Every finding on record at Courtland Rehabilitation and Healthcare Center

Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 51 residents (Resident #98), in the survey sample which constituted harm.The findings included: 1. The facility staff failed to provide adequate supervision to ensure Resident #98 was safe from falling while transferring, which constituted harm.Resident #98 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #98 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included Alzheimer's Disease, essential hypertension, major depressive disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/12/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #98's cognitive abilities for daily decision making were severely impaired.A synopsis of an event dated 8/30/23 revealed that Resident #98 had a witnessed fall while a Certified Nursing Assistant (CNA) was transferring Resident #98 from a wheelchair to the bed. Resident #98 and the CNA lost their balance and both fell to the floor. Resident #98 was transferred to the hospital on 8/30/23 and was diagnosed with the following: facial laceration, closed fracture of nasal bone, and closed nondisplaced fracture of second cervical vertebra.A review of section GG (Functional Abilities and Goals) dated 8/15/23 of Resident #98's Minimum Data Set (MDS) coded the resident as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for chair/bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair). A review of Resident #98's Occupational Therapy Treatment Encounter Note dated 8/25/23 read: stand pivot transfer to wheelchair total assist. On 1/28/26 at 2:15 PM an interview was conducted with the Director of Nursing (DON). The DON stated that due to Resident #98 being coded as dependent for chair/bed-to-chair transfers, the CNA should have had her hands on Resident #98 at all times or should have had the assistance of another staff member. On 1/28/26 at 3:55 PM an interview was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated that Resident #98 was coded as total assist with transfers. The Director of Rehabilitation also stated that the CNA should have had hands on the resident at all times during a transfer from the wheelchair to the bed.A review of Resident #98's nurses note dated 8/30/23 at 4:45 PM read: Called to residents room by CNA, resident was noted to be on the floor on her left side. Blood was noted on the floor. Laceration was noted to middle of residents forehead. She was assessed for further injury and was assisted to the bed. Pressure was applied to forehead to stop bleeding. 911 was called and resident was transported to ER via ambulance. She was sent with her transfer paperwork and bedhold policy. Residents daughter was made aware of fall.A review of Resident #98's nurses note dated 8/30/23 at 10:25 PM read: Resident returned from hospital via ambulance. She has aspen collar intact to her neck. She returned with diagnosis of facial laceration, closed fracture of the nasal bone, and closed nondisplaced fracture of the second cervical vertebra, unspecified fracture morphology. Residents daughter made aware. She stated that she would be at the facility first thing in the morning.A review of Resident #98's Emergency Department documentation dated 8/30/23 read: Final Impression- 1. Facial laceration, initial encounter 2. Closed fracture of nasal bone, initial encounter 3. Closed nondisplaced fracture of second cervical vertebra, unspecified fracture morphology, initial encounter (HCC).A review of Post Fall Review documentation dated 8/30/23 at 10:25 PM read: Fall during transfer with CNA. Resident became combative and lost her balance and fell to the floor.A review of an Incident Report dated 8/30/23 at 4:45 PM read, Nursing Description: This nurse was passing meds when called to residents room by CNA, resident was laying on her left side. Blood was noted on the floor. Resident was assisted back to bed with 2 person assist and pressure was applied to forehead laceration. EMS was called. Other Info: Per CNA when transferring resident from wheelchair to bed, resident began resisting care and was pushing against the CNA, both resident and CNA lost balance and both fell to the floor. Statement: Her hand went up towards my face, she was saying something and jerking away from me, and then I fell to the side because I tripped over the leg rest. I'm not sure how she ended up falling forward but she fell face forward to the ground. I called for help, I did not move her, then (Nurse's name) and (CNA name) came in to help. (Nurse's name) assessed her and then we got (Resident #98's name) into bed.On 1/28/26 at 5:30 p.m. a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on information from the resident council task, resident interviews, staff interviews, and review of facility documents, the facility staff failed to educate the residents on how to file a grievance and resolve grievances as well as keeping the residents appropriately apprised of progress toward resolution for 4 of 51 residents (Resident #14, Resident #16, Resident #10, and Resident #76) in the survey sample.The findings included: 1. On 1/22/26 at 3:00 PM while conducting the resident council task, residents voiced that they do not know how to file a grievance or what the process is for resolving a grievance. Residents also voiced that they have never been educated on the process for filing a grievance. On 1/22/26 at 4:45 PM an interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. The Administrator stated that the residents are educated on the grievance process. The question was asked to the Administrator, how are the residents educated on the process to file a grievance? The Administrator stated, I'm not sure. The Administrator then stated, it is done during the admission process. On 1/28/26 at 11:18 AM an interview was conducted with the Recreation Director. The Recreation Director stated that she conducts the monthly Resident Council Meetings with the Residents. The Recreation Director also stated that she reviewed the monthly Resident Council meeting minutes from the time span of April 2023 to today's date and the residents have not been educated on the process of how to file a grievance during this time period. The Recreation Director further stated that she was under the impression that the residents knew how to file a grievance but agreed that if they are not educated, they probably do not know what the process is for filing a grievance.On 1/28/26 at 12:45 PM an interview was conducted with the Social Services Director. The Social Services Director stated that she is the Grievance Officer. The Social Services Director also stated that she has never educated the residents on the process of how to file a grievance. The Grievance Officer also stated that she does not know about any other staff members educating the residents on the process of how to file a grievance. On 1/28/26 at 5:30 p.m. a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations during the Medication Storage and Labeling and Medication Administration tasks, staff interviews, and a review of clinical records, the facility failed to ensure that medications were safe for administration. The findings included: 1. The facility staff failed to ensure that unscored medications were not split.On 1/22/26 at approximately 9:22 AM, during the Medication Administration task, Licensed Practical Nurse (LPN) #2 was observed cutting an unscored Fluphenazine HCl 10 MG Oral Tablet to obtain a dose of 15 MG. The physician's Order Summary stated to administer Fluphenazine HCl Oral Tablet 15 MG by mouth two times a day for Schizophrenia/Psychosis. The label on the medication stated to administer 10 MG, but the dosage was changed on 12/25/25 to 15 MG.This medication carries a boxed warning. Black box warnings are added only when substantial clinical data show the drug can cause severe harm, hospitalization, or death. (What Is a Black Box Warning? | John Hopkins | [NAME] School of Public Health)An interview was conducted with LPN #2, who stated that a new medication package had not been sent to the facility since the change in dosage and that the pharmacy had not been notified of what they had on hand to administer the ordered dosage. She continued to split the pill to obtain the ordered dose.In the facility's Nursing Care Center Pharmacy Policy and Procedure Manual dated 2007. The manual instructed users to answer the following question to determine whether a pill could be split: Question #2 asked whether the tablet was scored (i.e., had an indented line in the center). If it is not, don't split the pill.An interview was conducted with the Director of Nursing (DON) on 1/23/26 at approximately 1:40 PM. The DON stated that the pharmacy had been notified of the need to split the medication to obtain the ordered dosage so they could send an appropriate medication to the facility. The DON further stated that the pharmacy sent the same medication to the facility, and the facility's staff would address the concern directly with the Pharmacist. On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no comments and voiced no concerns regarding the above information. 2. The facility staff failed to ensure that multi-dose vials, which were accessed, were dated when opened.On 1/22/26, the medication storage task was conducted at approximately 1:50 PM with LPN #3. An observation was made of an opened vial of Tuberculin, purified protein derivative, in the refrigerator. The date the vial was opened was not on the vial or box. LPN #3 stated she did not know when it had been opened or for whom it was opened for since neither the box nor the vial was dated. LPN #3 stated that if the date was on the vial stated when it was opened, it could be used for 28 days. LPN #3 returned the undated multi-dose vial of Tuberculin, purified protein derivative, to the refrigerator with medications that were safe for administration. On 1/23/25 at approximately 2:30 PM, the Director of Nursing stated that the undated multi-vial of Tuberculin, purified protein, had been removed from use and discarded because the date it was opened was unknown.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no comments and voiced no concerns regarding the above information. INDICATIONS AND USAGE - TUBERSOL Tuberculin Purified Protein Derivative (Mantoux) is indicated to aid the diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease. (https://www.fda.gov/media/74866/download) STORAGE - Store at 2 to 8 C (35 to 46 F). (20) Do not freeze. Discard product if exposed to freezing.Protect from light. Tuberculin PPD solutions can be adversely affected by exposure to light.The product should be stored in the dark except when doses are actually being withdrawn fromthe vial. (21)A vial of TUBERSOL which has been entered and is in use for 30 days should be discarded. (https://www.fda.gov/media/74866/download)

Based on observations, resident and staff interviews, and a review of clinical records, the facility staff failed to ensure resident care equipment was maintained in a safe operating condition for 1 of 51 residents (Resident #3) in the survey sample. The findings included: Resident #3 was initially admitted to the facility on [DATE], after a stay in another long-term care facility. The residents' diagnoses included diabetes and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/2/25, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of a possible 15. This indicated Resident #3's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as independent for eating and personal hygiene; dependent on upper-body dressing, lower-body dressing, toileting, removing footwear, and showering/bathing. In section GG0170. Mobility: the resident was coded as requiring partial/moderate assistance with rolling in bed, and as dependent for sit-to-lying, lying-to-sitting, and transfers.On 1/20/26 at 1:15 PM, the resident was interviewed in her room during the initial tour. Resident #3 stated the over-the-bed table had fallen on her knees again, and she needed pain medication to tolerate the discomfort. The resident also stated that she has knee pain, but they hurt more often since she was being hit by the over-the-bed table multiple times each day. The resident stated she has had the over-the-bed table since her admission to the facility and has complained to staff that it falls onto her knees without warning. She stated the nurses had tried to work on it, but it continued to drop down and hit her knees. An observation of the resident's knees on 1/20/26 at approximately 1:21 PM. Both knees were mildly reddened, and the right had a small purplish bruise. The resident stated that they may not look like they hurt, but they hurt, and to try having a table fall on your knees multiple times each day. Shortly after leaving the resident's room, the Rehabilitation Director was observed entering the resident's room with another over-the-bed table and later going down the corridor with another over-the-bed table. On 1/28/26, at approximately 3:09 PM, an interview was conducted with the Rehabilitation Director. She stated she overheard the resident complaining about the over-the-bed table. She attempted to repair it, but once her personal items were placed on the table, it would suddenly drop. The Rehabilitation Director stated that she obtained another over-the-bed table and replaced the defective one. She stated the defective table was given to the Maintenance Director for repair.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing, and the Regional Clinical Director. The above concerns were addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. They had no comments and voiced no concerns

Based on resident and staff interviews and a review of clinical records, the facility staff failed to include the discharge-preference information for 2 of 51 residents (Resident #67 and #25) in the survey sample. The findings included: 1. The facility staff failed to include Resident #67's discharge preference in the comprehensive person-centered care plan.Resident #67 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' diagnoses included dementia, colitis, and high blood pressure. The quarterly MDS assessment, with an assessment reference date (ARD) of 1/15/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 11 out of a possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were moderately impaired. A review was made of Resident #67's quarterly MDS assessment dated [DATE], section Q0400. Discharge Plan. The MDS was coded that active discharge planning was not underway to return the resident to the community. At Q0500. Return to Community. The MDS was coded that the resident, or another designated person, does not want to discuss the possibility of leaving this facility to return to the community to live and receive services.The residents' person-centered care plan, with a revision date of 10/26/25, had a problem that the length of stay was to be determined. The goal stated (name of resident) to work with staff to obtain her maximum potential to return home through the next review on 4/15/26. The intervention dated 10/14/25 stated that (name of the resident) will work with staff to go home alone. An interview was conducted with Resident #67 on 1/20/26 at 2:22 PM. Resident #67 stated that she wanted to move to a town closer to her friend so her friend would not have to travel 40 minutes to visit. The resident stated that her care plan conference was scheduled for 1/21/26, but the Interdisciplinary Team did not come to get her as they said they would, causing her to miss the conference. Resident #67 stated she wants the Team to work towards her goal of discharging to a facility closer to her friend.An interview was conducted with the Social Worker (SW) on 1/28/26 at approximately 1:50 PM. The SW stated that Resident #67 changes her mind frequently, and without the friend's input, they had not set an achievable goal. The SW stated that the resident's home had been foreclosed on and that she had nowhere to go because her friend's apartment was no longer an option. The SW stated that she was assessing the residents' finances before making any further decisions about where she could possibly reside. The SW stated she was not aware that the comprehensive care plan was to be developed and implemented to meet the residents' preferences and goals, regardless of the barriers. On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to provide additional information, but they did not, and no concerns were voiced regarding the above information. 2. The facility staff failed to include Resident #25's preference to return to the community on the comprehensive person-centered care plan.Resident #25 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include hypertension and chronic anemia. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/11/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 15 out of a possible 15. This indicated Resident #25's cognitive abilities for daily decision making were intact. A review was made of Resident #25's quarterly MDS assessment dated [DATE], section Q0400. Discharge Plan. The MDS was coded that active discharge planning was not underway to return the resident to the community. At Q0500. Return to Community. The MDS was coded that the resident, or another designated person, does not want to discuss the possibility of leaving this facility to return to the community to live and receive services. Section Q0610. Referral. It was also coded that a referral had not been made to the Local Contact Agency because it was not wanted.The residents' person-centered care plan, with a revision date of 1/14/26, failed to address the residents' preferences and their goal of returning to the community. An interview was conducted with Resident #25 on 1/21/26 at 11:10 AM. Resident #25 stated that he desired vision and dental services, but his greatest goal was to get out of the facility, for as long as he resided in the facility, he would not get to go fishing or have a relationship with a woman. An interview was conducted with the Social Worker (SW) on 1/28/26 at approximately 1:50 PM. The SW stated that Resident #25's brother interrupted the discharge plan for the resident's discharge to his home on 8/25. The SW further stated that the resident cannot return to the group home he previously resided in due to the condition it was left in, and that his income was too low to afford most places. The SW stated the resident recently approached her about discharging him to Union Mission, and she stated she would follow up on his suggestion after the bad weather passes. The SW stated she was not aware that the comprehensive care plan was to be developed and implemented to meet the residents' preferences and goals, regardless of the barriers. On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to provide additional information, but they did not, and no concerns were voiced regarding the above information.

Based on interviews with residents and staff and a review of the clinical record, the facility staff failed to protect 1 of the 51 residents in the survey sample (Resident #14) right to be free from physical abuse.Resident #14 was initially admitted to the facility on [DATE] following an acute-care hospital stay. The residents' current diagnoses include dementia, major depressive disorder, and atrial fibrillation. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/24/25, coded that the resident had completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated that Resident #14's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as independent with eating, oral hygiene, upper-body dressing, toileting, lower-body dressing, putting on/taking off footwear, and personal hygiene, and requiring partial/moderate assistance with showers/bathing. In section GG0170. Mobility: the resident was coded as independent with rolling in bed, sit-to-lying, lying-to-sitting, transfers, and walking.An interview was conducted with Resident #14 on 1/21/26 at 12:20 PM. The resident stated that she prefers not to eat in the dining room due to concerns about COVID-19 and influenza. The resident then stated her primary reason for not enjoying meals in the dining room was that a woman who wandered the hallways and into rooms had attacked her in the dining room. Resident #14 stated that she was in the dining room for the meal, and suddenly she was karate chopped 4 to 5 times from behind on her previously fractured right arm by the wandering woman. The resident stated that a man inside the kitchen rescued her from the woman. She stated that it was when she realized the severe pain in her right arm.A progress note written by the mental health NP dated 7/17/25 stated that during the visit, the resident continued to complain of right arm pain, and she discussed the attack. The mental health NP stated that the resident said that if she had her cane when she was attacked, she would have hit the person who attacked her in the head. The mental health NP stated the resident was redirected not to use violence but to inform staff so that they can handle the situation. She was encouraged to continue socializing with others, but to sit on the opposite side of the room from the person who attacked her.A review of the resident's nurse's notes revealed a progress note dated 7/16/25 at 12:40 PM, which stated the resident reported the attack and the pain she was experiencing. The nurse's note stated the resident reported a pain level of 8 to 10. The Nurse Practitioner's (NP) progress note dated 7/18/25 stated that the x-ray report showed no new findings, and the previous fracture was not completely healed. Over the days of the survey, 1/20/26 through 1/23/26 and 1/26/26 through 1/28/26. The resident who attacked Resident #14 was observed to wander from corridor to corridor and room to room with no interventions by the staff unless a resident called for assistance. Resident #14 stated that the attacker appears to be calmer, but she moves out of her way whenever she sees her coming.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. The Administrator stated that she did not complete a Facility-Reported Incident document because she believed it was not an abuse event, because it was not a willful act. The Administrator stated that she believed the other resident wanted Resident #14's attention.An example of a deliberate ( willful) action would be a cognitively impaired resident who strikes out at a resident within his/her reach. (SOM - Appendix PP, page 74)

Based on resident and staff interviews and a review of clinical records, the facility staff failed to notify the resident and/or the resident representative of changes for 2 of the 51 residents in the survey sample (Residents #37 and #88). The findings included:1. The facility's staff failed to notify Resident #37 of her test/laboratory results. Resident #37 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include diabetes, atrial fibrillation, and renal insufficiency. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/21/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated Resident #37's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as requiring setup or clean-up assistance with eating; partial/moderate assistance with oral hygiene and upper-body dressing; dependent assistance with toileting; lower-body dressing; putting on/taking off footwear; showering/bathing; and personal hygiene. In section GG0170. Mobility: the resident was coded as independent with rolling in bed, requiring partial/moderate assistance with sit-to-lying, lying-to-sitting, and transfers. On the initial tour with Resident #37 on 1/20/26 at approximately 1:31 PM. The resident stated that she had not been feeling well and was awaiting the results of the test conducted the day before, because the nurse suspected she might have the flu and a urinary tract infection (UTI). On 1/22/26, another interview was conducted with Resident #37, who stated that she had been asleep most of the day because she was still unwell. The resident further stated she had no appetite and was nauseated. She stated that she was still awaiting the results of her test. On 1/23/26 at approximately 1:55 PM, the resident again stated that she was not feeling well and that she had not been notified by nursing of the status of her test or of what could be done for her ill feelings. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 1/23/26 at approximately 2:25 PM. LPN #2 stated she had not been informed of any test results for Resident #37. LPN #2 reviewed the resident orders and identified the following orders dated 1/19/26: In-house COVID and flu test, one time only for 1 day, and a complete blood count, basic metabolic panel, urinalysis, and a urine culture and sensitivity, one time only for nausea/vomiting, dysuria for 2 days. LPN #2 stated that she would need to speak with Unit C Manager (UCM) to determine whether the tests ordered were completed and what the results revealed. LPN #2 later stated that UCM stated she would further investigate the identified concern and provide an update on the findings. On 1/28/26 at approximately 11:00 AM, Resident #37 stated that, shortly after our conversation on 1/23/26, a nurse came in and notified her that she had a yeast infection and would be started on a medication, and that she did not have COVID-19 or the flu. On 1/23/26, the Nurse Practitioner (NP) ordered the resident Fluconazole 150 MG: Give 1 tablet by mouth once daily for 7 days for a yeast UTI. On 1/23/26 at 5:23 PM, a late entry was documented in Resident #37's nurses' note for 1/19/26 at 2:23 PM. The late entry note stated that the resident was assessed per the provider's order for COVID-19 and Influenza swabs due to cold-like symptoms, and the results were negative for COVID-19 and Influenza. The note further stated that the Provider was notified of negative results. An interview was conducted with the NP on 1/28/26 at approximately 3:20 PM. The NP stated that it was not her responsibility to notify the resident and/or the resident's representative of test results, as that was the responsibility of the direct care nurses. The NP stated she added an addendum to her 1/19/26 progress note on 1/23/26 to state that the nurse notified her of Resident #37's test results on 1/19/26. The NP also stated that she delayed initiating medication for the yeast infection to determine whether additional laboratory results would be reported. The bottom of the lab report stated that no further workup performed. On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They offered no additional information and voiced no concerns regarding the above information. 2. The facility staff failed to notify the resident representative of a change in room for Resident #88. Resident #88 was originally admitted to the facility on [DATE]. The current diagnoses included; Alzheimer's Disease with late onset and malignant neoplasm of prostate. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were severely impaired. An interview was conducted with the Director of Nursing (DON) on 1/28/26 at 2:05 PM. The DON stated that Resident #88 had a change in room on five (5) different occasions and the resident representative was not notified. The DON also stated that the dates and location of the room changes were the following: 1/1/24 to Unit 1 30-A, 1/2/24 to Unit 1 28-A, 7/17/24 to Unit 1 26-A, 12/6/24 to Unit 2 33-A, and 12/6/24 to Unit 1 16-A. A review of the Clinical Census documentation for Resident #88 read that the resident had room changes on the following dates and room locations: 1/1/24 to Unit 1 30-A, 1/2/24 to Unit 1 28-A, 7/17/24 to Unit 1 26-A, 12/6/24 to Unit 2 33-A, and 12/6/24 to Unit 1 16-A. On 1/28/26 at 5:30 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. The Administrator stated, a resident or resident representative needs to be notified prior to the room change happening.

Based on observations and interviews with residents and staff, the facility staff failed to ensure a homelike environment for 2 of the 51 residents in the survey sample (Residents #36 and #50). The findings included:1. The facility staff failed to maintain a homelike environment for Resident #36, free of a wandering resident.Resident #36 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include a chronic left lower extremity blood clot, a stage 4 sacral wound, and an anxiety disorder. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/11/25, documented that the resident had completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated Resident #36's cognitive abilities for daily decision making were intact. On 1/20/26 at 12:06 PM, Resident #22 was observed in a wheelchair being pushed rapidly out of room [ROOM NUMBER], as the door slammed with great force, creating a loud noise that commanded attention; however, no one responded. Resident #22 was seen again at approximately 12:33 PM strolling on the opposite corridor of the unit, stopping at some doorways, and entering other rooms. She was observed asleep in her wheelchair in room [ROOM NUMBER], but the resident was out. At approximately 12: 46 PM, the resident was observed entering a dependent resident's room, who was asking her to leave the room, but Resident #22 continued to stroll about the room with no regard for the dependent resident's plea for her to leave. On 1/21/26 at approximately 10:13 AM, Resident #22 was observed again strolling along in the corridor and entering rooms that were not hers. There was no staff redirection, and when residents called for assistance to redirect her, she would be gone by the time staff responded to the call light. On 1/28/26 at 10:55 AM, an interview was conducted with Resident #36. Resident #36 stated that this is not a home because, if it were, you would be able to lock your doors to keep people out. Resident #36 also stated that the wanderers come in regardless of whether you are in or out, for they don't care. The resident stated that before leaving his room, he must ensure that all his mail, documents, cell phones, and personal items on the table are put away. The resident further stated that he must strategically position his bed and use other items to block wanderers from approaching the side of his bed where he keeps many personal effects, because he has had items removed from his room that were never recovered.The wandering concern was discussed with the facility staff on 1/22/26 at 4:35 PM, and the DON asked for recommendations for managing residents with wandering behaviors. The DON was directed to the facility's leadership.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information, but no concerns were voiced. 2. The facility staff failed to maintain a homelike environment for Resident #50, free of a wandering resident.Resident #50 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include Parkinson's disease, heart failure, and macular degeneration. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/2/25, coded that the resident had completed the Brief Interview for Mental Status (BIMS) and scored 14 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were intact. On 1/20/26 at 12:06 PM, Resident #22 was observed in a wheelchair being pushed rapidly out of room [ROOM NUMBER], as the door slammed with great force, creating a loud noise that commanded attention; however, no one responded. Resident #22 was seen again at approximately 12:33 PM strolling on the opposite corridor of the unit, stopping at some doorways, and entering other rooms. She was observed asleep in her wheelchair in room [ROOM NUMBER], but the resident was out. At approximately 12:46 PM, the resident was observed entering a dependent resident's room, who was asking her to leave the room, but Resident #22 continued to stroll about the room with no regard for the dependent resident's plea for her to leave. On 1/21/26 at approximately 10:13 AM, Resident #22 was observed again strolling along in the corridor and entering rooms that were not hers. There was no staff redirection, and when residents called for assistance to redirect her, she would be gone by the time staff responded to the call light. An interview was conducted with Resident #50 on 1/28/26 at 11:15 AM. Resident #50 stated that, because she has poor vision, she is unable to see all that the wandering resident is doing when the resident comes into her room. She said she asked the resident to leave, but it didn't result in her leaving. Resident #50 stated on one occasion that there was a book on tape at the bedside, and the resident picked it up. Resident #50 stated she used a bag of popcorn to bargain with the resident to prevent her from leaving with the audiobook. Resident #50 further stated that it is a problem to have the resident wandering into the room because she doesn't appear to understand what's said to her, and she fears she will take the items she keeps on the over-the-bed table.The wandering concern was discussed with the facility staff on 1/22/26 at 4:35 PM, and the DON asked for recommendations for managing residents with wandering behaviors. The DON was directed to the facility's leadership.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information, but no concerns were voiced.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed allow the residents' involvement in the care plan conference for 1 resident (Resident #67) in the survey sample of 51 residents.The findings Include:The facility staff failed to allow the residents' involvement in the care plan conference on 1/21/26.Resident #67 was initially admitted to the facility on [DATE], after an acute care hospital stay. The residents' diagnoses included dementia, colitis, and high blood pressure. The quarterly MDS assessment, with an assessment reference date (ARD) of 1/15/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 11 out of a possible 15. This indicated that Resident #67's cognitive abilities for daily decision making were moderately impaired. An interview was conducted with Resident #67 on 1/22/26 at 3:14 PM. Resident #67 stated that she did not like the activities the facility offered and wanted to move to a town closer to her friend so she would not have to travel 40 minutes to visit. The resident stated that her care plan conference was scheduled for 1/21/26, but the Interdisciplinary Team did not come to get her as they said they would, causing her to miss the conference.The resident had a letter in her possession that stated: Dear Resident/Representative, Your next Care Conference is scheduled for 1/21/26, at 11:15 AM. LOCATION: Please go to your resident's room; we will come and get you. The interdisciplinary team will meet to review your comprehensive plan of care. The meeting will take about 15 minutes, and you are encouraged to attend and participate in the planning of your care/your loved one's care. If you plan to attend, please RSVP by calling (name of the SW) at (phone number and extension).An interview was conducted with the Social Worker (SW) on 1/28/26 at approximately 1:50 PM. The SW stated that the resident came to her office before her conference was scheduled to begin. She instructed the resident to wait in her room, and that when her friend arrived, she would come to get her. The SW stated the resident's friend had called to confirm she would attend, but she did not show. The SW stated the Team wanted the friend present because Resident #67 changes her mind frequently, and the friend would help her set achievable goals. The SW stated that when the resident's friend did not show up, they did not go to get the resident to attend her care plan conference. The SW stated that, after discussing the concern, she recognized that the Team made a mistake by not involving the resident in participation.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to provide additional information, but they did not, and no concerns were voiced regarding the above information.

Based on family interview, staff interview, clinical record review and review of facility documentation the facility staff failed to ensure the necessary treatment, care and services were initiated for a Stage 2 pressure ulcer for 1 of 51 residents (Resident #96), a closed record resident, in the survey sample.The findings include: Resident #96 was originally admitted to the facility 06/09/23 and discharged to an acute care facility on 6/28/23. The current diagnoses included; Quadriplegia and Pressure induced deep tissue damage of the sacrum. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/16/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #96 cognitive abilities for daily decision making were intact.In sectionGG(Functional Abilities) the resident was coded as dependent toileting hygiene, lower body dressing, putting on/taking off footwear. Requires substantial/maximal assistance with upper body dressing and shower/bathe self. Coded as set-up or clean-up assistance with eating. In section M (Skin Conditions) coded as having an unstageable deep tissue pressure injury on admission.The above section M Skin conditions was not coded until in the MDS until 6/16/23. June 2023 Order Summary:Standard Pressure Ulcer Redistribution Mattress.AIR MATTRESS, verify function and settings per weight q shift every shift for to aid in wound healing Verbal Active 06/27/2023 06/27/2023AIR MATTRESS every shift for to aid in wound healing Verbal Active 06/15/2023 06/15/2023WEEKLY SKIN ASSESSMENT every evening shift every Thu for ROUTINE Phone Active 06/09/2023 06/15/2023 A review of the Hospital Discharge summary dated [DATE] read that the resident has a sacral wound requiring wound care with a foam border dressing. A review of the medical records on 6/09/23 through 6/12/23 revealed no wound care admission assessment had been completed on the resident until 6/13/23 by the Wound Care Nurse Practitioner (WCNP) reading Deep Tissue Injury (DTI).A review of the Baseline care plan dated 6/10/23 read Stage 2 sacrum. The BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK: dated 6/09/23 rated resident as a moderate risk, scoring a 14.0. SCORING:AT RISK 15-18MODERATE RISK 13-14HIGH RISK 10-12VERY HIGH RISK 9 or below. SENSORY PERCEPTION=Very limited. MOISTURE=occasionally moist. ACTIVITY=Chair Fast. MOBILITY=Very Limited. NUTRITION =Adequate. FRICTION &SHEAR=Potential Problem.The wound evaluation revealed dated 06/13/2023 revealed resident had a wound on her sacrum measuring Length: 2.0 cm. Width: 5.0 cm Depth 0.50 cm, Severity: DTI. Date wound acquired 6/09/23, present on admission with 50-74% epithelial, 50-74%granulation, 0% slough or eschar, Subcutaneous tissue with edges attached, fragile peri wound, scant amount of serosanguineous exudate, no odor. The Treatment: change dressing daily, cleanse with wound cleanser, treat with Medical grade honey with bordered foam dressing.A review of the Treatment Administration Record (TAR) for June 2023 revealed wound care treatments were initiated on 6/13/23 for Deep Tissue Injury (DTI). Prior to 6/13/23, no wound care treatment was observed in the Medication Administration Record (MAR) and TAR. A review of the June 2023 MAR/TAR revealed the following orders: Weekly skin assessment every shift on Thursdays beginning 6/09/23. Initialed on 6/16/23.Cleanse sacrum with normal saline, apply medihoney, cover with borderedgauze daily. every day shift for wound care dated 6/12/23, initial on 6/13/23. A review of medical records revealed Resident #96 was admitted to the facility on [DATE] from the hospital with a sacral wound requiring wound care. The Baseline care plan completed at the Long-Term Care (LTC) facility dated 6/10/23 revealed the resident had a stage 2 sacrum. The WCNP assessed the wound 3 days later indicating the resident was admitted with a DTI. The above assessments to include wound care, MDS documentation on wounds and wound care treatments were not assessed in a timely manner and treated until the WCNP had initiated treatment. On 1/26/26 at approximately 7:45 pm., a returned phone call was received by the resident's son (complainant). The family member said that the facility staff failed to keep his loved one from getting pressure ulcers by not providing care and treatment. He said that his mother was not aware that she had a stage 3 or 4 pressure ulcer when she was admitted to the facility. On 1/28/26 at approximately 10:10 am., an interview was conducted with the Wound Care Nurse Practitioner (WCNP). The WCNP said that she conducted the wound assessment on 6/13/23 as a Deep Tissue Injury (DTI). The WCNP also said that a stage 3 or 4 pressure ulcer was present on admission.On 1/28/26 at approximately 2:00 pm., an interview was conducted with Licensed Practical Nurse (LPN) #3 concerning Resident #96. LPN #3 said that she did the admission assessment and assessed the resident as a stage 2 pressure ulcer but don't remember the resident being that it was in 2023. LPN #3 also said that the Wound Care Nurse will come out the next day to assess the residents once notified if there's a wound.The Policy on Pressure Ulcers/Skin Breakdown-Clinical Protocol reads: The nursing staff and or practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. In addition, either the nurse, medical provider, or wound care provider, shall describe and document/report the following: Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will assist the staff to identify the type and characteristics of an ulcer. Deep Tissue Injury (DTI)- Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but due to the resiliency of the skin, the color change is not immediate, in contrast to a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotichttps://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htmOn 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. The Regional Clinical Director mentioned that a Performance Improvement Plan (PIP) dated 6/18/25 to 9/18/25 had been completed. The resident in question, Resident #96, was not included in the PIP. The DON said that nursing staff are not allowed to stage wounds and that the wound should have been assessed sooner.

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain dignity during mealtime for 1 of 51 residents (Resident #88), in the survey sample.The findings included: The facility staff failed to maintain dignity during mealtime by standing over a resident while feeding the resident. Resident #88 was originally admitted to the facility on [DATE]. The current diagnoses included; Alzheimer's Disease with late onset and malignant neoplasm of prostate.The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #88's cognitive abilities for daily decision making were severely impaired.In section GG (Functional Abilities) the resident was coded as setup or clean-up assistance with eating.On 1/22/26 at approximately 12:21 pm, a dining observation was made in the dining room. The Assistant Director of Nursing (ADON) was observed standing over Resident #88 while feeding the resident. The ADON continued to stand over Resident #88 for 9 (nine) minutes while continuing to feed the resident. On 1/23/26 at 2:35PM an interview was conducted with the ADON. The ADON stated that she should not have been standing over Resident #88 while she was feeding him. The ADON also stated that she knows this was wrong due to this being a dignity issue.On 1/28/26 at 5:30 p.m. a final interview was conducted with the Administrator, Director of Nursing, and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident and staff interviews and a review of facility documents, the facility staff failed to thoroughly investigate a report of missing personal property for 1 of 51 residents (Resident #14) in the survey sample.The findings includedResident #14 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include dementia, major depressive disorder, and atrial fibrillation. The annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/24/25, coded that the resident had completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated that Resident #14's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as independent with eating, oral hygiene, upper-body dressing, toileting, lower-body dressing, putting on/taking off footwear, and personal hygiene, and requiring partial/moderate assistance with showers/bathing. In section GG0170. Mobility: the resident was coded as independent with rolling in bed, sit-to-lying, lying-to-sitting, transfers, and walking.An interview was conducted with Resident #14 on 1/21/26 at 12:20 PM. The resident stated that a [NAME] watch her daughter had gifted to her was taken from her bedside table one night. The resident further stated that she recalled placing the watch in the drawer along with her cellphones before going to bed; however, when she opened the drawer the next morning, the phones were present, but the watch was absent. Resident #14 stated she reported to the nurse that her watch was missing. The resident also stated she believed she knew who had taken her watch from her drawer, but that person denied it.On 1/22/26 at approximately 3:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she searched under the mattress and other areas of the resident's room for the watch but did not find it. The DON also stated that she spoke with the resident's daughter regarding the missing watch, and the daughter was not concerned. The DON stated that the daughter said that the resident was known to misplace items and was unable to locate them later. A grievance report dated 7/29/25 was completed following the resident's report that her watch was missing. The grievance report stated that the resident's daughter said the watch was worth approximately $250.00, and she described it as a brown [NAME] watch with fake diamonds around the face. The grievance report was resolved on 8/5/25, but the watch was not located. and only the DON had actively attempted to locate it. No documentation was available from any other facility staff.An interview was conducted with the resident's daughter on 1/23/25 at approximately 10:14 AM. The daughter stated she had given the [NAME] watch to the resident and did not believe her mother had misplaced it.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information, but they did not.

Based on observations, resident and staff interviews, and a review of the clinical records, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 51 residents (Resident #52) in the survey sample.The findings included: Resident #52 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included GI bleeds, stroke, and high blood pressure. The quarterly MDS assessment, with an assessment reference date (ARD) of 1/4/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 12 out of a possible 15. This indicated that Resident #52's cognitive abilities for daily decision making were moderately impaired. An interview was conducted with Resident #52 on 1/20/26 at 2:44 PM. Resident #52 stated that the only assistance he sought was an eye examination and dentures. The resident stated that he had not received any dental services since admission to the facility. He opened his mouth to show that he had no natural teeth or dentures.A review of the comprehensive MDS assessment dated [DATE] at section L0200 (Dental), the resident was coded as having obvious or likely cavity or broken natural teeth.The Social Worker was informed of the resident's desires for a dental consultation for dentures on 1/28/26 at approximately 1:50 PM. The SW returned later and provided a document stating that the dentist would see the resident on 2/9/26. An interview was conducted with the MDS Coordinator on 1/28/26, at approximately 3:35 PM. The MDS Coordinator confirmed that the MDS assessment was not coded accurately and would modify it to reflect the resident's oral status: no natural teeth or fragments; edentulous. A copy of the modified MDS assessment was provided.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to provide additional information. They had no comments and voiced no concerns regarding the above information.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to one dependent Resident (Resident #10) in a survey sample of 51 Residents.The findings include: Resident #10 was originally admitted to the facility 9/19/2015 and re-admitted from an acute care facility on 7/11/25. The current diagnoses included; Pressure Ulcer Right Hip, Stage 4, Pressure Ulcer other site Stage 4 and Acquired absence of the Right Knee, above.The quarterly review Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. In Section GG Functional Abilities coded resident as dependent with showers/bathe self, toileting and personal hygiene. Resident coded as independent with eating.The person-centered care plan dated 4/25/25 read that the resident has an Activity of Daily Living (ADL) self-care performance deficit r/t paraplegic, limited ROM/contracture of left lower extremity and right AKA. The Goal for the resident was he will maintain current level of function, to be clean, odor free, well-groomed, appropriately dressed, well hydrated, and nourished throughout the review period through the review date. One of the Interventions was Bathing/showers: Per resident request bed bath only (revised on 1/22/2024).On 1/27/26 at approximately 11:18 am., a telephone interview was conducted with the resident's daughter with concerns that he was burned on his leg while staff was giving him a shower in 2023. 1/21/26 at approximately 1:57 pm., during the initial tour, an interview was conducted with Resident #10. Resident #10 said that he would like more showers, but they're saying they need more help due to being short-staffed.On 1/28/26 at approximately 10:57 am, a brief interview was conducted with Resident #10 concerning showers and the incident that his daughter alleges he was burned in the shower. Resident #10 said that he was never burned while taking a shower, but he did bump his leg against a wheelchair, causing his leg to bleed. The resident also reported that he showered last night. The resident also said that the staff had always told him that he couldn't take a shower due to the leg wound. The resident reports feeling much better since taking a shower. On 1/28/26 at approximately 2:00 pm., a brief interview was conducted with Licensed Practical Nurse (LPN) #3. She can't recall if the resident refused showers or was scalded in the shower. On 1/28/26, a brief interview was conducted at 3:00 pm. with Certified Nursing Assistant (CNA) #1 concerning Resident #10. CNA #1 said that Resident #10 get offered showers on the 11-7 shift on Thursdays and Sundays but will often refuse them.A review ADL (Activities of Daily Living) document reveal Resident #10 received a shower on the following days: 1/15/26 (Thursday), 1/22/26 (Thursday) and 1/28/26 (Wednesday).A review of the medical record revealed no shower refusals.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. The DON said that the resident refuses showers but no shower refusals were found in the medical record.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 1 of 51 residents (Resident #11), in the survey sample.The findings include:Resident #11 was originally admitted to the facility 5/23/24 and readmitted on [DATE] The current diagnoses included end stage renal disease requiring dialysis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #11 cognitive abilities for daily decision making were intact. The person-centered care plan dated 7/28/25 read that Resident #11 receive hemodialysis Monday, Wednesday and Friday (M/W/F) related to End Stage Renal Disease (ESRD). The Goal for the resident is resident will have immediate intervention should any s/s of complications from dialysis occur through the review date. The Interventions are to check dressing over dialysis port to ensure dry and intact every shift and to check vascular access monitoring every shift. A review of Resident #11's dialysis communication book and medical record revealed no dialysis communication notes from the dialysis center were available for review on 10/27/25 and 10/29/25. On 1/22/26 at approximately 3:58 pm., a brief interview was conducted with Resident #11 concerning her dialysis communication book. The resident stated she received dialysis services on Mondays, Wednesdays and Fridays from 11:00 am to 4:00 pm. The resident stated that the dialysis communication book is given to her to take to dialysis to communicate her care.On 1/22/26 at approximately 4:05 pm., a brief interview was conducted with Licensed Practical Nurse (LPN) #5 concerning the dialysis communication book. LPN #5 said that the communication book goes with the resident to dialysis and should have communication documentation in the book and in the Medical Records.On 1/28/26 at approximately 5:30 pm, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to provide additional information, but they did not, and no concerns were voiced regarding the above information.

Based on resident and staff interviews and a review of clinical records, the facility staff failed to document the results of in-house COVID and influenza tests for 1 of the 51 residents in the survey sample (Resident #37). The findings included:Resident #37 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses include diabetes, atrial fibrillation, and renal insufficiency. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/21/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scored 10 out of a possible 15. This indicated Resident #37's cognitive abilities for daily decision making were moderately impaired. In section GG0130. Self-Care: the resident was coded as requiring setup or clean-up assistance with eating; partial/moderate assistance with oral hygiene and upper-body dressing; dependent assistance with toileting; lower-body dressing; putting on/taking off footwear; showering/bathing; and personal hygiene. In section GG0170. Mobility: the resident was coded as independent with rolling in bed, requiring partial/moderate assistance with sit-to-lying, lying-to-sitting, and transfers.On the initial tour with Resident #37 on 1/20/26 at approximately 1:31 PM. The resident stated that she had not been feeling well and was awaiting the results of the test conducted the day before, because the nurse suspected she might have the flu and a urinary tract infection (UTI). On 1/22/26, another interview was conducted with Resident #37, who stated that she had been asleep most of the day because she was still unwell. The resident further stated she had no appetite and was nauseated. She stated that she was still awaiting the test results. On 1/23/26 at approximately 1:55 PM, the resident again stated that she was not feeling well and that she had not been notified by nursing of the status of her test or of what could be done for her ill feelings. A review of the resident Physician's Order Summary identified the following order dated 1/19/26: In-house COVID-19 and influenza (flu) test, one-time, for 1 day. An interview was conducted with Licensed Practical Nurse (LPN) #2 on 1/23/26 at approximately 2:25 PM concerning Resident #37's results of the COVID and flu test ordered on 1/19/26. LPN #2 stated she had not been informed of the COVID and flu test results for Resident #37. LPN #2 stated that she would need to speak with Unit C Manager (UCM) to determine whether the tests ordered were completed and what the results revealed. LPN #2 later stated that UCM stated she would further investigate if the test had been completed, and if they were, what the results were, and whether the information was documented in the resident's record.On 1/23/26 at 5:23 PM, a late entry was documented in Resident #37's nurses' note for 1/19/26 at 2:23 PM. The late entry note stated that the resident was assessed per the provider's order for COVID-19 and Influenza swabs due to cold-like symptoms, and the results were negative for COVID-19 and Influenza. The note further stated that the Provider was notified of negative results.On 1/28/26 at approximately 11:00 AM, Resident #37 stated that, shortly after our conversation on 1/23/26, a nurse entered and informed her that she did not have COVID or the flu. Before the inquiry about the ordered in-house COVID and flu test, no documentation was in the resident's record.An interview was conducted with the NP on 1/28/26 at approximately 3:20 PM. The NP stated she added an addendum to her 1/19/26 progress note on 1/23/26 to state that the nurse notified her of Resident #37's test results on 1/19/26, but she was unaware of the direct care nurse's documentation. On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information, and the DON stated that it is the responsibility of the licensed nurse who conducted the in-house test to document the test results in the resident's record.

Based on observations and staff interviews the facility staff failed to follow infection control practices. Therefore, increasing the chances of spreading infections, illnesses and diseases for 1 of 51 residents, Resident #10 in the survey sample. The findings include: Resident #10 was originally admitted to the facility 9/19/2015 and re-admitted from an acute care facility on 7/11/25. The current diagnoses included; Pressure Ulcer Right Hip, Stage 4, Pressure Ulcer other site Stage 4 and Acquired absence of the Right Knee, above. The quarterly review Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/22/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. In Section M skin conditions coded resident as dependent with showers/bathe self, toileting and personal hygiene. Resident coded as independent with eating.The person-centered care plan dated revised on 1/05/26 read resident has an actual impairment with potential for further skin impairment s/t decreased mobility/paraplegic, bowel incontinence. He prefers to always lay at a 45-degree angle or less at times in the bed. Resident is noncompliant with turning and repositioning. Actual wounds Stage 4 - Right Ischium, Stage 4 - Sacrum, Vascular- left lower leg. The Goal for the resident is Pressure wounds will show signs of improvement by review date. Vascular wound to left lower leg will resolve without complications through the next review date. The interventions are: Float left heel (as tolerated), Keep skin clean and dry and Observe location, size and treatment of skin injury, Report abnormalities, failure to heal, s/s of infection, maceration, etc. to MD and Treatments per orders.On 1/22/26 at approximately 11:00 am., wound care observation of Resident #10's Right Ischium was conducted with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). The ADON was observed providing wound care to the resident's right Ischium using the following steps: donned PPE (mask, glove and gown) washed hands, donned gloves, gathered supplies, placed supplies on the bedside table without sanitizing the table, removed old dressing, doff gloves, resident noticed to have an incontinent episode (BM), ADON left bedside, gathered briefs and incontinent wipes, doff gloves, donned gloves, provided incontinent care, kept gloves on and proceeded to provide wound care, doffed gloves, donned gloves, gathered supplies, placed soiled items in the trash can. Doffed gown, gloves, donned gloves took soiled items into soiled utility room, doffed gloves, washed hands.On 1/22/26 at approximately 4:32 pm., an end of day meeting was conducted with the Administrator, the Director of Nursing (DON) and with the Regional Clinical Nurse concerning the wound care observation concerns. No comments were made. On 1/28/26 at approximately 1:50 pm., a brief interview was conducted with the wound care nurse (WCN)/Assistant Director of Nursing (ADON). The WCN said that she should have washed her hands after providing incontinent care and should've had a barrier placed on the bedside table prior to providing wound care but that she became nervous and forgot.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information.

Based on staff interviews and a review of Infection Control documentation, the facility failed to maintain records of staff COVID-19 vaccinations. The findings included:On 1/28/26 at approximately 3:54 PM, the Infection Control task was completed with an interview with the Infection Preventionist (IP). The IP stated that education on COVID-19 vaccines is provided only to residents and/or their representatives. The IP also stated that there are no records of staff vaccinations because it is no longer a question asked of current or prospective hires. She stated she was recently employed by the facility and had not received the COVID-19 vaccine. The IP further stated that facility staff were not provided with education on the benefits and potential risks of the COVID-19 vaccine, nor were they offered the vaccine or information on how to obtain it. The facility's protocol, revised 7/25/23, titled Guidance and Protocol- COVID-19, stated under COVID-19 Vaccination that staff may be employed without providing evidence of COVID-19 vaccination. Vendors and contractors may provide services without evidence of COVID-19 vaccination, and the facility will offer vaccine education and vaccination to residents and staff.On 1/28/26 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing (DON), and Regional Clinical Director. An opportunity was offered to the facility's staff to present additional information. They had no comments and voiced no concerns regarding the above information.

Based on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and treatment for 5 out of 44 residents (Resident #84, #64, #79, #56, and #71) in the survey sample. For Resident #84, the facility staff failed to follow the Nurse Practitioner (NP) orders to provide [MEDICATION(S)] Intravenous (IV) fluids as ordered on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated for a resident who had a decline in oral fluids, decrease appetite and having loose stools. Resident #84 remained in the facility for 28 hours after the order was given on 02/04/22 to start IV fluids. On 02/05/22 at approximately 2:56 p.m., Resident #84 was observed in respiratory distress, unable to obtain blood pressure, and using accessory muscles for breathing. Resident #84 was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #84. For Residents #64 and #79, the facility staff failed to obtain blood sugars as ordered by the physician. For Resident #56, the facility staff failed to recognize, assess and intervene on an acute change in condition for a resident presenting with a four-pound weight gain in a week, increased [CONDITION(S)] to the resident's right leg, left arm, and face, and episodes of shortness of breath without flowing oxygen. For Resident #71, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: 1. Resident #84 was admitted to the nursing facility on 11/10/21. The resident was discharged to the local hospital on 02/05/22 and did not return to the nursing facility. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/17/21 coded the resident on the Brief Interview for Mental Status (BIMS) an 11 of 15 indicating moderate cognitive impairment. Resident #84 was coded total dependence of one with toilet use and bathing, extensive assistance of one with bed mobility and transfer, limited assistance of one with dressing and personal hygiene, and supervision with one assist with eating Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan created on 11/17/21 and a revision date of 01/11/22 identified Resident #84 with impaired cognitive function or impaired thought process related to an altered mental status. The goal set for the resident by the staff was that the resident will improve their current level of cognitive function through the next review on 03/09/22. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered. Monitor/document for side effects and effectiveness. On 02/04/22, the Nurse Practitioner's (NP) progress revealed the following information: Resident #84 is being seen today for loose stools, decrease intake, and COVID-19. Resident #84 reports having decreased appetite and increased thirst. Under diagnosis, assessment and plan it included but was not limited to start Sodium Chloride Solution at 50 ml/hour x 2 liters. The review of Resident #84's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with License Practical Nurse (LPN) #6 on 03/14/22 at approximately 4:12 p.m. When asked, what does it mean with an order that reads pending confirmation? The LPN stated, that the order was put in Point Click Care (PCC) but the nurse never confirmed the order, so the order was never initiated. A review of Resident #84's clinical record revealed the following documentation entered on 02/05/22 at approximately 2:56 p.m., by LPN #3. Resident #84 noted having respiratory distress, being unable to obtain blood pressure, oxygen saturation of 94% on room air, and heart rate of 102 while using accessory muscles for breathing. A new order was obtained to send to the ER for evaluation and treatment. A phone interview was conducted with Nurse Practitioner (NP) on 03/15/22 at approximately 2:08 p.m. The NP stated she assessed Resident #84 on 02/04/22 due to the staff reporting the resident was having loose stools and not eating. She said that during her discussion with the resident, he voiced to me that he was really thirsty and has no appetite. The NP said IV fluids were ordered and started on 02/04/22. The NP stated, IV fluids were ordered for hydration because Resident #84 was having loose stools and not eating She said the BMP was not ordered as STAT (now order) because I needed time for the IV fluids to hydrate the resident to help determine what further treatment was needed. The NP stated, Unfortunately, his IV fluids were never started and I was never notified. An interview was conducted with LPN#3 on 03/14/22 at approximately 1:46 p.m. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 and 02/05/22 (7-3 shift), the day Resident #84 was evaluated by the NP with new orders to start IV fluids. The LPN said she remembered Resident #84 was not eating or drinking. She said the NP came in and saw Resident #84 and wrote a bunch of new orders but I was never informed that an order to start IV fluids. On 03/15/22 at approximately 9:44 a.m., a phone interview was conducted with LPN #5. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 (11-7 shift). The LPN stated, I don't recall the nurse giving a report that Resident #84 had an order to start an IV to administer IV fluids. On 03/16/22 at approximately 2:53 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said the nurse(s) should have activated the order in PCC and the IV fluids should have been started as ordered by the (NP). He stated, If the nurse assigned was not able to start the IV, there is always someone in house that could have started the IV. He stated clysis could have been used to hydrate the resident. A phone interview was conducted with the Medical Director on 03/17/22 at approximately 5:11 p.m., when asked if the staff should have started the fluids IV or via clysis, he replied, Absolutely, not receiving the IV fluids could have contributed to his dehydration as well as Acute Renal Failure (AFR). The Medical Director stated, The NP or I should have been notified that Resident #84's IV fluids were never started. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/05/22 from (name of nursing facility) for further evaluation due to lethargy. The 911 transport revealed the following: Resident serum glucose was 14. The Emergency Medical Service (EMS) placed an IV, gave [MEDICATION(S)] and D10 and his glucose increased to 135. The ER records indicated Resident #84's rectal temperature at 89.4 degrees F (hypothermia - low body temperature) and placed on [NAME] for low rectal temperature. The resident's blood pressure was 89/40 (normal = 120/80). He was found to be in severe metabolic acidosis and septic shock. The urinalysis with reflex showed large leukocyte esterase, positive nitrites, and a moderate amount of blood with 3+ bacteria. The urine culture revealed more than 100,000 colonies and was positive for Kiebsiella pneumoniae. The resident had a high blood creatinine of 7.2 (0.59-1.04 = normal range). The creatinine test is a measure of how well your kidneys as performing their job of filtering waste from your blood (www.mayoclinic.org). The resident was started on IV sodium [MEDICATION(S)], given D50, and admitted to the Intensive Care Unit (ICU). Intravenous Fluids (IV), and IV antibiotic ([MEDICATION(S)] and [MEDICATION(S)]) was also started. Resident #84 is in the ICU, on a ventilator, sedated and unresponsive. The resident will need [CONDITION(S)] per nephrology but is pending due to his acute kidney injury. Resident #84 is being transferred to a higher level of care on 02/12/22. The resident is hemodynamically unstable for conventional hemodialysis and will benefit from continuous renal replacement therapy (CRRT), which this facility doesn't provide. At the time of discharge, resident remains on a mechanical ventilator. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/12/22 as a transfer from the originated hospital for further evaluation due to [CONDITION(S)] and Altered Mental Status (AMS). The resident was sent here for continuous renal replacement therapy (CRRT), which the previous hospital doesn't provide. The hemodialysis catheter placement was placed and (CRRT) was started on 02/13/22. A debriefing was conducted with the Administrator, Vice President of Clinical Services, and Regional Director of Clinical Services on 03/17/22 at approximately 5:45 p.m., Resident #84's issues were presented again. The facility did not present any further information about the findings prior to survey exit. Definitions: -Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body. Some causes of metabolic acidosis include but are not limited to severe diarrhea and severe dehydration. Treatment is aimed at the health problem causing acidosis. In some cases, sodium [MEDICATION(S)] may be given to reduce the acidity of the blood. Often, you will receive lots of fluids through the vein (https://medlineplus.gov). -Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. Many people, particularly older adults, don't feel thirsty until they're already dehydrated. That's why it's important to increase water intake when you're ill. Other dehydration causes include but are not limited to diarrhea and or acute diarrhea - that is, diarrhea that comes on suddenly and violently - can cause a tremendous loss of water and electrolytes in a short amount of time. Dehydration can lead to serious complications, including urinary and kidney problems. Prolonged or repeated bouts of dehydration can cause urinary tract infections, kidney stones, and even kidney failure. The only effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The best approach to dehydration treatment depends on age, the severity of dehydration, and its cause. Adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room . Salts and fluids delivered through a vein (intravenously) are absorbed quickly and speed recovery. -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Urinary tract infection occurs when there is a compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, UTIs is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of waste may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Sodium Chloride Solution 0.9%, solution is used to supply water and salt (sodium chloride) to the body. Sodium chloride solution may also be mixed with other medications given by injection into a vein (https://www.webmd.com/drugs). -Clysis or hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short-term hydration has the potential to reduce costs and transfers to the hospital (https://pubmed.ncbi.nlm.nih.gov). -A basic metabolic panel (BMP) is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP is used to check different body functions and processes, including kidney function, fluid and electrolyte balance, blood sugar levels, and acid and base balance (https://medlineplus.gov). -Klebiella pneumoniae is one of the bacteria most frequently causing healthcare-associated urinary tract infections (https://www.ncbi.nlm.nih.gov). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Mechanical ventilation is a form of life support. A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine (https://www.continued.com/resp-therapy/courses). 2. The facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #64 was admitted to the nursing facility on 11/12/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 02/22/22 coded the resident with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS coded Resident #64 requiring total dependence of one with bathing, extensive assistance of one with dressing, limited assistance of one with toilet use and personal hygiene and supervision with transfer and eating for Activities of Daily Living care. Under Section N for the use of insulin injection was coded as received daily during the last 7 days. The care plan created on 11/15/21 identified Resident #64 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Some of the interventions/approaches the staff would use to accomplish this goal is monitor/document/report as needed any signs or symptoms of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain and acetone breath (smells fruity). During the initial tour on 03/09/22 at approximately 3:27 p.m., an interview was conducted with Resident #64 who stated, The nurses do not always check my blood sugar. The resident stated my blood sugar is to be check everyday before my meals and at bedtime. Review of Resident #64's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify the physician for blood sugar less than 60 or greater than 400. 1. Review of January 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] were not obtained as ordered by the physician on the following days: 01/18 (before breakfast, 01/19 (at bedtime), 01/20 (before breakfast) and 01/24 (before breakfast). 2. Review of February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Regional Director of Clinical Services on 03/16/22 at approximately 2:53 p.m., who reviewed the documents mentioned above. He stated, the expectations is for all nurses are to obtain blood sugars as ordered by the physician. The Regional Director stated, If it's not documented, it didn't happen. A debriefing was held with the Administrator and Vice President of Operations on 03/17/22 at approximately 5:45 p.m., who were informed of the above findings; no further information was provided prior to exit. The policy titled: Obtaining a Fingerstick Glucose Level with a revision date of 10/11. Purpose is to obtain a blood sugar sample to determine the resident's blood glucose level. Documentation read in part: The person performing this procedure should record the following in the resident's medical record: 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The blood sugar results. Follow facility policies and procedure for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician interventions is needed to adjust insulin or oral medication dosages). 3. The facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #79 was assessed as a 15 on the BIMS assessment. A Care Plan dated 2/28/22 indicated: Potential for complications from Diabetes Mellitus diagnosis. Blood Sugar as ordered by doctor. Check all of body for breaks in skin and treat promptly as ordered by doctor. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Dietary consult for nutritional regimen and ongoing monitoring. Consult and notify doctor of any changes in diabetic medications. Inspect feet daily for open areas, sores, pressure areas, blisters, [CONDITION(S)] or redness. Monitor/document/report PRN any s/sx of [CONDITION(S)]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. Monitor/document/report PRN any s/sx of [CONDITION(S)]: Sweating, Tremor, Increased heart rate ([CONDITION(S)]), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait. Monitor/document/report PRN any s/sx of infection to any open areas: Redness, Pain, Heat, swelling or pus formation. Monitor/document/report PRN compliance with diet and document any problems. Offer substitutes for foods not eaten. Resident is at risk for injuries from falls related to history of falls, possible side effects from medications, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A 01/04/2022 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD less 60 or greater than 400. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Blood sugars were not taken at the 1700 and 2100 hour on the 25th. Blood sugars were not taken at the 0600 hour on the 26th. Resident #79 was noted to have the following physician orders: Insulin [MEDICATION(S)] [MEDICATION(S)] 100 unit/ML solution pen injector Inject as per sliding scale: if 0 - 199 = 0 units 200 -250 = 2 units 251- 300 = 4 units 301- 350 = 6 units 351- 400 = 8 units - if over 400 call MD, subcutaneously before meals and at bedtime for DM During an interview on 3/17/22 at 10:10 a.m. with the Corporate Clinical Nurse (CCN), he was asked what did the blank areas of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. The facility staff failed to recognize, assess and intervene on an acute change in condition for a resident presenting with a four pound weight gain in a week, increased [CONDITION(S)] to the resident's right leg, left arm and face and episodes of shortness of breath without flowing oxygen for Resident #56. Resident #56 was originally admitted to the facility 9/19/16 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/15/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56's cognitive abilities for daily decision making was intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene, bathing, dressing, and toileting, extensive assistance of two people with bed mobility and supervision of one person after set-up with eating. Resident #56 was observed seated in a wheel chair in her room. She was wearing a slipper to the right foot and her right lowered leg was with plus two [CONDITION(S)] and redness. The resident's left arm was also with plus two [CONDITION(S)] and her face appeared fuller than it was the prior evening. The resident had a portable oxygen tank on the back of her wheel chair but it was on empty and she had a nasal cannula in her nostrils. An interview was conducted with Resident #56 in her room on 3/10/22 at approximately 2: 30 p.m. Resident #56 stated she participated in the Resident Council meeting earlier on 3/10/22 and was waiting for the nurses to put her back in bed. Resident #56 stated she felt heavy as well as a little short of breath and it troubled her for in January 2022 she was hospitalized twice for shortness of breath caused by [CONDITION(S)] and congestive heart failure. The resident stated her doctor always told her to weigh daily and if there was a change of three pounds or more to contact the office and to be sure she monitored her intake of fluids. Resident #56 stated she asked Certified Nursing Assistant CNA) #6 to weight her on 3/10/22 and she weighed was 194.5 pounds. Resident #56 stated she's supposed to wear a TED hose to her right leg but the CNA wasn't able to locate one that morning. The resident also stated she received a fluid pill, a heart pill and oxygen to manage her breathing problems caused by [CONDITION(S)] and congestive heart failure. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's weight was 190.7 pounds on 3/7/22. Additional orders on the POS read; 8/25/21 [MEDICATION(S)] Tablet 40 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day for CHF. 08/17/2021- apply TED hose in AM and off in PM two times a day. 12/31/21 Oxygen 2 liters per minute by nasal cannula as needed for oxygen saturations below 92 percent. The resident's diet order dated 8/17/21 read, regular diet, regular texture, thin consistency, no added sodium; 1200 milliliters/24 hour fluid restriction. Fluid Restriction: 1200 cc (720cc with Meals and 480CC provided by Nursing) 7-3 = may give 240 cc 3-11 = may give 120 cc 11-7 = may give 120 cc. The current care plan had a problem dated 2/24/22 which read; resident has altered cardiovascular status r/t hypertension, CHF and [CONDITION(S)]. The goal read; the resident will be free from complications of cardiac problems through the review date. The interventions included; Assess lung and heart sounds as needed. Medications as ordered. Oxygen at 2 liters per minute via nasal cannula. Vital signs as ordered. Resident is a daily weight An interview was conducted with Licensed Practical Nurse (LPN) #10 on 3/10/22 at approximately 4:35 p.m. LPN #10 stated the resident's portable oxygen tank was empty but she connected the resident to the concentrator and her oxygen saturation was 8 percent. LPN #10 stated she didn't assess or obtain the resident's saturation prior to attaching her tubing to the concentrator. LPN #10 didn't acknowledge the resident's shortness of breath, increased weight or [CONDITION(S)] to her extremities but she stated the resident offered no concerns. LPN #10 stated she signed off for the resident's TED hose because she relied on the CNA to apply them as ordered. An interview was also conducted with LPN #8 on 3/10/22 at approximately 5:00 p.m. LPN #8 stated the resident's weights are charted and if they flagged, other actions would be taken. An interview was also conducted with the Director of Nursing (DON) on 3/10/22 at approximately 5:10 p.m. The DON stated the resident would be assessed and the physician/designee would be contacted for further instructions. On 3/11/22, Resident #56 was evaluated by the rounding Nurse Practitioner (NP). The NP assessment revealed the following; 3/11/22 staff reported 4.2 pounds weight gain over one week. Plus one [CONDITION(S)] to the right lower extremity with redness and warmth and fluid filled blisters and plus one [CONDITION(S)] to the left upper arm. Plan [MEDICATION(S)] 500 milligram every twelve hours for seven days, complete blood count, basic metabolic panel, brain natriuretic peptide, chest x-ray and urinalysis and culture and sensitivity. The chest x-ray results findings dated 03/12/22 were as follows; there is cardiomegaly. There is interstitial [CONDITION(S)]. There is pulmonary venous hypertension. There is no pneumonia, mass, or adenopathy. There is no effusion. There is congestive heart failure. There is no pneumothorax. There is a right base infiltrate increased from 02/23/2022. There is no [CONDITION(S)]. On 3/12/22 a new order was received to start for [MEDICATION(S)] every 6 hours for SOB and/or wheezing. On 3/15/22, an order was received to start [MEDICATION(S)] Tablet 20 MG; Give 1 tablet by mouth one time a day for CHF for 5 Days. This was in addition to the previously ordered [MEDICATION(S)] 40 mg two times each day. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the Vice President of Operations (VPO). No additional information was offered and no concerns were voiced. Heart failure signs and symptoms may include: Shortness of breath with activity or when lying down, fatigue and weakness, swelling in the legs, ankles and feet, rapid or irregular heartbeat, swelling of the belly area (abdomen), very rapid weight gain from fluid buildup . (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc- 142). The above information was obtained 3/24/22. 5. The facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #71 was originally admitted to the facility 1/11/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The five day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #71's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person with personal hygiene, dressing, toileting limited assistance of one person with eating and limited assistance of one after set-up with eating. Resident #71 was observed sitting in a wheel chair in her room on 3/9/22 at approximately 4:45 p.m. The resident stated she had surgery to the right knee and the physician had to go back in it and clean it out because of an infection; as a result she needed to have extensive antibiotic therapy intravenously. The resident further stated some of staff act like they have no idea how to administer the antibiotic. The resident had a PICC to the right upper arm and it was dated 3/9/22. Resident #71 stated the PICC dressing was supposed to be changed 3/5/22 but it wasn't changed until 3/9/22 and it was supposed to be changed again on 3/12/22 but it was now 3/17/22 and it hadn't been changed. Resident #71 stated she was concerned the PICC site may become infected and cause a delay in her going home. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2/25/22 IV PICC change needleless connector on admission, weekly every day shift/ Saturday for and as needed thereafter and change after every blood draw. 2/25/22 IV-PICC Measure catheter length on admission and with each dressing change thereafter. 2/25/22 IV-PICC change transparent dressing on admission, then weekly every day shift/Saturday and as needed thereafter. 2/21/22 [MEDICATION(S)] Sodium Solution Reconstituted 2 Grams - Use 2 gram intravenously in the evening for infection related to infection and [CONDITION(S)] reaction due to internal right knee prosthesis. An interview was conducted with Licensed Practical Nurse (LPN) #15, on 3/17/22 at approximately 1:15 p.m. LPN #15 stated she would take care of the dressing change today. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the Vice President of Operations (VPO). The VPSC stated he had spoken to the nurse caring for Resident #71 and the dressing was to be changed today. The below information was obtained from the following web site on 3/25/22 (https://medlineplus.gov/ency/patientinstructions/ 2.htm#:~:text=You%20sho uld%20change%20the%20dressing,you%20with%20the%20dressing%20change.) A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. COMPLAINT DEFICIENCY

Based on observation, staff interviews, and clinical record review, the facility staff failed to provide services to prevent pressure ulcers and promote healing for 2 of 9 Residents with pressure ulcers, the facility staff failed to properly classify, assess, and institute an appropriate treatment/care to Resident #8's pressure ulcer to the left hip to prevent deterioration to unstageable, presenting with 70 percent granulation tissue/30 percent slough (dead tissue) over four days, which constituted harm. For Resident #26, the facility staff failed to provide care and services to prevent pressure ulcer development in two areas prior to identification at an advanced stage; the sacrum with 100% slough/eschar and the right lateral ankle with 100% slough/eschar which constituted harm. The findings included: 1. Resident #8 was originally admitted to the facility on [DATE] and was discharged from the facility for an acute care hospital stay, returning on 3/29/14. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12.25/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated that Resident #8's cognitive abilities for daily decision-making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with bed mobility, transfers, total care of one person with dressing, eating, toileting, personal hygiene, and bathing. A review of the facility's matrix revealed Resident #8 was coded for having a facility-acquired unstageable pressure ulcer. A review of the clinical record revealed a nurse progress note authored by LPN #10 on 3/8/22 at 3:05 p.m., which read; that the Wound Care Nurse Practitioner (WCNP) was noted in the facility and was made aware that the resident's left hip was worsening. The clinical record offered no evidence that Resident #8 had an opened area to the left hip and there was no assessment and/or documentation of a left hip open area. This was the first documentation of a left hip open area. An interview with LPN #10 on 3/10/22 at approximately 4:15 p.m. revealed the left hip was being treated with; normal saline, dry and apply Triple-antibiotic ointment (TAO) and a border gauze. This was the order for the left buttock scratches. The clinical record revealed a change in condition document dated 3/4/22 which identified a reopened area to the left buttock due to observed self-inflicted and witnessed scratching on more than one occasion. An order was obtained to cleanse the scratches to the left buttock open area with normal saline, dry, and apply Triple-antibiotic ointment (TAO) and a border gauze every day until healed. The left buttock scratches were documented as healed on 3/8/22. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 3/17/22 at approximately 12:05 p.m. LPN #6 stated LPN #16 stated she obtained the left buttock treatment order from the primary Nurse Practitioner (NP) for self-inflicted and witnessed scratches to the left buttock, not a pressure ulcer, just as she documented on the change in condition form The left hip wound was assessed for the first time by the WCNP on 3/8/22 and the assessment revealed an etiology of pressure. The pressure ulcer measured; length 3.03 centimeters by a width of 2.17 centimeters, with no depth. It contained 70 percent granulation tissue/30 percent slough, had a scant amount of serosanguinous drainage, and no odor. The left hip pressure ulcer was classified as unstageable. The WCNP stated to discontinue the previous treatment to cleanse the left buttock open area with normal saline, dry, apply Triple-antibiotic ointment (TAO), and apply a border gauze every day until healed and to start to cleanse the left hip pressure ulcer with wound cleanser, pat dry and apply Medi-honey with a border dressing every day. The WCNP also recommended an air mattress for pressure reduction and provided the following; Plan of Care Assessment and Plan - resident has a pressure injury; pressure reduction and turning precautions discussed with staff at the time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. An observation was made on 3/10/22 at approximately 4:45 p.m., of the resident in bed lying to face the doorway. The resident was lying on a pressure-reducing reducing mattress, not the recommended low air loss mattress. A pair of pressure-reducing reducing boots were observed in the Broda chair (a special chair used for prevention and seating comfort) at the foot of the bed. The resident spoke nonsensically and rocked repetitively. Another observation was made on 3/14/21 at approximately 11:30 a.m., again the resident was in bed lying on a standard pressure-reducing mattress on her right side and facing the doorway. The recommended low air loss mattress was not on the bed. She was talking and rocking repetitively, asking what do you have to eat? The green pressure-reducing boots were on her lower extremities, but there was no low air loss bed. An interview was conducted with the WCNP on 3/15/22 at approximately 2:20 p.m. The WCNP stated she was asked on 3/8/22 to see Resident #8 because of a worsening left hip wound. The WCNP stated she had not seen the resident's wound prior to 3/8/22 and her assessment of the left hip wound revealed a pressure ulcer because it was over a bony prominence surrounded by old scar tissue and unstageable because it was comprised of granulation tissue and slough. Further review of Resident #8's clinical record revealed that weekly skin assessments had not been conducted since 12/31/21. During an interview with the Vice President of Operation (VPOC) on 3/17/22 at approximately 12:40 p.m., she stated she was aware skin assessments were only conducted sporadically and inconsistently. The VPOC stated a best practice would be to conduct skin assessment weekly on a shower day and ideally the CNAs should look at resident skin each time care is provided to identify changes. The VPOC also stated skin assessments should be completed upon admission as well as a Braden scale for Prediction of Pressure Sores. The VOP stated that although the resident had been under comfort care measures for many years it didn't relieve the staff of assuring necessary basic care was rendered including prevention of skin breakdown and early recognition of skin breakdown if it did occur. The VPO also stated recommendations from the WCNP should have been instituted along with the treatment orders therefore the low air loss bed should have been ordered for Resident #8. Resident #8 was also observed on 3/17/22 in bed at approximately 11:00 a.m., seated in the Broda chair waiting to have her hair cut. The lower extremities were contracted at the knees. At approximately 4:00 p.m., an observation was made of the resident's left hip pressure ulcer with Licensed Practical Nurse (LPN) #12. The wound was to the bony prominence of the left hip and it was surrounded by scar tissue. The left hip pressure ulcer was without odor or drainage but slough was present. The 3/17/22 WCNP assessment of the left hip pressure ulcer read; measured; length 3.54 centimeters by width 1.88 centimeters and no depth. It contained 70 percent granulation tissue/30 percent slough, had a scant amount of serosanguinous drainage and had no odor. The WCNP stated the wound was showing improvement and the treatment order remained as ordered on 3/8/22. On 3/11/22 at approximately an interview was conducted with Certified Nursing Assistant (CNA) #6. CNA #6 stated Resident #8 for many years enjoyed sitting in the common areas wearing a purple cap, greeting all who passed her, or simply napping. CNA #6 also stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #6 also stated the resident required total care with all activities of daily living and frequently asks for something to eat, and consumes approximately 75-100 percent of most meals. CNA #6 also stated that until this recent pressure sore of the resident's left hip she had only had scratches to her ankles and legs. An interview was conducted with the MDS Coordinator on 3/16/22 at approximately 2:10 p.m. The MDS Coordinator stated Resident #8 had been a comfort care resident since 2015 and it included no intravenous (IV) medications, no IV fluids, no hospitalization s, no tube feeding, no laboratory testing, no monthly vitals, no height, and no weights. The MDS Coordinator further stated that prior to the most recent skin impairment the resident had been with skin breakdown for many years. An interview was conducted with Licensed Practical Nurse (LPN) #6 on 3/17/22 at approximately 3:20 p.m. LPN #6 stated the resident had been on comfort care for many years yet her condition remained stable except for some falls. LPN #6 also stated that the low air loss bed had been ordered. The Braden Scale for Prediction of Pressure Sores was completed on 11/2/21. It revealed that the resident; responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over half of the body, skin is occasionally moist, requiring an extra linen change approximately once a day, confined to bed, never eats a complete meal. Rarely eats more than half of any food offered. Takes fluids poorly. Does not take a liquid dietary supplement, requires moderate to maximum assistance in moving, requiring frequent repositioning with maximum assistance. [CONDITION(S)], contractures, or agitation leads to almost constant friction, and the resident scored nine, indicating a very high risk for pressure ulcer development. The active care plan had a problem dated 3/15/22 which read; (name of the resident) has impaired skin integrity (left hip pressure injury) and is at risk for further skin breakdown related to a history of pressure injuries, immobility, incontinence, dementia, [CONDITION(S)], adult failure to thrive and contracture. The goal read; the left hip pressure injury will show improvement by the review date. The interventions included; a concave mattress, out of bed in a Broda chair, position resident as needed, and treatment per orders. A Dietary/Nutrition dated 4/9/2021 at 5:05 p.m., revealed the resident's current body weight is 90 pounds, reflective of weight loss -22.0% x 3 months. The Resident is under comfort care services. The Resident's usual body weight (UBW) is 90-100 pounds for 2 years. Weight in comparison on 1/4/21 of 115.4 pounds is an outlier from the resident's UBW. The resident is currently receiving a pureed texture diet with thin liquids. The resident is dependent on staff for the provision of meals and her PO intake was largely 76-100 percent per documentation. No open areas were noted to the skin. Considering resident's PO intake of meals is good and resident is under comfort care with no weight order in place - no new recommendations at this time. Continue Plan of Care to ensure the resident remains comfortable in accordance with wishes for comfort care. The clinical record revealed the following recent weight for Resident #8, 12/16/21 91.0 pounds; 2/4/22, 91.2 pounds and 3/9/22, 91.5 pounds. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, Vice President of Clinical Services and the Vice President of Operations. No additional information was provided or concerns voiced. Triple-antibiotic ointment (TAO) is a medication used is used to prevent minor skin injuries such as cuts, scrapes, and [CONDITION(S)] from becoming infected. (https://medlineplus.gov/druginfo/meds/a 8.html) Medi-honey is used to clean and remove necrotic tissue to promote wound healing. (https://mms.[NAME].com/product/ 3/[NAME]-Brand- ) The below information was obtained 3/23/22 from (https://medlineplus.gov/ency/patientinstructions/ 0.htm#:~:text=Stage%20II%20pressure%20sores%20should,They%20can%20damage%20the%20skin.) Caring for a Pressure Sore Stage I or II sores will often heal if cared for carefully. Stage III and IV sores are harder to treat and may take a long time to heal. Here's how to care for a pressure sore: Relieve the pressure on the area. Use special pillows, foam cushions, booties, or mattress pads to reduce the pressure. Some pads are water or air-filled to help support and cushion the area. The type of cushion used depends on the wound and whether the individual is in bed or in a wheelchair. Change positions often. If in a wheelchair, try to change position every 15 minutes. If in bed, repositioning should be about every 2 hours. Care for the sore as directed by physician or specialist. Keep the wound clean to prevent infection. Clean the sore with every dressing change. For a stage I sore, wash the area gently with mild soap and water. If needed, use a moisture barrier to protect the area from bodily fluids. Stage II pressure sores should be cleaned with a salt water (saline) rinse to remove loose, dead tissue. Or a specific cleanser as ordered by a physician. Do not use [MEDICATION(S)] or iodine cleansers. They can damage the skin. Keep the sore covered with a special dressing. This protects against infection and helps keep the sore moist so it can heal. Types of dressngs used may depend on the size and stage of the sore; may use a film, gauze, gel, foam, or other type of dressing. Most stage III and IV sores to include those with slough and necrosis will require specific orders from a physician. Avoid further injury or friction. 2. a. Resident #26 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident was never been discharged from the facility. According to the comprehensive skin assessment dated [DATE] at 8:12 PM a new wound was found on the resident's Sacrum. Acquired in-house. With 100% slough/eschar. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/26/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated that Resident #26 cognitive abilities for daily decision-making were moderately impaired. In section E (Rejection of Care) did the resident reject evaluation or care, marked O behavior not exhibited. In section G(Physical functioning) the resident was coded as requiring extensive assistance from two people with bed mobility and personal hygiene. Requiring extensive assistance of one person with dressing. Requiring total dependence of two persons with toilet use and bathing. Requires supervision with set-up help only with eating. In section M (Skin Conditions) M0150. Risk of Pressure Ulcers/Injuries. Codes as Yes. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. Left Blank. In section M (Skin and Ulcer/Injury Treatments) M1200. Turning/repositioning program: coded as No. Pressure ulcer/injury care: coded as No. The care plan dated 2/04/22 reads: Focus: SKIN INTEGRITY: Resident has potential impairment to skin integrity r/t (relating/ to) cancer, [CONDITION(S)] ([CONDITION(S)]) heart failure, [CONDITION(S)], Foley catheter, incontinence and need for ADL (Activity of Daily Living) assistance. Goal: The resident will maintain or develop clean and intact skin by the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Use lotion on dry skin. Observe location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor). The care plan dated 2/04/22 reads: Focus: ADL self-care performance deficit related to Heart failure, Acute kidney failure, Malignant [CONDITION(S)] of the lung, Malignant neoplasm of the brain. Goal: Resident to maintain the current level of function in (eating) through the next review date. Interventions: BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Avoid scrubbing & pat dry sensitive skin. Provide a tub bath/shower at least 2 days a week. Provide a sponge bath if a tub bath/ shower cannot be tolerated. Shave and shampoo hair as needed. BED MOBILITY: Requires (Limited to extensive assistance) of (1-2) staff to turn and reposition in bed Q 2-3 hours and as necessary. PERSONAL HYGIENE: Requires (limited to extensive assistance) of (1-2) staff with personal hygiene and oral care. SKIN OBSERVATION: Observe skin for rashes, redness, open areas, scratches, cuts and bruises and report changes for prompt treatment. A review of the Braden Scale assessment for predicting pressure sore risk was completed on 1/11/22 with a score of 18 which indicates Resident #26 is at risk for pressure sore. The remainder of the admission screening was incomplete. A review of the admission screening dated 1/11/22 at 6:36 PM reads: Pressure Ulcers: Is a pressure ulcer present? No. A review of the TAR (Treatment Administration Record) for February 2022 reads: 02/09/2022 00:12 Order Summary: Santyl Ointment 250 UNIT/GM ([MEDICATION(S)]) Apply to sacrum topically everyday shift for wound care. A review of the TAR (Treatment Administration Record) for March 2022 reads: Sacrum: Clean with wound cleanser, apply Dakin's wet-to-dry, and cover with bordered gauze. A review of nursing notes reveal the following: On 1/11/2022 at 6:53 PM resident was admitted to the Long Term Care facility from acute care via stretcher. No distress or complaints. A comprehensive wound evaluation for all new admits was completed by the Wound Care Nurse Practitioner (WCNP) on 1/13/22 at approximately 9:47 PM. The skin evaluation reads: Patient reports no rashes or known dermatologic conditions at the time of this exam. The dermatologic evaluation reads: Patient's skin is intact with no rashes. There are no open wounds on today's comprehensive skin examination. Wound plan of care: Recommend moisturizing bilateral legs and feet for *xerosis. Plan of Care Assessment & Plan explained all necessary basic foot care aspects. Patient understands that proper foot care is key to improved health, based on patient's comorbidities proper foot care is key to promoting the health of limbs. Other elements of Patient Evaluation: Wound rounds completed and reconciled with facility wound nurse today. All questions and concerns answered for staff and patient as applicable. Staff made aware that wound rounds were completed and of any changes in treatment plan. A review of the WCNP's Tissue Analytics (TA) weekly wound assessments revealed the following: Wound evaluation dated 2/08/22 revealed that an unstageable pressure ulcer of the sacrum was acquired in house. Measurements: Length: 5.35 cm. Width: 5.73 cm LxW: 30.66 cm Depth: 0. Observations: %slough/eschar: 100.00. Wound Status: New. Drain amount: Serosanguinous. No odor. Dressing change frequency: Daily. Cleanse wound with wound cleanser. Apply Santyl dressing with bordered gauze. Pressure Reduction/Offloading: Ensure compliance with turning protocol, wedges/foam cushion for offloading, wheelchair cushion, mattress overlay, and specialty bed. A review of the WCNP's weekly wound evaluation revealed resident's wound is stable dated 2/24/22: Unstageable Sacral Pressure Ulcer measurements: Length: 5.88 cm, Width: 6.02 cm, LxW: 35.40 cm, Depth: 0. Observations: % Granulation: 30.00. %Slough/eschar: 100.00. Wound Status: Stable. Drain Amount: Serosanguinous. Odor: Malodorous. Dressing Change Frequency: Daily. Pressure Reduction/offloading: Ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. Cleanse wound with: Wound cleanser. Apply Dakins moist-to-dry dressings. Bordered gauze. Another review of the WCNP's weekly wound evaluation revealed that the resident's wound is improving dated 3/03/22: Unstageable Sacral Pressure Ulcer of the sacrum. Measurements: Length: 5.94 cm, Width: 5.14 cm. LxW: 30.53 cm. Depth: 0. Observations: % granulation: 20.00. % slough/eschar: 80.00. Wound Status: Improving. Drain amount: Moderate. Drain Description: Serosanguinous. Odor: No odor. Dressing change frequency: Daily. Cleanse wound with: Wound Cleanser. Dakins moist-to-dry dressings and bordered gauze. Pressure Reduction/Offloading: Ensure compliance with turning protocol, wedge/foam/cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. A continued review of WCNP's weekly wound evaluation revealed that the resident had debridement of the sacrum dated 3/10/22: Sacrum unstageable pressure injury. Post (after)-debridement length (cm): 1. 63 as per ulcer noted. width (cm) 0. 96 as per ulcer noted. 100% debrided. Wound plan of care: Recommend obtaining an air mattress and applying foot protectors/heel boots. I am recommending an air mattress for pressure reduction. Plan of Care Assessment & Plan - Patient has a pressure injury; Pressure reduction and turning precautions discussed with staff at the time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Explained all aspects of necessary basic foot care. Patient understands that proper foot care is key to improved health, based on patient' s comorbidities proper foot care is key to promoting health of limbs. Factors Affecting Healing: Patient has frequent incontinence which can decrease healing rate of wound. Recommend providing incontinence care as needed, PRN. Increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Other elements of Patient Evaluation: Wound rounds completed and reconciled with wound nurse today. All questions and concerns answered for staff and patient as applicable. Patient was left as requested, lowest locked position with call bell within reach, no restraints in place. Staff made aware that wound rounds were completed and of any changes in treatment plan. A review of the weekly WCNP evaluation reveals Residents wound is improving dated 3/17/22: Unstageable sacral pressure ulcer of the sacrum. Measurements: Length: 7.66 cm. Width: 5.62 cm. LxW; 43.05 cm. Observations: % granulation: 20. % slough/eschar: 80.00. Other: Apply Santyl to necrosis. Wound Stasis: Improving. Draining: Moderate. Drainage description: Serosanguinous. Odor: Malodorous. Dressing Change Frequency: Daily. Cleanse wound with: Wound Cleanser. Dressings: Santyl, Dakin's moist-to-dry. Bordered gauze. Pressure Reduction/offloading: Ensure compliance with turning protocol, wedge/foam cushion for offloading, wheelchair cushion, mattress overlay, specialty bed. On 03/11/22 at approximately 9:39 AM, an interview was conducted with Resident #26 concerning his wounds on his sacrum and lower extremities. He was asked how he got the wounds. He stated, I got it since I've been in here. His heels were observed resting on the bed. No bunny boots or heel protectors were in place. The resident's heels were not floating but resting on his bed/mattress. Surveyor received permission from the resident to observe wound care. On 3/11/22 at approximately 10:45 AM., a wound care observation was made while LPN (Licensed Practical Nurse) #2 administered wound care/treatment to the resident's sacrum. Slough and eschar were present on the wound bed with moderate serosanguinous drainage. The resident tolerated the procedure without difficulty. No issues were noted. On 03/14/22 at 2:47 PM an interview was conducted with LPN #6 concerning Resident #26. She stated, He had an admission screen Braden scale. There's an admission assessment in here (PCC/Point Click Care/ electronic medical records) but it's not complete. It should have been completed. The area on the sacrum was found on 2/09/22 as unstageable. If it's covered in slough or eschar it's unstageable because we don't know what's under it. Upon arrival, we look at the resident's skin with the Wound Care Nurse Practitioner, then weekly. If the CNA sees any issues on the resident's skin they will report it to the nurse. Since I've been looking at his wound every week it's getting better. His sacrum was debrided on 3/10/22. I normally put a note in that I rounded with her but I didn't. On 03/14/22 at 2:47 PM an interview was conducted with LPN #6 (Unit Manager) concerning Resident #26. She stated, He had an admission screening Braden scale on 1/11/22. There's an admission assessment in here [PCC/Point Click Care (electronic medical records)] but it's not complete. It should have been completed. According to LPN#6, the area on the sacrum was found on 2/08/22 as unstageable with slough and eschar. She said, If it's covered in slough or eschar it's unstageable because we don't know what's under it. Upon arrival, we look at the resident's skin with the WCNP, then weekly if any pressure ulcer/wound issues. If the CNAs see any issues on the resident's skin they should report them to the nurse. The LPN continued to say that on 3/10/22 she failed to document that she rounded with the WCNP when the sacrum pressure ulcer was debrided. On 03/15/22 at 1:35 PM an interview was conducted with the WCNP concerning Resident #26's wounds. She stated, When he first got to the facility (1/11/22) he didn't have a wound. My admission skin sweep for the resident was on 1/13/22. When the facility told me to come to look at him he was already unstageable. I initially saw him on February 8th, 2022 (sacrum). I only see it once a week. For prevention: He needs to be turned every (q) 2 hours, heels floated, heel protectors, and an air mattress. The staff says he refuses to be turned and repositioned. I have had a nurse lately that does the dressings as I'm charting. She was asked was the wound found at an advanced stage on his right lateral ankle (2/24/22)? She stated, Yes because he didn't have it on his initial skin assessment. The staff should have communicated if they saw something open, redness, and documented it. I do a skin sweep quarterly on patients that don't have wounds. Most nurses should do weekly skin assessments. A review of the nurse's notes and or skin assessments from 1/31/22 through 2/8/22 did not reveal any skin integrity issues on the sacrum. Although there were no nurse's notes from this timeframe, the WCNP, per the above interview on 3/15/22, was asked by the nursing staff to come to look at his sacrum, which was identified as unstageable. A review of the resident's care plan shows no refusal of care. A review of the resident's care plan and nurse's notes showed no refusal of care to include skin assessments, bed baths, and or incontinence care. A review of ADL documentation records for January, February, and March 2022 show no refusal of care. On 03/15/22 at approximately 2:33 PM two CNAs were observed transferring Resident #26 back to bed via Hoyer lift. The resident was placed in a supine position. CNA #7 was asked if Resident #26 wears bunny boots or heel protectors when in bed. She stated, He has a regular mattress. You would think he would have a specialty mattress because of the pressure sores. On 03/16/22 at approximately 1:39 PM., an interview was conducted with LPN (Licensed Practical Nurse) #2. Concerning Resident #26. She stated, I keep resident off his bottom, turn and reposition him every two hours. His sacral wound looks about the same as when I first interacted with him. On 03/17/22 at approximately 11:38 AM., an interview was conducted with LPN #6/Unit Manager concerning communication with the WCNP. She stated, She would normally email us a spreadsheet of everybody that we saw during wound rounds. The orders either stay the same or change, then we update orders. During the interview, LPN#6 was asked about the following recommendations that the WCNP made after completing her rounds at each assessment that included foot protectors or heel protectors, bunny boots, pressure reduction devices to bony prominences, and air mattress. The original recommendation for the air mattress for pressure reduction was made on 2/8/22. On 3/10/22 and 3/17/22 during the WCNP's wound care assessment, these recommendations were still not implemented and were reiterated in her notes. LPN #6 stated, I would consult with the facility Nurse Practitioner (OSM #1) if the WCNP gives me an order (recommendations) and I will put the orders in. It (the previous recommendations) was an oversight. On 3/17/22 at approximately 12:15 PM., an interview was conducted with Vice President of Operations concerning Resident #26. She stated, The skin assessments are done sporadically by nurses they are not consistent. The best time is on the shower days at least once a week. If not getting showers they should be getting the skin assessments weekly. There should be an admission assessment done to include your Braden scale. On 3/17/22 at approximately 5:45 PM a Pre-exit interview was conducted with the Administrator, The Vice President of Operations, and the Vice President of Clinical Services concerning Resident #26. The Vice President of Operations Stated, The DON that was here had a wound care protocol but we can't find it but will re-implement it. *(1) Xerosis-Dry skin makes the skin look and feel rough, itchy, flaky, or scaly. The location where these dry patches form vary from person to person. It's a common condition that affects people of all ages. Dry skin, also known as xerosis or xeroderma, has many causes, including cold or dry weather, sun damage, harsh soaps, and overbathing. You can do a lot on your own to improve dry skin, including moisturizing and practicing sun protection year-round. Try various products and skincare routines to find an approach that works for you. This information was taken from https://www.mayoclinic.org/diseases-conditions/dry-skin/symptoms-causes/syc- 885. *(2) Unstageable pressure ulcer- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. National Pressure Ulcer Advisory Panel website at http://www.npuap.org/pr2.htm *(3) The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development .The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development. This information is taken from the website https://www.nlm.nih.gov/research/umls/sourcereleasedocs/current/LNC_BRADEN *(4.) Dakin's solution is used to pr [TRUNCATED]

Based on complaint investigation, staff interviews, clinical record review, and facility documentation, the facility staff failed to provide the necessary care and services for 2 of out 44 residents (Resident #84 and #71) in the survey sample. For Resident #84, the facility staff failed to provide [MEDICATION(S)] intravenous (IV) fluids as ordered by the Nurse Practitioner on 02/04/22 at approximately 10:30 a.m., to start Sodium Chloride Solution 0.9%, use 50 ml/hour intravenously (IV) x 24 hours for 2 liters for hydration which was never initiated. Resident #84 remained in the facility for 28 hours after the order was given to start IV fluids before the resident was noted as being in respiratory distress, unable to obtain blood pressure, and using his accessory muscles for breathing. Resident #84 was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with main diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #84. For Resident #71, the facility staff failed to change the peripherally inserted central catheter (PICC) dressings every seven days for site maintenance and prevention of infection. The findings included: 1. Resident #84 was admitted to the nursing facility on 11/10/21. The resident was discharged to the local hospital on 02/05/22 and did not return to the nursing facility. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 11/17/21 coded the resident on the Brief Interview for Mental Status (BIMS) an 11 of 15 indicating moderate cognitive impairment. Resident #84 was coded total dependence of one with toilet use and bathing, extensive assistance of one with bed mobility and transfer, limited assistance of one with dressing and personal hygiene, and supervision with one assist with eating Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan created on 11/17/21 and a revision date of 01/11/22 identified Resident #84 with impaired cognitive function or impaired thought process related to an altered mental status. The goal set for the resident by the staff was that the resident will improve current level of cognitive function through the next review on 03/09/22. One of the interventions/approaches the staff would use to accomplish this goal is to administer medications as ordered. Monitor/document for side effects and effectiveness. On 02/04/22, the Nurse Practitioner (NP) progress revealed the following information: Resident #84 is being seen today for loose stools, decrease intake, and COVID-19. Resident #84 reports having decreased appetite and increased thirst. Under diagnosis, assessment and plan it included but was not limited to start Sodium Chloride Solution at 50 ml/hour x 2 liters. The review of Resident #84's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with License Practical Nurse (LPN) #6 on 03/14/22 at approximately 4:12 p.m. When asked, what does it mean with an order that reads pending confirmation? The LPN stated, that the order was put Point Click Care (PCC) but the nurse never confirmed the order, so the order was never initiated. A review of Resident #84's clinical record revealed the following documentation entered on 02/05/22 at approximately 2:56 p.m., by LPN #3. Resident #84 noted having respiratory distress, being unable to obtain blood pressure, oxygen saturation of 94% on room air, and heart rate of 102 while using accessory muscles for breathing. A new order was obtained to send to the ER for evaluation and treatment. A phone interview was conducted with Nurse Practitioner (NP) on 03/15/22 at approximately 2:08 p.m. The NP stated she assessed Resident #84 on 02/04/22 due to the staff reporting the resident was having loose stools and not eating. She said that during her discussion with the resident, he voiced to me that he was really thirsty and has no appetite. The NP said IV fluids were ordered and started on 02/04/22. The NP stated, IV fluids were ordered for hydration because Resident #84 was having loose stools and not eating She said the BMP was not ordered as STAT (now order) because I needed time for the IV fluids to hydrate the resident to help determine what further treatment was needed. The NP stated, Unfortunately, his IV fluids were never started and I was never notified. An interview was conducted with LPN#3 on 03/14/22 at approximately 1:46 p.m. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 and 02/05/22 (7-3 shift), the day Resident #84 was evaluated by the NP with new orders to start IV fluids. The LPN said she remembered Resident #84 was not eating or drinking. She said the NP came in and saw Resident #84 and wrote a bunch of new orders but I was never informed that an order to start IV fluids. On 03/15/22 at approximately 9:44 a.m., a phone interview was conducted with LPN #5. The LPN was assigned to provide care and services to Resident #84 on 02/04/22 (11-7 shift). The LPN stated, I don't recall the nurse giving a report that Resident #84 had an order to start an IV to administer IV fluids. On 03/16/22 at approximately 2:53 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said the nurse(s) should have activated the order in PCC and the IV fluids should have been started as ordered by the (NP). He stated, If the nurse assigned was not able to start the IV, there is always someone in house that could have started the IV. He stated clysis could have been used to hydrate the resident. A phone interview was conducted with the Medical Director on 03/17/22 at approximately 5:11 p.m., when asked if the staff should have started the fluids IV or via clysis, he replied, Absolutely, not receiving the IV fluids could have contributed to his dehydration as well as Acute Renal Failure (AFR). The Medical Director stated, The NP or I should have been notified that Resident #84's IV fluids were never started. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/05/22 from (name of nursing facility) for further evaluation due to lethargy. The 911 transport revealed the following: Resident serum glucose was 14. The Emergency Medical Service (EMS) placed an IV, gave [MEDICATION(S)] and D10 and his glucose increased to 135. The ER records indicated Resident #84's rectal temperature @ 89.4 degrees F (hypothermia - low body temperature) and placed on [NAME] for low rectal temperature. The resident's blood pressure was 89/40 (normal = 120/80). He was found to be in severe metabolic acidosis and septic shock. The urinalysis with reflex showed large leukocyte esterase, positive nitrites, and a moderate amount of blood with 3+ bacteria. The urine culture revealed more than 100,000 colonies and was positive for Kiebsiella pneumoniae. The resident had a high blood creatinine of 7.2 (0.59-1.04 = normal range). The creatinine test is a measure of how well your kidneys as performing their job of filtering waste from your blood (www.mayoclinic.org). The resident was started on IV sodium [MEDICATION(S)], given D50, and admitted to the Intensive Care Unit (ICU). Intravenous Fluids (IV), and IV antibiotic ([MEDICATION(S)] and [MEDICATION(S)]) was also started. Resident #84 is in the ICU, on a ventilator, sedated and unresponsive. The resident will need [CONDITION(S)] per nephrology but is pending due to his acute kidney injury. Resident #84 is being transferred to a higher level of care on 02/12/22. The resident is hemodynamically unstable for conventional hemodialysis and will benefit from continuous renal replacement therapy (CRRT), which this facility doesn't provide. At the time of discharge, resident remains on a mechanical ventilator. A review of the hospital records revealed the following: Resident #84 presented in the emergency room (ER) on 02/12/22 as a transfer from the originated hospital for further evaluation due to [CONDITION(S)] and Altered Mental Status (AMS). The resident was sent here for continuous renal replacement therapy (CRRT), which the previous hospital doesn't provide. The hemodialysis catheter placement was placed and (CRRT) was started on 02/13/22. A debriefing was conducted with the Administrator, Vice President of Clinical Services, and Regional Director of Clinical Services on 03/17/22 at approximately 5:45 p.m., Resident #84's issues were presented again. The facility did not present any further information about the findings. Definitions: -Metabolic acidosis develops when too much acid is produced in the body. It can also occur when the kidneys cannot remove enough acid from the body. Some causes for metabolic acidosis included but not limited to severe diarrhea and severe dehydration. Treatment is aimed at the health problem causing acidosis. In some cases, sodium [MEDICATION(S)] may be given to reduce the acidity of the blood. Often, you will receive lots of fluids through the vein (https://medlineplus.gov). -Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. Many people, particularly older adults, don't feel thirsty until they're already dehydrated. That's why it's important to increase water intake when you're ill. Other dehydration causes include but are not limited to diarrhea and or acute diarrhea - that is, diarrhea that comes on suddenly and violently - can cause a tremendous loss of water and electrolytes in a short amount of time. Dehydration can lead to serious complications, including urinary and kidney problems. Prolonged or repeated bouts of dehydration can cause urinary tract infections, kidney stones, and even kidney failure. The only effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The best approach to dehydration treatment depends on age, the severity of dehydration, and its cause. Adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room . Salts and fluids delivered through a vein (intravenously) are absorbed quickly and speed recovery. -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Urinary tract infection occurs when there is a compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, [CONDITION(S)] is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Sodium Chloride Solution 0.9%, solution is used to supply water and salt (sodium chloride) to the body. Sodium chloride solution may also be mixed with other medications given by injection into a vein (https://www.webmd.com/drugs). -Clysis or hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short-term hydration has the potential to reduce cost and transfers to the hospital (https://pubmed.ncbi.nlm.nih.gov). -A basic metabolic panel (BMP) is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism. Metabolism is the process of how the body uses food and energy. A BMP is used to check different body functions and processes, including: kidney function, fluid and electrolyte balance, blood sugar levels, and acid and base balance (https://medlineplus.gov). -Klebiella pneumoniae is one of the bacteria most frequently causing healthcare-associated urinary tract infections (https://www.ncbi.nlm.nih.gov). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Mechanical ventilation is a form of life support. A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine (https://www.continued.com/resp-therapy/courses). 2. Resident #71 was originally admitted to the facility 1/11/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The five day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #71's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with bed mobility, extensive assistance of one person with personal hygiene, dressing, toileting limited assistance of one person with eating and limited assistance of one after set-up with eating. Resident #71 was observed sitting in a wheel chair in her room on 3/9/22 at approximately 4:45 p.m. The resident stated she had surgery to the right knee and the physician had to go back in it and clean it out because of an infection; as a result she needed to have extensive antibiotic therapy intravenously. The resident further stated some of staff act like they have no idea how to administer the antibiotic. The resident had a PICC to the right upper arm and it was dated 3/9/22. Resident #71 stated the PICC dressing was supposed to be changed 3/5/22 but it wasn't changed until 3/9/22 and it was supposed to be changed again on 3/12/22 but it was now 3/17/22 and it hadn't been changed. Resident #71 stated she was concerned the PICC site may become infected and cause a delay in her going home. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2/25/22 IV PICC change needleless connector on admission, weekly every day shift/ Saturday for and as needed thereafter and change after every blood draw. 2/25/22 IV-PICC Measure catheter length on admission and with each dressing change thereafter. 2/25/22 IV-PICC change transparent dressing on admission, then weekly every day shift/Saturday and as needed thereafter. 2/21/22 [MEDICATION(S)] Sodium Solution Reconstituted 2 Grams - Use 2 gram intravenously in the evening for infection related to infection and [CONDITION(S)] reaction due to internal right knee prosthesis. An interview was conducted with Licensed Practical Nurse (LPN) #15, on 3/17/22 at approximately 1:15 p.m. LPN #15 stated she would take care of the dressing change today. On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS and the Vice President of Operations (VPO). The VPSC stated he had spoken to the nurse caring for Resident #71 and the dressing was to be changed today. The below information was obtained from the following web site on 3/25/22 (https://medlineplus.gov/ency/patientinstructions/ 2.htm#:~:text=You%20sho uld%20change%20the%20dressing,you%20with%20the%20dressing%20change.) A dressing is a special bandage that blocks germs and keeps your catheter site dry and clean. You should change the dressing about once a week. You need to change it sooner if it becomes loose or gets wet or dirty. COMPLAINT DEFICIENCY

Based on information gleaned during a complaint investigation, family interview, staff interviews, and a clinical record review, the facility staff failed to admit and transcribe orders to obtain crucial pain medications for over forty-five hours to manage the pain for a resident two days post-surgery after a serious and complex lumbar fusion of the spine, resulting in severe pain which limited participation in day to day activities, the ability to sleep at night and physical decline which constituted harm for 1 of 44 residents (Resident #83), in the survey sample. The findings included: Resident #83 was originally admitted to the facility on [DATE], was discharged to acute care on 11/26/21, returned to the facility on [DATE], and discharged again on 1/1/22, and succumbed on 1/4/22. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #83's cognitive abilities for daily decision-making were intact. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of two people with transfers, extensive assistance of one person with dressing and toileting, limited assistance of one person with bed mobility and personal hygiene, and supervision after set-up with eating. In sections J0500A and B; the resident was coded that pain made it hard to sleep at night and limited day-to-day activities. At section M1040E; the resident was coded with a surgical wound. On 3/16/22 at approximately 10:30 a.m., an interview was conducted with the resident's listed Responsible party (RP). The RP stated they were familiar with the facility under different ownership for their mother had short stays after a number of hospitalization s. The RP further stated Resident #83 chose the facility for rehabilitation after surgery to regain strength and return home. The RP stated the resident was an eighteen-wheel truck driver and looked forward to getting back in the truck. The RP also stated the night of 11/19/21, Resident #83 arrived at the facility at approximately 6:00 p.m., by stretcher from a local hospital. She stated the resident was with significant functional limitations including transfers, walking, toileting, and other activities of daily living (ADL) and back pain secondary to surgical decompression and lumbar fusion of the spine. The RP stated the unit the resident was assigned to was staffed with one nurse, no other staff, and the nurse was overwhelmed and told her she had no orders to provide care to the resident. During the interview, the RP assured the facility's nurse that wasn't accurate for she had spoken with the hospital's Discharge Planner multiple times to ensure all necessary orders and instructions were provided to the facility prior to the resident leaving the hospital because she was aware of how interruptions in service may occur if all information wasn't provided timely to the facility. The RP stated the nurse told the family upon request for pain medication that she had no orders for medications therefore she couldn't administer any medications to the resident but they could go home and get his medications and they could administer them to the resident. The RP stated that the same evening, the day of admission 11/19/21, Resident #83 experienced severe pain and needed to void but because of a history of voiding only in a specific position it was necessary for him to get out of bed to void and there was no one to assist the resident. It was the family who had to assist the resident to get out of bed to void. The RP stated the only service the resident received the day of admission was to receive a bedside commode, no medications, no physical assistance. The RP further said during the above interview that over the course of the first two days her brother had to come into the facility and transfer the resident to the commode because the staff wouldn't. She stated the staff's rationale was rehabilitation services hadn't assessed the resident and he was experiencing severe pain on movement. The RP stated on one occasion the resident lay in feces for four hours because he feared the pain which would be inflicted on him by staff yanking on him to clean him up, therefore the resident called for his son to come to the facility and assist him to clean up. The RP also stated on 11/20/21 the nurse staff stated it would be three to four days before the resident's pain medications would arrive to the facility, and it was a relief when they finally arrived almost two days after his admission to the facility. Review of the hospital's discharge summary dated 11/19/21 included the following discharge medication orders; [MEDICATION(S)] 5/325 milligrams; one tablet by mouth every six hours as needed for pain, [MEDICATION(S)] 7.5/325 mg; one tablet by mouth every six hours as needed, [MEDICATION(S)] 5mg one tablet by mouth daily and [MEDICATION(S)] 4mg; one tablet by mouth three times daily as needed. A record review revealed on 11/20/21 at 10:07 a.m., (name of the on-call Nurse Practitioner) called to have a hard prescription sent to the pharmacy for [MEDICATION(S)]. The Nurse Practitioner (NP) stated she would send an electronic prescription to the pharmacy and the resident's son was informed when he arrived at the facility. A nurse's progress note dated 11/21/21 at 5:19 p.m. revealed that Resident #83's family members were in the facility demanding to speak with the Director of Nursing because the resident wasn't receiving two medications (a steroid and an [MEDICATION(S)]) instrumental in treating polymyalgia rheumatic; an [CONDITION(S)] disorder that causes muscle pain, muscle stiffness, and muscle spasms in various parts of the body which could easily be treated with steroids and an [MEDICATION(S)]. A progress note was also in the clinical record stating on 11/21/21 at 9:21 p.m., the on-call NP was notified that Resident #83's family desired to have the [MEDICATION(S)] and [MEDICATION(S)] resumed but the NP deferred the orders to the order until the resident was visited by the in-house Practitioner. During the interview with the RP on 3/16/22 at approximately 10:30 a.m., the RP stated when the resident's medications arrived at the facility from the pharmacy on 11/21/21 the steroid and [MEDICATION(S)] weren't included and they were the exact medications the hospital Discharge Planner was asked to ensure was included in the orders to the facility for they were required to treat the debilitating symptoms of polymyalgia rheumatic. The RP stated as a result of not receiving the steroid and [MEDICATION(S)] the resident suffered additional pain, spasms and other rebound symptoms of polymyalgia rheumatic along with the pain related to the spinal surgery. The RP stated the poor care in the facility resulted in her father's unnecessary pain and physical decline. An interview was conducted with Licensed Practical Nurse (LPN) #9 on 3/17/22 at approximately 9:52 a.m. LPN #9 stated she remembered Resident #83 and she was the nurse on duty the evening the resident arrived. She further stated the staff knew she wasn't proficient in admissions and she always worked the overnight shift to avoid admitting residents. LPN #9 stated she had never admitted a resident and the day Resident #83 arrived she was the only direct care staff on the unit; without any other nurses or Certified Nursing Assistants (CNA). LPN #9 stated the front office staff was also aware she was the only caregiver for the shift therefore they came to the unit to assist with answering call lights and providing limited care for the residents prior to going home for the night, but that was all. LPN #9 stated no one told her they were not going to admit Resident #83 to the facility and she didn't. LPN #9 stated she provided the Resident with a bedside commode and a son who was present and very involved in the resident's care assisted him to the toilet. LPN #9 also stated she was aware the resident was experiencing pain and she informed the resident's family that she had no orders to administer any medications to the resident. An interview was conducted with the facility's Admission Director on 3/17/22 at approximately 2:30 p.m. The Admission Director stated she doesn't have a clinical background, therefore, all clinical concerns are reviewed by the Director of Nursing prior to admissions arrival to the facility. The Admission Director stated there were no specific clinical concerns with Resident #83's 11/19/21 admission therefore all of the admission documents were given to the nursing staff for the unit to the resident was to be admitted and the nursing staff didn't ask her to obtain any specific documents from the hospital's Discharge Planner and no concerns were voiced by the nursing staff. Two other staff nurses were telephoned on 3/16/22 and 3/17/22 for interviews regarding the status of Resident #83 during the 11/19/21 admission but the calls were not answered and/or returned. One of the nurses assumed care of the resident on 11/20/21 and telephoned the Nurse Practitioner for a pain medication order and the other was the nurse who opened a Braden Scale for Predicting Pressure Sore Risk assessment but didn't complete any of it or any other admission paperwork on 11/19/21. An interview was conducted on 3/17/21 at approximately 1:30 p.m., with the facility's Vice President of Clinical Services (VPCS). The VPCS stated he was unable to provide evidence that the resident received any type of pain management prior to 11/21/21 at 3:50 p.m. when [MEDICATION(S)] 5/325 milligrams (mg) was delivered and administered. The VPCS stated the pain medication [MEDICATION(S)] 5/325 mg was included in the resident's orders on 11/19/21, as a hospital discharge medication and it was available in the facility's stat medication box, yet it wasn't withdrawn and administered to the resident and neither was the [MEDICATION(S)] administered at the time of obtaining the order for it on 11/20/21 for the 5/325 mg dose was also available in the stat box but not the 7.5/325 mg dosage. The VPCS further stated both drugs were in the stat box and could have been given. The VPCS On 3/17/22 at approximately 5:45 p.m., the above findings were shared with the Administrator, VPCS, and the Vice President of Operations (VPO). The VPCS stated the nurses working at the facility are competent and there is a resource book available for reference when needed therefore he was unable to explain why there was a delay in the resident's care. The VPO stated she too had reviewed the pain medication delays and felt the resident pain wasn't managed appropriately but she was unable to offer any insight into why the care wasn't provided promptly. COMPLAINT DEFICIENCY

Based on complaint investigation, staff interviews, clinical record review and facility documentation, the facility staff failed to provide the necessary care and services to prevent complications of a urinary tract infection for 1 of 8 residents (Resident #6) in the survey sample. The facility staff failed to recognize early signs and symptoms of [CONDITION(S)] to include altered mental status, decrease in intake and output, fever, pain and decreased blood pressure, as well as a failure to follow physician's STAT orders for urinalysis and culture and sensitivity that would have determined further treatment. The resident was discharged and admitted to the hospital on 06/03/20 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Resident #6 was originally admitted the nursing facility on 01/01/20. The resident was discharged to the local hospital on 06/03/20 and did not return to the nursing facility. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 05/25/20 coded Resident #6 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions. The MDS coded Resident #6 total dependence of one with dressing, toilet use, personal hygiene and bathing, extensive assistance of two with transfer and extensive assistance of one with bed mobility for Activities of Daily Living care. Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan with a created date of 01/10/20 identified Resident #6 with bladder incontinence. The goal set for the resident by the staff was that the resident will remain free from skin breakdown due to incontinence and brief use. One of the interventions/approaches the staff would use to accomplish this goal is to monitor/document/report any signs/symptoms of a [CONDITION(S)]. Resident #6's nurse's note written on 05/04/20 at approximately 12:20 p.m., by the Unit Manager, Registered Nurse #1 (RN) indicated the Resident #6 had a low grade temperature but the actual temperature was not recorded. The nurse's notes indicated Nurse Practitioner (NP) #2 was made aware that resident had a fever with new orders written for urine culture and sensitivity, chest x-ray, Complete Blood Count (CBC) and Basic Metabolic Panel (BMP). All of the physician ordered labs for 05/04/20 were obtained except for the urine culture with sensitivity. Review of the May 2020 Lab Administration Record (LAR), revealed two blank spaces on 05/04/20 and 05/05/20 that indicated the UA, C&S was not obtained, per the Director of Nursing (DON) acknowledgment during an interview on 08/24/20 at approximately 4:03 p.m. The lab results were not in the clinical chart and could not be located by the DON. A phone call was placed License Practical Nurse (LPN) #7 on 08/26/21 at approximately 1:06 p.m. The LPN was assigned to provide care and services to Resident #6 on 05/04/20 (7a-7p shift). A message was left, the LPN never returned the call. A phone interview was conducted with Resident #6's Representative on 08/25/21 at approximately 10:56 a.m. She stated she had contacted the facility on 05/20/20 (not sure of the exact time) and informed her nurse that Resident #6 was not acting or talking like herself. The Representative said the last time Resident #6 behavior was like this she had a bad [CONDITION(S)]. She said the facility ignored me by not addressing my concerns related to the change that I witnessed with Resident #6. The resident's Representative said, Resident #6 was transferred to (name of hospital) on 06/03/20 but was then transferred her to a second hospital because they can provide immediate onsite [CONDITION(S)] if necessary for Renal Failure. A nurse's note entered by LPN #7 on 05/20/20 (7a-7p) shift revealed the following concern voiced by Resident #6's Representative: Resident #6 was not sounding like her normal self. The family member stated the last time this happen she had a [CONDITION(S)]. The family is requesting for the NP to check resident for [CONDITION(S)]. The UM and NP were notified on 05/20/20 at approximately 2:51 p.m. Resident #6's nurse note from 05/20/20 - 05/29/20 failed to provide evidence that Resident #6 was ever assessed for a [CONDITION(S)]. NP #2's progress note dated 05/29/20 revealed the following information; Resident #6 is being seen today via telemedicine with the assistance of UM for decline in condition. Per nursing, Resident #6 has had a decrease in oral intake and sleeping more frequently. The NP wrote an order was for a STAT UA C&S for suspected [CONDITION(S)] along with a STAT (immediate) CBC and BMP with any abnormal results called to the on-call team. The UA, C&S, BMP and CBC was written as a one-time order instead of a STAT order, which meant the UA C&S could have been obtained at any time. This was not keeping with the orders by NP #2. Review of the May 2020 LAR, revealed evidenced of two blank spaces on 05/29/20 and 05/30/20 for UA, C&S which indicated the UA, C&S was not obtained, per the DON acknowledgment during an interview on 08/25/21 at approximately 3:45 p.m. The lab results were not in the clinical chart and could not be located by the DON. An interview was conducted with the DON on 08/24/21 at approximately 4:30 p.m. The DON stated, The order was given as a STAT order for a reason. The DON stated a STAT order is done within 2 hours. A standard order which a one-time order could be obtained at any time. It is the floor nurse's responsibility to make sure all labs are obtained as ordered by the physician. The DON stated all physician ordered labs are to be obtained and followed up with their results. On 08/25/21 at approximately 2:36 p.m., a call was placed to LPN #5 who was assigned to provide care and services to Resident #6 on 05/29/20 (7p-7a) shift; she never returned the call. This LPN documented in the resident's nurses note on 05/30/20 at 6:09 a.m., that she was not able obtain the UA, C&S as ordered due to resident discomfort. The progress note did not indicate the NP or physician was made aware the UA, C&S was not obtain due to the resident's discomfort. On 08/25/21 at approximately 3:45 p.m., an interview was conducted with the DON and Corporate nurse. The DON stated she was not the DON during the time Resident #6 resided in the facility. The DON stated due to Resident #6's pain and discomfort, she should have been sent out as an emergency to a higher level of care. The DON said, She should have been sent out to acute care because obviously, Resident #6 needed more help than what was being offered here in the facility. The nurse's notes on 06/02/20 at approximately 2:25 p.m., entered by LPN #6 included the following information: Resident #6's meal consumption for breakfast was 0% with 30 ml of meal replacement shake and consumed less than 50% of lunch. On the same day at approximately 6:41 p.m., the nurse's note indicated the resident is not eating or drinking, and the NP #2 was notified via phone and informed of the resident's change in condition. Orders were given again, for a UA/C&S, CBC with diff and BMP. The nurse's note indicated the vital signs were but not limited to the following: (BP) 88/51 - ([CONDITION(S)]) and oxygen saturation level at 91% on oxygen at 2 liters via nasal/cannula (oxygen saturation levels 96%-100% is considered normal on room air) (https://www.ncbi.nlm.nih.gov). The on call NP was notified via phone of change in condition and waiting on a call back for further instruction. On 06/03/20, a nurse's note entered at 1:08 a.m., included an order to send Resident #6 out for further testing. The nurse's note indicated Resident #6 was hospitalized due to scant urine. Resident #6 did not return to the nursing facility. Review of Resident #6 clinical record revealed the nursing staff was able to collect UA, C&S that was ordered by the NP on 06/02/20, which the results were received by facility on 06/03/20 at 1:54 a.m. The urine culture included the following: greater than 100,000 colonies, more than 2 different organisms; please submit a new specimen but by the time the urine culture was received to the facility. Resident #6 had already been discharged and admitted to the hospital at the time of these results. Review of the hospital records revealed Resident #6 presented in the emergency room (ER) on 06/03/20 as a transfer from the originated hospital's ER for further evaluation due to Altered Mental Status (AMS). On the evaluation work-up at (name of transferring hospital), the resident was diagnosed with Acute Renal Failure (ARF) with a blood creatinine above 19 (0.59-1.04 = normal range). A creatinine blood level measures of how well your kidneys as performing their job of filtering waste from your blood (www.mayoclinic.org). The resident's potassium level was 6.2 (H) (3.6 to 5.2 = normal range). High potassium levels ( [CONDITION(S)]) are apparent in the late stages of [CONDITION(S)], these alterations can reach statistically significant levels in the shock period (https://pubmed.ncbi.nlm.nih.gov/ 19/). Upon arrival to the hospital, the ER records indicated Resident #6's body temperature was 94.6 F(*hypothermia - low body temperature), with a *Bair [NAME] placed on the resident along with five warming blankets. The ER records indicated the resident was septic with shock requiring Intensive Care Unit (ICU) admission. Intravenous Fluids (IV), IV antibiotic ([MEDICATION(S)] and [MEDICATION(S)]) was started as well as an urgent central line for possible [CONDITION(S)]. The laboratory data revealed [CONDITION(S)] due to a renal source as her urinalysis has too numerous to count (white cells.) *Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). *Bair [NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). On 08/26/21 at approximately 1:30 p.m., a pre-exit meeting was held with the Administrator, DON and Corporate, the Resident #6's issues was presented again. No additional information was forth coming. Definitions: 1. Urinary tract infection occurs when there is compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, [CONDITION(S)] is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .ncbi.nlm.nih.gov). 2. [CONDITION(S)] is a serious medical condition. It's caused by an overwhelming immune response to infection. The body releases immune chemicals into the blood to combat the infection. Those chemicals trigger widespread inflammation, which leads to blood clots and leaky blood vessels. As a result, blood flow is impaired, and that deprives organs of nutrients and oxygen and leads to organ damage. In severe cases, one or more organs fail. In the worst cases, blood pressure drops, the heart weakens, and the patient spirals toward septic shock (https://www.nigms.nih.gov/education/Documents/[CONDITION(S)].pdf). 3. Severe [CONDITION(S)] symptoms may include but not limited to organ failure, such as kidney (renal dysfunction resulting in less urine) low platelet count and change in mental status, pain in the lower abdomen and blood in the urine. Systolic pressure is equal to or less than 100 millimeters of mercury (mmhg) and abnormal white blood cell count (either too high or too low). In some cases, [CONDITION(S)] may turn into septic shock, which is a drastic drop in blood pressure that can increase the risk of death. Signs of septic shock include but not limited to: needing medication to maintain systolic blood pressure equal to or greater than 64 mmHG and high levels of lactic acid in your blood, which means your cells aren't using oxygen in the right way. To prevent urosepsis, get treated as soon as possible. The longer you delay treating [CONDITION(S)], the more likely to develop urosepsis, septic shock, renal failure and death (https://webmd.com). 4. Acute Renal Failure is the rapid (less than 2 days) loss of your kidneys' ability to remove waste and help balance fluids and electrolytes in your body (https://medlineplus.gov). 5. Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a [CONDITION(S)] (http://www.webmd.com/a-to-z-guides/urine-culture). 6. Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture). Complaint deficiency

Based on observation, staff interviews, clinical record review, facility document review, and during the course of a complaint investigation, the facility failed to ensure 1 of 3 residents in the survey sample (Resident #1) was free from an avoidable fall from the bed during the provision of care that required emergency room evaluation with subsequent head injury resulting in harm. The Certified Nursing Assistant (CNA #2) failed to ensure Resident #1 was not too close to the edge of the bed prior to repositioning; as a result, the resident fell out of the bed, which was in a high position, onto the floor. The resident sustained [REDACTED]. After the fall the resident was fearful upon repositioning and suffered with ongoing headaches. The findings included: Resident #1 was originally admitted to the facility on [DATE] and had a re-admission date of [DATE] with [DIAGNOSES REDACTED]. The current Minimum Data Set, an annual, with an assessment reference date of 9/10/19 coded the resident as scoring a 10 out of a possible 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The resident was coded as requiring extensive assistance of one staff for bed mobility, transfers and toileting. The resident was wheelchair bound. The complainant alleged the resident was pushed out of the bed and sustained injuries to the forehead and a concussion on 11/1/19. Review of the clinical record and a facility investigation evidenced on 11/1/19 at approximately 4:25 a.m., CNA #2 went into the resident's room to provide incontinent care. The resident was not placed in the proper position, instead was positioned more to the edge of the bed and when the CNA turned the resident to the right side the resident fell to the floor. The nurse documented, This nurse was called to resident's room. C.N.A stated, she fell while I was changing her. Upon entering resident noted face down on floor with head bleeding profusely. The nurse instructed the CNA to apply pressure to the open area to the resident's left forehead, called the nurse practitioner and received orders to send the resident to the emergency room for evaluation and treatment. 911 was called and transported the resident to the local emergency room . The emergency room Physician notes dated 11/1/19 read, in part: The patient sustained injury to the head, contusion, pain, swelling. Head/face: Noted is contusion, that is deep, a lacerations(s), that is superficial. A CT scan was completed, initial encounter [MEDICATION NAME] trauma (contusions or hematomas) and concussion / head injury. The CT scan was negative for fractures. The resident was diagnosed with [REDACTED].). The resident was treated with one dose of an antibiotic (Keflex) and [MEDICATION NAME] ointment was applied to the forehead abrasion. The resident was sent back to the facility with discharge instructions for the treatment and monitoring of the forehead abrasion and adult head injury to include concussion (a jarring injury to the brain), contusion (a bruise of the brain, bleeding in the brain that can cause swelling) and hematoma (bleeding in the brain that collects, clots and forms a bump) The definitions were obtained from the ER discharge instruction sheets. The head injury sheet read, in part: After injuries such as yours, most problems occur within the first 24 hours, but side effects may occur up to 7-10 days after the injury. It is important for you to carefully monitor your condition and contact your health provider or seek immediate medical care if there is a change in your condition. Other causes of major head injuries include bicycle or motorcycle accidents, sports injuries, and falls. On 11/19/19 at 12:30 p.m., the Administrator was interviewed. She was asked about the avoidable fall. She stated, When she was repositioned with the sheet that was under her, she flipped, her weight was not distributed evenly .she went off the bed. CNA #2 was interviewed on 11/21/19 at 2:30 p.m. When asked about the resident's fall he stated, I went to do ADL (activities of living-incontinent care), I turned her and her legs went over, when I tried to pull her over her top half went over then her whole body went down to the floor .I had the bed elevated all the way up. He stated the Director of Nursing called him in later that day to do a one to one inservice on proper bed repositioning technique. He stated he did not have the resident closest to him and not near the middle of the bed and stated It was poor thinking on his part as to why the avoidable fall occurred. CNA #4 was interviewed on 11/21/19 at 11:00 a.m. She was asked about the resident's bed mobility and a sign that was posted above the resident's bed that had a picture of two figures. She stated, Two person, that started from the fall .two people need to be in there, for bed mobility, incontinent care, transfers . She stated that the resident was very fearful after she fell from the bed with repositioning but has gotten better and needs to be talked to calmly during repositioning. Review of the Visual/ Bedside Kardex Report for the CNA's that included care plan interventions failed to include that the resident was a two person assist during bed mobility, transfers, incontinent care and the posting of the sign above the head of the bed. The Person Centered Plan of Care also failed to evidence it was revised to include the two person bed mobility, two person incontinent care, or the two person assist sign. The physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The treatment order for the forehead wound was to cleanse with soap and water, apply [MEDICATION NAME] and a xeroform [MEDICATION NAME] dressing every day shift until 11/5/19. A second order dated 11/5/19 was to clean the facial wound with soap and water, apply [MEDICATION NAME] and cover with a Band-Aid daily until 11/14/19. The resident's vital signs and neurological checks were conducted every four hours for four days. On 11/19/19 at 12:45 p.m., the resident was sitting at the bedside in a wheelchair. A large Band-Aid was observed to the resident's left forehead. The resident was asked about the fall, and stated she fell from the bed. When asked how it happened she stated she did not want to get anybody in trouble and did not comment any further about the fall incident. When asked if she was having any pain, she stated Yes and pointed to her bandaged left forehead. A sign was posted above the bed with a picture of two individuals. At 1:30 p.m., the resident was still sitting at the bedside in the wheelchair. She was asked if she was still having pain and stated Yes, she rated the pain to her head a 7 out of a possible 10; 10 being the worst pain. On 11/20/19 at 3:39 p.m., CNA #11 who was assigned to care for the resident was interviewed. She was asked what the sign above Resident #1's bed was. She stated, Anything to do with transfers is two people. The CNA was asked about incontinent care for the resident while the resident was in bed how many staff would it take, she stated One person. The CNA stated she attended the Inservice for the two-person sign provided by the unit manager. The sign in sheet (with no date) had CNA #11's signature. On 11/21/19 at 11:11 a.m., the Director of Nursing (DON) was interviewed. The DON was asked based on the facility's investigation of the fall what did the facility determine was the cause of the resident falling from the bed during care. She stated the CNA Misjudged the positioning of the resident and should have had the resident closer to him. She stated the resident was, Too close to the edge of the bed .she was not positioned in the bed correctly. In response to the fall she provided one to one education to the CNA, an agency employee, implemented a sign above the resident's bed indicating the resident was a two person assist with bed mobility and care to include incontinent care in bed and all transfers. She stated the daughter was angry and she was the one who suggested two staff attend to the resident during bed mobility and during the provision of care. The DON further stated staff were to be inserviced on safe handling of residents in the bed, this training was started on 11/15/19. She stated that she was also going to schedule the training in their computer based education program Name. When asked about the resident's injuries, she stated, Her eye was swollen shut, it looked really bad. On 11/21/19 at 2:10 p.m., the dressing to the resident's left forehead was changed by Licensed Practical Nurse #10. The hematoma to the left forehead was approximately 3 centimeters by 3 centimeters, it stuck out approximately 1/2 an inch with an open area in the center with dark tissue measuring approximately 1/2 centimeter in diameter. The resident winced when the nurse cleansed the wound and applied the top dressing. The resident was asked if she had any pain when the nurse was cleaning the wound, she stated she experienced discomfort. On 11/21/19 at 2:50 p.m., the Nurse Practitioner was interviewed. She stated she was called on the early morning of 11/1/19 and was notified the resident had fallen out of the bed and was bleeding from her forehead. She gave the order to send the resident to the emergency room . She stated the resident sustained [REDACTED]. The above findings was shared with the Administrator, the Director of Nursing and the Nurse Consultant during a pre-exit meeting on 11/21/19. Following the pre-exit meeting the facility was provided ample opportunity to bring forward any other documents or information. No additional information was provided to the survey team prior to exit. Complaint Deficiency.

Based on staff interviews, clinical record review, facility document review and during the course of a complaint investigation the facility staff failed to safely use an assistance device to prevent accidents for 1 of 6 residents in the survey sample, Resident #6, that resulted in harm. The facility staff failed to implement interventions according to the comprehensive assessment and plan of care for Resident #6 to prevent accidents. During a transfer that required a 2-person assist with a mechanical lift the resident was transferred with only one staff that resulted in a fall and subsequent hospitalization requiring laceration repair with staples, ventilation* and intensive care. *Ventilation is the exchange of air between the lungs and the atmosphere so that oxygen can be exchange for carbon monoxide in the alveoli (the tiny air sacs in the lungs. (Reference: http://www.medicinenet.com/ script/main/art.asp?articlekey= ). The findings included: Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].* and stroke. *Dementia is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. (Reference: NIH U.S. National Library of Medicine: Medline Plus). The quarterly Minimum Data Assessment (MDS) with an assessment reference date of 6/17/16 coded Resident #6 with a score of 3 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating severe impairment in decision making skills. Resident #6 required total dependence for transfer and bed mobility with two-person physical assist and unable to walk. Resident #6's Care Plan with a revision date of 10/04/16, read, in part, as follows: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) old CVA (stroke). The goal was listed as: The resident will improve current level of function in ADL through the review date. One of the interventions was the resident requires 2-person assistance for transfers. Nurses Progress Notes documentation for Resident #6 included the following: LPN #2 (Licensed Practical Nurse) documented: 11/14/16 16:00 - Called to room per CNA (Certified Nurse Aide). Resident on floor with laceration* noted on back of head. CNA states RESIDENT ROLLED OFF BED. Assisted back to bed. *A laceration is a wound that is produced by the tearing of soft body tissue (Reference: https://medlineplus.gov/ency/imagepages/ .htm). 11/14/16 16:15 - Unable to reach son - spoke with daughter (name of daughter). 11/14/16 16:20 - Notified (name of physician) of fall and laceration. 11/14/16 16:30 - DON (name of Director of Nursing) called to unit to assess head laceration. To apply steri-strips* and not send out. *Steri-strips are adhesive skin closures. (Reference: http://www.woundcareshop.com/ReinforcedSteriStripsBy3M.aspx). Director of Nursing (DON) documented: 11/14/16 16:44 - Called by Charge Nurse to see patient post fall. Resident lying in bed. Laceration to back of head 2 cm (centimeter) in length. Small amount of bleeding noted. no depth noted. Resident neurochecks started Pupils equal and reactive, resident talkative, no changes in condition. Notified (name of physician) of findings. Apply steristrips to site. LPN #2 documented: 11/14/16 17:15 - Called to room per CNA. Resident actively seizing. Placed on side. 911 called. daughter and (name of physician) notified. On 11/14/16 Resident #16 was transferred to the hospital with an arrival time of 17:53. The Nursing Home to Hospital Transfer Form for Resident #6 dated 11/14/16 documented, Reason for transfer: Seizure*. Vital Signs: Blood Pressure - 162/92; Pulse Rate - 120; Respiratory Rate - 20; Temperature - 98.3. *Seizures are symptoms of a brain problem. They happen because of sudden, abnormal electrical activity in the brain. (Reference: https://medlineplus. gov/seizures.html). The ED (Emergency Department) Physician Documentation record at Hospital #1 documented: HPI (History of Present Illness) dated 11/14/16 18:04: .She (Resident #6) presents to ED via EMS (Emergency Medical System) - Ground with complaints of seizure, recent fall. HPI unobtainable due to: comatose* state PT (patient) had fall from bed .striking her head .no history of seizures .At 1710, pt (patient) started to seize. Multiple seizures witnessed. Pt seized continuously from 1720 - 1749 .HPI obtained from EMS. Laceration noted by EMS to posterior scalp and swelling left of face. Bleeding controlled . *A coma, sometimes also called persistent vegetative state, is a profound or deep state of unconsciousness. (Reference: http://www.ninds.nih. gov/disorders/coma/coma.htm). ED Course: 11/14/16 18:33 - .She was unresponsive, no seizure activity noted. The patient had no gag reflex. She was intubated after pre-oxygenation with nasal cannula and bag-valve-mask. 11/14/16 19:35 - .CT* results without hemorrhage but with [DIAGNOSES REDACTED]. Need transfer for neurosurgery . *A CT (Computed Tomography) scan uses x-ray technology to take multiple views of the inside of the body. (Reference: http://www.lifescript.com/health/centers/cancer/therapies-procedures/ct_scan_general.aspx) 11/14/16 20:22 - .Laceration repaired. Patient responded to pain when staples placed. 11/14/16 22:22 - .At this point the patient is not requiring any sedation and will be transferred to (name of hospital) for Neurology and eventual neuro surgical consultation. Disposition: 11/14/16 21:27 - Transfer ordered to Other Acute Care Facility. [DIAGNOSES REDACTED]. Reason for transfer: Neurology - Higher Level of Care On 11/15/16, Resident #6 was transferred and admitted to Hospital #2 as inpatient. The Neurology Consult dated 11/15/2016 documented, Reason for consultation: New onset seizure; Assessment - New onset seizure lasting 27 minutes requiring intubation and sedation, may be related to trauma from recent fall and infection (UTI (Urinary Tract Infection)). No documented h/o (history of) seizures. The Critical Care Management record dated 11/15/16 at 3:10 am documented, Disposition: Admit. HPI Comments: .presents to ED as transfer from outside facility for neuro evaluation and ICU (Intensive Care Unit) admission .On CT patient did not show any hemorrhage or skull fracture, however does have [DIAGNOSES REDACTED] with unknown acute vs chronic. Resident #6 was still confined at Hospital #2 ICU as of 11/18/16 when medical records were obtained. A written statement by CNA #1 dated 11/14/16 documented, This statement is concerning (name of resident), I put (name of resident) on the bed on her side and moved backed to get the lift out of the way, I saw her beginning to turn which she hardly ever does but I could not get to her before she fell on the floor. I take responsibility because it is my job to keep all of them safe. On 11/17/16 at 4:50 pm, an interview was conducted with CNA#1 and when asked to describe how the resident fell on [DATE], she stated, I put (resident name) on the lift and I was using the lift by myself. She wanted to go back to bed so I put her back to bed. I didn't put her on the bed all the way; I put her on her side. I moved the lift to get it out of the way .before I could get to her she rolled over on the floor. She hit the floor . She stated that the resident was regularly assigned to her and she usually doesn't turn. She stated, We are supposed to have 2 people when we use the Hoyer lift. I know that. When asked why she was by herself, she replied, Because the other CNA on the floor was changing her residents, I didn't ask her. It was not the other CNA's fault because I didn't ask her. When asked if the fall could have been avoided, CNA #1 replied, Yes, if I had somebody there with me it really could have. On 11/14/16, the DON provided a one-on-one training for CNA#1 on Transfer/Safety regarding (name of Resident #6). The sign-in sheet documented, Hoyer lift requires 2 person assist. When placing patient to bed must ensure they are in the center of the bed. Placing a patient on the edge of the bed increases risk of patient falling. CNA#1 stated that an inservice was offered for nursing staff by the DON and Unit Manager about using 2 people for the mechanical lifts. A written statement by LPN #2 dated 11/14/16, 3-11 shift, documented, At 4 pm during med pass I was called to room (number) per CNA #1 stated, (Name of resident) rolled off bed after transfer from chair to bed. (Name of Resident) on floor rt (right) side next to bed. Alert and responsive. Laceration noted on back of head. Called daughter (name of daughter), (name of physician), and DON (name of DON). At 5:15 pm called to room. Resident unresponsive and actively seizing. Called 911, (name of physician) and daughter. On 11/17/16 at 5:30 pm, an interview was conducted with LPN #2 and when asked to describe how the resident fell on [DATE], she stated, She (CNA#1) came to meet me . and said she fell . She was on the floor on the right side of the bed .I believe she was turned to the window. Those girls know that is a 2-person job .she rolled over the bed. She was intact neurologically at the time .Called (name of DON), (name of physician). When asked about the laceration, she stated, The laceration was in the middle of the back of the head .1.5 inches. An hour and 15 minutes later she started seizing, I called 911, called daughter back and (name of physician). EMS came right away. Resident was unresponsive, actively seizing. She didn't have a history of seizure, she wasn't on medication for seizure. When asked what her expectations were from staff, LPN#2 stated, They know now. Everybody knows. They will be written up. Most of the time they pair up when they get resident back in the bed. When asked if the fall could have been avoided, LPN#2 stated, Yes, if she had a second person. I think she turned to move the lift .then one would have been on the side to hold the resident. LPN #2 stated that they had an inservice on 11/17/16, offered by the DON on transferring residents with 2 people all the time. LPN #2 added, When I was in orientation that's a 2-person job. Shouldn't have been alone. A written statement by the DON dated 11/14/16 documented, Investigation/Interviews in resident room. Resident (name of resident) was placed back to bed from (brand name) chair on the left side of the bed (near bathroom). She was placed on the left side of bed and not in the center (side lying) facing the window. CNA (name of CNA#1) stated resident started turning herself on her back and before she could get close enough she rolled herself off the bed. She landed on the floor on her back hitting her head. Charge Nurse (name of LPN#2) notified when entering room resident was lying on back B/t (between) wall to BR (bathroom) and bed. Placed back bed laceration to back of head. On 11/17/16 at approximately 6:05 pm, an interview was conducted with the DON and when asked to describe how the resident fell on [DATE], she stated, (Name of CNA#1) had put (name of Resident #6) to bed, laying on left side facing the window .she laid her on the edge of the bed. (Name of Resident #6) started moving, before she could get to her, she rolled over towards the door on her back. She hit her head .laceration 2 cm on the back of the head. When asked if the fall could have been avoided, the DON replied, Yes. She's a 2-person transfer on care plan .even if end of bed, she could have potentially prevented it .If she could be at the center of the bed, then could not have fallen. She (referring to CNA#1) did not follow procedure to have 2 persons. The facility policy and procedure titled Mechanical Lift with an effective date of 2/01/15 read, in part, as follows: Policy: A mechanical lift may be used to enable staff to lift and transfer a patient safely. Procedure: 1. Two nursing staff must assist with mechanical lift and transfer. Ensure safety of patient then roll patient on side away from attendant. .6. Position chair and lock brakes. Swing patient feet off the bed; when patient has been lifted clear of bed, second staff person is to stabilize the seat sling. Grasp steering handles and move patient over the chair and lower into chair . 11. To return patient to bed, use the same procedure in reverse. 12. Center patient over bed and lower gently. The DON stated in response to the fall inservice training was conducted for nursing staff on the use of the mechanical lift; reviewed the policy, specifically procedure #1 that stated, Two nursing staff must assist with mechanical lift and transfer. Ensure safety of patient then roll patient on side away from attendant. Approximately 40% of staff had been trained, according to the DON. The DON stated that completion of training for all nursing staff is expected by 11/20/16. (Evidence submitted of all staff were trained 11/17/16). The DON provided the survey team with a corrective action plan dated 11/17/16, that read: F323 Accidents/supervision. Problem: Resident rolled out of bed while staff member in room and sustained injury to the head. Comment: 1. Hoyer lift used per policy 2. Proper position in bed. Action: 1. Review current residents that require (brand name) lift transfer and observe nursing staff to ensure that 2 nursing staff members are assisting when using the (brand name) lift. During this observation ensure that proper body positioning is provided at this time of observation to provide for the resident safety. Completion date: 11/17/16 2. Provide education to all licensed staff on the following: proper use of mechanical lift and 2 person assist when using mechanical lift; proper body positioning when resident place in w/c (wheelchair), bed, geri-chair to ensure resident safety. Completion date: 11/17/16 3. Complete weekly observations of resident transfers using mechanical lifts to ensure that there are 2 staff members assisting and that the resident is properly positioned after the transfer. Ongoing-no completion date. 4. Review the results of the audits in the QA committee meeting and address any issues with corrective action plans. Next QA meeting scheduled January 2017. 5. Date of completion is 11/17/16. There were no other falls related to the use of a mechanical lift transfer from 11/14/16 through the end of survey on 11/17/16; however, the facility did not met the necessary criteria for Past Non-Compliance (PNC) due to allegation of compliance (AOC) date. The Administrator and DON were made aware of these findings on 11/17/16 at 7:30 pm. No additional information was presented. COMPLAINT DEFICIENCY