Every finding on record at Dogwood Village of Orange County Health and Rehab

Based on resident interview, staff interview, facility document and clinical record review, the facility staff failed to implement the baseline care plan for one of 47 residents in the survey sample, Resident #147. The findings include: For Resident #147 (R147), the facility staff failed to implement her baseline care plan for medication administration. Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order for one of 46 residents in the survey sample, Resident #147. The findings include: On 3/4/25 at 8:55 a.m., R147 was observed sitting up in a chair beside her bed. She stated she has Parkinson's disease (1) and has not received her Sinemet (medication to treat Parkinson's) on time the past few days. She stated when she does not receive the medication timely, she experiences increased pain. A review of R147's clinical record, including physician orders and March 2023 MARs (medication administration records), revealed the following medication due times/administration times: Sinemet (to treat Parkinson's) 3/2/25 2:00 a.m./given at 5:29 a.m. Metoprolol (to treat high blood pressure) 3/2/25 at 6:00 p.m./given at 8:00 p.m. Sinemet 3/3/25 at 9:00 a.m./given at 12:27 p.m. Metoprolol 3/3/25 at 9:00 a.m./given at 12:25 p.m. Baclofen (a muscle relaxant) 3/3/25 at 9:00 a.m./given at 10:51 a.m. Celcoxib (to treat pain) 3/3/25 at 9:00 a.m./given at 11:21 a.m. Sinemet 3/4/25 at 2:00 a.m./given at 3:46 a.m. A review of R12's care plan dated 3/2/25 revealed, in part: Give meds (medications) per MD orders. On 3/5/25 at 10:43 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated care plans tell the staff to make sure residents get what they need. She stated all the staff is responsible for making sure the care plans are implemented. On 3/5/35 at 1:15 p.m., ASM (administrative staff member) #1, the executive director, and ASM #2, the director of nursing, were informed of these concerns. A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of admission .The baseline care plan will be used while the comprehensive admission .assessment is being conducted .The resident will receive the services and/or items included in the plan of care. No additional information was provided prior to exit. Reference (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow a physician's order for one of 46 residents in the survey sample, Resident #147. The findings include: On 3/4/25 at 8:55 a.m., R147 was observed sitting up in a chair beside her bed. She stated she has Parkinson's disease (1) and has not received her Sinemet (medication to treat Parkinson's) on time the past few days. She stated when she does not receive the medication timely, she experiences increased pain. A review of R147's clinical record, including physician orders and March 2023 MARs (medication administration records), revealed the following medication due times/administration times: Sinemet (to treat Parkinson's) 3/2/25 2:00 a.m./given at 5:29 a.m. Metoprolol (to treat high blood pressure) 3/2/25 at 6:00 p.m./given at 8:00 p.m. Sinemet 3/3/25 at 9:00 a.m./given at 12:27 p.m. Metoprolol 3/3/25 at 9:00 a.m./given at 12:25 p.m. Baclofen (a muscle relaxant) 3/3/25 at 9:00 a.m./given at 10:51 a.m. Celcoxib (to treat pain) 3/3/25 at 9:00 a.m./given at 11:21 a.m. Sinemet 3/4/25 at 2:00 a.m./given at 3:46 a.m. A review of R12's care plan dated 3/2/25 revealed, in part: On 3/5/25 at 10:43 a.m., LPN (licensed practical nurse) #3 was interviewed. She stated nurses are required to administer medications within an hour of its due time. On 3/5/35 at 11:41 a.m., ASM (administrative staff) #2, the director of nursing, was interviewed. She stated medications should be administered from an hour before up through an hour after its due times. She stated: It's what we've always done. On 3/5/35 at 1:15 p.m., ASM #1, the executive director, and ASM #2 were informed of these concerns. A review of the facility policy, Medication Administration: General Guidelines, revealed, in part: Medications are administered within 60 minutes before or after the scheduled time .Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the healthcare center. No additional information was provided prior to exit. Reference (1) Parkinson's disease (PD) is a type of movement disorder. It happens when nerve cells in the brain don't produce enough of a brain chemical called dopamine. Sometimes it is genetic, but most cases do not seem to run in families. This information is taken from the website https://medlineplus.gov/parkinsonsdisease.html.

Based on observation and staff interview, it was determined that the facility staff failed to serve food at a palatable temperature for one of six facility units observed, South Ground unit. The findings include: On 03/04/2025 at t approximately 12:50 p.m. a test tray consisting of pork, stewed tomatoes, lima beans and chicken noodle soup were placed in a food cart and sent to the South Ground unit. The cart was followed by another surveyor and OSM, (other staff member)#2, Director of Dining Services OSM # 4 and , Dietary Supervisor. At approximately 1:05 p.m., the last lunch tray was served to a resident on South Ground unit and OSM #2 was asked to remove the test tray from the food cart, and OSM #4 proceeded to take the temperatures of the food. The pork was 126° (degrees) F (Fahrenheit), lima beans at 120° F, stewed tomatoes at 114° F, and chicken noodle soup at 130° F., OSM #2 and OSM #4 sampled the food on the test tray and stated, The food was not palatable due to the low temperatures. On 03/04/2025 at approximately 4:55 p.m., ASM (administrative staff member) #1, Chief Executive Officer, and ASM #2, Director of Nursing, were made aware of the above findings. No further information was provided prior to exit. Complaint deficiency

Based on observation, staff interview, and facility document review, facility staff failed to store food in a sanitary manner in one of one facility kitchens and failed to maintain clean dishware, food storage containers and food serving pans in a sanitary manner in one of one facility kitchens. The findings include: 1. On 03/03/25 at approximately 6:15 p.m., an observation of the kitchen's walk-in refrigerator revealed a two-pound bag of Swiss cheese cubes on a shelf available for use. Further observation revealed a Use-By date on the bag of 1/31/25. 2. On 03/03/2025 at approximately 6:30 p.m., an observation of the kitchen's dish washing room revealed two 20-inch electric fans mounted on wall on the left side of the room above a table blowing down on two dish racks of clean dining plates. Observation of the fans revealed the fan blades, and the front and back fan guards were coated in dust. On 03/04/25 at approximately 9:10 a.m., an observation of the kitchen's dish washing room revealed two 20-inch electric fans mounted on wall on the left side of the room above a table blowing down on three dish racks of clean pans and food storage containers. Observation of the fans revealed the fan blades, and the front and back fan guards were coated in dust. On 03/04/2025 at approximately 9:15 a.m., an interview and observation of the fans in the kitchen's dish washing room was conducted with OSM (other staff member) #2, director of dining services. OSM #2 stated the fans were not clean and were blowing on the clean pans and food storage containers. She stated the fans were cleaned one time a week. OSM #2 had the clean pans and food storage containers removed and sent to be rewashed and turned off the fans. When asked why the fans should be kept clean, she stated to prevent the clean dishes from becoming contaminated. On 03/04/2025 at approximately 1:10 a.m., an interview was conducted with OSM #2 regarding the observation of the bag Swiss cheese cubes without a Use-By date. She stated the bag should have had a use-by date and all food items that had been opened should have a use-by date. The facility's policy Food Storage it documented in part, 13.f. All foods should be covered, labeled and dated and routinely monitored at assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. On 03/04/2025 at approximately 4:55 p.m., ASM (administrative staff member) #1, chief executive officer, and ASM #2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide privacy in 71 of 88 resident rooms. The findings include: For 71 of 88 rooms, the facility staff failed to provide closets in each resident's designated area of semi-private rooms. Residents had to enter other residents' side of the room to obtain personal belongings from their closets. Observations of resident rooms were conducted during the survey. In the semi-private rooms where two residents resided, built-in closets for both residents were located on Resident A's side of the room. Resident B had to pull the privacy curtain and enter Resident A's space to obtain personal belongings from his or her closet. On 3/4/25 at 2:11 p.m., an interview was conducted with OSM (other staff member) #1 (the director of maintenance). OSM #1 stated each resident does not have a closet on his or her side of the room. OSM #1 stated that in the semi-private rooms, residents have to enter the other resident's space/side of the room to get into their closet if the privacy curtain is closed. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/24, Resident #121 (R121) scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/21/25, Resident #103 (R103) scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 3/5/25 at 8:20 a.m., an interview was conducted with R121 and R103 (roommates). R121 stated she has to go past the privacy curtain and enter R103's side of the room to enter her closet. R103 stated R121 has to enter her side of the room to get into her closet. On 3/5/25 at 9:01 a.m., an interview was conducted with CNA (certified nursing assistant) #4. CNA #4 stated a resident on one side of a semi-private room has to go past the privacy curtain to the other resident's side of the room to obtain clothes from his or her closet, but some residents aren't able to or don't choose to get into the closet. CNA #4 stated she didn't know how to answer if privacy is being maintained in the room for residents who don't have their closet on their side of the room, but she offers to obtain their clothes from their closet. On 3/5/25 at 1:23 p.m., ASM (administrative staff member) #1 (the chief executive officer) and ASM #2 (the director of nursing) were made aware of the above concern. No policy regarding privacy in resident rooms was provided.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to maintain dignity for one of 46 residents in the survey sample, Resident #246. The findings include: For Resident #246 (R246), the facility staff failed to provide dignity for the resident's urinary Foley catheter bag (1). A review of R246's clinical record revealed a physician's order dated 2/17/25 for a urinary catheter for a diagnosis of urinary retention. On 3/4/25 at 10:18 a.m., R246 was observed sitting in a wheelchair in the bedroom. The resident's Foley catheter bag was attached under the wheelchair. There was no privacy cover on the bag, urine was observed in the bag, and the bag was visible from the hall. On 3/4/25 at 3:23 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated Foley catheter bags should be covered for privacy and dignity. On 3/4/25 at 4:57 p.m., ASM (administrative staff member) #1 (the chief executive officer) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Quality of Life- Dignity documented, 1. Residents shall be treated with dignity and respect at all times. Reference: (1) A urinary catheter is a tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Based on staff interview, resident interview, clinical record review and facility document review, it was determined the facility staff failed to review/revise the care plan for two of 46 residents in the survey sample, R126 and R346. The findings include: 1. The facility failed to revise the comprehensive care plan to include weight loss for R126. R126 was admitted to the facility on [DATE] with diagnosis that included but were not limited to osteomyelitis, spina bifida, DM (diabetes mellitus), scoliosis, RBKA (right below the knee amputation) and colostomy. The most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of 1/23/25, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for mobility/transfers/bathing/hygiene and independent for eating. A review of the comprehensive care plan dated 1/19/25 revealed, FOCUS: Resident has risk for alteration in nutritional status related to DM, anemia, obesity and therapeutic diet. GOAL: Resident will be free from significant weight changes over the next review. INTERVENTIONS: Monitor height and weight per physician order. On 01/20/2025, the resident weighed 209.6 lbs. On 02/25/2025, the resident weighed 170.5 pounds which is a -18.65 % Loss. No revision of care plan after weight loss. A review of the RD (registered dietician) note dated 1/21/25 at 12:33 revealed, 52 y/o Female resident admitted w/urosepsis, stage IV PI to sacrum. PMH includes UTI, colon cancer, R AKA, scoliosis, spina bifida, chronic lower back pain, migraines, VP shunt, anxiety, hydrocephalus, L hemicolectomy, type 2 DM. BIMS 14. Res is on a No Added Sugar diet + daily HS snack w/variable, 50-100% po intake. Height=60 W=208.2 pounds (1/21) BMI 40.7 (class III obesity). Rx methylprednisolone, linezolid (for wound infection), insulin. Will continue to monitor and f/u prn. A review of the progress note dated 2/21/25 at 1:11 PM revealed, Resident has had weight loss due to fluid. She had fluid built up on admission which has improved. Added wound healing supplements at this time. She is own RP and has agreed to try. She eats well for all meals. An interview was conducted on 3/5/25 at 10:30 AM with RN (registered nurse) #2. When asked what the care plan is based on, RN #2 stated, it is based on the resident assessment. When asked if the care plan should be revised if there is a weight loss, RN #2 stated, yes, it should be updated. An interview was conducted on 3/5/25 at 1: 30 PM with ASM (administrative staff member) #2, the director of nursing. When asked the purpose of the care plan, ASM #2 stated, the purpose is to identify the resident's needs. When asked if there is an approximately 30-pound weight loss within 1-2 weeks, should the care plan be revised, ASM #2 stated, yes, it should be revised. On 3/5/25 at approximately 2:00 PM, ASM #1, the administrator and ASM #2, the director of nursing was made aware of the above concern. A review of the facility's Comprehensive Centered Care Planning policy reveals, The Care Planning/Interdisciplinary Team is responsible for updating the care plan when there is significant change in the resident's condition. No further information was provided prior to exit. 2. The facility failed to revise the comprehensive care plan to include weight loss for R346. R346 was admitted to the facility on [DATE] with diagnosis that included but were not limited to cellulitis, venous stasis ulcers and morbid obesity. The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 11/15/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring moderate assist for mobility/transfers/bathing/hygiene and independent for eating. A review of the comprehensive care plan dated 9/16/24 revealed, FOCUS: Resident is at risk for alteration in nutrition related to morbid obesity, hypokalemia, hyponatremia, hyperthyroidism, anemia and pre-diabetes. 9/16/24 triggers for significant fluid-related weight loss related to diuresis, treatment- diet, obesity. Further fluid related weight changes anticipated. GOAL: Resident will be free from significant weight changes over the next review. INTERVENTIONS: Monitor height and weight per physician order. On 09/04/2024, the resident weighed 216.2 lbs. On 03/03/2025, the resident weighed 178.2 pounds which is a -17.58 % Loss. Resident's weight on 1/27/25 was 212 pounds and weight on 2/21/25 was 187.6 pounds. No revision of care plan after weight loss from January 2025 to February 2025. A review of the RD (registered dietician) note dated 8/19/24 at 11:33 AM revealed, Age: 72 Assessment: admission 8/11/24. Diagnoses include cellulitis, HTN, venous ulcers, anemia, hyponatremia, pre-DM, pain, edema, hypokalemia, CVI, thyrotoxicosis, anxiety, hyperthyroid. Food Allergies: NKFA. Diet Order/date: no added salt or sugar packets, 8/11/24-Intake average: >50%. Weight: 63, 220#, BMI 39, obese. IBW: 115#, 52kg Estimated needs: 1550cal (30cal/kg IBW), 65g pro (1.3g/kg IBW), and one ml/calorie fluid needs. Labs values: 8/11 reviewed. Skin status: cellulitis BLE, rash to groin. Dietary religious practices: Follows Lent Happy with CBW: I don't like weighing that .want to slim down. No goal weight. Accepting of diet as ordered: yes followed NAS diet at home. An interview was conducted on 3/5/25 at 10:30 AM with RN (registered nurse) #2. When asked what the care plan is based on, RN #2 stated, it is based on the resident assessment. When asked if the care plan should be revised if there is a weight loss, RN #2 stated, yes, it should be updated. When asked if the care plan should be revised after each significant weight loss, RN #2 stated, yes. An interview was conducted on 3/5/25 at 1: 30 PM with ASM (administrative staff member) #2, the director of nursing. When asked the purpose of the care plan, ASM #2 stated, the purpose is to identify the resident's needs. When asked if there is an approximately 30-pound weight loss within 1-2 weeks, should the care plan be revised, ASM #2 stated, yes, it should be revised. On 3/5/25 at approximately 2:00 PM, ASM #1, the administrator and ASM #2, the director of nursing was made aware of the above concern. A review of the facility's Comprehensive Centered Care Planning policy reveals, The Care Planning/Interdisciplinary Team is responsible for updating the care plan when there is significant change in the resident's condition. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide respiratory care and services for two of 46 residents in the survey sample, Residents #2 and #102. The findings include: 1. For Resident #2 (R2), the facility staff failed to clarify the physician's order for a specific rate of oxygen. A review of R2's clinical record revealed a physician's order dated 8/8/24 for continuous oxygen 2.5 to 3.5 liters via nasal cannula. On 3/4/25 at 8:10 a.m. and 3:15 p.m., R2 was observed receiving oxygen at a rate of three liters per minute. On 3/4/25 at 3:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the facility uses parameters for oxygen orders. RN #1 stated oxygen is a medication, and parameters aren't used for dosage of medications. RN #1 stated she personally thought parameters should not be used for oxygen orders and the orders should be clarified. On 3/4/25 at 4:57 p.m., ASM (administrative staff member) #1 (the chief executive officer) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Oxygen Administration failed to document information regarding the above concern. 2. For Resident #102 (R102), the facility staff failed to clarify the physician's order for a specific rate of oxygen. A review of R102's clinical record revealed a physician's order dated 2/26/25 for continuous oxygen 1.5 to 2.5 liters via nasal cannula. On 3/4/25 at 8:13 a.m. and 3:16 p.m., R102 was observed receiving oxygen at two liters per minute. On 3/4/25 at 3:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the facility uses parameters for oxygen orders. RN #1 stated oxygen is a medication, and parameters aren't used for dosage of medications. RN #1 stated parameters should not be used for oxygen orders and the orders should be clarified. On 3/4/25 at 4:57 p.m., ASM (administrative staff member) #1 (the chief executive officer) and ASM #2 (the director of nursing) were made aware of the above concern.

Based on observation, staff interview, and clinical record review, the facility staff failed to implement infection control practices for one of four residents in the medication administration observation, Resident #8. The findings include: For Resident #8 (R8), the facility staff failed to prepare and administer medication in a sanitary manner. A review of R8's clinical record revealed a physician's order dated 11/6/23 for one multivitamin tablet once a day for supplement. On 3/4/25 at 7:55 a.m., LPN (licensed practical nurse) #1 was observed preparing R8's medications. While preparing medications, LPN #1 dropped a multivitamin tablet on top of the medication cart then picked the pill up (with a glove) and placed the pill in a medication cup. After LPN #1 finished preparing medications, she administered the medications (including the multivitamin tablet) to R8. On 3/4/25 at 3:23 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated she should have thrown the multivitamin tablet away. On 3/4/25 at 4:57 p.m., ASM (administrative staff member) #1 (the chief executive officer) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication Administration: General Guidelines failed to document information regarding the above concern.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that all required information was provided to the receiving hospital when one out of 46 residents in the survey sample was transferred to the hospital, Resident # 31. The findings include: The facility staff failed to evidence provision of required resident information to the receiving facility at the time of discharge for Resident #31. Resident #31 was transferred to the hospital on 10/15/22. Resident #31 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), PNA (pneumonia), Chronic respiratory failure and OSA (obstructive sleep apnea). The most recent MDS (minimum data set) assessment, a 5-day Medicare assessment, with an ARD (assessment reference date) of 11/7/22, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as being totally dependent for transfer and bathing; requiring extensive assistance for bed mobility, dressing and is independent for eating. Walking and locomotion did not occur. A review of the comprehensive care plan with a revision date of 10/17/22 and 11/2/22, revealed, CATEGORY: Resident is at risk for impaired gas exchange related to COPD, chronic respiratory failure and OSA. He has a history of PNA and acute respiratory failure. readmitted to the facility post hospitalization with a diagnosis of pneumonia. INTERVENTIONS: Administer medications as ordered. Report any increased cough or shortness of breath. Monitor for cyanosis. Administer oxygen per physician orders. CPAP (continuous positive airway pressure) to be placed on resident at 11 PM per his request-settings per physician orders. A review of the nursing progress note dated 10/15/22 at 7:07 AM, revealed Called to room at approximately 6:00 AM to assess resident. Resident noted to be very confused, had taken off CPAP (continuous positive airway pressure) mask. Refused to keep on. Several attempts made to reapply CPAP mask and oxygen nasal cannula without success. Oxygen saturation at 55%, blood pressure 154/85, pulse 124, respirations 22 and temperature 97.3. COVID test negative with no cyanosis noted. NP (nurse practitioner) made aware of assessment. Gave new order to send to ER (emergency room ) to be evaluated. RP (responsible party) called and voice message left to call here concerning resident. DON (director of nursing) aware. 911 notified to transport resident to ER. Resident left via stretcher to ER. There was no evidence of clinical documents sent with the resident to the hospital on 10/15/22. A request for clinical documents sent to the facility with the resident was made on 12/7/22 at 8:50 AM. On 12/7/22 at 9:00 AM, ASM (administrative staff member) #2, the director of nursing, stated, We do not have any evidence of the clinical documents sent for this resident. On 12/7/22 at 10:45 AM, ASM #1, the executive director and ASM #2, the director of nursing was made aware of the findings. On 12/7/22 at 11:10 AM, ASM #2 stated, we do not have any policy related to documents sent to the facility when a resident is transferred. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence written RP (responsible party) notification was provided when one of 46 residents in the survey sample was transferred to the hospital; Residents #31. The findings include: The facility staff failed to evidence provision of written RP (responsible party) notification of transfer/discharge for Resident #31. Resident #31 was transferred to the hospital on 10/15/22. Resident #31 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), PNA (pneumonia), Chronic respiratory failure and OSA (obstructive sleep apnea). The most recent MDS (minimum data set) assessment, a 5-day Medicare assessment, with an ARD (assessment reference date) of 11/7/22, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the nursing progress note dated 10/15/22 at 7:07 AM, revealed Called to room at approximately 6:00 AM to assess resident. Resident noted to be very confused, had taken off CPAP (continuous positive airway pressure) mask. Refused to keep on. Several attempts made to reapply CPAP mask and oxygen nasal cannula without success. Oxygen saturation at 55% .NP (nurse practitioner) made aware of assessment. Gave new order to send to ER (emergency room ) to be evaluated. RP (responsible party) called and voice message left to call here concerning resident. DON (director of nursing) aware. 911 notified to transport resident to ER. Resident left via stretcher to ER. There was no evidence of written RP notification when the resident was transferred to the hospital on 10/15/22. A request for evidence of written RP notification when the resident was transferred was made on 12/7/22 at 8:50 AM. On 12/7/22 at 9:00 AM, ASM (administrative staff member) #2, the director of nursing, stated, We do not have any evidence of written RP notification for this resident. On 12/7/22 at 10:45 AM, ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. On 12/7/22 at 11:10 AM, ASM #2 stated they do not have any policy related to written RP notification when a resident is transferred. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence that bed hold notification was provided when one out of 46 residents in the survey sample was transferred to the hospital; Residents #31. The findings include: The facility staff failed to evidence a bed hold notification was provided to the resident or the responsible party (RP) at the time of transfer for Resident #31. Resident #31 was transferred to the hospital on 10/15/22. A review of the nursing progress note dated 10/15/22 at 7:07 AM, revealed Called to room at approximately 6:00 AM to assess resident. Resident noted to be very confused, had taken off CPAP (continuous positive airway pressure) mask. Refused to keep on. Several attempts made to reapply CPAP mask and oxygen nasal cannula without success. Oxygen saturation at 55% .NP (nurse practitioner) made aware of assessment. Gave new order to send to ER (emergency room ) to be evaluated. RP (responsible party) called and voice message left to call here concerning resident .Resident left via stretcher to ER. There was no evidence of bed hold notice when the resident was sent to the hospital on 10/15/22. A request for bed hold when the resident was sent to the hospital made on 12/7/22 at 8:50 AM. On 12/7/22 at 9:00 AM, ASM (administrative staff member) #2, the director of nursing, stated, We do not have any evidence of the bed hold for this resident. On 12/7/22 at 10:45 AM, ASM #1, the executive director and ASM #2, the director of nursing were made aware of the findings. On 12/7/22 at 11:10 AM, ASM #2 stated they do not have any policy related to bed hold when a resident is transferred. No further information was provided prior to exit.

Based on staff interview and facility document review, it was determined the facility staff failed to provide [CONDITION(S)] services, consistent with professional standards of practice, and the comprehensive person-centered care plan, for three of 45 residents in the survey sample, Resident #480, Resident #56 and Resident #22. The facility failed to evidence ongoing collaboration and communication with the [CONDITION(S)] treatment center on 6/18/21 and 6/23/21 for Resident #480. 2. The facility staff failed to ensure ongoing collaboration and communication with the [CONDITION(S)] center regarding Resident #56's care in May 2021 and June 2021. 3. The facility staff failed to ensure ongoing collaboration communication with the [CONDITION(S)] center regarding Resident #22's care in May 2021 and June 2021. The findings include: 1. The facility's policy on [CONDITION(S)]: Coordination of Hemodialysis Services dated 11/2016, documents in part, Residents requiring an outside [CONDITION(S)] facility will have services coordinated by the facility to include care planning, nursing, medications, nutritional, social services, activities and physician services. There will be communication between the facility and the [CONDITION(S)] facility regarding the resident. Procedure: A communication form will be initiated by the facility for any resident going to an [CONDITION(S)] facility for hemodialysis. This form will be kept in a binder that is sent with the resident for treatments. Nursing will collect information regarding the resident to send to the [CONDITION(S)] facility with the resident-information recommended but not limited to: resident information face sheet, copy of current physician orders, copy of care plan, blank progress note, blank hemodialysis communication form, changes in the resident's condition, any new labs. Nursing will send the resident information with the resident to the designated appointment at the [CONDITION(S)] facility. Nursing will give a brief summary of the resident's physical, mental and emotional condition, oral intake, activity tolerance and change in physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #480 was admitted to the facility on [DATE]. Resident #480's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #480's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: had not been coded. MDS Section H-Bowel and Bladder had not been coded. MDS Section O-Special Treatments / Procedures had not been coded. A review of Resident #480's baseline care plan dated 6/18/21 documents in part, Other conditions: [CONDITION(S)]: [CONDITION(S)]. Intervention: [CONDITION(S)] three times a week. Administer meds as ordered. Treatments per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Assess upon return from [CONDITION(S)] per physician orders. Monitor fistula to right upper extremity, dressing to fistula per physician orders. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Monitor fistula to right upper extremity. Check for bruit and thrill every shift, Assess resident upon return from [CONDITION(S)]. Dressing to fistula to be changed at [CONDITION(S)] on [CONDITION(S)] days. An activities progress note dated 6/19/21 at 12:05 PM, documented in part, He goes out to [CONDITION(S)] 3 times a week, wife transports. A review of the [CONDITION(S)] center's date of service communication with the facility, lists dates of service as 6/18/21, 6/21/21 and 6/23/21. An interview was conducted on 6/22/21 at 1:55 PM with Resident #480. When asked if he has [CONDITION(S)], Resident #480 stated, Yes, I go Monday, Wednesday and Friday. When asked if he takes papers from the facility to the [CONDITION(S)] center, Resident #480 stated, I'm not sure. If I do, they are in that orange bag. You can look in there. Observation inside the 'orange bag' referenced cy Resident #480 failed to evidence a [CONDITION(S)] communication book or papers from the facility other than papers dated 6/21/21 from the [CONDITION(S)] center. An interview was conducted on 6/22/21 at 2:05 PM with LPN (licensed practical nurse) # 3, regarding what communication is sent with a resident to [CONDITION(S)]. LPN #3 stated, If we had sent communication to the [CONDITION(S)] center it would be in this notebook we set up. Review of the binder referenced by LPN #3, failed to evidence a resident name and all pages in the binder were blank without any name. LPN #3 stated, I do not see any paperwork, so none was sent. I guess we have not set this up for him yet. LPN #3 stated, He [Resident #480] goes on Monday, Wednesday and Friday. Let's see if the paperwork is in his room LPN #3 was accompanied to Resident #480's room. LPN #3 found the paperwork from the [CONDITION(S)] center dated 6/21/21 in the orange bag. LPN #3 stated, This paperwork needs to be in the binder so we know their communication back to us. An interview was conducted on 6/23/21 at 1:45 PM with ASM (administrative staff member) #1, the director of nursing. When asked about the facility's process to communicate with the [CONDITION(S)] facility, ASM #1 stated, We don't communicate with the [CONDITION(S)] facility unless there is a change. That is what the [CONDITION(S)] facility wants. I will bring you the policy. An interview was conducted on 6/23/21 at 1:15 PM with Resident #480. When asked if he had taken any paperwork from the facility to the [CONDITION(S)] center, Resident #480 stated, If I did, it would be in the orange bag and you can look in there. A White binder with resident name found inside the orange bag. The pages inside the white binder were blank including the form from the 6/23/21 [CONDITION(S)]. The facility's [CONDITION(S)] Communication Form dated 1/18/17 is divided into two portions: top portion to be completed by skilled nursing facility, bottom portion for completion by [CONDITION(S)] center. Skilled nursing facility includes: resident name, date, changes since last visit: physical, mental, emotional (checkbox for none); physical order changes: (checkbox for order none; new labs: (checkbox of none) and checkbox for see attached; signature of nurse. An interview was conducted on 6/23/21 at 2:39 PM with LPN #2. When asked the facility process for ongoing communication with [CONDITION(S)] center, LPN #2 stated, I can double check. We usually do phone calls. There should be a section in the [CONDITION(S)] documentation book that we can relay information and they send information back to us. LPN #2 verified that the [CONDITION(S)] Communication Form is the correct form. LPN #2 stated, We would write a nurses note in the back of the book about the resident. When asked if staff would document phone calls with the [CONDITION(S)] center, LPN #2 stated, Yes, I would document it. LPN #2 stated, If anything changed such as meds [medications], status, hospital, nutrition; because it can impact them [residents']. The vital signs are not communicated every time, weights with increase or decrease, fistula bruit or thrill. If there were no change from baseline, I would write that in the book. We do communicate every day of [CONDITION(S)]. When asked how you would communicate a resident's fluid restriction, LPN #2 stated, I would let them know intake. We would send a copy of the advance directive. ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/21 at 4:45 PM. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 531. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 498. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 416. 2. The facility staff failed to ensure communication regarding Resident #56's care with the [CONDITION(S)] center in May 2021 and June 2021. Resident #56 was admitted to the facility on [DATE]. Resident #56's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56's significant change in status minimum data set assessment with an assessment reference date of 5/3/21, coded the resident as being cognitively intact. Section O coded Resident #56 as having received [CONDITION(S)]. Resident #56's comprehensive care plan dated 4/28/21 documented, WILL CONTINUE TO PARTICIPATE IN HEMODIALYSIS (1) 3X (times) WEEKLY WITHOUT CRISIS WITH AID OF [CONDITION(S)] STAFF, FACILITY STAFF AND MD (medical doctor) THRU NEXT REVIEW. COMMUNICATE CHANGES IN HIS CONDITION, FUNCTION OR BEHAVIOR TO [CONDITION(S)] CENTER VIA NOTEBOOK OR PHONE CALL. REPORT ABNORMAL LABS TO [CONDITION(S)] CENTER . Review of Resident #56's clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #56's clinical record (including May 2021 and June 2021 nurses' notes) failed to reveal evidence that the facility staff provided ongoing communication regarding Resident #56 to the [CONDITION(S)] center staff. Resident #56's [CONDITION(S)] communication book contained blank [CONDITION(S)] communication forms that contained sections for the facility staff to document physical, mental and emotional changes since the last visit, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/21 at 2:39 p.m., an interview was conducted with LPN (licensed practical nurse) #2, regarding the facility process for providing ongoing communication to the [CONDITION(S)] center staff. LPN #2 stated it had been a bit since she cared for a resident who received [CONDITION(S)]. LPN #2 stated she usually provided verbal communication to [CONDITION(S)] center staff via phone because it was quicker and she would document these phone calls. LPN #2 stated she would also write nurses' notes and place them in the communication book that was sent to the [CONDITION(S)] center. LPN #2 stated information such as medical status changes, medication changes, hospitalization s, nutritional changes, vital sign changes, weight changes and fluid intake (for resident on fluid restrictions) should be communicated from the facility staff to the [CONDITION(S)] center staff. LPN #2 stated she would also send the [CONDITION(S)] center a note documenting no changes if the resident was at his or her baseline. Review of Resident #56's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, review of nurses' notes revealed the following: -5/8/21- Resident #56 presented with a large, swollen, hard area on the inner left thigh. -5/26/21- A change in Resident #56's insulin. -5/28/21- Resident #56 presented with a significant weight gain. Further review of Resident #56's clinical record and the communication book revealed no evidence of communication from the facility staff to the [CONDITION(S)] center staff regarding the above changes. On 6/23/21 at 4:59 p.m., ASM (administrative staff member) #1 (the director of nursing) was made aware of the above concern. Reference: (1) When your kidneys are healthy, they clean your blood. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, you need treatment to replace the work your kidneys used to do. Unless you have a kidney transplant, you will need a treatment called [CONDITION(S)]. There are two main types of [CONDITION(S)]. Both types filter your blood to rid your body of harmful wastes, extra salt, and water. Hemodialysis uses a machine. It is sometimes called an artificial kidney. You usually go to a special clinic for treatments several times a week. This information was taken from the website https://medlineplus.gov/[CONDITION(S)].html. 3. The facility staff failed to ensure communication regarding Resident #22's care with the [CONDITION(S)] center in May 2021 and June 2021. Resident # 22 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 22's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 04/01/2021, coded Resident # 22 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 22 was coded as requiring supervision of one staff member for activities of daily living. Section O Special Treatments, Procedures and Programs coded Resident # 22 for [CONDITION(S)] while a resident. The POS [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 22 documented, [CONDITION(S)] T-TH-SAT [Tuesday-Thursday-Saturday] at 1200 [12:00 p.m.] [Name of [CONDITION(S)] Center]. Order Date: 06/10/2020. Start Date: 06/10/2020. The comprehensive care plan for Resident #22 dated 06/10/2020, documented in part, WILL CONTINUE TO PARTICIPATE IN HEMODIALYSIS [2] 3X (three times) WEEKLY WITHOUT CRISIS WITH AID OF [CONDITION(S)] STAFF, FACILITY STAFF AND MD (medical doctor) THRU NEXT REVIEW. Under Intervention COMMUNICATE CHANGES IN [Resident #22's] CONDITION, FUNCTION OR BEHAVIOR TO [CONDITION(S)] CENTER VIA [by] NOTEBOOK OR PHONE CALL. REPORT ABNORMAL LABS [laboratory tests] TO [CONDITION(S)] CENTER. Review of facility's nurse's notes dated 05/01/2021 through 06/22/2021, Resident # 22's failed to evidence documentation that the facility staff provided ongoing communication regarding Resident # 22 to the [CONDITION(S)] center staff. Further review of the nurse's notes documented, 5/26/2021 [at] 3:50 PM [p.m.] New order: Apply skin prep/foam dressing to right planter foot callus for skin irritation and 6/16/2021. 1:53 PM RNP [restorative nursing program] review with input from RNP staff; {Resident # 22] is participating; has had some soreness in BLE [bilateral lower extremity] with ambulation; monitoring . Review of Resident #22's [CONDITION(S)] communication book failed to evidence documentation from the facility staff to the [CONDITION(S)] center staff regarding the above changes. Further review of Resident #22's [CONDITION(S)] communication book revealed it contained blank [CONDITION(S)] communication forms that contained sections for the facility staff to document physical, mental and emotional changes since the last visit, physical order changes and new labs. The communication book also contained information from the [CONDITION(S)] center staff but no communication from the facility staff to the [CONDITION(S)] center staff. On 06/23/20 21 at 2:39 p.m., an interview was conducted with LPN (licensed practical nurse) #2, regarding the facility process for providing ongoing communication to the [CONDITION(S)] center staff. LPN #2 stated it had been a bit since she cared for a resident who received [CONDITION(S)]. LPN #2 stated she usually provided verbal communication to [CONDITION(S)] center staff via phone because it was quicker and she would document these phone calls. LPN #2 stated she would also write nurses' notes and place them in the communication book that was sent to the [CONDITION(S)] center. LPN #2 stated information such as medical status changes, medication changes, hospitalization s, nutritional changes, vital sign changes, weight changes and fluid intake (for resident on fluid restrictions) should be communicated from the facility staff to the [CONDITION(S)] center staff. LPN #2 stated she would also send the [CONDITION(S)] center a note documenting no changes if the resident was at his or her baseline. On 6/23/21 at 4:59 p.m., ASM [administrative staff member] #1, director of nursing, was made aware of the above concern. No further information was presented prior to exit. References: [1] The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm. [2] [CONDITION(S)] treats end-stage kidney failure. It removes waste from your blood when your kidneys can no longer do their job. Hemodialysis (and other types of [CONDITION(S)]) does some of the job of the kidneys when they stop working well. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 7.htm.

Based on observation, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to provide respiratory care, consistent with professional standards of practice, and the comprehensive person-centered plan of care for three of 45 residents in the survey sample, Residents #70, #480 and #115. The facility staff failed to administer oxygen to Resident #70 and Resident #115 at the flow rate prescribed by the physician and failed to ensure a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. The facility policy Oxygen Administration dated January 2016 documented in part, .This facility provides guidelines for safe oxygen administration per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #70 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #70's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/11/2021, coded Resident #70 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. Section O documented Resident #70 receiving oxygen while a resident at the facility. On 6/22/21 at approximately 12:42 p.m., an interview was conducted with Resident #70 in their room. Resident #70 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 6/16/21 attached to an oxygen concentrator. The oxygen flow rate set on the concentrator was observed set at 2.5 lpm (liters per minute). Resident #70 stated they wore the oxygen all the time. When asked if he ever adjusted the oxygen rate, Resident #70 stated that the nurses set the oxygen rate and he did not adjust the settings. Additional observations of Resident #70 on 6/22/21 at approximately 4:15 p.m. and 6/23/21 at approximately 11:45 a.m. revealed the oxygen flow rate set at 2.5 lpm. The physician order's for Resident #70 documented in part, Order Date: 5/10/21 .Resident to wear oxygen @ [at] 3L/min (liters per minute) via NC (nasal cannula) continuously for SOB (shortness of breath)/[CONDITION(S)]- Check flowmeter and O2 SATs (saturations) Q (every) shift . The comprehensive care plan for Resident #70 dated 12/31/2020 documented in part, [Resident #70] is at risk for impaired gas exchange R/T (related to) [CONDITION(S)], Pulmonary [CONDITION(S)] (hypertension) (4), allergies and OSA (obstructive sleep apnea) Under Intervention it documented in part, Administer oxygen per MD (medical doctor) orders, See eTAR (electronic treatment administration record). Start Date: 12/31/2020 . The eTAR dated June 2021 for Resident #70 documented oxygen at 3L/min continuously with flowmeter and O2 saturation checks each day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. On 6/23/2021 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the oxygen was set by centering the silver ball inside of the flow meter on the line beside the number of the liter that was prescribed. LPN #2 stated that oxygen was checked for the correct flow rate and set up at least once a shift. On 6/23/2021 at approximately 1:20 p.m., LPN #2 observed Resident #70's oxygen concentrator. LPN #2 stated that the oxygen was set at 2.5 lpm and they did not know how it had gotten set that way because it was supposed to be set at 3 lpm. LPN #2 adjusted the flow rate of Resident #70's oxygen to 3 lpm. The manufacturer's instructions for use for the oxygen concentrator in Resident #70's room provided by the facility documented in part, .2. Check the flow meter to make sure that the flow meter ball is centered on the line next to the prescribed number of your flow rate. Caution- It is very important to follow your oxygen prescription. Do not increase or decrease the flow of oxygen- consult your physician . On 6/23/21 at approximately 4:45 p.m., ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing were notified of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)] ([CONDITION(S)]): Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 2. Respiratory failure: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 3. Sleep apnea: is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html. 4. Pulmonary hypertension: (PH) is high blood pressure in the arteries to your lungs. It is a serious condition. If you have it, the blood vessels that carry blood from your heart to your lungs become hard and narrow. Your heart has to work harder to pump the blood through. Over time, your heart weakens and cannot do its job and you can develop heart failure. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=pulmonary+hypertension&_ga=2XXX 7636XXX 153XXX - XXX 2. During the facility tour on 6/22/21 at 11:30 AM, observation revealed a [CONDITION(S)] machine sitting on Resident #480's bedside nightstand with the nasal prongs uncovered. On 6/22/21 at 3:30 PM, a second observation revealed the [CONDITION(S)] machine on Resident #480's bedside nightstand with the nasal prongs uncovered. Resident #480 was admitted to the facility on [DATE]. Resident #480's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #480's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: had not been coded. MDS Section H-Bowel and Bladder had not been coded. MDS Section O-Special Treatments / Procedures had not been coded. A review of Resident #480's baseline care plan dated 6/17/21 failed to evidence documentation addressing the care and use of a [CONDITION(S)]. The baseline care plan, documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, all the boxes on Resident #480's baseline care plan were unchecked. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's history and physical dated 6/18/21, documented in part, Assessment and Plans: OSA on [CONDITION(S)]. A review of the nursing admission assessment dated [DATE] failed to evidence documentation of OSA or [CONDITION(S)] machine. An interview was conducted on 6/22/21 at 1:55 PM with Resident #480. When asked how often he uses the [CONDITION(S)] machine, Resident #480 stated, I use it every night. When asked if the [CONDITION(S)] nasal prongs were covered, Resident #480 stated, No, it's never covered. It fell on the floor once and I wiped it off before I used it again. I believe it should be covered when I'm in this building. Observation on 6/23/21 at 9:30 AM, of Resident #480's [CONDITION(S)] machine, revealed the [CONDITION(S)] was now covered with disposable, plastic grocery bag. An interview was conducted on 6/23/21 at 1:15 PM with Resident #480. When asked the frequency of using [CONDITION(S)], Resident #480 stated, I use it every night. When asked about the plastic grocery bag covering the [CONDITION(S)] nasal prongs, Resident #480 stated, After we talked yesterday, I decided to put them in the plastic bag to help keep them clean. An interview was conducted on 6/23/21 at 2:15 PM with LPN (licensed practical nurse) #5. When asked how [CONDITION(S)] nasal prongs are maintained, LPN #5 stated, They are covered with a plastic bag. When asked if treatments such as [CONDITION(S)] should have a physician order, LPN #5 stated, Yes, there should be an order. An interview was conducted on 6/23/21 at 3:00 PM with RN (registered nurse) #3, the clinical reimbursement director. RN #3 stated, I do not see [CONDITION(S)] on the care plan- it would usually be under Sleep Apnea. If there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/21 at 3:30 PM, RN #3 brought in a copy of the nursing progress noted dated and timed 6/23/21 3:12 PM which documented in part, Informed of [CONDITION(S)] machine in room. Resident reports [CONDITION(S)] was dropped off by wife a few days ago; he couldn't remember which day. He states he uses this at night for his sleep apnea. It was observed on his bedside table. Unit manager aware and following up. RN #3 also provided a revised baseline care plan for review, which documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, box checked and dated 6/23/21. Other condition: Sleep Apnea, Intervention: [CONDITION(S)] per order, dated 6/23/21. A copy of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident at night for OSA. Monitor on 3-11 and 11-7 shift. Ensure [CONDITION(S)] has distilled water in chamber at bedtime. [CONDITION(S)] face mask to be changed every 6 months by 3-11 shift in July and January. Wipe mask with [CONDITION(S)] wipes, allow 2 minutes to dry on clean surface and apply mask. An interview was conducted on 6/23/21 at 4:00 PM with ASM (administrative staff member) #1, the director of nursing. When asked the purpose of the physician orders, ASM #1 stated, Orders are to take care of the resident needs and for medications and treatments, oxygen and [CONDITION(S)] orders. When asked who is responsible to obtain/clarify physician orders, ASM #1 stated, Any nurse is to get physician orders. They can be obtained in the evening or weekend, we have on call physicians. We need a process if the family brings in a device to make sure we have an order. ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/21 at 4:45 PM. The facility's policy on Policy and Procedure for Cleaning of [CONDITION(S)] and [CONDITION(S)] Machines dated 5/2018, documents in part, Clean with [CONDITION(S)] mask/nasal pillow with [CONDITION(S)] wipes before use. The facility's policy on Tubing for Oxygen, [CONDITION(S)] and [CONDITION(S)] devices and Nebulizer Tubing Set-Up dated 6/2016, documents in part, Infection Control: When not in use, place tubing in drawstring bags. The facility's policy on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 141. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 531. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 498. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 416. 3. Resident #115 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/24/2021, coded Resident #115 as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. Resident #115 was coded as requiring limited assistance of one staff member for most of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using oxygen while in the facility. On 6/22/2021 at 10:45 a.m. observation revealed Resident #115 sitting in her recliner with oxygen on via a nasal cannula connected to an oxygen concentrator that was running. Further observation revealed the oxygen flow meter was set at 2.5 LPM (liters per minute). A second observation on 6/22/2021 at 3:39 p.m. revealed, the oxygen flow rated was set at 2.5 LPM. On 6/23/2021 at 9:30 a.m., observation of Resident #115 revealed oxygen was in use by the resident and the flow meter flow rate on the oxygen concentrator was set at 2.5 LPM. When asked if she adjusts the oxygen flow rate, Resident #115 stated she had it at home and knows how to adjust it but the staff here has told her not to touch it so she doesn't. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 2 L/MIN (liters per minute) continuously for SOB (shortness of breath)/[CONDITION(S)]) check flowmeter and O2 (oxygen) sats (saturations) Q (every) shift. The eTAR (electronic treatment administration record) documented, Resident to wear oxygen @ 2 L/MIN continuously for SOB/[CONDITION(S)] check flowmeter and O2 sats Q shift. The eTAR documented the use of oxygen on all three shifts for 6/22/2021 and 6/23/2021. It also documented a 2 under each shift for the liter flow rate. The comprehensive care plan dated 8/25/2020 documented in part, Care Plan - (Resident #115) has impaired gas exchange r/t (related to) [CONDITION(S)], Shortness of breath. She has hx (history) of wheezing. She is on continuous oxygen. She has a cough. The Interventions documented in part, Administer oxygen per MD (medical doctor) orders. On 6/23/2021 at 12:43 p.m. LPN (licensed practical nurse) # 6 was accompanied to Resident #115's room. LPN #6 was asked the flow rate setting of Resident #115's oxygen. LPN #6 observed the flow meter on Resident #115's oxygen concentrator and stated it was at 2.5 LPM. LPN #6 was then observed changing Resident #115's oxygen flow rate to 2LPM and stated, The order is for 2 LPM. When asked how to read the oxygen concentrator, LPN #6 stated that the line of the prescribed rate goes through the center of the ball. When asked how often a nurse is to check the rate of the oxygen, LPN #6 stated a nurse should check it at least every shift. ASM (administrative staff member) #1, the director of nursing, RN (registered nurse) #2, the director of compliance, and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/2021 at 4:48 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 138. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to ensure one of 45 sampled residents, (Resident #106), was assessed for self-administration of medications. A bottle of Refresh Tears was observed on Resident #106's nightstand and Resident #106 stated she uses them all the time. The clinical record failed to evidence a physicians order and assessment for Resident #106 to self administer the eye drops. The finding include: Resident #106 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (2) The most recent MDS (minimum data set) assessment, an assessment, with an assessment reference date of 5/20/2021, coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. Resident #106 was coded as independent for all of her activities of daily living except bathing in which she required limited assistance of one staff member. On 6/22/2021 at 10:41 a.m., observation of Resident #106's room revealed the resident in her recliner, and a bottle of Refresh Tears (moisturizing eye drops) on the bedside table. When asked if she uses the drops, Resident #106 stated she uses them all the time. She stated she was going to the eye doctor later today. On 6/23/2021 at 10:15 a.m., a second observation of the resident's room, again, the resident was in her recliner and the Refresh Tears sitting on the nightstand. Review of the physician orders failed to evidence an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the comprehensive care plan failed to evidence documentation related to the eye drops. An interview was conducted with LPN (licensed practical nurse) #6 on 6/23/2021 at 11:02 a.m. When asked if a resident can self-administer medications, LPN #6 stated not all medications but eye drops or creams they can. She further stated that they have to be stored in a locked box in their room. When asked if there is any type of assessment completed before this is done, LPN #6 stated yes. When asked if there should be a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked where the assessment is documented, LPN #6 stated she would have to check. LPN #6 returned and stated the unit manager and the physician have to do an assessment for the self-administration of medications. LPN #6 stated it would be in the assessment section in the computer record. An interview was conducted with RN (registered nurse) #5 on 6/23/2021 at 11:22 a.m. When asked if a resident is allowed to self-administer medications, RN #5 stated, yes, if they have been assessed and there is a physician order and we have to watch them perform it, if it's okay, then they can do it. When asked about the location in the clinical record for the self-administration of mediations, RN #5 stated it would be in the documents tab under forms and templates. A review of the clinical record failed to evidence an assessment for the self-administration of the Refresh Tears. There was a Self-Administration Of Medication assessment form completed for the use of a cream for pain management but there was no assessment form for the use of the Refresh Tears. At 12:35 p.m., LPN #6 was accompanied to Resident #106's room. When asked if she saw anything unusual on the nightstand, LPN #6 stated she [Resident #106] had Refresh Tear eye drops. Resident #106 stated she does have a lock box for her cream. She said she could keep them [Refresh Tear eye drops] there. Resident #106 stated her daughter bought them per the instructions of her eye doctor. LPN #6 went to the computer and stated there was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy, Self Administration of Medications by Patients/Residents documented in part, Policy Statement: Each patient/resident who desires to self-administer medications is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication .Procedure: .2. If the patient /resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. In addition, the resident or family member should in conjunction with the facility nurse, utilize the Electronic Medical Record Observation tool, Medication Self - Administration Observation to complete the administration of medication. 3. If the Licensed nurse determined the patient/resident or family member to be capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific mediations based on of the Self-Administration Medication Observation. 4. If the patient/resident or family member demonstrates the ability to safely, self-administer mediations, a further assessment of the safety of bedside medication storage is conducted. 5. Bedside Storage of Medications is permitted only when it does not present a risk to confused patients/residents who wander in to the rooms of, or room with patients/residents who self-administer. ASM (administrative staff member) #1, the director of nursing, RN (registered nurse) #2, the director of compliance, and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/2021 at 4:48 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 138. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55.

Based on staff interview and facility document review, it was determined the facility staff failed to develop a baseline care plan for one of 45 residents in the survey sample, Resident #480. The facility failed to develop a baseline care plan to address and include Resident # 480's use of a [CONDITION(S)] (continuous positive airway pressure) machine. The findings include: During the facility tour on 6/22/21 at 11:30 AM, observation revealed a [CONDITION(S)] machine sitting on Resident #480's bedside nightstand with the nasal prongs uncovered. On 6/22/21 at 3:30 PM, a second observation revealed the [CONDITION(S)] machine on Resident #480's bedside nightstand with the nasal prongs uncovered. Resident #480 was admitted to the facility on [DATE]. Resident #480's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #480's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: had not been coded. MDS Section H-Bowel and Bladder had not been coded. MDS Section O-Special Treatments / Procedures had not been coded. A review of Resident #480's baseline care plan dated 6/17/21 failed to evidence documentation addressing for Resident #480's use a [CONDITION(S)] (1). The baseline care plan, documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, all the boxes on Resident #480's baseline care plan were unchecked. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's history and physical dated 6/18/21, documented in part, Assessment and Plans: OSA [obstructive sleep apnea] on [CONDITION(S)]. Review of the nursing admission assessment dated [DATE], failed to evidence documentation of OSA [obstructive sleep apnea] or the use of a [CONDITION(S)] machine. An interview was conducted on 6/22/21 at 1:55 PM with Resident #480, regarding the [CONDITION(S)] machine. Resident #480 stated, I use it every night. When asked if the [CONDITION(S)] nasal prongs were covered, Resident #480 stated, No, it's never covered. It fell on the floor once and I wiped it off before I used it again. I believe it should be covered when I'm in this building. An interview was conducted on 6/23/21 at 2:15 PM with LPN (licensed practical nurse) #5. When asked the purpose of the baseline care plan, LPN #5 stated, The purpose of the care plan is to develop the plan for the resident and to meet their needs on admission. When asked if treatments such as [CONDITION(S)] should be included on the baseline care plan, LPN #5 stated, Yes they should be included as that is part of their treatment. An interview was conducted on 6/23/21 at 3:00 PM with RN (registered nurse) #3, the clinical reimbursement director. When asked who develops the baseline care plan, RN #3 stated, The IDT [interdisciplinary team] develops the baseline care plan. The purpose of the care plan is to provide care specific to a resident based on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/21 at 3:30 PM, RN #3 brought in a copy of the nursing progress noted dated and timed 6/23/21 3:12 PM which documented in part, Informed of [CONDITION(S)] machine in room. Resident reports [CONDITION(S)] was dropped off by wife a few days ago; he couldn't remember which day. He states he uses this at night for his sleep apnea. It was observed on his bedside table. Unit manager aware and following up. RN #3 also provided a revised baseline care plan for review, which documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, box checked and dated 6/23/21. Other condition: Sleep Apnea, Intervention: [CONDITION(S)] per order, dated 6/23/21. A copy of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident at night for OSA. Monitor on 3-11 and 11-7 shift. Ensure [CONDITION(S)] has distilled water in chamber at bedtime. [CONDITION(S)] face mask to be changed every 6 months by 3-11 shift in July and January. Wipe mask with [CONDITION(S)] wipes, allow 2 minutes to dry on clean surface and apply mask. An interview was conducted on 6/23/21 at 4:00 PM with ASM (administrative staff member) #1, the director of nursing. When asked the purpose of the baseline care plan, ASM #1 stated, It is the individualized plan of care for the resident to meet their needs. ASM #1 stated, The IDT (interdisciplinary team) initiates it [baseline care plan], but nursing is responsible for revisions. ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/21 at 4:45 PM. The facility's Policy and Procedure for Comprehensive Person-Centered Care Planning dated 3/2018, documents in part, A baseline care plan is developed within 48 hours of admission to include minimum healthcare information to properly care for the resident. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 141. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 531. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 498. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 416.

Based on observation, resident interviews, staff interviews, clinical record reviews and facility document reviews it was determined that the facility staff failed to implement the comprehensive care plan for two of 45 residents in the survey sample, Residents #70 and #115. The facility staff failed to implement the comprehensive care plan to administer oxygen per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: 1. Resident #70 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #70's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 5/11/2021, coded Resident #70 as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. Section O coded Resident #70 as receiving oxygen while a resident at the facility. On 6/22/21 at approximately 12:42 p.m., an interview was conducted of Resident #70 in their room. Resident #70 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 6/16/21 attached to an oxygen concentrator. The oxygen flow rate set on the concentrator was observed set at 2.5 lpm (liters per minute). Resident #70 stated that they wore the oxygen all the time. When asked if he ever adjusted the oxygen rate, Resident #70 stated that the nurses set the oxygen rate and he did not adjust the settings. Additional observations of Resident #70 on 6/22/21 at approximately 4:15 p.m. and 6/23/21 at approximately 11:45 a.m. revealed the oxygen flow rate set at 2.5 lpm. The comprehensive care plan for Resident #70 dated 12/31/2020 documented in part, [Resident #70] is at risk for impaired gas exchange R/T (related to) [CONDITION(S)], Pulmonary [CONDITION(S)] (hypertension) (4), allergies and OSA (obstructive sleep apnea) Under Intervention it documented in part, Administer oxygen per MD (medical doctor) orders, See eTAR (electronic treatment administration record). Start Date: 12/31/2020 . The physician order's for Resident #70 documented in part, Order Date: 5/10/21 .Resident to wear oxygen @ [at] 3L/min (liters per minute) via NC (nasal cannula) continuously for SOB (shortness of breath)/[CONDITION(S)]- Check flowmeter and O2 SATs (saturations) Q (every) shift . On 6/23/2021 at approximately 1:10 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated that the purpose of the care plan was to help everyone understand what care was to be provided to the resident. LPN #2 stated that the nursing staff used the care plans. On 6/23/2021 at approximately 1:20 p.m., LPN #2 observed Resident #70's oxygen concentrator. LPN #2 stated that the oxygen was set at 2.5 lpm and they did not know how it had gotten set that way because it was supposed to be set at 3 lpm. LPN #2 stated that the oxygen being set at 2.5 lpm was not following the plan of care. On 6/23/2021 at approximately 3:34 p.m., an interview was conducted with RN (registered nurse) #3, the clinical reimbursement director. RN #3 stated that they were not following the care plan if they were not administering the oxygen at the prescribed rate. The facility policy Policy and Procedure for Comprehensive Person-Centered Care Planning dated 3/2018 documented in part, .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychological needs identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 6/23/21 at approximately 4:45 p.m., ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing were notified of the findings. No further information was provided prior to exit. References: 1. [CONDITION(S)] ([CONDITION(S)]): Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[CONDITION(S)].html. 2. [CONDITION(S)]: When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html. 3. Sleep apnea is a common disorder that causes your breathing to stop or get very shallow. Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. This information was obtained from the website: https://medlineplus.gov/sleepapnea.html. 4. Pulmonary hypertension (PH) is high blood pressure in the arteries to your lungs. It is a serious condition. If you have it, the blood vessels that carry blood from your heart to your lungs become hard and narrow. Your heart has to work harder to pump the blood through. Over time, your heart weakens and cannot do its job and you can develop heart failure. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=pulmonary+hypertension&_ga=2XXX 7636XXX 153XXX - XXX 2. The facility staff failed to implement the comprehensive care plan to administer oxygen per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #115 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 5/24/2021, coded Resident #115 as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. Resident #115 was coded as requiring limited assistance of one staff member for most of her activities of daily living. In Section O - Special Treatments, Procedures and Programs, Resident #115 was coded as using oxygen while in the facility. The comprehensive care plan dated 8/25/2020 documented in part, Care Plan - (Resident #115) has impaired gas exchange r/t (related to) [CONDITION(S)], Shortness of breath. She has hx (history) of wheezing. She is on continuous oxygen. She has a cough. The Interventions documented in part, Administer oxygen per MD (medical doctor) orders. On 6/22/2021 at 10:45 a.m. observation revealed Resident #115 sitting in her recliner with oxygen on via a nasal cannula connected to an oxygen concentrator that was running. Further observation revealed the oxygen flow meter was set at 2.5 LPM (liters per minute). A second observation on 6/22/2021 at 3:39 p.m. revealed, the oxygen flow rated was set at 2.5 LPM. On 6/23/2021 at 9:30 a.m., observation of Resident #115 revealed oxygen was in use by the resident and the flow meter flow rate on the oxygen concentrator was set at 2.5 LPM. When asked if she adjusts the oxygen flow rate, Resident #115 stated she had it at home and knows how to adjust it but the staff here has told her not to touch it so she doesn't. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 2 L/MIN (liters per minute) continuously for SOB (shortness of breath)/[CONDITION(S)]) check flowmeter and O2 (oxygen) sats (saturations) Q (every) shift. The eTAR (electronic treatment administration record) documented, Resident to wear oxygen @ 2 L/MIN continuously for SOB/[CONDITION(S)] check flowmeter and O2 sats Q shift. The eTAR documented the use of oxygen on all three shifts for 6/22/2021 and 6/23/2021. It also documented a 2 under each shift for the liter flow rate. An interview was conducted with RN (registered nurse) #3 on 6/23/2021 at 3:30 p.m. When asked the purpose of the comprehensive care plan, RN #3 stated it mostly is to present the picture of the resident and what their person centered life and what the needs, desire and their preferences. It contains things other staff members need to provide care to them. When asked what it means if the comprehensive care plan includes an intervention to administer oxygen per the physician and the oxygen was not observed set at the physician prescribed rate, RN #3 stated that's not following the care plan but also not following the physician orders. ASM (administrative staff member) #1, the director of nursing, RN (registered nurse) #2, the director of compliance, and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/2021 at 4:48 p.m. No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 138. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 55.

Based on staff interview and facility document review, it was determined the facility staff failed to follow professional standards of practice in obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to follow professional standards of practice in obtaining physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #480. The findings include: During the facility tour on 6/22/21 at 11:30 AM, observation revealed a [CONDITION(S)] machine sitting on Resident #480's bedside nightstand with the nasal prongs uncovered. On 6/22/21 at 3:30 PM, a second observation revealed the [CONDITION(S)] machine on Resident #480's bedside nightstand with the nasal prongs uncovered. Resident #480 was admitted to the facility on [DATE]. Resident #480's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #480's most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 6/17/21, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: had not been coded. MDS Section H-Bowel and Bladder had not been coded. MDS Section O-Special Treatments / Procedures had not been coded. A review of Resident #480's baseline care plan dated 6/17/21 failed to evidence documentation addressing for Resident #480's use a [CONDITION(S)] (1). The baseline care plan, documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, all the boxes on Resident #480's baseline care plan were unchecked. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's history and physical dated 6/18/21, documented in part, Assessment and Plans: OSA [obstructive sleep apnea] on [CONDITION(S)]. Review of the nursing admission assessment dated [DATE], failed to evidence documentation of OSA [obstructive sleep apnea] or the use of a [CONDITION(S)] machine. An interview was conducted on 6/22/21 at 1:55 PM with Resident #480, regarding the [CONDITION(S)] machine. Resident #480 stated, I use it every night. When asked if the [CONDITION(S)] nasal prongs were covered, Resident #480 stated, No, it's never covered. It fell on the floor once and I wiped it off before I used it again. I believe it should be covered when I'm in this building. An interview was conducted on 6/23/21 at 2:15 PM with LPN (licensed practical nurse) #5. When asked who is responsible for obtaining physician orders, LPN #5 stated, Nursing is responsible for obtaining orders from the physician. When asked if treatments such as [CONDITION(S)] should have a physician order, LPN #5 stated, Yes, there should be an order. An interview was conducted on 6/23/21 at 3:00 PM with RN (registered nurse) #3, the clinical reimbursement director regarding physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated, If there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/23/21 at 3:30 PM, RN #3 brought in a copy of the nursing progress noted dated and timed 6/23/21 3:12 PM which documented in part, Informed of [CONDITION(S)] machine in room. Resident reports [CONDITION(S)] was dropped off by wife a few days ago; he couldn't remember which day. He states he uses this at night for his sleep apnea. It was observed on his bedside table. Unit manager aware and following up. RN #3 also provided a revised baseline care plan for review, which documented in part, Special Treatments/Procedures: [CONDITION(S)] & [CONDITION(S)] equipment. Cleaning/maintenance per facility protocol. Liters per minute___. Check boxes by each of these, box checked and dated 6/23/21. Other condition: Sleep Apnea, Intervention: [CONDITION(S)] per order, dated 6/23/21. A copy of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident at night for OSA. Monitor on 3-11 and 11-7 shift. Ensure [CONDITION(S)] has distilled water in chamber at bedtime. [CONDITION(S)] face mask to be changed every 6 months by 3-11 shift in July and January. Wipe mask with [CONDITION(S)] wipes, allow 2 minutes to dry on clean surface and apply mask. An interview was conducted on 6/23/21 at 4:00 PM with ASM (administrative staff member) #1, the director of nursing. When asked the purpose of the physician orders, ASM #1 stated, Orders are to take care of the resident needs and for medications and treatments, oxygen and [CONDITION(S)] orders. When asked who is responsible to obtain/clarify physician orders, ASM #1 stated, Any nurse is to get physician orders. They can be obtained in the evening or weekend, we have on call physicians. We need a process if the family brings in a device to make sure we have an order. ASM #1, the director of nursing, RN #1, the director of compliance and RN #4, the assistant director of nursing, were made aware of the above concern on 6/23/21 at 4:45 PM. The facility's policy on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information was provided prior to exit. References: (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 141. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 531. (3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 498. (4) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 7th edition, Rothenberg and Chapman, page 416.

Based on clinical record review, facility document review and staff interview, it was determined that facility staff failed to provide supervision and ensure an environment free of accident hazards for one of 45 residents in the survey sample, Resident # 108. The facility staff failed to provide supervision to prevent Resident # 108 from exiting the facility in his wheelchair unattended through an emergency exit door. Staff interview revealed the emergency exit door lock and alarm were not functioning at the time of Resident #108's elopement. The findings include: Resident # 108 was admitted to the facility with diagnoses that included but were not limited to: above the knee left leg amputation, dementia with behavioral disturbances [1], and muscle weakness. Resident # 108's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 05/20/2021, coded Resident # 108 as scoring a 1 [one] on the brief interview for mental status (BIMS) of a score of 0 - 15, one - being severely impaired of cognition for making daily decisions. Resident # 108 was coded as requiring extensive assistance of one staff member for activities of daily living. Section P0200 Alarms coded Resident # 108 as E. Wander / elopement alarm. Used daily. The baseline care plan for Resident # 108 dated 08/21/2020 documented in part, Initial Goals: Cognition: Elopement risk. The facility's Admission Data Collection Tool for Resident # 108 dated 08/21/2020 documented in part, Does resident have any history of wandering or elopement? Yes. The nurse's note for Resident # 108 dated 08/21/2020 at 9:39 p.m., documented in part, .Has been exit seeking since admission, when redirected from outside doors he likes to use the F word. The nurse's note for Resident # 108 dated 08/23/2020 at 11:26 a.m. documented, Resident was observed in wheel chair under shaded tree near [Name of County Health Department] off facility grounds around 1000 [10:00 a.m.] by staff. He was brought back to facility and released to the care of the nurse. Resident was assessed for injuries. None observed. Vital signs 97.2 [temperature] 124 [pulse], 18 [respiration], 91/67 [91 over 67 - blood pressure], 92% [pulse oximetry]. Nurse manager, NP [nurse practitioner - [Name of Nurse Practitioner], DON [director of nursing] and administrator notified. Guardian [Name of Guardian] notified of elopement and spoke with resident encouraging him to stay inside facility. When asked why he left he stated he was trying to get where he was going. While interviewed he states he was not harmed, he felt safe, and was just leaving. Resident has been placed on Q [every] 15 minute checks. Signed by: [Name of Licensed Practical Nurse # 8. Further review of the facility's nurse's notes for Resident # 108 failed to evidence any notes for 08/22/2020. The facility's 24 HOUR REPORT / CHANGE OF CONDITION REPORT dated 08/21/2020 documented in part, Resident: [Name of Resident # 108]. REMARKS (3-11) [3:00 p.m. to 11:00 p.m. shift]: Exit seeks. The facility's 24 HOUR REPORT / CHANGE OF CONDITION REPORT dated 08/22/2020 documented in part, Resident: [Name of Resident # 108]. REMARKS (11-7) [11:00 p.m. to 7:00 a.m. shift]: Exit seeking. The facility's 24 HOUR REPORT / CHANGE OF CONDITION REPORT dated 08/23/2020 documented in part, Resident: [Name of Resident # 108]. REMARKS (11-7) [11:00 p.m. to 7:00 a.m. shift]: Exit seeking. REMARKS (7-3) Left facility. The FRI [Facility Reported Incident] for Resident # 108 dated 08/23/2020 documented, Incident Date: 8/23/2020. Injuries: No. Resident Elopement. Staff noted resident in wheelchair down by lower parking lot area. Staff approached resident and brought resident back to nurse's station. Full body assessment completed by staff - no injuries. The facility's INCIDENT INVESTIGATION regarding Resident # 108 dated 8/23/2020 documented in part, Resident seen on [abbreviation for name of unit] lower end camera down by laundry room around 9:48 am [a.m.]. Resident seen on [abbreviation for name of unit] camera facing toward dumpster around 9:52 am. Resident seen going down hill [Sic.] towards lower back parking lot where 2 [two] aides seen resident in w/c [wheelchair]. Resident was brought back up to [name of unit abbreviation] nurse's station by aides. Event was less than 10 minutes. The facility's Completed Work Orders summary revealed that the facility's exit door alarms and magnetic locks were checked and in working order on 08/17/2020. Under Tasks it documented, Check Magnetic Locks. Under Description it documented, Check each door that has a magnetic locking device to be sure the device works properly. Check to be sure the magnetic lock releases and alarms if you push on it for 15 seconds. On 06/23/2021 at 8:40 a.m., an interview was conducted with OSM [other staff member] # 2, director of maintenance. When asked to explain the 'malfunction' of the emergency exit door on the [name of unit] on 08/23/2020, OSM # 2 stated that something in the key pad failed and didn't allow the 15 minute delay where the magnetic lock is engaged, keeping the door closed unless the push bar is held in for 15 seconds. After that, the magnetic lock releases and the door opens. OSM # 2 also stated that the audible alarm did not alarm either. When asked if the exit doors in the facility are checked or inspected on a regular basis, OSM # 2 stated that weekly preventative maintenance is conducted on every exit door in the facility. When asked what they check or look for in the inspection, OSM # 2 stated that they make sure the 15 minute delay is working, it alarms, the door is locking during that time and operating the way it should be. When asked if they were aware of the elopement of a resident on 08/23/2020, OSM # 2 stated that he was notified after the incident that the door was not working and that he changed out the entire key pad. On 06/23/2021 at 9:09 a.m., an interview was conducted with RN [registered nurse] # 1 regarding Resident # 108's elopement on 08/23/2020. RN # 1 stated that they were the unit manager at the time on the [name of unit] unit and was on-call that day. RN # 1 stated, I was called in when the incident happened. When asked to describe the procedure they follow when a newly admitted resident demonstrates exit seeking behaviors, RN #1 stated that staff closely monitor the resident. When asked to describe 'closely monitoring' RN # 1 stated that they would keep the resident in sight and if they are attempting to leave we would give them a wander guard. When asked if they were aware if Resident # 108 had exit seeking behaviors, RN # 1 stated no. On 06/23/2021 at 9:09 a.m., an interview was conducted with CNA [certified nursing assistant] # 1 regarding Resident # 108's elopement on 08/23/2020. After reviewing their witness statement CNA # 1 stated that they recalled Resident # 108 and the incident. CNA # 1 stated, I was in the dayroom at the end of the hall of the EM [east main] unit [directly above name of unit] looking out the window toward the back of the building and saw CNA # 2 pushing a person in a wheelchair up the driveway next to the employee parking lot. I went out to help [CNA # 2] and they told me he [Resident #108] was a resident from the facility. We took him to the nurse on [name of unit]. I didn't know or work with him. On 06/23/2021 at approximately 2:00 p.m., an interview was conducted with LPN [licensed practical nurse] # 8 regarding Resident # 108's elopement on 08/23/2020. When asked to describe the procedure staff follow when a newly admitted resident demonstrates exit seeking behaviors, LPN #8 stated, It takes time for a resident to settle down or orient to a new environment so we watch them, maybe put them on 15 minute checks. When asked how the staff are informed that a resident has exit seeking behaviors, LPN # 8 stated, By word of mouth and/or the 24 hour report. LPN # 8 was then asked to provide evidence that Resident # 108 was being monitored from the time of their admission. No further information was provided by LPN # 8 during the days of the survey. On 06/23/2021 at approximately 4:02 p.m., a telephone interview was conducted with LPN [licensed practical nurse] # 7 regarding Resident # 108's elopement on 08/23/2020. LPN # 7 stated that they were working on the [name of unit] on 08 23/2020, when Resident # 108 eloped and stated they worked PRN [as needed]. LPN # 7 stated, I was passing meds [medication] when the CNAs brought him in, I wasn't aware he left the building. When asked to describe the procedure staff follow when a newly admitted resident demonstrates exit seeking behaviors LPN #7 stated, Usually put them on 15 minute checks. LPN # 7 further stated that they could not recall Resident # 108 demonstrating exit seeking behaviors and didn't remember it being on the 24 hour report. On 06/23/2021 at 3:26 p.m., an interview was conducted with ASM [administrative staff member] # 1, director of nursing, regarding Resident # 108's elopement on 08/23/2020. When asked to describe the procedure staff follows when a newly admitted resident demonstrates exit seeking behaviors, ASM #1 stated, We monitor them closely, not one-to-one but line-of-sight. When asked to describe line-of-sight ASM # 1 stated, Walking up and down the hall putting eyes on them. ASM # 1 further stated, At the time [when Resident # 108 was admitted ] the [name of unit], the unit was the COVID observation unit, where residents who came in from the outside were placed for 14 day observation. The unit was closed off, at the one end we had a plastic wall up with the zipper door and the only other door out of the building was the emergency exit at the other end of the hallway. ASM # 1 stated that they assumed that Resident # 108 could not get off the unit because of the plastic barrier with the zipper door and the emergency exit at the other end that was alarmed but had no idea that the alarm was not working. When asked if they could provide evidence that Resident # 108 was being monitored for elopement on 08/21/2020, 08/22/2020 and on 08/23/2020 prior to the elopement ASM # 1 stated no. On 06/23/2021 at 4:17 p.m., an interview was conducted with CNA # 2 regarding Resident # 108's elopement on 08/23/2020. After reviewing their witness statement CNA # 2 stated that they recalled Resident # 108 and the incident. CNA # 2 stated, I was going out for lunch and saw a resident out toward [Name of Health Department] in the grassy area. I took him back to the unit. Another CNA came and helped me take him back. When asked if they knew the resident, CNA # 2 stated, I saw his name band and knew he was from the facility. When asked if they worked on the [name of unit] they stated, Not at that time. On 06/23/2021 at 5:07 p.m., a telephone interview was conducted with CNA # 3 regarding Resident # 108's elopement on 08/23/2020. CNA # 3 stated that they were working on the [name of unit] that day and recalled Resident # 108 but didn't recall them having exit seeking behaviors. When asked about the elopement CNA # 3 stated, I wasn't aware of it, I was in another resident's room providing care. When asked how there are informed of a resident having exit seeking behaviors, CNA # 3 stated that the charge nurse would inform them during report. When asked to describe the procedure staff follows when a newly admitted resident demonstrates exit seeking behaviors, CNA #3 stated, Do checks every 15 minutes. On 06/24/2021 at 8:30 a.m., an interview was conducted with CNA # 4 regarding Resident # 108's elopement on 08/23/2020. When asked how they know a resident has exit seeking behaviors, CNA # 4 stated, From the way they act, they will say they want to leave and/or they try to leave the building. When asked how they are informed that a resident has exit seeking behaviors, CNA # 4 stated, In report, by another CNA at shift change or the charge nurse will tell us. When asked if they were assigned to Resident # 108 on 08/23/2020, CNA # 4 stated that they could not remember. When asked if they were aware that Resident # 108 had exit seeking behaviors, CNA # 4 stated, We were all aware, he was adamant about leaving. His room was across from the nurse's station. He was in his door way when I was leaving to take my lunch. We were supposed to keep an eye on him. The facility's policy Elopement or Missing Resident it documented in part, If a staff member observes a nursing facility resident attempting to leave the facility: Attempt to prevent the resident from leaving the property while remaining with the resident; Attempt to notify other staff to assist as needed in a courteous manner, remain with resident while other staff member notifies charge nurse; When resident is returned to unit, notify MD [medical doctor], RP [responsible party] of exit seeking; If a resident does not have a Roam Alert, obtain order from MD; Resident should have increased monitoring On 6/23/21 at 4:59 p.m., ASM [administrative staff member] #1, director of nursing, was made aware of the above concern. No further information was presented prior to exit. References: [1] Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety [CONDITION(S)], agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 17/.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility failed to implement infection control procedures to prevent the spread of infection and communicable disease during a COVID 19 outbreak for five out of five residents in the survey sample, Residents #1, #2, #3, #4, and #5. The facility staff failed to sanitize vital sign equipment between use on Resident #1, #3, and #4 and failed to properly wash their hands between resident contact. The facility staff member failed to wear an isolation gown when in contact with Resident #5, who was on droplet precautions to prevent the spread of COVID-19. (1) The facility staff failed to maintain social distance between Residents #1 and #2 when they were in a common area per CDC (Center for Disease Control) guidance for COVID 19. The findings include: On 6/16/2020 at 10:32 a.m., CNA (certified nursing assistant) #3 was observed taking Resident #1's vital signs using an automated blood pressure cuff and device which measures the oxygen level in the blood (pulse oximeter). The resident was seated in the common area, and Resident #2 was less than three feet away from Resident #1. Both residents were seated in wheelchairs. Neither resident wore a mask. CNA #3 completed the vital sign assessment on Resident #1. Without sanitizing the blood pressure cuff or the pulse oximeter, she took the equipment into Resident #3's room. CNA #3 did not wash or sanitize her hands when she entered Resident #3's room. She placed the blood pressure cuff on Resident #3's left arm and the pulse oximeter on a finger on Resident #3's right hand. Once the assessment was complete, CNA #3 washed her hands for 20 seconds at the sink. She did not sanitize the vital sign equipment. She took the equipment to Resident #4's room, and placed the blood pressure cuff on Resident #4's left arm and the pulse oximeter on a finger on Resident #4's right hand. Resident #1 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/5/20 coded the resident as moderately impaired in ability to make daily life decisions. Resident #1's comprehensive care plan dated 3/24/20 for Risk of exposure to and/or transmission of COVID-19 included the following interventions: Educate and assist with frequent proper hand hygiene (dated 3/24/20). Educate and assist with respiratory hygiene and cough etiquette (dated 3/24/20). Educate on social distancing with no handshakes, hugging, communal dining and group activities (dated 3/24/20). Encourage to remain in their room if fever or respiratory symptoms occur (dated 3/24/20). Implement standard, contact and droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy (dated 3/24/20). Monitor for signs and symptoms of respiratory infections (e.g. new or change in cough, fever, sore throat, shortness of breath) on admission and every shift (dated 3/24/20). Monitor vital signs per orders, see eTAR (electronic treatment administration record) (dated 3/24/20). Provide resident/RP (responsible party) with updated information from CMS (Centers for Medicare and Medicaid Services) and VDH (Virginia Department of Health) on COVID-19 as appropriate and in a manner they can understand (dated 3/24/20). COVID-19 testing per orders (dated 6/3/20). Resident # 2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 5/13/20 coded the resident as being severely impaired in ability to make daily life decisions. Resident #2's comprehensive care plan dated 3/24/20 for Risk of exposure to and/or transmission of COVID-19 included the following interventions: Educate and assist with frequent proper hand hygiene (dated 3/24/20). Educate and assist with respiratory hygiene and cough etiquette (dated 3/24/20). Educate on social distancing with no handshakes, hugging, communal dining and group activities (dated 3/24/20). Encourage to remain in their room if fever or respiratory symptoms occur (dated 3/24/20). Implement standard, contact and droplet precautions for symptoms/undiagnosed Respiratory infections; follow facility policy (dated 3/24/20). Monitor for signs and symptoms of respiratory infections (e.g. new or change in cough, fever, sore throat, shortness of breath) on admission and every shift (dated 3/24/20). Monitor vital signs per orders, see eTAR (electronic treatment administration record) (dated 3/24/20). Provide resident/RP (responsible party) with updated information from CMS (Centers for Medicare and Medicaid Services) and VDH (Virginia Department of Health) on COVID-19 as appropriate and in a manner they can understand (dated 3/24/20). COVID-19 testing per orders (dated 6/3/20). Resident #3 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/10/20 coded the resident as severely cognitively impaired in ability to make daily life decisions. Resident #3's comprehensive care plan dated 5/28/20 for Risk of exposure to and/or transmission of COVID-19 included the following interventions: Educate and assist with frequent proper hand hygiene (dated 5/28/20). Educate and assist with respiratory hygiene and cough etiquette (dated 5/28/20). Educate on social distancing with no handshakes, hugging, communal dining and group activities (dated 5/28/20). Encourage to remain in their room if fever or respiratory symptoms occur (dated 5/28/20). Implement standard, contact and droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy (dated 5/28/20). Monitor for signs and symptoms of respiratory infections (e.g. new or change in cough, fever, sore throat, shortness of breath) on admission and every shift (dated 5/28/20). Monitor vital signs per orders, see eTAR (electronic treatment administration record) (dated 5/28/20). Provide resident/RP (responsible party) with updated information from CMS (Centers for Medicare and Medicaid Services) and VDH (Virginia Department of Health) on COVID-19 as appropriate and in a manner they can understand (dated 5/28/20). COVID-19 testing per orders (dated 6/3/20). Resident #4 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The annual MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 3/10/20 coded the resident as cognitively intact in ability to make daily life decisions. Resident #4's comprehensive care plan dated 3/24/20 for Risk of exposure to and/or transmission of COVID-19 included the following interventions: Educate and assist with frequent proper hand hygiene (dated 3/24/20). Educate and assist with respiratory hygiene and cough etiquette (dated 3/24/20). Educate on social distancing with no handshakes, hugging, communal dining and group activities (dated 3/24/20). Encourage to remain in their room if fever or respiratory symptoms occur (dated 3/24/20). Implement standard, contact and droplet precautions for symptoms/undiagnosed respiratory infections; follow facility policy (dated 3/24/20). Monitor for signs and symptoms of respiratory infections (e.g. new or change in cough, fever, sore throat, shortness of breath) on admission and every shift (dated 3/24/20). Monitor vital signs per orders, see eTAR (electronic treatment administration record) (dated 3/24/20). Provide resident/RP (responsible party) with updated information from CMS (Centers for Medicare and Medicaid Services) and VDH (Virginia Department of Health) on COVID-19 as appropriate and in a manner they can understand (dated 3/24/20). COVID-19 testing per orders (dated 6/3/20). On 6/16/2020 at 10:59 a.m., OSM (other staff member) #1, a physical therapist, was observed kneeling on the floor in front of Resident #5, who was seated in a wheelchair in her room. OSM #1 was wearing a mask; he was not wearing gloves or an isolation gown. A sign on the resident's door read: Please see nurse before entering. Observation revealed an isolation cart outside Resident #5's room. OSM #1 assisted Resident #5 to stand and to sit multiple times, touching her clothing on her legs and on her arms. OSM #1 assisted Resident #5 with ambulating in her room, and with maneuvering her walker around her bed. Observation revealed, OSM #1 brushed up against Resident #5's unmade bed with his clothing several times. Resident #5 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] documented that the resident was able to understand others and make herself understood. The assessment documented that the resident required the use of some assistive devices. Resident #5's baseline care plan dated 6/6/2020 included the following interventions: Isolation for Prevention, Type: Contact with mask. Contact isolation (gown, gloves, mask, face shields for prevention X 14 days). On 6/16/2020 at 11:09 a.m., RN (registered nurse) #2, the unit manager, was interviewed. When asked what the sign on Resident #5's door meant, RN #2 stated the sign is to indicate that the resident is still in 14-day isolation. When asked the purpose of the isolation, RN #2 stated that Resident #5 was a relatively new admission (within the past 14 days), and she was being isolated to prevent the possible spread of COVID-19. When asked what kind of PPE (2) should be worn in Resident #5's room, RN #2 stated, Gowns, gloves, and a mask, as a prevention. On 6/16/2020 at 11:10 a.m., OSM #1 was interviewed. When asked what the sign on Resident #5's door meant, OSM #1 stated, We have them (residents) on isolation when they come into the building. OSM #1 stated the proper PPE (personal protective equipment) to be worn for residents in isolation includes gown, masks, and gloves, and the nurse always wear those. We just wear our masks. On 6/16/2020 at 11:22 a.m., CNA (certified nursing assistant) #3 was interviewed. When asked if she was aware of anything she would have done differently after taking Resident #1's vital signs earlier, she stated she could not think of anything. When asked if she sanitized the pulse oximeter or the blood pressure cuff after taking Resident #1's and #3's vital signs, CNA #1 stated, No. I did not know if I was supposed to. She stated she knew she should have sanitized her hands after working with each resident. On 6/16/2020, ASM (administrative staff member) #1, the executive director, ASM #2, the director of nursing, and RN (registered nurse) #1, the assistant director of nursing and infection preventionist, were informed of these concerns. ASM #2 stated the facility staff is doing social distancing with the residents. ASM #2 stated, We do the best we can. We encourage masks. We attempt to keep them six feet apart. She stated some facility residents insist on going to the same spot each day, and that it is hard to manage cognitively impaired residents. ASM #2 stated the staff encourages residents to stay in their rooms. She stated vital sign equipment should be cleaned after use with each resident and that the staff has been provided with and educated on the use of disinfecting wipes. ASM #2 stated Resident #5 was a new admission, and had been admitted to the facility's yellow zone. ASM #2 stated these residents have been tested at the hospital for COVID-19, and the only isolation required is for the staff to wear a mask. When asked what kind of isolation Resident #5 was on, ASM #2 stated the resident (Resident #5) could have been exposed to COVID-19 between the time she was tested at the hospital and when she arrived at the facility. ASM #2 stated Resident #5 was on droplet isolation precautions, and that the staff should be wearing gown, gloves, and masks when entering the resident's room. She stated this practice should be followed in the case of a resident suspected of having COVID-19 and in the case of a resident who has had an opportunity of exposure prior to admission into the facility. A review of the facility policy, Hand Hygiene Using Alcohol Hand Rubs for Residents and Employees, revealed, in part: It is the policy of this facility to guide proper hygiene techniques to help prevent transmission of infections .Staff may use Alcohol Hand Rub in the following situations: Before direct contact with patients. Review of the facility policy, Policy and Procedure for Coronavirus Disease - COVID-19 - Admission of Resident with Suspected and/or [DIAGNOSES REDACTED]. The facility will screen all potential new admissions for exposure to COVID-19 .Before arrival of a resident suspected of having COVID-19 - Where possible the resident will be assigned a private room and be placed in 'quarantine' for 14 days and/or until cleared after consultation with the local health department. Implement and carry out transmission-based precautions as recommended by CDC (Centers for Disease Control), CMS (Centers for Medicare/Medicaid Services), and/or the local health department .The facility will make all reasonable efforts to minimize exposure to other residents. No further information was provided prior to exit. REFERENCES (1) Coronaviruses are a large family of viruses found in many different species of animals, including camels, cattle, and bats. The new strain of coronavirus identified as the cause of the outbreak of respiratory illness in people first detected in Wuhan, China, has been named [DIAGNOSES REDACTED]CoV-2. (Formerly, it was referred to as 2019-nCoV.) The disease caused by [DIAGNOSES REDACTED]-CoV-2 has been named COVID-19. This information was obtained from the website: https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments (2) PPE: Personal protective equipment is special equipment you wear to create a barrier between you and germs. This barrier reduces the chance of touching, being exposed to, and spreading germs. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 7.htm (3) [MEDICAL CONDITION] is a general term for chronic, nonreversible lung disease that is usually a combination of [MEDICAL CONDITION] and chronic [MEDICAL CONDITION]. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 124. Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment .Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. This information is taken from the website https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide care in a manner to prevent an accident resulting in injury and harm for one of 54 residents in the survey sample, Resident #132. On 1/11/19, two CNAs (certified nursing assistants) failed to use a mechanical lift to transfer Resident #132 from a wheelchair to a shower chair. The CNAs attempted to transfer the resident manually. As a result, the resident fell and sustained a laceration under his arm. This laceration required the resident to be transported to the emergency room where he received 19 stitches, resulting in harm. The findings include: Resident #132 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 8/28/19, he was coded as having mild impairment for making daily decisions, having scored 14 out of 15 on the BIMS (brief interview for mental status). He was coded as having unclear speech, as usually being understood by others, and as usually understanding others for communication. He was coded as requiring extensive assistance of two-plus staff members for transferring from one surface to another, and as not having walked in his room or on the unit during the look back period. On the most recent MDS prior to 1/11/19, a significant change assessment with an ARD of 10/19/18, Resident #132 was coded as having mild cognitive impairment for making daily decisions, having scored 13 out of 15 on the BIMS. He was coded as having unclear speech, as usually being understood by others, and as always understanding others for communication. He was coded as requiring the extensive assistance of one staff member for transferring from one surface to another, and as not having walked in his room or the unit during the look back period. On 9/18/19 at 10:05 a.m., Resident #132 was observed self-propelling in his wheelchair in his room. He was wearing long sleeves; neither arm was visible. When asked about the incident in (MONTH) when he received a cut under his arm, he stated, Yes, that happened; I don't really want to talk about it. He then stated he was late for a meeting and needed to go down hall. The resident left his room and headed toward the social area near the end of the hall. A review of the initial FRI (facility reported incident) related to Resident #132 submitted to the SA (stated agency) on 1/11/19 revealed, in part, the following: Report date: 01/11/19, Incident date: 01/11/19. Resident involved: (Resident #132). Injuries: Yes. Incident type: Unusual occurrence. Describe incident, including location, and action taken: 2 CNA's (sic) were transferring (Resident #132) by manually lifting without gait belt. Transfer status is 2 person with hoyer (mechanical) lift. Resident's left axillary (underarm) was torn when lowering resident to floor in west main shower room. Area measures 2.0 X (by) 8.0 X 2.0 (centimeters). Resident was sent out to ER (emergency room ) for placement of sutures. Name of employee(s) involved and their positions: (CNA #14) and (CNA #13). Employee action initiated or taken: Staff Education and suspension of employees. A review of the follow-up to the initial FRI dated 1/16/19 revealed, in part, the following: This letter serves as a follow-up to our initial FRI that was submitted on 1/11/19. Resident: (Resident #132) (Resident #132's room number) .Employee: (CNA #14), (CNA#13) On (MONTH) 11, 2019, (CNA #13 and CNA #14) were transferring (Resident #132). (Resident #132) was a Hoyer lift as of 1/4/19. (CNA #13) and (CNA #14) transferred (Resident #132) as a 2 person assist, as they were transferring him from the wheelchair to the shower chair, (Resident #132) became weak and started to fall. (CNA #14) and (CNA #13) grabbed by the arms to assist with fall causing a laceration (cut) in his axilla. (Resident #132) was sent to the emergency room and received 19 sutures and returned to the facility. (CNA #14) and (CNA #13) were suspended immediately on 1/11/19 pending an investigation. The investigation showed that (CNA #14) and (CNA #13) did not follow transfer orders and were terminated on 1/15/19. Staff education remains ongoing regarding resident transfer status. Based on staff interviews and statements, (CNA #14) and (CNA #13) were terminated for not following policy and procedure. A review of the document, Resident Incident Report, dated 1/11/19 at 7:30 p.m., revealed, in part, the following: Incident type: Fall/no head injury. Type of Injury: Skin Tear, Laceration - deep. Location: Shower room. Property involved: floor - tile/wood. Equipment: Shower chair - wheeled. Activity at time: From chair w/ (with) assist. Associate Involved: (CNA #13). Incident reported by: (CNA #14). Non-Witnessed. Narrative of incident and description of injuries: At approximately 7:30 p.m., resident was lowered to the floor during unsuccessful transfer in shower room on unit. Injuries include deep tissue skin tear to left posterior (back) axilla, measuring 2cm (centimeters) X 8cm X 2 cm deep. Moderate amount of blood noted to the area. Resident is assisted to the shower chair from the floor by multiple staff. Skin tear cleansed with NS (normal saline) and covered with dry dressing. (Name of attending physician) aware. RP (responsible party) aware. Shift super (supervisor) aware. Staff education was provided. Injuries include deep tissue skin tear to left posterior axilla measuring 2cm X 8cm X 2 cm deep. Moderate amount of blood noted to the area. Immediate Actions Taken: Skin assessment, ROM (range of motion) assessment, pain assessment, vital signs taken, assisted to the shower chair, wound cleansed and dressing applied .Temp (temperature) 97.4, Pulse 101, Resp (respirations) 24, BP (blood pressure) 143/83, Pain Scale 4 .Medical risk factors possibly related to incident: Fall history, Inability to understand directions, confusion/Disorientation, Incontinency (inability to control bowel and bladder), Sensory limitations. The report was completed by a nurse who was unavailable for interview at the time of the survey. A review of the clinical record revealed a nurses' note for Resident #132 dated 1/11/19 at 11:57 p.m. The note documented, in part, the following: At approximately 7:30 p.m., resident was lowered to the floor during unsuccessful transfer in shower room on unit. Injuries include deep tissue skin tear to left posterior (back) axilla, measuring 2cm (centimeters) X 8cm X 2 cm deep. Moderate amount of blood noted to the area. Resident is assisted to the shower chair from the floor by multiple staff. Skin tear cleansed with NS (normal saline) and covered with dry dressing. (Name of attending physician) aware. RP (responsible party) aware. Shift super (supervisor) aware. DON (director of nursing) aware. Staff education was provided. VS (vital signs) Temp (temperature) 97.4, Pulse 101, Resp (respirations) 24, BP (blood pressure) 143/83, (Blood oxygen level) 86% 3 L (liters) nc (nasal cannula). N.O. (new order) Send out to E. D. (emergency department) for further evaluation d/t (due to) deep tissue skin tear .Medical transportation takes resident to E. D. at 9pm. The nurse who wrote this note was unavailable for interview at the time of the survey. A review of Emergency Department Report for Resident #132 for 1/11/19 revealed, in part, the following: Evaluation: Physical exam shows patient to be (sic) no acute distress .Patient denies any other complaints except for laceration to left underarm. Has full active range of motion to left upper extremity without difficulty .Laceration repaired with deep layer superficial layer (sic) sutures. Good approximation noted. Patient tolerated procedure well. Wound thoroughly irrigated (cleaned with water) with pressure syringe saline prior to closure .Informed to have sutures out in 10-14 days .Procedures: Laceration/Wound Repair: Wound length (cm) 9, Wound's depth, shape: deep, linear .Wound repaired with: sutures .Number of sutures: 16 .Number Deep Layer Sutures: 3. Further review of the clinical record revealed a nurses' note for Resident #132 dated 1/12/19 at 1:06 a.m. The note documented, in part: Resident returned from ER with 19 sutures to left axilla. During assessment, noted multiple bruises over left arm. Resident also received tetanus shot at ER. Sutures need to be removed in 10-14 days. Resident in bed and denies any pain at this time. The nurse who wrote this note was unavailable for interview at the time of the survey. A review of the witness statement submitted 1/11/19 by CNA #13 revealed, in part, the following: At about 8ish, we went to get (Resident #132) from the recliner to get him cleaned up and ready for bed. When we got him up he stood, we removed his brief and it was beyond soiled. We then decided it would be best for his hygeine (sic) to rinse him of (sic) in the shower room. When we got him up to remove the wheelchair to put the shower chair underneith (sic) him he began to fall we encouraged him to stand (which he was doing great) but then he just kept falling, so we held on. But instead of letting him fall, we ease (sic) him to the floor. When we picked him up to get him up, I noticed blood on my glove and lifted his arm and noticed the tear. Then I went to get the nurse. As far as my knowledge it was said to me he was a 2 person assist. I began checking the CNA book but over the past few weeks, it has been changing. Also this is the first time (Resident #132) has been out of bed in over a week and a few days. A review of the witness statement submitted 1/11/19 by CNA #14 revealed, in part, the following: I was assisting another CNA in the .shower room to his shower chair. When he started to go down to the floor, we helped (sic) under his arms to assist him to the floor gently. I went then to the nurse for help and we saw the blood on the other aids (sic) gloves and informed the nurse of the skin tear on the left underarm of the resident. I was on the right hand side and the other aid (sic) had been on the left side. A review of Resident #132's ADL Assistance and Support record for 1/2/19 through 1/11/19 revealed that he was totally dependent on the physical assistance of at least two staff members for all transfers between surfaces. A review of physician's orders for Resident #132 revealed the following order dated 1/4/19 and discontinued on 1/13/19: Transfer status (mechanical) lift with 2 person assist. A review of Resident #132's care plan dated 12/27/17 revealed, in part, the following: Transfers: SARA (mechanical) lift with 2 people with green trim sling. A review of the facility's CNA communication book revealed the following entry dated 1/2/19: (Resident #132: Transfer: Hoyer + 2p (people). A review of the facility policy, Resident Transfers, revealed, in part, the following information: Safety is the first priority for residents .Follow directives in physicians' orders and the comprehensive care plan to perform safe transfers for all residents. A review of CNA #13's employee record revealed a termination notice dated 1/16/10. The notice documented, in part: Resident was transferred with 2 people instead of Hoyer, resulting in resident falling (lowered to the floor) and obtaining a significant skin tear to axillary. Resident required 19 stitches and treatment @ (at) ER .Action to be taken: Employee termination. The form was signed by both CNA #13 and ASM (administrative staff member) #2, the DON (director of nursing). A review of CNA #14's employee record revealed a termination notice dated 1/16/10. The notice documented, in part: Resident was transferred with 2 people instead of Hoyer, resulting in resident falling (lowered to the floor) and obtaining a significant skin tear to axillary. Resident required 19 stitches and treatment @ (at) ER .Action to be taken: Employee termination. The form was signed by both CNA #13 and ASM (administrative staff member) #2, the DON (director of nursing). Neither CNA involved who participated in the 1/11/19 transfer of Resident #132 is currently employed by the facility. On 9/18/19, CNA #17 was interviewed. She stated if she has a question about a resident's status, she checks with nurse or looks in the CNA book. She stated, You can also check it in the tablet. She stated she has worked with Resident #132 a couple of times. On 9/18/19 at 2:55 p.m., CNA #18 was interviewed. Can #18 stated, The residents can change from one day to the next, even over a shift. You should always double check on a transfer status if you have any questions. She stated she does not remember ever working with Resident #132. On 9/18/19 at 3:16 p.m., LPN (licensed practical nurse) #4, a unit manager, was interviewed. She stated Resident #132 resides on the unit she manages. LPN #4 stated she was the evening supervisor on 1/11/19. She stated she was in the building, but not in the shower room when the transfer happened. LPN #4 stated, I got called to the shower room and (Resident #132) was lying on the floor and bleeding. He was on the floor, on his bottom. I lifted up his left arm, under the axillae, and it was ripped. (CNA #13 and #14) said he had hit something on the shower chair behind him. But there was no way. We got the Hoyer lift to get him safely up and into a chair. He is so hard to get up once he falls. I assessed the area, held pressure. I had the floor nurse call 911 to get him sent out to get his stitches. I called to notify (ASM #3, the assistant director of nursing (DON)). I wrote the employees up. I had called (ASM #3) because (CNA #13 and #14) did not follow the transfer status. That was a written three-day suspension pending investigation. They were sent home. I had to notify the RP and the doctor. I knew there was no way the cut came from the shower chair. There was no blood on the nearby heating vent. I knew the CNAs were not telling me the truth. When asked what a CNA book is, LPN #4 stated, It's a book we keep on the unit. It has all the transfer statuses in it; each shift fills in one on each resident. It tells all about the resident - their likes and dislikes - things we can add to the care plan. The CNAs know they are in there. When asked if the expectation is that CNAs review the book, LPN #4 stated, Yes. They should review this when they come on a shift. Transfer status is something that can change day to day. And if they are unsure or confused, they can always ask the nurse. LPN #4 stated, I want to say we put out an inservice right away. We have a communication book that we put inservice material in for the nurses and CNAs to read and sign, saying they understand the material. Transfer specifics for (Resident #132) were specifically covered after this happened. Unit managers make sure the training gets done. On 9/18/19 at 3:38 p.m., ASM (administrative staff member) #3, the assistant DON, was interviewed about the events of 1/11/19. ASM #3 stated, I was not here. (LPN #4) was here as the supervisor. ASM #3 stated she called back to the facility, and was informed of what happened. There were a series of phone calls. I asked what his transfer status is. Let's make sure. Everything agreed. The care plan, the care guide/kiosk, the manual CNA book. It all matched. He had been a Hoyer lift for several days - like a week. He had not been back from the hospital long. When we realized that everything matched, there was no excuse. I told the evening supervisor to suspend (CNA #13 and #14) pending an investigation. We went over the write up by phone. The CNAs were sent home. We took their badges. The statements they wrote admitted what they did. When asked what a kiosk is, ASM #3 stated, It's a caregiver guide, electronic. It used to be on the walls, now it is a tablet. It has information about the resident's transfer status. On 9/18/19 at 5:27 p.m., ASM #1, the executive director, and ASM #2, the DON (director of nursing) were informed of these concerns. They were informed of the survey team's concern for harm to Resident #132 as a result of the improper transfer on 1/11/19. On 9/19/19 at 8:30 a.m., ASM #1, the executive director, and ASM #2 presented a plan of correction regarding the incident on 1/11/19 involving Resident #132. ASM #2 stated, On 1/4/19, the electronic record, the CNA book, the care plan, and the physician order all matched for Resident #132 in that all documented that the resident should be transferred by two people with a mechanical lift. She stated that as soon as she learned of the incident, the CNAs were suspended. She checked their training records, and determined that both CNAs had received training on, and successfully returned demonstration of, the use of a mechanical lift. She stated the facility did a complete plan of corrections, including a complete audit of the transfer status of all residents on 1/18/19. She stated multiple inservices were completed, and that she could provide documentation of all of the training that occurred since the event. Review of the plan of correction revealed, in part, the following: 1. The facility has established a corrective actin (sic) plan for (Resident #132). 2. The resident (sic) of the facility who require transfer in the facility have the potential to be affected. 3. Facility Nursing Staff were in serviced (sic) on 1/11/19, 1/17/19, 1/24/19, 2/7/19, 3/4/19, 7/11/19, and 9/5/19. 4. To ensure compliance, the Transfer status were reviewed on (sic) by nursing and verified by (name of administrative assistant) for correct transfer status. Compliance date: 5/13/19. Past non-compliance was discussed in QAPI 2/12/19 regarding resident with a FRI on 1/11/19; ALL FRI and ACCIDENTS AND INJURY ARE DISCUSSED DURING QAPI. ASM #2 provided credible evidence to confirm all other residents who had the potential to be affected were identified and staff education was provided. ASM #2 stated that in the inservices alleged in #3 of the plan of correction, she personally taught the inservices, and the content centered around how to verify a resident's transfer status, as well as how to transfer a resident using a mechanical life. She reinforced at each inservice that staff should follow the CNA sheets, the electronic information on the tablets, and the physician's order for a resident's transfer staff. She stated she used the incident regarding Resident #132 as an example during the training's. This was confirmed through multiple interviews with facility staff. Other residents were reviewed during the survey to ensure no similar incidents occurred after 1/11/19. No concerns were identified. All document review and staff interviews verified that the facility had completed the education as outlined in the plan of correction. No further information was provided prior to exit. PAST NONCOMPLIANCE (1) [MEDICAL CONDITION] disorder is a mental condition that causes both a loss of contact with reality ([MEDICAL CONDITION]) and mood problems (depression or mania). This information is taken from the website https://medlineplus.gov/ency/article/ 0.htm. (2) [MEDICAL CONDITION] (TBI) happens when a bump, blow, jolt, or other head injury causes damage to the brain. This information is taken from the website https://medlineplus.gov/traumaticbraininjury.html. (3) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. [MEDICAL CONDITION] (VaD) is caused by a series of small [MEDICAL CONDITION] over a long period. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (4) Acquired cognitive-communication deficits may occur after a stroke, tumor, [MEDICAL CONDITION], progressive [MEDICAL CONDITION] brain disorder, or other neurological damage. These deficits result in difficulty with thinking and how someone uses language. This information is taken from the website https://sphsc.washington.edu/cognitive-communication-deficits. (5) In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. This information was taken from the website https://www.ncbi.nlm.nih.gov/pubmed/ 092.

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care per the comprehensive care plan and resident preference, resulting in injury for one of 54 residents in the survey sample, Resident #136. Resident #136 presented with left sided paralysis and limited range of motion in the left arm due to a stroke. The comprehensive care plan dated 6/16/17 documented the resident prefers to manipulate her arms for ADLs (activity of daily living). On 2/11/19, CNA (certified nursing assistant) #5 raised the resident's left arm during ADL (activities of daily living) care, resulting in a left arm dislocation, and harm. The resident was transferred to the hospital where the left arm was fractured while a physician attempted to reduce the dislocation. The findings include: Resident #136 was admitted to the facility on [DATE]. Resident #136's [DIAGNOSES REDACTED]. Resident #136's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/18/19, coded the resident as being cognitively intact. Section G coded Resident #136 as requiring extensive assistance of one staff with dressing/personal hygiene and as having a functional limited range of motion of both upper extremities. Resident 136's comprehensive care plan dated 6/16/17 documented, (RESIDENT #136) HAS FUNCTIONAL STATUS LIMITATION REQUIRING VARIOUS LEVELS OF ASSIST WITH ADL'S (ACTIVITIES OF DAILY LIVING) DUE TO WEAKNESS, HX (HISTORY) [MEDICAL CONDITION]([MEDICAL CONDITION] (STROKE)) WITH LEFT [MEDICAL CONDITION] (PARALYSIS). ASSIST HER AS NEEDED FOR EATING, TOILETING CARE NEEDS, BED MOBILITY DRESSING AND BATHING . The care plan further documented, PER RP (RESPONSIBLE PARTY) AND RESIDENT'S CHOICE: RESIDENT PREFERS TO MANIPULATE HER ARMS FOR ADL'S . A nurse's note dated 2/11/19 documented, RESIDENT STATED CNA LIFTED HER LEFT ARM TOO HIGH DURING CARE. RESIDENT STATED IT HURT A LOT AT THE TIME (3:30 PM), AND STILL FEELS TENDER WHEN REPORTING TO THE NURSE AT 4:00 PM. RESIDENT AND RP (RESPONSIBLE PARTY) ARE REQUESTING AN XRAY FOR POSSIBLE DISL[NAME]ATION, PENDING APPROVAL FROM MD (MEDICAL D[NAME]TOR). PRN (AS NEEDED) TYLENOL ADMINISTERED FOR HEADACHE, RESIDENT STATED IT WAS HELPFUL. EVENING NURSE SUPERVISOR AWARE. A FRI (facility reported incident) submitted from the facility to the VDH (Virginia Department of Health) OLC (Office of Licensure and Certification) on 2/12/19 documented, Incident date: 2/11/19. Residents involved: (Resident #136) Injuries: Yes. X-ray showed a dislocated right shoulder. Describe incident, including location, and action taken: On 2/11/19 (Resident #136) stated to another C.N.[NAME] that the C.N.[NAME] working with her was rough. (Resident #136) expressed on 2/12/19 to unit manager that C.N.[NAME] working with her lifted her arm to (sic) high and heard a pop. (Resident #136) had new order per MD (medical doctor) for xray. Xray showed a dislocated right shoulder . Note: an interview with ASM (administrative staff member) #2 (the director of nursing) on 9/19/19 at 2:24 p.m. confirmed the documentation of a dislocation of the right shoulder in the FRI was typed in error and the dislocation was of the left shoulder. A witness statement signed by CNA #5 on 2/11/19 documented, On Monday 2-11-19 at approx (approximately) 3:00 I was asked by (name of another CNA) if I could give (Resident #136) a shower. I said I would. I went to (Resident #136) and let her know it was her shower day and I would do her shower if she was ready. I got all of her things together and took her to shower room & started her shower. 3/4 of the way through her shower I lifted her right (*Note it was the left arm see above) arm she stated, 'Ouch that hurts' to which I apologized and did not lift it that high again when I went to rinse the soap off. The water was beginning to get cold even at high heat setting for water so I quickly washed her leggs (sic) and rinsed her body off. I dryed (sic) her some in bathroom before wrapping a bed sheet around shower chair and we returned to (Resident #136's) room where I put lotion on her back, arms, legs, put powder under breast and got her dressed. A witness statement signed by RN (registered nurse) #5 on 2/12/19 documented, On 2-11-19, at 4:00 pm, (Resident #136) reported to me that one of the aides has always been too 'rough with me.' She also stated that after her shower (3:30 pm), the aide pulled her arm up too far when trying to put her shirt on. The resident stated it hurt a lot at the time, and still feels tender at the time it was reported. Another aide finished helping resident to get dressed and provide care. The nurse administered PRN (as needed) tylenol 650 mg (milligrams) which was effective. A witness statement signed by CNA #15 on 2/12/19 documented, I walked into the residents (sic) room after her shower and one of the other aids was getting her ready. I noticed the resident looked uncomfortable. I saw the aid holding her stroke arm (left) up. The resident said, 'I told you to do it from the back, that hurts. I told the aid I would finish helping the resident. When she left, the resident said, 'Don't ever leave me with her again. She's way too rough.' I asked her what she did. She replid (sic), 'She hurt my arm.' Nurse notified. A nurse's note dated 2/12/19 documented, NO PAIN TO LEFT ARM VOICED. RESIDENT STATES ITS (SIC) JUST TENDER AND STILL WOULD LIKE TO HAVE XRAY . A physician's orders [REDACTED]. A left shoulder x-ray dated 2/12/19 documented a shoulder dislocation. The hospital history and physical dated 2/12/19 documented, (Resident #136) is a very pleasant 79 yo (year old) female, with a history of stroke and residual L (left) sided weakness and hypertension (high blood pressure), brought to the ED (emergency department) from her assisted living facility with complaint of L should (sic) pain and report of dislocation. Patient states that yesterday evening a health aide at her facility was hoping (sic) move her left arm secondary to residual weakness when she had acute onset of pain. Pain is in the left shoulder does not radiate. She has old weakness but denies any numbness over her arm or shoulder. She denies any falls or injuries. Patient states that an x-ray was obtained earlier today by her assisted living facility, which revealed a shoulder dislocation. The note further documented a reduction of the dislocation was attempted and resulted in a fractured humerus (upper arm bone). A nurse's note dated 2/13/19 documented, RESIDENT C/O (COMPLAINED OF) HAVING A BAD NIGHT THIS AM WITH C/O NOT GETTING MUCH SLEEP DUE TO ER (emergency room ) VISIT AND HER SCHEDULE GETTING MESSED UP. THIS WRITER CALLED INTO RESIDENTS (SIC) ROOM THIS AM TO ASSIST GETTING RESIDENTS (SIC) SHIRT OVER SLING. WHILE THIS WRITER WAS ASSISTING WITH MORNING CARE RESIDENT BECAME NAUSEATED AND C/O FEELING LIKE SHE WAS GOING TO PASS OUT. SKIN COLOR PALE. RESIDENT DID HAVE EMESIS (VOMIT) OF A SMALL AMOUNT OF YELLOWISH LIQUID X (TIMES) 2. RESIDENT WAS ABLE TO GET HERSELF TOGETHER SHORTLY AFTER EPISODE OF EMESIS AND CONTINUE WITH AM CARE. RESIDENT DENIES NEED FOR PAIN MEDS OR VITAL SIGNS THIS AM BUT DID TAKE PRN [MEDICATION NAME] (1) FOR NAUSE[NAME] RESIDENT SEEMS VERY UPSET AND BELIEVES HER FEELING THIS WAY THIS AM IS DUE TO STRESS ABOUT HER ARM INJURY AND HAVING TO GO OUT TO THE ER, NOT GETTING ENOUGH SLEEP AND HER ROUTINE GETTING OFF TRACK. SLING IN PLACE TO LEFT ARM. A final report submitted to the VDH OLC from the facility on 2/15/19 documented, This letter serves as a follow-up to our initial F.R.I. that was submitted on 2-12-18 (wrong year) involving: Resident: (name of Resident #136). unspecified convulsions, presence of right artificial should (sic) joint, other instability, right shoulder, pain in right shoulder, [MEDICAL CONDITION] (paralysis affecting one side of the body), muscle weakness, muscle spasm, foot drop of left foot, coronary (heart) artery without out (sic) [MEDICAL CONDITION] pectoris (chest pain), [MEDICAL CONDITION], essential (sic), mild intermittent asthmas, chronic obstructive [MEDICAL CONDITION] (lung) disease, [MEDICAL CONDITION] (underactive [MEDICAL CONDITION]), [MEDICAL CONDITION] (high cholesterol),[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease (digestive disorder)), allergic rhinitis (symptoms affecting the nose), constipation, malaise (discomfort), dry eye syndrome, adjustment disorder with anxiety, hypo osmolality, [MEDICAL CONDITION] (low sodium), difficulty in walking, [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], pain in leg, pain right fingers, tinea uniguuum (sic) (nail fungus), [MEDICAL CONDITION] (swelling), and pain in the leg in room (number) with a BIMS (brief interview for mental status) of 15 (on a scale from 0 to 15, indicating the resident is cognitively intact). Employee: (Name of CNA #5) On (MONTH) 11, 2019 at appx (approximately) 330pm (Resident #136) stated to a charge nurse that a C.N.[NAME] working with her lifted her arm to (sic) high up and she felt something in her arm that felt like a pop. The responsible party requested and (sic) X-ray and staff sought MD (medical doctor) confirmation. A new order to obtain an X-ray was given on 2/12/19. The results showed that her left shoulder had a dislocation. The MD requested that the resident be sent to ER. Resident returned with sling on arm and it was noted that while the ER was attempting to manually place arm back in place, (Resident #136) obtained a left a (sic) humerus fracture. (Resident #136) returned to the facility and had an orthopedic follow up on 2/15/19 that stated that resident is appropriate for non-operative treatment. She was placed in an elastic immobilizer which was much more comfortable for (Resident #136), (Resident #136) is to remain in the immobilizer 24/7 and return 2 weeks for repeat x-rays. The Office of licensure and certification, Ombudsman, Adult Protective and Town of (name of town) Police Department Services were notified on 2-12-19. (CNA #5) was sent home immediately pending an investigation. (Resident #136's) responsible party and MD were both notified. (Resident #136) had a skin audit by a licensed nurse that revealed no open areas, no redness and no bruising. (Resident #136) received a pain assessment from a licensed nurse on 2/11/19 with complaints of pain at the time of arm feeling popped. The Town of (name of town) Police Department reported to the facility and stated that this is not a criminal case. They did visit with (Resident #136) who stated that (CNA #5) lifted her arm too high to apply deodorant and is not afraid to be in the facility. After review of (CNA #5''s) work record it was noted that she has worked with (Resident #136) in the past and has given her a shower and placed deodorant. (Resident #136) stated that this time while (CNA #5) was working with her, she appeared rushed and did not seem concerned about her as a person, only with getting her task done while rushing around. (Resident #136) has had no change in mood or behavior since the alleged occurrence. We did find evidence of neglect with this allegation that (CNA #5) had cared for (Resident #136) in the past and had no issues. However, when caring for (Resident #136) this time and rushing per (Resident #136's) statement an injury occurred to her left shoulder. (CNA #5) will be notified of termination by Director of Nursing and human resources on 2/18/19, she will remain on suspension until notification. Social Services at (name of facility) met with (Resident #136) and her daughter on 2/15/19 and she stated she did feel safe to be in the facility and was not fearful . On 9/18/19 at 12:46 p.m., an interview was conducted with Resident #136. The resident was sitting in a wheelchair and the resident's left arm was lying limp in the resident's lap. Resident #136 stated she has limited range of motion in the left arm as a result of a stroke. Resident #136 stated she can slightly move the left arm forward and back and slightly raise the arm but is not able to lift the shoulder. Resident #136 was asked to describe the incident that occurred on 2/11/19. Resident #136 stated the CNA had given her a shower on 2/11/19 and was assisting her with getting dressed. Resident #136 stated, I told her you cannot raise that arm so what does she do? She pulled it up and raised. Resident #136 was asked how high the CNA lifted her left arm. Resident #136 stated from what she could recall, the CNA raised her left arm high enough to where hand was parallel with her face. Resident #136 stated, It felt funny as soon as she raised it. Resident #136 stated she complained to one of the nurses and the nurses had the x-ray unit come in and complete x-rays and then the nurse came in and told her that her arm was dislocated. Resident #136 stated she was sent to the hospital and confirmed her arm was broken while the physician was trying to reduce the dislocation. Resident #136 was asked how the incident made her feel. Resident #136 stated, Having the aide not listen to what I told her. I'm a stroke patient to begin with and am very much aware with what is going on and she being a CNA and not paying attention to what I told her, I think it was pretty rotten. I did not know her and she did not know me. Excuse my language but it pissed me off. Resident #136 stated most CNAs are very careful with her arm but that CNA just jerked her arm up. On 9/18/19 at 3:09 p.m., an interview was conducted with CNA #8 (a CNA who cares for Resident #136). CNA #8 was asked if Resident #136 has any physical limitations. CNA #8 stated the resident had a stroke and one arm is affected to the point where the resident can't lift the arm and her hand is in a fist. CNA #8 was asked how she knows how to care for Resident #136. CNA #8 stated the first day she cared for Resident #136, the resident explained to her that she had a history of [REDACTED]. CNA #8 further stated Resident #136's care plan documents to not lift the resident from her shoulders or pull on her shoulders. On 9/18/19 at 3:53 p.m., an interview was conducted with RN #5 (a nurse caring for Resident #136 on 2/11/19). RN #5 was asked to explain the incident regarding Resident #136 on 2/11/19. RN #5 stated, The CNA was assisting her with care after her shower. The CNA lifted her arm too high and it caused some pain to the resident's arm. It was reported to me close to the beginning of the 3-11 shift around 4:00 p.m. and I went in to see her. She said that when it first happened that it was painful and when I talked to her the pain was not as bad. I talked to her and her daughter and they wanted to get an x-ray to see the status of her arm and shoulder. They didn't think it was an emergency; just when the x-ray people could come. I talked to the CNA to let her know to go with the resident's pace and to be careful with the affected side. RN #5 was asked if Resident #136's left arm should have been raised as high as the resident reported the CNA lifted it on 2/11/19. RN #5 stated, I don't think it should be raised that high. It may be able to be raised that high if done slowly. RN #5 was asked if she would raise Resident #136's arm to that level and stated, If I did it slowly and saw it wasn't causing any pain. On 9/18/19 at 4:16 p.m., an attempt to contact CNA #15 was made. The CNA did not answer the phone. On 9/18/19 at 5:28 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern and the concern for harm. On 9/19/19 at 8:32 a.m., ASM #1, ASM #2 and ASM #3 (the assistant director of nursing) presented a plan of correction regarding Resident #136's incident on 2/11/19. The plan of correction documented, 1. The facility has established a corrective actin (sic) plan for resident (name of Resident #136). 2. The resident (sic) of the facility who require transfer in the facility have the potential to be affected. 3. Facility Nursing Staff were in serviced on 2/14/19 3/14 7/11 9/5- additional listed. 4. To ensure compliance random care giver task (sic) were reviewed on (sic) by nursing and verified by (name of administrative assistant) for correct information. Compliance date: 5/13/19. Past non compliance was discussed in QAPI 3/19/19 regarding resident with a FRI on 2/11/19; ALL FRI and ACCIDENTS AND INJURY ARE DISCUSSED DURING QAPI. ASM #2 provided credible evidence to confirm all other residents who had the potential to be affected were identified and staff education was provided. The staff education documented a list of topics that were covered in a nursing staff meeting in (MONTH) 2019. The topics included transfers and incidents/accidents. ASM #2 stated she verbalized to staff that they needed to follow residents' care plans and should not rush while providing care. ASM #2 stated she used the incident regarding Resident #136 as an example during the meeting. This was confirmed through interviews with facility staff. Other residents were reviewed during the survey to ensure no similar incidents occurred after 2/11/19. No concerns were identified. On 9/19/19 at 11:37 a.m., an interview was conducted with OSM (other staff member) #10 (the rehab director). OSM #10 was asked if she could provide any rehab notes regarding Resident #136's left arm. OSM #10 stated Resident #136's left arm was injured from a stroke in 2008. OSM #10 stated the only documentation she had was an occupational therapy evaluation from (YEAR) that documented the resident's left upper extremity range of motion was impaired. OSM #10 stated the evaluation documented the resident had minimal active range of motion due to the stroke and the resident was able to use the arm as a stabilizer but had minimal functional use. OSM #10 was asked to describe the function of Resident #136's left arm. OSM #10 stated the arm is flaccid most of the time but gets tone with reflexes such as sneezing. OSM #10 stated the arm is not functional. OSM #10 was asked if someone should be lifting Resident #136's left arm in the manner that the resident reported a CNA did on 2/11/19. OSM #10 stated the resident was not being seen by the rehab department at the time. OSM #10 stated the CNA lifting Resident #136's arm was passive range of motion and she (OSM #10) did not have measurements of what passive range of motion the resident could withstand at the time so she could not answer the question. On 9/19/19 at 2:24 p.m., ASM #2 was asked to provide the standard of practice used by the facility. ASM #2 stated the facility staff follows the facility policies. On 9/19/19 at 3:18 p.m., RN #8 confirmed the facility did not have a policy regarding ADL care. On 9/19/19 at 3; 22 p.m., ASM #2 confirmed the facility did not have a policy regarding resident preferences except for meal choices. The facility policy regarding comprehensive care plans documented, 2) The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs .9) The resident will receive the services and/or items included in the plan of care . No further information was presented prior to exit. PAST NON-COMPLIANCE (1) [MEDICATION NAME] is used to prevent nausea and vomiting. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 9.html