Every finding on record at Goodwin House Alexandria

Based on observation, staff interview and facility document review, the facility staff failed to maintain the dumpster area in a clean and sanitary manner for one of one dumpster. The findings include: The facility staff failed to maintain the dumpster area in a clean and sanitary manner. Trash and debris were observed on the ground around the dumpster. On 4/4/23 at 9:45 a.m., observation of the dumpster was conducted with OSM (other staff member) #2, the registered dietitian, and OSM #4, a cook. Trash and debris (including four gloves that were folded inside out, saran wrap, paper debris, an empty specimen cup, a plastic drink cup and a plastic drink cup lid) were observed on the ground around the dumpster. OSM #4 stated the utility department staff goes out to the dumpster to dump trash every hour or so and they should make sure there is not all of that debris around the dumpster. On 4/4/23 at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the director of nursing, and OSM (other staff member) #6, the director of dining services, were made aware of the above concern. The facility policy titled, Disposing of Garbage and Refuse documented, 2. Waste must be properly contained and covered in dumpsters/compactors .5. The garbage storage area must be maintained in a sanitary condition to prevent the harborage and feeding of pests .

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to implement the resident's comprehensive care plan for psychotropic drug use monitoring. R56's comprehensive care plan dated 9/27/22 documented, Psychotropic Drug Use .observe for side effects . A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine (1) 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily 1/1/23 through 4/2/23. Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was observed for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2, in regard to the comprehensive care plan. RN #2 stated, It's sort of like an outline for the patient's care so everybody can be on the same page. Everybody can be on the same page for the goals and for everyone from interdisciplinary teams to see what the plan is for this resident . RN #2 stated residents' care plans are available for nurses to review. In regard to psychotropic medication use, RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. The facility policy titled, Resident Centered Care Planning documented, Care plan interventions provide direction to the nursing and interdisciplinary staff regarding specific actions and treatments identified as useful or necessary in helping the resident achieve established goals and objectives. Reference: (1) Quetiapine is used to treat schizophrenia, bipolar disorder and depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html. 2. For Resident #28 (R28), the facility staff failed to implement the resident's comprehensive care plan for psychotropic drug use monitoring. R28's comprehensive care plan dated 3/12/23 documented, Psychotropic Drug Use .monitor for side effects . A review of R28's clinical record revealed a physician's order dated 3/9/23 for citalopram (1) 10 mg (milligrams) once daily. A review of R28's MARs (medication administration records) for March 2023 and April 2023 revealed the resident was administered citalopram once daily 3/10/23 through 4/2/23. Further review of R28's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for March 2023 and April 2023) failed to reveal the resident was monitored for side effects from the medication citalopram. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2, in regard to the comprehensive care plan. RN #2 stated, It's sort of like an outline for the patient's care so everybody can be on the same page. Everybody can be on the same page for the goals and for everyone from interdisciplinary teams to see what the plan is for this resident . RN #2 stated residents' care plans are available for nurses to review. In regard to psychotropic medication use, RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. Reference: (1) Citalopram is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to monitor the resident for side effects from the antipsychotic medication quetiapine (1). A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily (1/1/23 through 4/2/23). Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was monitored for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. The facility policy titled, Antipsychotic Medication Use documented, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA (transient ischemic attack). Reference: (1) Quetiapine is used to treat schizophrenia, bipolar disorder and depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html. 2. For Resident #28 (R28), the facility staff failed to monitor the resident for side effects from the antidepressant medication citalopram (1). A review of R28's clinical record revealed a physician's order dated 3/9/23 for citalopram 10 mg (milligrams) once daily. A review of R28's MARs (medication administration records) for March 2023 and April 2023 revealed the resident was administered citalopram once daily (3/10/23 through 4/2/23). Further review of R28's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for March 2023 and April 2023) failed to reveal the resident was monitored for side effects from the medication citalopram. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. Reference: (1) Citalopram is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html.

Based on observation, staff interview and facility document review, the facility staff failed to ensure food items available for use were used or discarded prior to the best when used by date, in one of eight small house kitchens, the occoquan kitchen. The findings include: The facility staff failed to store mayonnaise in a safe manner. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of [DATE] were observed in the occoquan kitchen pantry. On [DATE] at 12:12 p.m., observation of the occoquan kitchen was conducted. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of [DATE] were observed available for use, on the shelf, in the pantry. On [DATE] at 9:56 a.m., an interview was conducted with OSM (other staff member) #5, the sous chef. OSM #5 stated unopened mayonnaise should be discarded after the best when used by date. OSM #5 stated, I don't want residents to get sick, and the quality has gone down. On [DATE] at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the director of nursing, and OSM (other staff member) #6, the director of dining services, were made aware of the above concern. The facility policy titled, Intake and Storage of Food documented, 4. Before use food will be checked for expiration date and discarded if expired.

Based on observation, staff interview, and facility document review it was determined facility staff failed Store, food in accordance with professional standards for food service safety in one of eight kitchens observed, [NAME] small house kitchen. The facility failed to dispose of plain Greek yogurt with a best by date of [DATE] and honey mustard dressing with a use by date of [DATE] located on the [NAME] small house kitchen. The findings include: On [DATE] at approximately 1:30 p.m., an observation was made of the [NAME] small house kitchen in the facility. Observation of the French door refrigerator located in the kitchen area revealed an unopened 32 ounce container of plain Greek yogurt. The container was observed to have the manufacturers date documenting Best by 19 [DATE]. Observation of the standing side by side refrigerator/freezer located in the pantry area of the [NAME] small house kitchen revealed a one gallon container of honey mustard dressing approximately one-quarter full. The container was observed to have a manufacturer's date of mfg: 21/Jan/2020 with a facility label documenting prep date: [DATE], Use by: [DATE]. On [DATE] at 1:44 p.m., an interview was conducted with CNA (certified nursing assistant)/Care Partner #1. CNA #1 stated that they worked in the [NAME] small house kitchen serving resident meals and maintaining the kitchen area. CNA #1 stated that they checked for expired items each morning prior to breakfast and the night shift staff also checked for any expired items or food items that may have gone bad. CNA #1 observed the 32 ounce container of plain Greek yogurt and stated that they used the manufacturer's best by date on the container as the date to discard items. CNA #1 stated that the container with the best by date of 19 [DATE] should have been discarded and not available for use in the refrigerator. CNA #1 observed the one gallon container of honey mustard dressing with the label documenting use by [DATE] and stated that they only kept dressings for one month after opening and they were not sure how that container was not caught during their checks. CNA #1 stated the container was approximately one-quarter full. On [DATE] at 3:07 p.m., an interview was conducted with OSM (other staff member) #1, executive chef and OSM #2, the director of dining. OSM #2 stated that they had checks in place to ensure expired items were removed promptly. OSM #2 stated that the cooks came in and checked the kitchens once a day and the overnight care partner staff had a checklist in place to complete. OSM #2 stated that any opened refrigerated items were dated when opened. OSM #2 stated that they dated the one gallon dressing containers with the first day of prep and then a one month use by date. OSM #2 stated that some of the products did not come with an expiration date or a best by date and that was the reason for their labeling system. OSM #2 stated that products that had a best by date from the manufacturer were discarded on that date. OSM #2 stated that they used the best by date as the expiration date. On [DATE] at approximately 3:15 p.m., a request was made to OSM #1 and OSM #2 for the manufacturer's recommendations for shelf life storage of the one gallon honey mustard dressing after opening and for the best by dates on the plain Greek yogurt. On [DATE] at 4:20 p.m., OSM #1 stated that they had checked with the manufacturer regarding the one gallon dressing containers and they did not provide any specific guidelines for shelf life after opening so they followed their policy of discarding after one month. OSM #1 stated that the manufacturer also did not have any specific guidelines for use regarding the best by dates and both items should have been discarded prior to [DATE]. On [DATE] at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the facility policy on storage of refrigerated food items in the kitchen. The facility policy Intake and Storage of Food dated [DATE] documented in part, .Before use food will be checked for expiration date and discarded if expired . On [DATE] at approximately 4:45 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a safe and sanitary manner, in two of eight facility household kitchens, the Maherrin household kitchen and the Rappahannock household kitchen. 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens. The findings include: 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. On 1/29/19 at 12:22 p.m., observation of the Maherrin household kitchen was conducted. The following was observed: In the refrigerator: - An opened glass jar of homemade apricot pineapple jam that documented a resident's name on the top label. The top label documented, Apricot Pineapple Jam (YEAR). The jar did not contain manufacturer's information. A facility sticker on the jar documented a prep date of 12/22/18 and a use by date of 1/22/19. In the freezer: -An opened plain disposable container that contained a pink frozen substance. The container did not contain manufacturer's information. A facility sticker on the container identified the substance as sherbet and documented a prep date of 1/6/19 and a use by date of 1/9/19. -An opened plain disposable container that contained a white frozen substance that resembled ice cream. The container did not contain manufacturer's information and it was not labeled with any information. -An opened quart container of lactose free ice cream. The container was not fully closed and the top of the container was busted, exposing the contents to potential contaminates. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 was asked about the facility process for labeling and storing food. OSM #1 stated condiments including dressings are labeled and used for 30 days after being opened; dry foods are labeled and used for 30 days after being opened, and juices, milk, deli meats and eggs are kept for four days after being opened. OSM #1 stated the facility staff labels opened food with the name of the item, the day it was opened or prepped and the day the item needs to be used by. OSM #1 confirmed everything that is opened should be labeled and the integrity of the packaging should not be damaged. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Intake and Storage of Food documented, Storage practices which maintain food quality will be used .If the product expiration date is not indicated, use a food label to indicate food receipt and expiration date . No further information was presented prior to exit. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. On 1/29/19 at 12:36 p.m., observation of CNA (certified nursing assistant) #1 obtaining the holding temperatures of food in the Maherrin household kitchen was conducted. CNA #1 obtained the temperature of sliced provolone cheese that was prepared for sandwiches. The holding temperature of the cheese was 50 degrees Fahrenheit. The cheese was then placed on sandwiches that were served to two residents. On 1/30/19 at 11:49 a.m., observation of CNA #2 obtaining the holding temperatures of food in the Rappahannock household kitchen was conducted. CNA #2 obtained the temperature of club sandwiches that contained sliced turkey, bacon, lettuce, tomatoes and mayonnaise. The holding temperature of the sandwiches was 53 degrees Fahrenheit. The sandwiches were then served to four residents. On 1/30/19 at 2:42 p.m., an interview was conducted with CNA #1. CNA #1 was asked if there was any parameters for cold food holding temperatures and what should be done if the temperature does not meet those parameters. CNA #1 stated she sets the food out and lets it warm up if it is too cold for residents. CNA #1 then stated she calls the cook if the food is too cold. CNA #1 was asked if there was any safety concerns for cold food, being held too warm. CNA #1 stated cold food should stay cold but not below the normal temperature. When asked what the normal temperature was, CNA #1 stated 41 degrees. On 1/30/19 at 3:02 p.m., an interview was conducted with CNA #2. CNA #2 was asked at what temperature cold food should be held. CNA #2 stated 40 degrees and lower. CNA #2 was asked what should be done if the holding temperature of cold food is above 40 degrees. CNA #2 stated the food should be put back in the refrigerator. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 confirmed CNAs obtain the holding temperatures of food prior to serving in each household. OSM #1 stated the holding temperature of cold food should be below 41 degrees. When asked why, OSM #1 stated, So bacteria won't start growing on it. As long as it's 41, it should not grow. When asked what should be done if the holding temperature of cold food is above 41 degrees, OSM #1 stated the food should be put back in the refrigerator or freezer to get it to the temperature it needs to be. When asked if cold food held at a temperature above 41 should be served to residents, OSM #1 stated, No. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Serving Food at the correct temperature documented To ensure that all meals are prepared and served in a safe and sanitary manner, the dining services and nursing staff shall prepare and serve meals in a safe and sanitary manner and in accordance with all applicable government regulations .4. Foods that are to be served chilled should remain in the refrigeration until served. Chilled foods should be served at 41 F (degrees Fahrenheit) or below . No further information was presented prior to exit. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens. On 1/29/19 at 12:22 p.m., observation of the Maherrin household kitchen was conducted. An eight-cup pitcher was stored lying down in a cabinet. A small puddle of water was observed inside the pitcher. On 1/30/19 at 11:59 a.m., observation of the Rappahannock household kitchen was conducted. An eight-cup pitcher was stored lying down in a cabinet. A small puddle of water was observed inside the pitcher. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 was asked about the facility process followed for washing and storing pitchers and if the pitchers should be completely dry before being stored. OSM #1 stated, Yes. We let them air dry on the mats on top of the dishwasher. When asked why, OSM #1 stated, So no bacteria will get stuck on them and the moisture won't draw in any airborne stuff; so dust won't collect on them. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Washing Dishes documented, 9. Place dishes in dishwasher racks. Avoid overloading and nesting. 10. Close door and start machine. 11. Upon completion of dishwashing, empty the dishwasher and place dishes in storage . No further information was presented prior to exit.

Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide pain management for two of 31 residents in the survey sample, Residents # 46 and # 70. 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70. The findings include: 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. Resident # 46 was admitted to the facility on [DATE] with a readmission of 01/09/19 with [DIAGNOSES REDACTED]. Resident # 46's most recent MDS (minimum data set), 5 (five)-day assessment with an ARD (assessment reference date) of 01/16/19, coded Resident # 46 as scoring a 2 (two) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 2 (two)- being moderately impaired of cognition for making daily decisions. Resident # 46 was coded as requiring extensive assistance of one staff member for activities of daily living. The physician's orders [REDACTED]. Start Date: 01/09/19. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 46 documented, [MEDICATION NAME] 500MG (milligram) tablet- one tab (tablet) po (by mouth) every 6 (six) hours as needed for break through pain. Start Date: 01/09/19. Review of the eMAR revealed [MEDICATION NAME] 500mg was administered on 01/17/19 at 3:54 p.m., with a pain level of four. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. Review of the nurse's progress notes for Resident # 46 dated 01/17/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. The comprehensive care plan for Resident # 46 dated 01/09/2019 documented, Category : 019 Pain. Impaired comfort R/T (related to) diabetes,[MEDICAL CONDITION](cerebral vascular disease), impaired mobility, advanced age, c/o (complaint of) acute pain of right lower extremity. Start Date: 01/09/2019. Under Intervention it documented, Determine location, onset, duration and character of pain. Start Date: 01/09/2019. Complete pain assessment as ordered and per facility protocol using PAINAID Scale. Start Date: 01/09/2019. Further review of the comprehensive car plan for Resident # 46 failed to evidence documentation of the use of non-pharmacological interventions. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication) and documented in the nurse's notes. The facility's policy Pain Management documented, Non-Pharmacological Interventions. Pharmacological Interventions may help manage pain effectively when used either independently or in conjunction with pharmacologic agents. The nurse is required to document the effectiveness of the required nonphamacological intervention as well as the documenting the effectiveness of the pharmacological intervention. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: [MEDICAL CONDITION], Palsy, [MEDICAL CONDITIONS]. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. (3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. (4) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70. Resident # 70 was admitted to the facility on [DATE] with a readmission of 06/26/17 with [DIAGNOSES REDACTED]. Resident # 70's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/18, coded Resident # 70 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 70 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Section J Health Considerations coded Resident # 70 as having occasional moderate pain. The physician's orders [REDACTED].# 70 dated 01/30/2019 documented, [MEDICATION NAME] 50MG (6) (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 70 documented, [MEDICATION NAME] 50MG (6) (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. Review of the eMAR revealed [MEDICATION NAME] 50mg was administered on the following dates: - 01/01/19 at 5 300 a.m., with a pain level of six, - 01/02/19 at 12:27 a.m., with a pain level of seven, - 01/04/19 at 2:13 a.m., with a pain level of six, - 01/05 at 11:30 a.m., with a pain level of seven, - 01/07/19 at 1:50 a.m., with a pain level of six, - 01/08/19 at 2:00 a.m. with a pain level of five, - 01/09/19 at 2:40 a.m., with a pain level of five, - 01/10/19 at 3:30 a.m., with a pain level of six, - 01/14/19 at 11:01 a.m., with a pain level of eight, - 01/18/19 at 5:32 a.m., with a pain level of four, - 01/19/19 at 3:07 a.m. with a pain level of six, - 01/20/19 at 4:30 a.m., with a pain level of seven, - 01/23/19 at 5:11 a.m., with a pain level of six and on - 01/27/19 at 4:13 a.m., with a pain level of six. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. Review of the nurse's progress notes for Resident # 70 dated 01/01/19 through 01/29/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. The comprehensive care plan for Resident # 70 dated 03/30/2018 documented, Category : 019 Pain. Impaired comfort R/T (related to) lumbar spondolyosis. Under Interventions it documented, Offer non-pharmacological pain relief methods as needed. Start Date: 03/30/2018. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication and documented in the nurse's notes. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) There are many different forms of [MEDICAL CONDITION]. The most common cause of [MEDICAL CONDITION] is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called [MEDICAL CONDITION] and happens slowly over time. It's the major reason people have [MEDICAL CONDITION]. Other kinds of heart problems may happen to the valves in the heart, or the heart may not pump well and cause heart failure. Some people are born with [MEDICAL CONDITION]. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body. This information was obtained from the website: https://medlineplus.gov/[MEDICAL CONDITION].html. (4) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

Based on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in two of eight resident dining rooms. 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the(NAME)household unit. 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit. The findings include: 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the(NAME)household unit. On 1/29/19 at 5:06 p.m., an observation of the evening meal was conducted on the(NAME)household unit. CNA (certified nursing assistant) # 3 was observed in the kitchen area, wearing plastic gloves preparing and serving food. While wearing the gloves CNA # 3 was observed opening and closing the oven door, placing the serving dishes of food on the kitchen island, opening and closing kitchen cabinets and drawers to retrieve dinner plates and serving utensils. While wearing the same gloves CNA # 3 removed the plastic wrap on the serving platters of cooked squash and roasted potatoes, carried them to the dining table one at a time and carried it to each resident sitting at the table. Observation of CNA # 3's placement of her thumbs revealed they were on the surface of the serving platter next to the food. CNA # 3 then placed the platter next to each resident, asked the resident if they would like that food item and how much. CNA #3 then picked up the residents dinner plate placing her thumb on the food surface of the plate and then placed the food item on the plate. This process was observed for the service of the squash and roasted potatoes for four of the eight residents seated at the dining table. While still wearing the same gloves, CNA # 3 opened the oven, removed the casserole dish containing the pot roast, placed it on a serving tray on the kitchen island and closed the oven door. After removing the lid from the casserole dish, CNA # 3 picked up the tray with the casserole dish, placed her thumbs over the outside edge and on the inside edge of the casserole dish to keep it from sliding on the tray and then took it to the dining table to serve the residents. CNA # 3 carried the tray and casserole dish to each resident at the dining table with her thumbs over the outside edge and and on the inside edge of the casserole dish to keep it from sliding on the tray, and asked the residents if they would like that food item. CNA #3 then picked up the resident dinner plates placing her thumb on the food surface of the plate and served the food item onto the plate. This process was observed for four of the eight residents seated at the dining table On 1/29/19 at 5:55p.m., an interview was conducted with CNA # 3. When asked to describe the purpose for wearing gloves during food preparation and service, CNA # 3 stated, For sanitary reasons to keep the food from being contaminated. When asked if her thumbs or fingers should on the inside of the serving dishes or dinner plates CNA # 3 stated, No. When asked if she changed her gloves between tasks and before serving, the residents' their food, CNA # 3 stated, No. On 01/30/19 at approximately 5:45 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of clinical services were made aware of the findings. No further information was provided prior to exit. (2) [MEDICATION NAME] is used to treat pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 1.html (3) [MEDICATION NAME] is used to treat pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 4.html 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit. On 1/29/19 at 12:36 p.m., a dining observation was conducted in the Maherrin household unit. The following was observed: -CNA #1 washed her hands and applied a pair of disposable gloves. CNA #1 opened a cabinet with a gloved hand and removed bowls from the cabinet. While handling the bowls, CNA #1's gloved hand that was used to open the cabinet was observed touching the food contact area of a bowl. Soup was then placed in that bowl and served to a resident. -CNA #1 washed her hands and applied a pair of disposable gloves. CNA #1 opened a cabinet with both gloved hands and removed plates from the cabinet. While handling the plates, CNA #1's gloved hands that were used to open the cabinet were observed touching the food contact area of a plate. Food was then placed on that plate and served to a resident. On 1/30/19 at 2:42 p.m., an interview was conducted with CNA #1. CNA #1 was asked if she should touch the inside of a serving bowl or plate with the same gloves that were worn while touching the handles of a cabinet. CNA #1 stated she should wash her hands and change gloves after touching the handle of a cabinet because she does not know what is on the handle. When asked if touching the inside of a serving bowl or plate with the same gloves worn while touching a cabinet handle is an infection control issue, CNA #1 stated, Yes. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Proper Handling Of Food Glassware Dishes And Utensils documented, 1. The food contact area of plates bowls glasses or cups should not be touched . No further information was presented prior to exit.

Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure respiratory care and services were provided in accordance with professional standard of practice and the comprehensive person-centered care plan for one of 31 residents in the survey sample, Resident # 72. The facility staff failed to administer Resident # 72's oxygen according to the physician's orders [REDACTED]. The findings include: Resident # 72 was admitted to the facility on [DATE] with a readmission 03/13/2018 with [DIAGNOSES REDACTED]. Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/18, coded Resident # 72 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 72 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Under section O. Special Treatment, Procedures and Programs Resident # 72 was coded for C. Oxygen therapy. On 01/29/19 at 12:22 p.m., an observation of Resident # 72 revealed she was sitting up in an armchair reading the paper receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate was set at two and a half liters per minute. On 01/30/19 at 7:59 a.m., an observation of Resident # 72 revealed she was lying in bed receiving oxygen by nasal cannula. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. 01/31/19 at 7:42 a.m., an observation of Resident # 72 revealed she was lying in bed awake receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. The POS (physician's orders [REDACTED].# 72 dated 01/30 2019documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / [MEDICAL CONDITIONS]. Order Date: 09/10/2018. The comprehensive care plan for Resident # 72 dated 03/13/2018 documented, Ineffective airway clearance related to [MEDICAL CONDITION], pneumonia, paraneumonic right pleural effusion as evidenced by: increased coughing, oxygen saturation dropping with exertion. Under Interventions it documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / [MEDICAL CONDITIONS]. Start Date: 03/13/2018 On 01/31/19 at 7:44 a.m., an observation of Resident # 72's oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 3. When asked how to read the flow rate on the oxygen concentrator LPN # 3 stated, The liter line should be in the middle of the ball. When asked to read the flow rate on the oxygen concentrator for Resident # 72, LPN # 3 stated, It's at two and a half liters. When asked what physician's orders [REDACTED].# 72's oxygen, LPN # 3 stated Two liters. When asked how often the flow rate on oxygen concentrators is checked, LPN # 3 stated, Every shift. According to Fundamentals of Nursing, Perry and Potter, 6th edition, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity. As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders [REDACTED]. The six rights of medication administration also pertain to oxygen administration. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. Reference: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (4) A buildup of fluid between the layers of tissue that line the lungs and chest cavity. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm.

Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure the comprehensive care plan was implemented for two of 31 residents in the survey sample, Resident # 72 and Resident #70. 1. During multiple observations, Resident #72 was receiving oxygen at 2 (two) and a half, liters instead of the 2 L (two liters) ordered by the physician and per the residents comprehensive care plan. 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70. The findings include: 1. Resident # 72 was admitted to the facility on [DATE] with a readmission 03/13/2018 with diagnoses, which included but were not limited to: heart failure (1), [MEDICAL CONDITION] (2), dysphagia (3) and pleural effusion (4). Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/18, coded Resident # 72 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 72 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Under section O. Special Treatment, Procedures and Programs Resident # 72 was coded for C. Oxygen therapy. The POS (physician's orders [REDACTED].# 72 dated 01/30 2019documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / [MEDICAL CONDITIONS]. Order Date: 09/10/2018. The comprehensive care plan for Resident # 72 dated 03/13/2018 documented, Ineffective airway clearance related to [MEDICAL CONDITION], pneumonia, parapneumonic right pleural effusion as evidenced by: increased coughing, oxygen saturation dropping with exertion. Under Interventions it documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) On 01/29/19 at 12:22 p.m., an observation of Resident # 72 revealed she was sitting up in an armchair reading the paper receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate was set at two and a half liters per minute. On 01/30/19 at 7:59 a.m., an observation of Resident # 72 revealed she was lying in bed receiving oxygen by nasal cannula. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. 01/31/19 at 7:42 a.m., an observation of Resident # 72 revealed she was lying in bed awake receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. On 01/31/19 at 7:44 a.m., an observation of Resident # 72's oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 3. When asked how to read the flow rate on the oxygen concentrator LPN # 3 stated, The liter line should be in the middle of the ball. When asked to read the flow rate on the oxygen concentrator for Resident # 72, LPN # 3 stated, It's at two and a half liters. When asked what physician's orders [REDACTED].# 72's oxygen, LPN # 3 stated Two liters. When asked how often the flow rate on oxygen concentrators is checked, LPN # 3 stated, Every shift. According to Fundamentals of Nursing Lippincott[NAME] and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care (5) On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. Reference: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (4) A buildup of fluid between the layers of tissue that line the lungs and chest cavity. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm. (5) Fundamentals of Nursing Lippincott[NAME] & Wilkins 2007 Lippincott Company Philadelphia pages 65-77 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70. Resident # 70 was admitted to the facility on [DATE] with a readmission of 06/26/17 with [DIAGNOSES REDACTED]. Resident # 70's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/18, coded Resident # 70 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 70 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Section J Health Considerations coded Resident # 70 as having occasional moderate pain. The comprehensive care plan for Resident # 70 dated 03/30/2018 documented, Category : 019 Pain. Impaired comfort R/T (related to) lumbar spondylosis. Under Interventions it documented, Offer non-pharmacological pain relief methods as needed. Start Date: 03/30/2018. The physician's orders [REDACTED].# 70 dated 01/30/2019 documented, [MEDICATION NAME] 50MG (6) (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 70 documented, [MEDICATION NAME] 50MG (6) (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. Review of the eMAR revealed [MEDICATION NAME] 50mg was administered on the following dates: - 01/01/19 at 5 300 a.m., with a pain level of six, - 01/02/19 at 12:27 a.m., with a pain level of seven, - 01/04/19 at 2:13 a.m., with a pain level of six, - 01/05 at 11:30 a.m., with a pain level of seven, - 01/07/19 at 1:50 a.m., with a pain level of six, - 01/08/19 at 2:00 a.m. with a pain level of five, - 01/09/19 at 2:40 a.m., with a pain level of five, - 01/10/19 at 3:30 a.m., with a pain level of six, - 01/14/19 at 11:01 a.m., with a pain level of eight, - 01/18/19 at 5:32 a.m., with a pain level of four, - 01/19/19 at 3:07 a.m. with a pain level of six, - 01/20/19 at 4:30 a.m., with a pain level of seven, - 01/23/19 at 5:11 a.m., with a pain level of six and on - 01/27/19 at 4:13 a.m., with a pain level of six. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. Review of the nurse's progress notes for Resident # 70 dated 01/01/19 through 01/29/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of [MEDICATION NAME]. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication and documented in the nurse's notes. According to Fundamentals of Nursing Lippincott[NAME] and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care (6) On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) There are many different forms of [MEDICAL CONDITION]. The most common cause of [MEDICAL CONDITION] is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called [MEDICAL CONDITION] and happens slowly over time. It's the major reason people have [MEDICAL CONDITION]. Other kinds of heart problems may happen to the valves in the heart, or the heart may not pump well and cause heart failure. Some people are born with [MEDICAL CONDITION]. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (3) A disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body. This information was obtained from the website: https://medlineplus.gov/[MEDICAL CONDITION].html. (4) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (6) Fundamentals of Nursing Lippincott[NAME] & Wilkins 2007 Lippincott Company Philadelphia pages 65-77

Based on staff interview and clinical record review, it was determined that the facility staff failed to complete a discharge minimum data set (MDS) assessment for one of 31 residents in the survey sample; Resident #2. Resident #2 expired in the facility on [DATE]. The most recent MDS in the facility's system was a quarterly MDS with an ARD (assessment reference date) of [DATE]. As of [DATE], the date of the survey, there had been no discharge MDS assessment completed. The findings include: Resident #2 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of [DATE]. The resident was coded as mildly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, and toileting; limited assistance for hygiene; supervision for eating; and was continent of bowel and bladder. A review of the clinical record revealed a nurse's note dated [DATE] that documented, At 0605 (6:05 a.m.) when this nurse was doing rounds observed resident unresponsive, no BP (blood pressure) no pulse, no respirations. Writer called nurse supervisor, he came immediately assessed resident pronounced her death. Resident was last seen at 0400 (4:00 a.m.) during rounds sleeping bed comfortably with no distress. At 0520 (5:20 a.m.) care partner (certified nursing assistant) took resident to bath room and helped transferred to bed comfortably A review of the clinical record failed to reveal any evidence of a discharge, death in facility MDS assessment. On [DATE] at 5:14 p.m., in an interview with RN #4 (Registered Nurse) the MDS coordinator, she stated, You are right, it wasn't done. She stated the facility has 7 days to complete the MDS after discharge and then another 14 days to submit it. RN #4 stated it should have been done by approximately (MONTH) 21, (YEAR). RN #4 stated it was not done because it did not show up on her calendar as an incomplete/missed MDS. On [DATE] at 6:01 p.m., RN #4 was asked about the policy used by the facility to complete MDS assessments, RN #4 stated the RAI Manual (Resident Assessment Instrument). On [DATE] at 6:01 p.m., the ASM (administrative staff member) #1, the Administrator and ASM #2, director of clinical services were made aware of the findings. No further information was provided. According to the RAI Manual, (MONTH) (YEAR), page ,[DATE], Death In Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking record. No Discharge assessment is required. And, on page ,[DATE] in a table, was documented that the Death in Facility MDS must be completed no later than death date plus 7 calendar days, and submitted by death date plus 14 calendar days.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to meet the appropriate transfer requirements for three of 31 residents in the survey sample; Resident # 46, # 21, and # 69. 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18. The findings include: 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. Resident # 46 was admitted to the facility on [DATE] with a readmission of 01/09/19 with [DIAGNOSES REDACTED]. Resident # 46's most recent MDS (minimum data set), 5 (five)-day assessment with an ARD (assessment reference date) of 01/16/19, coded Resident # 46 as scoring a 2 (two) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 2 (two) - being moderately impaired of cognition for making daily decisions. Resident # 46 was coded as requiring extensive assistance of one staff member for activities of daily living. The nurse's Progress Notes, dated 01/06/2019 for Resident # 46 documented, Around 1800 (6:00 p.m.), writer was notified by charge nurse of resident's [DIAGNOSES REDACTED] episode. Upon assessment, resident noted lethargic, difficult to arouse with verbal stimulation touch, noted with SOB (shortness of breath), and expiratory wheezing, O2 (oxygen) 2L (two liters) administered, neb (nebulizer) tx (treatment) administered but wheezing continues. Message sent to urgent care, resident sent to (Name of Hospital) ER (emergency room ) via (by) 911 with RP (responsible party) (Name of Responsible Party) at bedside. Bed hold policy and notice of transfer given to RP. Call placed to (Name of Hospital) ER at 2255 (10:55 p.m.), resident is being admitted for AMS (altered mental status) and acute asthma. Review of the facility's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19 for Resident # 46 failed evidence documentation that the residents comprehensive care plan goals were sent to (Name of Hospital) for this facility initiated transfer of Resident # 46. On 01/31/19 at 8:19 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services. When asked to describe the process followed for a facility initiated transfer of a resident to the hospital, ASM # 2 stated, Obtain the physician's orders [REDACTED]. Notification to the ombudsman is done by the social worker, and the care plan goals are part of the transfer form. After review of Resident # 46's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19, ASM # 2 agreed the form failed evidence documentation that the residents comprehensive care plan goals were sent to the receiving facility at the time of Resident # 46's facility initiated transfer on 01/06/19. The facility's policy Facility-initiated Transfer documented, Procedure: 1. The licensed nurse (Nursing Supervisor or designee) will provide the receiving providers (hospital) with the following information upon transfer. e. Comprehensive Care Plan Goals. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: [MEDICAL CONDITION], Palsy, [MEDICAL CONDITIONS]. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. (3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. (4) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. Resident # 21 was admitted to the facility on [DATE] with a readmission of 01/10/19 with [DIAGNOSES REDACTED]. Resident # 21's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/23/19, coded Resident # 21 coded as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 21 was coded as requiring extensive assistance of one staff member for activities of daily living. A nurse's Progress Notes, dated 01/07/2019 for Resident # 21 at 1605 (4:05 p.m.) documented, Physician transport with two crew from (Name of Doctor ' s Office) arrived at 1430 (2:30 p.m.), Resident is transferred from her bed to a stretcher by the crew, she is transferred to (Name of Hospital) at 1510 (3:10 p.m.). Writer called (Name of Hospital) and gave report to (Name of Nurse). Completed EMS (emergency medical service) form, immunization, Transfer to and from form, reason for transfer (nurse ID note), labs (laboratory results), insurance card, medication list sent with resident. Review of the facility's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/07/19 for Resident # 21 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the facility initiated transfer of Resident # 21. On 01/31/19 at 8:19 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services. When asked to describe the process followed for a facility initiated transfer of a resident to the hospital, ASM # 2 stated, Obtain the physician's orders [REDACTED]. Notification to the ombudsman is done by the social worker, and the care plan goals are part of the transfer form. After review of Resident # 21's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19 ASM # 2 agreed the form failed to evidence the residents comprehensive care plan goals were sent to the receiving facility at the time of Resident # 21's facility initiated transfer on 01/07/19. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting [MEDICAL CONDITION], stroke, and other problems. The medical term for high blood cholesterol is lipid disorder, [MEDICAL CONDITION], or [MEDICAL CONDITION]. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. (2) A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing [MEDICATION NAME] damage. This information was obtained from the website: https://medlineplus.gov/ency/article/ 6.htm . (3) A disease that causes the airways of the lungs to swell and narrow. It leads to wheezing, shortness of breath, chest tightness, and coughing. Information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18. Resident #69 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 12/26/18. The resident was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed nurses notes dated 12/11/18, that documented Resident #69 was transferred to the hospital. The note documented in part, No improvement seen, condition remain the same. All paper work in place, Staff at bedside, resident shows no distress. 911 call, family updated. Further review of the clinical record failed to reveal evidence that the comprehensive care plan goals were provided to the receiving hospital. On 1/31/19 at 8:20 a.m., in an interview with ASM #2 (Administrative Staff Member - the Director of Nursing - DON), she stated that the information documented on the hospital transfer form is reflective of what the care plan goals are. She provided a copy of this document as it was completed for Resident #69 on 12/11/18. This document included demographic information, insurance information, Living Will / Do Not Resuscitate information. The document included, Medical Condition which was not completed Medical History which was not completed, allergies [REDACTED]. There was nothing-documenting comprehensive care plan goals, and the information provided was incomplete and insufficient to address the goals of the comprehensive care plan. On 1/31/19 at 10:46 a.m., in an interview with RN #3 (Registered Nurse) when asked if care plan goals are sent to the hospital when a resident is transferred, RN #3 stated, We have not sent them to the hospital. On 1/31/19 at 10:52 a.m., in an interview with RN #2, she stated, We send the care plan goals. We were inserviced 2 weeks ago. When asked if the comprehensive care plan goals were being sent in (MONTH) (YEAR) when Resident #69 went to the hospital, RN #2 stated, I can't say if care plan goals were sent in December. It was a new inservice (the one from 2 weeks ago). I don't remember sending it back then. At this time, RN #2 showed the inservice information she received to this writer. It documented the following: Checklist for Facility-Initiated Transfers to Hospital 1. The licensed nurse (nursing supervisor or designee) will provide the hospital with the following information: * Print EMS form and complete to include: Immunizations Transfer to and from Reason for transfer Any other pertinent information (such as labs or x-ray) * Print Advanced Directives from (facility electronic system) * Print Insurance cards from (facility electronic system) * Print Medication list from (facility electronic system) 2. The licensed nurse (nursing supervisor or designee) will provide the resident (and resident responsible party if present): * Print Bed Hold notice * Print and complete notice of transfer or Discharge form 3. The licensed nurse will document in the electronic record that all the items were provided and family notified. 4. The licensed nurse will make a copy of the EMS form, Notice of Transfer or Discharge form, and checklist. Copies are to be put in the ADON (assistant director of nursing) office for review. On 1/31/19 at 11:08 a.m., in an interview with RN #2, after reviewing the above document she provided, when asked if it addresses anything about sending the comprehensive care plan goals, RN #2 stated, It doesn't. No further information was provided by the end of the survey.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote dignity for one of 31 residents in the survey sample, Resident # 37. During a dining observation, in the Willis household unit dining room, Resident # 37 was observed sitting at the dining room table and waiting 23 minutes to be served and assisted with eating his meal by staff, while watching seven residents seated at the table with him, eat their dinner. The findings include: Resident # 37 was admitted to the facility on [DATE] and a readmission on 01/121/2016 with [DIAGNOSES REDACTED]. Resident # 37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/04/18, coded Resident # 37 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 37 was coded as requiring total dependence for activities of daily living of one staff member and as requiring extensive assistance of one staff member for eating. The comprehensive care plan for Resident # 37 dated 03/20/2018 documented, ADL Function: Self-neglect related to advanced dementia AEB (as evidenced by) (Resident # 37) requires total assistance with bed mobility, transferring, toileting, dressing, grooming, bathing and eating r/t (related to) cognitive impairment due to advanced dementia, decline, (sic) [MEDICAL CONDITION] and [MEDICAL CONDITION] disk disease. Start Date: 03/20/2018. Under Intervention it documented, Provide 1:1 (one to one) assistance with feeding r/t dysphagia and Alzheimer's Dementia. Start Date: 03/20/2018. On 01/29/19 at 5:06 p.m., an observation was conducted of the Willis household unit dining room. An observation of the dining room table revealed eight residents were seated at the table, 7 women and Resident # 37. At 5:22 p.m., salads were served to the seven women and they began eating; Resident # 37 seated at the end of the table had a glass of juice and a glass of water and a place setting in front of him on the table. Further observation revealed Resident # 37 had not receive a salad nor had he received a sip if his water or juice. At 5:38 p.m., the seven women were served the main meal consisting of pot roast, potatoes and squash and began eating; Resident # 37 seated at the end of the table still had a glass of juice and a glass of water and a place setting in front of him on the table. Further observation revealed Resident # 37 did not receive the main meal nor had he received a sip of his water or juice. At 5:44 p.m., a staff member placed Resident # 37's meal in front of him. At 5:45 p.m., a staff member sat down next to Resident # 37 and began assisting Resident # 37 with his food and drink. Resident # 37 sat at the dining room table and waited approximately 23 minutes before his meal was provided and a staff member to begin to assisting him with eating, while watching the other seven residents seated at the table with him, eat their dinner. On 01/29/19 at approximately 5:55 p.m., an interview was conducted with CNA (certified nursing assistant) # 3. When asked why Resident # 37 had to wait approximately 23 minutes to eat when everyone else was eating, CNA # 3 stated, They should not have to wait. We serve the ladies first and serve (Resident # 37) within five or ten minutes. When asked if it was appropriate and dignified for Resident # 37 to wait over 20 minutes to eat while everyone else at the table was eating, CNA # 3 stated, No. He requires one to one assistance; he should be eating at the same time as everyone else. The facility's RESIDENT RIGHTS documented, 15. The right to be treated with courtesy, respect and dignity. On 01/30/19 at approximately 5:45 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of clinical services were made aware of the findings. No further information was provided prior to exit. References: (1) A brain disorder that seriously affects a person's ability to carry out daily activities). This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. (2) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (3) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. (4) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for three of 31 residents in the survey sample, Residents #223, #127 and #68. 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in (MONTH) 2019. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in (MONTH) 2019. 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in (MONTH) 2019. The findings include: 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in (MONTH) 2019. Resident #223 was admitted to the facility on [DATE]. Resident #223's [DIAGNOSES REDACTED]. Resident #223's admission MDS (minimum data set) was not complete. Resident #223's admission nursing assessment dated [DATE], documented the resident was oriented. Resident #223's care plan dated 1/25/19 documented, Impaired comfort related to L1 (lumbar one vertebrae) Compression fracture .Provide PRN (as needed) medication as per MD (medical doctor) orders. The care plan failed to document information regarding non-pharmacological interventions. Review of Resident #223's clinical record revealed the following physician's orders: 1/25/19- [MEDICATION NAME] (1) 5-325 mg (milligrams) - one tablet every six hours as needed for severe pain. 1/25/19- [MEDICATION NAME] (2) 50 mg- one tablet every 12 hours as needed for moderate back pain. 1/25/19- [MEDICATION NAME] (3) 325 mg- two tablets every eight hours as needed for generalized pain. Review of Resident #223's (MONTH) 2019 eMAR (electronic medication administration record) revealed the resident was administered the above medications on the following dates: [MEDICATION NAME] on 1/25/19 through 1/30/19. [MEDICATION NAME] on 1/26/19 and 1/28/19 through 1/30/19. Tylenol on 1/27/19 through 1/30/19. Further review of Resident #223's clinical record (including the (MONTH) 2019 eMAR and nurses' notes) failed to reveal documentation that non-pharmacological interventions were offered to the resident prior to the administration of as needed [MEDICATION NAME], as needed [MEDICATION NAME] and as needed Tylenol on the above dates. On 1/30/19 at 4:55 p.m., an interview was conducted with Resident #223. Resident #223 was asked if nurses offer non-pharmacological interventions such as repositioning, heat, or cold therapy before giving her as needed pain medication. Resident #223 stated, No. I don't think so. On 1/30/19 at 5:07 p.m., an interview was conducted with RN (registered nurse) #1 (a nurse who administered some of the above as needed pain medications on some of the above dates). RN #1 was asked what should be done prior to administering as needed pain medication. RN #1 stated, You have to assess the resident first. When asked if anything else should be done, RN #1 stated, You can also check if their last prn (as needed pain medication) was effective. When asked if nurses should offer non-pharmacological interventions prior to administering as needed pain medication, RN #1 stated, That depends. You need a doctor's order. When asked to clarify that statement, RN #1 stated nurses sometimes, but not always, need a doctor's orders for non-pharmacological interventions. When asked if she offers residents non-pharmacological interventions, RN #1 stated, Yes. When asked to describe the non-pharmacological interventions she offers Resident #223, RN #1 stated she repositions the resident prior to administering as needed pain medication. When asked if she documents the non-pharmacological interventions, she offers Resident #223, RN #1 stated, No. When asked if that should be documented, RN #1 stated, Yeah. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. On 1/31/19 at 7:26 a.m., an interview was conducted with LPN (licensed practical nurse) #1 (another nurse who administered some of the above as needed pain medications on some of the above dates). LPN #1 was asked what should be done prior to administering as needed pain medication. LPN #1 stated, Whenever a resident asks for pain medication I'll ask them to rate their pain. I'll try to do non-pharmacological interventions first. If that don't work I'll given them what I'm supposed to according to the pain scale. LPN #1 was asked to describe the non-pharmacological interventions she offers Resident #223. LPN #1 stated assists the resident with repositioning and has provided a blanket to the resident. When asked if she documents the non-pharmacological interventions she offers Resident #223, LPN #1 stated, Sometimes I do. LPN #1 confirmed she does not always document the non-pharmacological interventions she provides although she is supposed to. The facility policy titled, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents .The nurse is required to document the effectiveness of the required nonpharmacological intervention . No further information was presented prior to exit. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in (MONTH) 2019. Resident #127 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) had not yet been completed due to the recent admission time frame. The admission nursing assessment dated [DATE] documented the resident as oriented to person and place, but not time; as requiring assistance with activities of daily living; and as being continent of bowel and bladder. A review of the clinical record revealed a physician's order dated 1/21/19 for [MEDICATION NAME] {1} 5 mg (milligram) tablet, take 2.5 mg (half tablet) every 6 hours as needed for post-surgical pain. A review of the (MONTH) 2019 MAR (Medication Administration Record) revealed that Resident #127 received the as-needed [MEDICATION NAME] once each day on the dates of (MONTH) 24, 25, 26, 27, 28, 29, and 30, 2019. Further review of the clinical record failed to reveal any evidence of non-pharmacological interventions being offered or attempted. On 1/31/19 at 10:43 a.m., in an interview with RN #3 (Registered Nurse), RN #3 stated, Usually she (Resident #127) rates pain at a 5 most of the time. When you touch the right leg, she will grimace and guard herself. Her behavior expresses pain. Her daughter assisted with communication of pain. When she has pain, we turn her, reposition her to make her comfortable; sometimes she allows us to apply heat, it helps to relax her. When asked about documenting these non-pharmacological interventions, RN #3 stated, I have not documented on the non-pharmacological. It should be documented as part of her pain management. A review of the care plan for Resident #127 included one for pain, however, it did not include the use of, or documentation of non-pharmacological interventions. A review of the facility policy, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents The nurse is required to document the effectiveness of the required nonpharmacological intervention On 1/31/19 at approximately 10:30 a.m., ASM #2 (Administrative Staff Member, the director of clinical services) was made aware of the findings. No further information was provided by the end of the survey. {1} [MEDICATION NAME] is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in (MONTH) 2019. Resident #68 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/2/18. The resident was coded as moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for dressing, toileting and hygiene; limited assistance for transfers; supervision for ambulation and eating; and was coded as continent of bowel and as having an indwelling catheter for bladder. A review of the clinical record revealed a physician's order dated 4/18/18 for Tylenol {1} 325 mg (milligrams), give 2 tabs (tablets) (650 mg) every 4 hours as needed for generalized discomfort. Also noted, was a physician's order dated 4/18/18 for [MEDICATION NAME] {2} 5 mg tablet, give 1 tablet every 4 hours as needed for severe breakthrough pain. A review of the (MONTH) 2019 MAR (Medication Administration Record) revealed that Resident #68 received the Tylenol once on 1/7/19; and the [MEDICATION NAME] once on each date of (MONTH) 4, 5, 7, 8, 14, 19, 20, 21, and 22, 2019, without documented evidence of non-pharmacological interventions being offered or attempted. On 1/31/19 at 10:48 a.m., in an interview with RN #2 (Registered Nurse), RN #2 stated, Knowing him (Resident #68) I find out what he has been doing, if he has been walking too much, I have him sit down, put a pillow behind him, give him water, let him sit. If he says this is not going away after monitoring for 5-10 minutes, I rate the scale 1-10 how painful, where it is, etc. When asked if she documents the non-pharmacological interventions that she attempted, RN #2 stated, That's the problem. We haven't been in the process of documenting that. A review of the care plan for Resident #68 included one for pain, however, it did not include the use of, or documentation of non-pharmacological interventions. A review of the facility policy, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents The nurse is required to document the effectiveness of the required nonpharmacological intervention On 1/31/19 at approximately 10:30 a.m., ASM #2 (Administrative Staff Member, the director of clinical services) was made aware of the findings. No further information was provided by the end of the survey. {1} Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html {2} [MEDICATION NAME] is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (1) [MEDICATION NAME] is used to treat pain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm

Based on resident interview, 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 two of 21 residents in the survey sample, Residents #39 and #43. 1. The facility staff failed to review and revise Resident #39's comprehensive care plan following a [DIAGNOSES REDACTED]. 2. The facility staff failed to review and revise Resident #43's comprehensive care plan to include the resident's preference not have male caregivers. The findings include: 1. The facility staff failed to review and revise Resident #39's comprehensive care plan following a [DIAGNOSES REDACTED]. Resident #39 was admitted to the facility on [DATE], with a readmission on 10/15/15, with [DIAGNOSES REDACTED]. Resident #39's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/6/17, coded Resident #39 as scoring a 15 out of a possible 15 on her BIMS (brief interview for mental status), indicating that Resident #39 was competent to make decisions regarding tasks for daily life. 01/24/18 at 10:25 a.m., an interview was conducted with Resident #39. When asked if she had been diagnosed with [REDACTED].#39 stated, I just had one recently. The doctor gave me an antibiotic; I think it's better now. A review of Resident #39's comprehensive care plan dated 8/1/14 did not reveal any documentation related to a recent urinary tract infection or antibiotic treatment for [REDACTED]. A review of Resident #39's physician orders revealed, in part, the following orders: - 1/2/18 Lab Urine culture - One time only. - 1/7/18 M (medication) [MEDICATION NAME] (1) (an antibiotic used to treat bacterial infections) 250 mg (milligrams) tablet by mouth. Twice daily For for (sic) UTI (urinary tract infection). On 01/25/18 at 01:05 p.m., an interview was conducted with RN (registered nurse) #1, the MDS coordinator. RN #1 was asked who was responsible for completing a care plan. RN #1 stated, I am responsible for creating the comprehensive care plan after the nurses have started the initial admission care plan. When asked who does the care plan revisions, RN #1 stated, I review and revise the care plans quarterly, unless there is a fall then the nurse taking care of that person will update the care plan accordingly. RN #1 was asked whether the care plan is updated if the resident has an infection with a specific treatment. RN #1 stated, I haven't seen that, no. We do not update for infections. There is not a thing for that. RN #1 was asked to state the reason for a comprehensive care plan. RN #1 stated, So that staff know how to care for a resident and their specific needs. RN #1 was asked to review Resident #39's comprehensive care plan. RN #1 was asked if there was a revision in the comprehensive care plan that addressed Resident #39's UTI. RN #1 stated there was not. RN #1 further stated, It should be there, I have never care planned for that (an infection) in this facility, we just didn't do it. I understand now that it should be updated. An end of day meeting was conducted on 1/25/18 at 5:25 p.m. with ASM (administrative staff member) #1, the executive director, ASM #2, the administrator, ASM #3, the director of nursing, ASM #4, the assistant director of nursing, and OSM (other staff member) #4, the dietitian. ASM #1, ASM #2, ASM #3, ASM #4 and OSM #4 were made aware of the above findings and a request was made at this time for a copy of the policy for completing a comprehensive care plan. A review of the facility policy titled Resident Centered Care Planning revealed, in part, the following documentation; POLICY: A comprehensive assessment followed by periodic re-assessment of resident's needs shall be conducted in accordance with current Federal and State regulations for the RAI (resident assessment instrument). PURPOSE: Care plan interventions provide direction to the nursing and interdisciplinary staff regarding specific actions and treatments identified as useful or necessary in helping the resident achieve established goals and objectives. PR[NAME]EDURE: Assessment: 2. the assessments will be comprehensive and current in order to identify a Plan of Care which follows residents' needs and desires. B. Development: 10. All care plans are available for review and update in the Electronic Health Record. (1) To reduce the development of drug-resistant bacteria and maintain the effectiveness of [MEDICATION NAME] and other antibacterial drugs, [MEDICATION NAME] should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. This information was obtained from the following website; https://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid= 5 2. The facility staff failed to review and revise Resident #43's comprehensive care plan to include the resident's preference not have male caregivers. Resident #43 was admitted to the facility on [DATE] with a recent readmission on 9/15/17, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data) set assessment, a quarterly assessment, with an assessment reference date of 12/19/17, coded the resident as scoring an eight on the BIMS (brief interview for mental status) score, indicating that she was moderately impaired to make daily cognitive decisions. She was coded as always understanding others and always making herself understood. Resident #43 was coded as requiring extensive assistance of one or more staff members for bed mobility, transfers, moving on the unit, toileting, personal hygiene and bathing. An interview was conducted with Resident #43 on 1/24/18 at 2:37 p.m. The resident stated that she did not like having a male care partner when using the bathroom, changing or showering. An interview was conducted with Resident #43 on 1/25/18 at 2:31 p.m. When asked if she had told the staff of her request to not have a male attendant for toileting and showers, Resident #43 stated that she had and it only happens every once in a while now. Resident #43 stated, I'm an old fashioned person and I don't want to expose my body to a man. It makes me uncomfortable and I just want to cringe. The resident could not recall whom she told about her request. Review of the comprehensive care plan dated 9/8/17 documented in part, Nursing Dx (diagnosis): Self-care deficit with bed mobility, transferring, locomotion on/off the unit, dressing, toileting, hygiene and bathing related to volume overload 2nd to ARF (acute [MEDICAL CONDITION]), newly Dx with [MEDICAL CONDITION] and metabolic [MEDICAL CONDITIONS] [MEDICAL CONDITION] and SOB (shortness of breath). The Interventions documented in part, Staff will provide extensive assistance with ADLs (activities of daily living) depending on her mood and alertness. Resident will be encouraged to participate as much as she can. Resident requires one person assistance with toileting depending on her mood, will call for assistance. Resident takes showers twice a week and as needed on Monday and Thursday on 3-11 shift. Resident requires total assistance with showers. Resident uses special medicated toothpaste every morning and requires set up assistance with oral hygiene. Resident is able to dress her upper body, requires lower body assistance with dressing. There was no documentation of resident's request for no male care partners for toileting, bathing or dressing. An interview was conducted with care partner (CP) #3 on 1/25/18 at 2:35 p.m. When asked how she is made aware, if a female resident does not wish to have a male care partner, of that, CP #3 stated, It should be in their care card on the computer. When asked if anyone currently residing on the Willis unit had that request, CP #3 stated she was unaware of anyone with that request. On 1/25/18 at 3:00 p.m., CP #3 came to find this surveyor and stated that (Resident #43) had a request that she doesn't want a male care partner. An interview was conducted with CP #1 on 1/25/18 at 2:45 p.m. CP #1 was asked how she is made aware, if a female resident does not wish to have a male care partner. CP #1 stated, It should be on the care card and in the care plan. When asked if she had access to the care plan, CP #1 stated, Yes. An interview was conducted with CP #2, a male care partner, on 1/25/18 at 3:04 p.m. When asked how he would know if a female resident did not wish to have a male care partner, CP #2 stated, If it's a new resident, I would ask the resident if it was okay to take care of them. You can tell by a resident's behavior. If they are hesitant or by their body language. When asked if he normally worked on the Willis unit, CP #2 stated that he floated to all of the floors. When asked if there were any residents on the name of unit that did not wish to have a male care partner, CP #2 stated that (Resident #43) doesn't like a male care partner to assist her to the bathroom or shower her. When asked where staff documented the resident wish not to have a male care partner, CP #2 stated, It's on the care guide in the computer and on the care plan. The care guide for Resident #43 was reviewed with CP #2. There was no documentation regarding her request for no male care partners. CP #2 stated that many times there are notes in the book the care partners use to communicate with each other. A request was made to see the book and CP #2 provided the book for review. A copy of an email sent to various staff members, not to the director of nursing or the MDS coordinator, dated 1/5/18. The email was from the administrator. It documented in part, Please read the following reminders as requested by (Resident #43) and reply back to me that you have read it: 4. Only female aides should help (Resident #43) change her clothes or use the bathroom. An interview was conducted with LPN (licensed practical nurse) #1 on 1/25/18 at 3:15 p.m. When asked where a resident preference for a male or female care partner would be documented, LPN #1 stated it should be communicated by report and sometimes it's in the MAR (medication administration record). LPN #1 reviewed Resident #43's MAR for (MONTH) (YEAR) and stated it (Resident #43's preference for no male caregivers) wasn't there. She stated that it should be in the Special Instructions Box. When asked who updates the care plans, LPN #1 stated, We update as we can but (name of RN (registered nurse) #1), the MDS coordinator, usually does it. LPN #1 stated, We haven't been officially trained on how to do the care plans but I've just done it as I can figure it out. An interview was conducted with RN #1, the MDS coordinator, on 1/25/18 at 3:45 p.m. When asked who updates the care plans, RN #1 stated she does the quarterly updates and the supervisors, charge nurses and other disciplines do the updates. When asked if a resident's request to not have a male care partner should be on the care plan, RN #1 stated that it should be. When asked if it should be on the care guide for the care partners, RN #1 stated, Yes, it should be on it. RN #1 was asked to review the care plan for Resident #43. When asked if Resident #43's caregiver preference was documented on the resident's care plan, RN #1 stated that she did not see it documented on the care plan. The email that was sent on 1/5/18 by ASM #2 was shown to RN #1. When asked if she had seen this email before, RN #1 stated, This is the first time I've seen this. When asked if these preferences from Resident #43 should be included on the care plan, RN #1 stated, Yes, Ma'am. An interview was conducted with ASM (administrative staff member) #2, the administrator, on 1/25/18 at 3:58 p.m. When asked how he communicates care needs he has discussed with a resident to the staff to ensure it is included in the residents care, ASM #2 stated, I should have notified the director of nursing and/or MDS coordinator to have it placed on the care plan. When asked if it should be on the care plan, ASM #2 stated, Absolutely. When asked if it should be on the care partner's care guide, ASM #2 stated, Of course it should. ASM #1, the executive director, ASM #2, the administrator, ASM #3, the director of nursing, RN #1, ASM #4, the assistant director of nursing, and other staff member #4 were made aware of the above concern on 1/25/18 at 5:25 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop a baseline care plan to address care needs for one of 21 residents in the survey sample, Resident #266; and failed to ensure the baseline care plan was implemented for two of 21 residents in the survey sample, Resident #266 and Resident #166. 1. a. The facility staff failed to develop a baseline care plan to address the care required for Resident #266's [DIAGNOSES REDACTED]. 1. b. The facility staff failed to implement Resident #266's baseline care plan to monitor the resident's weight as ordered. 2. The facility staff failed to follow Resident #166's baseline care plan for Impaired Comfort regarding the assessing of the resident's pain for location, onset, duration, and characteristics of his pain. The findings include: 1. a Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no minimum data set completed at the time of the survey. Review of the nurse's admission assessment dated [DATE] at 3:42 p.m. documented Resident #266 had [DIAGNOSES REDACTED]. Review of the nurse's admission note dated 1/14/18 at 5:47 p.m.; documented Resident #266 was alert and oriented to self, knew the year, but did not know where she was or the time. The resident required assistance for activities of daily living. Review of Resident #266's baseline care plan did not evidence documentation regarding the resident's [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Daily weights. Notify MD (medical doctor) of weight gain > (greater than) 2lbs (pounds) in 24hrs - Once daily For [MEDICAL CONDITIONS]/[MEDICATION NAME] therapy. Review of the (MONTH) treatment administration record documented the weights were obtained on each day except for 1/18/18 and 1/20/18. Review of the intake and output record for (MONTH) (YEAR) documented Resident #266's fluid restriction was being monitored. An interview was conducted on 1/26/18 at 9:15 a.m. with RN (registered nurse) #1, the MDS (minimum data set) coordinator. When asked why residents had care plans, RN # 1 stated, We care plan (residents) to ensure we are going along with the plan of care, and monitoring what she was in the hospital for. To follow doctor's orders. When asked who completed the baseline care plan, RN #1 stated, The interim care plans are done by the nursing staff. I do the comprehensive care plan. When asked if the resident's care plan would include their main diagnosis, RN #1 stated, Yes if there was a specific treatment and orders around it. An interview was conducted on 1/26/18 at 11:20 a.m. with RN #5, the resident's nurse. When asked why residents had care plans, RN #5 stated, So this is what we are going to do. We are going to make a care plan for them. We have to follow the care plan. For safety for the resident and well-being. When asked who completed the initial care plan, RN #5 stated, Normally the nurse does that. You do it quickly. You have to update it. When asked what was included on the initial care plan, RN #5 stated, Pain. If they're alert and oriented. When asked if a care plan would include the admitting [DIAGNOSES REDACTED].#5 stated, For her (meaning Resident #266) I would put her on fluid restriction and weights. When asked if that would have been care planned, RN #5 stated, Of course. When asked to review Resident #266's care plan, RN #5 stated, If there's nothing there then that's our mistake. When asked if she saw a care plan for the care required for Resident #266's [MEDICAL CONDITION], RN #5 stated, I don't see any. On 1/26/18 at 11:35 a.m. ASM (administrative staff member) #2, the administrator and ASM #3, the director of nursing were made aware of the findings. Review of the facility's policy titled, Resident Centered Care Planning did not specifically address the initial care plan. No further information was provided prior to exit. According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . (1) Fundamentals of Nursing Lippincott Williams & Wilkins 2007 Lippincott Company Philadelphia pages 65-77. Basic Nursing, Essentials for Practice, 6th edition, (Potter and Perry, 2007, pages 119-127), was a reference for care plans. A nursing care plan is a written guideline for coordinating nursing care, promoting continuity of care and listing outcome criteria to be used in the evaluation of nursing care. The written care plan communicates nursing care priorities to other health care professionals. The care plan also identifies and coordinates resources used to deliver nursing care. A correctly formulated care plan makes it easy to continue care from one nurse to another. If the patient's status has changed and the nursing [DIAGNOSES REDACTED]. An out of date or incorrect care plan compromises the quality of nursing care. 1. b. The facility staff failed to implement Resident #266's baseline care plan to monitor the resident's weight as ordered. Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no minimum data set assessment completed at the time of the survey. Review of the nurse's admission assessment dated [DATE] at 3:42 p.m. documented Resident #266 had [DIAGNOSES REDACTED]. Review of the nurse's admission note dated 1/14/18 at 5:47 p.m. documented Resident #266 was alert and oriented to self, knew the year, but did not know where she was or the time. The resident required assistance for activities of daily living. Review of the baseline care plan initiated on 1/22/18 documented, Nursing Dx (diagnosis). Intervention. Monitor weight per order. Review of the physician's orders [REDACTED]. Daily weights. Notify MD (medical doctor) of weight gain > (greater than) 2lbs (pounds) in 24hrs - Once daily For [MEDICAL CONDITIONS]/[MEDICATION NAME] therapy. Review of the (MONTH) (YEAR) TAR (treatment administration record) did not evidence documentation that the Resident's weight was obtained on 1/18/18 and 1/20/18. An interview was conducted on 1/25/18 at 10:45 a.m. with LPN (licensed practical nurse) #2, the resident's nurse. When asked why Resident #266 was on daily weights, LPN #2 stated, Well to find out what is going on. If there is [MEDICAL CONDITION], if there is anything abnormal. The doctor may need to adjust her medication. LPN #2 was asked to review Resident #266's treatment administration record for the resident's weights. When asked what the blank spaces meant, LPN #2 stated that the weights were not obtained. When asked if the weights should have been obtained, LPN #2 stated yes. When asked why resident's have care plans, LPN #2 stated, The reason is to address the resident's concerns and issues and to direct us to know what to do for the resident. When asked who used the care plan, LPN #2 stated, The nursing staff. When asked if the care plan was to be followed, LPN #2 stated, It has to be followed. LPN #2 was asked to review Resident #266's care plan for nutrition. When asked if the care plan had been followed, LPN #2 stated, No. An interview was conducted on 1/25/18 at 1:10 p.m. with ASM (administrative staff member) #4, the assistant director of nursing. When asked why residents had care plans, ASM #4 stated, So we follow it to provide continuity of care for the resident. When asked who used the care plan, ASM #4 stated, All the staff. When asked if staff were expected to implement and follow the care plan, ASM #4 stated, Yes. When asked if Resident #266's nutrition care plan had been implemented and followed, ASM #4 stated, No. ASM #4 was made aware of the concern at that time. Review of the facility's policy titled, Resident Centered Care Planning documented, PURPOSE: Care plan interventions provide direction to the nursing and interdisciplinary staff regarding specific actions and treatments identified as useful or necessary in helping the resident achieve established goals and objectives. No further information was provided prior to exit. 2. The facility staff failed to follow Resident #166's baseline care plan for Impaired Comfort regarding the assessing of the resident's pain for location, onset, duration, and characteristics of his pain. Resident #166 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Due to the recent admitted , an MDS (Minimum Data Set) assessment had not yet been completed. The admission nursing assessment dated [DATE] documented the resident as being alert and oriented, requiring assistance with transfers and activities of daily living, and as being continent of bowel and bladder. The admission pain assessment dated [DATE] documented Resident #166's pain was from the left foot abscess and from the right knee. The pain assessment documented Resident #166 had pain less than daily and that the pain was described as being uncomfortable. The assessment documented Resident #166 rated his pain as mild. A review of the clinical record revealed the baseline care plan Impaired Comfort R/T (related to) age, [MEDICAL CONDITION], foot infection. This care plan was initiated on 1/17/18. The interventions included, Determine location, onset, duration and character of pain. This intervention was dated 1/17/18. A review of the clinical record revealed physician's orders [REDACTED]. The orders did not differentiate when to use the Tylenol and when to use the [MEDICATION NAME]-[MEDICATION NAME]. A review of the MAR (Medication Administration Record) revealed Resident #166 received the [MEDICATION NAME]-[MEDICATION NAME] as follows: - 1/18/18 at 10:55 a.m., for right knee pain at a pain level of 5. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/19/18 at 11:08 a.m., for complained of right knee pain at a pain level of 4. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/20/18 at 8:52 p.m., for resident c/o (complained of) pain 4/10 (a 4 out of 10 on 0-10 scale). me {sic - med} given as ordered. A follow up assessment at 10:09 p.m., only documented effective. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/21/18 at 8:37 p.m., for a pain level of 3. Review of the clinical record failed to evidence the location of the pain, and failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. A follow up assessment at 11:08 p.m., only documented effective. - 1/23/18 at 10:25 p.m., for a pain level of 0. Review of the clinical record revealed a nurse's note dated 11/23/18 at 11:21 p.m., which documented, .Report of left foot pain on a scale of 5/10. Medicated with [MEDICATION NAME] one tab (tablet) at 21:00 (9:00 p.m.) with effective result noted. Pain level decrease to 0/10 . Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication. - 1/24/18 at 4:00 a.m., for a pain level of 3. A nurse's note dated 1/24/18 at 4:02 a.m., documented, Resident complained of mild knee pain in {sic} a scale of 3/10 [MEDICATION NAME] ([MEDICATION NAME]) given as ordered. A follow up nurse's note dated 1/24/18 at 6:46 a.m., documented, medication effective pain scale 0/10 as per resident Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication. In addition to the above, the notes section of the MAR indicated [REDACTED]. These were: - 1/19/18 at 3:49 a.m., for complained of head each {sic - ache} scale is 5/10. The follow up note at 6:19 a.m., documented, medication effective, resident slept well, pain scale is 0/10. - 1/21/18 at 2:15 p.m., documented, right knee pain. No further information about this administration was documented. - 1/23/18 at 8:46 p.m., for C/O (R) (right) knee pain on a scale of 5/10. The follow up note dated 1/23/18 at 9:37 p.m., documented, Pain level decrease to 1/10. Review of Resident #166's (MONTH) (YEAR) MAR's revealed the Tylenol was administered as follows: - 1/18/18 at 2:00 p.m., for right knee pain. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/24/18 at 8:34 a.m., for Resident c/o headache 5/10. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. In addition to the above, the notes section of the MAR indicated [REDACTED]. These were: - 1/18/18 at 7:00 a.m. for right knee pain. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. On 1/24/18 at approximately 11:00 a.m., in an interview with Resident #166, he stated that the nurses sometimes ask him some things about his pain but he could not specifically clarify what was asked and when, or if the assessment questions were consistently asked at each administration of pain medication. On 1/24/18 at 10:46 a.m., in an interview with LPN #4 (Licensed Practical Nurse) she stated that for mild pain, about a 3 or 4, Tylenol should be given, and the orders for the Tylenol and the [MEDICATION NAME]-[MEDICATION NAME] should have been clarified to indicate when to give each medication. On 1/25/18 at 1:49 p.m., in an interview with LPN #3, she stated when there is more than one medication ordered, there should be parameters for when to give each medication. She stated it would be based on the resident's pain scale. LPN #3 stated the doctor should have been called to clarify the orders. LPN #3 stated regarding the care plan, according to the clinical record, the care plan was not followed. On 1/25/18 at 5:22 p.m., at the end of day meeting, the Administrator (ASM #2 - Administrative Staff Member), the Executive Director (ASM #1) and the Director of Nursing (ASM #3) were made aware of the findings. No further information was provided by the end of the survey. (1) [MEDICATION NAME] - is used to relieve pain, tenderness, swelling and stiffness caused by [MEDICAL CONDITIONS] arthritis, and ankylosing spondylitis and to relieve other types of short-term pain including pain caused by injuries, surgery and other medical or dental procedures, or medical conditions that last for a limited time. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (2) [MEDICATION NAME] - is used to relieve pain from [MEDICAL CONDITION]. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (3) Tylenol ([MEDICATION NAME]) - is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. [MEDICATION NAME] may also be used to relieve the pain of [MEDICAL CONDITION] . Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (4) [MEDICATION NAME]-[MEDICATION NAME] is used to relieve moderate to severe pain . is also available in combination with [MEDICATION NAME] . Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html

Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to notify the physician of a change in condition for one of 21 residents in the survey sample, Resident #54. The facility staff failed to notify the physician they were administering [MEDICATION NAME] (a narcotic pain medication) to Resident #54 when the resident did not have any pain. The findings include: Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a 14 day assessment, with an assessment reference date of 11/24/17 coded Resident #54 as having scored a 6 out of 15 on the brief interview for mental status, indicating the resident was severely impaired cognitively. The resident was coded as requiring assistance from staff for all activities of daily living. In Section J, titled Health Conditions under pain assessment, Resident #54 was coded as not having pain in the last five days. An observation was made of Resident #54 on 1/23/18 at 1:30 p.m. The resident was lying in bed, eyes closed and breathing through his mouth. An observation was made of Resident #54 on 1/23/18 at 6:00 p.m., the care partner (CP) went in to feed the resident. Resident #54 was observed waking up for a few seconds and then falling back to sleep despite the CP shaking his shoulders and calling his name. An observation was made of Resident #54 on 1/24/18 at 8:10 a.m. Resident #54 was lying on his side with his eyes closed and breathing through his mouth. The resident did not show signs of pain or shortness of breath. An observation was made of Resident #54 on 1/24/18 at 12:03 p.m. The resident was lying on his back with his eyes closed and breathing through his mouth. The resident's wife was in the room and attempted to wake the resident several times. The resident would mumble something and fall back to sleep. The resident did not show signs of pain or shortness of breath. Observations were made of Resident #54 on the following dates and times: 1/24/18 at 3:55 p.m., 1/25/18 at 8:15 a.m., and 1/25/18 at 1:30 p.m. during all observations, the resident was lying on his back with his eyes closed and breathing through his mouth. The resident did not show signs of pain or shortness of breath. An observation was made of Resident #54 on 1/26/18 at 8:15 a.m. The resident was lying on his back with his eyes closed and breathing through his mouth. His respirations appeared a little labored at that time. Review of the resident's care plan initiated on 1/25/18 documented, Nursing Dx (diagnosis) Impaired comfort. Intervention. Discuss a comfort goal with (name of Resident #54) and identify the acceptable level of pain. Further review of the clinical record did not evidence documentation of the resident's acceptable level of pain. Review of the physician's orders [REDACTED].=0.5 ml) Sub lingual (under the tongue) Every 4 hours For pain and/or sob (shortness of breath). Review of the (MONTH) Medication Administration Record [REDACTED]=0.5 ml) Sub lingual (under the tongue) Every 4 hours For pain and/or sob (shortness of breath); Diagnosis/Reason = pain and/or sob. The [MEDICATION NAME] was documented as being given every four hours except on 1/8/18, 1/20/18, 1/22/18 at 4:00 a.m. and 1/22/18 at 1:00 a.m. On these dates and times there was no documentation regarding if the [MEDICATION NAME] was given. The resident's pain level was consistently documented as zero throughout the month of (MONTH) indicating the resident did not have any pain. Review of the (MONTH) (YEAR) nurses' notes documented Resident #54 had no pain or shortness of breath except on 1/6/18 when the resident was moaning and on 1/8/18 when the resident complained of back pain. The nurses' notes documented Resident #54 was given the [MEDICATION NAME] even though he had no pain. There was no documentation that the physician had been notified that the resident did not have pain. Review of the nurse's note written by RN (registered nurse) #2 on 1/24/18 at 4:17 p.m. documented, Resident is alert and oriented to self, verbally responsive this morning. No moaning nor nonverbal pain signs, but given scheduled [MEDICATION NAME] ([MEDICATION NAME]) as ordered and was well tolerated and effective. An interview was conducted on 1/25/18 at 9:55 a.m. with RN (registered nurse) #2, the resident's nurse. When asked to review the resident's order for [MEDICATION NAME], RN #2 stated, This is scheduled so we give it every four hours. When asked if the resident looked like he was in pain today, RN #2 stated, No. When asked if the resident received the [MEDICATION NAME] today, RN #2 stated he had. When asked why the resident was receiving pain medication when he was not in pain or having shortness of breath as it was ordered by the physician, RN #2 stated, That's a [MEDICATION NAME] question. This order should be clarified with the doctor. When asked to review her note of 1/24/18, RN #2 stated, Well I was told the wife wanted him to have it. When asked if this was, an acceptable reason to administer pain medication to a resident who was not in pain, RN #2 stated, I understand what you're saying. A telephone interview was conducted on 1/25/18 at 12:45 p.m. with ASM (administrative staff member) #5 the resident's hospice physician. When asked if she was made aware, Resident #54 was receiving the [MEDICATION NAME] even though his pain level was always zero and he was difficult to arouse, ASM #5 stated she was not. ASM #5 stated, I would reduce it (the [MEDICATION NAME]) by 25 to 50 percent if I knew that. When asked if she only wanted the resident to receive the [MEDICATION NAME] when he was in pain, ASM #5 stated, Yes. The nurses have the ability to hold the dose and call me. On 1/25/18 at 5:30 p.m. ASM #1, the executive director, ASM #2, the administrator and ASM #3, the director of nursing were made aware of the findings. An interview was conducted on 1/26/18 at 9:10 a.m. with the resident's wife. When asked if she wanted the resident to receive pain medication the wife stated, Yes, I don't want him in pain. When asked if she wanted the resident to receive pain medication when he was not in pain, the resident's wife stated, No. Review of the facility's policy titled, Pain Assessment and Management documented, Purpose. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Monitoring and Modifying Approaches: 5. If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper [MEDICATION NAME] medications to the extent possible. 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]. 1. Hepatic [MEDICAL CONDITION] -- Hepatic [MEDICAL CONDITION] (HE) is a brain disorder caused by chronic liver failure, particularly in alcoholics with [MEDICAL CONDITION], which results in cognitive, psychiatric, and motor impairments. In these patients, the number of functional liver cells is reduced, and some blood is diverted around the liver before toxins are removed. This information was obtained from: HTTPS://pubs.niaaa.nih.gov/publications/arh27-3/240-246.htm 2. Ventriculoperitoneal shunt -- relating to or serving to communicate between a ventricle of the brain and the peritoneal cavity ·a ventriculoperitoneal shunt. This information was obtained from: https://www.merriam-webster.com/medical/ventriculoperitoneal 3. [MEDICATION NAME] -- [MEDICATION NAME] INJECTION is indicated for the management of pain severe enough to require an opioid [MEDICATION NAME] and for which alternate treatments are inadequate. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4d f-874f-9c87-2d80-ca467c7690a1

Based on resident interview, staff interview, clinical record review and review of facility documentation, the facility staff failed to ensure care was provided in a manner to promote dignity and quality of life for one of 21 residents in the survey sample, Resident #43. The facility staff failed to ensure Resident #43 received personal care, toileting and showering from a only a female care partner per the residents request. The findings include: Resident #43 was admitted to the facility on [DATE] with a recent readmission on 9/15/17, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data) set assessment, a quarterly assessment, with an assessment reference date of 12/19/17, coded the resident as scoring an eight on the BIMS (brief interview for mental status) score, indicating that she was moderately impaired to make daily cognitive decisions. She was coded as always understanding others and always making herself understood. Resident #43 was coded as requiring extensive assistance of one or more staff members for bed mobility, transfers, moving on the unit, toileting, personal hygiene and bathing. An interview was conducted with Resident #43 on 1/24/18 at 2:37 p.m. The resident stated that she did not like having a male care partner when using the bathroom, changing or showering. An interview was conducted with Resident #43 on 1/25/18 at 2:31 p.m. When asked if she had told the staff of her request to not have a male attendant for toileting and showers, Resident #43 stated that she had and it only happens every once in a while now. Resident #43 stated, I'm an old fashioned person and I don't want to expose my body to a man. It makes me uncomfortable and I just want to cringe. The resident could not recall whom she told about her request. Review of the comprehensive care plan dated 9/8/17 documented in part, Nursing Dx (diagnosis): Self-care deficit with bed mobility, transferring, locomotion on/off the unit, dressing, toileting, hygiene and bathing related to volume overload 2nd to ARF (acute [MEDICAL CONDITION]), newly Dx with [MEDICAL CONDITION] and metabolic [MEDICAL CONDITIONS] [MEDICAL CONDITION] and SOB (shortness of breath). The Interventions documented in part, Staff will provide extensive assistance with ADLs (activities of daily living) depending on her mood and alertness. Resident will be encouraged to participate as much as she can. Resident requires one person assistance with toileting depending on her mood, will call for assistance. Resident takes showers twice a week and as needed on Monday and Thursday on 3-11 shift. Resident requires total assistance with showers. Resident uses special medicated toothpaste every morning and requires set up assistance with oral hygiene. Resident is able to dress her upper body, requires lower body assistance with dressing. There was no documentation of resident's request for no male care partners for toileting, bathing or dressing. An interview was conducted with care partner (CP) #3 on 1/25/18 at 2:35 p.m. When asked how she is made aware, if a female resident does not wish to have a male care partner, of that, CP #3 stated, It should be in their care card on the computer. When asked if anyone currently residing on the Willis unit had that request, CP #3 stated she was unaware of anyone with that request. On 1/25/18 at 3:00 p.m., CP #3 came to find this surveyor and stated that (Resident #43) had a request that she doesn't want a male care partner. An interview was conducted with CP #1 on 1/25/18 at 2:45 p.m. CP #1 was asked how she is made aware, if a female resident does not wish to have a male care partner. CP #1 stated, It should be on the care card and in the care plan. When asked if she had access to the care plan, CP #1 stated, Yes. An interview was conducted with CP #2, a male care partner, on 1/25/18 at 3:04 p.m. When asked how he would know if a female resident did not wish to have a male care partner, CP #2 stated, If it's a new resident, I would ask the resident if it was okay to take care of them. You can tell by a resident's behavior. If they are hesitant or by their body language. When asked if he normally worked on the Willis unit, CP #2 stated that he floated to all of the floors. When asked if there were any residents on the name of unit that did not wish to have a male care partner, CP #2 stated that (Resident #43) doesn't like a male care partner to assist her to the bathroom or shower her. When asked where staff documented the resident wish not to have a male care partner, CP #2 stated, It's on the care guide in the computer and on the care plan. The care guide for Resident #43 was reviewed with CP #2. There was no documentation regarding her request for no male care partners. CP #2 stated that many times there are notes in the book the care partners use to communicate with each other. A request was made to see the book and CP #2 provided the book for review. A copy of an email sent to various staff members, not to the director of nursing or the MDS coordinator, dated 1/5/18. The email was from the administrator. It documented in part, Please read the following reminders as requested by (Resident #43) and reply back to me that you have read it: 4. Only female aides should help (Resident #43) change her clothes or use the bathroom. An interview was conducted with LPN (licensed practical nurse) #1 on 1/25/18 at 3:15 p.m. When asked where a resident preference for a male or female care partner would be documented, LPN #1 stated it should be communicated by report and sometimes it's in the MAR (medication administration record). LPN #1 reviewed Resident #43's MAR for (MONTH) (YEAR) and stated it (Resident #43's preference for no male caregivers) wasn't there. She stated that it should be in the Special Instructions Box. An interview was conducted with ASM (administrative staff member) #2, the administrator, on 1/25/18 at 3:58 p.m. When asked how he communicates care needs that he has discussed with a resident, to the staff, for inclusion in their care, ASM #2 stated, I should have notified the director of nursing and/or MDS coordinator to have it placed on the care plan. When asked if it should be on the care plan, ASM #2 stated, Absolutely. When asked if it should be on the care partner's care guide, ASM #2 stated, Of course it should. ASM #1, the executive director, ASM #2, the administrator, ASM #3, the director of nursing, RN (registered nurse) #1, ASM #4, the assistant director of nursing, and other staff member #4 were made aware of the above concern on 1/25/18 at 5:25 p.m. On 1/26/18 at 11:47 a.m., ASM #2 approached this writer and stated the following: He had talked to Resident #43 last night. He stated Resident #43 stated she had not had any concerns since the administrator had a meeting with her on 1/5/18. Since the meeting on 1/5/18, the resident (Resident #43) expressed no concerns with having a male care partner take her to the bathroom, change her clothes or toileting. On 1/26/18 at 12:01 p.m., during an interview with Resident #43. When asked if she has had a male care partner since her talk with the administrator (ASM #2) on 1/5/18, Resident #43 stated, yes, she had, one time. She stated that (ASM #2) was not made aware of the situation. Resident #43 verified this one incident had occurred since she met with ASM #2 on 1/5/18 and he put things in place for her. Resident #43 stated, Yes, he doesn't know about that one time. The facility policy, Quality of Life documented in part, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Resident shall be groomed as they wish to be groomed .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined the facility staff failed to follow professional standards of practice for two of 21 residents in the survey sample, Resident #54 and Resident #166. 1. The facility staff failed to clarify Resident #54's physician's orders [REDACTED]. 2. The facility staff failed to clarify Resident #166's physician orders [REDACTED]. The findings include: Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a 14 day assessment, with an assessment reference date of 11/24/17 coded Resident #54 as having scored a 6 out of 15 on the brief interview for mental status, indicating the resident was severely impaired cognitively. The resident was coded as requiring assistance from staff for all activities of daily living. In Section J, titled Health Conditions under pain assessment, Resident #54 was coded as not having pain in the last five days. An observation was made of Resident #54 on 1/23/18 at 1:30 p.m. The resident was lying in bed, eyes closed and breathing through his mouth. An observation was made of Resident #54 on 1/23/18 at 6:00 p.m., the care partner (CP) went in to feed the resident. Resident #54 was observed waking up for a few seconds and then falling back to sleep despite the CP shaking his shoulders and calling his name. An observation was made of Resident #54 on 1/24/18 at 8:10 a.m. Resident #54 was lying on his side with his eyes closed and breathing through his mouth. The resident did not show signs of pain or shortness of breath. An observation was made of Resident #54 on 1/24/18 at 12:03 p.m. The resident was lying on his back with his eyes closed and breathing through his mouth. The resident's wife was in the room and attempted to wake the resident several times. The resident would mumble something and fall back to sleep. The resident did not show signs of pain or shortness of breath. Observations were made of Resident #54 on the following dates and times: 1/24/18 at 3:55 p.m., 1/25/18 at 8:15 a.m., and 1/25/18 at 1:30 p.m. during all observations, the resident was lying on his back with his eyes closed and breathing through his mouth. The resident did not show signs of pain or shortness of breath. An observation was made of Resident #54 on 1/26/18 at 8:15 a.m. The resident was lying on his back with his eyes closed and breathing through his mouth. His respirations appeared a little labored at that time. Review of the resident's care plan initiated on 1/25/18 documented, Nursing Dx (diagnosis) Impaired comfort. Intervention. Discuss a comfort goal with (name of Resident #54) and identify the acceptable level of pain. Further review of the clinical record did not evidence documentation of the resident's acceptable level of pain. Review of the physician's orders [REDACTED].=0.5 ml) Sub lingual (under the tongue) Every 4 hours For pain and/or sob (shortness of breath). Review of the (MONTH) Medication Administration Record [REDACTED]=0.5 ml) Sub lingual (under the tongue) Every 4 hours For pain and/or sob (shortness of breath); Diagnosis/Reason = pain and/or sob. The [MEDICATION NAME] was documented as being given every four hours except on 1/8/18, 1/20/18, 1/22/18 at 4:00 a.m. and 1/22/18 at 1:00 a.m. On these dates and times there was no documentation regarding if the [MEDICATION NAME] was given. The resident's pain level was consistently documented as zero throughout the month of (MONTH) indicating the resident did not have any pain. Review of the (MONTH) (YEAR) nurses' notes documented Resident #54 had no pain or shortness of breath except on 1/6/18 when the resident was moaning and on 1/8/18 when the resident complained of back pain. The nurses' notes documented Resident #54 was given the [MEDICATION NAME] even though he had no pain. There was no documentation that the physician had been notified that the resident did not have pain. Review of the nurse's note written by RN (registered nurse) #2 on 1/24/18 at 4:17 p.m. documented, Resident is alert and oriented to self, verbally responsive this morning. No moaning nor nonverbal pain signs, but given scheduled [MEDICATION NAME] ([MEDICATION NAME]) as ordered and was well tolerated and effective. An interview was conducted on 1/25/18 at 9:55 a.m. with RN (registered nurse) #2, the resident's nurse. When asked to review the resident's order for [MEDICATION NAME], RN #2 stated, This is scheduled so we give it every four hours. When asked if the resident looked like he was in pain today, RN #2 stated, No. When asked if the resident received the [MEDICATION NAME] today, RN #2 stated he had. When asked why the resident was receiving pain medication when he was not in pain or having shortness of breath as it was ordered by the physician, RN #2 stated, That's a [MEDICATION NAME] question. This order should be clarified with the doctor. When asked to review her note dated 1/24/18, RN #2 stated, Well I was told the wife wanted him to have it. When asked if this was, an acceptable reason to administer pain medication to a resident who was not in pain, RN #2 stated, I understand what you're saying. An interview was conducted on 1/25/18 at 12:40 p.m. with ASM (administrative staff member) #3, the director of nursing. ASM #3 was asked to review Resident #54's order for [MEDICATION NAME] and asked when the staff should administer the medication, ASM #3 stated, It's ordered around the clock. When asked if the staff should administer the medication if the resident was not in pain or did not have shortness of breath. ASM #3 stated they should not. When asked if the order should be clarified ASM #3 stated it should. ASM #3 was asked what professional standard the facility used, ASM #3 stated, Lippincott. A telephone interview was conducted on 1/25/18 at 12:45 p.m. with ASM (administrative staff member) #5 the resident's hospice physician. When asked if she was made aware, Resident #54 was receiving the [MEDICATION NAME] even though his pain level was always zero and he was difficult to arouse, ASM #5 stated she was not. ASM #5 stated, I would reduce it (the [MEDICATION NAME]) by 25 to 50 percent if I knew that. When asked if she only wanted the resident to receive the [MEDICATION NAME] when he was in pain, ASM #5 stated, Yes. The nurses have the ability to hold the dose and call me. On 1/25/18 at 5:30 p.m. ASM #1, the executive director, ASM #2, the administrator and ASM #3, the director of nursing were made aware of the findings. An interview was conducted on 1/26/18 at 9:10 a.m. with the resident's wife. When asked if she wanted the resident to receive pain medication the wife stated, Yes, I don't want him in pain. When asked if she wanted the resident to receive pain medication when he was not in pain, the resident's wife stated, No. Review of the facility's policy titled, Pain Assessment and Management documented, Purpose. The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Monitoring and Modifying Approaches: 5. If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper [MEDICATION NAME] medications to the extent possible. Lippincott, Williams and Wilkins, Fundamentals of Nursing, 2007, Ambler, PA, page 181 reads, Nurses carry a great deal of responsibility for making sure that patients get the right drugs at the right time, in the right dose and by the right routes .this includes accurate documentation and explanation . No further information was provided prior to exit. 1. Hepatic [MEDICAL CONDITION] -- Hepatic [MEDICAL CONDITION] (HE) is a brain disorder caused by chronic liver failure, particularly in alcoholics with [MEDICAL CONDITION], which results in cognitive, psychiatric, and motor impairments. In these patients, the number of functional liver cells is reduced, and some blood is diverted around the liver before toxins are removed. This information was obtained from: HTTPS://pubs.niaaa.nih.gov/publications/arh27-3/240-246.htm 2. Ventriculoperitoneal shunt -- relating to or serving to communicate between a ventricle of the brain and the peritoneal cavity ·a ventriculoperitoneal shunt. This information was obtained from: https://www.merriam-webster.com/medical/ventriculoperitoneal 3. [MEDICATION NAME] -- [MEDICATION NAME] INJECTION is indicated for the management of pain severe enough to require an opioid [MEDICATION NAME] and for which alternate treatments are inadequate. This information was obtained from: https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4d f-874f-9c87-2d80-ca467c7690a1 2. The facility staff failed to clarify Resident #166's physician orders [REDACTED]. Resident #166 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Due to the recent admitted , an MDS (Minimum Data Set) assessment had not yet been completed. The admission nursing assessment dated [DATE] documented the resident as being alert and oriented, requiring assistance with transfers and activities of daily living, and as being continent of bowel and bladder. The admission pain assessment dated [DATE] documented Resident #166's pain was from the left foot abscess and from the right knee. The pain assessment documented Resident #166 had pain less than daily and that the pain was described as being uncomfortable. The assessment documented Resident #166 rated his pain as mild. A review of the clinical record revealed the care plan Impaired Comfort R/T (related to) age, [MEDICAL CONDITION], foot infection. This care plan was initiated on 1/17/18. The interventions included, Determine location, onset, duration and character of pain. This intervention was dated 1/17/18. A review of the clinical record revealed physician's orders [REDACTED]. The orders did not differentiate when to use the Tylenol and when to use the [MEDICATION NAME]-[MEDICATION NAME]. A review of the MAR (Medication Administration Record) revealed Resident #166 received the [MEDICATION NAME]-[MEDICATION NAME] as follows: - 1/18/18 at 10:55 a.m., for right knee pain at a pain level of 5. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/19/18 at 11:08 a.m., for complained of right knee pain at a pain level of 4. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/20/18 at 8:52 p.m., for resident c/o (complained of) pain 4/10 (a 4 out of 10 on 0-10 scale). me {sic - med} given as ordered. A follow up assessment at 10:09 p.m., only documented effective. Further review of the clinical record failed to reveal any evidence of a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/21/18 at 8:37 p.m., for a pain level of 3. Review of the clinical record failed to evidence the location of the pain, and failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. A follow up assessment at 11:08 p.m., only documented effective. - 1/23/18 at 10:25 p.m., for a pain level of 0. Review of the clinical record revealed a nurse's note dated 11/23/18 at 11:21 p.m., which documented, .Report of left foot pain on a scale of 5/10. Medicated with [MEDICATION NAME] one tab (tablet) at 21:00 (9:00 p.m.) with effective result noted. Pain level decrease to 0/10 . Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication. - 1/24/18 at 4:00 a.m., for a pain level of 3. A nurse's note dated 1/24/18 at 4:02 a.m., documented, Resident complained of mild knee pain in {sic} a scale of 3/10 [MEDICATION NAME] ([MEDICATION NAME]) given as ordered. A follow up nurse's note dated 1/24/18 at 6:46 a.m., documented, medication effective pain scale 0/10 as per resident Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication. In addition to the above, the notes section of the MAR indicated [REDACTED]. These were: - 1/19/18 at 3:49 a.m., for complained of head each {sic - ache} scale is 5/10. The follow up note at 6:19 a.m., documented, medication effective, resident slept well, pain scale is 0/10. - 1/21/18 at 2:15 p.m., documented, right knee pain. No further information about this administration was documented. - 1/23/18 at 8:46 p.m., for C/O (R) (right) knee pain on a scale of 5/10. The follow up note dated 1/23/18 at 9:37 p.m., documented, Pain level decrease to 1/10. Review of Resident #166's (MONTH) (YEAR) MAR's revealed the Tylenol was administered as follows: - 1/18/18 at 2:00 p.m., for right knee pain. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. - 1/24/18 at 8:34 a.m., for Resident c/o headache 5/10. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. In addition to the above, the notes section of the MAR indicated [REDACTED]. These were: - 1/18/18 at 7:00 a.m. for right knee pain. No further information about this administration was documented. Review of the clinical record failed to evidence a complete pain assessment to include quality descriptors of pain, and any non-pharmacological interventions attempted, prior to the administration of pain medication, and measurable criteria of a pain reassessment after the administration of pain medication. On 1/24/18 at 10:46 a.m., in an interview with LPN #4 (Licensed Practical Nurse) she stated that for mild pain, about a 3 or 4, Tylenol should be given, and the orders for the Tylenol and the [MEDICATION NAME]-[MEDICATION NAME] should have been clarified to indicate when to give each medication. On 1/25/18 at 1:49 p.m., in an interview with LPN #3, she stated when there is more than one medication ordered, there should be parameters for when to give each medication. She stated it would be based on the resident's pain scale. LPN #3 stated the doctor should have been called to clarify the orders. LPN #3 stated regarding the care plan, according to the clinical record, the care plan was not followed. On 1/25/18 at 5:22 p.m., at the end of day meeting, the Administrator (ASM #2 - Administrative Staff Member), the Executive Director (ASM #1) and the Director of Nursing (ASM #3) were made aware of the findings. No further information was provided by the end of the survey. (1) [MEDICATION NAME] - is used to relieve pain, tenderness, swelling and stiffness caused by [MEDICAL CONDITIONS] arthritis, and ankylosing spondylitis and to relieve other types of short-term pain including pain caused by injuries, surgery and other medical or dental procedures, or medical conditions that last for a limited time. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (2) [MEDICATION NAME] - is used to relieve pain from [MEDICAL CONDITION]. Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html (3) Tylenol ([MEDICATION NAME]) - is used to relieve mild to moderate pain from headaches, muscle aches, menstrual periods, colds and sore throats, toothaches, backaches, and reactions to vaccinations (shots), and to reduce fever. [MEDICATION NAME] may also be used to relieve the pain of [MEDICAL CONDITION] . Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (4) [MEDICATION NAME]-[MEDICATION NAME] is used to relieve moderate to severe pain . is also available in combination with [MEDICATION NAME] . Information obtained from https://medlineplus.gov/druginfo/meds/a 2.html

Based on staff interview and clinical record review, it was determined the facility staff failed to ensure one of 21 residents in the survey sample, Resident #266, received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. The facility staff failed to follow the physician's orders [REDACTED].#266 on 1/18/18 and 1/20/18. The findings include: Resident #266 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no minimum data set completed at the time of the survey. Review of the nurse's admission assessment dated [DATE] at 3:42 p.m. documented Resident #266 had [DIAGNOSES REDACTED]. Review of the nurse's admission note dated 1/14/18 at 5:47 p.m. documented Resident #266 was alert and oriented to self, knew the year, but did not know where she was or the time. The resident required assistance for activities of daily living. Review of Resident #266's baseline care plan initiated on 1/22/18 documented, Monitor weight per order. Review of Resident #266's physician's orders [REDACTED]. Daily weights. Notify MD (medical doctor) of weight gain > (greater than) 2lbs (pounds) in 24hrs - Once daily For [MEDICAL CONDITIONS]/[MEDICATION NAME] therapy. Review of Resident #266's (MONTH) (YEAR) TAR (treatment administration record) did not evidence documentation that the Resident's weight was obtained on 1/18/18 and 1/20/18. An interview was conducted on 1/25/18 at 10:45 a.m. with LPN (licensed practical nurse) #2, the resident's nurse. When asked why Resident #266 was on daily weights, LPN #2 stated, Well to find out what is going on. If there is [MEDICAL CONDITION], if there is anything abnormal. The doctor may need to adjust her medication. LPN #2 was asked to review Resident #266's treatment administration record for the resident's weights. When asked what the blank spaces meant, LPN #2 stated that the weights were not obtained. When asked if the weights should have been obtained, LPN #2 stated yes. When asked if the doctor's orders were followed, LPN #2 stated, No. When asked if the care plan had been followed, LPN #2 stated, No. An interview was conducted on 1/25/18 at 1:10 p.m. with ASM (administrative staff member) #4, the assistant director or nursing. When asked who obtained the resident's weights, ASM #4 stated, The CNA (certified nursing assistant) takes the weight and gives it to the nurse. When asked to review Resident #266's (MONTH) (YEAR) TAR for the weights, ASM #4 stated the weight was not done on 1/18/18 and 1/20/18 as ordered by the physician. ASM #3 was made aware of the concern at that time. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to implement interventions for the prevention of a fall that resulted in harm for one of 18 residents in the survey sample, Resident #18. The facility staff failed to implement fall prevention interventions, per the care plan, to prevent a fall, as a result of this failure Resident #18 fell sustained a head laceration and subdural hematoma***, was transferred to a local hospital and expired. ***A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. A subdural hematoma is usually the result of a serious head injury. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. The findings include: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].* with poor functional status, high blood pressure, difficulty swallowing and respiratory failure. Resident #18's most recent MDS (minimum data set), an admission assessment, with an ARD (assessment reference date) of [DATE] coded the resident as being cognitively intact. Resident #18 was coded as needing the physical assistance on one staff member for all activities of daily living. The discharge MDS, with a discharge assessment date of [DATE], in Section J -- 1800, coded the resident as having had a fall since admission. Section J -- 1900 coded the resident as having one fall since admission resulting in an injury (expect major). A review of a facility reported incident (FRI) involving Resident #18 dated [DATE] documented, Resident noted with laceration after fall reported by Home Care Aide. Resident sent to hospital, investigation pending. A review of the nurse's notes dated [DATE] documented in part, Her gait is unsteady, ambulating with cane and one staff person stand by assist to the bathroom. Review of nurse's notes dated from [DATE] through[DATE] documented the resident's unsteady gait and need to have one staff person stand by assistance to the bathroom. Review of the nurse's notes dated [DATE] at 11:06 p.m. documented, @ (at) 1950 (7:50 p.m.), home health aide/sitter came to call on this nurse stating that the resident had fallen. Upon arrival in resident's room resident found half-laying on the bed with legs dangling, eyes half closed and fixed. Resident did not verbally respond, was able to slightly move limbs. There was a spot of blood on the pillow that was supporting resident's head, back of head assessed and noted to have bled, and appeared to have a laceration of about 3 cm. Home health aide also noted to have a spot of blood on her sweatshirt to her mid upper chest. Aide reported that she was assisting the resident from the bathroom, that resident was ambulating with a cane and she was right behing (sic) the resident when resident slid on the landing mat and fell backwards onto the aide's chest . Review of Resident #18's care plan initiated on [DATE] documented, Nursing Dx (diagnosis), Impaired physical mobility related to: ALS, inability to care for self as evidenced by requiring extensive assistance with bed mobility, transferring, toileting, dressing, grooming and bathing. Intervention, Ambulates with the assistance of one, use of gait belt. Nursing Dx, Risk for falls related to hx (history) of fall, ALS, poor sitting and standing balance, Intervention, Follow nursing standards of care for falls prevention: low bed, call light within reach, supervise/assist with transfers, Refer to physical therapy for exercise program that targets strength, balance, flexibility, endurance. A review of Resident #18's fall risk assessment dated [DATE] scored the resident's fall risk as a five indicating the resident was a moderate fall risk. A review of the fall risk assessment dated [DATE] scored the resident's fall risk as a four indicating the resident was a moderate fall risk. A review of the fall risk assessment dated [DATE] scored the resident's fall risk as a 12 indicating the resident was a high fall risk. A review of the physician's orders [REDACTED]. Review of Resident #18's physician's orders [REDACTED]. FMP (facility maintenance plan) in place, pt (patient)/nursing educated. Review of the physician's orders [REDACTED]. Landing strip (fall mat) to side of bed (floor) when in bed for safety. A review of the physical therapy notes dated [DATE] documented, Discharge recommendations: Pt (patient) recommended to perform FMP/home exercises provided to patient and nursing staff, recommended for patient to have CGA (contact guided assistance) with transfers and ambulation with quad cane. A review of the rehabilitation discharge program (the education given from the physical therapist to the staff) dated [DATE] documented that the resident should be walked and transferred with a gait belt, have contact guided assistance from a staff person when ambulating and to use the quad cane. In the section on the form titled, Signature of individuals trained there were two nurses and two CNAs (certified nursing assistants) signatures. A review of the complete facility's reported incident documented the [DATE] interview with the homecare aide agency's medical director, the nursing supervisor and CNA #12, the homecare aide caring for Resident #18 at the time of the fall. CNA #12 stated that she was walking behind the resident when she was returning to bed after ambulating to the bathroom. The resident was using a quad cane and was wearing TED** stockings on her feet. The resident tripped on the fall mat and started falling backwards. The aide stated that the resident lurched backward and she (the aide) was in a crouching position behind the resident and that the resident hit her head on the aide's chest. The aide caught the resident and put her on the bed. When CNA #12 was asked if the resident could have struck her head on the footboard of the bed, CNA #12 stated it was possible but she did not perceive this as the incident occurred so quickly. When asked if the resident could have hit her head on her cane CNA #12 stated it might be possible but she was not sure. CNA #12 stated she was not wearing any jewelry that the resident could have hit with her head. CNA #12 stated that the resident was wearing TED stockings and the aide when asked stated no other footwear was in evidence. There was no documentation that a gait belt was in use on the resident. Further review of the facility's report revealed evidence that ASM (administrative staff member) #2, the director of nursing, documented on [DATE] in her investigative findings that CNA #12 ambulated the resident without first removing the fall mat thereby leaving an unstable walking surface and that the resident wore only TED stockings and that the non-skid footwear available in the resident's room had not been donned. ASM #2 also expressed concerns that the homecare aides accounting of the mechanics of the resident's fall seemed inconsistent with the severity of the injuries. A review of CNA #12's license documented her license was valid at the time of the incident. A review of an email dated [DATE] from ASM (administrative staff member) #2, the director of nursing, to the medical director of the homecare company that CNA #12 worked for requested information regarding CNA #12's education around transferring residents. The medical director from the homecare agency documented, We do not have a record of (name of CNA #12) receiving continuing education in transfers from our company, besides what she would have received in her C.N.A. training program and her experience as a previous employee of long-term care facilities. A review of the hospital records that Resident #18 was admitted to, documented the resident was on a respirator to support her breathing. The resident's pupils were document as, Eyes: Pupils are unequal***, round and non-reactive to light. R (right) eye 2 mm (millimeter), L (left) eye 5 mm. The resident was diagnosed with [REDACTED].***, brain compression and coma. On [DATE] (date incorrect, resident was admitted on [DATE]) at 11:54 p.m. the physician documented, Had discussions with family regarding goals of care and poss (possible) comfort care measures given unsurvivability of TBI (traumatic brain injury). A review of the computerized axial tomography x-ray dated [DATE] documented, Acute on (sic) chronic left subdural hematoma with associated mass effect, midline shift*****. A note from the neurosurgeon on [DATE] at 12:09 a.m. documented in part, Pt (patient) seen and examined this AM.presenting with massive L (left) hemispheric acute on (sic) chronic SDH (subdural hematoma) and a very poor neurological exam, including bilaterally fixed and dilated pupils and essentially absent brainstem reflexes. Prognosis is particularly poor and any neurosurgical effort is like to be futile in this case. Discussion to be held with family regarding goals of care. Patient is likely to progress to brain death, irrespective of treatment. The resident's death was pronounced on [DATE] at 7:03 p.m. An interview was conducted on [DATE] at 9:55 a.m. with ASM #2, the director of nursing, regarding the process for giving report about a resident to an agency aide. ASM #2 stated, Our aide gave report to the agency aide. The CNA (CNA #12) was PRN (as needed) and had cared for the resident in her home but not here. When (name of nurse) asked her (CNA #12) if she had cared for the resident before the CNA stated yes. The RN assumed she had cared for her in the facility and knew what to do for the resident. When asked if it was acceptable for residents to walk in TED stocking, ASM #2 stated, No, they don't walk in TEDs. I asked the nurse (RN, registered nurse) #6 if she discussed the TEDs with the aide and the nurse stated that she didn't think so because its common sense (that residents don't walk in TED stockings). An interview was conducted on [DATE] at 10:50 a.m. with CNA #3. CNA #3 was asked what the process for getting report on a resident was. CNA #3 stated, I have to report to the nurse and the nurse tells me what's going on (with the resident). When asked what information was given CNA #3 stated it pertained to the resident care needs. CNA #3 was asked if she remembered Resident #18. CNA #3 stated that she did and she remembered that the resident had a companion (the homecare aide). When asked what her responsibility was to the resident when there was a homecare aide present CNA #3 stated, I check frequently to see how the aide was doing. She seemed to be doing ok; she sat at the side of the bed. When asked if she gave report to the companion on the resident care needs CNA #3 stated that the homecare aide told her she knew how to care for the resident. CNA #3 was asked what was done with the fall mat when the resident was out of bed. CNA #3 stated, The mat can trip us so we move it out of the way. CNA #3 was asked if walking in TED stockings was routine. CNA #3 stated, When (they) have TED's, have to put something over them. When asked why that was necessary CNA #3 stated, Because they are slippery. An interview was conducted on [DATE] at 11:00 a.m. with LPN (licensed practical nurse) #1. When asked how agency aides know what to do for the resident LPN #1 stated, We ask them to come get report. They must contact a nurse every time they come in. When asked her role in supervising the agency aides, LPN #1 stated, I get in touch with the aide and see what her routine is. When asked how she ensures the agency aides were following the plan of care LPN #1 stated, Check on them during the shift. I pop in and see how things are going. I just had one (an agency aide) this morning and she came to me to get report. An interview was conducted on [DATE] at 11:06 a.m. with RN #1. When asked how agency aides know what to do for the resident RN #1 stated, Give report to the aide, go through the TAR (treatment administration record) and convey that information. When asked her role in supervising the agency aides RN #1 stated, Check on the resident and aide during my rounds. An interview was conducted on [DATE] at 11:10 a.m. with OSM (other staff member) #4, the physical therapist. OSM #4 was asked if she remember Resident #18. OSM #4 stated that she did. When asked about the resident's therapy OSM #4 stated, We evaluated her but she was not interested in therapy. We always try to get a few refusals for therapy before we discharge a resident. She (resident #18) refused therapy and was discharged with an FMP. When asked to describe Resident #18's FMP, OSM #4 stated, We educated the nurses and caregivers about safety awareness, fall risk and contact guard. Everyone should have a gait belt when transferring especially when they're a fall risk. Her (the resident) safety awareness wasn't too good, she would just do things without thinking about it, she wasn't really steady. OSM #4 was asked to explain what contact guard assist meant. OSM #4 stated, You always have hands on the resident and should have a gait belt on with hands on the gait belt. When asked if the FMPs were followed by the facility staff, OSM #4 stated, Yes I believe they are followed through on. An interview was conducted on [DATE] at 11:30 a.m. with CNA #2. When asked the process for learning how to care for the residents CNA #2 stated, We get report from the charge nurse when we come in. When asked what information was given CNA #2 stated, Their routine, getting dressed and getting up. When asked what it meant when a resident was to have contact guided ambulation, CNA #2 stated, Put a gait belt on (the resident) for safety. When asked what if anything was done with the fall mat when a resident was getting out of bed CNA #2 stated, We pick up the fall mat for safety. We don't want them to fall. When asked if the residents wore anything on their feet when ambulating CNA #2 stated, We put shoes on them. When asked if it was okay for a resident to walk in TED stockings CNA #2 stated, No, TEDs are slippery and they can fall so have to have shoes. An interview was conducted on [DATE] at 11:40 a.m. with LPN #5. When asked how agency aides know what to do for the resident LPN #5 stated, We have a process in place we have a log book that (the aide) must check in. We verify that they have a license. We go through the plan of care for the resident with the homecare aide. The homecare aide will tell us the limits of what they can do, some are only here to feed and dress (the resident). When asked his role in supervising the aides LPN #2 stated, I check to see how it is going throughout the shift and to see if they need anything. If there is anything that needs to be done outside their responsibility then tell them they must report to you (and the regular staff would then do those things). At the end of the shift or their stay they must come to me and give report to me and the regular aide. If at any time I see they are not doing anything correctly I educate them and make them do a return demonstration. An interview was conducted on [DATE] at 11:40 a.m. with CNA #7. When asked the process for learning how to care for the residents CNA #7 stated, Before we start the nurse gives report about everything, what (the resident) can do and can't, if they can walk without assistance or with assistance. When asked the process for getting a resident who had a fall mat out of bed CNA #7 stated, Remove the fall mat out of the way and put the gait belt on and then walk the person. When asked what contact guided ambulation meant CNA #7 stated, Have the gait belt on and stand close by. When asked what the process was for ambulating a resident with TED stockings on, CNA #7 stated, Oh, no we have to put shoes on. Those things are slippery, they're dangerous. An interview was conducted on [DATE] at 11:44 a.m. with CNA #8. When asked the process for learning how to care for the residents CNA #8 stated, We get report from the nurse first. When asked the process for getting a resident who had a fall mat out of bed CNA #8 stated, Take the fall mat up so they don't fall. When asked what contact guided ambulation meant CNA #8 stated, We explain to the resident about the gait belt. If they refuse we tell the nurse before we get them up. When asked what the process for ambulating a resident with TED stockings was CNA #8 stated, You have to put shoes on; you can slide and fall in TEDs. An interview was conducted on [DATE] at 11:46 a.m. with CNA #9. When asked the process for learning how to care for residents CNA #9 stated, Get report from the nurse and sometimes from the aide going home. When asked what contact guided ambulation meant CNA #9 stated, Ask (the resident) if can use a gait belt. If they refuse I won't risk it, I call the nurse. When asked the process for getting a resident who had a fall mat out of bed CNA #9 stated, If they are not in bed the fall mat is off the floor. Sometimes the fall mat can be a little sticky for residents and a fall can occur. When asked what the process for ambulating a resident with TED stockings was CNA #8 stated, Put shoes on because TEDs are slippery, we have those sock with antislip. An interview was conducted on [DATE] at 11:52 a.m. with CNA #4, a homecare aide. When asked how you know how to take care of the resident CNA #4 stated, I meet with the nurse about what's going on and I talk to the CNA. An interview was conducted on [DATE] at 11:55 a.m. with RN #3. When asked how agency aides knew how to care for residents RN #3 stated, They sign a log book when they come in. We must tell them the plan of care for the resident they are to take care of. Any fall precautions, ambulation, incontinence, feeding. Especially if this is a new aide. When asked what her role in supervising the agency aides was RN #3 stated, I check on them to see that they are following the plan of care. If not doing something correctly I correct them because I'm responsible. When they leave they give report to me or the staff here at the time. A telephone interview was conducted on [DATE] at 12:15 p.m. with CNA #5, the CNA who was on duty at the time of the resident's fall. When asked what he remembered CNA #5 stated, Yes, exactly so. I was in another room and the nurse called me to come help. I went to help the resident and the supervisor called 911, when EMS arrived I went back (to the other resident). When asked if he had ever cared for Resident #18 directly CNA #5 stated, Yes, I worked with her one or two nights before the incident. When asked if he had ever ambulated the resident CNA #5 stated, Yes I walked her. We were side by side. I used the gait belt to get her from the bed. CNA #5 stated that it was normal routine to use a gait belt when transferring residents and that Resident #18 was limited to some extent but was able to walk to the bathroom. When asked what the process for getting a resident with a fall mat out of bed was CNA #5 stated, When the resident's on the bed, the fall mat is on the floor. We pick up the fall mat before we ambulate (the resident). When asked what the process for ambulating a resident with TED stockings was CNA #5 stated, If going to step on the floor and to go to the bathroom make sure they have shoes on, they should not walk in those stockings. A telephone interview was conducted on [DATE] at 12:30 p.m. with RN #7, the nursing supervisor. When asked if she recalled Resident #18 and the evening she (Resident #18) fell , RN #7 stated she did. RN #7 stated that around 8:30 p.m. she was making rounds. The charge nurse called her to come because the resident had fallen. RN #7 went to resident's room and found the resident with her head on the bed, and her lower body on the floor. The homecare aide was there and said that the resident had fallen. The resident could not talk and was very lethargic. The vital signs were checked by the charge nurse. RN #7 went to the nurse's station and dialed 911 to have the resident transported to the hospital. RN #7 then returned to the room and noticed a spot of blood the size of a quarter on the resident's pillow case. She then checked the resident's head and found a laceration. There was a quarter sized spot of blood on the aide's chest. The aide told her that the resident's head had hit her chest. RN #7 stated that the fall mat had been disturbed and that the resident had TED stockings on and thought the resident may have slipped. When asked if this was normal footwear for residents RN #7 stated, No, should be wearing shoes. When asked if she thought the resident got a head laceration from hitting the aide's chest RN #7 stated, No, it didn't make sense at all. I asked the aide if she was telling the truth. When asked about ambulating Resident #18, RN #7 stated, Its aide 101, the aide should be using a gait belt. A telephone interview was conducted on [DATE] at 12:50 p.m. with RN #6, the charge nurse. When asked to describe what she remembered about the day Resident #18 fell , RN #6 stated, I checked in the room around 3:00 p.m. I didn't remember seeing her (the aide) before. I usually get information from the agency for who is taking care (of a resident). Since she was there since the morning shift I didn't share too much and told the aide to let me know if she needed help. RN #6 went on to say that later in the evening the aide came out of the room and asked the nurse to come to the resident's room. RN #6 stated, I asked her what was going on and she said she fell , when I asked who fell she told me it was (the resident's name). I saw the supervisor and asked her to come with me, I ran into the room. The resident's feet were dangling on the floor. I asked the aide where and how she fell . The aide said she (the resident) was walking back from the bathroom and the landing strip (fall mat) was still on the floor and she tripped. The aide was behind her and the resident fell backwards and landed on her (the aide's) chest. She (the aide) said she carried her and put her on the bed. I assessed the resident and asked her if she was okay. She didn't respond which was really odd. I took vital signs and noticed blood on the pillow. I said she's bleeding what did she hit her head on and the aide said she hit her head on her chest. There was a round spot of blood on the aide's chest. The vital signs were very high; I called 911 and the daughter. I asked the aide what really happened and the aide said that she (the resident) just fell backward onto her chest. I did not believe her story, I don't know if we would have acted any quicker. A review of the facility's policy titled, Private Duty Personnel documented in part, Resident care should be monitored and supervised by the professional nurses on staff 2. Private duty personnel must meet the facility standards and adhere to ALL (name of facility) policies. A review of the facility's policy titled, Rehab (rehabilitation) Discharge Program documents in part, PURPOSE: To establish a process to follow when completing the Physical, Occupational, Speech Rehab Communication/Cognition and Dysphagia Rehab discharge Program forms (hereinafter referred to as Form) POLICY: A Form shall be established for discharged residents who remain in the facility that are less than independent. PROCEDURE: Complete the form as follows: 1. Resident Name .4. Start date for Program. 5. Type of Program .7. Program information .9. Signature of individuals trained. A memorandum to the nurses and CNAs from ASM #2, the director of nursing and ASM #3, the assistant director of nursing on [DATE] documented, Nursing/CNA staff MUST use a gait belt when transferring a resident It is critical we put this practice in place because not only is it a healthcare standard practice but our residents are experiencing an increase in skin tears and bruise which must be prevented. A review of the facility's policy titled, (Name of facility) Standards of Care - 2015 documented in part, SAFETY, including PREVENTION OF CHOKING AND FALLS PREVENTION - Well-fitting nonskid footwear is to be used when out of bed. On [DATE] at 1:35 p.m. ASM #1, the administrator and ASM #2, the director of nursing were made aware that concern for harm. ASM #2 presented credible evidence that a five point plan of correction had been put into place following the above referenced incident. The credible evidence presented included the following: 1. Investigation of the incident revealed a lack of communication between the facility staff and the agency homecare aides. An action plan was put into place to educate charge nurses on their responsibility to provide direction and oversight to private caregivers. This education was completed on [DATE] with 100% attendance from nursing staff. 2. Investigation of the incident revealed that agency homecare aides were not educated on the resident's plan of care. An action plan was put into place to create an on-unit sign-in /sign-out log for all private caregivers wherein they acknowledge awareness of the resident's individualized care plan. This was completed on [DATE]. 3. The facility notified individual caregiver agencies of the newly implemented log and performance expectations. This was completed on [DATE]. During the survey, no concerns were identified by observation or record review with providing care to a resident while ambulating. No further information was provided prior to exit. Promoting Safety and Comfort during Ambulation: Practice the safety measures to prevent falls. Use a gait belt when helping a person with ambulation. Also use it to help a person stand. Page 359Safety Measures to Prevent Falls: Non-skid footwear is worn. Socks, bedroom slippers and long shoelaces are avoided. Page 93. Mosby's Essentials for Nursing Assistants 3rd edition, Sorrentino and Gorek. Most falls could be prevented by a vigilant physician anticipating, assessing, and correcting fall risks, which may be medical, mechanical, or environmental. The impact of chronic disease and medication, balance and gait, and home risks should be assessed routinely. Falls are an important public health concern. They can result in serious injuries, enduring disabilities, drastic lifestyle changes, escalating healthcare expenses, and even death. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 73/ *[DIAGNOSES REDACTED] (ALS) is a nervous system disease that attacks nerve cells called neurons in your brain and spinal cord. These neurons transmit messages from your brain and spinal cord to your voluntary muscles - the ones you can control, like in your arms and legs. https://www.nlm.nih.gov/medlineplus/amyotrophiclateralsclerosis.html **TED hose -Thromboembolic deterrent (TED) stockings are commonly used in the prevention of deep venous thrombosis. <http://www.ncbi.nlm.nih.gov/pubmed/ 824> ***Pupillary abnormalities are commonly seen in patients presenting with severe traumatic brain injury (TBI). <http://www.ncbi.nlm.nih.gov/pubmed/ 711> **** A subdural hematoma is usually the result of a serious head injury. When it occurs this way, it is called an acute subdural hematoma. Acute subdural hematomas are among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death. https://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm *****Midline shift -- Brain midline shift (MLS) is a life-threatening condition that requires urgent [DIAGNOSES REDACTED].ncbi.nlm.nih.gov/pmc/articles/PMC 28/

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and services for the prevention of pressures sores for one of 19 residents in the survey sample, Resident #8. Resident #8 was readmitted to the facility on [DATE] with a right fractured tibia/fibular* in a soft cast (or partial cast splint) ** wrapped with an elastic bandage. The facility staff failed to clarify physician's orders [REDACTED].#8's right lower leg; as a result, the resident developed an unstageable pressure ulcer(1). ** What is the difference between a cast and a splint? A cast wraps all the way around an injury and can only be removed in the doctor's office. A splint is like a "half cast." The hard part of a splint does not wrap all the way around the injured area. It is held in place by an elastic bandage or other material. Unlike casts, splints can be easily removed or adjusted. Many splints are custom-made from fiberglass or plaster. Splinting involves subsequent application of a non-circumferential support held in place by an elastic bandage. Splints are faster and easier to apply; allow for the natural swelling that occurs during the acute [MEDICAL CONDITION] phase of an injury; are easily removed for inspection of the injury site .... Complications of Cast or Splint Immobilization: Pressure sores and skin breakdown. Unstageable/Unclassified pressure ulcer: Full thickness skin or tissue loss - depth unknown: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. (1) Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. (2) The findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/14, Resident #8 was observed on the floor, sent to the hospital and diagnosed with [REDACTED]. Resident #8's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 7/26/14, coded the resident's cognition as being severely impaired. Section G documented: Resident #8 required extensive assistance of two staff with bed mobility and transfers; the resident was totally dependent of one staff with bathing. Section M documented Resident #8 was at risk of developing a pressure ulcer. Section M1200 "Skin and Ulcer Treatments" coded a check mark beside "Pressure reducing device for bed" and "Applications of ointments/medications other than to feet." The hospital discharge instructions dated 7/19/14 documented, "Reason for Admission: Fall, initial encounter; closed fracture of right tibia and fibula, initial encounter...Discharge Instructions: Patient Instructions: None...You have a break (fracture) of the leg. A fracture is treated with a splint or cast or special boot. It will take about 4-6 weeks for the fracture to heal...Home Care: You will be given a splint, cast, boot, or other device to prevent movement at the site of injury. Unless you were told otherwise, use crutches or a walker and do not bear weight on the injured leg until cleared by your doctor to do so...Keep your leg elevated to reduce pain and swelling...Apply an ice pack over the injured area for 20 minutes every 1-2 hours for the first day...Keep the cast/splint/boot completely dry at all times. Bathe with your cast/splint/boot out of the water..." The instructions failed to document any information regarding removal of the cast for skin assessments. Review of Resident #8's clinical record revealed Resident #8's readmission orders [REDACTED] ? "TX (treatment): Monitor R (right) leg, toes for circulation q (every) shift. ? Skin assessment weekly on shower day Tuesday 3-11 (3:00 p.m. to 11:00 p.m. shift). ? Braden scale on admission then q week X (times) 3..." Resident #8's TARs (treatment administration records) for July 20, 2014 through September 30, 2014 revealed nurses' initials signed each shift indicating the resident's right leg and toes were monitored. Resident #8's TARs for July 22, 2014 through September 30, 2014 revealed nurses' initials signed once a week indicating a skin assessment had been completed. Review of Resident #8's July and August 2014 TARs revealed nurses' initials signed on 7/19/14, 7/26/14, 8/2/14 and 8/9/14, indicating the Braden scale was completed on those dates. However, review of the computerized Braden scales revealed Braden assessments were documented on the following dates: ? 7/20/14- A score of 16 (Note: the assessment documented the resident was considered at risk for pressure ulcer development for a score of 12 or less). ? 8/2/14- A score of 15. ? 8/9/14- A score of 15. ? 9/28/14- A score of 11. A skin assessment form dated 7/20/14 documented, "Nurses Notes: DURING ADMISSION ASSESSMENT A CAST NOTED ON THE RIGHT LOWER EXTREMITY, EXTENDING FROM ANKLE TO BELOW THE KNEE, resident sustained [REDACTED]." A physician's note dated 7/21/14 documented, "The patient is a [AGE] years old white female with a possible medical history significant for long-standing hypertension, [MEDICAL CONDITION] ([MEDICAL CONDITIONS]), DJD ([MEDICAL CONDITION] joint disease), chronic [MEDICAL CONDITION], and wants (sic) dementia who is a resident of (name of facility) where she was doing fairly well until 2 days ago when she was noted to have deformity of the right leg which she did have an x-ray done which was consistent with [MEDICAL CONDITION] of the tibia and proximal end of the fibula do (sic) to which patient was transferred to (name of hospital) where she was evaluated by both intravenous (sic) and also previous and was considered to be a nonsurgical candidate and has been treated with cast...Physical Exam: Musculoskeletal: She exhibits no [MEDICAL CONDITION] and no tenderness. No decubitus ulcer*** Right lower extremity wrapped up up (sic) to tibial Tubercle****...Plan: We will continue conservative treatment and her overall prognosis remains guarded and she does remain at risk for [MEDICAL CONDITION] ([MEDICAL CONDITION] and decubitus ulcer..." Resident #8's comprehensive care plan dated 7/21/14 documented in part, "Problems/Strengths/Etiologies:(Name of Resident #8) is at risk for impaired skin integrity related to immobility, fragile skin, right lower leg cast and incontinence AEB (as evidenced by) Braden of 15. Goals: (Name of Resident #8) will have no avoidable skin breakdown. Approaches: Assess skin around soft cast sites every shift. Check skin temperature, color, capillary refill. Check pedal pulses when unwrapped to assess skin..." A skin assessment form dated 7/22/14 failed to document any notes. "Inapplicable" was documented regarding numerous computer generated areas including wounds, nutrition and treatments. A skin assessment form dated 7/27/14 documented "Nurses Notes: POST-COMPLETE BED BATH, SKIN ASSESSED, CAST NOTED ON RIGHT LOWER EXTREMITY. SKIN NOTED INTACT, A BRUISE NOTED ON RLE (right lower extremity) POSTERIOR RIGHT LEG JUST ABOVE CAST." A skin assessment form dated 7/30/14 documented "Nurses Notes: SKIN ASSESSED POST THOROUGH BED BATH, CAST REMAIN ON RIGHT LOWER EXTREMITY. THE REST OF RESIDENTS' SKIN IS NOTED INTACT." A physician's orders [REDACTED].#9 documented, "Clarification orders: Monitor soft cast on RLE (right lower extremity) every shift and see that it is in place. DX (diagnosis): Fx (fracture) s/p (status [REDACTED]. Monitor skin integrity and any open area on RLE then notify M.D. (medical doctor) DX s/p Tib/Fib Fx." The August 2014 and September 2014 TARs documented, "Monitor soft cast on RLE every shift and see that it is in place...Monitor skin integrity and any open area on RLE then notify MD..." Nurses' initials were signed each shift indicating the order had been completed. A physician's note dated 8/4/14 documented, "Physical Exam: Skin: Skin is warm and dry. No rash noted. No [DIAGNOSES REDACTED]..." Skin assessment forms dated 8/5/14, 8/12/14 and 8/19/14 failed to document any notes. "Inapplicable" was documented regarding numerous computer generated areas including wounds, nutrition and treatments. A physician's note dated 8/18/14 documented, "Physical Exam: Musculoskeletal: She exhibits no [MEDICAL CONDITION] and no tenderness. Right leg cast up to knee level noted distal neurocirculation intact..." A skin assessment form dated 8/26/14 documented, "Nurses Notes: Cast remains on right lower extremity, skin assessed post-through bed bath, skin assessment indicated no open area." Review of ADL (activities of daily living) daily charting for 9/1/14 through 9/22/14 revealed Resident #8 only received sponge/partial baths and bed baths for those dates. No showers were given. A skin assessment form dated 9/2/14 failed to document any notes. "Inapplicable" was documented regarding numerous computer generated areas including wounds, nutrition and treatments. A skin assessment form dated 9/9/14 documented, "Nurses Notes: Skin assessed post-thorough bed bath, noted soft cast on RLE, entire skin noted intact..." A skin assessment form dated 9/16/14 documented, "Nurses Notes: Weekly skin assessment done, Soft cast on right lower extremity remains intact." A skin assessment form dated 9/22/14 documented, "Site: Foot Right Outer; Category: Skin Condition; Type: Other; Description: DARK ESCHAR TO THE OUTER ASPECT OF THE RIGHT FOOT. SKIN AROUND ESCHAR INTACT, NO DRAINAGE NOTED; Size Length: 2.2 cm (centimeters) Width: 1.5 cm Depth: 0." A physician's note dated 9/22/14 documented, "Physical Exam: Musculoskeletal: She exhibits no [MEDICAL CONDITION] and no tenderness. Right leg no obvious deformity, no focal tenderness over the tibia, Small decubitus ulcer over proximal end of the fifth metatarsal ^* which is about 1 cm in diameter with eschar from irritation from partial cast. No decubitus ulcer over her heels or sacrum...Plan: Due to development of [MEDICAL CONDITION] on the right foot we will try to see if patient will do fairly okay with Air cast over right leg and ankle. She will continue her PT (physical therapy) and OT (occupational therapy) and we will continue local wound care as per protocol as it appears to be dry at the present time and monitored closely. A physician's orders [REDACTED]. A physician's orders [REDACTED].@ (at) all times for Rt tibia Fx (fracture) and fibula Fx." Review of nurse's notes for September 2014 revealed frequent documentation that Resident #8's soft cast was in place and the resident's toes were assessed for circulation. No nurse's notes revealed documentation that the soft cast had been unwrapped or removed for assessment of the skin underneath. Nurse's notes dated 9/16/14 and 9/17/14 documented Resident #8 was observed removing the ace wrap around the soft cast. The ace wraps were reapplied. The nurse's notes failed to document the resident's skin underneath the soft cast was assessed at this time. A nurse's note dated 9/18/14 documented Resident #8 was found with the cast off and the cast was reapplied. The nurse's note failed to document the resident's skin underneath the soft cast was assessed at this time. On 11/13/14 at 5:55 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated in the past, she used to conduct wound rounds but when Resident #8's pressure ulcer was found, she was not conducting wound rounds. RN #1 stated she resumed wound rounds in October 2014. RN #1 was asked what she knew regarding Resident #8's soft cast and pressure ulcer development in September 2014. RN #1 stated during September 2014, Resident #8 had a removable cast wrapped in ace wrap. RN #1 stated, "I have nothing to say except I guess people weren't checking under there (the soft cast). Later, I think it was changed to an inflatable pillow cast. Now she has a new window cast." On 11/17/14 at 12:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3 (a nurse who cared for Resident #8 during September 2014 and the nurse responsible for completing Resident #8's skin assessment on 9/22/14). LPN #3 was asked to describe the soft cast Resident #8 wore in September 2014. LPN #3 stated the soft cast had an ace wrap and a brace. LPN #3 stated he looked at Resident #8's toes to check for color and blood flow. When asked if Resident #8's soft cast was removable, LPN #3 stated, "Most of those things you have to have an order from the doctor. You can't just remove." When asked if he (LPN #3) ever unwrapped or removed Resident #8's soft cast to look at the resident's skin, LPN #3 stated, "The order wasn't there at the time." When asked if anyone had asked Resident #8's physician if the soft cast was supposed to be removed, LPN #3 stated, "Not that I remember." LPN #3 was asked if clarification from the physician should have been sought regarding the removal of the soft cast to inspect the skin underneath, LPN #3 stated, "Yeah." When asked if anyone clarified this with Resident #8's physician, LPN #3 stated, "That's not up to my knowledge. No." On 11/17/14 at 1:00 p.m., an interview was conducted with Resident #8's physician (ASM #3 (administrative staff member)). When asked to describe the soft cast Resident #8 wore from July 2014 through September 2014, ASM #3 stated the cast was a splint that covered the back of the leg and foot. ASM #3 stated the splint was covered with ace wrap. ASM #3 stated Resident #8 wore the soft cast for more than eight weeks and the cast rubbed the lateral foot which created a pressure ulcer. When asked what care should have been provided regarding the soft cast and skin assessments, ASM #3 stated the staff was supposed to remove the ace wrap, check the skin and ensure no open areas daily. ASM #3 stated he removed the soft cast to inspect the skin every week because he was concerned Resident #8 would develop a pressure ulcer on her heel. ASM #3 stated the pressure ulcer was a stage two when he saw the area. ASM #3 stated the staff was changing the ace wrap once a week because it was falling apart. ASM #3 was shown the physician's readmission order dated 7/19/14 that documented, "TX (treatment): Monitor R (right) leg, toes for circulation q (every) shift." ASM #3 was asked for clarification regarding the order. ASM #3 stated the order was a hospital order that was transcribed onto the readmission orders [REDACTED]. ASM #3 stated if the staff had any doubts then they should have asked him. When asked if the nurses were removing the soft cast, ASM #3 stated, "I can't say." On 11/17/14 at 1:23 p.m., an interview was conducted with RN (registered nurse) #4 (a nurse who cared for Resident #8 during September 2014). RN #4 stated all she could remember about the description of Resident #8's soft cast was that it contained an ace wrap and a cotton interior. RN #4 stated she "Didn't think it (the soft cast) was allowed to come off." RN #4 stated the nurses have meetings every Monday and Friday and she later found out the soft cast could be removed. RN #4 stated the order from the physician wasn't clear. RN #4 was asked to describe her assessments of Resident #8's right leg and toes. RN #4 stated she checked the toes and pushed to check the toes for capillary refill^**. RN #4 was asked if she removed the soft cast. RN #4 stated, "No." When asked what should be done if a physician's orders [REDACTED].#4 stated, "It should have been clarified by calling the physician. It should have been done when she (Resident #8) came from the hospital." On 11/17/14 at 1:40 p.m., an interview was conducted with CNA (certified nursing assistant) #1 (a CNA who had given Resident #8 baths prior to the pressure ulcer development). CNA #1 stated in September 2014, the resident was in a cast up to her knee. CNA #1 stated that during September 2014, the staff were not giving Resident #8 showers but was giving the resident bed baths. When asked if she recalled whether she or anyone else ever removed the cast, CNA #1 stated, "No." On 11/17/14 at 1:45 p.m., an interview was conducted with Resident #8's physician (ASM #3) to clarify the stage of the pressure ulcer on Resident #8's right foot when it was found on 9/22/14. ASM #3's note dated 9/22/14 documenting the finding of eschar was reviewed. ASM #3 was then asked to clarify the statement during the previous interview that the pressure ulcer was initially found at stage two. ASM #3 stated there is no staging with eschar and a stage two pressure sore is superficial. ASM #3 stated the pressure sore was partially covered with eschar when he initially saw it. On 11/17/14 at 1:50 p.m., a telephone interview was conducted with LPN #2 (the nurse who signed the skin assessments dated 7/17/14, 7/20/14, 7/27/14, 7/30/14, 8/26/14 and 9/9/14). LPN #2 described Resident #8's soft cast as a simple cast with a wrap around on the top so it didn't come off and with Velcro at the ends to hold it in place. LPN #2 was asked if the soft cast was removable. LPN #2 stated the staff did not have orders to remove the soft cast and at the time, he thought it shouldn't have been removed because the resident's leg needed to be immobile so the bones could heal. LPN #2 stated he did not remove Resident #8's soft cast to complete the skin assessments. LPN #2 stated he assessed the resident's toes and the skin above the cast. On 11/17/14 at 3:12 p.m., the Administrator and Director of Nursing (DON-ASM #2) were made aware of the above concern for harm. On 11/18/14 at 8:15 a.m., an interview was conducted with LPN #8 (a nurse who cared for Resident #8 during September 2014). LPN #8 described Resident #8's soft cast as being similar to a regular cast with gauze and clean cotton inside. LPN #8 stated the cast was open on the sides and was covered with ace wraps. When asked how she monitored Resident #8's skin during September 2014, LPN #8 stated skin assessments were done on a weekly basis. LPN #8 stated the nurses were checking for capillary refill and checking the skin around the cast on the resident's thigh and foot. When asked if she removed the soft cast, LPN #8 stated, "I did not. The doctor didn't give an order." When asked if she thought to clarify this with the physician, LPN #8 stated another nurse (LPN #9) had told her the physician said not to remove the soft cast. LPN #8 stated the physician's orders [REDACTED]." When asked if the order should have been clarified with the physician, LPN #8 stated the order dated 8/3/14 was a clarification order but it should have been clarified even more. On 11/18/14 at 8:40 a.m., this surveyor requested all policies regarding pressure ulcers, clarifying physician's orders [REDACTED]. On 11/18/14 at 10:00 a.m., ASM #2 stated the facility did not have any policies regarding casts or splints. On 11/18/14 at 10:10 a.m., a telephone interview was conducted with LPN #9. When asked if Resident #8's soft cast was removable, LPN #9 stated the physician didn't want the nurses to remove the soft cast. When asked if the physician told her this, LPN #9 stated she arrived home from her shift one day and another nurse called her and stated the soft cast was observed off Resident #8's leg and the physician had stated he didn't want the cast off. On 11/18/14 at 10:20 a.m., ASM #2 stated the facility did not have any policies regarding clarification of physician's orders [REDACTED]. The facility "Standards of Care" documented in part, "The (name of facility) Skin Health Management Program utilizes the interdisciplinary team for the development of an individualized plan of care that promotes healthy skin, aims to prevent new skin breakdown and manage skincare (sic) issues. The skin health management program covers: 1. The staff training and continuing education that include: Skin inspection methods and maintenance care...Roles and responsibilities related to assessment and prevention..." The facility policy titled "Pressure Ulcer Risk Assessment" documented in part, "3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen...Assessment: 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a 'skin alert,' performing routine skin inspections daily or every other day as needed..." On 11/17/14 at 6:00 p.m., an interview was conducted with ASM #2. ASM #2 stated the facility employees increased their focus on skin documentation in August 2014 and September 2014. ASM #2 stated after Resident #8 developed the pressure sore, the facility identified there was a problem. ASM #2 presented documentation of a risk meeting form dated 9/26/14 that documented 14 employee names that were present at the meeting. ASM #2 stated she, the administrator, day shift charge nurses, nurse leaders and a night shift supervisor were present. The form documented, "Discussed skin issue where pressure ulcer developed underneath resident's soft cast. Reviewed order written 8/3/14 stating 'Assess resident's skin on right lower extremity for areas of breakdown.' Charge nurses present were asked to describe how they would complete this assessment when a soft cast was present. None of the charge nurses were able to state that the soft cast could be removed unless there was a specific order to do so. Proper technique for assessment of skin underneath soft cast was reviewed with the group. Emphasized if unsure about removing cast, charge nurse should clarify with Nurse Leader, DON or physician. Also discussed was observing for localized pain different from orthopedic pain or drainage. Reviewed and discussed general skin checks on shower days and documentation of skin check." ASM #2 also presented an email sent to nurses regarding computerized documentation of skin inspections. ASM #2 was asked if all nurses were educated regarding clarification of physician's orders [REDACTED]. ASM #2 stated each nurse leader conducts meetings with nurses on their units. ASM #2 was asked to provide credible evidence that all nurses had been educated. ASM #2 was unable to do so. Also, ASM #2 confirmed the facility had not had any residents with casts since Resident #8's pressure sore development. On 11/17/14 at 6:14 p.m., an interview was conducted with LPN #1 regarding what to do if a resident is admitted with an orthopedic device. LPN #1 stated she would look at the physician's orders [REDACTED]. LPN #1 confirmed the facility had not provided her with any training or education regarding care of orthopedic devices. On 11/17/14 at 6:17 a.m., an interview was conducted with LPN #4. LPN #4 stated she hadn't had to care for anyone with a soft cast. When asked if a resident was admitted with orthopedic equipment, how would she know what care to provide, LPN #4 stated she would obtain the information from the physician's orders [REDACTED]. When asked if she had received any training or education from the facility regarding care for orthopedic devices including soft casts, LPN #4 stated, "No." On 11/18/14 at 8:10 a.m., observation of Resident #8 receiving wound care was conducted. No concerns were identified. At this time, the resident had a hard cast on her right lower extremity, beginning just above her knee and extending to her toes. A portion of the cast located on the right lateral side was removed and displayed the dressing that covered the resident's pressure ulcer. On 11/18/14 at 11:45 a.m., ASM #2 presented a typed document titled "Timeline for compliance with skin care for (name of Resident #8). The timeline documented the assessments and care provided for the resident's pressure sore after the area was found on 9/22/14. The information documented in the timeline was confirmed through clinical record review; however, the timeline did not provide any further information prior to 9/22/14. No further information was presented prior to exit. (1) The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories (2) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 October 2011, pages M-22. * The tibia and fibula are the two bones in the lower leg. This information was obtained from the website: <http://www.niams.nih.gov/Health_Info/Growth_Plate_Injuries/default.asp> ** This information was obtained from the website: <http://www.aafp.org/afp/2009/0101/p16.html> ***A decubitus ulcer (also known as a pressure ulcer or pressure sore) is "An area of skin that breaks down when something keeps rubbing or pressing against the skin." This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm> **** The tibial tubercle is "A bony bump below the knee." This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm> ^*The metatarsal bones are the long bones in your foot that connect your ankle to your toes. They also help you balance when you stand and walk...The 5thmetatarsal is the outer bone that connects to your little toe. It is the most commonly fractured metatarsal bone." This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/ 1.htm> ^**"The capillary nail refill test is a quick test done on the nail beds. It is used to monitor dehydration and the amount of blood flow to tissue." This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm>

Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure for one of 19 sampled residents, (Resident #4), who was identified as at risk for pressure sores received timely assessment and treatment for [REDACTED]. a. Resident #4 was documented as having a change in skin condition by the CNA (certified nursing assistant) on 9/22/13, 9/25/13 and 9/28/13. There were no nursing assessments or treatment orders for Resident # 4's change in skin condition on these dates documented in the clinical record. On 9/30/13, Resident # 4 was found with an unstagable pressure area on her great toe. An Unstagable pressure wound is a known wound but not stagable due to coverage of wound bed by slough and/or eschar. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. (2) b. The CNA documented a change in skin condition on 11/3/13 and 11/6/13 for Resident #4. There was no nursing assessment for the changes in skin condition documented on these dates in the clinical record. On 11/12/13 Resident # 4 was found with a stage II pressure area on her sacral region. A pressure ulcer is an inflammation or sore on the skin over a bony prominence (e.g., shoulder blade, elbow, hip, buttocks, or heel), resulting from prolonged pressure on the area, usually from being confined to bed. Also called bedsores. Pressure sores. (1) A stage II pressure ulcer is described as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (non viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture). May also present as an intact or open/ruptured blister. (2) The findings include: a. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/7/13, coded the resident with both short and long term memory difficulties. The resident was coded as being severely impaired to make daily cognitive decisions. Resident # 4 was coded as being dependent upon one or two staff members for moving in the bed, transfers, moving on and off the unit, toileting, personal hygiene and bathing. The resident was coded as requiring extensive assistance of one staff member for eating. In Section M - Skin Conditions, the resident was coded as being at risk for developing pressure ulcers and was coded as having one, stage two, pressure ulcers. Resident #4 was coded as being incontinent of both bowel and bladder. Observation of Resident #4's toe was conducted on 11/14/13 at 11:43 a.m. accompanied by LPN (licensed practical nurse) #2 and CNA #3. The resident's right great toe had an area measured at 0.5 cm by 0.3 cm that was dark black in color. LPN #2 described the wound as an unstagable pressure ulcer. It couldn't be staged due to the scab like appearance of the area. The tissue around the area was pink and dry. The resident's great toe was observed bent at the knuckle at the foot and also at the toe knuckle. This caused the resident's toe to be bent towards the second toe. The surface of the toe was in contact with the resident's shoes when out of bed. Resident # 4 was observed with shoes on while out of bed. When asked how this area could have developed, LPN #2 stated, "With the deformity of her toes, the shoes must have rubbed the area to cause this." Review of the clinical record revealed the "Braden Score for Predicting Pressure Ulcer Risk" form. The form, documented an assessment dated [DATE] that coded the resident with a score of "12." The form documented, "If the residents total is 12 or less, consider him/her at risk for pressure ulcer development." An assessment dated [DATE] documented the resident with a score of "13." The next documented Braden score assessment was dated, 10/14/13 in which the resident scored a "10." Review of the "Daily Charting for "Skin Condition - CNA - resident has a skin problem?" revealed on 9/7/13, the CNA documented a "1" which is indicated a "yes." On 9/22/13, 9/25/13 and 9/28/13, the CNA documented a "1" or "yes" for if the resident had a skin problem. Review of the nurse's notes did not reveal any documentation from 9/1/13 until 9/30/13. The nurse's note dated, 9/30/13 documented, "Resident seen by (name of doctor) for 60 day review. Resident noted with dried dark blister to plantar region of R (right) great toe that measures L (length) 1.0 cm (centimeters) X (by) W (width) 1.5 cm. Surrounding skin pink, dry and intact. Denies pain to area. (Name of doctor) ordered skin prep to area twice daily until dried skin peels off of her R great toe. ...Resident stable and resting in bed with feet elevated." The physician telephone order dated, 9/30/13, at 4:55 p.m. documented, "Cleanse dark dried blister to plantar region of right great toe with soap and water. Rinse, pat dry, apply skin prep twice daily and leave open to air until healed." The "Skin Assessment Form" dated, 9/30/13, documented, "Dark dried blister to plantar region of R great toe. Surrounding skin pink, dry and intact. Denies pain to area. Skin prep to dark dried blister to plantar regions of R great toe." The wound was documented as measuring 1.3 cm by 1.0 cm with no depth. There were no skin assessment forms in the chart prior to 9/30/13. Review of the comprehensive care plan dated, 8/3/13, documented, "Problem: (Resident #4) is at risk for skin breakdown r/t (related to) decreased mobility; inability to clearly express discomfort." The "Interventions/Approaches" documented, "Reposition every 2 hours during the day when in bed or chair. Reposition during the night every 2 hours (Discipline assigned - CNA). Monitor skin during baths and weekly. (Discipline assigned - CNA - NUR (nurses). Apply lotion to arms and legs every am (morning) and HS (at bed time). Provide incontinence care as needed. Float heels on pillow when in bed." The "Evaluation" area of the care plan documented on 9/23/13, "Care plan reviewed, skin is intact. Remains at risk, continues with preventative interventions. Care Plan remains appropriate." An attempt was made to interview the CNA responsible for documenting on 9/22/13, 9/25/13 and 9/28/13. The two CNAs were unable to be interviewed. An interview was conducted with RN (registered nurse) #1, the MDS coordinator, on 11/14/13 at 9:28 a.m. When asked where the weekly skin assessments were located in the computerized clinical record, RN #1 stated, "We don't do them." When asked if they chart by exception, RN #1 stated, "Yes, we only document when they find something." RN # 1 was asked if the nurse's completed weekly skin assessments. RN #1 stated, "No." RN #1 stated, "I've had discussions with the previous DON (director of nursing) on multiple occasions regarding this." When clarified with RN #1 that the facility does not do weekly skin assessment, RN #1 stated, "Yes, that's what I am telling you." When asked if the facility has any documentation that they have looked at resident's skin on a routine basis, RN #1 stated, "No." An interview was conducted with administrative staff member (OSM) #2, the interim DON, on 11/14/13 at 9:50 a.m. OSM #2 stated, "The CNAs document on their iPads. They have a section that they can identify skin conditions. If they answer yes, it gives them guidance to inform the nurse." When asked if there is an alert sent via the computer to the nurse, OSM #2 stated, "No, there is no alert system to the nurse." When asked where the facility has documentation that the nurse did an assessment after the CNA told them about an area, OSM #2 stated, "There is no documentation unless it's in the IDT (interdisciplinary team) notes. The system (computer system) is not perfect and we have a few things to work out." OSM #2 was notified on 11/14/13 at 10:05 a.m. the concern for harm for Resident #4. An interview was conducted with LPN (licensed practical nurse) # 2, on 11/14/13 at 10:45 a.m. regarding skin assessments of the residents. LPN #2 stated, "We do them on admission, after a fall, and when they come back from a leave of absence or if a resident has specific orders to assess their skin. Occasionally I will assess the resident when the CNAs are giving showers, if I'm not too busy and nothing is going on at the time. If the CNAs see something, they call me. The CNAs observe during care and they tell us if they see anything new." An interview was conducted with RN #3, a charge nurse, on 11/14/13 at 10:52 a.m., regarding skin assessments on the residents. RN #3 stated, "Every Tuesday, during wound rounds." When asked if every resident is assessed on Tuesdays, RN #3 clarified that it is only the residents that have wounds that are assessed on Tuesdays. When asked if he does skin assessments on his residents, RN #3 stated, "Everyday I do a general assessment of my residents. I talk with my aides and they do skin care they are to tell me if they see anything, such as redness or anything unusual." When asked where he documents that he has assessed something the CNAs have brought to his attention, RN #3 stated, "In the IDT notes. The skin assessment form is only for if they have an issue." When asked if there was any other form on which the staff documents skin assessments, RN #3 stated, "No, there are no other forms." An interview was conducted with CNA #6 on 11/14/13 at 10:55 a.m., regarding when she performs resident skin assessments. CNA #6 stated, "In the morning when I am getting the resident undressed from the night and getting them dressed for the day. It's an ideal time to look at all of their skin." When asked what she does if she sees something, CNA #6 stated, "I notify the nurse. I go get someone to come and look at it right away or I call for someone to go get the nurse." When asked should she document a new skin concern, CNA #6 stated, "On my iPad where it asks if there are any skin conditions." An interview was conducted with RN #2, the wound care nurse and supervisor, on 11/14/13 at 11:02 a.m. When asked how the resident's skin is assessed, RN #2 stated, "We do it upon admission and when we do the Braden scale." When asked how often the Braden scale is done, RN #2 stated, "We do them for the first four weeks after admission, then quarterly and with any change in condition, skin condition." When asked what the CNAs do if they discover something new or different from before, RN #2 stated, "They (the CNAs) chart it on the iPads and then tell the nurse. The nurse then does a skin assessment." When asked when the nurse's do skin assessments, RN #2 stated, "They assess them when they complete the Braden scale and when a CNA reports as change in condition." When asked if a weekly skin assessment is performed on each resident, RN #2 stated, "No." When asked if the nurses are dependent on the CNAs to report any skin conditions, RN #2 stated, "Yes." RN #2 stated, "Nurses only do a full skin assessment when they do the Braden scale." At 4:00 p.m. on 11/14/13, OSM #2 was requested to present any information or documentation regarding the treatment of [REDACTED]. No further information was provided. The facility policy, "Prevention of Pressure Ulcers" documented, "General Guidelines: 6. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed." The facility policy, "Pressure Ulcer Risk Assessment" documented, "Assessment: 1. Risk Assessment - A pressure ulcer risk assessment will be completed upon admission, with each assessment; quarterly, annually and with significant changes. 2. Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a "skin alert", performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches...Documentation: The following information should be recorded in the resident's medical record: 1. The type of assessment conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The position in which the resident was placed upon completion of the assessment. 4. The name and title of the individual conducted the assessment. 5. Any changes in the resident's condition. 6. The condition of the resident's skin (the size and location of any red or tender areas). 7. How the resident tolerated the procedure or his/her ability to participate in the procedure." treatment of [REDACTED]. Department of Health and Human Services, Publication Number 15, documents, in part: "All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the boney prominences. Results of the skin inspection should be documented ... Skin inspection provides the information essential for designating interventions to reduce risk and for evaluation outcomes of those interventions." The assessment of an individual with a pressure ulcer is the basis for planning treatment, evaluating treatment effects, and communicating with other caregivers. Initially, the clinician should determine the location, stage, and size of the pressure ulcer. Accurate staging and description of pressure sores is a perquisite to the development and implementation of appropriate, effective treatment protocols and to effective, ongoing monitoring of tissue healing." The administrative team was made aware on 11/14/13 at 5:50 p.m. the concern for harm for Resident #4. b. Review of the "Daily Charting for "Skin Condition - CNA - resident has a skin problem?" revealed on 11/3/13 the CNA documented a "1" which is indicated a "yes." On 11/6/13, the CNA documented a "1" or "yes" for if the resident had a skin problem. The most recent Braden scale assessment on 10/14/13, documented the resident's score of "10." If a residents total is 12 or less, consider him/her at risk for pressure ulcer development. The review of the physician order [REDACTED].* topically every shift to prevent skin breakdown." The review of the October and November treatment administration record (TAR) documented, "Cleanse peri-area with soap and water - pat dry - apply Nutrashield topically every shift to prevent skin breakdown." The Nutrashield was documented as applied each shift for October and November. A "Skin Assessment Form" dated, 11/12/13, documented, "Full thickness wound. Type: Pressure Ulcer. Description: Pressure ulcer noted to sacral region with 100% granulation noted to wound bed. Surrounding skin, pink dry and intact. Stage: 2." The "Nurse's Note" at the bottom of the form documented, "Resident noted with open area to sacral region, with 100% granulation to wound bed. No drainage noted. Surrounding skin pink, dry and intact. Resident is incont (incontinent) of bowel and bladder; incont care provided. [MEDICATION NAME] paste will be used to area, every shift after each incont episode until healed. Resident was assessed during wound rounds this AM (morning). MD (doctor) and Son updated." Observation of the wound was conducted on 11/13/13 at 11:43 a.m. with LPN #3 and CNA # 3. The open area was located between the buttocks on the sacrum. The area was measured by LPN #3 to be 2 cm in length and 0.5 cm in width. There was 100%granulation tissue noted. The skin around the wound was noted to be pink and was blanchable when LPN #3 tested the area. There was no measurable depth. LPN #3 stated that it was a stage 2 wound that had "just opened yesterday during morning care." Review of the wound tracking logs, "Skin Summary" documented on 11/12/13, Resident #4's name and room number. "Wound type - p/u (pressure ulcer), Acq/Adm (acquired/admitted ) acquired; Location - sacrum; Wound Description - Stage II, 100% granulation; Size - L (length) 2.0, W (width) 0.5." The telephone physician order [REDACTED]. Rinse, pat dry, apply [MEDICATION NAME] paste ** to area every shift after each incontinent episode until healed. Dx (diagnosis): Open area." An interview was conducted with CNA #6, the CNA that documented on 11/3/13 on Resident #4. When asked what skin condition the resident had on 11/3/13, CNA #4 could not recall why she answered yes to that question on her iPad. On 11/14/13, OSM #2 was aware of the concern that the CNA documented a skin concern on 11/3/13 and 11/6/13 with no nursing assessment documented and the resident acquired a stage 2 pressure area on her sacrum. The administrative team was made aware of the concern for harm on 11/14/13 at 5:50 p.m. No further information was provided prior to exit. References: *Nutrashield is a topical cream used to provide an effective, long [MEDICATION NAME] moisture barrier against incontinent episodes while relieving the dryness, abrasion or denuded skin. It protects the skin with an advanced silicone system. Information taken from facility provided product information by Remedy Advanced Skin Care from Medline. ** [MEDICATION NAME] Protectant Paste is a zinc oxide based barrier that protects against moisture and minor irritation. Menthol cools irritated skin and calms inflamed tissue. [MEDICATION NAME] also helps absorb light exudate from compromised skin. Information taken from facility provided product information by Remedy Advanced Skin Care from Medline. (1) Barron's Dictionary of Medical Terms for the Non Medical Reader 2006; Mikel A. Rothenberg, M.D. and Charles F. Chapman. Pages: 155, page 206. (2) Centers for Medicare & Medicaid Services; Long-Term Care Facility Resident Assessment Instrument User's Manual; Version 3.0 July 2010, pages M-15,M-18, M-2.