Every finding on record at Complete Care at Sheriden Commons

Based on observation, interview, and record review, the facility failed to ensure all portions of the call light systems are working by ensuring the system can be heard away from the nurses' station on the second and third floor of the facility. This failure affected 8 residents (R1, R6, R7, R8, R9, R10, R11, and R12) of 10 residents reviewed for the facility's call light system on the second and third floor unit. On 4/6/2026 at 1:49 PM, R1 stated R1 stated that response times to call lights vary depending on who is on the floor; sometimes staff respond quickly, but at times the call light stays on for 20-30 minutes and the call light on the unit was broken for about two months.On 4/8/2026 at 9:30 AM, surveyors tested the new call light system in the hallway of wing B on the third floor by R8's room. The call light above R8's door turned on but there was no audible sound heard from the nursing station where the new call light system was located which was about 30 feet away from the nurse's station.On 4/8/2026 at 9:45 AM, the call light was activated in R10's room and no sound could be heard by surveyors. V10 (certified nurse's assistant-(CNA) verified she could not hear the call light from the nurse's station and stated that she (V10) can hear the call lights go off anywhere on the unit if she is at the nurse's station but cannot hear the call lights when she is in another resident's room.On 4/8/2026 at 9:49 AM, V10 (certified nurse assistant-(CNA) verified the call light system cannot be heard from the nurse's station and there are no other speakers in the hallway of the unit to increase the volume of the call lights from the call light device at the nursing station. V13 stated the call light system could not be heard near R6, R7, R8, R9, and R10's room. On 4/8/2026 at 10:43 AM, R11 and R12's called light activated by V13 (certified nurse's assistant-(CNA) and the light above the door to R11 and R12's room lit up and V13 verified the sound from the call light system designated at the nurse's station could not be heard.On 4/8/2026 at 10:45 AM, V13 (certified nurse assistant-(CNA) stated that during her shift she monitors call lights by frequently checking the hallway lights above residents' doors, even if she cannot hear the call light sound from the nurses' station; she (V13) she cannot hear a call light if she is inside another resident's room, and therefore may not know when another resident activates their call light; morning care typically takes about 20 minutes, and if a resident pulls the call light due to an emergency such as choking or a fall, their condition can change quickly and may result in death; and the call light sound was not working at one point, but the visual hallway lights were functioning and the system was repaired the same day.On 4/8/2026 at 10:43 AM, R11 and R12's called light activated by V13 (certified nurse's assistant-(CNA) and the light above the door to R11 and R12's room lit up and V13 verified the sound from the call light system designated at the nurse's station could not be heard.On 4/8/2026 at 10:45 AM, V13 (certified nurse assistant-(CNA) stated that during her shift she monitors call lights by frequently checking the hallway lights above residents' doors, even if she cannot hear the call light sound from the nurses' station; she (V13) she cannot hear a call light if she is inside another resident's room, and therefore may not know when another resident activates their call light; morning care typically takes about 20 minutes, and if a resident pulls the call light due to an emergency such as choking or a fall, their condition can change quickly and may result in death; and the call light sound was not working at one point, but the visual hallway lights were functioning and the system was repaired the same day.On 4/8/2026 at 11:39 AM, V2 (Director of Nursing) stated the call light system has been in place for more than six months and includes a hallway light and an audible ping sound at the nurses' station; did not know whether the sound volume could be increased; was not aware that staff could not hear the call light at the end of the hallway and said he (V2) would notify maintenance; the visual light outside each resident's door is the primary mechanism alerting staff, but they intend to enhance the audible sound further; that if staff cannot hear the call light from inside another resident's room, residents may be at risk; and the expectation is to answer call lights as soon as they are activated.On 4/8/2026 at 12:28 PM, V14 (Maintenance Director) stated the call light should generally be heard by all staff on the unit and that any staff member may answer it; the call light audible sound at the furthest end of the hallway near the nurses' station is very low and cannot be heard if there is any background noise; this was the first time he had been made aware of the issue, and they respond quickly to all repair needs; he was contacting an electrician to install a duty station sound system that would announce call light activations at both ends of each hallway so that all staff can hear them.Reviewed the work order place on 4/8/2026 for an electrician to install a sound system to amplify to sound of the call lights on units 2 and 3. Facility's CNA job description undated documents, in part, Provides certified nursing assistant services to assigned residents in accordance with care plans, facility policies, and procedures at the direction of supervisors; always follow appropriate safety and hygiene measures to protect residents and themselves; provides supportive services to nurse(s) and other staff as needed and performs duties as assigned; and assists residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures.Facility's Maintenance Job Description documents, in part, documents Directs the day-to-day activities of the Maintenance Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and to assure the facility is maintained in a safe and comfortable manner.Facility's policy titled Call Lights: Accessibility and Timely Response dated 9/1/2024 to revise 1/15/2026 documents, in part, the purpose of this policy is to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow resident to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on observation, interview, and record review, the facility failed to ensure residents' received accommodation in the correct incontinent product size as evidence by the facility ordering only a size 3 extra-large for resident measuring a size 5 extra-large per the incontinent product brand's measuring guidelines. This failure affected 2 of 2 residents (R1 and R3) reviewed for incontinent product sizing. A.On 4/6/2026 at 1:49 PM, R1 stated incontinence briefs provided by the facility do not fit her (R1); she weighs about three hundred and fifty pounds or more and residents are told these are the only sizes available.On 4/6/2026 at 2:26 PM, V7 (certified nurse assistant) stated she (V7) noted occasional issues obtaining size 3, 4, or 5 incontinent products if shipments arrive late.R1's Face Sheet dated 4/8/2026 documents a diagnosis of but not limited to morbid (Severe) obesity, difficulty in walking, constipation, heart failure, and chronic kidney disease and minimum data set section c dated 1/14/2026 documents a BIMS (Brief Interview Mental Status) of a 14 which is an indication of an intact cognition.R1's Minimum Data Set section GG dated 1/14/2026 documents functional abilities of impairment on both sides and is dependent on toileting hygiene.R1's Care Plan documents a focus of requires assist with bed mobility as evidenced by the following limitations and potential contributing diagnosis Heart failure, HTN, unsteadiness, CAD, morbid obesity. Date Initiated: 05/08/2021 Revision on: 05/06/2023 and FUNCTIONAL, bladder/bowel incontinence r/t Physical limitations secondary to Dx Morbid obesity, HLD, CAD, Heart failure, Insomnia, CKD and require assistance from staff. Date Initiated: 04/24/2023 Revision on: 05/07/2023.B. On 4/6/2026 at 2:42 PM, R3 stated her (R3) incontinence product size is no longer available; the facility previously stocked sizes 4 and 5 but recently changed companies; complained to V6 (central supply coordinator) who involved the incontinent product company representative and explained to the new central supply company's representative that the current product is too small and not absorbent; the third floor has more dependent residents and several may need care simultaneously; the facility changed management companies about 3-4 months ago and the new management company only orders incontinent products up to a size 3 extra-large; and she (R3) weighs about 450 pounds and wears a size 4 to 5 extra-large.On 4/6/4026 at 2:55 PM, observed R3 has 2 bags of size 3 extra-large incontinent product briefs in her room but she (R3) stated she usually a 4 extra-large or 5 extra-large. R3's Face Sheet documents a diagnosis of but not limited to respiratory failure with unspecified hypoxia, type 2 diabetes mellitus, unspecified asthma, hyperkalemia, and other specified disorders of muscle.R3's Care Plan dated 3/27/2025 documents FUNCTIONAL, bowel and bladder incontinence r/t Impaired Mobility, Physical limitations, Presence of catheter pure wick secondary to diagnosis of diabetes mellitus, hypertension, morbid obesity, necrotizing soft tissue infection, respiratory failure, vitamin d deficiency, shoulder pain, anemia, major depression. Date Initiated: 10/18/2024 Revision on: 11/03/2024.R3's Minimum Data Set Section C documents a BIMS (Brief Interview Mental Status) of a 15 which indicates an intact cognition.R3's Minimum Data Set Section GG documents R3 is dependent on toileting hygiene.On 4/6/2026 at 2:26 PM, V7 (certified nurse assistant) stated she (V7) noted occasional issues obtaining size 3, 4, or 5 incontinent products if shipments arrive late.On 4/6/2026 at 3:08 PM, V9 (certified nurse assistant) stated no resident complained of being left in a soiled incontinent product for a long period of time and the largest incontinent product is 3 extra-large.On 4/8/2026 at 9:57 AM, surveyors observed V5 (Activities Director) and V11 (Nurse's Aide) used the central supply company's incontinent product measuring tape to measure R3 from hip to hip and stated R3 measured 55 inches or 109 cm which is equivalent to a size 5 extra-large in the new incontinent product briefs the facility has adopted using. On 4/7/2026 at 9:32 AM, V6 (central supply coordinator) stated the facility orders diapers in sizes small through 3 extra-large; some residents have reported diapers being too small; under new ownership, the facility now orders supplies through an outside central supply company and uses an EHR (electronic health record) sizing tool to determine a resident's incontinent product size; residents reported incorrect sizing after the certified nurse's assistants (CNAs) were in-serviced by the central supply company on how to size a resident for an incontinent product with the incontinent products measuring tape but the sizing issue persisted; identified discrepancies where some residents needed larger sizes than indicated; after gathering data, V6 emailed the central supply company; weight is part of the sizing criteria; and the largest size currently available is 3 extra-large.On 4/7/2026 at 11:18 AM, V2 (Director of Nursing) stated residents are measured from hip to hip not by a residents weight via the central supply companies incontinent product brand's measurement tape; a resident that weighs 300 pounds will wear the same size incontinent product as a resident who weighs 400 pounds if their hip to hip size is the same; a couple of residents complained about the central supply company way of measurement was not sufficient to meet their incontinent product size and so central supply company updated our order based on the residents request; and the largest size incontinent brief the facility supplies to the residents is a 3 extra-large.On 4/7/2026 at 2:05 PM, V3 (Regional Nurse Consultant) stated that if a resident complained about his/her incontinent products was too small, she would perform a physical assessment checking for redness or creasing in the area if the brief is not containing urine. V3 stated the incontinent product briefs are not inexpensive, and if a resident requests a larger size than indicated by central supply measurement guidelines, the central supply company will educate the resident that a 4XL will not fit properly and will be too large because the facility follows the central supply companies guidelines of measuring residents from hip to hip with a measuring tape specific for measuring sizes appropriate to the companies incontinent brief's brand. On 4/7/2026 at 2:28 PM, reviewed central supply company's incontinent product brand measurements document which documents 3 ways to measure a resident for sizing:By taking hip and hip waist measurements with the measuring tape specific to the incontinent products the facility has adopted measuring tape.From 1 inch to 14 inches a small incontinent product brief/protective underwearFrom 15 inches to 20 inches a size of medium incontinent product brief/protective underwearFrom 20 inches to 26 inches a size large incontinent product brief/protective underwearFrom 27 inches to 30 inches a size extra-large (xl) incontinent product brief/protective underwearFrom 31 inches to 33 inches a size 2 extra-large (xl) incontinent product brief/protective underwearFrom 34 inches to 37 inches a size 3 extra-large (xl) incontinent brief/protective underwearGreater than 40 inches: assess for a 4 extra-large (xl) or 5 extra-large (xl)2. By using the incontinent product tape measure3. By using the height and weight charts below which document up to a size 2 extra-large with weights between 220 pounds to 255 pounds. On 4/7/2026 at 2:28 PM, reviewed central supply company's in-service education with staff on sizing residents for an accurate size incontinent brief with no concerns.Reviewed facility's central supply product invoices created 3/30/2026 and approved 4/1/2026 documents sizes large, extra-large, 2 extra-large, and 3 extra-large briefs were ordered.Reviewed facility's central supply product invoices created 3/25/2026 documents sizes small, large, extra-large, 2 extra-large, and 3 extra-large briefs were ordered and large, extra-large, and 3 extra-large underwear were ordered.Reviewed facility's central supply product invoices created 3/23/2026 documents sizes large, extra-large, 2 extra-large, and 3 extra-large briefs were ordered.Reviewed facility's central supply product invoices created 3/13/2026 documents sizes large, extra-large, 2 extra-large, and 3 extra-large briefs were ordered.Reviewed facility's central supply product invoices created 3/9/2026 documents sizes large, extra-large, 2 extra-large, and 3 extra-large briefs were ordered and size large, 2 extra-large, and 3 extra-large incontinent protective underwear wear ordered.Facility's CNA job description undated documents, in part, Provides certified nursing assistant services to assigned residents in accordance with care plans, facility policies, and procedures at the direction of supervisors; always follow appropriate safety and hygiene measures to protect residents and themselves; provides supportive services to nurse(s) and other staff as needed and performs duties as assigned; and assists residents with or performs activities of daily living for resident in accordance with care plans and established policies and procedures.Facility's Policy titled accommodation of needs dated 9/1/2024 and revised 1/15/2026 documents, in part, The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered.Facility's policy titled Resident Rights dated 9/1/2024 and revised 3/26/2026 documents, in part, residents have the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on observations, interviews, and record review the facility failed to ensure staff donned appropriate PPE (Personal Protective Equipment) while providing high contact resident care for a resident (R77) on EBP (Enhanced Barrier Precautions), failed to perform hand hygiene during a wound dressing change for a resident (R77), failed to ensure that urine collection canister was not placed on the floor, failed to ensure EBP signs were posted and PPE bins were available for 2 (R14 and R17) residents on EBP, and failed to sanitize medication tray between residents (R7 and R44) usage. These failures affected 5 (R7, R14, R17, R44, and R77) residents reviewed for infection control and have the potential to affect all 41 residents on the second floor and all 40 residents on the third floor. Findings include: The (03/10/2025) facility census indicated 41 residents on the second floor. #1 On 03/10/2025 at 10:08am on the second floor, V8 (Registered Nurse) stated everyone who has an indwelling catheter, with wounds, and g-tube are on EBP (enhanced barrier precautions). V8 stated (R14) has a wound and (R17) has an indwelling catheter. On 03/10/2025 at 10:16 AM, there was no EBP sign posted, and no PPE bin noted by R14's room. On 03/11/2025 at 9:08am, there was no EBP sign posted and no PPE bin available by R14's door. On 03/11/2025 at 9:10am, inquiring if R14 has a wound. V3 (ADON/Infection Preventionist) went inside R14's room and checked. V3 stated yes she has a wound on her left heel. This surveyor inquired for the EBP signage and PPE bin for R14. V3 stated we don't have an EBP sign posted for her (R14) and no PPE bin outside her room. #2 On 03/10/2025 at 10:59am, there was no EBP sign posted and no PPE bin available by R17's room. These observations were pointed out to V3. V3 stated he should be on EBP. There is no EBP sign posted and no PPE bin outside of his room. On 03/10/2025 at 11:07am, V3 instructed V12 (Housekeeping Supervisor) to set up the PPE bin for R17 and stated I (V3) will put up the EBP sign. #3 On 03/11/2025 at 8:44am, during the medication administration task with V14 (Licensed Practice Nurse). After dispensing the medications in a med cup, V14 poured water in a drinking cup and placed the med cup and the drinking cup on a medication tray. On 03/11/2025 at 8:45am, V14 knocked on R7's door and mentioned R7's name and stated that R7's meds were ready. R7 swallowed the medications from the med cup and put the med cup back on the medication tray, drank the water in drinking cup and put this, as well, back to the medication tray. On 03/11/2025 at 8:46am, V14 disposed of used med cup and drinking cup in trashcan and placed the med tray on top of the medication cart and started preparing R44's medications without sanitizing the medication tray he used for R7. On 03/11/2025 at 8:51am, V14 poured R44's pantoprazole in a med cup. The med cup was on a med tray that was previously used for R7. At this time, this surveyor stopped V14 from dispensing R44's other medications and inquired about the facility policy when using a med tray between residents. V14 stated, I should have sanitized the med tray first before preparing the medications of the next resident to prevent the spread of germs to the next resident. On 03/12/2025 at 12:02pm, V2 (Director of Nursing) stated for residents on EBP, there should be a sign posted and PPE bin for the residents. Purpose of posting an EBP sign is for the staff to determine what appropriate PPE to wear when they give direct care to the resident to prevent cross contamination of infection. PPE bin should also be available so PPEs will be readily available for staff. On 03/12/2025 at 12:05pm, V2 stated I don't have a policy on medication tray but the expectation is to sanitize the med tray between residents to prevent cross contamination of infection. R7's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) human immunodeficiency syndrome and benign prostatic hyperplasia. R14's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) obesity, mild intellectual disabilities and lack of coordination. Diagnostic: x-ray L (left) foot/heel, active draining wound, r/o (rule out) osteo (sic). Order date: 01/22/2025. Left hell cleans with NSS (normal saline solution) Apply skin pre to periwound. Apply Calcium Alginate, cover with ABD pad and wrap with kerlix. Order date: 03/05/2025. R14's (12/30/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R14's mental status as cognitively intact. Section M. M0300. F. Unstageable pressure ulcers: 1. Number of these unstageable pressure ulcer that were present upon admission: 1. R14's (Target Date: 03/31/2025) care plan documented, in part has unstageable pressure sore to left and right heel. R17's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) acute kidney failure and benign prostatic hyperplasia. foley catheter Fr. 16. With 10cc balloon. For urinary retention. Order Date: 12/13/2024. R17's (12/19/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 02 Indicating R17's mental status as severely impaired. Section H - Bladder and Bowel. H 0100. Appliances. A. indwelling catheter. R17's (Target Date: 03/25/2025) care plan documented, in part has indwelling catheter. R17's (Target Date: 03/25/2025) care plan documented, in part Enhanced Barrier Precautions. Risk for infection related to compromised host defenses and exposure to pathogens. Ensure appropriate PPE is available and used correctly by staff. R44's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) chronic obstructive pulmonary disease and muscle weakness. The (03/12/2025) email correspondence with V6 (MDS Coordinator) documented, in part In our commitment to maintain the highest standards of care and to prevent contamination during medication administration, it is crucial to adhere to effective medication pass strategies specially when passing multiple medications to a resident. Using of tray to ensure accuracy in medication delivery is permitted. If using tray is necessary to minimize risk of error, tray should be sanitized between uses to ensure infection control protocol. The facility provided document (7/2021) Consideration For Use Of Enhanced Barrier Precautions In Skilled Nursing Facilities documented, in part Framework For Applying Enhanced Barrier Precautions In Skilled Nursing Facilities. Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage out of residence room indicating the type of PPE required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room. The (undated) EBP (Enhanced Barrier Precautions) documented, in part Policy statement. Enhanced Barrier Precautions are used in the care for residents with wounds requiring dressings or indwelling medical devices. Policy Interpretation and Implementation. 4. Enhanced based (sic) precautions will be implemented for residents with wounds that requiring dressing changes. 5. Enhanced Based (sic) precautions will be implemented for residents with indwelling devices. 45196 Findings include: On 03/11/25 at 9:15 am, V1 (Administrator) presented a facility census of 40 residents on the third floor. R77's face sheet shows that R77's has diagnosis which include but not limited to necrotizing fasciitis, supraventricular tachycardia, type 2 diabetes mellitus with hyperglycemia, vitamin D deficiency, hyperkalemia, and respiratory failure. R77's Brief Interview for Mental Status (BIMS) dated 02/17/25 shows that R77 has a BIMS score of 15 which indicates that R77 is cognitively intact. On 03/10/25 at 10:40 am, R77's room door was observed with a sign on the door titled Enhanced Barrier Precaution. Surveyor observed R77 with a Purewick external catheter in place with the Purewick canister next to R77's bed on the bare floor. On 03/10/25 at 10:46 am, V2 director of Nursing, DON) and V17 (Certified Nursing Assistant, CNA) was observed entering R77's room without donning a gown to perform wound care to R77's left lower abdomen surgical wound. V17 was observed donning gloves without performing hand hygiene in R77's room. During R77's wound care dressing change to R77's left lower abdomen surgical wound V2 and V17 was observed not wearing proper PPE (Personal Protective Equipment) a gown. V2 was observed removing R77's soiled left lower abdominal wound dressing, throwing R77's soiled left abdominal wound dressing in the trash, donning gloves, removing gauze from R77's wound tray and dressing R77's left abdominal wound without performing hand hygiene. On 03/10/25 at 11:15 am, Surveyor brought R77's Purewick canister on the bare floor observation to V2 and V2 stated Her (R77's) Purewick canister should not be on the floor we will get a crate or something to put it on. When V2 was asked regarding the importance of R77's Purewick canister not being on the bare floor and V2 stated, It should be on a stand so that bacteria doesn't get inside of it. V2 was asked regarding the facility's expectation for residents with a wound requiring EBP precautions and V2 stated, I (V2) should have worn a gown when I did her (R77's) wound care. I forgot. When V2 was asked regarding performing hand hygiene when removing a soiled dressing and V2 stated, Oh I (V2) did not do that. I was nervous. Surveyor asked V2 regarding the importance of EBP for residents with wounds and performing hand hygiene after removing soiled dressings and V2 stated, It is important to protect staff and residents from acquiring infections. On 03/12/25 at 11:37 am, V3 (Assistant Director of Nursing, ADON) stated that residents who are on EBP staff are required to wear gown and gloves when providing high contact patient care to prevent residents from acquiring a Multi Drug Resistant Organism. V3 explained that if a staff does not wear gown and gloves while providing high contact care to residents with EBP then staff are at risk for spreading infections such as MDRO to residents. The facility's undated document and titled Enhanced Barrier Precautions documents, in part: Enhanced Barrier Precautions are used in the care for residents with wounds requiring dressings or indwelling medical devices and successfully admit and care for those residents with and XDRO (Extensively Drug Resistant Organism) or epidemiologically important MDRO (Multi Drug Resistant Organism). 1. Enhanced Barrier Precautions means that a gown and gloves are to be used when providing care to the resident during high contact-care activities that provides opportunities for transfer of organisms from resident to staff hands and clothing. Gown and gloves are not needed to be utilized during non-high contact care activities. 2. Enhanced Barrier Precautions is to be implemented in conjunction with Standard Precautions. 3. The following are high contacts care activities that require gown and gloves to be worn if a resident is placed on Enhanced Barrier Precautions. 4. Enhanced Based Precautions will be implemented for residents with wounds that requiring dressing changes (e.g., pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers) and only when the wound drainage is contained. 7. Enhanced Barrier precautions are to remain in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device placed that placed them at higher risk. R77's Physician Order Sheet (POS) shows that R77 has orders for Enhanced Barrier Precautions for wound care. Gloves and gown to be worn during wound care and prolonged contact activity . Surgical Wound-Across Left Lower ABD (Abdomen): Cleanse w/ NSS (with normal saline) Or Wound Cleanser. Pat Dry. Apply Skin Prep to peri wound. Apply collagen, then calcium Alg (Alginate) w/ silver (with) , (May use regular Alg (Alginate) if silver unavailable) to entire wound bed, cover with hydro lock and secure with med fix tape. ABD optional if drainage is excessive.

Based on Observation, interview, and record review, the facility failed to ensure that residents' Low Air Loss Mattresses (LALM) for pressure ulcer prevention are set at the correct weight settings. This failure affected four residents (R4, R25, R37, R77) out of four residents reviewed for pressure ulcer prevention and treatment in a sample of 45 residents. Findings include: R4's Face sheet dated March 12, 2025, documents that R4 was admitted to facility on October 12,2023 with diagnosis including Encephalopathy, hemiplegia, cerebral palsy, chronic obstructive pulmonary disease, major depressive disorder, hypertension, convulsions, dysphagia, cerebral infraction, cirrhosis of liver. R4's MDS (Minimum Data Set) dated December 27,2024, shows R4 has a BIMS score of 8 which means R4 is has mild cognitive impairment, Section (M) Skin Conditions/ Determination of Pressure Ulcer/Injury Risk states resident at risk of developing pressure ulcers/injuries. R4's Braden scale score dated 12/30/24 has a score of 13 which means R4 is at Moderate risk for developing pressure ulcers. R4's Physician Orders Sheet dated 2/21/2024 The low air loss mattress is set according to the manufacturer guideline. On 3/10/25 at time 10:15 am, R4 was observed in bed, low air loss mattress setting was observed by surveyor between 325-350 pounds, the air loss mattress was located at foot of bed. On 3/12/2025 at 11:28am V6(Registered Nurse/ MDS Coordinator) provided Monthly Weight Report sheet with R4's March weight that is 176.6 pounds. R37's Face sheet dated March 12, 2025, documents that R37 was admitted to facility on June 18,2024 with diagnosis including Dementia, cerebral infarction, aphasia, bipolar disorder, protein calorie malnutrition, hypertension, hyperlipidemia. R37's MDS (Minimum Data Set) dated December 20,2024, shows R37 has a BIMS score of 00 which means R37 is has severe cognitive impairment, Section (M) Skin Conditions/ Determination of Pressure Ulcer/Injury Risk states resident at risk of developing pressure ulcers/injuries. R37's Braden scale score dated 12/23/24 has a score of 10 which means R37 is at High risk for developing pressure ulcers. R37's Physician Orders Sheet dated 6/19/2024 The low air loss mattress is set according to the manufacturer guideline, pressure reducing device for bed to be used. On 3/10/25 at time 11:30 am, R37 was observed in bed, low air loss mattress setting was observed by surveyor between 300-320 pounds, the air loss mattress was located at foot of bed. On 3/12/2025 at 11:29am V6 provided Monthly Weight Report sheet with R37's March weight that is 168.1 pounds. On 3/12/2025 at 9:50am V13 Licensed practical Nurse stated R37 currently weighs 168.1 and that low air loss mattress setting was currently set at 350. V13 stated she was not aware why the low air loss mattress was set at such high rate and when a low air loss mattress is set at such a high setting it can cause pressure or harm to the patient. On 3/12/2025 at 9:54 am V2 Director of Nursing stated that staff need to check low air loss mattresses daily to ensure that mattress setting is appropriate according to residents' weight, if low air loss mattress is set to high causing the mattress to be to firm it will cause harm to patient. R77's Face sheet dated March 12, 2025, documents that R77 was admitted to facility on July 11,2024 with diagnosis including Necrotizing Fasciitis, supraventricular tachycardia, diabetes mellitus, major depressive disorder, post-traumatic stress disorder, respiratory failure with hypoxia. R77's MDS (Minimum Data Set) dated February 17,2025, shows R77 has a BIMS score of 15 which means R77 is cognitively intact, Section (M) Skin Conditions/ Determination of Pressure Ulcer/Injury Risk states resident at risk of developing pressure ulcers/injuries, pressure reducing device for bed to be used. R77's Braden scale score dated 2/18/25 has a score of 16 which means R77 is at Risk for developing pressure ulcers. R77's Physician Orders Sheet dated 7/13/2024 The low air loss mattress is set according to the manufacturer guideline. On 3/10/25 at time 10:40 am, R77 was observed in bed, low air loss mattress setting was observed by surveyor between 660-750 pounds, the air loss mattress was located at foot of bed. On 3/12/2025 at 14:20pm V6(Registered Nurse/ MDS Coordinator) provided Monthly Weight Report sheet with R77's March weight that is 405.8 pounds The facility's policy dated 6/8/22 titled as Low Air- Loss Mattress/Bed States Purpose as: A specialty bed will be obtained upon provider order. The low air-loss mattress/bed will be utilized according to manufacturer's recommendations. General Guidelines include protecting the resident's skin: Ensure Low air loss mattress is set correctly to residents weight based on resident's desired firmness and healthcare professionals' suggestion in accordance with manufacturer's recommendations to prevent skin breakdown. The Manufacturer guideline for air loss mattress on weight setting is described as follows: Users can adjust air mattress to a desired firmness according to patient's weight or suggestion from a health care professional. 47303 Findings include: R25 is [AGE] year old with diagnosis including but not limited to: stage 4 pressure ulcer of sacral region, paraplegia, lymphedema, subluxation of unspecified lumbar vertebra and unspecified osteoarthritis. R25's BIMS (Brief Interview of Mental Status) score is 15, which indicates, no cognitive impairment. On 3/10/25 at 11:15 AM, R25 was observed lying on a LALM (Low Air Loss Mattress). At that time, the settings on R25's mattress was 200 lbs. (pounds) and the mattress was thin/ deflated. Surveyor asked R25 if she was comfortable in bed. On 3/10/25 at 11:15 AM, R25 said that she would like her mattress a little firmer because she felt like it was too soft. Surveyor inquired about the purpose of the LALM. On 3/12/25 at 2:25 PM, V2 (DON/ Director of Nursing) said the purpose of a LALM is to prevent a resident's wound from worsening and to prevent skin breakdown. Surveyor inquired about expectations regarding LALM settings. On 3/12/25 at 2:30 PM, V23 (Wound Care Coordinator) said that the LALM is set based on a resident's weight and that when the LALM setting is lower than the resident's weight, it deflates and makes the mattress less firm. R25's Monthly weight report for March of 2025 documents a weight of 231 Lbs. R25's Section M- Skin conditions assessment dated [DATE] documents, R25 has one stage 4 pressure ulcer; R25 uses a pressure reducing device for bed. Facility policy titled Low Air- Loss Mattress/ Bed documents, ensure low air loss mattress is set correctly to resident's weight based on resident's desired firmness and healthcare professionals suggestion in accordance with manufacturer's recommendations to prevent skin breakdown.

Based on observations, interviews and record reviews, the facility failed to follow Pharmacy recommendation for medication storage, failed to ensure multidose medications have open and discard dates, failed to ensure the refrigerator was within the temperature range for proper storage of medication, and failed to ensure a treatment cart was kept locked when unattended. These failures affected 3 (R29, R57, and R83) residents reviewed for medication storage and have the potential to affect all 41 residents on the second floor and all 40 residents on the third floor. Findings include: The (03/10/2025) Resident Listing Report documented that there were 41 residents on the second floor and 40 residents on the 3rd floor. On 03/10/25 at 11:35AM during the medication storage and labeling task with V7 (Registered Nurse) of the second floor wing 2 medication cart, noted the following observations: 1. R29's opened Dorzolamide and Timolol eye drops with no open date and end date. 2. R57's unopened Novolin R with auxiliary pharmacy label 'Store in Refrigerator'. 3. R83's opened Glargine vial with no open date and end date. On 03/10/2025 at 11: 36am, V7 stated the unopened Novolin R should be kept refrigerated until opened. And the nurse who opened the Dorzolamide eye drops, timolol eye drops, and the Glargine vial should write the open date and end date, so we know when to discard these medications. On 03/10/2025 at 11:58am, of the 2nd floor medication storage room with V7. Prior to opening the refrigerator, V7 was informed that V7 has to check first the temperature reading on the small refrigerator thermometer. Upon opening the refrigerator, V7 checked the temperature registered on the thermometer and stated the temperature is 52F. V7 stated the refrigerator temperature should be below 46F. Inside the refrigerator were medications including unopened insulin vials and tubersol for TB test. On 03/12/2025 at 11:56am, V2 (Director of Nursing) stated if the insulin vial is not yet opened, our policy is to keep it in the refrigerator to ensure the potency of the medications is maintained. On 03/12/2025 at 11:59am, V2 stated the multidose medications have yellow sticker where nursing will write the open date of the medication. It is already indicated in the container of the dorzolamide, timolol and Glargine that staff has to write the date it was opened. I don't know why they still missed it. The purpose of labeling the multidose medications with open date is to remind the staff how long they can use the medication and when to discard the medication. On 03/12/2025 at 12:02pm, V2 stated refrigerator temperature should be kept below 46F to ensure the potency of the medication is maintained. R29's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) ocular hypertension, conjunctival hyperemia, and exposure keratoconjunctivitis. Order Summary: dorzolamide HCL solutions 2%. Instill in both eyes. Order Date: 10/27/2022. Timolol Maleate Solution 0.25% instill in both eyes. Order Date: 10/27/2022. R57's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus. Order Summary: Insulin regular Human Solution inject 3units subcutaneously. Order Date: 05/19/2022. R83's (Active Order as Of: 03/06/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus. Order Summary: Insulin Glargine solution 100unit/ml. Inject 45 units subcutaneously at bedtime for diabetes. Order date: 02/15/2025. The (03/13/2025) email correspondence with V8 (MDS coordinator) documented, in part Thank you for your inquiry regarding our pharmacy's auxiliary label practices. Our policy stated that all staff strictly adhere to auxiliary label instructions unless contraindicated by specific patient circumstances or medication interactions. This protocol ensures consistency, accuracy, and patient safety throughout our operations. The (undated) Daily Refrigerator Temperature log documented, in part Acceptable temperature ranges are Medication Storage 36F - 46F for refrigerators. The (undated) storage of medications documented, in part policy heading the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation #1 drugs and biologicals used in the facility are stored in locked compartments under proper temperature. 7. Medications requiring refrigeration are stored in a refrigerator located in a drug room at the nursing station or other secured location. The (undated) labeling of medication containers documented in part Policy Statement. All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. 8. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 45196 Findings include: On 03/11/25 at 9:15 am, V1 (Administrator) presented a facility census of 40 residents on the third floor. On 03/11/25 at 10:39 am, Surveyor toured the facility's third floor unit and observed residents ambulating in the hallways without assistance. On 03/11/25 at 10:50 am, Surveyor observed the third-floor treatment cart unlocked and unattended while V2 (Director of Nursing, DON) was performing wound care inside R77's room. On 03/11/25 at 11:15 am, Surveyor brought this observation to V2 and V2 stated, The treatment cart should be locked at all times when not in use. When Surveyor questioned V2 regarding the importance of the treatment cart being locked when not in use and V2 stated, Residents can be poisoned if they drink the medication solutions inside. The facility's undated policy and titled Storage of Medications documents, in part: The facility stores all drugs and biological's in a safe, secure, and orderly manner. 1. Drugs and biological's used in the facility are stored in locked compartments under proper temperatures, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biological's are locked when not in use. Unlocked medications carts are not left unattended and always in site or in view of the nurse.

Based on observation, interview, and record review, the facility failed to serve hot foods to the residents at a temperature of 135 degrees Fahrenheit (F) per facility policy. This failure has the potential to affect all 42 residents residing on the 3rd floor receiving an oral diet. Findings include: On 3/11/25 at 10:35 am, in the resident council meeting multiple residents stated that the food is cold when served during mealtimes. On 3/11/25 at 11:45 am, Food temperature for lunch before plating were mechanical pork 176, mechanical vegetables 183, rice 190, regular vegetables 185, puree vegetables 157, puree meat 166, regular pork 180, grill cheese 159, hotdog 180, regular pork 198. Temperature steam noted coming from food while being plated. The plate was then covered with a lid and placed on the food transport cart. On 3/11/25 at 12:10 pm, observed third floor second cart lunch trays being served to resident on the 3rd floor. Residents in the dining area were served first then residents eating lunch in their rooms were served. Observation of V16 CNA (Certified Nursing Assistant) passing resident lunch trays in their rooms alone for 8 minutes. V5 Human Resource came and assisted V16 with passing lunch trays to the residents in their room on the third floor. After the last resident received their lunch tray at 12:25 pm, a test tray that consisted of pork, rice and vegetables was tested for temperatures with V15 Dietary Supervisor. Test tray temperatures were rice 135 degrees F, pork 120 degrees F, and vegetables 116 degrees F. On 3/11/25 at 12:28 pm, V15 Dietary Supervisor stated that the food should be served at a temperature of 135 degrees or higher. On 3/12/25 at 12:20 pm, DON (Director of Nursing) stated that there are 4 CNAs on each floor every day. Everyone can pass food trays. No one has complained of food being cold. All CNAs, nurses and staff are responsible for passing food trays. It should have been more than one person passing lunch trays yesterday. Facility's policy titled Tray Service undated documents in part, Procedure: Hot foods will be served at 135 degrees F or higher . Facility's job description titled Certified Nursing Assistant documents in part, Essential Duties and Responsibilities: Provide assistance with serving meals .

Based on observation, interview, and record review, the facility failed to ensure the indwelling catheter drainage bag was covered for dignity. This failure affected 1 (R51) resident reviewed for indwelling catheter in the total sample of 45 residents. Findings include: On 03/10/2025 at 11:21am, R51's indwelling catheter drainage bag did not have a privacy bag. The indwelling catheter drainage bag was facing R51's door. On 03/10/2025 at 11:27am, this observation was pointed out to V3 (Assistant Director of Nursing/Infection Preventionist). V3 stated he (R51) does have an indwelling catheter and the catheter drainage bag is not in privacy bag and it is facing the door. Anybody who has indwelling catheter should have the catheter drainage bag in a privacy bag for privacy of the resident. On 03/12/2025 at 11:43am, V2 (Director of Nursing) stated the policy is everyone who has an indwelling catheter, the drainage bag should have privacy bag for dignity and privacy of the resident. R51's (active orders as of: 03/11/2025) Order Summary Report documented in part Diagnoses: (include but not limited to) cerebral infarction, benign prostatic hyperplasia, neuromuscular dysfunction of bladder, and obstructive and reflux uropathy. Change Indwelling catheter drainage bag every 4 weeks and as needed. Order date: 01/02/2025. R51's (01/30/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 09. Indicating R51's mental status as moderately impaired. Section H - Bladder and Bowel. H 0100. Appliances. A. indwelling catheter. R51's (01/27/2025) care plan documented, in part has indwelling catheter. The (undated) Dignity policy and procedure documented, in part Each resident shall be cared for in manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy Interpretation and Implementation. 1. Residents are treated with dignity and respect at all times. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist resident; For example: a. helping the resident to keep urinary catheter bags covered.

Based on observation, interview, and record interview, the facility failed to complete Medication Self-Administration Safety Screen Assessment and failed to get an order to, may self-administer medication and treatment prior to a resident initiating self-administration of medication and treatment. This failure affected 1 (R36) resident reviewed for self-administration of medication in the total sample of 45 residents. Findings include: On 03/10/2025 at 10:23am, there were Trimove oral drops and Calamine lotion on top of R36's bedside table. R36 stated the Trimove is my vitamin. I put one drop under my tongue once a day. ON 03/10/2025 at 10:30am, with V8 (Registered Nurse) inside R36's room. R36 stated I used the calamine lotion for my stomach because I get the heparin shot. Wound care gave me the calamine lotion. This surveyor pointed to V8 the Trimove oral drops and calamine lotion which were on top of R36's bedside table. V8 stated I don't know why she has these medications. On 03/10/2025 at 10:37am, V8 stated I don't know if the doctor was called about the treatment and medication. Our policy is to let the doctor know about the meds at bedside, that she (R36) wanted them at bedside. It should also be care planned, and resident should be assessed if she knows how to use the medication, knows the principles of medication administration like the route, dose, administration time and frequency of medication administration. On 03/12/2025 at 11:14am, V2 (Director of Nursing) stated we should know the BIMS (Brief Interview for mental status) of the resident first, then assess if the resident can open the medication, then we notify the doctor, get an order from the doctor to may self-administer the medication, and to care plan the self-administration of medication. So, we know if the resident is cognitively and physically able to do the self-administration safely. On 03/12/2025 at 1:26pm, V6 (MDS Coordinator) stated all medications to be self-administered should be ordered by the doctor. Any medications, even OTC (over-the-counter) meds have to be disclosed by the resident in case there is a contraindication. This be documented and we can educate the resident. On 03/12/2025 at 2:05pm, V8 stated I spoke with (V24- R36's Primary Care Physician) today and he (V24) said to talk to the resident and ask when the resident started the calamine lotion and trimove. According to her (R36), the calamine lotion was given by her family and was started last week with no specific day. She did not say specifically stated when, but last week. She only used it as needed for itching. Trimove was used Monday and Tuesday. She got 2 doses only. Her doctor did not want her to take the Trimove. This surveyor inquired how medication should be ordered in electronic health record. V8 stated it should be ordered as calamine lotion, may keep at bedside, and may self-administer Calamine Lotion. R36's (Active Order as Of: 03/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) morbid severe obesity due to excess calories and Type 2 Diabetes Mellitus. Of note, no order to may self-administer medication or treatment; and no order noted for Calamine Lotion and Trimove oral drops. R36's (01/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R36's mental status as cognitively intact. R36's (07/15/2024) Self-Administration of Medication was reviewed with no list of medications to be self-administered. R36's (03/12/2025) MEDICATION SELF-ADMINISTRATION SAFETY SCREEN documented, in part INSTRUCTIONS. Complete this assessment prior to resident initiating self-administration of medication and with any medication order changes, changes in function, condition that might affect the resident's ability to safely self-administer medications. Ongoing assessment should occur at a minimum of quarterly. A. Medications. List all medications that are being considered for resident self-administration. Medication #1. Calamine Lotion 8%. Storage: bedside. Medication #2. Tolnaftate 1%. Storage: bedside. Of note, screening was completed prior to 03/10/2025 observation and Trimove drops was not included for self-administration and no other self-administration of medication screening was provided between 07/15/2024 and 03/12/2025. R36's (03/2025) MAR (medication Administration record) was reviewed with no order to may self-administer Trimove. R36's (03/2025) TAR (Treatment Administration Record) documented, in part May self-administer Calamine lotion. may keep at bedside as needed for self-administration. Start Date. 03/12/2025 1500. The (undated) Self-Administration Of Medications documented, in part Policy Heading. Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation And Implementation. 6. For self-administering residents, the nursing staff determines who is responsible for documenting that medications are taken. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. 9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. 12. Nursing staff reviews the self-administered medication record for each nursing shift, and transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that doses were self-administered.

Based on observation, interview, and record review the facility failed to label and date oxygen equipment (oxygen tubing) and failed to properly contain oxygen equipment (Bilevel Positive Airway Pressure mask and oxygen tubing) when not in use. These failures affected two residents (R52 and R233) reviewed for respiratory care in a sample of 45 residents. Findings include: R52's admission diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease (COPD), pneumonia, acute respiratory distress, heart failure, and dependence on supplemental oxygen. R52's Brief Interview of Mental Status (BIMS) score is 15. R52 is cognitively intact. On 3/10/25 at 10:33 am, observed R52's BIPAP mask laying on the nightstand in R52's room uncontained. R52's (Active orders as of 3/11/25) Order Summary Report) documents in part, BIPAP (Bilevel Positive Airway Pressure) at nighttime every shift. R233's admission diagnoses includes but not limited to Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, congestive heart failure, bronchiolitis, and Respiratory Syncytial Virus (RSV). R233's Brief Interview of Mental Status (BIMS) score is 15. R233 is cognitively intact. R233's Active orders as of 3/11/25 documents in part, Oxygen per nasal cannula as needed every 24 hours as needed SOB (Shortness of Breath). On 3/10/25 at 12:35 pm, observed R233's nasal cannula on the floor in R233's room not dated when changed and not contained. On 3/12/25 at 12:20 pm, V2 DON (Director of Nursing) stated that if the oxygen and mask is not being used it needs to be in a plastic bag to prevent gross contamination. Oxygen tubing should not be on the floor. If a tubing is on the floor it needs to be changed because it can acquire an infection. Oxygen tubing is changed weekly and prn (as needed). V2 stated tubing's should be dated when changed. Facility's policies titled Departmental (Respiratory Therapy)- Prevention of Infection undated documented in part, Steps in the Procedure: 7. Change the oxygen cannula and tubing every 7 days, or as needed. 8. Keep the oxygen cannula and tubing used PRN (As Needed) in a plastic bag when not in use. Facility's job description titled Registered Nurse (RN), dated 3/25/16 documented in part, Summary: The RN is responsible for providing direct nursing care to the resident, and to supervise the day-to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care in maintained at all times. Facility's job description titled Licensed Practical Nurse (LPN), dated 4/1/17 documented in part, Summary: The LPN is responsible for providing direct nursing care to the resident, and to supervise the day-to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care in maintained at all times.

Based on observations, interviews and record review, the facility failed to provide routine dental services for one resident (R54) whose teeth are dark with multiple holes in his teeth. Findings include: R54 is [AGE] year old with diagnosis including but not limited to: cognitive communication deficit, cellulitis, dysphagia, hemiplegia and hemiparesis following cerebral infarction. R54's BIMS (Brief Interview of Mental Status) score is 12, which indicates moderately impaired. During investigation on 03/10/25 at 11:06 AM, Surveyor observed R54 with black substance on teeth and multiple teeth that with small holes in them. R54 stated that he had not received dental services in over 6 years, since living in the facility. On 3/12/25 at 2:25 PM, V2 (DON/ Director of Nursing) said that although R54's teeth are discolored and looked decayed, he (R54) said that his teeth don't hurt. On 3/12/25 at 2:25 PM, V2 (DON) said, R54 has not seen the dentist since his admission to the facility in 2019. It is hard to get a dental appointment for Medicaid patients. I have been trying to get him (R54) an appointment. Surveyor asked about the importance of regular dental visits, V2 said that regular dental maintenance is important to prevent tooth decay, bacteria and infection in the mouth. R54's Section GG- Functional Abilities assessment dated [DATE] documents, R54 requires maximal assistance with oral hygiene. Facility policy titled Dental services documents, routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

Based on interview and record review, the facility failed to identify and treat the cause of new pain in left arm; failed to timely review x-ray results; failed to relay x-ray results to physician; failed to obtain verbal or telephone order from physician for pain patch for one resident (R4) in a total sample of 3 residents (R4, R5, and R6). These deficient practices resulted in harm for R4 experiencing new onset left arm pain for 34 days with limited mobility due to a left humerus fracture diagnosed at an outside hospital. Findings include: On 08/13/24 at 12:48pm V19 Medical Doctor (MD) stated, R4 came to the emergency room (ER) unable to move his (R4) left arm and was found to have a subacute fracture to the left humerus. We (medical staff) think the fracture is a pathologic fracture from the cancer, but the problem is how long did he (R4) have this fracture without it being treated. He (R4) was admitted with acute kidney injury (AKI), fecal impaction, dehydration, subacute fracture and pneumonia. R4's hospital note dated 07/30/24 documents in part that R4 has a diagnosis of metastatic cancer of unknow origin (present on admission), and also noted that R4 had significant left arm pain. R4 was unable to move arm on exam .X-ray of the left humerus showed subacute fracture of the proximal left humerus. R4's diagnosis includes but are not limited to Major depressive disorder, Chronic respiratory failure, Chronic obstructive pulmonary disease, Morbid obesity, Venous insufficiency, Sleep Apnea. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 13 which indicates R4's cognition is intact. On 08/12/24 at 12:01pm V20 Licensed Practical Nurse (LPN) stated, (R4) did complain of pain to his (R4) left arm. (R4) complained of arm pain for about a week or so before (R4) left. At first, (R4) wasn't complaining about the arm then (R4) started complaining of arm pain. (R4) told me (V20) that the lady came to draw (R4's) blood and (R4's) arm had been hurting ever since then. (R4) couldn't lift (R4's) arm anymore, (R4) said the arm hurt to lift. (R4) would use (R4's) right hand to lift (R4's) left arm because the left hurt (R4) too bad to try to move. The DON (Director of Nursing) and the doctor both knew about the pain in (R4's) arm. I'm (V20) not sure if they (DON and Doctor) did anything about the pain, possibly an x-ray. Record review of R4's physicians orders show that an x-ray of R4's left shoulder was ordered on 06/25/24 due to pain. Record review of radiology results of R4's x-ray to left shoulder taken on 06/26/24 show that V2 reviewed R4's left shoulder x-ray results on 07/19/24. Record review of R4's progress notes show that no documentation of x-ray results was communicated to V22 until 07/19/24 by V2. On 08/13/24 at 2:00pm V2 Director of Nursing (DON) stated that R4 was having new pain and R4 denied anything happened to his arm. V2 stated that V2 was auditing the chart on 07/19/24 and noted that there was no documentation about R4's x-ray done on 6/26/24, so V2 notified V22 medical doctor. On 08/13/24 at 1:15pm V13 Certified Nursing Assistant (CNA) affirmed that R4 started complaining of pain to R4's left arm approximately 2 weeks before R4 left the facility. V13 stated that V13 told the nurse that R4 was complaining of pain to R4's left arm. On 08/13/24 at 2:22pm V16 CNA stated that R4 complained of pain to his (R4) left arm starting a few weeks before R4 left the facility. V15 told the nurse that R4 was complaining of pain and the nurse gave R4 Hydrocodone. On 08/14/24 at 10:30am V22 MD stated, I (V22) don't remember ordering lidocaine patch for (R4), the nurses might have just put the order in my (V22) name. I (V22) don't recall anyone informing me (V22) of any x-ray results. In my (V22) practice I (V22) usually don't order Lidocaine. That order I (V22) did not give. I (V22) usually look at what causes the pain instead of just ordering a patch. I (V22) don't have a memory of the DON calling me (V22). The nursing home has their own specific nurse practitioner (NP). I don't have an NP. It's not normal for staff to put an order in my name and I (V22) expect staff to call me (V22). My (V22) name is on (R4's ) chart as the attending, so the nurse probably just picked my (V22) name for the lidocaine order. On 08/14/24 at 10:55am V2 stated, Residents with pain need to be assessed to find out where the pain is and the level of pain and then give them (residents) PRN (as needed) pain medications. New pain is considered a change of condition. Some residents have psychological pain. For new pain an SBAR (situation, background, assessment and recommendation) should be done, the doctor should be notified and the family of the resident if the resident is not alert, and then give the resident whatever the doctor orders. For severe pain we (nurses) should send the resident to the hospital. We (nurses) check for swelling and bruising in the area of pain, and for safety purposes do an x-ray. R4's progress notes dated 06/25/24 through 07/29/24, show no SBAR for new pain, no documentation that physician was notified of new pain, and no documentation of next of kin notification of new pain for R4 found as V2 stated in above interview should be completed for new pain. On 08/14/24 at 1:55pm V23 LPN stated, I (V23) am not familiar with R4. I (V23) don't know how my (V23) name can be on an order for R4 because I (V23) don't ever take care of R4. R4 was in room with others and sometimes when R4 would put the call light on, I (V23) would answer the call light and R4 would ask me (V23) to tell R4's nurse (R4) needs pain medication, water or that (R4's) oxygen wasn't working but that's it. I (V23) don't know how the order was entered under my (V23) name. On 08/14/24 at 2:41pm V1 Administrator stated, Staff are not allowed to share passwords. The nurse should transcribe the order correctly. With any change in condition the nurse is to notify the doctor. The nurse cannot enter an order without contacting the doctor. On 08/14/24 at 2:50pm V24 RN stated, Actually there was a time when R4 came from an appointment, and I (V24) saw a prescription for lidocaine patch to his (R4) left arm. Normally nurses have to advise the doctor or the NP if we (nurses) get an order from a resident's appointment. I (V24) don't know when the pain in R4's arm started. Normally R4 would just ask for the Norco for pain but then one day R4 wanted the Norco and the lidocaine patch. R4 Physician Order Set (POS) dated 07/19/24 documents in part, Lidocaine External Patch 5% .apply to left arm. Facility's undated policy titled Pain - Clinical Protocol documents in part, Assessment and Recognition .1. The physician and staff will identify individuals who have pain or who are at risk for having pain .a. This includes reviewing know diagnoses and conditions that commonly cause pain .2. The nursing staff will assess each individual for pain whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .5. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life. Facility's undated policy titled Change in a Resident's Condition or Status documents in part, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and /or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a .d. significant change in the resident's physical/emotional/mental condition .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Facility's undated policy titled Activities of Daily Living (ADL's), Supporting documents in part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's) .1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADL's) do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADL's are unavoidable .a. The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADL's. Facility's undated policy titled Resident Rights documents in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .c. be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review the facility failed to properly assess and manage oral fluid intake, urinary output and bowel output in a resident (R4) who was at risk for dehydration. This deficient practice resulted in harm for one resident (R4) requiring hospitalization for acute kidney disease and fecal impaction. Finding include: R4's diagnosis includes but are not limited to Major depressive disorder, Chronic respiratory failure, Chronic obstructive pulmonary disease, Morbid obesity, Venous insufficiency, Sleep Apnea. R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 13 which indicates R4's cognition is intact. R4's nursing progress note dated 07/29/24 documents in part, V22 Medical Doctor (MD) requests for resident (R4) to be sent out to hospital due to critical BUN (blood urea nitrogen) 150 mg/dL (milligrams per deciliter). R4's nursing progress note dated 07/30/24 documents in part, Staff called the hospital and spoke with the nurse who stated that R4 had been admitted for AKI (acute kidney injury) possible pneumonia. R4's hospital note dated 07/30/24 documents in part, R4 noted severe abdominal pain .R4 also complained of constipation .daily enemas for constipation. On 08/12/24 at 11:50am V12 Registered Nurse (RN) stated, Things that can cause constipation are medications like iron, not drinking enough water or not eating enough vegetables. The purpose of care plans is for improvement. We (staff) have meetings about the progression of the residents. I (V12) check the resident care plan monthly or every two months. R4's Care plan dated 12/20/21 documents in part, R4 has potential for pain related to decreased mobility, comorbidities, and impaired skin integrity .monitor/document for side effects of pain medication .Observe of constipation. On 08/12/24 at 12:01pm V20 Licensed Practical Nurse (LPN) stated, The certified nursing assistants (CNA's) supposed to notify us (nursed) when the residents have a bowel movement (BM). Sometimes it (BM) can be missed with a resident not having a BM if we (nurses) don't ask about it (BM). He (R4) was incontinent of bowel and bladder. I'm (V20) am the one who sent R4 out on the day R4 went to the emergency room (ER). I (V20) notified the Director of Nursing (DON) and called R4's primary doctor, and I (V20) was told to send R4 out. R4 was a little confused, but R4 was still alert when R4 left the facility. R4 had a urinary tract infection (UTI) before and presented with the same symptoms. R4 didn't really drink water; R4 would drink a lot of diet cola and I (V20) told R4 that he (R4) drinks too much soda. On 08/13/24 at 12:06pm V2 DON stated, We (staff) don't do intake and output (I&O) but if the resident is on fluid restriction, then we (staff) remove the water from the bedside. We (staff) check the resident's hydration sometimes through the blood or skin turgor and we (staff) check the tongue for moisture. The CNA does the patient care and is supposed to tell the nurse if a resident did not have a bowel movement. The expectations for following the care plan interventions are that the nurses should follow the care plan 100%. Record review of R4's progress notes show that R4 has a risk for dehydration care plan with interventions to monitor intake and output. Per V2's statement the care plan should be followed 100%. Per V2's statement, the facility does not do intake and output. R4's Care plan dated 06/19/24 documents in part, At possibly risk for dehydration .R4 will be free of symptoms of dehydration and maintain moist membranes, good skin turgor .Monitor and document intake and output as per facility policy .Monitor/document/report PRN (as needed) and s/sx (sign or symptoms) of dehydration: decreased or no urine output, concentrated urine, strong odor .confusion. On 08/13/24 at 1:35pm V14 Certified Nursing Assistant (CNA) stated, We (CNA) chart in the computer if the resident has a BM or did not have a BM. If the resident has loose stool, then I (V14) would report it to the nurse. If the nurse asks me (V14) if the resident did not have a BM, then I (V14) would let the nurse know, otherwise the nurse can see my (V14) charting. I V14) pass water as needed when the resident asks for water. I (V14) might refresh the water if it has been siting for a while. R4 liked ice not, water. On 08/14/24 at 10:55am V2 stated, If a resident is diagnosed with a UTI the doctor will order antibiotics and then we (staff) encourage fluids for the resident unless the resident is on fluid restriction. We (staff) tell the staff that the resident has a UTI and to encourage the resident to drink more water and make sure that the resident always has a pitcher of water at the bedside. We (staff) only do care plans if the resident is noncompliant or if the resident has a new problem, then we (staff) involve all the disciplines and do a care plan at that time. The facility's expectation is for the staff to keep up with the resident's elimination. The CNA should report to the nurse if the resident did not have urine output or a BM. The expectation of the nurse is to report to the doctor if the resident did not have a BM or no urine output and then follow the order of the doctor. R4's nursing progress noted dated 06/03/24 documents in part, Called hospital for the status of resident, resident has been admitted with diagnosis of altered mental status and UTI (urinary tract infection). Facility's Job description titled Certified Nursing Assistant dated 03/24/16 documents in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents .Essential duties and responsibilities .Providing fresh water and nourishment between meals .recording intake and output information.

Based on observations, interviews, and records review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to unload clean dishes from the dishwasher in a sanitary manner. (d) dishwasher temperatures not consistently documented. These deficiencies have the potential to affect 76 residents who are on an oral diet and receiving meals from the kitchen. Findings include: On [DATE] at 9:30am, during tour of the kitchen with V3(Dietary Manager), in the dry food pantry was observed three types of cereals: frosted flakes, rice krispies, and honey nut cheerios in open bags in a box with no open by date or expiration dates. V3 said all foods including the opened ones should have a open by date and expiration date so that kitchen staff know when the food needs to be thrown out and staff need to follow the first in first out rule. V3 said residents should be given fresh food that is not expired and stale, to prevent residents getting sick from expired foods. V3 said residents' appetite can be affected by stale foods. On [DATE] at 9:43am, while observing kitchen staff washing dishes with V3, V4(Dietary Aide) was observed rinsing dirty dishes and putting them in the dishwasher, and when the dishwasher was done washing, V4 was observed taking out the clean dishes and putting then on the clean dishes cart without changing her gloves. V3 said V4 should be changing gloves before touching the clean dishes to prevent cross contamination which can cause residents to get sick. V4 said she should have changed her dirty gloves before touching the clean dishes to prevent them from getting dirty/contaminated, which can make residents sick. V3 said the dish washer is tested every day and test strips of the temperature outcome are placed on the Dish washer temperature log to keep track of the temperatures to make sure the temperatures are above 150 degrees during washing cycle. Review of Dish Washer Temperature Log with V3 showed no temperature log was recorded for [DATE], [DATE], ,d+[DATE] and there was no temperature label for those days. V3 said the dishwasher temperature log should be completed every day to make sure the dish washer is washing at the right temperature to prevent food borne illness to the residents. On [DATE] at 11:57am during kitchen tour and food temperature checks with V3, Oven fried chicken was observed in the warmer and V8 (Cook) was observed serving the chicken into residents' plates to be bused to units. V3 checked temperatures of foods in the tray being served onto resident plates and the last of the Oven fried Chicken's temperature was 121 degrees F. V3 said foods should reach the correct internal temperature and chicken should reach at least 165F to prevent residents from risk of getting food borne illnesses. On [DATE] at 11:37am during kitchen tour and food temperature checks with V3, Spaghetti was observed in the warmer and V8 (Cook) was observed serving food into residents' plates to be bused to units. V3 took temperature of the Spaghetti and it was observed to be 101F. V3 said foods such as Spaghetti should reach the correct internal temperature of at least 145F when cooked to prevent residents from risk of getting food borne illnesses form uncooked foods. Facility policy titled Labeling and Dating Foods, no date documents: -Prepared and packaged foods will be labeled and rotated to decrease the risk of food borne illnesses, provide the highest quality product for the residents and minimize waste. - Bagged or boxed food once removed from the original package will be placed in an ingredient bin that is labeled with the common name of the food and the date the item is placed in the bin. Examples of these items include oatmeal, cereals flour, sugar, and thickeners. Facility Policy titled Dietary Department-Sanitation & Safety Operations, no date, documents: -Wash hands between handling soiled and clean ware. -Hot foods will be held at a minimum temperature of 135 degrees F for a minimum of 4 hours Facility Dish washer log documented the last temperature test completed was [DATE].

Based on observation, interview, and record review, the facility failed to a.) ensure controlled substances were counted, and documented, at the beginning and end of each shift for 4 out of 22 shifts and b.) keep an accurate count of all narcotic medications for two (R11, R22) residents reviewed for medications. These failures have the potential to affect 42 residents residing in the facility. Findings include: On 02/06/2024 at 10:03AM, V5 (LPN/Licensed Practical Nurse) states that she did not perform a narcotic drug count. V5 was responsible for the 3rd floor Team 2 medication cart for rooms 301 and rooms 309-320. On 02/06/2024 at 10:03AM, review of the Shift Change Accountability Record Sheet for Control Substances for the month of February 2024 for cart identified as Team 2 medication cart located on the 3rd floor of the facility indicated for 2 shifts in February 2024, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 02/05/24, 1st shift oncoming and off-going (7am-7pm) On 02/06/24, 1st shift oncoming (7am-7pm) On 02/06/2024 at 10:03AM, surveyor and V5 (LPN) located on the third floor of the facility performing a controlled substance count and record review. Surveyor observed the following: A medication bingo card labeled R11's name, Lacosamide 100mg, surveyor observed there were 6 pills inside of the medication bingo card. R11's controlled drug receipt record documents a count of 8 pills. A medication bingo card labeled R11's name, Clobazam 10mg, surveyor observed there were 13 pills inside of the medication bingo card. R11's controlled drug receipt record documents a count of 14 pills. A medication bingo card labeled R22's name, Hydroco/Apap 5-325mg, surveyor observed there were 27 pills inside of the medication bingo card. R22's controlled drug receipt record documents a count of 28 pills. On 02/06/2024 at approximately 10:16AM, V6 (RN/Registered Nurse) located on the third floor of the facility with V2 (Director of Nursing). V2 and V6 observed standing at the medication cart identified as Team 1 medication cart with a red controlled substance book open. Surveyor observes V6 writing inside of the red controlled substance book as surveyor approaches the Team 1 medication cart. On 02/06/2024 at approximately 10:18AM, surveyor asks V6 what did she just write inside of the red controlled substance book? V6 pointed to the February 6th 7am-7pm shift on the Shift Change Accountability Record Sheet for Control Substances and states, I just signed here. V6 (RN/Registered Nurse) states she forgot to sign her signature for the narcotic count when she started her shift this morning. V6 was responsible for the 3rd floor Team 1 medication cart for rooms 302-308. On 02/06/2024 at 10:18AM, review of the Shift Change Accountability Record Sheet for Control Substances for the month of February 2024 for cart identified as Team 1 medication cart located on the 3rd floor of the facility indicated for 2 shifts in February 2024, nurses had not counted and documented the controlled substances. The following dates were missing signatures: On 02/03/24, 2nd shift (7pm-7am) On 02/06/24, 1st shift (7am-7pm) (Shift surveyor observed V6 signing) Facility census dated 02/06/2024 documents a total of 42 residents on the third floor of the facility reside in rooms 301-320. Facility policy dated 03/01/2022 titled Controlled Substances, documents in part, 8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (5) quantity of the medication remaining; 12. At the End of Each Shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determines the count together.

Based on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect 35 residents residing in the facility. Findings Include: On 02/07/2024 at 8:09AM, surveyor located on the second floor of the facility. During medication administration pass with V11 (LPN), V11 observed preparing liquid antibiotic medication for R57. V11 observed leaving liquid antibiotic medication on top of his medication cart (identified as Team 2 medication cart) and walks away leaving the liquid medication unattended and out of V11's view. On 02/07/2024 at 8:09AM, V11 returns to the medication cart and states to surveyor, I knew you were standing here so that's why I left the medication on top of the cart. Surveyor states to V11 that surveyor is not responsible for monitoring V11's medication cart. V11 states a resident could have gotten the medication and self-administered it and possibly caused harm to the resident since the liquid medication was left unattended. On 02/07/2024 at 8:56AM during medication administration pass with V11 (LPN), V11 observed entering R52's room and leaves his medication cart unlocked and unattended. Medication cart observed with the outward side facing the hallway and accessible to the residents or anyone passing by. V11 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. Facility census dated 02/06/2024 documents that a total of 35 residents reside on the 2nd floor of the facility. Facility policy, dated 01/22/2022 titled Storage of Medications documents in part, 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended and always in site or in view of the nurse. 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to the residents or others passing by.

Based on interview and record review, the facility failed to provide their bed hold policy, upon discharge to hospital, for one (R74) out of three residents reviewed for discharge. Findings include: R74's medical record (Face Sheet, MDS/Minimum Data Set, dated dated dated [DATE]) documents that R74 is a [AGE] year-old male who is cognitively intact with a BIMS/ Brief Interview for Mental Status score of 15/15. R74 has diagnoses not limited to: Malignant neoplasm of cerebral meninges, chronic obstructive pulmonary disease, malignant neoplasm of right lung, malignant neoplasm of left lung, stage 3 chronic kidney disease, and essential hypertension. On 02/08/2024 at 12:39PM V16 (Clinical Director of Admissions) states whenever a resident is discharged to the hospital, she does not provide written bed hold notification to the resident or resident's representative. V16 states she only sends out an internal email to the facility staff and the liaison at the hospital to let them know that the resident is able to return back to the facility. V16 states she doesn't give the resident any notification because the resident can decide on their own if they want to return to the facility or go to another facility. V16 states a bed hold notification was not provided to R74 when R74 was discharged to the hospital on 01/30/2024. R74's Facesheet documents that R74 was discharged to the hospital on 01/30/2024. There is no documentation to show that R74 or R74's family was made aware of the facility's bed hold policy. Facility's policy dated 07/25/2022, titled Bed-Holds and Returns documents in part 1. All residents/representatives are provided written information regarding the facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these policies at least twice: a. well in advance of any transfer (e.g., in the admission packet); and b. at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Based on interview and record reviews the facility failed to refer three (R5, R24, R30) residents with newly evident or possible serious mental disorder to the appropriate state-designated authority for review. Findings include: On 02/08/24 at 1:39 PM, V16 (Clinical Director of Admissions) stated that she is responsible for making sure Level 1 Pre-Admission Screening and Resident Review (PASARR) are in the residents' records. V16 said that sometimes the residents are admitted to the facility from the hospital before a level 1 PASARR is completed. V16 said that she then makes the level 1 PASARR request, and the assigned state agency will come into the facility and complete the screening. V16 stated that if a resident requires a level 2 PASARR screening then the state agency sends her an email requesting for updated resident information. V16 stated that this is a situation she has not delt with before. V16 stated that she was informed by the state agency that social services need to notify V16 of the residents with mental health conditions that should have a level 2 PASARR. V16 stated that she will collaborate with social services to conduct a list and send the request to the state agency to get those residents to have a level 2 PASARR completed. R5's Face sheet documents that R5 is a [AGE] year-old male admitted to the facility on [DATE] who has diagnoses not limited to: schizophrenia, major depressive disorder. There is no documentation to show that R5 was screened for a Level 2 PASARR. R24's current face sheet document R24 is a [AGE] year-old individual admitted to the facility on [DATE] and current medical diagnosis are listed to include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified. Review of R24's health records do not document a Level 2 PASARR was completed for R24. R30's Facesheet documents that R30 is a [AGE] year-old female who has diagnoses not limited to: delusional disorders, major depressive disorder, schizophrenia, and brief psychotic disorder. R30's Facesheet documents that R30 was admitted to the facility on [DATE]. R30 has a diagnosis of schizoaffective dated 05/02/2022 and a diagnosis of delusional disorders dated 11/02/2020. Record reviewed documents that R30 has an initial Level 1 Pre-Admission Screening and Resident Review/PASARR dated 06/26/2020. There is no documentation to show that R30 was screened for a Level 2 PASARR. Facility policy date 02/01/2022 titled Admission Criteria documents in part, 9. b. If the level I screen indicates that the individual may meet the criteria for a MD (mental disorder), ID (intellectual disability), or RD (related disorder), he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (2) The social worker is responsible for making referrals to the appropriate state-designated authority.

Based on observation, interview, and record review, the facility failed to ensure that two low air loss mattresses were set according to manufacturer recommendation for residents (R29, R33) who are identified as high risk for pressure injury. Findings include: On 02/06/2024 at 10:15am, Surveyor observed R29 lying on a low air loss mattress with the weight control/knob set at 350lbs. On 02/06/2024 at 12:45pm, Surveyor observed R33 lying on a low air loss mattress control with the weight control/knob set at 180lbs. On 02/06/2024 at 12:25pm, V11 (Licensed Practical Nurse) states, Air mattress settings should be the same as the resident weights. If the settings are not correlated with residents weight it can cause a pressure wound. On 02/08/2024 at 9:30am, V14 (wound care nurse) states, Low air mattress should be set at residents' current weight according to the manufacturer's recommendations. I have a wound tech that check settings daily. I also check settings daily when doing wound rounds to make sure bed is on proper settings. Air loss mattress could work against you, if it's not on the proper weight setting it can possibly cause a pressure wound or skin breakdown. R33 Physician order sheet (POS) 2/7/2024 orders document may use air loss mattress. please verify it's in good working condition every shift for wound care. According to facility weight and vital summary R33 most current weight documents on 2/1/24 R33 weighed 54.8lbs R33 recent BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK assessment dated [DATE] documents R33 scored 10.0 indicating R33 is at high risk for pressure injury. R29 Physician order sheet (POS) 2/7/2024 documents Low Air Loss Mattress every shift According to facility weight and vitals summary R29 most current weight documents on 2/8/24 R29 weighed 180lbs. R29 recent BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK assessment dated [DATE] documents R29 scored 10.0 indicating R29 is at high risk for pressure injury. Facility policy not dated, titled Low Air-loss mattress/Bed documents in part, A specialty bed will be obtained upon provider order. The low air-loss mattress/bed will be utilized according to manufacturer's recommendations. Operational [NAME] titled Proactive Medical Products documents in part, operating instructions step six states, determine the patients' weight and set the control knob to that weight setting on the control unit.

Based on interviews and records review, the facility failed to obtain consent for psychotropic medication administration for two (R24, R34) residents reviewed for psychotropic medications in a sample of 18 residents. Findings include: R24's current face sheet documents R24 is a [AGE] year-old individual admitted to the facility on [DATE], with current medical diagnosis that include but not limited to: bipolar disorder, current episode depressed, severe, without psychotic features, major depressive disorder, single episode, unspecified, anxiety disorder, unspecified. R24's Minimum Data Set (MDS) section C dated 1/24/2024 documents R24 has a Brief Interview for Mental Status (BIMS) score of 11/15 indicating R24 has moderately impaired cognation. On 02/08/2024 at 2:20pm, V2(Director of Nursing) stated psychotropic consents needs to be signed by the resident or their representatives before the resident starts to take the medications so that the resident can be aware of what he/she is taking the medications for. V2 stated she does not start psychotropic medications before a resident signs the consent form. On 2/08/2024 at approximately 2:35pm, surveyor asked V12 (Infection Preventionist) for the psychotropic consent form for R24. V12 brought the consent form for R24 with a signed date of 2/8/2024 by V12. V12 said residents should sign the consent form before they start receiving the medication. Review of R24's Psychotropic Medication Consent form documents V12 signed the consent form on 02/08/2024. R24's current Physician Order Sheet (POS) documents: Active 8/6/2022 -Sertraline HCl Tablet. Give 50 mg by mouth one time a day related to anxiety disorder, unspecified, major depressive disorder, single episode. Active 8/7/2023 -SEROquel Tablet 50 MG (QUEtiapine Fumarate). Give 0.5 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition. R34 R34's Facesheet documents that R34 is a [AGE] year-old female who has diagnoses not limited to: Cerebral infarction, type 2 diabetes mellitus, schizoaffective disorder, unspecified dementia, and major depressive disorder. R34's Facesheet documents that R34 was admitted to the facility on [DATE]. R34 has a diagnosis of schizoaffective disorder dated 02/25/2022. R34's physician order sheet/POS documents an order for Seroquel 25mg- Give 1 tablet by mouth two times a day. With a start date of 12/28/2023. R34's psychotropic medication consent form was requested from the facility on 02/08/2024. Record reviewed documents that R34's psychotropic medication consent form was signed by V2 (Director of Nursing/DON) on 02/08/2024. Facility policy titled Antipsychotic Medication Use, no date, documents: -All psychotropics will have either a verbal or written consent from the patient or patient guardian within the time guidelines set for by the state requirements.

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R23, R57) out of four residents reviewed for medication administration resulting in an 11.11% error rate. Findings Include: R57's medication administration record (MAR) dated 02/01/2024- 02/07/2024 documents: Nebivolol HCL 5mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. On 02/07/2024 at 8:24AM, surveyor observed that this medication was not given during the 9:00AM medication administration pass with V11 (Licensed Practical Nurse/LPN). R23's medication administration record (eMAR) dated 02/01/2024 - 02/07/2024 documents: Protonix 40mg- Give 1 tablet by mouth one time a day scheduled at 9:00AM. Valsartan 80mg- Give 2 tablets by mouth two times a day scheduled at 9:00AM. On 02/07/2024 at 8:42AM during medication administration pass, V11 (Licensed Practical Nurse/LPN) observed administering three tablets of Valsartan 80mg to R23. On 02/07/2024 at 8:42AM, V11 (LPN) states that R23's scheduled Protonix medication is not available for administration. V11 states he will reorder the medication and deploys R23's electronic medication administration record (eMAR). Surveyor observes on R23's eMAR that R23's Protonix medication was reordered from the pharmacy on 01/28/2024. V11 states he is unable to locate R23's Protonix medication in the medication cart. V11 (LPN) states he would normally borrow Protonix medication from another resident to give to R23 but today he will notify his supervisor V2 (Director of Nursing/DON) of R23's missing medication. V11 continues his medication administration pass for other residents in the facility. V11 states he did not notify R23's physician of R23's missing Protonix dose. On 02/08/2024 at 1:48PM, V2 (DON) states the physician does not need to be notified of a resident's missing medication dose as long as the pharmacy delivers the medication in time. On 02/08/2024 at 1:57PM, V17 (LPN) states she is the nurse assigned to care for R23 today and R23's Protonix is still unavailable for administration, and she did not notify R23's physician. Facility policy, titled Administering Medications documents in part, 4. Medications are administered in accordance with prescriber orders, including any required time frames. 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to provide ice for a resident's orthopedic cold therapy ice machine used for pain and swelling and failed to timely provide and administer a controlled substance seizure medication to a resident which affected one resident (R1) of four residents (R1, R2, R3, and R4) reviewed for improper nursing care and resident rights. This failure resulted in R1 experiencing a seizure and emergently being sent to the hospital. Findings include: R1's Admission Record, documents, in part, that R1's diagnoses include encounter for other orthopedic aftercare, epilepsy, lack of coordination, difficulty in walking and unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is a 13 which indicates that R1 is cognitively intact. R1's Functional Status for Functional Limitation in Range of Motion for upper extremity is coded as 1 which indicates impairment on one side. R1's Order Summary Report documents, in part, orders as followed: Apply cold therapy machine to right arm to reduce swelling as needed (start date 2/3/23) and Apply cold therapy machine to right to reduce swelling and pa (pain) as needed (start date 2/5/23). R1's Care Plan, with admitted [DATE], documents, in part, a focus of (R1) has an alteration in musculoskeletal status r/t (related to) right arm fracture with an intervention of heat/cold applications as ordered and as tolerated. On 3/14/23 at 10:18 am, V6 (Nurse Practitioner, NP) stated, V6 is the in-house NP who rounded and visited R1 on multiple occasions during R1's one month stay at the facility. V6 stated, R1 was admitted from the hospital after R1 had surgery to repair a shoulder fracture from a fall in the community. V6 stated, R1 came from the hospital with 2 cold therapy ice machines that were to be filled with ice and water. V6 stated, the cold therapy ice machine was a great help for (R1). V6 stated, Ice machine was lifeline for (R1's) pain. V6 asked if at any time was there was an incident when no ice was in R1's cold therapy ice machine. V6 stated, Yes. I (V6) was making rounds. (There was) no ice in (R1's). (V6) and (V9, Assistant Director of Nursing, ADON) dealt with it. Ice had not been delivered yet that morning. V6 stated, R1 would have pain with ice machine off most of the time. V6 stated, V14 (Wound Care Nurse) informed V6, It's magical when talking about the cold therapy ice machine. In R1's Physician's Progress Notes, V6 (NP) documented, in part, the following notes: 1) On 2/8/23 at 9:30 am: . (R1) c/o (complained of) pain in R (Right) shoulder surgical site, noted ice pump was off last night. Back up pump is at bedside, refilled with water and ice, and re-initiated at bedside with (V6) and (V9, ADON). 2) On 2/20/23 at 12:30 pm: . (R1) also c/o surgical site pain, noted ice pump is not on. (V6) reinforced nursing importance of having ice pump on for pain management. 3) On 3/2/23 at 10:05 am: . Ice machine in not on due to no ice at night sift, ensure ice machine in on, reconnected this morning with good (pain) relief. On 3/15/23 at 12:23 pm, V14 (Wound Care Nurse) stated, V14 was seeing R1 for R1's right shoulder surgical incision care. V14 stated, the cold therapy ice machine had a double lumen tubing that came out of the ice bucket where ice cold water would flow from the ice bucket through one lumen, up the to pad that was secured on R1's right shoulder and then the ice cold water would return back down through the other lumen to the ice bucket. V14 stated on one occasion, V14 did fill up R1's ice bucket due to R1 stating that the cold therapy ice machine was not cold and that V14 had observed mostly water in the ice bucket. On 3/14/23 at 12:24 pm, V9 (ADON) stated, R1 was using the cold therapy ice machine to help with both pain and swelling of R1's surgical site. V9 stated, staff puts ice in the ice bucket which is connected to a wrap that looks like a blood pressure cuff that goes over R1's right shoulder. V9 stated, one morning, V9 did assist R1 with filling ice in the cold therapy ice machine due to staff had not gotten to her yet, and the ice machine bucket was mostly water in the bucket. R1's Medication Administration Record (MAR) for February 2023 documented, in part, that for R1's order to apply cold machine to right arm to reduce swelling and pain as needed, only one administration entry (2/17/23) was noted documented by nursing staff. On 3/14/23 at 12:57 pm, V11 (LPN) stated that R1's cold therapy ice machine had a bucket that had a line at the bottom of the ice box where staff would fill small amount of water and then fill the remaining box full of ice. V11 stated, V11 taught the CNAs about R1's cold therapy ice machine and how to refill the majority of the ice box with ice. V11 stated, R1 wanted it on all the time and used to reduce swelling and to help with pain. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated that non-pharmacological interventions for pain include ice (cold therapy). V2 stated, for the nursing staff must go to the kitchen to retrieve ice from the ice machine and brings it back upstairs to the floor. V2 stated, if nursing staff need to get ice during the night shift, the staff member will retrieve a key from the receptionist desk and go downstairs to unlock the kitchen to access the ice machine. V2 stated, V2 did recall a complaint from R1 about not having ice, and when V2 followed up with staff, V2 stated, a CNA was given a hard time about trying to get ice in the kitchen. V2 stated, V2 then got the message out to kitchen staff to allow nursing staff to retrieve ice from the kitchen. V2 stated, R1's cold therapy ice machine was used to help with R1's swelling and pain. R1's Order Summary Report documents, in part, the Clonazepam orders as follows: Clonazepam Oral tablet 1 mg (milligram). Give 3 tablet by mouth two times a day for anticonvulsants (order date of 2/3/23) and Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = (equal to) 3 mg (order date of 2/5/23). R1's Medication Administration Record (MAR) for February 2023 documents, in part, that for the scheduled Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = 3 mg on 2/5/23 at 9:00 pm, V15 documented a chart code of 9 which indicates Other/See Progress Notes. In R1's Orders - Administration note (EMAR, electronic MAR note), on 2/5/23 at 9:04 pm, V15 (LPN) authors, Clonazepam tablet 2 mg. Give 1 tablet by mouth two times a day for anticonvulsants. Add with 1 mg = 3 mg. On order MD (Doctor) aware. On 3/15/23 at 12:03 pm, V15 (LPN) stated, on 2/5/23, R1 stated that R1 was allergic to anything blue. V15 stated, when V15 went to administer the Clonazepam 1 mg tablets (blue in color), R1 stated that R1 didn't want to take the blue colored Clonazepam (1 mg dose) due to R1's allergy to the blue dye. V15 stated, I (V15) documented it. To call (R1's) doctor or pharmacy to change the medication (Clonazepam dose). When this surveyor asked if V15 called R1's doctor on 2/5/23, V15 stated, No. I (V15) endorse to the morning nurse (V11, LPN). At night, I (V15) don't want to wake the doctor up. In R1's Orders - Administration noted, on 2/5/23 at 9:41 pm, V15 (LPN) authored, Clonazepam oral tablet 1 mg. Give 3 tablet by mouth two times a day for anticonvulsants. The medication comes in a blue color, and (R1) 'state I (R1) can't take anything with blue dye.' MD aware. On 3/15/23 at 3:59 pm, when this surveyor asked V11 (LPN) about V11's authored EMAR note (2/6/23 at 11:45 am) which documented, in part, Physician needs to change order, V11 stated, on 2/6/23, V11 punched out one of R1's Clonazepam 1 mg tablets from the controlled substance medication dispensing card and showed the blue table to R1. V11 stated, R1 was allergic to the blue dye in the medication. V11 stated, V11 then called the pharmacist and was informed that the 2 mg tablets were white in color; therefore, R1 would be able to take one 2 mg tablet and a half of another 2 mg table of Clonazepam to equal the ordered 3 mg dose. V11 stated, V11 then phoned V18 (Nurse Practitioner) on 2/6/23 for the new order of Clonazepam 2 mg tablets to get the 3 mg dose. V11 stated, At first, I (V11) thought I (V11) didn't need a new order for the different color. I (V11) called for a stat order. This surveyor then asked V11 if V11 had R1's new Clonazepam 2 mg tablets order (total dose of 3 mg) prescription signed by V18, and V11 stated, For the change in color (of Clonazepam), it ended up that I (V11) needed a new script. I (V11) got it signed right then and there. I (V11) put the new order in and asked for it stat. (V6, NP) was here. I (V11) said (to V6), 'Can you please write the script?' V11 stated that R1's Clonazepam 2 mg tablets (white in color) were delivered to the facility on the same day when V11 changed the Clonazepam order which was the same day that R1 was sent to the hospital after having a seizure. This surveyor reviewed with V11 from R1's electronic medical record (EMR) where R1 was sent to the hospital after a seizure in the facility on 2/7/23, but that V11 had documented in a Nurses Note on 2/6/23 at 5:23 pm, D/C (discontinue) Clonazepam 3 mg and start 2 mg w/ (with) half. V11 stated, On 2/7/23, I (V11) ordered it stat. When the man from the pharmacy came up, (R1) was being sent out to the hospital. When asked about Clonazepam being a controlled substance, V11 stated, I (V11) can't get (Clonazepam) medication without a script (signed prescription). This surveyor asked V11 when V11 documented changing R1's Clonazepam order to 2 mg tablets on 2/6/23, why was there a delay with R1's Clonazepam 2 mg tablets getting delivered to the facility on [DATE]. V11 stated, (V6) was probably out of the building. I (V11) could not get the script. I (V11) endorse to night nurse. I (V11) knew I (V11) would be here the next day (on 2/7/23) and had to get it taken care of. R1's Order Summary Report, documents, in part, an order of Clonazepam Oral Tablet 2 mg. Give 3 mg by mouth two times day for seizures. Give one and half tablet to equal 3 mg (start date of 2/6/23). In R1's Nurses Note, dated 2/6/23 at 5:05 pm, V11 documented, (R1) has allergy to blue dye in which one of (R1's) medications contains it. Writer (V11) called the pharmacist, and she recommended giving (R1) a 2 mg tab and half because its white and it won't affect allergy. On 3/14/23 at 12:57 pm, V11 (LPN) stated that V11 was R1's primary nurse on 2/7/23 when V11 witnessed R1's seizure in R1's bed from 2:27 pm to 2:33 pm. V11 stated that 911 emergency services were called and that R1 was transferred emergently to the hospital on 2/7/23 after R1's seizure. In R1's Nurses Note, dated 2/7/23 at 4:43 pm, V11 documented, in part, that V11 was called to R1's room by a physical therapist where V11 observed (R1) experiencing a seizure. Seizure started at 2:27 and lasted until 2:33 (pm) . Once seizure stopped, (R1) was unresponsive with eyes open. 911 called . Ambulance took (R1) to (local hospital) for eval (evaluation) at 2:45 (pm). R1's prescription (paper) for Clonazepam Oral Tablet 2 mg. Give 3 mg by mouth two times day for seizures. Give one and half tablet to equal 3 mg with an order date of 2/7/23 was signed by V6 (NP) for a 2 week supply. On 3/14/23 at 10:18 am, V6 (Nurse Practitioner, NP) stated that due to R1's allergy to blue dye in medications, V6 did change the Clonazepam from 1 mg tablets which were blue to the 2 mg tablets which were white pills. V6 stated, V6 will sign paper prescriptions when nursing staff needs medications ordered or reordered that require a nurse practitioner or physician's signature. V6 stated, within the EMR, the nurse will hit print script button, and the paper prescription will print in the facility where V6 will then sign the medication prescription. V6 stated, once or twice there was a problem with the printer in the facility where the prescription wouldn't print for V6 to sign. V6 stated , V6 was asked by V11 to sign R1's prescription for changing the Clonazepam dosage due to R1's allergy. V6 stated, V6 signed the new Clonazepam prescription on the same day that V11 asked for V6 to sign it (2/7/23) and was informed that for 2 days, R1 had not been taking the Clonazepam (due to blue dye allergy). V6 stated, the nursing staff had called the primary NP (V18) to get the new Clonazepam prescription signed, but that it was not signed yet. V6 stated, I (V6) wasn't aware. They (nurses) were telling me (V6) that they were trying to contact primary. I (V6) don't know to ask. I (V6) was not notified that (R1) wasn't getting the medication (Clonazepam). They (nurses) asked me 'Can you sign this' for (R1's) seizure medication (Clonazepam). When asked if R1 is not receiving a seizure medication, could this cause R1 to have a seizure, Yes. It could cause (R1) in having a seizure, when (R1's) missing medication. Upon this surveyor reviewing R1's MAR from February 2023, no documentation of nurses administering R1's Clonazepam 3 mg orally twice a day for seizures is noted from R1's re-admission to the facility on [DATE] to R1's hospitalization on [DATE] for a seizure in the facility. R1's Care Plan, with admitted [DATE], documents, in part, a focus of (R1) has a seizure disorder with an intervention of give seizure medications as ordered by doctor. On 3/15/23 at 3:38 pm, V18 (Primary NP) stated that V18 saw R1 twice in the facility. This surveyor informed V18 that R1 was ordered for Clonazepam from the hospital with an original dose in 1 mg tablets that were blue in color. When asked if nursing staff notified V18 of this, V18 stated, I (V18) don't recall that. When residents come from the hospital each time, I (V18) tell the nurses to follow on discontinued hospital medications. When asked since R1 was ordered for Clonazepam and the dose needed to be changed due to R1's blue dye allergy (to change Clonazepam from blue to white color tablets), did V18 write or sign a prescription for R1's new Clonazepam order, and V18 stated, No, I (V18) didn't write the script. I (V18) confirm the orders over the phone with the nurse. I (V18) don't have a fax at home. And I'm (V18) in the clinic once a month. I (V18) don't have the access to send to a script to pharmacy for controlled substances. This surveyor informed V18 that R1 was ordered for Clonazepam for seizures. V18 stated, I (V18) am not aware of that. That (R1) was on Clonazepam for seizures. I (V18) tell the nurses for anything medical, follow everything with the hospital. If it's a medication for psych, then call the psych doctor for clarification. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated that Clonazepam is a controlled substance and that the nurse must have the paper prescription signed to be faxed to the facility's pharmacy. V2 stated that during the day shift, the in-house NP can sign any prescription for controlled substances. V2 stated nurses can remove emergency medication from the facility's emergency medication dispensing machine if needed. V2 stated, the process for administering meds is for the nurse to verify the dosage and medication name; use aseptic technique; determine proper way to administer (crushed or whole); and then document in EMAR that medication is given. V2 stated, a check mark will appear on the EMAR when the nurse administers the medication, or the nurse will document a chart code if nurse is not able to give medication for whatever reason. On 3/15/23, V2 provided this surveyor a list of the emergency medications housed in the emergency dispensing machine in the facility, and Clonazepam is not on the emergency medication list. Facility policy, titled Pain Assessment and Management and dated 1/2/22, documents, in part, Purpose: The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . Implementing Pain Management Strategies: 1. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: . b. Physical - ice packs, cool or warm compresses. Facility policy, titled Documentation of Medication Administration and dated 3/1/22, documents, in part, Policy heading: The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation: 1. A nurse . shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. Facility policy, titled Medication Orders and dated 6/2/22, documents, in part, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . Recording Orders: 1. Medication Orders - When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. Facility policy, titled Controlled Substance and dated 3/1/22, documents, in part, Controlled Substances. Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling , storage, disposal and documentation of controlled medications. Policy Interpretation and Implementation: . 9. c. An individual resident controlled substance record is made for each resident who is receiving a controlled substance. Facility policy, titled Resident Rights and dated 2/1/23, documents, in part, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . jj. equal access to quality care. Facility job description titled Licensed Practical Nurse, (LPN) and dated 4/1/17, documents, in part, Summary: The LPN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties and Supplies: . Prepare & administer medications as ordered by the physician. If a medication is unavailable, the physician is to be notified for further instruction and potential follow up orders . Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.

Based on interview and record review, the facility failed to provide adequate supervision to a resident who was assessed as a high fall risk which resulted in a fall. This failure affected one resident (R2) of three residents (R2, R3, R4) reviewed for falls in the facility. Findings include: R2's Admission Record, documents, in part, that R2's diagnoses include encephalopathy, epilepsy, contracture of muscle, unsteadiness on feet, and difficulty in walking. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that R2's Brief Interview for Mental Status (BIMS) score is a 12 which indicates that R2 is has moderate cognitive impairment. R2's Functional Status for Functional Limitation in Range of Motion for upper extremity is coded as 1 which indicates impairment on one side and for lower extremity is coded as 2 which indicates impairment on both sides. R2's Order Summary Report documents, in part, the following order: (R2) may use (reclining wheelchair) for mobility (12/30/22). R2's Fall Risk Assessment, dated 2/3/23, documents, in part, a score of 75 which is the category of High Risk for Falling with a history of previous falls. In R2's Nurses Notes, on 3/7/23 at 8:00 pm, V5 (Licensed Practical Nurse, LPN) documents, in part, Writer was notified that (R2) slide off (R2's) wheelchair to the floor. Stated, '(R2) slide from my wheel chair.' (R2) was assessed. On 3/15/23 at 12:23 pm, R2 stated, on 3/7/23, R2 was in R2's reclining wheelchair in the dining room (day room) for dinner service. R2 stated that R2 was dozing off and that R2 was leaning to one side and R2 was sliding steadily out of the chair. R2 stated, R2 was yelling, Help, help, from the dining room to get staff's attention due to no staff member present in the dining room. R2 stated, R2's feet were touching the floor and that R2's upper body was still partly in the reclining wheelchair. R2 stated, R2 couldn't remember the time lapse of how long R2 waited for staff assistance but staff didn't respond quickly. R2 stated, V5 (LPN) came into the dining room and that V3 (Certified Nursing Assistant, CNA) came after V5 called for V3 to come help. On 3/16/23 at 12:37 pm, V3 (CNA) stated that V3 was assigned as R2's CNA on the evening shift (3:00 pm - 11:00 pm) on 3/7/23. V3 stated that for dinner time on 3/7/23, R2 was moved by another staff member to the dining room in R2's reclining wheelchair. V3 stated, V3 provided R2 the dinner tray and R2 began eating the dinner meal. V3 stated, another resident (R8) who was on R2's floor but is now on another floor did not receive a dinner tray and that I (V3) had to go to the kitchen to get a dinner tray for R8. When asked if V3 informed any staff that V3 was leaving R2's floor, V3 stated, I (V3) didn't let anyone (staff) know. For me, to verbally facilitate that I (V3) am not going to be there on the floor. Honestly, I (V3) didn't tell anyone. I (V3) was gone for 10 minutes. V3 stated, V3 delivered the dinner tray to R8 and returned back to the dining room. When asked who else was in the dining room when V3 returned from the kitchen, V3 stated that there were 3 other residents who needed to be put back to bed but V3 could not recall their names. V3 stated, R2 was in R2's reclining wheelchair and was coming down slowly (in wheelchair). I (V3) had to reposition (R2). I (V3) lifted (R2) up a little but (R2's) heavy. V3 stated, V3 left the dining room to get ready to place R2 back to bed. When asked if R2 was secure in the reclining wheelchair when V3 left the dining room to prepare R2 to get back to bed, V3 stated, Slightly as much. I (V3) put (R2) in position if (R2) where to fall position. I (V3) needed to make a correct position. Surveyor asked V3 if V3 positioned R2's butt back in the reclining wheelchair before V3 left the dining room. V3 stated, No. (R2's) butt was forward, and (R2) was leaning to the right with (R2's) upper body. V3 stated, I (V3) got ready to put (R2) back to bed. I (V3) was looking as well for someone to help (staff). I (V3) had went back to area by dining room. I (V3) was in room [ROOM NUMBER], I (V3) had responded to what was needed. V3 further stated, I (V3) heard (V5) saying, 'Where are the CNAs. (R2) has fallen.' Surveyor asked V3 what was V3 doing after V3 left R2 unattended in the dining room. V3 stated, I (V3) was looking for the (mechanical) lift. It is usually on the 3rd floor, but I (V3) saw it down the hallway. I (V3) then was making up (R2's) bed in (R2's) room. I (V3) slowly coming back to day room, and the call light was on in room [ROOM NUMBER], so I (V3) was chatting with (the resident) for a moment. I (V3) heard 'Help' from (V5). I (V3) was looking for help. I (V3) did three things when I (V3) left (R2). 1) Find people to help, 2) Get (mechanical) lift, 3) Make up (R2's) bed. When asked if V3 found help from other staff members on the floor, V3 stated, No, (V16 and V17 CNAs) were changing other people, and it was shift change. This surveyor asked if V3 asked a nurse for help, and V3 stated, I (V3) don't keep track of what the nurses are doing. That's not my responsibility. Surveyor asked V3 if there were any staff in the day room after V3 repositioned R2 in the reclining wheelchair and then left R2 in the dining room, V3 stated, There was no staff in the day room. On 3/14/23 at 1:52 pm, V5 (LPN) stated that on 3/7/23 at 7:20 pm, V5 was getting ready to give report to the oncoming night shift nurse when V5 heard shouting from the dining room. V5 stated, R2 had slid out of R2's reclining wheelchair and was shouting for help. V5 stated, V5 then called out for help from other staff and that V3 came from room residents room near the dining room. V5 stated, R2's lower body was on the floor but that R2's upper body and head were still on the reclining wheelchair. V5 stated, V5 assessed R2 and that V3 and V5 then carefully placed R2's entire body on the floor. V5 stated, V16 and V17 (CNAs) then came into the dining room to assist with transferring R2 via mechanical lift to the reclining wheelchair. On 3/15/23 at 1:43 pm, V2 (Director of Nursing, DON) stated, R2 is approved for a reclining wheelchair and that R2's buttocks should be positioned directly on the seat of the chair with the head at 30 degrees and legs up on the recliner leg pad. V2 stated, V3 did state to V2 that V3 did leave R2 in the dining room to get another resident's tray. V2 stated, staff should maintain fall risk interventions by supervising and frequently monitoring residents to prevent falls. R2's Care Plan, with revision date of 5/14/21, documents, in part, a focus of (R2) is high risk for falls with interventions of place resident back in bed after dinner and purposeful rounding at least every hours. Anticipate and meet the resident's needs. Facility document, untitled and undated, documents, in part, that R2's fall occurred on 3/7/23 at 7:50 pm with an intervention of 3/7/23, staff will monitor and reposition resident as needed to prevent sliding. Facility document, titled Fall Risk Identifiers and undated, documents, in part, . All nurses and CNAs are responsible for providing supervision and a safe environment. Facility policy, titled Falls and Fall Risk, Managing and dated 7/1/22, documents, in part, Policy Heading: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Definition. According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of overwhelming force . Fall Risk Factors: . 2. Resident conditions that may contribute to the risk of falls include: . c. cognitive impairment . e. lower extremity weakness . i. functional impairments . Resident-Centered Approaches to Managing Falls and Fall Risk: 1. The staff . will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Facility policy, titled Fall Risk Assessment and dated 7/1/22, documents, in part, Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Facility job description titled Certified Nursing Assistant and dated 3/24/16, documents, in part, Summary: The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensures the health, welfare and safety of all residents. Essential duties and responsibilities: . Provide assistance with serving meals and feeding . Provide assistance in ambulating, turning, and positioning residents . Adhere to professional standards, company policies and procedures, and all federal, state, and local requirements.

Based on interview and record review, the facility staff failed to ensure that a resident got timely transportation to follow up with the surgeon for adequate post-operative care and failed to notify the physician of resident's change in condition of the surgical wound. These failures affected one resident(R1), who missed two scheduled post-operative appointments with the surgeon, and it resulted in infection and dehiscence of the surgical site on R1's left above-the-knee-amputation (AKA) stump. At the hospital, R1 was diagnosed with AKA Stump Complication, as one of the diagnoses. Findings include: R1's Hospital Records dated 9/5/22 show the following: Time of Arrival in the emergency room was 9/5/22 at 12:21pm. ED (Emergency Department) Provider Notes written by V11(emergency room Physician) on 9/5/22 at 1:21pm, under Musculoskeletal: Large open wound with purulent drainage, foul smelling. On 9/5/22 at 3:04pm, written by V12 (Hospital Physician) that R1's X-Ray of left femur shows that R1's left stump has [CONDITION(S)] (Infection in the bone). The X-Ray Findings also states in part: Surgical Clips are noted within the distal soft tissues. Under Emergency Department Medical Decision Making written by V11, R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/15/22 at 12:49pm, V8 (Hospital Registered Nurse/RN) who took care of R1 at the hospital on 9/5/22 stated The patient's wound on the stump was looking horrible, sloughing-off, with stinking drainage that you can smell it in the hallway. I wonder how the nursing home was able to keep the patient in there without taking care of the infection. The odor was everywhere. Since the situation shows that the nursing home was obviously neglectful, I informed the Social Worker. On 9/15/22 at 1:38pm, V9(Hospital Social Worker) was interviewed regarding this. V9 stated I actually got all the information about this nursing home resident from the RN, about the wound being neglected at the nursing home. The nurse can better describe the situation. The patient is still in the hospital, and you can speak to him at this phone number . On 9/15/22 at 3:14pm, the surveyor spoke with R1 in the hospital. R1 stated I'm here in the hospital and they said I have to do another surgery on my leg. I would not have been in this situation if they would have got the transportation right. I told them they need to do a better job. The transportation they arranged was for someone in the wheelchair. During this investigation on 9/14/22 at 12:01pm, V3(Facility's Wound Care Director) was interviewed regarding R1's surgical wound on the left stump. V3 stated (R1) was admitted here from the hospital after amputation of the left leg. I did majority of the wound treatment on Mondays through Fridays. But I had a family emergency, and during the one week off, the other wound nurse(V4) was doing the treatment. (V4) reported to me that the wound started dehiscing. On 9/14/22 at 12:50pm, V3 told the surveyor Please, I need to bring in my lap-top to answer the questions. V3 brought a lap-top computer to the conference room and was reading through R1's records and stated He (R1) was admitted with a wound V.A.C. (Vacuum Assisted Closure) to the left A.K.A. stump on 8/10/22. He (R1) had an appointment with the surgeon on the 14th (8/14/22), but the transportation arrived too late to take him to the appointment, and the clinic told them he had to re-schedule. So, they re-scheduled for 9/7/22, which I considered too late, because I know the surgeon needed to see the stump. So, I rescheduled it to a sooner appointment for 8/31/22. V3 told the surveyor that the surgeon who did the amputation wanted the wound V.A.C. in place until he sees the patient at the appointment. V3 added, unfortunately, there was another issue with transportation on August 31st (8/31/22). At this time, V3 stated that he(V3) would call (V5), the lady that is in charge of transportation and V5 can explain better. On 9/14/22 at 1:25pm, V5(Transportation and Guest Relations Staff) was interviewed regarding the reasons why R1 missed the surgeon's appointment on both 8/14/22 and 8/31/22. V5 stated I just started in this position less than a month ago. The person that was responsible for the appointment of 8/14/22 no longer works here, and I'm not sure of the reason he missed the appointment. For the appointment of 8/31/22, I called to schedule the appointment 2 days ahead. The (Transporting Company) came that day with a medicar and refused to take him because they said they did not know the patient was a double [CONDITION(S)]. I asked them if they can send an ambulance with a bariatric stretcher, but they would not. So, that was how this appointment was missed also. On 9/14/22 at 1:10pm over the phone and in the presence of V3, V4 (Wound Nurse) was interviewed regarding R1's left stump. V4 stated I work weekends and some Thursdays. My first encounter with him (R1) was when he came with a portable wound V.A.C. that was quite small for drainage. On September 3rd (9/3/22), I removed the staples because the staples were clinging to the skin and not holding. The staples were not holding anything together. So, I removed all the staples except one. I tried to call the clinic, but they were closed at that time. So, we put a treatment plan in place because the Wound NP (Nurse Practitioner) here does not treat surgical patients unless the surgeon gives her instructions. So, I just started using the Dakin's Solution for the wound since September 3rd (9/3/22). I was notified by the D.O.N. (Director of Nursing) that he (R1) was scheduled for appointment on September 7th. While V3(Wound Care Director) was in the conference room with the surveyor, the surveyor inquired from V4 who put a treatment plan in place, considering the fact that the resident missed follow-up appointments with the surgeon that did the surgery. V4 responded she (V4) and the Wound Care Director(V3) put the treatment plan in place. However, V3 immediately responded that V4 only notified him (V3) of the Dakin's Solution Treatment Plan for the wound, and that he (V3) was not involved in the plan for Dakin's solution. R1's Wound/Skin Assessment notes dated 9/3/22 written by V4 states: Wound V.A.C. discontinued due to dehiscence. 49 staples removed with one staple remaining because difficult to remove at this time. Attempted to notify Vascular Surgeon, however, clinic was closed at this time. Treatment started with Dakin's Moistened Gauze Dressing. R1's Care plan dated 8/12/22 with revision on 8/22/22 states: The resident was admitted with a surgical wound to left lower abdomen and left AKA stump. Intervention states: Monitor surgical sites for signs and symptoms of infection. Notify MD (Medical Doctor) if any is noted. There is no record to show that R1's primary physician (V10) was notified of the issues with R1's stump. R1's progress notes dated 8/31/22 written by V3 states: Weekly wound assessment done. Resident aware of wound progression. Resident missed his appointment with Surgeon. New appointment scheduled. R1's progress notes dated 9/5/22 at 11:09am shows that R1's blood potassium level was high, and the Nurse Practitioner ordered to send R1 to the emergency room . R1's discharge instructions from the hospital after the left leg amputation surgery shows that R1 was scheduled for surgeon's appointment for 8/17/22. This appointment was supposed to be replaced by the appointment of 8/14/22 that was missed due to transportation issues. On 9/14/22 at 1:39pm, V2 (Director of Nursing) stated I've only been here for six months, and (Transportation Company) is always late. I helped the wound nurse on that day when he (R1) was getting ready to go to the hospital, and the wound on the stump was not looking good. On 9/14/22 at 2:04pm, V1(Administrator) stated I was just made aware today that there were issues with (Transportation Company). I would assume that the nurse would inform the D.O.N. (Director of Nursing) and the Medical Director that the patient has not been seen since after surgery, because this situation is considered a change in condition, and it's important for the doctor to know. On 9/14/22 at 4:10pm, V10(R1's Physician/Facility's Medical Director) was interviewed regarding R1's situation. V10 was asked if he(V10) was notified that R1 missed his appointments to see the Surgeon after the surgery. V10 responded in part: I don't remember if they told me. I don't see any notation here that they informed me. Maybe they did, but I'm not sure. V10 stated that R1's left stump needs a revision surgery, and that the main reason R1 was sent to the hospital was not because of the left stump, it was because of [CONDITION(S)] and other issues. On 9/19/22 at 11:25am, V2(Director of Nursing) was asked a general question about how soon after surgery the residents at the facility usually go back on appointment to see the surgeon who did the surgery. V2 responded that it's usually between 2-3 weeks, depending on the surgeon, the type of surgery and the kind of staples on the surgical site. V2 explained that the wound nurse scheduled the appointment earlier, but the resident missed the appointment due to transportation issues. On 9/20/22 at 11:48am, V2 was asked about the reason for the antibiotic [MEDICATION(S)] 500 mg tablet by mouth every 12 hours that R1 was given from 8/13/22 through 8/19/22. V2 stated that she(V2) was not sure, but that V3, the Wound Care Director would know. V3 came on the phone and stated that the records he has shows that R1 had Leukocytosis (Elevated White Blood Cells) and the Infectious Disease Doctor ordered [MEDICATION(S)]. V3 explained that he (V3) did not believe that the antibiotic use was for the wound because the wound was okay at that time. Regarding notification of the physician about R1's stump situation, V3 stated that he (V3) was not sure if the primary physician was notified and V3 referred to the notes written by V4 on 9/3/22 that states that the Surgeon's Office was closed on 9/3/22 when V4 attempted to notify the Surgeon. R1's progress notes with Effective Date 8/12/22 at 8:47pm and Created Date 8/27/22 at 8:47pm shows that R1 was ordered [MEDICATION(S)] oral antibiotics for elevated white blood cells as stated by V3. Facility's policy titled Transportation, social Service with revision date 9/1/22 states Our facility shall help arrange transportation for residents as needed. #2 states: If the resident needs an ambulance or medicar, the facility will contact an ambulance company and order for one for the resident. #3 states: Social Services and or designee in the facility will help the resident as needed to obtain transportation. Facility's policy titled Surgery-Related (Pre- and Post-Operative) Management-Clinical Protocol states (under Monitoring) with revision date 6/13/22 states: #1: After readmission to the facility post-operatively, the physician and staff will maintain appropriate communication with the referring surgeon to ensure that the resident receives adequate post-operative care and that the staff and Attending Physician receive relevant medical information. #4 states: The staff and physician will monitor for, and address post-operative risks and complications such as infection, [CONDITION(S)], cardiac arrhythmia, bleeding, failure of surgical wounds to heal, urosepsis from indwelling catheters inserted in the hospital, [CONDITION(S)], depression, etc. Facility's policy titled Physician Services with revision date 2/1/22 states: The medical care of each resident is supervised by a licensed physician. #3 states: Supervising the medical care of residents includes (but is not limited to) #b: Monitoring changes in resident's medical status.

Based on observation, interview and record reviews, the facility failed to implement interventions in preventing accidents and falls for one (R1) of three residents reviewed for accidents. This failure resulted in R1 sustaining multiple facial lacerations which caused bleeding and subsequent emergent transfer to the emergency room where R1 required life-saving intubation. R1 also acquired an oblique oriented fracture of right side nasal bones. Findings include: R1 is a [AGE] year old, male, admitted in the facility on 08/13/18 with [DIAGNOSES REDACTED]. MDS (Minimum Data Set) dated 04/02/19 documented the following: Section C - BIMS (Brief Interview for Mental Status) score of 15 which means cognitively intact cognition. Section G - needs extensive assistance from one person physical assist during bed mobility, transfer, dressing and toileting; has impairment on both sides in lower extremities Section J - no fall incidents since admission R1's POS (Physician order [REDACTED]. R1's Care Plan for falls documented the following interventions: 08/20/18: Be sure (R1) call light is within reach and encourage (R1) to use it for assistance as needed. (R1) needs prompt response to all requests for assistance. 08/20/18: Follow facility fall protocol. 10/10/18: (R1) re-educated on his primary mode of transfers and that safety wise he isn't allowed to self transfer himself. He agreed to comply with care regimen. 04/15/19: Re-educated (R1) on utilizing the reacher when trying to get items from a distance and to utilize the call light when he needs staff. 04/16/19: Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. R1's Care Plan for ADL (activities of daily living) documented the following interventions: 08/20/18: Transfer - (R1) requires mechanical lift with two staff assistance for transfers 08/20/18: Encourage (R1) to use bell for call for assistance. R1's care plan for [MEDICAL CONDITION] documented the following interventions: 12/13/18: Monitor/document/report PRN (when necessary) following signs and symptoms of [MEDICAL CONDITION]: Pallor, fatigue, dizziness, [MEDICAL CONDITION], headache, palpitations, weakness, feeling of cold, low hemoglobin/hematocrit, shortness of breath on exertion, sore tongue, chest pain tinnitus, headache, changes in condition. R1's Fall Risk Assessments documented the following: 08/13/18 - score of 55 which means high risk for falling 10/10/18 - score of 55 which means high risk for falling 04/02/19 - score of 40 which means moderate risk for falling 04/13/19 - score of 35 which means moderate risk for falling 05/01/19 - score of 80 which means high risk for falling R1's Incident Reports documented the following: 10/10/18 - observed in a sitting position on the floor in his room resting against his motorized wheelchair. R1 stated that he was transferring to his chair and lost his grip and could not do it. No injuries or trauma noted. 04/13/19 - observed sitting on some bags and garbage can between his bed and window. No injuries noted. 04/16/19 - found on the floor in his room between his bed and window side. R1 stated that he reached out for something and fell . No open wound, no redness but has slit at tip of penis and was in pain. R1 was sent to the hospital. 05/27/19 - observed in room sitting in his motorized wheelchair with his upper body leaning over the left arm of his power chair. R1's left side of his head was laying on his small dresser. Upon assessment, R1 was noted with changes in level of consciousness and with lacerations on his face. Lacerations were actively bleeding. R1 was sent to the hospital. Hospital records dated 05/27/19 under Clinician History of Present Illness, R1 presented to the emergency room after a reported fall from the wheelchair and subsequent mental status. Lacerations to forehead were noted on R1 and has shallow labored respirations. R1's Vital Signs at 6:15 PM indicated that blood pressure was 83/54; pulse rate of 93/min (per minute); respiratory rate of 21/minute; Pulse Oximetry was 99% on room air. R1's Glasgow coma score was 5 which means can vocalize no words; abnormal extension posturing and no eye opening. R1 was on profound obtundation. Endotracheal intubation was performed on R1. Further review of R1's hospital records also revealed the following nursing assessment: Pulmonary - slow respirations: 8; shallow respirations noted. Poor respiratory effort. No stridor. On room air, O2 sat greater than 92%, no cough. Circulatory/Cardiac - regular heart rate and rhythm noted. Hypotensive. Neurologic - Confused; poorly responsive; disoriented. History of head injury/trauma. Gag reflex present. Pupils equal. Slowly reactive to light, nonverbal. Skin/Soft Tissue - skin feels cool to touch. Moist sweaty skin. There are a total of 3 separate lacerations with a total length of 1 cm noted over the right side of forehead. Nursing Consultation notes orders: Patient on respirator, cardiac monitor, awaiting ICU (Intensive Care Unit) bed placement. R1's CT (Computerized [NAME]ography) of head and brain revealed an oblique oriented fracture of right side nasal bones. R1's laboratory tests also indicated the following results: 1. CBC (Complete Blood Count): a. WBC (white blood cells) - 17.2 which was high; b. HGB (hemoglobin) - 8.9 which was low. 2. Nasal Culture resulted to light growth staphylococcus aureus 3. Urine culture result: 50,000 to <100,000 col/ml (colony per milliliter) proteus mirabilis R1's Patient Discharge Transition Record 05/27/19 documented the following primary Diagnoses: [REDACTED]. On 06/04/19 at 11:21 AM, R1 was asked regarding the incident happened on 05/27/19. Dried lacerations on the bridge of nose, middle of forehead and on above right eye were observed on R1's face. R1's lower extremities are paralyzed and uses upper extremities for movement. R1 stated, I got dizzy because of the infection in my genital area and hit my head in the drawer of the television stand. I passed out. I was in the wheelchair that time and I was getting something from the drawer, I got dizzy and hit my head. Staff saw me, I was bleeding, I tried to talk but I was too dizzy. V4 (Licensed Practical Nurse, LPN) was also observed in his room who had just finished providing wound care and was asked about R1. V4 stated, I am helping with the wound care since last week. He's pretty much independent and he tells you what he needs. Don't know about any falls. R1 was asked if he is able to transfer himself into the wheelchair, stated, I can transfer myself from bed to this wheelchair, done it for already 8 years and I don't need any assistance from staff. On 06/04/19 at 11:50 AM, V5 (LPN) was interviewed regarding R1 incident on 05/27/19. V5 stated that she was the nurse at the time. V5 stated, He (R1) was in his room, his room was near nurses' station. I was at the nurses' station and just got off the phone. I stood up and took my medication cart when I saw him in his wheelchair with his body leaning on the left side of the wheelchair and he was in front of the television stand. So I called out, he did not respond so I went around to his room and saw blood on his face and on the floor. I shook him and tried to wake him up. He responded to verbal but not conscious enough to talk. He had laceration over the bridge of his nose, around right eye and forehead hairline. He was going in and out of consciousness. I applied ice pack and cold wet rag on his face and bleeding stopped. 911 was called and V9 (Primary Physician) was notified. I called hospital emergency room and gave report of what happened to R1. And I also did the incident report. He (R1) was alert, oriented, no unusual signs prior to this incident. On 06/05/19 at 2:46 PM, V2 (Director of Nurses, DON) was asked regarding accident and fall preventions. V2 stated, I have been here for three weeks. But I have nursing experience for [AGE] years, as a DON which is close to [AGE] years. I am now the fall coordinator. This is the role I have taken on. Responsibilities: proper documentation of the incident in the computer; appropriate follow-ups and investigation of the root cause whether its preventable or not is done, check appropriate referrals. I am responsible making sure that care plans are updated regularly upon admission, quarterly and any significant change in condition. For injuries happened to R1, there is a need to update the care plan but I have not done it yet because I don't know how to access the care plan portion in the computer. So for him (R1), we did a safety sweep into his room; close monitoring for 72 hours post readmission; he does not want re-arranging his room furnitures, again I don't know or think any more interventions for him (R1). There is also a need to update care plan post fall incident. V2 was also asked on how to ensure that interventions in preventing fall and accidents are implemented. V2 further stated, Personally, I go the residents' room and check for implementation of interventions like re-arranging the room to have better access as permitted by resident, make sure call light is within reach; situate the room across the nurses' station for close monitoring and observation by keeping his door open except during provision of care. Again, I haven't read his (R1) care plan and don't know if I need to initiate a new care plan or update an existing care plan. On 06/06/19 at 2:45 PM, V9 was interviewed regarding R1. V9 stated, He's (R1) been under my care since last year or about (YEAR). His sacral lesion got infected and hard for him to move around. His wound was severely infected requiring surgical debridement. He'd been in and out of the hospital due to wound infections. He has issues [MEDICAL CONDITION], wound graft was in place. General surgery is seeing him for antibiotics and Infectious Diseases for management and prevention. I was informed by staff on 05/27/19 that he had fallen from bed and landed on the wheelchair and was sent to the hospital due to sustained lacerations. This is my understanding of the situation that he fell . He was found to have an infection when he came there in the facility. He has a wound and not healing and tends to bleed and he becomes anemic. His hemoglobin is low. He is very independent when he is not septic. Then, his infection suddenly will take over. He has episodes that he is fine, he is independent and then will change all of a sudden due to infection. His [MEDICAL CONDITION] predisposes him to get dizzy and its hard to predict on when that is going to happen. He (R1) tries to be independent all the time but when these changes happen, staff need to be more on precautions for falls. The facility needs to follow fall protocol. Close monitoring on him (R1) like frequent blood checks, side rails for him (R1) for he is a stubborn resident thinking he is independent, maybe bed alarms. Staff knows that he (R1) has chronic wound infections and that's becoming unpredictable so they can develop interventions to address this condition. I could meet with them to help them. On 06/10/19 at 10:00 AM, V5 was asked regarding interventions in preventing accidents and falls on R1. V5 stated, He is usually independent, just monitoring and needs encouragement to ask for help before transfer now that he had this [MEDICAL CONDITION] spell. I didn't know anything about it. I didn't realize that he has this [MEDICAL CONDITION] spells until I witnessed it last time. I didn't know his reaction if he is sick. I have been taking care of him since (MONTH) (YEAR). That time, he said he was trying to call my name be he can't. When I found him, half of his body was laying on the table like falling. Now I know that he has [MEDICAL CONDITION] spells, he need to have side rails and I called V9 and she ordered side rails. I believe he does the transfer of himself but actually he needs assistance. He had incidents of falling before, he has a reacher to use. He actually did not have any unusual signs and symptoms before that incident, the 05/27/19. On 06/10/19 at 10:15 AM, V10 (Certified Nurse Aide, CNA) was also asked regarding R1. V10 stated, He (R1) is okay. He does transfer himself to wheelchair. If he needs assistance, he will push the call light or get into his chair and come out of his room. He is not at risk for falls. I was not aware if he went to the hospital. For him (R1), he really does things for himself. So I check on him first thing in the morning and make sure he has everything he needs. During the day, I monitor him for safety and for anything he needs. On 06/10/19 at 10:32 AM, V11 (LPN, Restorative Director) was asked regarding accidents and fall interventions. V11 stated, I do care plans for falls as long as there is no injury. The DON is the one responsible for injury/fall care plans. For him (R1), I re-educated him on using the reacher stick and the use of call light for assistance. I didn't know the incident last time happened to him. Any type of injury during fall, that is the DON's job. I am more on the preventative care plan. Once fall occurs, I update the care plan, we do meet about wounds, falls, behavior and we discuss the interventions. There is a cardex in the computer that actually shows the interventions to be implemented, I was the one who put it and floor nurses should be able to check it every day. In preventing future falls or accidents, we do re-education on safety awareness; call lights within reach, appropriate lighting and footwear. We review past falls and see how resident actually had fallen. Facility's policy titled Falls - Clinical Protocol, revised (MONTH) 2010 stated in part but not limited to the following: Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors to subsequent falling. c. While many falls are isolated individual incidents, a significant proportion occur among a few residents/patients. Those individuals may have a treatable medical disorder or functional disturbance as the underlying cause. Treatment/Management: 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of serious consequences of falling. a. Examples of such interventions may include calcium and vitamin D supplementation to address [MEDICAL CONDITION], use of hip protectors, addressing medical issues such as [MEDICAL CONDITION] and dizziness, and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up: 3. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions.

Based on observation, interview and record review the facility failed to follow their policy and procedures to prevent the development of avoidable pressure sores. The facility also failed to follow physician orders [REDACTED].?) reviewed for pressure sores from a sample of 10 residents. These failures resulted in all 6 residents developing facility¿ acquired pressure sores ranging in severity from stage 3 and stage 4 pressure sores to unstageable pressure sores. Findings include: On [DATE], V2 (Director of Nursing) presented surveyor a list of all wounds being treated by the facility. Surveyor asked who treated the wounds in the facility, V2 stated, We have a wound nurse (V8), but she called off sick today. On [DATE] at 2:00 PM, surveyor asked V4 (RN) to accompany surveyor inside R2's isolation room. As the door opened, a strong pungent odor of feces and urine presented itself. The resident was in bed with brown, stained and crumpled sheets strewn about his bed. To the left of the bed were 2 large red isolation bins overflowing with garbage to the floor surrounding these bins. Surveyor asked R2 if he needed a nurse, R2 stated, I've been waiting all morning and no ones's come in so I guess I just fell asleep. V4 called in V9(CNA-Certified Nurses Aide) to help change R2's sheets and undergarments. R2 was turned over to his side to reveal a golf ball sized hole above his anus. Surveyor asked V4 if there was any type of treatment for [REDACTED]. here for awhile. R2 was then turned on his other side revealing an even larger softball-sized gaping hole on the right hip. V4 stated, I don't know why there is nothing to cover that either but I will find out. On R2's right ankle there was a beige colored bandage wrapped several times around the ankle. Surveyor asked V4 to show the wound under the bandages. The bandages appeared moist with dried blood that bled through them. Upon bandage removal, there was an undated covering that was under the bandages which was saturated with dried blood. R2 was asked if anyone came in to change any of his bandages, R2 stated, I haven't seen that nurse that did them before over a week ago when she was with some doctor. Surveyor asked V4 to show the treatment administration record for R2. Surveyor accompanied V4 to her station to bring up the treatment records on her computer. V4 stated, I don't know how to get the treatment records. Surveyor asked V4 how she can do the wound care without knowing how to get to the treatment records, V4 replied, We don't do the treatments. It's just the wound nurse(V8) that does them. R2's physician order [REDACTED]. 2. Dakins solution 0.5% apply to right hip with 0.5% solution pack loosely with Silver Calcium Alginate; Cover with a gauze, pads and secure with tape. Change daily and as needed. 3. Silver Calcium Alginate every day shift for wound care Cleanse Right Hip with 0.5% Dakin's solution packed loosely with Silver Calcium alginate, cover with a gauze, ABO (abdominal) pads and secure with tape. Change Daily and as needed. These wound orders did not appear to have been conducted as observed by the surveyor with V4 on [DATE]. Surveyor approached another nurse on the same floor about wound treatments, V5 (LPN¿ Licensed Practical Nurse) stated, It's my second day here. I wasn't shown how to do them. Asked if she did any her first day here, V5 stated, I was told the wound nurse did them all. Surveyor went to the third floor and interviewed V6 (LPN) about wound treatments. V6 stated, We don't do the treatments here. There's a wound nurse that comes and does them. Asked what she would do if resident had to have their wound dressings changed if they got soiled or wet, V6 stated, I guess I'd have to change it but no one's ever asked me to. On [DATE] at 2:26 PM, R4 was observed in bed. Surveyor asked V13 (CNA-Certified Nurses Aide) to turn R4 to his side to reveal his wound. V13 removed the incontinence pad from R4 but there was no dressing on R4's buttock as ordered by the physician. Review of R4's physician orders [REDACTED]. Cleanse right buttock with 0.9 normal saline, pack loosely with silver calcium alginate; Cover with a dry dressing, pads, and secure with tape. Change daily and as needed when negative pressure therapy is unavailable. Surveyor asked V7 (LPN) about R4 and about negative pressure therapy, V7 stated, I haven't seen the wound nurse and I haven't seen a wound vac (negative pressure therapy) that's done here for awhile. I can't even remember when. On [DATE] at 2:50 PM, R3, was observed on an extra-wide (bariatric)bed that occupied one side of the room with two wheelchairs to the left of his bed filled clothes. A waste basket with two urine¿ filled urinals hung inside the waste basket. The room was pungent with strong urine and body odor. Surveyor asked R3 if any staff came to assist him to go to the bathroom. R3 stated, I've been having the hardest time here and I've talked to everyone, you name it. They tell me that I have to get out of bed to shower before they can do anything like doing my sores on my back and butt but they don't even have anyone to help do that. They'll tell you I refuse, but I refuse because I don't feel safe with anyone of them trying to transfer me. Surveyor to clarify who he spoke to, R4 stated, I spoke to the director of nursing (V2) and any nurse that I see. Speaking of which, the last time I saw V8(wound nurse), I can't even tell you because I can't remember when she was last here. If I had to guess it was over a week ago. (V8) said to me she can't do my wound care unless I get a shower. That's fine but who's going to get me on a shower chair? They just give excuses to not help me or do what they're suppose to do. I want to go back to the VA hospital. Surveyor asked V9 (CNA-certified nurses aide) to assist in turning R3 over to observe his wound. When turned, R3 was laying atop bunched up and crumpled sheets that were stained with dried blood. There was a strong and dank smell that was piercing to the nose. On R3's left upper hip area appeared a large golf¿ ball sized hole. The skin around the hole was reddened and had dried blood surrounding the hole. There was no bandage cover and the crater-like hole remained exposed and appeared untreated. R3's Physician orders [REDACTED]. Cleanse left ischium (hip) with 0.9 normal saline; Apply a [MEDICATION NAME] dressing and Change every 3 days and as needed. On [DATE] at 3:10 PM, Surveyor went in to R5's room who was in bed asleep. Surveyor asked V? (LPN) to see R5's wounds, V7 stated, I think he used to have sores but not anymore. Review of facility wound report show R5 acquiring two stage 3 pressure sores on each thigh on [DATE]. Per wound records, RS's stage 3 to the right medial thigh measured 2 centimeters long by 2.3 centimeters wide and 0.2 centimeters deep. The other facility-acquired wound is a stage 3 to the left medial thigh measuring 3.0 centimeters long by 1.5 centimeters wide and 0.2 centimeters deep. Surveyor asked V2 (DON) if R5's wounds were considered unavoidable wounds, V2 stated, Well we heeled them, so I guess not. Does that count? Surveyor asked for any assessment to show R5's wounds were unavoidable, V2 stated, I don't have anything to show you on that. On [DATE], Surveyor reviewed the facility's wound report provided by V2 (Director of Nursing). Per this report, R6 obtained a facility¿ acquired stage 3 pressure sore to the left buttock on [DATE] measuring 3.6 centimeters in length by 2.1 centimeters wide and 0.2 centimeters deep. Surveyor asked V2 if he could provide any documentation to show R6's wounds were unavoidable, V2 stated, She was a hospice patient and she died just this last April. Asked if she was placed on hospice before or after obtaining her wound, V2 stated, I think she got them before because she went on hospice in (MONTH) Asked again to provide any clinical assessments to show R6's wounds were unavoidable, V2 could not present any to the surveyor. Review of R6 show the MOS (Minimum Data Set) admission assessment dated [DATE] show no pressure ulcers upon admission however was considered at risk for pressure ulcers/injuries. The facility did not place R6 on any turning/or repositioning program nor on any nutrition or hydration intervention despite this risk. Two months later, on [DATE], R6 sustains a facility-acquired stage 3 pressure sore to the left buttock. Surveyor asked V1(administrator) for the latest skin assessment conducted for R6 on [DATE] by V6 (wound nurse). V1 presented surveyor with a blank and empty assessment initiated by V6 however, all treatments that day were all allegedly completed per the treatment administration records. Asked to comment on this, V1 replied, We are in the process of finding another wound care nurse. Another resident on the facility-acquired wound list show R7 acquired an Unstageable Pressure Sore on [DATE] to the superior Sacrum measuring 1.0 centimeters long by 1.0 centimeters wide by undeterminable depth. Per V2(director of nursing), R7 was transferred to another facility late April. Surveyor asked to provide any clinical assessments that support R7's wounds to be unavoidable, V2 stated, I don't know about that but I will check. Surveyor never received any assessments from V2 except for R7's treatment administration records for (MONTH) which showed wound treatments conducted daily by the nurses. Further review however contradict actual treatments that were conducted with progress notes documenting that R7 frequently refused wound care. For example, on [DATE], nursing documentation by V8 (Wound Nurse) writes three separate entries on [DATE] showing R7's refusal of the wound treatment. However on the treatment administration record of [DATE] both R7's treatment orders were initialed as completed by V8 contradicting her own progress note written for the same day. On [DATE] at 10:55 AM, Surveyor asked V1 (Administrator) to contact the wound care nurse (V8). V1 stated, She is not here again today, she texted and said she had an emergency but we've been trying to get a hold of her and she doesn't respond until days later with a text. We're considering no longer having her work here. On [DATE] at 11:05 AM, Surveyor obtained TARs (treatment administrations records) for R2. Per R2's treatment records, V2 (Director of Nursing) performed 3 separate wound treatments on Sunday [DATE] as per his initials. Upon interview V2 affirmed conducting treatments and stated, I came in and did all the wound treatment including (R2). At 11:15 AM, Surveyor requested V4 (RN) to accompany him to view R2 who was asleep in his room. V4 turned R2 turned over to his side and showed the golf ball sized hole above his anus with no dressing cover or indication of treatment that was ordered by the doctor. R2 was then turned on his other side revealing the larger softball-sized gaping hole on the right hip. V4 stated, I don't know why there is nothing to cover that it must have come off. Surveyor asked what staff should do if a resident requires additional treatments due to them coming off or soiled, V4 stated, I would call the wound nurse but I guess I can try to change it. On R2's right ankle there was a beige colored bandage wrapped several times. Surveyor asked V4 to show the wound under the bandages. Upon bandage removal, there was an undated and unmarked covering that was under the bandages to show when and who conducted the treatment. R2 was asked if anyone came in to over the weekend to change any of his bandages, R2 stated, I remember you from last week but I still haven't seen the other nurse (V8). Some nurse wrapped my ankle I think on Friday. Surveyor asked R2 if he knew what day it was, R2 correctly responded, It's Monday. Interview with V16 (Medical Director) on [DATE] at 2:15 PM states, I can't recall when I've been to a quality assurance meeting at that facility but I can tell you the director of nursing and the wound team talk to me regularly about any issues however, I am not aware there is a problem there with wounds. Surveyor asked V16 to clarify his statement about a wound care team as there is only one wound nurse. V16 stated, I mean all the nurses are responsible for the treatments there. Is there a problem with them there? Surveyor asked V16 about facility- acquired wounds,V16 stated, Yes, but I'm not aware we had as many facility-acquired wounds as you say we have. If that's true then moving forward I need to set up a meeting with the administration right away to discuss what we need to do. I also need to meet with the administrator because we do need to address the staffing problem because it would affect the quality of care there. Surveyor asked expectation of the staff at the facility, V16 stated, I expect that wound care is conducted but that is under the wound doctor who I know goes there regularly. On [DATE] at 3:00 PM, Surveyor asked V2 (Director of Nursing) to provide additional TARs (Treatment Administration Records) for R2, R3, R4, R5, R6, and R7. Surveyor asked what a blank space on the day shown of the treatment administration record meant, V2 stated, It means that the treatment was not done or the resident was out. Upon receipt of the TARs on [DATE] at 4:00 PM, the treatment records show that the blank spaces that were originally blank on [DATE], were now filled-in with the initials of V2. Surveyor asked to identify whose initials were written in the original blank spaces, V2 stated, That's me, I did the wound treatments. Surveyor asked to clarify whether he came in every weekend to do the wound treatments in April, V2 stated, Yes, I live nearby. Surveyor asked about the (MONTH) treatment blanks and why he didn't do those, V2 stated, I have a life too. Surveyor asked for the administrator to come in to discuss V2's claims. V1 (administrator) stated to V2, I was not aware he(V2) came in to do the treatments. Surveyor asked V2 if wound treatments were all done on the weekend by him, why the records were blank when initially viewed by the surveyor. V2 then affirmed, I inputted my initials this past weekend and went back a month and added them. Asked if he should be going back a month to input a treatment he did over a month ago was acceptable practice, V2 stated, I don't know, but I came in to do them but I just didn't sign off on them. Surveyor asked V1 if this was acceptable practice by the facility, V1 stated, No this is not and I will have to terminate V2 for this. We do not do this here. If he did the treatment, he should have signed off on them right then and there and not go back a month to show that he did because this is highly improper. Asked privately if their electronic system allowed changes to the record, V1 stated, You can go back about a month to make changes, but it won't allow you to do that past 30 days. That's probably why (MONTH) was unchanged. Surveyor asked if he believed V2 conducted all the treatments he claimed to do in April, V1 stated, I don't believe that at all. I know he came in this past weekend but certainly not all those he signed. V10 (Wound Care Doctor) at 3:30 PM stated, I usually come there every week to see all the wounds the facility needs me to see. I try to come there on Tuesdays but it all depends on the availability of the wound nurse. Surveyor asked about negative pressure therapy, V10 stated, They really needed a [DEVICE] for some of the wounds there but the only person who knows how to operate one is no longer there. I've asked the director of nursing to train someone but they already have staffing problems there so I try to keep my wound orders as simple as possible so even the weekend nurses can do the wound dressing changes. Asked if she was aware of any staffing issues, V10 stated, I know they have staffing problems because just last week when I came to do my rounds, I was told the wound nurse wasn't there again. I asked for any nurse to round with me and I couldn't even find anyone willing to do that. Surveyor asked V10 her expectations on wound care, V10 stated, I expect that they off-load the wound and at a minimum every two hours. They should minimize the sheets to avoid it getting saturated and bunched up under the skin. I've told the staff and director of nursing to even avoid using those cotton pads that go under the resident because they can become saturated with moisture and you end up with worsened wounds. I think I will contact the medical director along with the administrator moving forward because staffing definitely impacts the care and certainly whether my orders get carried out or not. If you don't have enough staff, how can you expect them to turn or reposition the resident. Surveyor asked what the risks are in not doing wound care treatments for the residents, V10 stated, Infection of the wound, deterioration of the wound, and if it's a highly compromised resident [MEDICAL CONDITION] and death. Facility's undated Policy and procedures titled Pressure Ulcer Prevention and Managing Skin Integrity states, Nursing in collaboration with the health care team, will assess and manage skin integrity for all patients throughout the hospital stay. Risk for pressure ulcer development will be evaluated upon admission to a nursing unit and on a routine basis for all adult patients using the Braden Scale. Risk assessments will be done more often when the patient condition warrants more frequent assessment. Skin inspections will be completed on admission and daily for all hospital patients. Any patient with a Braden score < 12 or when nursing assessments indicate a patient need, skin inspections will be done every 8 hours.

Based on interview and record review the facility failed to operate a motorized wheelchair safely and check speed and power controls prior to transferring resident to power wheelchair for 1 of 3 residents R16 reviewed for safe transfers. This failure resulted in R16 sustaining an acute posterior calcaneal fracture (left heel fracture). Findings Include: On 10/31/18 at 1:22 Pm, R16 said on 10/2/18, V5 (CNA) was assisting her from bedside commode to electronic wheelchair. R16 said her back was to her wheelchair and V5 moved commode out of way to move wheelchair closer to R16. V5 turned power on the wheelchair and must have turned up the speed of wheelchair. R16 said the wheelchair than moved forward fast, hitting her in the back of left foot. V5 caught R16 so R16 would not fall and V5 called for help. On 11/2/18 at 12:04 Pm, V5 (CNA) said in regards to incident on 10/2/18, that she was assisting R16 from bedside commode to electric wheelchair. V5 assisted R16 up from commode to her walker to stand. V5 said she moved bedside commode to side and that electronic wheelchair was behind R16. V5 than turned on electric wheelchair and moved it forward towards R16 so she could sit down in wheelchair. V5 said wheelchair went faster than expected and hit V5 and R16. V5 said she caught R16 so she would not fall and called for help. V5 said she could not see the speed on the electronic wheelchair when moving it forward and did not check the speed of chair prior to moving the chair. On 11/2/18 at 4:20 PM, V32 (physical therapy assistant) said when transferring any resident to a power wheelchair, staff would ensure the power wheelchair was powered off prior to transfer. On 11/2/18 at 4:25 PM, V33 (Occupational Therapist) said for any residents transferring to an electronic wheelchair you should check to make sure power is off prior to transferring the resident for safety. ON 11/2/18 AT 4:55 Pm, V2 ( DON) said Certified Nursing assistants are not trained on how to use residents power/electric wheelchairs upon hire. Local Hospital records dated 10/5/18 documents under care, You were admitted to the hospital for evaluation of left heel pain and found to have left calcaneus fracture likely from trauma from motorized wheelchair. Local hospital x-ray of left foot dated 10/3/18 documents [MEDICAL CONDITION] inferior aspect of the calcaneus. Local x-ray company report dated 10/2/18 documents under impression acute posterior calcaneal fracture. Facility's incident report dated 10/2/18 documents the root cause analysis determined incident occurred because the chair was already set at a high speed which caused chair to move faster and scrape the residents left foot.

Based on interview and record review, the facility neglected to implement the Suspected Substance Abuse Care Plan after testing positive for opiates and neglected to follow their Outside Pass privilege Policy by not revising or restricting outside pass privileges after testing positive for opiates for 1 of 1 (R1) residents reviewed for substance abuse. This failure resulted in R1 being allowed to independently access the community and was found lying outside on a sidewalk unresponsive, and being pronounced dead by the local paramedics. R1's death certificate documents the cause of death [MEDICATION NAME] (4-ANPP), [MEDICATION NAME], and [MEDICATION NAME] toxicity. Findings Include: R1 is a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was found unresponsive on 7/25/18 on a sidewalk and pronounced dead by paramedics. R1's death certificate documents cause of death as [MEDICATION NAME] (4-ANPP), [MEDICATION NAME], and [MEDICATION NAME] toxicity. After review of R1's POS (physician's orders [REDACTED]. There is an order for [REDACTED]. R1 has a unsupervised open pass to the community by V15 MD (Medical Doctor) The Community Survival Skills assessment dated [DATE] documents, R1 appears capable of unsupervised outside passes. Section 10. The resident sufficiently follows rules addressing medication compliance, participation in his/her treatment plan, appropriate hygiene and grooming and treats others with respect, is checked off yes. On 8/15/18 at 9:00 AM V1 Administrator, V3 ADON (Assistant Director of Nursing), V4 Social Services, V12 Acting DON (Director of Nursing), and V13 Assistant Administrator stated that the Community Survival Skills Assessment is based on the MDS (Minimum Data Set) 7 day look back period. For R1 this was 6/1 through 6/7 / (YEAR). R1 was compliant during this period. Writer asked if this is a true assessment of behavior during the entire quarter and they answered no. Progress notes dated 6/3/18 document R1 missed his blood sugar test at 11:30 and missed his 5:00 PM medications and blood sugar test due to remaining out on pass. Writer asked why a more precise drug screen was not ordered for R1, when there was a suspicion of substance abuse, and R1 was prescribed [MEDICATION NAME]. V1 answered that's what the doctor ordered. V1 stated the Substance Abuse Care Plan was initiated because of the 5/6/18 incident, we did not suspect substance abuse before that, and there was no history. On 8/2/18 at 4:30 PM V1 Administrator stated that R1 left the facility around 8:00 AM on 7/24/18. R1 signed out in the log book. I got a call from the police the morning of 7/25/18 saying they found R1 on Lawrence (Street) unresponsive. The paramedics pronounced him dead, and stated it did not appear to have been from foul play. R1 signed out but did not put a time returning in the log book. R1 had an order for [REDACTED]. On 8/16/18 at 2:20 PM via telephone V1 stated that when R1 will not return at curfew, 10:00 PM, we (facility staff) called his cell phone and didn't get an answer, we called the family and left a message, we did not call the police. On 8/3/18 at 9:49 AM and 8/8/18 at 12:30 PM V4 Social Service Director stated that R1 had an order for [REDACTED]. The residents are supposed to be back in the building by 10:00 PM. If they are not, they have to call the Nurse on duty. There had been a few encounters where we educated and counseling R1 on refusing care meds and treatment. R1 was able to make his own decisions and had a right to refuse meds and treatment, we cannot control that. The only intervention we used for R1 was re-education. We did not do a behavioral contract. We had never suspended pass privileges for R1. The only intervention we used was counseling and education. We suggested groups for R1, but he refused to attend. The drug test in (MONTH) was positive, but R1 was prescribed [MEDICATION NAME] here. I was informed of his suspected drug use on 7/6/18. I have been here since (MONTH) of this year, since then, I have not suspected R1 of drug abuse. R1 has some resistance to wound care, he was getting better after education. Our policy for pass privileges is the the first offence is education and counseling, but no suspension of pass privilege. The second offense, we restrict pass privileges. R1 was here for rehab and medication management. R1 has never had a suspension of pass privileges. On 8/15/18 at 12:30 PM V15 Primary Care Physician via telephone stated that I did not suspect substance abuse, that's why I didn't order a more detailed test. R1 was noncompliant, but I would talk with him and he would get better. I was not aware he was discharged from Physical Therapy for lack of participation. I did know he would refuse medication and wound care, but after talking with him he would improve, so I didn't restrict his pass. The Minimum Data Set Section C Brief Interview for Mental Status (test for cognation) dated 6/8/18 for R1 documents 15 out of 15. Progress Notes for R1 document; 7/3/18 Resident been oof (out of facility) since apprx 10:30 AM resident missed his 1 PM/5 PM meds (medications) and blood sugar at that time. Resident left in fair condition. 7/4/18 Resident refused all meds. 7/5/18 Glucerna two times a day Glucerna 1.2 did not want. 7/8/18 @ (at) approx. 10:25 AM resident went oof (out of facility) without returning for 1 PM/5 PM meds and blood sugar @ this time. Resident left in fair condition via w/c (wheelchair) @ that time. 7/10/18 Resident invited to community integration group, Stepping Stones and has agreed to join. However, resident was not in attendance today due to being out on pass. 7/13/18 Social Services, Care Plan and Therapy Representative met with resident on 7/11/18 to have a Care Plan meeting on 7/12 at 9 AM to discuss care issues. CP (Care Plan ) was to be in his room (per his request). At 9 AM staff from SS (Social Services), CP (Care Plan) and Therapy present for meeting. Resident not in his room, not in Dining Room, not on smoking Patio. Resident signed out of building at 7:10 AM and has not returned, DON (director of Nursing) and Administrator aware. 7/17/18 Resident refused his 7 U (units) of Humalog (insulin) @ this time. Resident stated I'll be back. social services notified @ at this time. 7/16/18 Resident given 1/2/cup juice. Resident went oof (out of facility) before writer could re-check his blood sugar. Social Services notified @ this time. 7/19/18 Humalog inject 7 U subcutaneously three times a day related to type two diabetes mellitus without complications. Resident did not want it. R1 continues to be noncompliant with letting staff weigh him weekly, will try and get social services involved. 7/21/18 Humalog inject 7 U subcutaneously three times a day related to type two diabetes mellitus without complications. Out on pass. On 8/10/18 at 11:30 AM V10 Physical Therapy Director stated that R1 was discharged on [DATE] from PT (Physical Therapy ) for lack of participation. The PT order was for prosthetic leg training starting on 5/6/18. There was a Care Plan meeting and a re-evaluation was done on 7/20/18. We saw R1 once on 7/23. On 8/8/17 at 10:30 AM V7 Wound Care Nurse stated that I have worked here about two months. R1 sometimes just flat out refused wound care. Other times he was not in the building when the wound care was to be done. We talked about compliance many times, educated on turning, off loading, he understood. I would set up times agreeable to R1 for wound care and he would not be in the building. He had a manual wheelchair with a cushion and a low air loss mattress. R1 was supposed to take supplements for his wounds, he didn't usually take them. R1 refused to see the Wound Care Doctor. R1 has declined wound care numerous times. Progress Note dated 6/12/18 written by V11 Wound Care Physician documents ; Signing off on patient who remains in the facility due to refusals. Progress Note dated 6/19/18 by V7 Wound Care Nurse documents Resident (R1) approached for wound care and assessment by wound care nurse and wound care physician this AM. The resident stated that he had not been seen by a wound doctor in a long time. Wound Doctor advised the resident that she used to follow him however he never was available to be seen and he was always out of the facility when doing her rounds. Resident was asked if he wanted to be seen by wound care doctor this morning and he refused again stating maybe in a month. The resident has refused wound care multiple times. He has been educated multiple of the risks and consequences of not following proper wound protocol and protective and preventive measures. The resident is frequently verbally abusive to staff and frequently refuses wound care. MD (Medical Doctor) aware, no new orders at this time, Adam (administration) and Social Services also aware. R1's wound assessment worksheet dated 1/8/18 documents R1's sacrum pressure ulcer measured 1 (centimeter) by 1 (centimeter) with a depth of 0.3 (centimeter). The Skin and Wound assessment dated [DATE] documents R1's sacrum pressure ulcer as measuring 3.2 (centimeter) by 3.0 (centimeter) with a depth of 0.2 (centimeter). The documents do not indicate centimeter. V7 stated that the measurements were in centimeters. On 8/10/18 at 9:30 AM V8 LPN (Licensed Practical Nurse) stated that R1 was compliant about AM meds, not compliant with afternoon meds. He did not take meds with him. I work Wednesday, Thursday, Friday. Not often here for afternoon meds. He usually came back around 9 to 10 PM, so I didn't see him return. My shift ends at 7 PM. Progress Notes dated 5/2/18 at 1:40 PM by V1 Administrator document ; R1 is suspected to be under the influence. He appears to be drowsy and sleepy. Staff collected urine. Awaiting for results. Will make needed recommendations when result comes. Laboratory results for R1 collected 5/2/18 document urine drug screen positive for opiates. There are no quantitative or qualitative results. On 8/10/18 at 10:30 AM ADON (Assistant Director of Nursing) stated that the drug test for R1 was positive, we assumed it was from his prescription for [MEDICATION NAME] here and did not restrict pass. The Care Plan for R1 dated 5/2/18 documents; R1 is suspected to be under the influence of substance abuse-drowsy and sleepy. Fair developed ability to control impulses. Allowing negative, inappropriate persons to influence his use of substances. Problems and symptoms are manifested by: Going into the community to become intoxicated. On going self-harmful/self-destructive behavior (e.g.continuing to use substances in spite of serious health problems/consequences. Poor compliance with facility rules and regulations, not entering a treatment program. Failure to accept responsibility for actions and to be honest with oneself. Interventions: Work with resident to establish a verbal or written behavioral contract specifying what is and what is not allowed Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances and intoxication. Meet with the IDT (interdisciplinary Team) to discuss the extent of the resident's illness. The physician may consider a referral to the psychiatrist and/or write an order restricting pass privileges. Implement increasingly restrictive interventions in an effort to help the resident break the addictive cycle. Interventions may include, supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substances. The Care Plan for R1 dated 5/22/18 documents, R1 appears to be capable of outside passes. Interventions/Tasks- Explain that receiving and maintaining an on-going pass privilege is contingent upon compliance with her/his care/treatment plan. Explain that any violation of the facility policy governing substance use alcohol, illicit drugs will result in immediate revocation of this pass. The facility policy titled,Outside Pass Policy dated 8/2017 documents Consequences of Non Compliance; Persons who receive an outside pass and engage in non-compliant behavior, including but not limited to, substance use/abuse, bringing contraband into the facility, criminal behavior, behaviors that constitute a public nuisance or danger and aggressive, inappropriate behavior. Administration, the physician and or social service director will evaluate the individuals behavior and consider revoking outside pass privileges. Once revoked, the following consequences apply. First revocation- two weeks of pass suspension. Second revocation - one month pass suspension.

Based on interview and record review, the facility failed to implement the Suspected Substance Abuse Care Plan for one resident (R1) by not restricting outside pass privileges when resident was tested positive for opiates. The facility also failed to follow the outside pass policy and revise or restrict outside pass privileges after testing positive for opiates for 1 of 1 (R1) residents reviewed for psychosocial services and substance abuse behaviors. These failures resulted in R1 being allowed to independently access the community and was found lying outside on a sidewalk unresponsive, and being pronounced dead by the local paramedics. R1's death certificate documents the cause of death [MEDICATION NAME] (4-ANPP), [MEDICATION NAME], and [MEDICATION NAME] toxicity. Findings Include: R1 is a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1 was found unresponsive on 7/25/18 on a sidewalk and pronounced dead by paramedics. R1's death certificate documents cause of death as [MEDICATION NAME] (4-ANPP), [MEDICATION NAME], and [MEDICATION NAME] toxicity. After review of R1's POS (physician's orders [REDACTED]. There is an order for [REDACTED]. R1 has a unsupervised open pass to the community by V15 MD (Medical Doctor) The Community Survival Skills assessment dated [DATE] documents, R1 appears capable of unsupervised outside passes. Section 10. The resident sufficiently follows rules addressing medication compliance, participation in his/her treatment plan, appropriate hygiene and grooming and treats others with respect, is checked off yes. On 8/15/18 at 9:00 AM V1 Administrator, V3 ADON (Assistant Director of Nursing), V4 Social Services, V12 Acting DON (Director of Nursing), and V13 Assistant Administrator stated that the Community Survival Skills Assessment is based on the MDS (Minimum Data Set) 7 day look back period. For R1 this was 6/1 through 6/7 (YEAR). R1 was compliant during this period. Writer asked if this is a true assessment of behavior during the entire quarter and they answered no. Progress notes dated 6/3/18 document R1 missed his blood sugar test at 11:30 and missed his 5:00 PM medications and blood sugar test due to remaining out on pass. Writer asked why a more precise drug screen was not ordered for R1, when there was a suspicion of substance abuse, and R1 was prescribed [MEDICATION NAME]. V1 answered that's what the doctor ordered. V1 stated the Substance Abuse Care Plan was initiated because of the 5/6/18 incident, we did not suspect substance abuse before that, and there was no history. On 8/15/18 at 12:30 PM via telephone V15 Primary Care Physician stated that I did not suspect substance abuse, that's why I didn't order a more detailed test. R1 was noncompliant, but I would talk with him and he would get better. I was not aware he was discharged from Physical Therapy for lack of participation. I did know he would refuse medication and wound care, but after talking with him he would improve, so I didn't restrict his pass. Progress Notes for R1 document; 7/3/18 Resident been oof (out of facility) since apprx 10:30 AM resident missed his 1 PM/5 PM meds (medications) and blood sugar at that time. Resident left in fair condition. 7/4/18 Resident refused all meds. 7/5/18 Glucerna two times a day Glucerna 1.2 did not want. 7/8/18 @ (at) approx. 10:25 AM resident went oof (out of facility) without returning for 1 PM/5 PM meds and blood sugar @ this time. Resident left in fair condition via w/c (wheelchair) @ that time. 7/10/18 Resident invited to community integration group, Stepping Stones and has agreed to join. However, resident was not in attendance today due to being out on pass. 7/13/18 Social Services, Care Plan and Therapy Representative met with resident on 7/11/18 to have a Care Plan meeting on 7/12 at 9 AM to discuss care issues. CP (Care Plan ) was to be in his room (per his request). At 9 AM staff from SS (Social Services), CP (Care Plan) and Therapy present for meeting. Resident not in his room, not in Dining Room, not on smoking Patio. Resident signed out of building at 7:10 AM and has not returned, DON (director of Nursing) and Administrator aware. 7/17/18 Resident refused his 7 U (units) of Humalog (insulin) @ this time. Resident stated I'll be back. social services notified @ at this time. 7/16/18 Resident given 1/2/cup juice. Resident went oof (out of facility) before writer could re-check his blood sugar. Social Services notified @ this time. 7/19/18 Humalog inject 7 U subcutaneously three times a day related to type two diabetes mellitus without complications. Resident did not want it. R1 continues to be noncompliant with letting staff weigh him weekly, will try and get social services involved. 7/21/18 Humalog inject 7 U subcutaneously three times a day related to type two diabetes mellitus without complications. Out on pass. On 8/10/18 at 11:30 AM V10 Physical Therapy Director stated that R1 was discharged on [DATE] from PT (Physical Therapy ) for lack of participation. The PT order was for prosthetic leg training starting on 5/6/18. There was a Care Plan meeting and a re-evaluation was done on 7/20/18. We saw R1 once on 7/23. Progress Note dated 6/12/18 written by V11 Wound Care Physician documents ; Signing off on patient who remains in the facility due to refusals. Progress Note dated 6/19/18 by V7 Wound Care Nurse documents Resident (R1) approached for wound care and assessment by wound care nurse and wound care physician this AM. The resident stated that he had not been seen by a wound doctor in a long time. Wound Doctor advised the resident that she used to follow him however he never was available to be seen and he was always out of the facility when doing her rounds. Resident was asked if he wanted to be seen by wound care doctor this morning and he refused again stating maybe in a month. The resident has refused wound care multiple times. He has been educated multiple of the risks and consequences of not following proper wound protocol and protective and preventive measures. The resident is frequently verbally abusive to staff and frequently refuses wound care. MD (Medical Doctor) aware, no new orders at this time, Adam (administration) and Social Services also aware. On 8/10/18 at 9:30 AM V8 LPN (Licensed Practical Nurse) stated that R1 was compliant about AM meds, not compliant with afternoon meds. He did not take meds with him. I work Wednesday, Thursday, Friday. Not often here for afternoon meds. He usually came back around 9 to 10 PM, so I didn't see him return. My shift ends at 7 PM. On 8/8/17 at 10:30 AM V7 Wound Care Nurse stated that I have worked here about two months. R1 sometimes just flat out refused wound care. Other times he was not in the building when the wound care was to be done. We talked about compliance many times, educated on turning, off loading, he understood. I would set up times agreeable to R1 for wound care and he would not be in the building. The wounds remained stable. He had a manual wheelchair with a cushion and a low air loss mattress. R1 was supposed to take supplements for his wounds, he didn't usually take them. R1 refused to see the Wound Care Doctor. R1 has declined wound care numerous times. Progress Notes dated 5/2/18 at 1:40 PM by V1 Administrator document ; R1 is suspected to be under the influence. He appears to be drowsy and sleepy. Staff collected urine. Awaiting for results. Will make needed recommendations when result comes. Laboratory results for R1 collected 5/2/18 document urine drug screen positive for opiates. There are no quantitative or qualitative results. On 8/3/18 at 9:49 AM and 8/8/18 at 12:30 PM V4 Social Service Director stated that R1 had an order for [REDACTED]. The residents are supposed to be back in the building by 10:00 PM. If they are not, they have to call the Nurse on duty. There had been a few encounters where we educated and counseling R1 on refusing care meds, and treatment. R1 was able to make his own decisions and had a right to refuse meds and treatment, we cannot control that. The only intervention we used for R1 was re-education. We did not do a behavioral contract. We had never suspended pass privileges for R1. The only intervention we used was counseling and education. We suggested groups for R1, but he refused to attend. The drug test in (MONTH) was positive, but R1 was prescribed [MEDICATION NAME] here. I was informed of his suspected drug use on 7/6/18. I have been here since (MONTH) of this year, since then, I have not suspected R1 of drug abuse. R1 has some resistance to wound care, he was getting better after education. Our policy for pass privileges is the the first offence is education and counseling, but no suspension of pass privilege. The second offense, we restrict pass privileges. R1 was here for rehab and medication management. R1 has never had a suspension of pass privileges. On 8/2/18 at 4:30 PM V1 Administrator stated that R1 left the facility around 8:00 AM on 7/24/18. R1 signed out in the log book. I got a call from the police the morning of 7/25/18 saying they found R1 on Lawrence unresponsive. The paramedics pronounced him dead. R1 signed out but did not put a time returning in the log book. R1 had an order for [REDACTED]. On 8/10/18 at 10:30 AM V3 ADON (Assistant Director of Nursing) stated that the drug test for R1 was positive, we assumed it was from his prescription for [MEDICATION NAME] here and did not restrict pass. On 8/8/18 at 11:45 AM R 4 stated that R1 had a known substance abuse problem. He probably thought he was tolerate and took to much. They (facility) probably didn't know, or didn't want to know about his drug use. The Minimum Data Set Section C Brief Interview for Mental Status (test for cognation) dated 6/8/18 for R1 documents 15 out of 15. The Care Plan for R1 dated 5/2/18 documents; R1 is suspected to be under the influence of substance abuse-drowsy and sleepy. Fair developed ability to control impulses. Allowing negative, inappropriate persons to influence his use of substances. Problems and symptoms are manifested by: Going into the community to become intoxicated. On going self-harmful/self-destructive behavior (e.g.continuing to use substances in spite of serious health problems/consequences. Poor compliance with facility rules and regulations, not entering a treatment program. Failure to accept responsibility for actions and to be honest with oneself. Interventions: Work with resident to establish a verbal or written behavioral contract specifying what is and what is not allowed Make sure the resident is aware of rules prohibiting use of alcohol, illicit substances and intoxication. Meet with the IDT (interdisciplinary Team) to discuss the extent of the resident's illness. The physician may consider a referral to the psychiatrist and/or write an order restricting pass privileges. Implement increasingly restrictive interventions in an effort to help the resident break the addictive cycle. Interventions may include, supervision while in the community, restricted independent pass privileges, implementation of money guidance and budget controls to reduce/prevent access to substances. The Care Plan for R1 dated 5/22/18 documents, R1 appears to be capable of outside passes. Interventions/Tasks- Explain that receiving and maintaining an on-going pass privilege is contingent upon compliance with her/his care/treatment plan. Explain that any violation of the facility policy governing substance use alcohol, illicit drugs will result in immediate revocation of this pass. The facility policy titled,Outside Pass Policy dated 8/2017 documents Consequences of Non Compliance; Persons who receive an outside pass and engage in non-compliant behavior, including but not limited to, substance use/abuse, bringing contraband into the facility, criminal behavior, behaviors that constitute a public nuisance or danger and aggressive, inappropriate behavior. Administration, the physician and or social service director will evaluate the individuals behavior and consider revoking outside pass privileges. Once revoked, the following consequences apply. First revocation- two weeks of pass suspension. Second revocation - one month pass suspension.

Based on observation, record review and interview, the facility failed to provide adequate, accurate and timely care for two sampled residents, R7, R20. This deficient practice resulted in the following: 1. R7 developed a pressure related lacerated wound to her left earlobe which was discovered during a recent hospital stay for an unrelated problem; R7 required a repeat surgical intervention of a chest mass wound which was not being assesses by staff; 2. R20's venous access site for [MEDICAL TREATMENT] treatment became clotted and R20 required surgical intervention to unclog this access site. Findings include: 1. R7 is a [AGE] year old resident admitted to the facility on [DATE]. R7's [DIAGNOSES REDACTED]. R7 also has a history of Shortness of Breath and requires continuous Oxygen therapy. On 11/12/10 R7 underwent surgical biopsy of a chest mass. During general observations on 11/16/10 at approximately 10:30am, R7 was observed in bed, awake and alert. The surgical incision site on R7's chest was exposed and the wound appeared swollen and beet-red in color, with sutures intact. Oxygen therapy was in progress, the oxygen nasal cannula in place with the left segment of tube taped to R7's left cheek and not behind the ear. R7's left ear was not visible behind her hair and at surveyor's request R7 pushed her hair aside for a view of the left ear. There was no dressing on the earlobe and there was a notable area on laceration at the junction of the left earlobe and the head. When surveyor asked R7 about the origin of this wound, R7 stated she did not want to talk about it as she does not want to get anyone in trouble. R7 stated that her physician ordered an ointment for the left ear wound but staff have not put any on the wound since re-admission. Nursing notes dated 10/3/10 through 11/12/10 states R7 was receiving oxygen therapy and resident's skin being intact, with occasional documentation of onychomycosis of both feet. Nursing notes dated 11/12/10 states R7 was sent to hospital for a scheduled outpatient biopsy of a soft tissue chest wall mass at 7:30am. At 11:50pm nurses notes states that R7 did not return to the facility from the appointment. R7 returned to the facility on [DATE]. There is no documentation as to the reason R7 was admitted to the hospital. Z6 told surveyor during an interview that when R7 was at the hospital for an outpatient procedure, R7 was noted to have a lacerated wound to the left earlobe, which, per R7's report to hospital staff, was a result of the Oxygen nasal cannula cord being too tight around R7's face. Z6 stated that R7 said complained repeatedly to facility staff about cord being too tight and that facility staff failed to address R7's complaint. Review of R7's hospital records dated 11/12/10 states R7 arrived to the operating room with an erosion on the left earlobe. A separate documentation stated "left ear noticed to have some [DIAGNOSES REDACTED] (swelling) and cartilage breakdown. Patient is a nursing home resident, sometimes requiring oxygen". R7's head assessment revealed "costochondritis of left ear with breakdown through cartilage". R7's Nursing notes does not show what time R7 was readmitted to the facility. On 11/16/10's skin assessment states 'left ear breakdown' later described as 'skin irritation'. The surgical chest wound is described as 'reddened, dry, warm, [MEDICAL CONDITION] present'. The physician's orders [REDACTED]. E15, Treatment Nurse, told surveyor during an interview on 11/18/10 that this ear wound was due to the oxygen nasal cannula cord being too tight. During an interview with E15, Treatment Nurse, on 11/16/10 at approximately 2:30pm, E15 named all the residents on the unit receiving wound treatment. R7's name was not included. At 3pm R7 was again observed with no dressing on the left earlobe. Nursing notes dated 11/17/10, 6:17pm states R7 was transferred to the hospital for 'chest mass---- redness, swelling and warm to touch, and vomiting'. Later notation at 7:01pm states 'infection to biopsy site'. Social Service notes dated 11/17/10 at 6:33pm describes R7 refusing to eat lunch and complaining of nausea. Notes also stated that 'mass was swelling up and red', and that 'resident reported having burning pain surrounding mass at level of 8 - 10'. There is no documentation as to what time these symptoms developed. Nursing notes state the physician was contacted at 3:30pm, family at 6pm and resident transferred out at 6:17pm. There is a late entry note dated 11/18/10 at 5:44pm stating R7 was transferred to the hospital on [DATE] at 4:30pm. Nursing notes shows no evidence that timely and comprehensive assessments of R7's chest incision and left ear laceration having been done. Z6 told surveyor during an interview on 11/19/10 at 1pm that R7 underwent surgical intervention for an infected chest mass. 2. R20 is a [AGE] year old resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 was observed on 11/18/10 at 10am in her room, in bed, awake, watching television. R20's left forearm had multiple areas of bruising and four sutured incisions. R20 told surveyor that her [MEDICAL TREATMENT] became 'clogged' and she underwent a surgical procedure to remove the clot. R20 stated she has been receiving [MEDICAL TREATMENT] treatment since June 2010 and the access site has 'clotted' twice. R20 went on to say that facility staff do not monitor her access site; the only thing facility does is to arrange for transportation to and from the [MEDICAL TREATMENT] site. When asked by surveyor whether the nurses assess her [MEDICAL TREATMENT] upon return from [MEDICAL TREATMENT] treatment, R20 said 'No. They don't even check my blood pressure unless i ask them to'. R20 stated 'the staff at the [MEDICAL TREATMENT] center instructed her on how to check for bruit at the site and, if present, that means the site is open'. R20's clinical record confirms [MEDICAL TREATMENT] treatment three times weekly and the presence of an [MEDICAL CONDITION]-ventricular (AV) shunt in the left arm. The care plan states AV shunt is to be checked for bruit and staff to report to physician if absent. Care plan also states that facility is to coordinate with the [MEDICAL TREATMENT] center regarding treatments and change in status. During staff interview on 11/18/10 at approximately 11:30am, E18, Nurse, identified R20 as the only resident on her unit receiving [MEDICAL TREATMENT]. When asked what days R20 go to [MEDICAL TREATMENT], E18 stated she was not sure and proceeded to contact the facility staff who arranges for transportation. E18 was asked by surveyor what care is provided to residents on [MEDICAL TREATMENT], namely R20. E18 stated that she administers medications to the resident. Surveyor repeated the question asking whether she provides additional care for R20, a [MEDICAL TREATMENT] patient. E18 again stated that all she does for R20 is administer medications, and upon request to review nursing policy, stated that policy is locked up in the director of nursing's office. E4, Assistant Director of Nursing (ADON) told surveyor during a separate interview on 11/18/10 at 12 noon, that he does not know what the facility's policy on caring for a resident with AV shunt is. E4 stated that he worked as a floor nurse at the facility for four months and has been in an acting position as DON for the past one-and-a-half weeks. E4 went on to describe his opinion of nursing responsibility in caring for [MEDICAL TREATMENT] residents. Surveyor in turn requested of E1, Administrator, to the facility policy for nursing responsibilities in caring for [MEDICAL TREATMENT] residents. E1 stated that the nursing policy manual is not available because it was sent to it's corporate office for revision. E1 later presented to survey team a document which constitutes a statement that the facility has an agreement with an outside entity for provision of [MEDICAL TREATMENT]. Surveyor asked E1 again for it's nursing policy and E1 referred surveyor to the presented statement. Approximately 30 minutes after interview, E18 told surveyor that apart from giving medications to R20 that she also check the arm for bruit. During a telephone interview with Z7 on 11/18/10 at 1:15pm, Z7 confirmed that R20's [MEDICAL TREATMENT] became clogged twice, on 10/3/10 and on 11/15/10. Z7 explained to surveyor that R20's clogged access site was discovered when R20 arrived at the [MEDICAL TREATMENT] center, and this would have been discovered by the facility staff if they were monitoring R20's AV shunt. Z7 confirmed that R20 is educated by [MEDICAL TREATMENT] center staff on how to monitor and care for her 'shunt'. Z7 went on to say that there is no exchange of communication between [MEDICAL TREATMENT] center and the facility.