it was pointed out as potential safety hazards. The elevated exposed tree roots were pointed out to both Maintenance Directors. During the time that the 2 State Surveyors and Corporate and Facility Maintenance Directors was viewing the offsite smoking area, Resident #55 was sitting in his wheelchair smoking and observed flicking cigarette ashes onto the grass and into the plastic bucket filled with paper and other debris. Resident #55 stated that he would come to the offsite smoking area during the day and night. He stated that at night there was some light from the street light located by the tree in the offsite smoking area. Resident #55 stated that he normally if alone would park his wheel chair just up on the grass by the Cox Cable Box and would go over to the tree if other smokers were there. On 5/31/18 at approximately 5:08 PM, the Unit 1 Manager was asked what did indirect supervision mean related to a resident. She stated, I don't know. Because of the Director of Nursing comment of not being responsible for Resident safety while on LOA made on 5/31/18 at 6:04 PM, the surveyor asked on 6/1/18 at approximately 11:15 AM while in a meeting with the Administrative Team, the Director of Nursing was asked while the rest of the Team were talking, if Resident #59 asked to go independently to the end of the Street the Facility was located on (2-3 blocks away from the facility) would she consider it safe for her to do so. The Director of Nursing answered, No. On 6/1/18 at approximately 11:49 AM, Housekeeper #5 stated that she would often on weekends that she worked, empty the plastic bucket located in the offsite smoking area. Housekeeper #5 stated that she was aware of three other employees that emptied the bucket. She stated that 2 of the employees no longer worked at the facility and that one RN (Registered Nurse) whose office was located around the corner also emptied the buckets. On 6/1/18 at approximately 12:08 PM, the Materials Handler #12 was interviewed. She stated that a potential hazard of Residents having lighters and matches in their room would be Facility Fires and Explosions. On 6/1/18 at approximately 11:51 AM, RN #5 was interviewed. RN #5 stated that she emptied the plastic buckets located on the offsite smoking area when she noticed them to be full. When asked what risks Residents had that smoked off campus, she stated that they could fall. The facility Maintenance Director was interviewed on 6/5/18 at approximately 10:08 AM. The Facility Maintenance Director stated that he filled in the hole by the Cox junction box located off campus in the area the facility non-compliant smokers smoked on 6/5/18. When asked if the Cox junction box served the facility, he stated he didn't know. The Facility Maintenance Director stated when asked what was under the Cox junction box that he felt plastic there and felt that it was a plastic container covered with concrete. The Facility Maintenance Director was asked the risk if someone's foot or leg went into the hole by the Cox junction box. He stated that it's not a good thing and made no further comment. The Facility Maintenance Director stated that he filled the depression in the facility drive way asphalt that is located to the right of the front entrance 1/2 circle. The Facility Maintenance Director stated that it was approximately 18 inches in diameter and about 1/4 inch deep. Resident interviewed on 6/5/18 at approximately 10:15 AM. She was asked if she felt safer in the new on campus smoking area. Resident stated that she never felt unsafe on the off campus smoking area. Resident #59 was asked if she liked the new smoking area. She stated that she felt bad for residents the ambulances brought through the smoking area because she didn't want the smoke to get in their face. An interview with the Unit Manager of Unit 1 where Resident #59 lives was conducted on 6/5/18 at approximately 10:40 AM. The Unit Manager #1 stated that she has worked at the Facility for 4 years. She was asked if she felt that Resident #59 had safety risks going to the off facility smoking area. The Unit Manager stated, Yes. When asked for specific safety risks, the Unit Manager stated, Balance. The Unit Manager continued to state that if Resident #59 took her time and did not rush that she would be safer. The Unit Manager was asked about Resident #59's fall on 6/4/18. The Unit Manager stated that the fall occurred late afternoon while Resident #59 stood up and tied to scratch her other leg with her foot. The Unit Manager was asked what potential risk there were when residents would keep lighters and cigarettes in their room. She stated, that anyone having an open flame in the room could cause a fire. When the Unit Manager was asked if she was aware of any residents on Unit 1 smoking, she replied, Not to my knowledge. The Unit Manager also added that other potential risks of residents going to the off site smoking area would be cars coming and going in the parking lot and potential for falls. The Facility Policy titled, Job Aid: Life Care - Preventive Maintenance Schedule - Annual and Semi Annual / Daily / Weekly / Monthly / Quarterly Rounds with a revision date of 7/31/17, documented the following: Policy Statement: The Maintenance Department will be responsible for completing annual and semi-annual rounds and assuring that preventative maintenance is complete. Annual Schedule Exterior Inspections Inspect fencing, courtyards, guttering, sprinkler system, pavement, and sidewalks. The Facility Procedure titled, Life Care - Fall Risk Prevention Program with a revision date of 9/28/17 documented the following: Purpose: The fall prevention program is designed to: (1) establish a culture of awareness and implement fall prevention strategies to prevent falls, and (2) prevent patient and resident falls/falls with injury through appropriate assessment of fall risk and implementation of appropriate fall/injury prevention interventions. Residents in the Falling Leaf Program should be monitored closely for the following: Transferring from one surface to another Ambulating or attempting to ambulate Standing up after sitting or lying down Changes in medications or behaviors (especially after addition of [MEDICAL CONDITION], antihypertensive or diuretic) In bright or dark areas, or going from inside to the outside or reverse. The Facility Policy titled, No Smoking and Tobacco-Free Campus with a revision date of 1/2017, documented the following: Policy Statement: To support (Facility's) mission to improve health every day by providing a tobacco-free environment. The use of tobacco, smokeless tobacco products, or the use of any device, such as an e-cigarette or vaporizer (to include vapor-producing products), designed to deliver a non-prescribed substance for inhalation are not permitted anywhere on the property. Exceptions: This policy may not apply on the exterior/grounds of any (Facility) office that is leased, if property is owned by a company that does not require a tobacco-free environment (example: an outpatient rehab facility in a shopping center). The policy would still apply to any area(s) of that property controlled by Sentara. The Facility Policy titled, Life Care Smoking with a revision date of 10/26/17 documented the following: (Facilities) are smoke free and education is provided upon admission. The use of electronic cigarettes and smokeless tobacco products are not permitted. Exceptions: Residents residing in the facility prior to time of facility designated themselves as smoke free status are allowed to smoke These residents will be screened quarterly and with significant change to determine level of assistance/supervision required and if protective device(s) is required. Residents are permitted to smoke only in areas specifically designated for that purpose and designated times. Proper ashtrays and receptacles will be provided in designated areas. Ashtrays of noncombustible material and safe design shall be provided in all areas Mental containers with self-closing cover devices into which ashtrays can be emptied shall be readily available in areas The use of oxygen in smoking area is prohibited Residents identified as smokers will be assessed for appropriateness of residents' capabilities, cognitive ability, manual dexterity and mobility. The residents capabilities and deficits will determine whether or not supervision is required Residents who are unable to smoke independently will be supervised The facility will limit the accessibility of matches and lighters by residents. Residents should be reassessed either quarterly, annually, or change of condition The facility administration was informed of the findings during a briefing on 6/5/18 at approximately 2:15 PM. The facility did not present any further information about the findings. 2. The facility staff failed to assess Resident #78, who was identified as a smoker, for safe smoking practices who kept her lighter and cigarettes stored in her room. The facility staff indicated they used the RAI (Resident Assessment Instrument)process and care planning to determine residents were safe to smoke. The facility staff indicated the resident was aware of the no smoking policy on facility grounds to include in the building. On 5/30/18, nursing staff was aware that the resident had smoked in her room. In addition, the facility did not safeguard residents in the designated off campus smoking areas where environmental hazards were identified. The resident was allowed to come and go at anytime without signing out leave of absence (LOA), per their policy when residents go out of the building. All of the aforementioned issues contributed to a potential immediate jeopardy situation for Resident #78. Resident #78 was admitted to the nursing facility on 5/15/18 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment was an admitted d 5/22/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a 13 out of a possible score of 15 which indicated she was intact with the necessary cognitive skills. The resident had no problems understanding staff and was understood. The resident was assessed to have problems sleeping. Resident #78 was not assessed to have any mood or behavioral problems. The resident was coded to require extensive assistance from one staff for bed mobility, dressing and bathing. She required limited assistance from one staff for transfers, ambulation and toilet use. Resident #78 was coded as not steady and required staff assistance at all times when moving from a seated position to a standing position, walking, turning around to face the opposite direction while walking, moving on and off the toilet and surface to surface transfers (between bed and chair or wheelchair). She was assessed impaired in range of motion on one side of lower extremity. The resident was coded to use a walker and wheelchair as mobility devices. The resident was assessed to have fallen once with no injury since admission. The resident was coded on this assessment to receive opioids, antidepressants, antipsychotics 7 out of the 7 assessment days. She was assessed to have oxygen therapy while a resident in and out of the facility. The resident was assessed to receive occupational and physical therapy. The resident was admitted for short term rehabilitation skilled care with the goal to return to the community. Resident #78 was coded for a mental health diagnosis, [MEDICAL CONDITION] disorder. The MDS did not have an area that assessed a resident's smoking status. The facility's Admission assessment dated [DATE] assessed the resident for fall risk with a score of 35. Scores between 25-44 indicated she was at moderate risk for falls. The resident fell on [DATE] while ambulating without assistance and without assistive devices (walker). The Admission Assessment indicated the resident was oriented to the handbook, smoking rules, nursing unit, call light, bathroom, bath schedule and meal times. There was no place on the Admission Assessment that specifically addressed a resident's smoking status. The care plan dated 5/22/18 identified the resident was unable to transfer from bed to chair without assistance due to weakness related to left hip prosthetic removal and antibiotic spacer replacement. She was also identified at risk for falls and an actual fall due to medications (antipsychotic, antidepressant and opioids) and mobility problems. The resident was identified on pain management. The resident was also identified to smoke and the goal set for the resident by the staff was that she would only smoke in designated smoking areas. The staff was to ensure she did not smoke with oxygen use and that they were to check clothing [MEDICAL CONDITION] well as fingers and skin, and report to nurse if identified. No smoking assessments were located in the clinical record for Resident #78. On 5/30/18 at 2:30 p.m., Resident #78 was observed in her wheelchair with smoking materials in her lap (cigarettes and lighter) going out the front door, through the facility's driveway to an area that was totally obliterated by tall hedges. Requested Smoking assessments and stated they could not find them at the time for Resident #78, but may have one and would continue to look for it. She stated the facility basically used the RAI for functional and cognitive status and care planned she was safe to have smoking material. On 5/31/18 at 4:00 p.m., this surveyor along with a second surveyor, escorted by the facility's Maintenance Director and Corporate Maintenance Director, walked the smoker's pathway to the designated off grounds smoking area. The area was measured to be 275 feet from the front door of the facility behind rows of tall hedges. At the time one of the facility's residents was actively smoking, seated in his wheelchair, Resident #55. This resident will be fully addressed within the body of the 2567 by another surveyor. The following concerns were addressed with both Maintenance directors: The uneven side walk and curb lip that measured 1/2 inch. Twenty-nine inches from the walkway was a square paved area in the grass, identified as cable communications box underneath. Directly beside the communications box was an obvious hole that measured 9 inches in depth. It was determined this hole was created due to water run off. Underneath one of the trees was a telephone box with exposed wires where obviously resident's smoked due to large amounts of cigarette butts observed on the ground. Two tall plastic buckets were observed, positioned in the grass along the hedges. Upon closer inspection these buckets were partially filled with sand, but on top of the sand overflowing were paper trash to include candy wrappers, straws, napkins, potato chip bags, cookie wrappers and other unidentified trash. Resident #55 was observed flicking ashes from his cigarette into one the buckets, as well as on the grass. The ground in some areas were uneven with obvious large exposed roots near a large tree. Both directors stated the area was considered city property and they did not do anything with the property. When asked where the buckets came from or who emptied them when they were overfilled with trash, neither could provide the information. The facility Maintenance Director stated he had been here 4 years and they had been there and it was possible staff put them there for the residents since they smoke in the vicinity. Both directors agreed the hole in the grass, the uneven sidewalk, the curb height, trash in buckets, exposed roots and the trash filled buckets presented potential hazards to the residents that smoked in the area. The directors said, although the residents could not be seen from the building, the residents had been assessed to be safe while smoking and able to keep their lighters and cigarettes on them and stored in their rooms. They stated staff smoked in the vicinity, but not actually with them and the residents could smoke anytime of the day or night. When asked if city knew their resident were smoking there, no response, but that it was not their property and they had nothing to do with it. When asked why they filled the nine inch hole in the ground when it was city property according and not their responsibility per earlier statement, they stated, It was because you all were here and saw it. On 5/31/18 at 11:40 a.m., an interview was conducted with the Administrator. Two other surveyors were present. The Administrator stated there was a smoking assessment tool, but they used the RAI to determine cognitive and functional status and care planned they were a smoker, thus they did not utilize the smoking assessment tool. She stated she was concerned about maintaining the safety of the residents in the smoking areas off campus in order to keep them safe, and was also concerned that her policy needed t (TRUNCATED)

Based on staff interviews, clinical record review and facility document review the facility staff failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers (1) and does not develop pressures wounds for 1 out of 21 residents (Resident #17) in the survey sample resulting in harm. Resident #17 was discharged from another facility, to the hospital and entered the facility on 02/08/17 without any pressure ulcers. On 02/13/17, Resident #17 was first identified with a total of nine (9) pressure ulcers to the following areas: left heel, right posterior heel, right heel, right mid heel, right inner ankle, left and right buttocks, left great toe and 2nd toe on right foot. The findings included: Resident #17 was admitted to the facility on [DATE] and discharged home on[DATE]. [DIAGNOSES REDACTED]. Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date of 02/15/17 coded Resident # 17's Brief Interview for Mental Status (BIMS) score of 09 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #17 total dependence of two with bed mobility, transfers and toilet use, total dependence of one with dressing, eating and bathing and requiring extensive assistance of two with personal hygiene for Activities of Daily Living care. A Braden Risk Assessment Report was completed on 02/08/17; Resident #17 scored an 11 indicating high risk for the development of pressure ulcers. Mobility (ability to change and control body position) coded very limited - does not make even slight changes in body or extremity position without assistance, sensory perception (ability to respond meaningfully to pressure-related discomfort) coded very limited - unresponsive to painful stimuli due to diminished level or consciousness or sedation or limited ability to feel pain over most of body surfaces. Review of Resident #17's Nursing Admission Assessment Comprehensive dated 02/08/17 indicated the following: skin turgor (good), skin color (normal for ethnicity), skin type (diaphoretic), pressure ulcers (no), pressure ulcers on prior assessment (no). In addition, the 02/08/17 Nursing Admission Assessment Comprehensive indicated always incontinent of bowel and bladder. The weekly skin condition progress report documentation revealed Resident #17 was first identified with the following pressure ulcers on 02/13/17: Left heel - Deep Tissue Pressure Injury (DTI) measuring 5.5 cm (centimeter) x 4.5 cm x 1, right posterior heel (DTI) measuring 2 cm x 3 cm x 0.1, right heel (stage 1 (5)) measuring 7 cm x 10.5 cm x 0.1 cm area that wraps around the heel with a (stage II) ruptured blister inside the noted area which measured 5.5 cm x 6.2 cm, right inner ankle as (stage II (6)) measuring 5.5 cm x 3.2 cm x 0.1 cm, right mid heel as (DTI (7)) measuring 1 cm x 4 cm x 0.1 cm, left buttocks as (stage II - intact blister) measuring 1 cm x 1.5 cm x 0.1 cm, right buttocks as (stage II - intact blister) measuring 1 cm x 1.2 cm x 0.1 cm, left great toe as (DTI) measuring 0.2 cm x 0.2 cm x 0.1 cm and right toe 2nd digit (DTI) measuring 0.2 cm x .2 cm x 0.1 cm. The MDS with an ARD of 2/15/17 under section M under skin condition (M0100) was coded: Resident has a stage 1 or greater (M0150) at risk for developing pressure ulcers was coded yes, (M ) was coded yes for unhealed pressure ulcers, (M0300) was coded for having 1 (stage 1), coded for having 3 (stage 2) and coded for having 5 (DTIs). The MDS with an ARD of 2/15/17 under section M (Skin and Ulcer Treatments) also revealed the resident was not coded for pressure reducing device for chair, turning/repositioning program, applications of ointments/medications other than feet. The resident was coded always incontinent for bowel and bladder under section H (Bladder and Bowel). Under section E (Behaviors) was coded 0 for behavioral symptoms - presence and frequency, rejection of care to include ADL assistance. On 06/22/17 at 12:00 p.m., surveyor requested behavior monitoring sheet from Director of Nursing (DON) who replied she reviewed Residents #17's medical record and was unable to locate any behavioral monitoring sheet for her. Clinical record review did not indicate any type of behaviors from 02/08/17 through resident's discharge to home on 02/17/17. An interview was conducted with LPN #1 who stated, Resident #17 never exhibited any behaviors to include refusal of care in ADL's or positioning with bed mobility. Resident #17's Interim care plan documented resident with actual problem with skin integrity related to immobility, incontinence and on 2/13/17 multiple DTIs and blisters. The goal: absence of skin breakdown as evidenced by redness/swelling; skin intact breakdown with evidence of healing & no infection. Some of the intervention/approaches to manage goal included: position every 2 hours & prn (as needed), assess skin every week and as needed, implement pressure reducing devices as needed, maintain nutritional and mobility status, main hygiene routine skin care and treatment as ordered. According to the Treatment Administration Record (TAR) for February 2017, a new order was written for Prevalon boots (8) continuous except during physical therapy (PT) and low air loss mattress (9) to protect skin starting on 02/13/17. The current treatment as of 02/13/17 is to clean blister to right heel with DWC (wound cleanser), skin prep (10) around blister, apply Xeroform (yellow gauze bandage) and apply abdominal pad and Opsite (11) every other day. The current treatment to left heel as of 02/13/17 is to apply skin prep and apply Allevyn (12) every other day. The current treatment as of 02/13/17 is to skin prep sacrum and intact blister and apply sacrum Allevyn every other day. During medical record review, Resident #17 was assessed by PACE (Programs of All-Inclusive Care for the Elderly) physician on 02/16/17 and documented: Prevalon boots not on but did address a dressing was intact to the right medial malleolus (right ankle). The resident's Treatment Administration Record (TAR) for February 2017, revealed there was no active order for the right inner ankle wound. During the review of the medical record and TAR for February 2017 revealed there was no treatments for the following pressure ulcers: right inner ankle as (stage II) measuring 5.5 cm x 3.2 cm x 0.1 cm, right posterior heel (DTI) measuring 2 cm x 3 cm x 0.1, right mid heel as (DTI) measuring 1 cm x 4 cm x 0.1 cm, left great toe as (DTI) measuring 0.2 cm x 0.2 cm x 0.1 cm and right toe 2nd digit (DTI) measuring 0.2 cm x .2 cm x 0.1 cm. An interview was conducted on 06/21/17 at approximately 9:50 a.m. with Occupational Therapy who stated Resident #17 was totally dependent with bed mobility and showed difficulty following commands. The surveyor asked if resident had a specialty cushion in her wheel chair or recliner when out of bed. The occupation therapy (OT) stated after reviewing OT notes, I didn't see where it was documented; that something that is mentioned in our notes if a resident was sitting on a specialty cushion. The OT also stated the resident's chart was reviewed for skin issues but did not see where she had skin problems so we wouldn't have given her a specialty cushion. An interview was conducted with physical therapy (PT) on 06/21/17 at approximately 10:20 a.m., who stated if there was a specialty cushion in Resident #17's wheel chair, we would have documented in our notes if resident was on a specialty cushion. PT also stated, We read all admission paperwork and will address needs as indicated. There was nothing in the hospital discharge notes about resident having any wounds or skin issues; we also review the discharge summary to include active orders, skin assessment and treatments. An interview was conducted with LPN #1 on 06/21/17 at approximately 2:30 p.m., who stated, The PACE nurse was here to see someone else but decided to do a skin assessment on Resident #17 and needed another nurse to assist with the assessment. I was Resident #17's nurse so I assisted with the skin assessment. LPN #1 stated, A CNA reported to me earlier, before my assessment with the PACE nurse that Resident had a pressure ulcer to her right heel and I reported it to the unit manager (RN #1) but didn't do an assessment at that time. LPN #1 also stated, The PACE nurse is the one that completed the skin assessment and found all the pressure ulcers on Resident #17 except for the right heel, I wrote all the measurements down as she called them out to me. The unit manager (RN #1) informed the RR (Resident Representative) of all pressure ulcers. During the interview with LPN #1 on 06/21/17 at approximately 2:30 p.m., the surveyor asked if a Resident receives weekly skin assessment and prn (as needed), when is the prn assessment completed and by whom, the LPN replied, Mainly by the CNA but anyone really, if they see any areas they will notify the nurse. The surveyor then asked, The prn is only after an area is found, the LPN replied, Pretty much, but the CNAs should be looking at the residents skin daily. On 06/21/17 at approximately 3:50 p.m., an interview was conducted with RN #1 who stated, I wasn't in the room during the skin assessment on Resident #2 but I did inform the responsible party (RP) of all the wounds found on 06/13/17. The surveyor asked if resident's have daily skin assessments done, RN #1 stated, Yes, the CNAs should be doing skin assessments daily and to inform nurses of skin changes. The resident's nutritional assessment was completed by the registered dietitian (RD) on 02/09/17. The assessment indicated Resident #17's oral intake was Good/fair with a current weight of 179 lbs. (overweight related to excessive caloric intake as evidenced by BMI = 27.5 -29.9). The nutritional supplements included ensure [MEDICATION NAME] three times daily and Prostat twice daily. Resident's current diet was puree with thin liquids. On 02/16/17 Ensure was increased to four times daily. The RD note dated 02/16/17 reads as follows: (Resident #17) was noted a 28-lbs weight loss over 5 months (13.5%); verified a 39-lb loss in past 7 months (17.9% significant). Pureed diet with thin liquids. Appetite poor (<20%) (Fed by staff/family). Receives Ensure and Prostat 30 ml twice daily. Plan: Goals to included but not limited to: 1) Stabilize weight (<or=a 2 lb weight change/month); comfort-focused care, 2) Honor food preferences/intolerance and RD will update regularly, 3) Suggest 3 cans daily if poor appetite, 2 cans if fair, 1 can if good appetite in the home, 4) Daughter and grandson at the conference today; planned discharge home on 02/17/17. Labs results for 02/17 revealed an [MEDICATION NAME] level of 4.5; the normal [MEDICATION NAME] range (3.4 to 5.4 g/dL.) a low [MEDICATION NAME] level is indicative of prolonged protein depravation / malnutrition. Low [MEDICATION NAME] levels are indicative that the body has begun to breakdown muscle to compensate for an inadequate intake of protein. In individuals with bed sores, protein is essential to help the body heal the wounds. https://www.bedsorefaq.com/what-does-a-patients-[MEDICATION NAME]-level-have-to-do-with-bed-sores/ An interview was conducted with the Medical Director (MD -who is a wound care specialist) and RN #3 on 06/22/17 at approximately 3:05 p.m. with four other surveyors. The surveyor informed the MD and RN #3, Resident #17 was first identified on 02/13/17 with 9 pressure ulcers to her lower extremities including both heels (DTIs). The MD stated, I reviewed Resident #17's medical record and was under the impression that all of her wounds had resolved. The surveyor informed the MD and RN #3 that the surveyor had spoken with the resident's responsible party (RP) the morning of 06/21/17 and she stated, My mom came home from Windermere with pressure ulcer to her heels, toes and buttocks. The MD then stated, I didn't realize that, I thought they all had been resolved, that changes things. The MD also stated her records indicated she had pedal pulses; if you can palpate a pulse is reasonable to say she had blood flow to her lower extremities. The MD proceeded to say, We must do everything we can to prevent skin breakdown starting with good care; I'm transparent, we have to take ownership of this one and do better, you as surveyors are here to educate us so we can do a better job. On 06/22/17 at 3:20 p.m., an interview was conducted with unit manager (RN#1); the surveyor asked, An order was written on 02/13/17 for Prevalon boots to be worn continuous, can you tell me when they were applied and if she wore them continuous as ordered? On the same day at 3:40 p.m., after RN #1 reviewed Resident's #17's nurses notes and TAR, she replied, I don't know when they were applied or if she wore them at all, she then proceed to say, The way the order was written, it did not generate over to the TAR to be signed off with initials as applied and nothing was documented in the nurses notes that she ever wore them. The surveyor informed unit manager (RN #1) on 02/16/17 the resident was seen by the PACE physician and document, Prevalon boots not on indicating resident was not wearing her Prevalon boots during the time of her assessment, she replied, I didn't know that. During the pre-exit meeting on 06/22/17 at approximately 4:10 p.m. with four other surveyors and the facility's administration, the surveyor stated, Resident #17 was first identified on 02/13/17 with nine (9) pressure ulcer, What should or could have been done to prevent Resident #17's pressure ulcers from developing The Administrator stated, We could have done a better with prevention; we recognized there was a problems with skin issues; we did a huge training on identifying skin issues sooner and the Interim Director of Nursing stated, We should have evaluated her as a whole, looked more closely at the diagnosis, reviewed hospital record before coming to the facility and the type of mattress that's needed. The facility's policy: Life Care- Pressure Ulcer Prevention: (Revised 06/23/16). Policy Statement: To prevent development of pressure ulcers. Performed by: SLC Nursing Staff 1.) All residents are assessed for pressure ulcer on admission, every week x 4 weeks after admission, quarterly, with significant change and annually using the Braden Scale. Braden Score Risk: High Risk = Score of 12 or less Moderate Risk= Score of 13 or 14 Low Risk = Score of 15 to 18 2) Turning and repositioning frequency is dependent on resident assessment and chart on TAR. 3) Pressure ulcer prevention order set is implemented based on need. Exceptions: None Monitoring: Outcomes Monitoring Document Management (1) Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). (2) Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions (https://medlineplus.gov/ency/article/ 5.htm). (3) [MEDICAL CONDITION] is a mood disorder. It occurs when feelings of sadness, loss, anger, or frustration get in the way of your life over a long period of time (https://medlineplus.gov/ency/article/ 5.htm). (4) Muscles weakness is reduced strength in one or more muscles (https://medlineplus.gov/ency/article/ 5.htm). (5) Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). (6) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis; Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). (7) Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). (8) Prevalon helps minimize pressure, friction and shear on the feet, heels and ankles of non-ambulatory individuals. By off-loading the heel, it delivers total, continuous heel pressure relief (www.hdis.com/prevalon-boot-heel-protector.html). (9) Low air loss mattress is used for pressure prevention and treatment of [REDACTED]. (10) Skin prep is a thin liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films (http://www.smith-nephew.com/professional/products/advanced-wound-management/skin-prep/). (11) Opsite is a transparent, adhesive film. The film is moisture vapor permeable, [MEDICATION NAME] and extensible. It is widely used to provide a moist wound environment for superficial wounds (http://www.smith-nephew.com/professional/products/advanced-wound-management/opsite/). (12) Allevyn Adhesive Hydroceullar Foam Dressing allows for the formation and maintenance of a moist wound healing environment, preventing eschar formation and promoting rapid, trouble-free healing (http://www.hightidehealth.com/allevyn-adhesive-foam-dressing-home.html). COMPLAINT DEFICIENCY

Based on observation, staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to provide an environment free of accident hazards over which the facility has control and provide supervision to prevent an avoidable accident for 1 of 3 residents in the survey sample, Resident #1. Resident #1 was found to have first and second degree thermal burns to the right inner and outer thigh areas, right lower abdomen and right knee on 12/25/15. The thermal burns were a result of coffee spillage. The resident was known by the facility to have dementia, poor safety awareness and unsafe behaviors such as placing multiple beverage cups filled with cold and hot beverages such as coffee in between her legs and tucked inside the wheelchair arms next to her thighs while ambulating in the wheelchair throughout the facility. The resident obtained these beverages independently from two self serve beverage machines located on Unit two and the main dining room. The findings included: Resident #1 an [AGE] year old was admitted to the facility on [DATE] following a hospitalization requiring skilled services. The resident's [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) with an assessment reference date of 12/3/15 coded the resident as scoring a 5 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired cognition. The resident had received the antipsychotic medication (Seroquel 12.5 mg (milligrams) daily during the seven days of the assessment period. The resident was wheelchair bound due to a left above-the-knee amputation. A Facility Reported Incident (FRI) was sent to the State Agency Office on 12/28/15. The FRI described an injury of unknown origin was noted by a CNA (certified nurse aide) on Resident #1's right thigh on 12/25/15 at approximately 11:27 pm. The injury was described as Blisters .intact and some open. The resident stated she spilled coffee on her leg. The Administrator documented, This occurrence was brought to the attention of the administrator on 12/28/15 at approx. 9:15 am. The Administrator was interviewed on 1/11/16 at 3:00 pm. He stated, .the patient spilled coffee on herself .she did not tell the nursing staff until they were changing her .I found out on Monday (12/28/15) and met with the son (Responsible Party/RP) to recap what had happened .the coffee machine in the dining room was initially turned off Sunday (12/27/15). He stated the vendor came to check the self serve coffee dispenser on 12/29/15. The vendor turned down the hot water temperature from 191 degrees to 175 degrees. He further stated the coffee machine contains a pouch of cold liquid coffee that is mixed with the hot water when dispensed. He stated after the hot water temperature setting was decreased the temperature of the coffee dispensed was 174 degrees. As corrective action he stated the self serve coffee machine was made inoperable effective 12/28/15. He stated the residents now have to ask staff for coffee during off hour meal times. The Administrator stated the self serve coffee machine had been kept on unit two inside the Coastal Cafe. The self serve coffee machine was moved from the Coastal Cafe to the main dining room after the renovations were completed (prior to Thanksgiving). He further stated Resident #1 was known to place cups of beverages (independently obtained from the self service juice dispenser and coffee dispenser) between her legs while moving about the facility in her wheelchair. The Administrator stated there is no assigned staff in the dining room to provide supervision to resident's outside of meal times and activities held in the dining room. The Director of Nursing (DON) and the unit one nurse manager were interviewed on 1/11/16 at 3:45 pm. The DON stated, I was notified of the injury on Sunday (12/27/15) at 8:00 pm by (name of unit one manager), she called me at home .she (the unit one manager) had instructed the 3-11 pm nurse supervisor to turn off the coffee machine. The unit one nurse manager stated she was notified of the thermal burns by one of the nurses through a phone call due to the resident's son threatening to call APS (Adult Protective Services) in response to the injuries on Sunday evening (12/27/15). Prior to this phone call the DON and the nursing manager on weekend duty (the unit one manager) had not been informed of the injury of unknown origin (thermal burns). The DON stated, I notified the Administrator the next day during morning meeting (12/28/15). The DON stated the resident often refused care, could be combative and drank coffee everyday, stating the resident was known and observed to takes multiple cups of drinks at a time and place them in the wheelchair and between her legs .they would slosh. She stated a cup holder was placed on the resident's wheelchair sometime in December but the resident continued to place multiple cups of beverages to include coffee between the wheelchair arm rests and between the resident's leg. She stated the son had brought in a cup with a lid. The DON stated the resident recognizes her son but does not remember the staffs name and has poor safety awareness. The DON stated the facility had obtained a cup holder for the resident's wheelchair and asked the son to bring in a cup with a lid for the resident. There were no other interventions implemented or trialed to correct the unsafe behavior of placing multiple beverage cups filled with cold and hot beverages in between her legs and tucked inside the wheelchair arms while ambulating in the wheelchair throughout the facility. There was no increased supervision implemented to promote safety for the resident while in the dining room or the Coastal Cafe. The unit manager stated after the cup holder was placed on the wheelchair the resident, Still placed cups on her lap. The CNA (certified nurse aide #1) who discovered the thermal burns on 12/25/15 was interviewed on 1/11/16 at 5:30 pm. She stated when she first arrived on duty she observed the resident in a wheelchair in the hallway outside the resident's room. CNA #1 stated later the resident was gone for a little while down on the second unit. There was some altercation that happened between the resident and another staff .she (the resident) swung at a pregnant nurse .the police were called because of the resident's combativeness. CNA #1 stated after the police left she assisted the resident to bed at approximately 7:00 pm. She stated when she was assisting the resident with putting on a gown she observed the burn to the resident's right thigh area. She asked the resident how this happened, the resident responded, I spilled coffee on myself .it happened the day before. The CNA stated she notified the nurse who then assessed the resident. The 7 am-3 pm nursing supervisor for 12/25/15 was interviewed on 1/12/16 at 2:30 pm. He stated, She (Resident #1) was seen on unit two .she had spilled a couple of cups of juice .the nurse attempted to remove the cups and the resident swung at her hitting her on her left arm, I grabbed the wheelchair arm and swung it around away from the nurse and the resident hit me in the gut and scratched my arm .I called the police to see if we could get a TDO (temporary detaining order) and a record of her violent behavior .she had five cups of juices, one in the cup holder, one on the inside of each wheelchair arm rests and one between her legs and one on the armrest .but there was no coffee . On 1/12/16 at 2:00 pm, the day shift CNA #2 assigned to care for Resident #1 on 12/25/15 was interviewed. She stated she assisted the resident with morning care by handing the resident wash clothes and clothes to change into. The CNA stated, I stayed on the left side of the bed because she can kick you real fast with that right leg . The CNA was asked if she noted any redness to the resident's right leg at that time and she stated, No. She stated because she was on the left side of the bed she was not in a position to have had full visual access to the residents right thigh area. She stated the resident drank coffee everyday and would go to unit two to get it when the coffee machine was located on that unit. The CNA stated she had removed the resident's linen due to them being wet with urine as the resident had refused incontinent care from the night shift. She did not observe any coffee stains on the linen. CNA #2 stated the resident does not get into the wheelchair and ambulate in the hallways as she did prior to the injury, she indicated the resident now stays in bed. On 1/13/16 at 9:52 am, the Food Service Director (FSD) was interviewed. He stated he observed the resident on an almost daily basis throughout the day obtain not only juice but coffee from the self service machines. He stated, She has a habit of placing it between her legs .she adamantly refused to let you take the cups to the table to help her .she would have a cup of something in between her legs I would say 80 to 90% of the time. The FSD stated as a result of Resident #1's thermal burns the self serve coffee machine was made inoperable on 12/28/15 by unplugging the electrical cord, removing the coffee bag from inside of it and locking it. He stated he maintains the key on his key chain and the spare keys inside the kitchen. He stated the nursing staff does not have access to these keys. He stated if the resident's request coffee the staff get it from the kitchen. He stated the kitchen staff were inserviced on 12/28/15. The FSD stated the plans include having the vendor remove the self serve coffee machine from the dining room. The FSD stated there is only one coffee machine in the facility and it is located inside the kitchen. The FSD stated at the time of the burn injury the facility did not have lids available for the cups at the self serve juice and coffee beverage stations. The FSD stated the facility is currently looking into options for lids for the cups. The Followup Psych Assessment & Treatment Plan dated 10/1/15 read, in part: (Resident name) is awake, delusional, confused and uncooperative. She continues to be violent with staff when touched. When asked why she is hitting staff states they are aggravating me that's why. She is currently on Seroquel 12.5 mg po (by mouth) qd (every day). This dose of Seroquel is not sufficient to alleviate delusions or stop physical aggression. A nurses note dated 11/13/15 read, in part: .Resident was pouring coffee in cups and had several cops of coffee that were spilling on resident and floor informed resident was going to assist her with the coffee and went to take coffee from resident to assist with placing in her room and resident raised her fist at staff. Resident went to closed meal cart opened it up and pulled trays out onto the floor . A nurses note dated 11/24/15 read, in part: .reminded son of incidents of resident going to juice machine and pouring several cups of juice and coffee and placing {sic}wheelchair and then resident spilling beverages on floor as she mobilizes wheelchair and staff having to clean the floor .Asked son to bring in cup with a lid that resident could use. A nurses note dated 12/16/15 read, in part: Call placed to son to request a cup with cover for resident to use to drink fluids. Resident obtains fluids from drink machine and spills on floor and down hallway and when {sic} try to assist resident she becomes agitated and refuses or try's {sic} and throws the fluids on staff. A nurses notes dated 12/28/15 at 1:42 pm, read, in part: Resident at front door throughout this shift setting the alarm off. Resident was asked to move away from door and attempted to be redirected. Resident continued to swing both fists at this nurse when asked to move. later this shift resident was seen to have a cup on lap. Nothing in the cup. This nurse was told that resident had spilled coffee on floor in dinning {sic} area. Will monitor. Review of the resident's plan of care failed to evidence a revised care plan to include the resident's unsafe behavior of placing multiple cups of hot and cold beverages along the inside of the wheelchair arms and between her legs. On 1/11/16 at 3:05 pm, on initial tour the resident was observed in bed and awake. The resident was asked about the incident. She stated, I burned myself with coffee the resident pointed to her right leg. When asked where she had obtained the coffee from she yelled abruptly, I don't know where they got the coffee from. The resident was observed agitated at that point and the interview was stopped. A clear plastic tumbler with a lid and straw was observed empty on the sink, away from the residents reach. Another pink sip cup was observed on the residents night stand, away from the residents reach with approximately 30 ml of clear fluid inside it. The resident's wheelchair was observed to have a cup holder attached to the right armrest. On 1/12/16 and 1/13/16 from 10:00 am to approximately 2:00 pm, the resident remained in bed. The clear plastic cup remained on the sink, the pink sip cup remained on the dresser drawer with the same amount of clear fluid as seen on initial tour. The clinical record evidenced the resident was sent to the emergency department following the discovery of the blisters. The resident arrived at the first emergency department (ED) on 12/26/15 at 00:13 am. The ED notes read, in part: .thermal burns to the right thigh, knee and leg after spilling coffee on self this am at~0800. Blisters ruptured at this time. Pain improved. Given morphine in the ER (emergency room ) .Patient likely requires burn scrub. Discussed with (name of second ED) and will transfer patient for evaluation by burn team. In my opinion, this is a condition that a prudent lay person (who possesses an average knowledge of health and medicine) may expect to result in serious jeopardy, or cause serious impairment of bodily function, or serious dysfunction of bodily organs .Pt with both 1st and 2nd deg (degree) burns to rle (right lower extremity), will tx (treat) pain and txfer (transfer) to (initial of second ED) for burn care. The resident arrived at the second ED on 12/26/15 at 02:33 am. The resident was diagnosed with [REDACTED].approx 3-4% TBSA (total body surface area) 2nd degree burn. Non-circumferential (did not go around the leg). The burns were cleaned, treated with Bacitracin 500 unit/ gram topical and a dressing was applied. A follow up appointment with the burn clinic was to be scheduled as soon as possible for a visit in 2 days for burn care and to ensure healing. The resident was discharged from the ED at 04:08 am on 12/26/15 back to the facility. The resident was assessed by the nurse practitioner on 12/28/15. The burns were described as: Right thigh & knee with 1st and 2nd degree burns with the larger areas measuring 6.5 x 1.5 cm (centimeter) 6.5 x 4.5 cm, and 8 x 3 cm with few scattered areas of 1st degree [DIAGNOSES REDACTED] (redness), small approx 3-4 cm area on the RLQ (right lower quadrant) abdomen 1st degree [DIAGNOSES REDACTED]. The resident was seen in the burn clinic on 1/4/16. The burn clinic notes read, in part: Mental health: Occasional anxiety and dementia causing altered mental status .she is awake, alert, and oriented slightly confused extremely feisty .right lower extremity has a 4% total body surface area burn involving her thigh, knee and calf that is varied stages of healing from epithelialization to an area on her proximal medial knee that is significantly granulated with some pseudo eschar (dead tissue) that is present. The entire area was cleansed with chlorhexidine today removing a significant amount of devitalized tissue (dead tissue) and roughly 50% of the pseudo eschar that is present over the area of granulation. This area is quite obviously the deepest burn that she sustained . The treatment was changed to Silvadene dressing changes with thorough cleansing with chlorhexidine and premedicating with morphine one hour prior to the daily dressing changes. During the initial tour of the facility on 1/11/16 and the survey days of 1/12/16 and 1/13/16 the self serve coffee machine was observed inside the main dining room. The coffee machine was inoperable. There were no other coffee machines found in any of the resident common areas. One coffee machine was located inside the kitchen. The plan of correction to prevent further accidents from the self serve coffee machine included: 1. The self service coffee machine was immediately turned off on 12/27/15. 2. The machine was made inoperable on 12/28/15. 3. Employees will obtain coffee for residents through the kitchen staff during off meal hours. 4. All kitchen staff were inserviced on maintaining the self service coffee machine inoperable on 12/28/15. 5. The vendor was contacted and will remove the self service coffee machine from the building. The facility was in compliance as of 12/28/15. COMPLAINT DEFICIENCY-PAST NON COMPLIANCE

Based on observation, staff and resident interview and clinical record review facility staff failed to identify and provide care services to promote healing, prevent development of additional wounds and/or prevent infection of pressure sores for 2 of 22 residents in the survey sample, Residents #10 and #2. 1. Facility staff failed to identify and treat Resident #10's a Stage 2 pressure ulcer and the resident subsequently developed two more Stage 2 pressure sores. Facility staff failed to provide treatment (dressing change) in a manner to prevent infection for Resident #2. The findings included: A stage 2 pressure ulcer is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open blister. Resident #10 was [AGE] years old and was admitted to the facility 6/26/2010. The most recent MDS (Minimum Data Set) evidenced the resident was a 12 of 15 cognitively and required assistance with all activities of daily living. Resident #10's [DIAGNOSES REDACTED]. At the time of the survey the resident also had a [MEDICAL CONDITION] and a Foley catheter. On 3/7/12 at 2:20 p.m. the surveyor went into talk with Resident #10. She stated that her [MEDICAL CONDITION] bag was leaking. Resident #10 pulled the sheet and blanket back to reveal her [MEDICAL CONDITION]. The resident lifted the bag, the underside of bag was wet with stool and there was two half dollar size stool stains on her blanket. The resident then spread her legs and pointed to her peri-area. The area was red and the resident stated, "it itches so bad." The surveyor stated that she would get one of the nurses. RN #3 stated that she would apply her treatment of [REDACTED]. RN #3 came out of the room some minutes later and requested that LPN #2 assist her by holding Resident #10 on her side so that they could better see and treat Resident #10 backside. The surveyor accompanied the two nurses. When the resident was turned on her side an open area was observed on the right buttocks and a quarter sized serous (blood tinged) drainage was observed on the pad under the resident. LPN #2 stated that she would get fresh linens and pads for the resident. The resident's buttocks were reddened but RN #3 was able to whiten or blanch the areas when slight pressure was applied. The surveyor then reviewed the resident's clinical record. The resident had been diagnosed with [REDACTED]. Because the rash was slow to respond the physician also ordered that a Foley catheter be inserted on 2/28/12 to aid the healing process. The current orders were: cleanse body and peri area with [MEDICATION NAME] soap each day, apply [MEDICATION NAME] cream to body BID (twice a day), [MEDICATION NAME] powder to buttocks and peri area and under [MEDICAL CONDITION] bag three times a day, [MEDICATION NAME] cream to rash on legs/abdomen, outer buttocks twice a day and Influent 150 mg each day. The following morning, 3/8/12 the clinical record was again reviewed. The RN who had assisted Resident #10 did not document her observations of 3/7/12. There was a note from LPN #4 who came on duty at 3 p.m. on 3/7/12. LPN #4 documented, "notified (physician assistant) that resident's behind remains red and raw painful for the resident but some improvement in peri area. Requested that MD see resident during rounds in a.m." Resident was reminded to stay on her side so area may heal. The description of the open area was not included in the documentation. On the morning of 3/9/12 the record was again reviewed and evidenced a note at 5 p.m. on 3/8/12. "(Name of PA) in to see resident re:rash to underside/buttocks. Wishes to continue with current ordered tx (treatment), turn every (q) 2 hours and encourage resident to stay on side." There was no evidence of assessment by either the nurse or the PA. The PA did not document a note. On 3/9/12 (approximately 9:30 a.m.) two surveyors requested RN #3 to accompany them to Resident #10 room. The resident was asked if the surveyors and the nurse could see her buttocks. She readily agreed and began to turn herself on her side. Resident #10 stated that her buttocks were painful. The resident was wearing a brief even though she had a catheter and a [MEDICAL CONDITION]. The RN stated she didn't know why it was on that it would seem to do more harm than good but when she finished she reapplied the brief. The surveyor requested to see the items used for treatment. The [MEDICATION NAME] powder was in the treatment cart but the [MEDICATION NAME] cream was not. The [MEDICATION NAME] soap and cream were located in the resident bedside table. The jar of cream was observed. It was dated as received from the pharmacy on 2/28/12 but when open was almost full. The RN stated it did not appear to have been used twice a day since 2/28/12. Observation of the buttocks evidenced a denuded area at the gluteal fold, (where the drainage was observed on 3/7/12) and two other open areas. One on each buttocks. The open area on the right buttocks appeared to have more depth than the one on the left. At 10:30 a.m. the DON was interviewed, she stated she was unaware of the open areas. She stated that she and the Unit manager would go in and check on Resident #10. The survey team was provided a note from the Unit manager dated 3/9/12 at 11:45 a.m. "Buttocks re-evaluated, noted very small open areas R (right) buttock .5 X .8, L (left) buttock .5 x .5 area shearing is 2 x 1.5 and overall butterfly shaped area that is fungal with ongoing treatment is 13.5 x 8.5 also noted linear open area mid center buttocks of 1x .2. " Family and physician notified. The DON stated the resident still had on a brief which she requested be removed and not reapplied. The DON stated the resident told her that the nurse had used the last of the [MEDICATION NAME] cream the evening before but it had not been reordered, that she had done it herself that morning after talking the surveyor. The DON was also shown the jar of [MEDICATION NAME], and agreed that it did not appear to have been used for 10 - 11 days twice a day. 2. Resident #2 was a [AGE] year old admitted to the facility on [DATE] and a readmitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Siginifcant Change Minimum Data Set (MDS) dated ,[DATE], evidenced Resident #2 was severely impaired for cognitive skills. Resident #12 required extensive assistance from staff with all aspects of ADL's (Activities of Daily Living). Review of Resident #2's clinical record evidenced the resident was being treated for [REDACTED]. A review of the facilities documentation evidenced the Wound Nurse was physically at the facility once a week. A review of the facilities weekly skin assessment dated [DATE], identified the new pressure sore areas and indicated treatment. No measurements of the identified areas was evidenced. A review of the clinical record evidenced no nursing notes giving a description with measurements of the identified pressure areas. A Registered Nurse Practitioner (NP) order dated 2/27/12 indicated the following: Cleanse area to upper right and left buttock with wound cleaner, pat dry and cover with Solosite (maintains an optimal moist wound environment as it desloughs and debrides) and [MEDICATION NAME] (absorbs exudate effectively and minimizes the risk of peri-wound skin maceration) every other day. On 3/6/12, the Family Nurse Practitioner (FNP), wrote the staff noted bilateral inner buttocks breakdown on 2/27/12 with new skin orders started (Solosite - maintains an optimal moist wound environment as it desloughs and debrides) and Allevyn (wound care dressings for effective protection and exudate absorption), and wrote the following revised orders: Start cleaning bilateral inner buttock wounds with wound cleaner, Apply skin prep. Q AM - apply santyl (continuously removes necrotic tissue from wounds at the microscopic level) to sites Q PRN - apply 1/8 strength Dakins (treats infected wounds) with dressing. Ok to use Santyl until Dakins arrives. On 3/6/12, the Family Nurse Practitioner (FNP), wrote the following orders revised orders: ? Start cleaning bilateral inner buttock wounds with wound cleaner, Apply skin prep. ? Q AM - apply Santyl to sites ? Q PRN - apply 1/8 strength Dakins with dressing. Ok to use Santyl until Dakins arrives. On 3/8/12 at 11:30 AM., Licensed Practical Nurse (LPN #1) with assistance from Registered Nurse (RN #2), was observed performing a dressing change for Resident #2 with the following being evidenced: ? Checked TAR (Treatment Administration Record) ? Spray bottle wound cleanser, bottle Bottle of skin prep, open pack of 4x4's, tube of Santyl, rolled of paper tape dated with 3/8/12 date and initials were already placed on a clean towel on the bed side stand at start of dressing change. ? closed room door and pulled side curtains ? wash hands and put on clean gloves. ? assisting RN, wearing gloves rolled resident on left side ? LPN #1, open disposable briefs covering buttocks (did not change gloves and wash hands and put on new pair of gloves) ? Sprayed areas with wound cleaner and then patted dry with 4x4, (did not change gloves and wash hands and put on new pair of gloves) ? Clean peri area of wound with skin prep, (did not change gloves and wash hands and put on new pair of gloves) ? Applied Santyl with finger of hand to wound area, (did not remove gloves, wash hands then put on new pair of gloves, and did not use an applicator to apply the Santyl ). ? Covered with 4x4, (did not change gloves and wash hands and put on new pair of gloves) ? Taped with dated paper tape, (did not change gloves and wash hands and put on new pair of gloves) ? Replaced disposable brief. ? Removed gloves and washed hands for the first time since starting the dressing change ? Placed soiled items in trash bag ? Placed wound supplies in wound cart ? Did not re-clean the bedside stand top ? Signed off on Treatment Administration Record (TAR) LPN #1 did not wash or disinfect her hands and put on new gloves after she opened the disposable brief. LPN #1 went from one dirty field to another and did not change gloves and wash hands putting on a new pair of gloves. LPN #1, applied Santyl with finger of hers hand to the wound area and never changed her gloves and rewashed her hands from the start of the dressing change. LPN #1 recovered the area with dated tape, reapplied the brief and did not change and wash hands or put on a new set of gloves. On 3/8/12 at 11:48 during an interview with LPN #1 and RN #2, LPN #1 acknowledged that she did not wash hands and change gloves when going from one dirty field to another, applied treatment using the same gloves put on at the start and never washed hands or change gloves when she went to a clean field, did not clean the bed side stand up when she was completed.