Every finding on record at George Washington Health & Rehabilitation

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed provide care and services for the treatment of pressure injuries for two of seven residents in the survey sample, Residents #3 and #6. The findings include: 1.a. For Resident #3(R3), the facility staff failed to implement treatments for four pressure injuries upon admission on 6/11/24 until 6/14/24. The Admission Assessment, dated 6/11/24, documented the following skin concerns: 1. Right trochanter (hip) - Pressure - 4 cm (centimeters) in length - 2.5 cm in width - no depth documented; no stage documented. 2. Left ankle (outer) - Pressure - 4 cm in length - 2.5 cm in width - no depth documented; no stage documented. 3. Sacrum - Pressure - 11.5 cm in length - 9 cm in width - 0.5 cm in depth - no stage documented. 4. Right shoulder (front)- Pressure - 1 cm in length - 1 cm in width - no depth documented - no stage documented. Review of the physician orders failed to evidence physician orders for the treatment of the above wounds until 6/14/24. The physician orders dated 6/14/24, documented: 1. Cleanse right hip with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B (followed by) gauze island dressing. Change daily on 7-3 shift. 2. Cleanse left ankle with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B (followed by) gauze island dressing. Change daily on 7-3 shift. 3. Cleanse sacral wound with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B clean dry dressing daily on 7-3 shift. 4. Cleanse right shoulder with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B gauze island dressing. change daily on 7-3 shift. The wound care physician started following the resident's wounds on 6/18/24. The comprehensive care plan dated 6/11/24, documented in part, Focus: (R3) has actual impairment to skin integrity r/t (related to) admitted with sacrum wound, left ankle, right hip and right shoulder. The Interventions dated 6/11/24, documented in part, Administer medications, supplements and treatments as ordered. A request was made for evidence of treatment for the above wounds from 6/11/24 until 6/14/24. On 8/15/24 at 9:45 a.m. ASM (administrative staff member) #3, the regional director of clinical operations stated there was no documented wound care from 6/11/24 through 6/13/24. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 1.b. For Resident #3, the facility staff failed to accurately document skin assessments. The Skin Observation Weekly dated 6/24/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A No, was documented. 6. Additional information: Previous pressure ulcers to sacrum, treatment orders in place. The Skin Observation Weekly dated 7/22/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A No, was documented. 6. Additional information: Resident continues to receive wound care exiting (sic) sacral wound ulcer, right figure (sic) and heels. No new skin issues noted. The Skin Observation Weekly dated 7/29/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A Yes was documented. 5a. Select all that apply: Open area. Open Area Location: Other. Is this a NEW skin condition? No. 6. Additional Information: Treatments in place for areas of skin trauma. The Skin Observation Weekly dated 8/5/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A No, was documented. 6. Additional information: Blank - nothing documented. The Skin Observation Weekly dated 8/12/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A No, was documented. 6. Additional information: no new skin issues noted. An interview was conducted with LPN #1 on 8/14/24 at 3:40 p.m. When asked how often skin assessments are to be done, LPN #1 stated they are done every week on shower days. LPN #1 was asked what is to be documented, LPN #1 stated the nurse goes in and looks at the skin. They should document any new or old areas. She stated sometimes they write if it's an old wound that treatment is in place. The facility policy, Pressure Injury Preventions and Management, documented in part, Identification: 1. Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity. 2. Weekly skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. 3. Observations of new pressure ulcer/injury will be: a. Reported to the physician / practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 2a. For Resident #6 (R6), the facility staff failed to evidence documentation of treatment to the resident's pressure injuries from 6/12/24 through 8/14/24. The physician order dated, 6/12/24, documented, Cleanse left hip with Dakins solution, pat dry and apply Calcium Alginate to wound bed and cover with dry dressing daily. The physician order stated 6/12/24, documented, Cleanse left ischium with N/S (normal saline) pat dry and apply calcium alginate q (every) day until healed. The physician order dated, 6/12/24, documented, Cleanse stage 4 decub (decubitus ulcer - pressure injury) to sacrum with Dakins pat dry and apply calcium alginate dressing to wound bed and cover with dry dressing q day. Review of the June, July and August 2024, treatment administration record, failed to evidence the orders above. There was no documentation that the treatments had been completed from 6/12/24 through 8/13/24. Review of the wound care physician notes from 5/24/24 through 8/13/24, evidenced the wounds had decreased in size, indicating healing. The comprehensive care plan dated, 6/2/24, documented in part, Focus: (R6) has wounds to sacrum, left ischium, left hip and abrasion to right buttock R/T (related to) immobility, generalized weakness, and ongoing disease process. The Interventions documented in part, Administer medications, supplements and treatments as ordered. On 8/15/24 at 9:45 a.m. ASM (administrative staff member) #3, the regional director of clinical operations stated there was no documented wound care from 6/12/24 through 8/13/24. He stated that the order was not put in the computer correctly. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 2b. For Resident #6, the facility staff failed to accurately document skin assessments. The Skin Observation Weekly dated 7/8/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A yes, was documented. 5a. Select all that apply other. 5a6. Other - specify sacral wound. Additional information: Treatment ongoing. The Skin Observation Weekly dated 7/21/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A yes, was documented. 5a. Select all that apply other. 5a6. Other - specify sacral wound. Additional information: Wound care provided; treatment ongoing. The Skin Observation Weekly dated 7/28/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A No, was documented. 6. Additional information: none. The Skin Observation Weekly dated 8/4/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A yes, was documented. 5a. Select all that apply open area. 5a6. Other - specify coccyx. Additional information: Treatment in progress. The Skin Observation Weekly dated 8/11/24, documented in part, 5. Are there any bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted? A yes, was documented. 5a. Select all that apply open area. 5a6. Other - specify coccyx. Additional information: Treatment being applied to open area. The comprehensive care plan dated, 7/6/24, documented in part, Focus: (R6) has wounds to sacrum, left ischium, left hip and abrasion to right buttock R/T (related to) immobility, generalized weakness, and ongoing disease process. The Interventions documented in part, Follow facility policies/protocols for routine skin monitoring. Report any changes to MD/NP (medical doctor/nurse practitioner). An interview was conducted with LPN #1 on 8/14/24 at 3:40 p.m. When asked how often skin assessments are to be done, LPN #1 stated they are done every week on shower days. LPN #1 was asked what is to be documented, LPN #1 stated the nurse goes in and looks at the skin. They should document any new or old areas. She stated sometimes they write if it's an old wound that treatment is in place. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit.

3. For Resident #6(R6), the facility staff failed to implement infection control practices during a wound treatment. Observation was made of LPN (licensed practical nurse) #1, on 8/14/24 at 10:55 a.m. performing wound care for R6. The resident had three wounds accessible for wound care treatments, left ischium, right buttock, sacrum and an old scar on right hip. LPN #1 removed all the dressings in place. Changed her gloves. She proceeded to use the same gloves to clean each wound, starting with the right hip, went to buttock wound, ischium wound and then sacral wound, all with the same gloves on. LPN #1 didn't have gloves on and dried the right hip and buttock wound with dry gauze. She then put gloves on and wiped the sacral wound with a dry gauze. She proceeded to use dry gauze to dry the ischium and buttock wounds, using the same gloves. An interview was conducted with LPN #1 on 8/14/24 at 3:40 p.m. When asked if a resident has multiple wounds, do you treat each wound separately, taking off dressing, cleansing it, putting prescribed treatment in place, prior to moving on to the next wound, LPN #1 stated, yes. The above observation was shared with LPN #1. The facility policy, Clean Dressing, documented in part, POLICY: The purpose of this procedure is to provide guidelines for the application of clean dressings. DEFINITIONS: Clean technique involves strategies used in resident care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies. No 'sterile to sterile rules apply. ASM #1, the administrator, ASM #2, and ASM #3, the regional director of clinical operations, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 49369 Based on observations, staff interview, facility document review and clinical record review, the facility staff failed to implement an infection prevention & control program and failed to implement infection control practices for two of seven residents in the survey sample, Residents #3 and #6. The findings include: 1. The facility staff failed to provide infection control surveillance program evidence prior to June 2024. On 8/15/24 at 10:41 a.m., ASM (administrative staff member) #2 was interviewed. She stated the facility is starting to track infection control on Point Click Care (PCC). She sated that they cannot produce evidence for infection tracking before June 2024. Infection control tracking after June 2024 is available on point click care. On 8/15/24 at 11:56 a.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, a regional director of clinical operations, were informed of these concerns. A review of the facility policy, Surveillance for Infections, revealed: The infection preventionist (designee) will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcomes and that may require transmission-based precautions and other preventative interventions. No further information was provided prior to exit. 2. For Resident #3, the facility staff failed to use PPE and handwashing in Transmission Based Precaution (TBP) room. On 8/16/24 at 2:40 p.m., an observation was made of staff members not wearing full personal protective equipment (PPE) when performing incontinence care on R3. A sign that indicated resident was on Enhanced Barrier Precautions (EBP) was posted on the door and a bin with some PPE supplies were outside the door. LPN (licensed practical nurse) #2 was wearing a gown and gloves but did not have a mask. CNA (certified nursing assistant) #1 wore gloves but did not have a gown or mask on. At 2:55 p.m., CNA#1 exited R3's room without performing hand hygiene. A review of R3's physician's orders dated 6/25/24, revealed: Infection precautions-enhanced barrier precautions. A review of R3's clinical record, including the resident's comprehensive care plan revealed: The resident has the potential for infection on Enhanced barrier precaution r/t wounds. The resident will be free from complications related to infection through review date. Maintain universal precautions when providing resident care. On 8/13/24 at 2:58 p.m., CNA#1 was interviewed. She stated that it is important to wash your hands before and after taking off gloves because it is a matter of infection control for the resident. She stated that it is important to perform hand hygiene when performing incontinence care especially if they are on EBP to get rid of bacteria. She stated that knows that it should have worn PPE and washed her hands but forgot to do so because she was in a rush. On 8/15/24 at 11:36 a.m., LPN#1 was interviewed. She stated that it is important to wash your hands to protect yourself and the resident. She also stated that hand hygiene is done as an infection control matter because hands can be a carrier to bacteria and germs. LPN1 stated when entering a room when someone is on EBP the staff should don/doff gown, gloves and mask as well as perform hand hygiene. On 8/15/24 at 11:56 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, a regional director of clinical operations, were informed of these concerns. A review of the facility policy, Enhanced Barrier Precautions (EBP) Policy, revealed: The purpose of this policy is to outline the guidelines for implementing Enhanced Barrier Precautions (EBP) in order to reduce the transmission of multidrug-resistant organism (MDROs) within our facility. EBP will be utilized in conjunction with standard precaution to provide targeted gown and glove use during high-contact resident care activities. EBP should be utilized during the following activities .changing briefs or assisting with toileting. A review of the facility policy, Hand hygiene, revealed: The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility .All staff are responsible for following hand hygiene procedures . b. Before and after having direct contact with a resident's intact skin . f. Before and after wearing gloves .During Routine Resident Care a. Use an ABHR (alcohol-based hand sanitizer): i. immediately before touching a resident ii. Before performing an aseptic task . iii. Before moving from work on a soiled body site to a clean body site on the same resident iv. After touching a resident or the resident's immediate environment v. Immediately after removing gloves. No further information was provided during exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain dignity during a dressing change for one of seven residents in the survey sample, Resident #6. The findings include: For Resident #6 (R6), the facility staff failed to maintain dignity for the resident while performing wound care. Observation was made on 8/14/24 at 10:55 a.m. of LPN (licensed practical nurse) #1 performing wound care to R6's left hip wound. LPN #1 performed the wound care. After putting on the dressing, LPN #1 took a pen and wrote on the dressing, while on the resident, the date and her initials on the dressing. An interview was conducted on 8/14/24 at 3:40 p.m. with LPN #1. When asked if you should write on a resident's dressing after it is applied to the resident's hip, LPN #1 stated, she has to put a date on it, but she wasn't sure if you could write on the dressing while it was on the resident. An interview was conducted on 8/14/24 at 3:56 p.m. with ASM (administrative staff member) #2, the director of nursing. When asked if the nurse can write on a dressing, after applying it to the resident, ASM #2 stated, no. When asked why, ASM #2 stated, it's a dignity concern. The facility policy, Dignity, documented in part, POLICY: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. DEFINITIONS: Dignity: is the right of a person to be valued and respected for their own sake, and to be treated ethically. SPECIFIC PROCEDURES / GUIDANCE: 1. Residents will be treated with dignity and respect at all times. The facility policy, Clean Dressing, documented in part, 19. Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing prior to placing on resident. ASM #1, the administrator, ASM #2, and ASM 33, the regional director of clinical operations, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit.

2. For Resident #3 (R3) the facility staff failed to implement the comprehensive care plan for the treatment of pressure injuries. The comprehensive care plan dated 6/11/24, documented in part, Focus: (R3) has actual impairment to skin integrity r/t (related to) admitted with sacrum wound, left ankle, right hip and right shoulder. The Interventions dated 6/11/24, documented in part, Administer medications, supplements and treatments as ordered. The Admission Assessment, dated 6/11/24, documented the following skin concerns: 1. Right trochanter (hip) - Pressure - 4 cm (centimeters) in length - 2.5 cm in width - no depth documented; no stage documented. 2. Left ankle (outer) - Pressure - 4 cm in length - 2.5 cm in width - no depth documented; no stage documented. 3. Sacrum - Pressure - 11.5 cm in length - 9 cm in width - 0.5 cm in depth - no stage documented. 4. Right shoulder (front)- Pressure - 1 cm in length - 1 cm in width - no depth documented - no stage documented. Review of the physician orders failed to evidence physician orders for the treatment of the above wounds until 6/14/24. The physician orders dated 6/14/24, documented: 1. Cleanse right hip with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B (followed by) gauze island dressing. Change daily on 7-3 shift. 2. Cleanse left ankle with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B (followed by) gauze island dressing. Change daily on 7-3 shift. 3. Cleanse sacral wound with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B clean dry dressing daily on 7-3 shift. 4. Cleanse right shoulder with normal saline. Pat Dry. Apply Calcium Alginate to wound bed F/B gauze island dressing. change daily on 7-3 shift. A request was made for evidence of treatment for the above wounds from 6/11/24 until 6/14/24. On 8/15/24 at 9:45 a.m. ASM (administrative staff member) #3, the regional director of clinical operations stated there was no documented wound care from 6/11/24 through 6/13/24. An interview was conducted with LPN (licensed practical nurse) #1, on 8/15/24 at 11:32 a.m. When asked the purpose of the care plan, LPN #1 stated it's the plan of care for the resident. She stated they have to care plan everything, so we know how to take care of the resident. LPN #1 was asked if the care plan should be followed, LPN #1 stated, yes, we have to look at it all the time. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 3. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan for the treatment of pressure injuries. The comprehensive care plan dated, 6/2/24, documented in part, Focus: (R6) has wounds to sacrum, left ischium, left hip and abrasion to right buttock R/T (related to) immobility, generalized weakness, and ongoing disease process. The Interventions documented in part, Administer medications, supplements and treatments as ordered. The physician order dated, 6/12/24, documented, Cleanse left hip with Dakins solution, pat dry and apply Calcium Alginate to wound bed and cover with dry dressing daily. The physician order stated 6/12/24, documented, Cleanse left ischium with N/S (normal saline) pat dry and apply calcium alginate q (every) day until healed. The physician order dated, 6/12/24, documented, Cleanse stage 4 decub (decubitus ulcer - pressure injury) to sacrum with Dakins pat dry and apply calcium alginate dressing to wound bed and cover with dry dressing q day. Review of the June, July and August 2024, treatment administration record, failed to evidence the orders above. There was no documentation that the treatments had been completed from 6/12/24 through 8/13/24. An interview was conducted with LPN (licensed practical nurse) #1, on 8/15/24 at 11:32 a.m. When asked the purpose of the care plan, LPN #1 stated it's the plan of care for the resident. She stated they have to care plan everything, so we know how to take care of the resident. LPN #1 was asked if the care plan should be followed, LPN #1 stated, yes, we have to look at it all the time. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit. 49369 Based on observations, staff interview, facility document review, and clinical record review, the facility staff failed to follow comprehensive care plan for 2 of 7 sampled residents. The findings include: 1. For Resident #3 (R3), the facility staff failed to implement a comprehensive care plan regarding Transmission Based Precaution. On 8/13/24 at 2:40 p.m., an observation was made of staff members not wearing full personal protective equipment (PPE) when performing incontinence care on R3. A sign that indicated resident was on Enhanced Barrier Precautions was posted on the door and a bin with some PPE supplies were outside the door. LPN (licensed practical nurse) #2 was wearing a gown and gloves but did not have a mask. CNA (certified nursing assistant) #1 wore gloves but did not have a gown or mask on. At 2:55 p.m., CNA#1 exited R3's room without performing hand hygiene. A review of R3's physician's orders dated 6/25/24, revealed: Infection precautions-enhanced barrier precautions. A review of R3's clinical record, including the resident's comprehensive care plan revealed: The resident has the potential for infection on Enhanced barrier precaution r/t wounds. The resident will be free from complications related to infection through review date. Maintain universal precautions when providing resident care. On 8/13/24 at 2:58 p.m., CNA#1 was interviewed. She stated that she did not follow EBP precautions for the resident because she was in a rush. She stated that the care plan was not followed for the resident. On 8/15/24 at 10:41a.m., ASM (administrative staff member) #2 was interviewed. She stated that the purpose of the comprehensive care plan is to have a plan of care for the resident. She also stated that everyone is responsible for implementing the care plan. On 8/15/24 at 11:36 a.m., LPN #1 was interviewed. She stated that the purpose of the care plan is to be a point of care for the patients to know how to take care of the resident. She stated that it should be followed and looked at to confirm what should be done. On 8/15/24 at 11:56 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, a regional director of clinical operations, were informed of these concerns. A review of the facility policy, Care Planning-Comprehensive Person-Centered, revealed in part: 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 as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1, the facility staff failed to review and revise the comprehensive care plan after a fall on 8/1/23. The nurse's note dated 8/1/23 at 9:18 a.m. documented in part, Pt (patient) observed lying supine in bed with L (left) forehead hematoma with two dots of dried blood, no bleeding noted at this time. Pt is unable to tell staff whether he is in pain or not but is holding his forehead occasionally. Call placed out to (name of doctor)'s office and updated MD (medical doctor) on call (name of doctor). Order received from MD to transfer pt to (name of hospital) ER (emergency room ) via 911 for further evaluation r/t (related to) L - forehead hematoma. Order noted and activated the Rescue Squad. Pt is picked up at 0925 (9:25 a.m.) and transported to (initials of hospital) ER. Family is updated. The comprehensive care plan dated, 7/19/23, documented in part, Fall: (R1) had actual fall and is at risk for further falls R/T (related to) Gait/balance problems, confusion, history of falls, generalized weakness. The Interventions dated 7/19/23, documented in part, Reinforce to call for assistance when needed. Be sure the resident's call light is within reach and encourage the resident to use it or assistance as needed. The resident needs prompt response to all requests for assistance. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). Anticipate and meet the resident's needs. Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Follow facility fall protocol. There was no documented review of the care plan, or any new interventions put in place after the fall of 8/1/23. An interview was conducted on 8/15/24 at 10:44 a.m. with ASM (administrative staff member) #3, the regional director of clinical operations. ASM #3 stated after he reviewed the clinical record, there was no revision made to the care plan after the fall of 8/1/23. An interview was conducted with LPN (licensed practical nurse) #1 on 8/15/24 at 11L32 a.m. When asked the purpose of the care plan, LPN #1 stated it's the plan of care for the patient. They have to care plan everything, so we know how to take care of the patient. LPN #1 was asked who updates the care plan, LPN #1 stated, nurses, all departments, it's everyone's responsibility. When asked if a resident has a fall, does the care plan get updated, LPNM #1 stated, yes, immediately to help prevent another fall. The facility policy, Care Planning - Comprehensive Person Centered, documented in part, 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: b. When there has been a significant change in the resident's condition. c. When the desired outcome is not met. d. When the goals, needs and preferences change. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, were made aware of the above findings, on 8/15/24 at approximately 11:30 a.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement their policy to report an injury of unknown origin to the State Agency in a timely manner for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1) the facility failed to implement their policy to report a right chest bruise of unknown origin, discovered 9/25/23; it was not reported to the State Agency until 10/2/23. On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/7/23, R1 was coded as being severely impaired for making daily decisions. She was coded as sometimes able to understand others, and as sometimes understanding others. She was admitted to the facility with a diagnosis of dementia. A review of R1's care plan dated 4/5/22 and updated 10/12/23 revealed, in part: [R1] has difficulty communicating related to decline in cognitive status, lack/limited use/understanding of English (fluent in Spanish). A review of R1's clinical record revealed the following progress notes: 9/24/2023 09:30 (a.m.) Nursing Note Text: Resident noted this morning at 9:00 am shouting loud and speaking in Spanish language. Nurse went in to see what the problem is. Nurse noted resident in Geri-chair showing signs of discomfort and not allowing nurse to touch her left arm. Nurse immediately went in to call nursing supervisor and Spanish staff to help with interpretation of what resident was saying. She told staff that her left arm hurt and also want to go home to her family .AM (morning) prescribed meds given to resident and PRN (as needed) pain med given as well to help with pain .Sitting at nurses' station at the moment with nurse for supervision. All safety measures maintained. This note was written by LPN (licensed practical nurse) #1, who was unavailable for interview during the survey. 9/25/2023 13:44 (1:44 p.m.) Physician/NP (nurse practitioner) Progress Note Text: Chief Complaint: follow up; c/o (complaint of) rt (right) chest wall bruising .Patient is long term resident in here and follow up for c/o rt chest wall bruising noticed by aide. pt (patient) lying on bed, not in distress .Assessment / Plan 1. Contusion of right chest wall - rt chest wall under rt axilla .close observation, follow up prn. 9/25/2023 14:01 (2:01 p.m.) Skin Observation Weekly (Licensed Nurse) Note Text: Weekly skin observation completed. Bruise to right arm. Unknown Origin. 9/25/2023 15:11 (3:11 p.m.) Nursing Note Text: Patient was seen by the visiting MD (physician) this afternoon, head to toe assessment done by the MD on unknown origin of bruises noted @ (at) the right arm of the patient, no new order received @ this time, nursing will continue to monitor. RP (responsible party) notified. A review of the facility synopsis of events dated 10/2/23 revealed, in part: Report date 10/2/23 .Incident date: unknown - 9/24/23 per progress note .Incident type .injury of unknown origin .Describe incident .The Director of Nursing was informed on 10/2 of x-ray results taken on 9/29 for a dislocation of the humeral head for resident [#1] .Facility has initiated the investigation into the injury of unknown origin. Resident continues with ongoing pain management regimen and MD notified. A review of the facility policy, Abuse Investigation and Reporting, revealed, in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin re thoroughly investigated by facility management .All violations involving .injuries of unknown source .will be reported by the facility administrator, or his/her designee .to the state licensing/certification agency .An alleged violation of .injuries of unknown source .will be reported immediately, but not later that .two hours if the alleged violation involves abuse or has resulted in serious bodily injury .or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. On 11/2/23 at 9:05 a.m., ASM #3, the attending physician, was interviewed. He stated on 9/25/23, a nurse told him about R1's bruising on her right side. He stated the bruising was in somewhat of a line under the armpit along the chest wall. He stated when he touched the area, the resident did not exhibit any expression of tenderness or pain. He stated at the time, in the course of his physical assessment, he did not suspect the resident had a shoulder injury. He stated she did not display any physical signs of such an injury on 9/25/23. On 11/1/23 at 10:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional nurse consultant, and RN (registered nurse) #1, the assistant director of nursing, were interviewed. ASM #4 stated he came to the facility to help with the investigation of the resident's bruising. ASM #2 stated she and ASM #1 were out of the facility on vacation the week of September 24 and 25, 2023, when the first report of the bruise appeared in the record. ASM #4 stated it took some time to identify which staff members may have been allegedly involved in the injury to R1, and when those staff members were identified, they were suspended pending the results of the investigation. ASM #4 stated the management staff identified that the report to the state agency was not timely, and they put a plan of correction in place. A review of the facility's plan of correction for the lack of timely reporting to the state agency revealed in part, Abuse and Neglect .The facility reported the injury of unknown origin on 10.2.23 when the NHA (nursing home administrator) and DON (director of nursing) was (sic) made aware of the injury. The facility failed to report timely when the injury was first noted by the nurse on 9/24/23 .All residents of the facility are at risk to be affected by this deficient practice. Abuse screening questionnaire will be completed on residents that are interviewable and have a BIMS (brief interview for mental status) score of 8 (eight) or higher. For non-interviewable residents, skin assessments will be completed, assessing for any signs or symptoms of abuse .Any identified areas will be addressed according to the facility abuse and neglect policy .All staff of the facility will be reeducated on the facility abuse and neglect policy. This education will focus on types of abuse, abuse reporting, investigations, and reporting of injuries of unknown origin. The Regional Nurse will provide abuse and neglect training to the facility leadership on 10/9/23. The facility will add this education to new hire orientation. No staff members will be allowed to return to work until the mandatory education has been completed .The facility will conduct an adhoc QAPI (quality assurance performance improvement) meeting on 10/9/23 to review and approve the allegation of compliance .The facility social worker will complete abuse questionnaires on a random sample of three residents weekly. Results of the weekly audits will be submitted monthly to the QAPI committee monthly. The QAPI committee is responsible for the ongoing monitoring of compliance .Date of compliance: 10/9/23. The facility presented credible evidence that this plan of correction had been implemented. This credible evidence included staff education modules, interviews with staff, review of facility audits, and opportunities for facility reports to the state agency since the allegation of compliance date of 10/9/23. No concerns were identified with the implementation of the plan of correction. No further concerns regarding implementation of the abuse policy were identified during the survey. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to report an injury of unknown origin to the State Agency in a timely manner for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1) the facility failed to report a right chest bruise of unknown origin, discovered 9/25/23, to the State Agency until 10/2/23. On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/7/23, R1 was coded as being severely impaired for making daily decisions. She was coded as sometimes able to understand others, and as sometimes understanding others. She was admitted to the facility with a diagnosis of dementia. A review of R1's care plan dated 4/5/22 and updated 10/12/23 revealed, in part: [R1] has difficulty communicating related to decline in cognitive status, lack/limited use/understanding of English (fluent in Spanish). A review of R1's clinical record revealed the following progress notes: 9/24/2023 09:30 (a.m.) Nursing Note Text: Resident noted this morning at 9:00 am shouting loud and speaking in Spanish language. Nurse went in to see what the problem is. Nurse noted resident in Geri-chair showing signs of discomfort and not allowing nurse to touch her left arm. Nurse immediately went in to call nursing supervisor and Spanish staff to help with interpretation of what resident was saying. She told staff that her left arm hurt and also want to go home to her family .AM (morning) prescribed meds given to resident and PRN (as needed) pain med given as well to help with pain .Sitting at nurses' station at the moment with nurse for supervision. All safety measures maintained. This note was written by LPN (licensed practical nurse) #1, who was unavailable for interview during the survey. 9/25/2023 13:44 (1:44 p.m.) Physician/NP (nurse practitioner) Progress Note Text: Chief Complaint: follow up; c/o (complaint of) rt (right) chest wall bruising .Patient is long term resident in here and follow up for c/o rt chest wall bruising noticed by aide. pt (patient) lying on bed, not in distress .Assessment / Plan 1. Contusion of right chest wall - rt chest wall under rt axilla .close observation, follow up prn. 9/25/2023 14:01 (2:01 p.m.) Skin Observation Weekly (Licensed Nurse) Note Text: Weekly skin observation completed. Bruise to right arm. Unknown Origin. 9/25/2023 15:11 (3:11 p.m.) Nursing Note Text: Patient was seen by the visiting MD (physician) this afternoon, head to toe assessment done by the MD on unknown origin of bruises noted @ (at) the right arm of the patient, no new order received @ this time, nursing will continue to monitor. RP (responsible party) notified. A review of the facility synopsis of events dated 10/2/23 revealed, in part: Report date 10/2/23 .Incident date: unknown - 9/24/23 per progress note .Incident type .injury of unknown origin .Describe incident .The Director of Nursing was informed on 10/2 of x-ray results taken on 9/29 for a dislocation of the humeral head for resident [#1] .Facility has initiated the investigation into the injury of unknown origin. Resident continues with ongoing pain management regimen and MD notified. On 11/2/23 at 9:05 a.m., ASM #3, the attending physician, was interviewed. He stated on 9/25/23, a nurse told him about R1's bruising on her right side. He stated the bruising was in somewhat of a line under the armpit along the chest wall. He stated when he touched the area, the resident did not exhibit any expression of tenderness or pain. He stated at the time, in the course of his physical assessment, he did not suspect the resident had a shoulder injury. He stated she did not display any physical signs of such an injury on 9/25/23. On 11/1/23 at 10:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional nurse consultant, and RN (registered nurse) #1, the assistant director of nursing, were interviewed. ASM #4 stated he came to the facility to help with the investigation of the resident's bruising. ASM #2 stated she and ASM #1 were out of the facility on vacation the week of September 24 and 25, 2023, when the first report of the bruise appeared in the record. ASM #4 stated it took some time to identify which staff members may have been allegedly involved in the injury to R1, and when those staff members were identified, they were suspended pending the results of the investigation. ASM #4 stated the management staff identified that the report to the state agency was not timely, and they put a plan of correction in place. A review of the facility's plan of correction for the lack of timely reporting to the state agency revealed in part, Abuse and Neglect .The facility reported the injury of unknown origin on 10.2.23 when the NHA (nursing home administrator) and DON (director of nursing) was (sic) made aware of the injury. The facility failed to report timely when the injury was first noted by the nurse on 9/24/23 .All residents of the facility are at risk to be affected by this deficient practice. Abuse screening questionnaire will be completed on residents that are interviewable and have a BIMS (brief interview for mental status) score of 8 (eight) or higher. For non-interviewable residents, skin assessments will be completed, assessing for any signs or symptoms of abuse .Any identified areas will be addressed according to the facility abuse and neglect policy .All staff of the facility will be reeducated on the facility abuse and neglect policy. This education will focus on types of abuse, abuse reporting, investigations, and reporting of injuries of unknown origin. The Regional Nurse will provide abuse and neglect training to the facility leadership on 10/9/23. The facility will add this education to new hire orientation. No staff members will be allowed to return to work until the mandatory education has been completed .The facility will conduct an adhoc QAPI (quality assurance performance improvement) meeting on 10/9/23 to review and approve the allegation of compliance .The facility social worker will complete abuse questionnaires on a random sample of three residents weekly. Results of the weekly audits will be submitted monthly to the QAPI committee monthly. The QAPI committee is responsible for the ongoing monitoring of compliance .Date of compliance: 10/9/23. A review of the facility policy, Abuse Investigation and Reporting, revealed, in part: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown origin re thoroughly investigated by facility management .All violations involving .injuries of unknown source .will be reported by the facility administrator, or his/her designee .to the state licensing/certification agency .An alleged violation of .injuries of unknown source .will be reported immediately, but not later that .two hours if the alleged violation involves abuse or has resulted in serious bodily injury .or 24 hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. The facility presented credible evidence that this plan of correction had been implemented. This credible evidence included staff education modules, interviews with staff, review of facility audits, and opportunities for facility reports to the state agency since the allegation of compliance date of 10/9/23. No concerns were identified with the implementation of the plan of correction. No further concerns regarding timely reporting to the State Agency was identified during the survey. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of five residents in the survey sample, Resident #4. The findings include: For Resident #4 (R4), the facility staff failed to develop a care plan to address her language needs. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 10/12/23, R4 was coded as being severely impaired for making daily decisions. She was coded as rarely understanding others and as rarely being understood by others for communication. On 11/1/23 at 11:46 a.m., R4 was observed as she was transferred from her bed to a wheelchair by way of a mechanical lift. Throughout the transfer process, the facility staff used a Russian translator, present through an iPad, to communicate with the resident. A review of R4's admission nursing assessment dated [DATE] revealed, in part: Preferred language: Other .Other language: Russian. A review of R4's comprehensive care plan dated 10/22/23 revealed no evidence of interventions related to the resident's language barrier or need for communication devices. On 11/1/23 at 12:23 p.m., RN (registered nurse) #2, the MDS coordinator, was interviewed. When asked the process for developing a resident's comprehensive care plan, she stated: I review the hospital records, the notes in [the electronic medical software] and doctor's notes. She stated she visits the resident, as well. When asked if a resident's preference for a language other than English should be included in the care plan, she stated it should. After reviewing R4's comprehensive care plan, she stated it had not included the resident's preference for speaking Russian, and the need for a translator. On 11/1/23 at 2:25 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #4, the regional nurse consultant were informed of these concerns. A review of the facility policy, Care Planning - Comprehensive Person-Centered, revealed, in part: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident .All reasonable efforts will be made to incorporate the resident's personal and cultural preferences in developing goals of care. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to coordinate care with the resident's hospice provider for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to communicate with the resident's hospice provider regarding the results of an X-ray obtained on 9/29/23. A review of R1's clinical record revealed the following progress notes: 9/24/2023 09:30 (a.m.) Nursing Note Text: Resident noted this morning at 9:00 am shouting loud and speaking in Spanish language. Nurse went in to see what the problem is. Nurse noted resident in Geri-chair showing signs of discomfort and not allowing nurse to touch her left arm. Nurse immediately went in to call nursing supervisor and Spanish staff to help with interpretation of what resident was saying. She told staff that her left arm hurt and also want to go home to her family .AM (morning) prescribed meds given to resident and PRN (as needed) pain med given as well to help with pain .Sitting at nurses' station at the moment with nurse for supervision. All safety measures maintained. This note was written by LPN (licensed practical nurse) #1, who was unavailable for interview during the survey. 9/25/2023 13:44 (1:44 p.m.) Physician/NP (nurse practitioner) Progress Note Text: Chief Complaint: follow up; c/o (complaint of) rt (right) chest wall bruising .Patient is long term resident in here and follow up for c/o rt chest wall bruising noticed by aide. pt (patient) lying on bed, not in distress .Assessment / Plan 1. Contusion of right chest wall - rt chest wall under rt axilla .close observation, follow up prn. 9/25/2023 14:01 (2:01 p.m.) Skin Observation Weekly (Licensed Nurse) Note Text: Weekly skin observation completed. Bruise to right arm. Unknown Origin. 9/25/2023 15:11 (3:11 p.m.) Nursing Note Text: Patient was seen by the visiting MD (physician) this afternoon, head to toe assessment done by the MD on unknown origin of bruises noted @ (at) the right arm of the patient, no new order received @ this time, nursing will continue to monitor. RP (responsible party) notified. 9/29/2023 21:22 (9:22 p.m.) Nursing Note Text: X-ray tech arrived to the unit for an order to do arial view of the right humerus by [name of hospice provider] pending result. A review of the X-ray result for R1 dated 9/29/23 at 10:55 p.m. revealed, in part: FINDINGS: No fracture is seen but there is a dislocation of the humeral head (shoulder). 10/2/2023 18:13 (6:13 p.m.) Alert Note Text: Writer Called [name of hospice provider] to investigate as to why they used an outside contracting company to do an x-ray on the patient and was not communicating this to writer. On call nurse could not give an answer will follow up in the am. Patient has a bruise of unknown origin and a dislocation of the right humeral head (probably anteriorly and inferiorly). 10/3/2023 09:45 (a.m.) Change of Condition Note Text: New order received to transfer out patient to Hospital FOR FURTHER EVALUATION AND TREATMENT for dislocation of the Humeral head. On 10/3/23, an interview was documented by the facility between ASM (administrative staff member) #2, the director of nursing) and RN (registered nurse) #3, the hospice case manager, who was not available for interview during the survey. A review of the facility interview document dated 10/3/23 revealed, in part: On 9/29/23 .[RN #3] informed [LPN (licensed practical nurse) #1] that she was going to get an X-ray [for R1] to rule out fracture of the humerus .RN #3 was off 9/30 - 10/1. She received the results on 10/2/23 and called the physician. (LPN #1 was not available for interview during the survey). On 11/2/23 at 9:05 a.m., ASM #3, the attending physician, was interviewed. He stated on 9/25/23, a nurse told him about R1's bruising on her right side. He stated the bruising was in somewhat of a line under the armpit along the chest wall. He stated when he touched the area, the resident did not exhibit any expression of tenderness or pain. He stated at the time, in the course of his physical assessment, he did not suspect the resident had a shoulder injury. He stated she did not display any physical signs of such an injury on 9/25/23. On 11/1/23 at 10:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional nurse consultant, and RN (registered nurse) #1, the assistant director of nursing, were interviewed. ASM #4 stated he came to the facility to help with the investigation of the resident's bruising. ASM #2 stated she and ASM #1 were out of the facility on vacation the week of September 24 and 25, 2023, when the first report of the bruise appeared in the record. ASM #2 stated she discovered the lack of communication between the facility and hospice provider on 10/2/23 when she returned from vacation. She stated she followed up with the hospice provider and expressed her frustration at the lack of communication about the X-ray results. She stated the X-ray was obtained on a Friday night, and the hospice case manager was not on duty again until the following Monday morning. When asked who is ultimately responsible for a resident's care, even when hospice is involved, ASM #2 stated: We are. When asked to provide evidence that the facility staff followed up on the results of an X-ray they knew had been obtained on 9/29/23, ASM #2 and ASM #4 stated they did not have any such evidence. A review of the facility policy, Hospice Services, revealed, in part: The facility will communicate and collaborate with the hospice provider. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to obtain timely results of an X-ray for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain timely results of an X-ray that was performed on 9/29/23. On the quarterly MDS (minimum data set) with an ARD (assessment reference date) of 9/7/23, R1 was coded as being severely impaired for making daily decisions. She was coded as sometimes able to understand others, and as sometimes understanding others. She was admitted to the facility with a diagnosis of dementia. A review of R1's care plan dated 4/5/22 and updated 10/12/23 revealed, in part: [R1] has difficulty communicating related to decline in cognitive status, lack/limited use/understanding of English (fluent in Spanish). A review of R1's clinical record revealed the following progress notes: 9/24/2023 09:30 (a.m.) Nursing Note Text: Resident noted this morning at 9:00 am shouting loud and speaking in Spanish language. Nurse went in to see what the problem is. Nurse noted resident in Geri-chair showing signs of discomfort and not allowing nurse to touch her left arm. Nurse immediately went in to call nursing supervisor and Spanish staff to help with interpretation of what resident was saying. She told staff that her left arm hurt and also want to go home to her family .AM (morning) prescribed meds given to resident and PRN (as needed) pain med given as well to help with pain .Sitting at nurses' station at the moment with nurse for supervision. All safety measures maintained. This note was written by LPN (licensed practical nurse) #1, who was unavailable for interview during the survey. 9/25/2023 13:44 (1:44 p.m.) Physician/NP (nurse practitioner) Progress Note Text: Chief Complaint: follow up; c/o (complaint of) rt (right) chest wall bruising .Patient is long term resident in here and follow up for c/o rt chest wall bruising noticed by aide. pt (patient) lying on bed, not in distress .Assessment / Plan 1. Contusion of right chest wall - rt chest wall under rt axilla .close observation, follow up prn. 9/25/2023 14:01 (2:01 p.m.) Skin Observation Weekly (Licensed Nurse) Note Text: Weekly skin observation completed. Bruise to right arm. Unknown Origin. 9/25/2023 15:11 (3:11 p.m.) Nursing Note Text: Patient was seen by the visiting MD (physician) this afternoon, head to toe assessment done by the MD on unknown origin of bruises noted @ (at) the right arm of the patient, no new order received @ this time, nursing will continue to monitor. RP (responsible party) notified. 9/29/2023 21:22 (9:22 p.m.) Nursing Note Text: X-ray tech arrived to the unit for an order to do arial view of the right humerus by [name of hospice provider] pending result. A review of the X-ray result for R1 dated 9/29/23 at 10:55 p.m. revealed, in part: FINDINGS: No fracture is seen but there is a dislocation of the humeral head (shoulder). 10/2/2023 18:13 (6:13 p.m.) Alert Note Text: Writer Called [name of hospice provider] to investigate as to why they used an outside contracting company to do an x-ray on the patient and was not communicating this to writer. On call nurse could not give an answer will follow up in the am. Patient has a bruise of unknown origin and a dislocation of the right humeral head (probably anteriorly and inferiorly). 10/3/2023 09:45 (a.m.) Change of Condition Note Text: New order received to transfer out patient to Hospital FOR FURTHER EVALUATION AND TREATMENT for dislocation of the Humeral head. On 10/3/23, an interview was documented by the facility between ASM (administrative staff member) #2, the director of nursing) and RN (registered nurse) #3, the hospice case manager, who was not available for interview during the survey. A review of the facility interview document dated 10/3/23 revealed, in part: On 9/29/23 .[RN #3] informed [LPN (licensed practical nurse) #1] that she was going to get an X-ray [for R1] to rule out fracture of the humerus .RN #3 was off 9/30 - 10/1. She received the results on 10/2/23 and called the physician. (LPN #1 was not available for interview during the survey). On 11/2/23 at 9:05 a.m., ASM #3, the attending physician, was interviewed. He stated on 9/25/23, a nurse told him about R1's bruising on her right side. He stated the bruising was in somewhat of a line under the armpit along the chest wall. He stated when he touched the area, the resident did not exhibit any expression of tenderness or pain. He stated at the time, in the course of his physical assessment, he did not suspect the resident had a shoulder injury. He stated she did not display any physical signs of such an injury on 9/25/23. On 11/1/23 at 10:39 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #4, the regional nurse consultant, and RN (registered nurse) #1, the assistant director of nursing, were interviewed. ASM #4 stated he came to the facility to help with the investigation of the resident's bruising. ASM #2 stated she and ASM #1 were out of the facility on vacation the week of September 24 and 25, 2023, when the first report of the bruise appeared in the record. ASM #2 stated the hospice provider ordered the resident's X-ray, and she discovered the lag between the X-ray and the facility's notification of the results when she returned from vacation on 10/2/23. She stated the X-ray was obtained on a Friday night, and the hospice case manager was not on duty again until the following Monday morning. When asked who is ultimately responsible for a resident's care, even when hospice is involved, ASM #2 stated: We are. When asked to provide evidence that the facility staff followed up on the results of an X-ray they knew had been obtained on 9/29/23, ASM #2 and ASM #4 stated they did not have any such evidence. A review of the facility policy, Radiology and Diagnostic Services, revealed, in part: The facility will promptly notify the ordering physician/practitioner of diagnostic results that fall outside of clinical reference ranges .The facility in collaboration with the physician/practitioner will establish means of communication and time frames for notification of diagnostic test results. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of five residents in the survey sample, Resident #2. The findings include: For Resident #2 (R2), the facility staff failed to document in the clinical record, the findings of the Resident's report of a request for an unwanted sexual act. Review of facility synopsis of events submitted to the state agency dated 5/17/23 revealed R2 made an allegation of an unsolicited sexual act. Review of the facility synopsis of events revealed, in part: Resident made an allegation at approximately 7:00 am that a white male entered her room and stated, 'Can you suck my [expletive].' The resident denies being touched inappropriately and participating in any sexual activity. Resident was unable to identify the accused when presented with four random male choices. Further review of clinical record failed to reveal progress notes regarding the incident. On 11/1/23 at 8:45 a.m., ASM (Administrative Staff Member) #1, the administrator, was interviewed. She stated that she took the resident statement when R2 voiced the issue. She stated that she asked various questions and followed up in the chart. She stated that the resident's allegation would be documented in the progress notes. At 10:48 a.m., she added, We have missed an opportunity to document. We do not see anything in the record. On 11/1/23 at 10:48 a.m., an interview was conducted with ASM#3, Regional Nurse Consultant. He stated, Nothing recorded in medical record outside of psych visit. On 11/01/23 at 10:49 a.m., ASM#1 and ASM#2 (Director of Nursing), ASM#3 were made aware of above concern. A review of the facility policy, Charting and Documentation, revealed, in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, will be documented in the resident's medical record. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide treatment to promote healing of a pressure injury for one of 29 residents in the survey sample, Resident #36. The findings include: For Resident #36 (R36), the facility staff failed to evidence treatment to a pressure injury (1) initially observed on 4/5/2023. A treatment was not started until 4/12/2023. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/30/2023, the resident scored 3 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired for making daily decisions. Section M documented R36 having one unstageable pressure injury. On 6/13/2023 at 11:00 a.m., an observation was made of RN (registered nurse) #3, the wound nurse, providing wound care to R36's pressure injury to the left heel. There were no concerns with the pressure injury treatment observation. The progress notes for R36 documented in part; 04/05/2023 08:05 (8:05 a.m.) Skin. Note Text : Resident is alert and verbally responsive. Resident was assessed during weekly body audits. Area identified includes: L-Heel (DTI): Impaired skin integrity measuring 2.0 cm (centimeter) (L) (length) x 2.0 cm (W) (width). x 0.1 cm (depth). Tissue type is 100% Necrotic with no drainage. Periwound is erythematous. PUSH: 11. This skin condition was [sic] remains the same since last evaluated. Tx: Apply Betadine pad and cover with dry dsg. Q (every) Day shift and PRN (as needed) .Preventative measures in place at this time, such as sage boats on while in bed, daily wound treatment, and encourage turning & repositioning by staff while in bed and as tolerated. Resident/RP (responsible parties) and all disciplines made aware of treatment plan. MD (medical doctor) Notified. The physician orders for R36 documented in part, - DTI (deep tissue injury) (2) to L-Heel: Apply Betadine pad and cover with dry dsg (dressing) every day shift for wound care and as needed for wound care. Order Date: 4/11/2023 16:47 (4:47 p.m.). - Body audit every evening shift Mon (Monday) for skin observation. Order Date: 10/11/2021. The eTAR (electronic treatment administration record) for R36 dated 4/1/2023-4/30/2023 documented in part, DTI to L-Heel: Apply Betadine pad and cover with dry dsg every day shift for wound care. Start Date: 04/12/2023 0700 (7:00 a.m.). The eTAR documented the treatment to the left heel pressure injury beginning on 4/12/2023. The eTAR further documented Body Audits completed every evening shift on Mondays for skin observation. The eTAR documented a body audit completed on 4/3/2023. The eTAR for R36 dated 3/1/2023-3/31/2023 documented body audits completed on 3/6/2023, 3/13/2023, 3/20/2023 and 3/27/2023. The wound physician assessment dated [DATE] for R36 documented in part, .Wound #1 Left Heel is a chronic Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2 cm length x 2 cm width x 0.1 cm depth, with an area of 4 sq cm (square centimeters) and a volume of 0.4 cubic cm Plan: Wound Orders: Wound #1 Left Heel. Cleanse/Protect Wound, Cleanse wound with normal saline. Wound dressing: Apply: - Apply Betadine pad and cover with dry dsg Q day and evening shift and prn . On 6/13/2023 at 12:52 p.m., an interview was conducted with RN #3, wound nurse. RN #3 stated that the staff conducted weekly wound assessments and any newly identified wounds were assessed, reported to the physician and a treatment order was obtained until the wound physician came in the next Wednesday to assess, measure and make any changes to the treatment as needed. RN #3 stated that R36 had a history of the pressure injury on the left heel and it had healed and reopened in the past and was last healed in September of 2020. RN #3 reviewed R36's clinical record and stated that the left heel pressure injury was first identified as reopening on 4/5/2023 and they had contacted the physician for a treatment order. RN #3 stated that they did not see a physician order for the treatment until 4/12/2023 and there was no evidence that a treatment was done between 4/5/2023 to 4/11/2023. RN #3 stated that if it was not documented they could not evidence that it was done. The facility policy, Pressure Injury Prevention and Management documented in part, .Treatments, including preventative interventions, will be documented in the resident's medical record . On 6/13/2023 at approximately 5:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were notified of the findings. No further information was provided prior to exit. Reference: (1) Pressure injury A pressure sore is an area of the skin that breaks down when something keeps rubbing or pressing against the skin. Pressure sores are grouped by the severity of symptoms. Stage I is the mildest stage. Stage IV is the worst. Stage I: A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft. Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated. Stage III: The skin now develops an open, sunken hole called a crater. The tissue below the skin is damaged. You may be able to see body fat in the crater. Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm. (2) DTI- deep tissue injury Pressure sores that develop in the tissue deep below the skin. This is called a deep tissue injury. The area may be dark purple or maroon. There may be a blood-filled blister under the skin. This type of skin injury can quickly become a stage III or IV pressure sore. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000740.htm

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to provide monitoring of a resident receiving TPN (total parenteral nutrition) consistent with professional standards of practice for one of 29 residents in the survey sample, Resident #84. The findings include: For Resident #84 (R84), the facility staff failed to monitor blood glucose levels while receiving TPN (1). R84 was admitted on [DATE], hospitalized on [DATE], then readmitted and d/c'd on the same day 4/1/22. On the most recent MDS (minimum data set) an admission assessment with an ARD (assessment reference date) of 3/13/2022, the resident was assessed as receiving parenteral/IV (intravenous) feeding while at the facility and receiving 51% or more of their total calories through the parenteral feeding. The physician orders for R84 documented in part, - TPN Therapy per physician order (reminder: check for additional medications to be added by nurse): Solution: __ ; Volume: 2000 ; Rate: 50 ; Frequency: Q (every) 12 per IV. Catheter type/size: 10 drops/ml every 12 hours for Small [NAME] [sic] Obstruction. Order Date: 03/09/2022. - CMP (comprehensive metabolic panel), CBC (complete blood count), magnesium, phosphate, triglyceride, total bilirubin every night shift every Monday. Order Date 3/13/2022. A review of R84's progress notes from 3/9/2022-4/1/2022 failed to evidence blood glucose monitoring. A review of R84's eMAR (electronic medication administration record) dated 3/1/2022-3/31/2022 and 4/1/2022-4/30/2022 failed to evidence documentation of blood glucose monitoring. A review of R84's eTAR (electronic treatment administration record) dated 3/1/2022-3/31/2022 and 4/1/2022-4/30/2022 failed to evidence documentation of blood glucose monitoring. The comprehensive care plan for R84 documented in part, Nutritional/hydration status as evidenced by TPN, GJ (gastrojejunal) Tube, therapeutic diet, underweight BMI, hx/dx/meds (history/diagnosis/medications) Date Initiated: 03/10/2022. Revision on: 03/10/2022. The nutritional assessment for R84 dated 3/13/2022 documented in part, .Parenteral feeding: Yes. Reason for parenteral feeding: Small bowel obstruction. Order/Rate/Volume: 2000ml (milliliter) Vol (volume): 90ml x1 hr (hour); 182ml x 10 hr, 90 ml x 1 hr. Composition: Dextrose: Grams: 300; Dextrose: Calories: 1020 .TPN providing 100% of needs .BMI (body mass index) below reference range. Labs indicate hyponatremia (low sodium) and hyperphosphatemia (high phosphate) as well as increased BUN (blood urea nitrogen) level. Spoke to pharmacy about adjusting TPN. Recommended to increase fluid volume to 2250ml, decrease protein to 90g (gram) and increase dextrose by 7g for 307g dextrose, and increased by 2g fat for 52 total grams of lipids. Labs didn't indicate a glucose or potassium level. Will follow up with MD (medical doctor) . On 6/13/2023 at 2:42 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they did not remember R84 but worked with residents at the facility receiving TPN. RN #1 stated that the facility monitored labs on the residents weekly which they sent to the pharmacy to adjust the dosing of the TPN and they also monitored blood glucose each day depending on the physician's orders. On 6/14/2023 at 8:25 a.m., an interview was conducted with RN #4. RN #4 stated that they worked with R84 when they were at the facility. RN #4 stated that residents who received TPN had weekly labs monitored that determined the dosing and makeup of the TPN by the pharmacy and also the nurses monitored the residents blood sugars routinely each day. RN #4 stated that the blood sugars were monitored at least twice a day unless the resident was diabetic and then they were four times a day. RN #4 reviewed the clinical record and stated that they were unable to find any blood sugar monitoring for R84. On 6/14/2023 at 9:16 a.m., an interview was conducted with ASM (administrative staff member) #4, medical doctor. ASM #4 stated that they did not remember R84 when they were at the facility. When asked if resident's receiving TPN should have the blood sugar monitored, he stated, Definitely. He stated that the blood sugar should be monitored based on the resident's history, diagnoses and prior range of blood sugars. ASM #4 stated that the facility staff monitored for clinical symptoms and things like infection, bacteremia, dehydration could alter the blood sugar. He stated that the setting was different from the hospital with staff caring for 18-20 residents and if R84 were stable the staff may have been able to monitor the blood sugar less often. The facility policy Total Parenteral Nutrition Care Procedure dated 2015 documented in part, Clinical considerations: . 2. Hypoglycemia: Hypoglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes and they include a headache, a low blood glucose level, shakiness, clammy and cool skin, blurry vision, diaphoresis and unconsciousness and seizures. This complication of total parenteral nutrition, like hyperglycemia, can be prevented with the close monitoring of the resident's blood glucose levels and an adequate dosage of insulin as based on these levels. 3. Hyperglycemia: Hyperglycemia can occur as the result of the high dextrose content of the total parenteral nutrition solution as well as the lack of a sufficient amount of administered insulin. The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same as those associated with poorly managed diabetes and they include a high blood glucose level, thirst, excessive urinary output, headache, nausea and fatigue. This total parenteral nutrition complication can be prevented with the continuous monitoring of the resident's blood glucose levels and the titration of insulin administration as based on these levels Capillary or serum blood glucose levels: QID (4 times a day) capillary blood glucose initially to monitor glycemic control, then reduce monitoring when blood sugars are stable or as per agency policy. May be done more frequently if glycemic control is difficult. Indicates metabolic tolerance to dextrose in TPN solution and resident ' s glycemic status . According to [NAME] Manual of Nursing Practice 10th edition page 753 documented in part, Table 20-3, Complications of Total Parenteral Nutrition and Treatment .Complications: Hyperglycemia; Causes: Insufficient insulin secretion, High glucose content of fluid, blood sample contaminated by parenteral nutrition. Interventions: Monitor blood glucose frequently . According to Fundamentals of Nursing 8th edition, [NAME] & [NAME], pages 1021-1023 documented in part, .Parenteral nutrition (PN) is a form of specialized nutrition support in which nutrients are provided intravenously .Safe administration depends on appropriate assessment of nutrition needs, meticulous management of the central venous catheter (CVC), and careful monitoring to prevent or treat metabolic complications .Clinical and laboratory monitoring by a multidisciplinary team is required throughout PN therapy . It further documented, Table 44-8 Metabolic Complications of Parenteral Nutrition .Problem: Hyperglycemia; Signs/Symptoms: Thirst, headache, lethargy, increased urination. Intervention: Monitor blood glucose level every 6 hours . On 6/14/2023 at 10:00 a.m., ASM #1, the administrator was informed of the concern. No further information was provided prior to exit. Reference: (1) Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein provides most of the nutrients the body needs. The method is used when someone can't or shouldn't receive feedings or fluids by mouth. A person may need TPN for a short time over weeks or months, or for life. It depends on the condition that causes the need for TPN. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000177.htm

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a pain management program per physician orders, for one of 29 residents in the survey sample; Resident #72. The findings include: For Resident #72, the facility staff failed to implement parameters for an as-needed (PRN) pain medication that was ordered for severe pain. The facility staff administered the medication for pain levels that were less than severe (mild or moderate) on a pain scale of 0-10 with 10 being the most severe level of pain. A review of the clinical record revealed a physician's order dated 4/28/23, discontinued on 5/5/23 and reordered on 5/6/23 for oxycodone-acetaminophen (1) 10-325 mg, give one tab every four hours as needed for severe pain. There were no orders for any PRN pain medication for levels that would be considered mild or moderate. A review of the Medication Administration Record (MAR) for May 2023 and June 2023 revealed the resident received this medication on the following dates for the following pain ratings that fell below the level of severe. On 5/2/23 the medication was administered for a pain level of a 5. On 5/4/23 the medication was administered twice for pain levels of a 5. On 5/9/23 the medication was administered twice for pain levels of a 5. On 5/10/23 the medication was administered for a pain level of a 5. On 5/13/23 the medication was administered for a pain level of a 4. On 5/18/23 the medication was administered for a pain level of a 5. On 5/22/23 the medication was administered for a pain level of a 5. On 5/23/23 the medication was administered for a pain level of a 5. On 5/25/23 the medication was administered for a pain level of a 6. On 5/26/23 the medication was administered for a pain level of a 5. On 5/30/23 the medication was administered for a pain level of a 4. On 5/31/23 the medication was administered twice for pain levels of a 3 and a 4. On 6/4/23 the medication was administered twice for pain levels of a 5 and a 2. On 6/9/23 the medication was administered twice for pain levels of a 5. On 6/12/23 the medication was administered for a pain level of a 5. On 6/13/23 the medication was administered for a pain level of a 3. The facility policy, Pain Management was reviewed. This policy documented, The organization will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences The policy did not identify the utilization of the pain scale of 0-10 with 10 being the most severe level of pain, or parameters as to what numbers on the scale constitute mild, moderate and severe levels of pain. On 6/13/23 at 3:19 PM an interview was conducted with LPN #2 (Licensed Practical Nurse). When asked what is considered severe pain she stated it is a 5 and higher. When asked what should staff do when a resident complains of pain that is less than severe, she stated to give the resident a Tylenol (2). When asked what if there isn't an order for Tylenol, she stated that staff would need to call the doctor to get an order. When asked if a resident should be administered Oxycodone that was ordered for severe pain, if their pain level was mild or moderate, she stated that it should not be administered for pain levels that low. When it was noted that on some occasions, she was the nurse that administered the Oxycodone for low pain levels, and when asked if she called the doctor to get an order for Tylenol instead, she stated that she did not. On 6/13/23 at 5:41 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing (DON). When asked what is considered a mild pain level, a moderate pain level and a severe pain level on the 0-10 pain scale, she stated that mild would be 0 to 3, moderate would be 4 to 7, and severe would be 8 to 10. When asked if at anytime would a 3 or a 5 be considered a severe pain level, she stated that it was not. When asked if a resident was ordered Oxycodone for severe pain level, should the staff be administering it for pain levels of 3 or 5, she stated that they should not be. No further information was provided by the end of the survey. References: 1. Oxycodone-acetaminophen is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a682132.html 2. Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html

Based on staff interview, facility document review and clinical record review, the facility staff failed to respond to pharmacy recommendations for two of 29 residents in the survey sample, Residents #60 and #44 The findings include: 1. For Resident #60 (R60), the facility staff failed to respond to pharmacy recommendations dated 8/23/22 and 10/24/22 for lab tests. A review of R60's clinical record revealed a pharmacy recommendation dated 8/23/22 that documented to consider monitoring a liver function test, lipid panel and a basic metabolic panel on the next lab day, and a pharmacy recommendation dated 10/24/22 that documented to consider monitoring a digoxin level on the next lab day. Further review of R60's clinical record failed to reveal these pharmacy recommendations were addressed and failed to reveal the lab results. On 6/14/23 at 10:34 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that once the pharmacist has completed their review, the staff print out the pharmacy recommendations, give them to the doctor, and the doctor acts upon them. On 6/14/23 at 10:57 a.m., ASM (administrative staff member) #1 (the administrator) was made aware of the above concern. The facility policy titled, Medication Regimen Review documented, 9.a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review. b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response . 27660 2. For Resident #44 (R44), the facility staff failed to evidence documentation of a response to pharmacy recommendations for three months. The pharmacy recommendation for 4/20/2022 documented, Recommendations: Miconazole Nitrate Cream 2%, Apply to L (left) arm rash topically one time a day. This order does not have a stop date. Please reevaluate therapy and add a stop date. If continued therapy is warranted, please document the rationale for continued use. Additional Recommendations/Suggestions: Evaluate a stop date. The pharmacy recommendation for 6/13/2022, documented, Recommendations: Miconazole Nitrate Cream 2%, Apply to L (left) arm rash topically one time a day. This order does not have a stop date. Please reevaluate therapy and add a stop date. If continued therapy is warranted, please document the rationale for continued use. Additional Recommendations/Suggestions: Evaluate a stop date. There was no action taken from the 4/20/2022 recommendation and the pharmacist had to repeat the recommendation on 6/13/2022. The pharmacy recommendation for 7/13/2022, documented, Recommendations: Seroquel mg (milligrams) (Quetiapine Fumarate) (1), Give 1 tablet by mouth at bedtime and Trazadone HCL (2) 50 mg Tablet, Give 1 tablet orally at bedtime. Recommended: Please consider a dose reduction. Additional Recommendations/suggestions: Consider discontinuing Seroquel 50 mg and consider Seroquel 25 mg PO (by mouth) HS (bedtime). The pharmacy recommendation for 10/25/2022, documented, Recommendations: Seroquel mg (milligrams) (Quetiapine Fumarate), Give 1 tablet by mouth at bedtime and Trazadone HCL 50 mg Tablet, Give 1 tablet orally at bedtime. Recommended: Please consider a dose reduction. Additional Recommendations/suggestions: Consider discontinuing Seroquel and Trazadone, and consider Seroquel 25 mg HS and Trazadone 100 mg HS. Review of the clinical record failed to evidence action taken upon these pharmacy recommendations or a provider note to document the reason for not changing the doses of medications. The last psychiatry note was dated 4/15/2022. The note documented in part, Treatment Plan: 1. Dementia -Aricept and Namenda. 2. BPBD - Seroquel on reduced dose, stable. An interview was conducted with RN (registered nurse) #3 on 6/14/2023 at 10:34 a.m. When asked the process for when the pharmacist makes recommendations, RN #3 stated that when they [the pharmacist] does their review, we go into the system [computer] and print out the recommendations. We hand them to the unit managers who takes them to the doctors. Once the doctor has reviewed, the nurse takes the orders and puts them in the computer. The unit manager makes sure this it done. The above concerns were shown to RN #3 for follow up. RN #3 returned at 10:45 a.m. and stated he had nothing related to the above pharmacy recommendations. RN #3 stated he could not find any doctor's notes related to the pharmacy recommendations. The facility policy titled, Medication Regimen Review documented, 9.a) The consulting pharmacist will provide copy of recommendations to the attending physician, medical director, and director of nursing within 5 working days of completion of the review. b) The director of nursing or designee will review the recommendations and the attending physicians will be contacted for review and response . ASM (administrative staff member) #1, the administrator, was made aware of the above finding on 6/14/2023 at 11:10 a.m. No further information was obtained prior to exit. References: (1) Seroquel - Quetiapine extended-release tablets are also used along with other medications to treat depression. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a698019.html (2) Trazodone is used to treat depression. This information was obtained from the following website:https://medlineplus.gov/druginfo/meds/a681038.html

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for two of 29 residents in the survey sample, Residents #60 and #285. The findings include: 1. For Resident #60 (R60), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (1) medication Eliquis (2). A review of R60's clinical record revealed a physician's order dated 4/4/23 for Apixaban (Eliquis) 5 mg (milligrams) by mouth every 12 hours for atrial fibrillation. A review of R60's MARs (medication administration records) for April 2023 through June 2023 revealed the resident was administered Apixaban 5 mg every 12 hours every day. Further review of R60's clinical record (including the MARs, assessments and nurses' notes for April 2023 through June 2023) failed to reveal the resident was monitored for side effects (bleeding) from Apixaban (except for 4/5/23 and 6/9/23). On 6/13/23 at 4:27 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that residents who are administered anticoagulant medication should be monitored for bleeding, bruising, bloody urine or bloody stool every shift. RN #1 stated nurses should document this monitoring, even if no bleeding is observed. RN #1 stated it is important to monitor residents who receive anticoagulant medication because they could bleed to death. On 6/13/23 at 5:31 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Medication and Treatment Orders documented, Order for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring. Reference: (1) Anticoagulants are a family of medications that stop your blood from clotting too easily. https://my.clevelandclinic.org/health/treatments/22288-anticoagulants (2) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds& 42106 2. For Resident #285 (R285), the facility staff failed to monitor for adverse effects of a prescribed anticoagulant (1)medication. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. The assessment failed to evidence documentation of R285 receiving anticoagulant medications. The physician orders for R285 documented in part, Apixaban Oral Tablet 5 MG (milligram) (Apixaban) Give 1 tablet by mouth every 12 hours for A Fib (atrial fibrillation). Order Date: 06/08/2023. The eMAR (electronic medication administration record) dated 6/1/2023-6/30/2023 for R285 documented the Apixaban administered beginning on 6/8/2023 at 9:00 p.m. and each day at 9:00 a.m. and 9:00 p.m. through the present. The eMAR failed to evidence anticoagulant adverse effect monitoring. The progress notes for R285 failed to evidence documentation of anticoagulant adverse effect monitoring. Review of the clinical record failed to evidence a baseline care plan regarding use of an anticoagulant. On 6/13/2023 at 4:27 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that they monitored residents for bleeding by looking for bruising, blood in urine or stool every shift due to the risk of bleeding with anticoagulants. RN #1 stated that this was documented in the progress notes every shift whether there was bleeding observed or not. On 6/13/2023 at approximately 5:30 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were made aware of the findings. No further information was provided prior to exit. Reference: (1) Anticoagulants are a family of medications that stop your blood from clotting too easily. https://my.clevelandclinic.org/health/treatments/22288-anticoagulants

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review an advance directive and/or have copies of the advance directive documents in the clinical record for two of 29 residents in the survey sample, Resident #48 and #60. The findings include: 1. For Resident #48 (R48), the facility staff failed to evidence documentation of a periodic review of the resident's advance directive. R48 was readmitted to the facility on [DATE]. The physician orders dated 6/6/2023 failed to evidence documentation of a code status. The Admit/Readmit Screener dated 6/6/2023 documented, Health care directives/code status - full code. On 6/13/2023 at 12:06 p.m., ASM (administrative staff member) #1, the administrator, stated there is no evidence of an advance directive discussion per what the records indicate. The social worker plans to address this at their next care plan meeting as the resident has expressed they wanted to discuss their advance directives. R48 had a care plan meeting scheduled for next week. An interview was conducted on 6/13/2023 at 4:48 p.m. with OSM (other staff member) #1, the social services director. When asked the process for reviewing the advance directives with a resident, OSM #1 stated it is usually reviewed annually for long term residents. If the resident is a short term resident, then it is reviewed on admission. They also review it if there has been a significant change in a resident's condition. OSM #1 was asked where it was documented, OSM #1 stated it is different here from where she came from. Here they have assessments. Before, she stated, she wrote a progress note with the information. OSM #1 stated she was going to review advance directives with (R48) at their care plan meeting next week The facility policy, Advance Directives documented in part, 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family member and/or his or her legal representative, about the existence of nay written advance directives. 7. Information of whether or not the resident has executed an advance directive shall be displayed prominently in the medical record 18. The Interdisciplinary Team will periodically with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. ASM #1, ASM #2, the director of nursing and ASM #3, the regional director of operations, were made aware of the above on 6/13/2023 at 5:27 p.m. No further information was provided prior to exit. 31753 2. For Resident #60 (R60), the facility staff failed to maintain the resident's healthcare power of attorney document in the clinical record. A social services assessment dated [DATE] documented R60 had a healthcare power of attorney in place. Further review of R60's clinical record failed to reveal the healthcare power of attorney document and failed to reveal documentation that the facility staff attempted to obtain the document. On 6/13/23 at 4:57 p.m., an interview was conducted with OSM (other staff member) #1 (the social services director). OSM #1 stated that if a resident has a healthcare power of attorney in place, then she would request a copy of the document. OSM #1 stated that if she obtained a copy of the document then she would make sure the document was in the clinical record. OSM #1 stated that if she was unable to obtain a copy of the document then she would document that she requested the document or print out an email to evidence her attempt to obtain the document. On 6/13/23 at 5:31 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Advance Directives failed to document information about maintaining power of attorney documents on the clinical record.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to develop a baseline care plan for the use of an anticoagulant for one of 29 residents in the survey sample, Resident #285. The findings include: Resident #285 (R285) was admitted to the facility on [DATE]. Review of the clinical record failed to evidence a baseline care plan regarding use of an anticoagulant. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. The assessment failed to evidence documentation of R285 receiving anticoagulant medications. The assessment included baseline care plan triggers which failed to evidence documentation of anticoagulant medications. The physician orders for R285 documented in part, Apixaban Oral Tablet 5 MG (milligram) (Apixaban) Give 1 tablet by mouth every 12 hours for A Fib (atrial fibrillation). Order Date: 06/08/2023. The progress notes for R285 documented in part, 06/08/2023 19:41 (7:41 p.m.) Admit/Readmit Summary .A baseline care plan has been initiated. A copy of the baseline care plan and any revisions will be provided to [Name of R285] and/or representative on or before the comprehensive care plan meeting . On 6/13/2023 at 4:27 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that the baseline care plan was completed by the nurse who admitted the resident and completed the admission assessment. RN #1 stated that during the assessment the computer generated the care plan based on the nurse's answers. RN #1 stated that normally the unit manager reviewed the care plan the day after admission to make sure it was accurate. RN #1 stated that the purpose of the care plan was for the staff to use to care for the patient. RN #1 stated that anticoagulant medication use should be addressed on the baseline care plan because they monitored residents for bleeding by looking for bruising, blood in urine or stool every shift. RN #1 stated that the monitored was done due to the risk of bleeding with anticoagulants. RN #1 stated that the nurse should go through the medications that the resident was ordered on admission and address them on the care plan. The facility policy Baseline Care Plans undated, documented in part, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. initial goals based on admission orders; b. Physician orders . On 6/14/2023 at approximately 10:00 a.m., ASM #1, the administrator was made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 29 residents in the survey sample, Resident #60. The findings include: For Resident #60 (R60), the facility staff failed to review and revise the resident's comprehensive care plan for the use of an incentive spirometer (1). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/2/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. R60's diagnoses included but not limited to, secondary pulmonary hypertension and obstructive sleep apnea. On 6/12/23 at 12:29 p.m., R60 was observed sitting up in bed. An incentive spirometer was observed sitting on the resident's nightstand. R60 stated they use the incentive spirometer every now and then. On 6/13/23 at 8:45 a.m., the incentive spirometer was observed on the resident's nightstand. A review of R60's comprehensive care plan dated 5/25/22 failed to reveal documentation regarding incentive spirometer use. There was no physician order for the use of the incentive spirometer. On 6/13/23 at 2:48 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated, We care plan everything. It tells you what to do, when to do and what to look for and the diagnosis for that. It guides you as a nurse. LPN #1 stated a resident's incentive spirometer use should be on the care plan. On 6/13/23 at 5:31 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Planning - Comprehensive Person-Centered documented, 16. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans . Reference: (1) The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer teaches you how to take slow deep breaths. https://medlineplus.gov/ency/patientinstructions/000451.htm

Based on observations, resident interview, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide respiratory care and services for two of 29 residents in the survey sample, Resident #285 and Resident #60. The findings include: 1. For Resident #285, the facility staff failed to obtain a physician's order for the use of oxygen. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment dated [DATE] documented the resident being alert and oriented to person, place, time and situation. The assessment documented Resident #285 (R285) receiving oxygen at the facility. On 6/12/2023 at 1:57 p.m., an interview was conducted with R285 in their room. R285 was observed in bed wearing an oxygen nasal cannula. R285 stated that they wore oxygen at all times during the day and wore a CPAP (continuous positive airway pressure) at night due to congestive heart failure. R285 was observed to be receiving oxygen at 2.5 liters per minute. Additional observations of R285 receiving oxygen at 2.5 liters per minute were made on 6/12/2023 at 4:30 p.m. and 6/13/2023 at 8:55 a.m. A review of the physician orders for R285 failed to evidence an order for oxygen. The progress notes for R285 documented in part, 06/08/2023 23:21 (10:21 p.m.) Admit/Readmit .93% (oxygen saturation) NC (nasal cannula) at 2 liters . The progress notes further documented, 06/08/2023 19:41 (7:41 p.m.) Admit/Readmit Summary .(Name of R285) will receive the following specialized services during this stay: Oxygen . The baseline care plan for R285 documented in part, The resident has oxygen therapy. Date Initiated: 06/08/2023. On 6/13/2023 at 1:30 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that when they received new admissions to the facility they reviewed the discharge summary from the hospital with the physician to approve the orders and then entered the orders into the computer. She stated that R285 came from the hospital receiving oxygen and wore it all the time and that there should be an order for the oxygen so the staff knew the amount of oxygen prescribed. LPN #3 reviewed R285's physician orders and stated that they did not see an order for the oxygen and that it may not have been transcribed. On 6/13/2023 at 2:42 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that residents who were admitted to the facility from the hospital with oxygen came with an order for the oxygen which the nurse reviewed, verified with the facility physician and transcribed into the electronic medical record physician orders. The facility policy Oxygen Administration undated, documented in part, .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . On 6/13/2023 at approximately 5:30 p.m., ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of operations were made aware of the findings. No further information was provided prior to exit. 31753 2. For Resident #60 (R60), the facility staff failed to obtain a physician's order for the use of an incentive spirometer (1) and failed to store the incentive spirometer in a sanitary manner. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/2/23, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact. A review of R60's clinical record failed to reveal a physician's order for an incentive spirometer. R60's comprehensive care plan dated 5/25/22 failed to document information regarding the use of an incentive spirometer. On 6/12/23 at 12:29 p.m., R60 was observed sitting up in bed. An incentive spirometer was observed on the resident's nightstand. The incentive spirometer mouthpiece was uncovered and exposed to air. R60 stated they use the incentive spirometer every now and then. On 6/13/23 at 8:45 a.m., R60 was observed sitting up in bed. The incentive spirometer remained uncovered on the resident's nightstand. On 6/13/23 at 5:17 p.m., an interview was conducted with R60. R60 stated staff has never covered the incentive spirometer. On 6/13/23 at 2:48 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated residents should have a physician's order for an incentive spirometer, so nurses know how to use the device and how often to use the device. LPN #1 stated an incentive spirometer should be stored in a bag for infection control. On 6/13/23 at 5:31 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Incentive Spirometry documented, To have patient perform sustained maximal inspiration without added resistance or positive pressure while presenting visual feedback of effort. Incentive Spirometry can be instructed/administered by an Respiratory Care Practitioner upon written physician's order. Reference: (1) The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer teaches you how to take slow deep breaths. https://medlineplus.gov/ency/patientinstructions/000451.htm

Based on staff interview, facility document review, clinical record review and in the course of complaint investigation, it was determined that the facility failed to maintain the highest level of wellness for one of twenty residents in the survey sample, Resident #7. Facility staff failed to review Resident #7's right shoulder x-ray on 11/13/15 which showed a impacted humeral (upper arm bone) neck fracture resulting in a three day delay in providing the resident treatment causing a decline in the fracture. The findings include: Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/8/16 coded the resident having a nine out of 15 on the BIMS (brief interview for mental status) indicating the resident was moderately impaired cognitively to make daily decisions. The resident was coded as requiring the assistance from staff for all activities of daily living. Review of the care plan created on 10/30/15 and revised on 5/30/16 documented, Focus. At risk for falls due to impaired balance/poor coordination .Interventions. Call light within reach with rapid response. Encourage/Assist to turn and reposition per resident's needs. Have commonly used articles within easy reach, low bed. Review of the fall assessment dated [DATE] at 2:20 p.m. documented in part, Physical Performance Limitations. 4. Impaired balance during transitions. Disease & Conditions. 11. Decline in functional status. 20. Chronic or acute condition resulting in instability. 31. Impulsivity or poor safety awareness. No falls at this time fall precaution in place. Review of the occupational therapy notes dated 11/12/15 documented in part, Stand from bed for repositioning, max (maximum) A (assistance). Review of the nurse's notes dated 11/13/15 at 12:27 p.m. documented, Extensive assistance with ADLS (activities of daily living) and transfers. Review of the facility's document titled, STATEMENT from LPN (licensed practical nurse) #7, the nurse caring for the resident, documented, I was informed by the other nurse that this patient fell but has been assisted back to bed. So I asked the supervisor to assist me to assess this patient upon arrival to patient room she started (sic) c/o (complain /of) severe pain to R (right) shoulder. X-Ray to R shoulder ordered stat (Immediate). Review of Resident #7's 11/13/15 right shoulder x-ray report documented, Examination: SHOULDER COMPLETE .Conclusion: Acute or subacute mildly impacted humeral neck fracture. The report was faxed to the facility on [DATE] at 7:46 p.m. Review of the nurse's notes dated 11/14/15 at 2:28 a.m. Res (resident) is (sic) sitting at the foot of the bed in front of her w/c (wheelchair) when asked (sic) she said she was trying to transfer herself from w/c and lost her balance and fell on her R (right) shoulder Head to toe assessment was done no apparent injury noted at this time Res c/o pain on (sic) shoulder [MEDICATION NAME] (a narcotic pain medication (1)) 1 tab (tablet) was giving (sic) an order received for R shoulder x-ray. Review of the physician's notes did not evidence documentation regarding the x-ray results. Review of the nurse's notes dated 11/14/15 at 8:12 p.m. documented, Right shoulder noted large bruise/[MEDICAL CONDITION] (swelling) s/p (status [REDACTED]. Ice applied PRN (as needed). Safety/fall precautions maintained. Review of the nurse's notes dated 11/15/15 at 9:30 p.m. documented, Right shoulder remains bruised/[MEDICAL CONDITION]. No fx (fracture) per result of X ray. Safety/fall precautions maintained. Review of the occupational therapy notes dated 11/16/15 documented, R (right) UE (upper extremity) swelling and bruising noted. Pt (patient) c/o (complained of) pain. ROM (range of motion) of elbow attempted. RN (registered nurse) notified, requested x-ray. Pt has fx (fracture), being sent out to hospital. Review of Resident #7's right shoulder x-ray dated, 11/16/15 documented, Results: Compared to the examination 11/13/2015 the previously noted fracture, has changed position. There is no evidence of healing. Conclusion: Fractures change position into a less favorable relationship. Review of the emergency room record dated 11/16/15 at 2:04 p.m. documented in part, 96 y.o. (years old) female h/o (history of) dementia currently in rehab (rehabilitation) brought from rehab s/p (status [REDACTED]. Per family, pt (patient) was trying to get out of wheelchair but fell . Patient currently has right arm ecchymosis and severe pain when moving right arm 4. Severity (of pain): moderate, 5. Timing: constant. 6. Activities that worsen symptoms: moving. 11. Are symptoms worsening? yes. Review of the orthopedic doctor's note dated 11/16/15 documented, Plan: Discussed with patient and family. Non operative management. Right upper extremity will be placed in a sling. Review of the facility's document titled, STATEMENT from OSM (other staff member) # 14, receptionist, documented in part, Between 500-530 (5:00 p.m. to 5:30 p.m.) (name of resident) daughter called and said that she was talking to her mother on the phone and she said she needed help because she fell and she thinks she may have broken her shoulder I spoke with (RN (registered nurse) #5, the nursing supervisor) and told her what the daughter said. Review of the facility's document titled, STATEMENT by RN #5 dated 11/17/15 documented, Did you work with (name of resident) on 11/13/15 at 3-11 (3:00 p.m. to 11:00 p.m.) shifts (sic)? NO. How did you come involved in her care? I was the supervisor and nurse taking care of her called me to help her assess her, when went there she was complaining of pain to right shoulder. I immediately called the doctor and I called for stat X-ray while awaiting a call back from the doctor What is the process when you call in a STAT x-ray? You place a call in for order, they give you a claim number and then you wait for a fax confirmation we placed in the chart. What do you do to follow up? You wait for them to call you regardless of the results and then you to look into the fax. Did you call before you left to (name of x-ray company) to follow up with result? I didn't call to follow up because .Did you give report to incoming nurse? Yes I told her that the result of the x-ray was pending. The following day when I came in around 3pm (LPN #6) told me the result was negative. Then I assessed the patient she looked worse than she did on Friday . Review of the facility's document titled, STATEMENT by RN #4 dated 11/18/15 documented, On Friday 11/13/15 when you arrived on your 11-7 (11:00 p.m. to 7:00 a.m.) shift who gave you report about the unit? When I arrived, after I made my rounds I took report from (RN #5) who was the supervisor that evening, she proceeded to tell me that (name of resident) fell and she has sustained an injury to her right should, they have been (sic) medicated her for pain and an X-ray was ordered and the results were negative for any broken bones. Did you see the actual x-ray results? NO. did you call to follow up about the X-ray results with (name of x-ray company)? NO. Review of the facility's document titled, STATEMENT by RN #2, the unit manager, not dated documented, She (RN #5) told me she (Resident #7) had fallen trying to transfer. She told me an x-ray was done and was negative according to her. However she said the Pt. was c/o pain and their (sic) were swelling on that shoulder .The family wanted her to be seen by the doctor. An interview was conducted on 8/10/16 at 5:10 p.m. with RN #5, the nursing supervisor. When asked about the events related to Resident #7's fall on 11/13/15, RN #5 stated, I was supervisor that night, I had two nurses and we had three admissions and they take a lot of work. The nurse assigned to her was new and I was trying to help her. So, we were told that the patient had fallen so we went there (to the resident's room). She (LPN #7, the nurse caring for the resident) didn't know what to do so I went there, I assessed the patient. I got the order after I called the doctor. I called x-ray so they came and it was done. I was waiting for them to call me if there was a fracture before they would fax it. When asked if she had checked the fax machine for the shoulder x-ray results, RN #5 stated, There was a lot of admissions, I was doing a lot of stuff. I wrote the report at the end of the shift and told them to follow up (on the x-ray) because we didn't get the report. The next day in the afternoon I asked the nurse if we got the x-ray, she said there was no fracture, so I charted that there was no fracture. But I should have seen the results so I took her word. An interview was conducted on 8/10/16 at 5:20 p.m. with ASM (administrative staff member) #2, the director of nursing. When asked about the events related to Resident #7's fall on 11/13/15 (a Friday), ASM #2 stated, On Monday I looked at her shoulder and said it didn't look right. When asked who was responsible to check a stat x-ray result, ASM #2 stated, The nurse caring for the resident, all of us. On 8/11/16 at 9:10 a.m. ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern for harm due to staff failing to follow up on Resident #7's shoulder x-ray on 11/13/15 which created a delay in treatment and a decline in the fracture. ASM #1 and ASM #2 were made aware of the complaint allegations at that time. An attempt to contact LPN #7, the nurse who cared for Resident #7 on 11/13/15, was made on 8/11/16 at 9:28 a.m. A message was left for LPN #7 to call the facility. The LPN did not return the call. An interview was conducted on 8/11/16 at 10:10 a.m. with LPN (licensed practical nurse) #3. When asked what staff did in regards to a physician's orders [REDACTED].#3 stated, When stat, says it all, it means now. When get results work on it right away and call the doctor. When asked if there was any time stat x-ray results were not followed up on, LPN #3 stated, No. An interview was conducted on 8/11/16 at 10:15 a.m. with LPN #4. When asked the process staff followed in regards to a physician's orders [REDACTED].#4 stated, Means I have to have to do it right away, call the radiology company for stat, call the family and let them know we are going to do it stat. When asked how staff followed up in regards to getting the x-ray results, LPN #4 stated, If I have a stat order I always check (the fax machine) frequently and sometimes I even call (the x-ray company). A telephone interview was conducted on 8/11/16 at 10:59 a.m. with LPN #6, the nurse who assisted Resident #17 to bed after the fall. When asked what she recalled about the fall Resident #7 sustained on 11/13/15, LPN #6 stated, I remember I wasn't her nurse. I went to help her and get the patient to bed. We got an x-ray which was a problem .I remember, honestly, oh boy, the nurse who had the patient, I don't know if she got the results right away. Follow up was rough; we didn't get a clear picture of what was going on. When asked what process staff followed when a stat x-ray was done, LPN #6 stated, you ' re supposed to check on the x-ray before you leave the building. I remember that day was busy all over. An interview was conducted on 8/11/16 at 11:35 a.m. with ASM #1 and ASM #2. ASM #2 stated, When I found out about the issue, I initiated a PIP (performance improvement plan). My priority was patient comfort. When asked what they determined from the investigation, ASM #2 stated, We did not follow our policy in following up on an x-ray in a timely manner. I was concerned about delay in treatment. I discussed it with the supervisor and the actual nurse that took care of the patient and did immediate education. We have a plan of correction in place to follow up (on diagnostic tests). We have asked the (x-ray) company to notify the DON (director of nursing) and the administrator of all positive results. We have the (x-ray) results now come to (name of software) directly so when the nurse opens up the computer it is right there. Review of the facility's plan of correction documented, Identified Patient(s): (Name of resident (Resident #7)) fell on [DATE], X-ray ordered stat. Results received but MD (medical doctor) was not notified. Like Patients: Current patients in house have the potential to be affected. Diagnostic records of all patients in house have been audited from Nov. 13 2015 until current. System Correction: All LPN/RN will be re-educated in lab (laboratory) tracking process/Guidelines. Staff discipline per facility protocol. Copies of daily Diagnostic results will be brought to the morning QA (quality assurance) meeting to ensure appropriate document has been made. Monitoring: DCDs (department care directors) will do random audits daily and monthly for 2 months to ensure diagnostics results are and documentation has been placed in chart. Resolution Date: 1/15/16. QAPI (quality assurance performance improvement) Committee: Identified concerns will be brought to the facility QA committee for further recommendations and revisions to the plan of correction. A review of the facility's laboratory and diagnostic education to the nurses was dated 11/20/15. Review of the facility's laboratory and diagnostic tracking forms revealed complete documentation of the residents' testing and results. Review of the facilities titled, REQUIREMENTS AND GUIDELINES FOR CLINICAL RECORD CONTENT documented, Labs and Special Reports. The findings for each lab or special test ordered are retained in the patient's clinical record. When a lab or test result is received, a nurse reviews the results, notes the findings, initials and dates the report, contacts the physician as clinically indicated or as requested by the physician and enters a progress note. During the survey current residents were reviewed and no concerns were identified. No further information was provided prior to exit. In Basic Nursing, Essential for Practice, 6th edition (Potter and Perry, 2007, pages 56-59), was a reference source for physician's orders [REDACTED]. The best way to avoid being liable for negligence is to follow standards of care, to give competent health care, and to communicate with other health care providers. The physician or health care provider is responsible for directing the medical treatment of [REDACTED]. Past non compliance COMPLAINT DEFICIENCY (1) [MEDICATION NAME] is indicated for the management of moderate to moderately severe pain, severe enough to require an opioid [MEDICATION NAME] and for which alternative treatments are inadequate. This information was obtained from the website: <https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4dd36cf5-8f73-404a-8b1d-3bd53bd90c25>