Every finding on record at Harbor Post Acute Center

Based on interview and record review, the facility failed to notify the physician and/or pharmacy when a medication was unavailable and the resident did not receive it for 4 of 4 residents reviewed (R1, R2, R3, and R4) for medication administration. Findings include: R1 A review of R1's admission Record, dated 6/30/26, revealed R1 was a [AGE] year-old resident that was admitted to the facility on [DATE] with multiple diagnoses that included depression, dysphagia (difficulty swallowing), and anxiety. A review of R1's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 6/24/26, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed R1 was mildly cognitively intact. A review of R1's Medication Administration Record (MAR), dated 6/18/26 to 6/30/26, revealed that R1 did not receive her morning doses of bupropion (a medication for depression), duloxetine (a medication for depression), esomeprazole (a medication for acid reflux), and levothyroxine (a thyroid medication) on 6/19/26. A further review of R1's MAR revealed she did receive the morning doses of her other prescribed medications on that day. A review of R1's electronic medical record (EMR), dated 6/18/26 to 6/30/26, revealed that she was not administered her morning doses of bupropion, duloxetine, esomeprazole, and levothyroxine on 6/19/26 because the medications were not available and the back-up medication machine was not working. In addition, the progress notes revealed the pharmacy was notified. However, R1's progress notes failed to reveal if the physician/healthcare provider had been notified that these medications were not available and/or that R1 did not receive them. During an interview on 6/30/26 at 1:45 PM, R1 stated there was only one time that she had not received her medication since she had been at the facility. She stated she thought that was close to the time she was admitted to the facility. During an interview on 6/30/26 at 1:55 PM, Licensed Practical Nurse (LPN) F stated the medication carts have the residents' medications in them and there was a machine which had the back-up prescription medications in it. LPN F further stated if a medication was not available in the medication cart or the backup machine, then they would notify the pharmacy to see when it would be delivered. She stated she would call the physician/healthcare provider after talking to the pharmacy to let them know that the medication was not available. She stated she would tell them when the pharmacy delivery would be and would ask them if there was another medication that they wanted the resident to have instead of the unavailable medication or if it was ok to just wait until the medication arrived. LPN F stated if the physician/healthcare provider wanted the resident to have the medication prior to the next pharmacy delivery or if the medication was a critical medication that needed to be given within a strict time frame and it would not arrive in time, then she would call the pharmacy back and request a STAT drop (an immediate delivery of the medication by a courier) from the pharmacy. R2 A review of R2's admission Record, dated 6/30/26, revealed R2 was an [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included diabetes, hypertension (high blood pressure), and hyperlipidemia (high cholesterol). A review of R2's MAR, dated 6/20/26 to 6/30/26, revealed that R2 did not receive her hydrochlorothiazide (a medication for high blood pressure), Mounjaro (a medication for diabetes), pantoprazole (a medication for acid reflux), losartan (a medication for high blood pressure- morning dose), metformin (a medication for diabetes), and metoprolol (a medication for high blood pressure) on 6/21/26. A further review of R2's MAR revealed she did receive the morning and evening doses of her other prescribed medications on that day. A review of R2's EMR, dated 6/20/26 to 6/30/26, revealed that she was not administered her hydrochlorothiazide, Mounjaro, pantoprazole, losartan, metformin, and metoprolol on 6/21/26 because the medications were not available. However, R2's progress notes failed to reveal if the physician/healthcare provider and/or pharmacy had been notified that these medications were not available and/or that R2 did not receive them. R3 A review of R3's admission Record, dated 6/30/26, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included anemia. A review of R3's MAR, dated 6/1/26 to 6/30/26, revealed that R3 did not receive his weekly dose of Epogen on 6/27/26. A further review of R3's MAR failed to reveal that he was administered the Epogen after 6/27/26 A review of R3's EMR, dated 6/1/26 to 6/30/26, revealed that he was not administered his Epogen on 6/27/26 because it was pending pharm (pharmacy) delivery. However, R3's progress notes failed to reveal if the physician/healthcare provider had been notified that this medication was not administered on 6/27/26 and/or that it had not been administered after the medication arrived from pharmacy. During an interview on 6/30/26 at 3:10 PM, Registered Nurse (RN) G stated if a medication was not available in the medication cart or the back-up machine, then she would call the pharmacy and put a progress note in the resident's EMR. RN G stated if the medication is a critical medication that needs to be given at a specific time of the day (e.g., a heart medication) she will call the physician and let them know. She stated she will also call the physician if the medication is a prescription medication like metformin or Epogen. RN G stated if she calls the physician she will document that in a progress note in the resident's EMR. RN G also stated she would not call the physician if the unavailable medication was a supplement like a vitamin or mineral or if pharmacy can send the medication and it can be given before it is overdue or next due. RN G stated an example of a medication that would be overdue would be one that was ordered more than once a day and it was over an hour since it was scheduled. She further stated that if the medication was ordered to be given daily, as long as the medication can be given the same day, she would not call the physician because it would be administered before it was next due. R4 A review of R4's admission Record, dated 6/30/26, revealed R4 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple diagnoses that included fibromyalgia (a long-term condition that causes widespread muscle pain, fatigue, and brain fog), hypothyroidism (low thyroid levels), diabetes, depression, and osteoarthritis. A review of R4's MARs, dated 4/15/26 to 6/30/26, revealed that R4 did not receive the following medications on the following dates: - Prednisolone ophthalmic (an eye medication for pain) on 4/16/26 (morning dose), 5/10/26, 5/11/26 (morning dose), 6/10/25 (evening dose only), and 6/11/26 (evening dose only). - Levothyroxine (a medication for hypothyroidism) on 4/16/26 - Paroxetine (a medication for depression) on 4/16/26 - Pioglitazone (a medication for diabetes) on 4/16/26 - Prednisone (a medication for osteoarthritis) on 4/16/26 A review of R4's EMR, dated 4/15/26 to 6/30/26, revealed that she was not administered her prednisone, pioglitazone, paroxetine, levothyroxine, and prednisolone ophthalmic on 4/16/26 because these medications were on order. A further review of R4's EMR revealed that she was not administered her prednisolone ophthalmic on 5/10/26, 5/11/26 (morning dose), 6/10/26 (evening dose), and 6/11/26 (evening dose) because the medication was unavailable or not available. In addition, R4's EMR failed to reveal if the physician/healthcare provider had been notified that these medications were on order or not available and/or that R4 did not receive them. During an interview on 7/1/26 at 9:30 AM, LPN H stated that if a resident's medication was not in the medication cart she would check the back-up machine and/or supply room for it. She stated if it was not in those places, then she would call the provider and let them know that the medication was not at the facility. LPN H also stated she would ask the provider if they wanted something else given instead, if they wanted to hold the medication until it arrives, or if they want to have the facility call the pharmacy to have it drop shipped (sent immediately via a courier). She stated she would then call pharmacy and see when the medication was expected to arrive and if the physician wanted it given before it arrived, she would ask the pharmacy to drop ship it. She stated she would also document in a progress note in the resident's EMR that she called the physician and she called pharmacy. During an interview on 7/1/26 at 10:15 AM, the Director of Nursing (DON) stated if medication was unavailable (not at the facility) the nurse should call the physician and let them know. She stated nurses should also call the pharmacy to see when it will be delivered. The DON further stated the nurses should also document that they called the physician and pharmacy in a progress note in the resident's EMR. In addition, the DON stated she was aware that there was an issue with documenting physician and pharmacy notifications in the progress notes. She said they sent a mass text out last night reminding staff to notify the physician if medication was not available. The DON was notified of the concerns with documenting physician/healthcare provider and/or pharmacy notifications in the EMR's for R1, R2, R3, and R4 for the above listed dates and medications. The surveyor requested additional information that would demonstrate that the physician/healthcare provider and/or pharmacy (if applicable) were notified that the medications for these residents were not available and/or not administered on those dates/times. As of the completion of the survey and exit from the facility, the facility failed to provide additional documentation that the physician/healthcare provider and/or pharmacy (if applicable) were notified. A review of the facility's Medication Administration Medication Orders Policy/Procedure, dated 7/11/18, revealed, . 3. If the prescribed medication is not available: Attempt to pull the medication from the Back-up box. If the medication is not available in the back-up box, notify the provider and follow up with directives given.

Based on interview and record review, the facility failed to prevent an elopement for one of three resident's (Resident #100) reviewed for accidents and hazards. The deficient practice was corrected on 01/06/26, prior to the start of this survey and, therefore, this deficiency is considered Past Noncompliance.Resident #100 (R100)Review of an admission Record revealed R100 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of a recent hip fracture and Alzheimer's disease. During an interview on 01/14/26 at 8:20 AM, R100 laid in bed resting with her eyes open. R100 stated that she remembered being outside the building last week but I couldn't tell you why I did that, I just did. R100 stated that she was not harmed and felt safe and that she wouldn't be doing that again. Review of a Facility Reported Incident dated 01/05/26 reflected the following: (a) at approximately 9:15 PM on 01/05/26, R100 was observed to be standing outside the facility next to the south/east stairwell door, (b) staff brought R100 back into the building and completed a head-to-toe assessment and found no concerns of physical harm, (c) R100 was dressed appropriately for the 35 degree weather minus having one sock and shoes on, (d) the appropriate parties were notified and R100 was placed on a 1:1 for safety, (e) a complete head count was done of all residents, and (f) it was learned that at approximately 9:00 PM Registered Nurse F had heard the second floor door alarm sounding and silenced the alarm without further investigation the reason the alarm had sounded. A review of all at risk for elopement residents was completed and verified that care plans were updated. Multiple staff were interviewed regarding their recent education regarding the policy and procedure for door alarms and elopement to verify fund of knowledge. During an observation on 01/14/26 at 8:40 AM, this surveyor and maintenance technician A verified that all emergency exits were alarmed and functioning properly. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included an enhanced weekly audit of emergency exit alarms to ensure proper functioning, on-going staff education regarding the elopement procedure, and ongoing review of all residents (including new admissions) deemed at risk for wandering/elopement and updated care plans. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to secure prescription medications according to professional standards and facility policies for 5 of 5 resident's (Resident #25, Resident #10, Resident #39, Resident #56, and Resident #45) and for one of four medication carts reviewed. Findings: Resident #25 (R25)Review of an admission Record revealed R25 was an [AGE] year-old female who admitted to the facility on [DATE]. Review of a Self-Medication Administration Safety Screen (SMASS) for R25 completed 06/04/25 revealed R25 could administer the following medications to herself unsupervised by nursing staff: (1) Trelegy 100-62.5-25 mcg (micrograms) inhaler and (2) an Albuterol Sulfate inhaler. During an observation on 12/02/25 at 11:30 AM, R25 sat in her wheelchair speaking with a staff person from the activity department and a small plastic medication cup containing pills sat on the nurse's station counter. R25 then took the plastic medication cup of pills and self-prolled herself to the common area near the nurse's station. During an interview at the same time, R25 stated that the cup of medication belonged to her and that she was supposed to take them as soon as the nurse gave them to her but that she got distracted by talking with a staff member. R25 then took the medications without a nurse supervision. The SMASS completed on 06/04/25 for R25 did not include approval for R25 to self-administer and medications in pill form. Resident #10 (R10)Review of an admission record revealed R10 was a [AGE] year-old male who admitted to the facility on [DATE]. During an observation on 12/03/25 at 8:06 AM, the unlocked medication cabinet inside R10's room contained a cup of pre-set medications. During an observation on 12/03/2025 at 1:35 PM the pre-set cup of medications was no longer in the medication cabinet inside R10's room, however, the cabinet remained unlocked and contained multiple prescription 5% Lidocaine patches. Review of the EHR (electronic health record) for R10 did not reflect that R10 had been assessed to self-administer his own medications. Resident #39 (R39) Review of an admission Record revealed R39 was a [AGE] year-old male that last admitted to the facility on [DATE]. During an observation on 12/03/25 at 8:10 AM, the medication cabinet in R39's room was unlocked and held two small plastic medication cups that contained pre-set pills. One cup had R39's first name and 1200 written on it. The second cup had R39's first name and 1600 written on it. During an observation on 12/03/25 at 1:33 PM, R39 sat in a chair in his room next to a small table. On the table sat an empty plastic medication cup with R39's first name and 1200 written on it. R39 stated that he had taken his noon medications but had not yet thrown away the medication cup. Resident #56 (R56)Review of an admission Record revealed R56 was a [AGE] year-old female who admitted to the facility on [DATE].During an observation on 12/03/25 at 8:18 AM the medication cabinet in R56's room was unlocked and contained prescription medications including eye drops, solution for a breathing treatment, a gel for pain, and a rescue metered dose inhaler. Resident #45 (R45)Review of an admission Record revealed R45 was a [AGE] year-old female who admitted to the facility on [DATE]. During an observation on 12/03/25 at 1:39 PM, the medication cabinet in R45's room was unlocked and contained prescription medications including a Fluticasone inhaler, Atropine sulfate 1% drops, solution for a breathing treatment, and an albuterol sulfate metered dose inhaler. During an interview on 12/03/25 at 1:44 PM Licensed Practical Nurse (LPN) E stated that nurses may not pre-set medications and that the medication cabinets in the residents' rooms must be locked at all times. During an observation of the 300 high hall medication-cart on 12/03/25 at 1:49 PM, the narcotic lock box was not secured and opened without the use of a key. During an interview on 12/03/25 at 2:45 PM Licensed Practical Nurse (LPN) F stated that he had pre-set medications for R10 and R39 but it was not the standard of practice. LPN F also stated that the medication cabinets in the resident's rooms should be locked at all times. During an interview on 12/04/25 at 7:50 AM, Registered Nurse (RN) H stated that nurses do not pre-set medications and that the medication cabinets in the resident's room must be locked at all times. Review of the facility policy Medication Storage and Access reflected .only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications are allowed to access medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access and scheduled controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. Review of the facility policy Administration of Drugs revealed .medications may not be set up in advance.

This citation pertains to intake 2680029. Based on observation, interview and record review, the facility failed to create and implement person centered care plans for two (R27 and R63) of 13 residents reviewed for care plans. Findings include:Resident #27 (R27)Review of a Face Sheet revealed R27 had pertinent diagnoses of dementia, mixed incontinence, and metabolic encephalopathy (brain disfunction). Review of a Nursing admission assessment dated [DATE] for R27 revealed she was incontinent of bowel and continent of bladder. She had a non-blanchable red area on the left medial buttock. Review of a Braden Scale for Predicting Pressure Sore Risk dated 9/30/25 upon admission revealed R27 had a moderate risk for skin breakdown. Review of the Care Plan dated 10/8/25 revealed R27 had an ADL self-care performance deficit. Interventions included but are not limited to: Showering/Bathing per schedule or as needed. (No schedule was implemented.) The Care Plan had a focus for potential impairment to skin integrity related to metabolic encephalopathy, Dementia, osteoarthritis, covid 19, weakness, limited mobility, incontinence, with interventions that included, but not limited to: BRIEF USE: Resident uses incontinence management products. Change per protocol, preference, and as needed. No toileting schedule documented. No Care Plan for MASD or risk for pressure ulcers. Review of the Order Summary for R27 revealed an order for Tamsulosin once a day for urinary retention. No diagnoses in the electronic medical record revealed urinary retention and no care plan focus/interventions for urinary retention. Resident #63 (R63)Review of a Face Sheet revealed R63 had pertinent diagnoses of chronic kidney disease, heart failure, dementia, diabetes. No diagnosis of hypothyroid. Review of the admission Minimum Data Set (MDS) dated [DATE] for R63 revealed he had occasional urinary incontinence and always continent of bowel. Not in the Care Plan. Review of the Order Summary for R63 revealed an order for Levothyroxine (hypothyroid medication). Not in the Care Plan. During several observations on 12/2/25 at 11:00 AM, 12/3/25 at 8:15 AM, 12/4/25 at 9:00 AM, R63's room had a strong urine smell that permeated throughout the room and bathroom. In an interview on 12/3/25 at 8:15 AM, Registered Nurse (RN) A reported R63 toilets himself and thinks he urinates on the floor. In an interview on 12/4/25 at 9:06 AM, Housekeeper (HK) B reported R63 may be missing the toilet and urinating on the floor. The bathroom floor is wet and sticky at times and thinks the mattress on the bed needs to be switched out. HK B reported she cleaned his room twice the day before. During an observation and an interview on 12/4/25 at 9:08 AM, Licensed Practical Nurse (LPN) C reported R63 will not use his call light and will toilet himself and thinks he may urinate on the floor. R63 will use a urinal at times. No interventions or revisions were added to the care plan. In an interview on 12/4/25 at 9:17 AM, Certified Nursing Assistant (CNA) D reported she thought R63's mattress had a strong urine smell even though it had been cleaned. CNA D reported R63 does wear a pull up brief and will urinate on himself sometimes. When asked how often he is offered toileting, CNA D reported she will offer toileting 8-9 times a day and R63 will have already urinated or be in the process of it. CNA D reported she did not know what else to do and agreed the room had a strong permeating urine smell. Review of the Physician Orders for R63 revealed he receives 80 milligrams (mg) of Lasix (Furosemide), a diuretic once a day in the mornings for congestive heart failure. (A normal dose is 20 - 80 mg). Not in the Care Plan. Review of the Care Plan for R63 revealed he can ambulate to the toilet as a one person assist with a wheeled walker. No toileting schedule, no continence/incontinence, or pullup briefs are on the Care Plan. No focus for diabetes was acknowledged on the care plan. Review of a Toileting Task documentation dated 11/5/25 to 12/3/25 revealed R63 had mixed continence/incontinence/incontinence two to three times a day most days and several days he was only toileted once. In an interview on 12/4/25 at 10:01 AM, the Director of Nursing (DON) reported R63 wants to be independent and the facility is trying to respect his dignity when it comes to his toileting. When staff toilet R63, he forgets he was already toileted. Staff find R63 up trying to urinate again right after they offer/assist with toileting him. He misses the urinal and has tried different urinals with no success. While discussing R63's use of diuretics which causes frequent urination, the DON reported the facility had not put R63 on a toileting schedule and suggested the facility could increase toileting assistance in the mornings after he receives his diuretic and increase the daily cleaning of the bathroom to control the urine smell. Discussed with the DON how the care plans do not reflect a person-centered approach or reflect resident focused care for R27 and R63 and the DON acknowledged the concern.

This citation pertains to intake 2680029. Based on interview and record review, the facility failed to provide showers for one (R27) of 3 residents reviewed for activities of daily living (ADL). Findings include:Review of a Face Sheet revealed R27 had pertinent diagnoses of dementia, mixed incontinence, and metabolic encephalopathy (brain disfunction). Review of the Care Plan dated 10/8/25 revealed R27 had an ADL self-care performance deficit. Interventions included but are not limited to: Showering/Bathing per schedule or as needed. (No schedule was implemented.) The Care Plan had a focus for potential impairment to skin integrity related to metabolic encephalopathy, Dementia, osteoarthritis, covid 19, weakness, limited mobility, incontinence, with interventions that included, but not limited to: BRIEF USE: Resident uses incontinence management products. Change per protocol, preference, and as needed. No toileting schedule documented. Review of the Toileting task documentation dated 11/5/25 to 11/24/25 revealed R27 was documented as being continent or incontinent one to two times a day on most days. Review of an ADL task documentation and Shower sheets for R27 revealed in October (10/6/25 to 10/31/25) she received 2 showers. In November (11/1/25 to 11/24/25 (discharge), she received 3 showers. Review of a Skilled Charting document dated 11/23/25 for R27 revealed the resident had moisture associated skin damage (MASD) over her sacrum, coccyx, and buttocks. In an interview on 12/4/25 at 11:13 AM, the Director of Nursing (DON) reported that the system did not trigger the documentation for showers for staff and staff only documented showers on an as needed basis instead of a regular schedule. The standard of care requires facilities to bathe residents twice a week. When questioned about resident toileting documentation, the DON reported staff should document every time they toilet a resident or provide incontinence care and acknowledged that staff document it once a shift. When asked about R27's skin and the MASD, the DON reported R27 admitted with MASD on the left gluteal that cleared up and acknowledged that the resident developed more MASD that returned prior to her discharge.

Based on observation, interview and record review, the facility failed to implement a person-centered toileting program for one (R63) of 1 resident reviewed for toileting. Findings include:Resident #63 (R63)Review of a Face Sheet revealed R63 had pertinent diagnoses of chronic kidney disease, heart failure, and dementia. During an observation on 12/2/25 at approximately 11:00 AM, R63 was just returning to his room with a Therapy Staff member when a strong urine smell was noticed throughout the room. The bathroom had a stronger smell, the floor was sticky when walked on, and the toilet had urine sitting in the toilet. A urinal was noticed hanging on the edge of the counter with some residual urine. During an observation and interview on 12/3/25 at 8:15 AM, R63 was in bed sleeping and did not smell urine but the bathroom had a strong urine smell. Registered Nurse (RN) A reported R63 toilets himself and thinks he urinates on the floor. RN A then asked the housekeeper to clean his bathroom well. During an observation and an interview on 12/4/25 at 9:00 AM, R63 was sitting up in his chair and a strong urine smell permeated throughout the room, including the bathroom. R63 had his call light close by and reported he never needed to use it. When asked if he needed assistance for toileting, R63 denied needing assistance. In an interview on 12/4/25 at 9:06 AM, Housekeeper (HK) B reported R63 may be missing the toilet and urinating on the floor. The bathroom floor is wet and sticky at times and thinks the mattress on the bed needs to be switched out. HK B reported she cleaned his room twice the day before. During an observation and an interview on 12/4/25 at 9:08 AM, Licensed Practical Nurse (LPN) C reported that R63's wife usually assists the resident at the facility with his activities of daily living (ADL's) including toileting R63. LPN C thinks the wife brings items from home that have a urine smell. LPN C went to R63's room and confirmed a strong smell and that the bathroom floor was sticky. LPN C reported R63 will not use his call light and will toilet himself and thinks he may urinate on the floor. R63 will use a urinal at times. In an interview on 12/4/25 at 9:17 AM, Certified Nursing Assistant (CNA) D reported she thought R63's mattress had a strong urine smell even though it had been cleaned. CNA D reported R63 does wear a pull up brief and will urinate on himself sometimes. When asked how often he is offered toileting, CNA D reported she will offer toileting 8-9 times a day and R63 will have already urinated or be in the process of it. CNA D reported she did not know what else to do and agreed the room had a strong permeating urine smell. Review of the Physician Orders for R63 revealed he receives 80 milligrams (mg) of Lasix (Furosemide), a diuretic once a day in the mornings for congestive heart failure. (A normal dose is 20 - 80 mg). Review of the Care Plan for R63 revealed he can ambulate to the toilet as a one person assist with a wheeled walker. In an interview on 12/4/25 at 10:01 AM, the Director of Nursing (DON) reported R63 wants to be independent and the facility is trying to respect his dignity when it comes to his toileting. Staff toilet R63, and he forgets. Staff find R63 up trying to urinate again right after they offer/assist with toileting him. He misses the urinal and has tried different urinals with no success. While discussing R63's use of diuretics which causes frequent urination, the DON reported the facility had not put R63 on a toileting schedule and suggested the facility could increase toileting assistance in the mornings after he receives his diuretic and increase the daily cleaning of the bathroom to control the urine smell.

Based on interview and record review the facility failed to maintain accurate documentation regarding the disposition of controlled substances for 1 of 2 resident's (Resident #62) reviewed. Findings:Resident #62 (R62) Review of an admission Record revealed R62 was a [AGE] year-old female last admitted to the facility on [DATE]. Review of a physician order revealed R62 was prescribed Morphine Sulfate (MS) oral solution 20mg (milligrams) / 5 ml (milliliters) give 0.25ml every 3 hours as needed for pain and shortness of breath. Review and comparison of the Controlled Substance Proof of Use Record (CSPUR) and the Electronic Medication Administration Record (Emar) revealed the following discrepancies as related to R62's use of MS: (1) a 0.25 ml dose of MS was signed out on 08/04/25 at 3:21 PM but was not documented as given on the Emar. (2) a 0.25 ml dose of MS was signed out on 08/05/25 at 8:30 AM but was not documented on the Emar as given to R62, (3) the Emar dated August 2025 reflected an order to discontinue the Morphine Sulfate at 11:59 PM on 08/05/25, however a dose was signed out on the CSPUR for R62 on 08/06/25 at 8:27 AM and again on 08/20/25 at 12:30 PM. No documentation was located in the electronic health record (EHR) that discussed whether or not R62 received either of the doses of MS that were signed out after the order had been discontinued, (4) further review of the CSPUR for R62 and the use of Morphine Sulfate 20mg/5ml reflected that the amount of the medication remaining on 08/20/25 was 19 ml. The next entry on the CSPUR for R62 was dated 10/19/25 and had a corrected remaining amount documented as 17 ml. No additional doses of MS had been documented on the Emar as given to R62 between 08/05/25 and 10/19/25, and (5) the following entry on the CSPUR for R62 was dated 11/06/25 and had a corrected remaining amount documented as 16 ml. No additional doses of MS had been documented on the Emar as given to R62 between 10/20/25 and 11/06/25. Review of a physician order revealed R62 was prescribed Oxycodone 5 mg one tab every 4 hours as needed for pain. Review and comparison of the Controlled Substance Proof of Use Record (CSPUR) and the Electronic Medication Administration Record (Emar) as related to R62's use of Oxycodone 5mg tabs revealed the following discrepancies: (1) a 5mg tab was signed out by nursing staff on 08/14/25 at 10:00 PM but was not documented on the Emar as given to the resident, (2) a 5mg tab was signed out on the CSPUR by nursing on 08/22/25 at 7:30 AM and was not documented on the Emar, (3) a 5mg tab was signed out on 08/22/25 at 7:32 PM and was not documented as given to R62 on the Emar, and (4) a 5mg tab of Oxycodone was signed out on 09/18/25 at 11:15 AM and there was no nurses' signature on the CSPUR. During an interview on 12/04/25 at 11:50 AM, the Director of Nursing (DON) stated that the expectation for nurses administering and documenting controlled substances was for the documentation on the CSPUR and Emar's to always match, there should always be signatures noting which nurse signed out the medication, and any discrepancy in the count/amount remaining of a controlled substance should be reported to the DON immediately.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer care and treatment consistent with professional standards of practice for one resident (Resident #37) of 3 residents reviewed for care and treatment of pressure ulcers, resulting in harm and the deterioration of Resident #37's pressure ulcer. Findings include: Review of an Admission Record revealed Resident #37 (R37) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and peripheral vascular disease. Review of a Minimum Data Set (MDS) assessment for R37, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R37 was cognitively intact. Further review of same MDS assessment revealed R37 required assistance with toileting and repositioning. Review of a current Care Plan focus for R37, initiated 7/23/2024, revealed R37 was at risk for impaired skin integrity related to limited mobility, incontinence, and impaired sensation. Further review revealed an intervention directing staff to assist R37 to reposition her body with pillows and devices to protect bony prominence's. Review of current impaired skin integrity Care Plan interventions for R37, initiated 8/13/2024, directed staff to keep R37's skin clean and dry. In an interview on 10/7/2024 at 9:36 AM, R37 reported she had a wound on her backside and the night shift Certified Nursing Assistant (CNA) from the previous night did not check on her between 10:00 PM and 6:00 AM to change or reposition her. R37 reported her brief was soaked this morning because she had not been changed the entire night. In an interview on 10/7/2024 at 2:59 PM, CNA N reported R37 had told her that morning that she had not been check and changed by the night shift CNA the previous evening. CNA N reported night shift CNA R told her rounds were completed at 5:30 AM just prior to shift change but R37's brief was soaked when CNA N checked on her after shift change. CNA N reported it did not appear R37 had been recently changed. In an observation and interview on 10/7/2024 at 2:22 PM in R37's room, Lead CNA I pulled R37's brief down to prepare for her dressing change and revealed the wound on her coccyx to be exposed to the air and without a dressing in place. R37's brief appeared to be wet with urine. Lead CNA I reported R37 must not have had a dressing in place since her shower earlier that morning. R37 reported she had the shower at approximately 10:00 AM. Licensed Practical Nurse (LPN) M reported the CNA had told her R37's dressing had come off in the shower earlier that morning. LPN M reported she normally tried to replace dressings just after showers but had been too busy to replace the dressing. LPN M took a washcloth, applied bar soap from the room sink, and inserted the washcloth into R37's large open coccyx pressure ulcer to clean the ulcer, turning the washcloth as she applied pressure to the wound bed. LPN M reported she normally liked to use wound cleanser but did not have any and the order was to use soap and water. Review of R37's active Physician's Orders, started 10/1/2024, revealed an order to cleanse R37's wound with soap and water daily prior to placing the new dressing. Review of R37's October 2024 Treatment Administration Record (TAR) revealed nursing staff documented they cleaned R37's coccyx wound with soap and water prior to placing the new dressing on 10/2/2024, 10/3/2024, 10/4/2024, 10/5/2024, 10/6/2024, and 10/7/2024. Review of R37's weekly Wound Assessments revealed the coccyx pressure wound was documented as 4.0 by 4.5 by 0.2 cm's on 9/16/2024, 3.5 by 6.0 by 1.7 cm's on 9/23/2024, and 3.0 by 4.5 by 2.0 cm's on 10/1/2024. Wound assessment treatment documentation prior to 10/1/2024 was to wash the wound with soap and water prior to placing the dressing. On 10/1/2024 the treatment changed from washing the wound with soap and water to cleansing the wound with wound cleanser prior to placing the dressing. In an interview on 10/7/2024 at 3:06 PM, LPN Unit Manager E reported a dressing should be replaced immediately after a shower or as soon as possible and within 30 minutes. LPN Unit Manager E reported it did not sound right to be packing R37's coccyx wound with soap and that wound cleanser would be appropriate. LPN Unit Manager E reported the facility Wound Registered Nurse (RN) O was responsible for accurately updating wound treatment orders in the electronic medical record. In a telephone interview on 10/8/2024 at 10:29 AM, Wound RN O reported the contract wound specialist evaluated R37's coccyx ulcer for the first time on 10/1/2024 because the wound was worsening. Wound RN O reported the treatment recommendation changed from washing the coccyx wound with soap and water to using wound cleanser on 10/1/2024 because of the deteriorating depth of the wound. Wound RN O reported if R37's coccyx dressing order was still directing staff to wash the wound with soap and water this was a mistake on her part as she intended to change the order from soap and water to wound cleanser on 10/1/2024 per the wound specialist's recommendation. Wound RN O reported R37's dressings should be replaced after showers right away or as soon as possible. Wound RN O reported 4 hours was too long to wait for a dressing to be replaced after taking a shower. Review of R37's Wound Specialists Initial Evaluation Note, dated 10/1/2024, revealed .Post-Debridement Measurement: 3by4.5by2.1 cm . active dx: Pressure ulcer of sacral region, stage 3 . Plan: Wound #1 sacral pressure treatment recommendations: 1. Cleanse with wound cleanser . In an observation on 10/8/2024 at 11:27 AM in R37's room, LPN Unit Manager E measured R37's coccyx wound to be 3.3 by 4.0 by 3.8 cm's, the wound depth increasing from 2.1 cm's after debridement on 10/1/2024 to 3.8 cm's deep on 10/8/2024. In an interview on 10/8/2024 at 1:51 PM, concerns regarding the recent deterioration of R37's pressure ulcer were discussed with the Nursing Home Administrator (NHA). The NHA requested that I view the wound again with the wound specialist that afternoon because wound measurements could be different based on who measured the wound. In an observation and interview on 10/8/2024 at 1:51 PM in R37's room with the Wound Specialist Physician's Assistant (PA) and the Director of Nursing (DON), Wound Specialist PA P measured R37's coccyx wound to be 2.7 by 4 by 2.6 cm's. Wound Specialist PA P stated the wound was much deeper than the initial evaluation that took place on 10/1/2024. Wound Specialist PA P reported there was undermining (erosion under the wound edges) of the wound that was not present on 10/1/2024. Wound Specialist PA P told the DON R37 needed to be sent to the hospital urgently for surgical debridement. Wound Specialist PA P stated, I think we need to send her to the hospital. This is getting really deep; it seems to be getting worse. If we don't get this taken care of it could cause infection throughout your whole body. Wound Specialist PA P reported she could feel bone with her finger. In an interview on 10/8/2024 at 2:00 PM, Wound Specialist PA P reported soap and water was not indicated for a deep pressure ulcer such as R37's coccyx wound because the washcloth is rough on granulated tissue, and you could leave soap inside that would irritate the wound. Wound Specialist PA P reported wound cleanser was the best practice for the treatment of pressure ulcers and she recommended wound cleanser on 10/1/2024 for the treatment of R37's pressure ulcer. Wound Specialist PA P reported the dressing should be replaced immediately after taking showers or as soon as possible. Wound Specialist PA P reported leaving a pressure ulcer open to the air allowed urine, stool, flies, and other things to contaminate the wound. Review of facility policy/procedure Skin Treatment- Guidelines for Pressure Injuries, updated 3/2020, revealed . It is the policy of this center to utilize treatment guidelines when providing care for residents with pressure injury and to prevent further deterioration of pressure injury . A physician order will be obtained for the pressure injury treatment . Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominence's (WOCN, 2010). The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure 48-15), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions (see Chapter 39). [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 72244-72253). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to provide medications upon admission in a timely manner for 1 resident (Resident #207) of 13 residents reviewed for professional standards of practice. Findings include: Resident #207 (R207) Review of an Admission Record revealed Resident #207 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and diabetes. In an interview on 10/6/2024 at 9:12 AM, R207 reported she admitted to the facility on [DATE] at approximately noon and had not been receiving all her medications since admission. Review of R207's Nursing Progress Note, dated 10/5/2024 at 1:42 PM, revealed R207 admitted to the facility on [DATE] at 1:00 PM. In an interview on 10/6/2024 at 9:45 AM, Licensed Practical Nurse (LPN) L reported she admitted R207 to the facility on [DATE]. LPN L stated, There were 5 pages of medications, it took a lot of time to get them into the computer. LPN L reported medications would be delivered at 4:00 PM by the pharmacy if they were entered into the computer quickly enough. She was not able to enter the medications quickly enough to arrive by 4:00 PM, so they were delivered in the night. LPN L reported all R207's medications were now available. LPN L reported R207 complained she did not receive all her medications the previous evening, but she was not sure which as she had gone home for the day and another nurse was taking care of R207 last night. Review of R207's October Medication Administration Record (MAR) revealed- 1-HS (evening) Aggrenox (antiplatelet medication to prevent formation of blood clots) on 10/5/2024 was documented as not given, 9. 2-HS carbamazepine (used to treat seizures, nerve pain, and bipolar disorder) was not given the evening of 10/5/2024, not ordered to start until the morning of 10/6/2024. 3-HS Fiber capsule (bulk stool softener) on 10/5/2024 was documented as not given, 9. 4-HS Mometasone inhaler (used to reduce swelling and irritation in the airways) on 10/5/2024 was documented as not given, 9. 5-HS lamotrigine (used to treat seizures, nerve pain, and bipolar disorder) on 10/5/2024 was documented as not given, 9. In an interview on 10/7/2024 at 1:44 PM, LPN L reported nursing staff would normally pull medications from stock when they were ordered but not yet available from the pharmacy. LPN L reported if any ordered medications were not available, the medical provider should be notified and further direction requested. In an interview on 10/7/2024 at 1:50 PM, LPN Unit Manager E reported the number 9 on the MAR indicates other, see nurses note. LPN Unit Manager E reported the carbamazepine should have been ordered to start the evening of 10/5/2024 instead of the morning of 10/6/2024 and was available in the backup medication cart. LPN Unit Manager E reported the fiber and lamotrigine were both available in the backup medication cart and she was not sure why they were not administered by the nurse working the evening of 10/5/2024. LPN Unit Manager E reported nursing staff were expected to contact the on call medical provider regarding any ordered medications that were not available to request further direction and then document this direction in the electronic medical record. LPN Unit Manager E reviewed the electronic medical record and could not find any documentation that nursing staff documented in a nurses note as indicated or that the on call medical provider had been notified of the missed doses of medication for R207 the evening of 10/5/2024. Review of facility policy/procedure Medication Administration, dated 1/1/2023, revealed .It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations . Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician . Review of facility policy/procedure Documentation of Medication Administration, dated 7/2023, revealed .documentation must include, as a minimum . reason(s) why a medication was withheld, not administered, or refused (as applicable) .

Based on observation, interview, and record review, the facility failed to: 1. Ensure working spray bottles are labeled as to content, 2. Ensure water filters were being replaced as required on equipment, 3. Ensure ice machines food contact surface/equipment are clean and maintained, and 4. Ensure the 2nd & 3rd floor kitchenette/pantries flooring is clean and free of debris and the cooler unit's door, door seals, openings and bottoms, resulting in an increased potential of contaminated foods and an increased risk of food borne illness possibly affecting 52 residents that consume food from the kitchen and kitchenettes/pantries. Findings include: A follow-up kitchen inspection took place on 10/07/24 at 8:23 AM, with Dining Services Manager (DSM) C, the following issues were observed: Observation of a working chemical spray bottle was found unlabeled as to the chemical content. Review of the FDA 2017 Food Code Section, 7-102.11 (Labeling and Identification) Common Name Reflected the following Working containers for storing POISONOUS OR TOXIC MATERIALS such as cleaners and Sanitizers taken from the bulk supplies shall be clearly and individually identified with the common name of the material. Observation of the kitchen water filters for the Combi Oven (A oven that can use steam, convection, can proof, sous vide, broil, toast food etc .) was labeled as 7/23. The date/label does not identify/reflect as install or replacement date. The 3 large water filters (located in the kitchen janitor's closet) that connect to ice machine and direct plumbed equipment were found to be undated/labeled. Observation of 2nd and 3rd floor kitchenette/pantries revealed: 2nd floor ice machine filter had a date/label of 4/20. 3rd floor ice machine filter was undated/labeled. Review of the FDA 2017 Food Code Section, 5-205.15 System Maintained in Good Repair. Reflected, A PLUMBING SYSTEM SHALL be: (A) Repaired according to LAW; and (B) Maintained in good repair. During an environmental tour of the facility on 10/07/24, Environmental Services Manager (EVSM) A revealed that a new company had taken over the maintenance of the chemical dispensers, the chemicals and the water filters. EVSM A revealed the water filters would be installed and dated once they came in. Observations of the 2nd and 3rd floor kitchenettes/pantries revealed dirt and debris under equipment and along the floor/wall junctures. The 2nd & 3rd floor cooler doors, door seals, door opening, and bottoms of the unit need a cleaning to remove build-up and debris. Further observation of the kitchenettes/pantries revealed that the 3rd floor ice machine had a slight pink/orange slime build- up. The 2nd floor ice machine had some scale build-up. Clean as often as necessary to prevent build-up and debris on inside food/non-food contact surfaces. Review of the FDA 2017 Food Code Section, 6-501.12 Cleaning, Frequency and Restrictions. Reflected, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Review of the FDA 2017 Food Code Section, 4-602.13 Nonfood- Contact Surfaces. Reflected, NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. Review of the FDA 2017 Food Code Section, 4-602.11 Equipment Food-Contact Surfaces and Utensils. Reflect, . (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacture, or (b) Absent manufacture specifications at a frequency necessary to preclude accumulation of soil or mold.

This citation contains 2 Deficient Practice Statements (DPS), DPS A and DPS B. DPS A Based on observation, interview, and record review, the facility failed to implement their smoking policy and procedure for 1 resident (Resident #25) of 1 resident reviewed for smoking. Findings include: Review of an Admission Record revealed Resident #25 (R25) admitted to the facility on [DATE] with pertinent diagnoses which included chronic pain syndrome, legal blindness, and chronic obstructive pulmonary disorder. Review of a Minimum Data Set (MDS) assessment for R25, with a reference date of 6/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R25 was cognitively intact. Review of a current smoking Care Plan intervention for R25, initiated 9/6/2024, revealed resident smoked independently and was required to sign in and out as he left facility property to smoke. Review of R25's admission Smoking Policy Rules and Acknowledgement, signed by R25 6/28/2024, revealed .(facility) is not a smoke-free environment and does allow for monitored smoking within designated areas. If the resident wishes to smoke on premises, they must abide by the following smoking criteria: Smoking will occur only in designated location. Day to day cigarettes are kept locked in the medication cart of the respective floor. Extra packs/cartons are kept locked in the medication cart of the respective floor . Review of facility policy/procedure Smoking Policy- Residents, updated 1/2023, revealed .The facility will permit supervised smoking in designated areas only . The designated smoking area is _______ (line blank) . Residents must keep all smoking materials (lighters, matches, cigarettes, pipes, cigars, smoking tobacco, tobacco, electronic cigarettes, etc.) at the nursing station. At no time are the residents permitted to keep smoking materials in their room . Smoking material will not be distributed to the resident until they are in the designated smoking area . Residents who sign themselves out of the center are prohibited from smoking on the center's property . Residents may not sign themselves out to smoke between scheduled smoke times unless they are leaving the center's property . In an observation and interview on 10/6/2024 at 10:31 AM, R25 was sitting on the bed in his room with a package of cigarettes visible in his sweatshirt pocket. R25 reported he kept his lighter and cigarettes on his person. R25 reported he was not required to sign out when leaving the 2nd floor to smoke. R25 reported he smoked in a designated area outside of the front door on the 1st floor. R25 walked to the elevators and left the 2nd floor without signing out of the unit leave of absence book. In an observation on 10/6/2024 at 12:50 PM, R25 was sitting on a bench just outside the facility front door smoking a cigarette while having a conversation with the Nursing Home Administrator (NHA). A no smoking sign was visible above the bench near where R25 was smoking. In an interview on 10/6/2024 at 1:10 PM, the NHA reported R25 was able to smoke independently and was not allowed to smoke on facility property. In an interview on 10/6/2024 at 2:26 PM, Licensed Practical Nurse (LPN) L reported R25 was not required to sign out when leaving the unit to smoke unless he was leaving the property. Review of the leave of absence book revealed R25 signed out when leaving the facility to go to a local grocery store on 10/5/2024 but did not sign out when going outside to smoke. In an observation on 10/7/2024 at 9:03 AM, two packages of cigarettes and a lighter were on R25's bed and unattended while R25 was in his bathroom. In an interview on 10/7/2024 at 9:11 AM, Lead Certified Nursing Assistant (CNA) I reported R25's cigarette supplies were usually locked in the covey in his room and given to him when he asked to smoke. In an interview on 10/7/2024 at 9:13 AM, LPN Unit Manager E reported R25's smoking supplies were kept locked up with his supplies in his room. In an interview on 10/7/2024 at 12:25 PM, the NHA reported he considered the facility to be a nonsmoking facility regardless of the admission Smoking Policy Rules and Acknowledgement and the facility smoking policy. Discrepancies between current facility practice, the admission Smoking Policy Rules and Acknowledgement, and the facility smoking policy including smoking location for independent smokers, the procedure for storage of smoking supplies, and the procedure for signing off the unit when smoking were discussed. The NHA reported there were not currently any residents that required supervision while smoking and there were no designated areas to smoke on the facility grounds. The NHA reported he needed to review the facility policy and procedure with his company to clarify how the facility would handle smoking in the future. DPS B Based on observation, interview, and record review, the facility failed to ensure residents were transferred according to the current care plan for 1 resident (Resident #37) of 13 residents whose care plans were reviewed, resulting in the potential for residents to fall and for residents to not meet their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #37 (R37) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and peripheral vascular disease. Review of a Minimum Data Set (MDS) assessment for R37, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R37 was cognitively intact. Further review of same MDS assessment revealed R37 required assistance with toileting, transferring, and repositioning. Review of a current Care Plan focus for R37, initiated 7/23/2024, revealed R37 was at an increased risk for falls related to hypertension, emphysema, and chronic pain. Review of a current activities of daily living Care Plan intervention for R37, revised 8/21/2024, revealed R37 required the assistance of two staff with the sit to stand lift when transferring. In an observation and interview on 10/7/2024 at 2:22 PM, Lead Certified Nursing Assistant (CNA) I transferred R37 from her bedside chair to her bed using a sit to stand lift by herself and without the assistance of another staff member. Lead CNA I reported R37 allowed her to transfer her without the assistance of another staff member but technically she should not. In an interview on 10/7/2024 at 3:06 PM, Licensed Practical Nurse (LPN) Unit Manager E reported R37 required the assistance of two staff with the sit to stand lift when transferring.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained according to professional standards of practice for 4 residents (Resident #26, Resident #27, Resident #43 and Resident #48) out of 4 residents reviewed for respiratory care. Findings: Resident #26 (R26) Review of an Admission Record Reflected R26 admitted to the facility with diagnoses that included chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen. During an observation on 10/06/24 at 11:28 AM, nebulizer equipment in R26's room was uncovered, assembled, resting on R26's bedside table without a barrier in place and appeared to have been used as evidenced by droplets in the equipment. During an observation and interview on 10/08/24 at 10:19 AM, R26's nebulizer equipment was assembled and in an undated clear plastic bag. R26 reported that staff sometimes clean her nebulizer equipment. Resident #27 (R27) Review of an Admission Record reflected R27 admitted to the facility on [DATE] with pertinent diagnoses that included acute respiratory failure with hypoxia and chronic obstructive pulmonary disease (COPD) with acute exacerbation. Review of R27's Treatment Administration Orders for October 2024 reflected Oxygen at 2L (liters)/min per nasal cannula intermittently every shift for COPD. Further review of the treatment orders did not indicate orders for the maintenance of R27's oxygen equipment. During an observation and interview on 10/06/24 at 9:44 AM, R27 reported she uses oxygen at night. R27 was seated in a recliner chair with her feet elevated. The oxygen tubing was not secured in a plastic bag but was hanging loose off the oxygen supply apparatus on the wall. Resident #43 (R43) Review of an Admission Record reflected R43 admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), asthma, and emphysema. During an observation on 10/06/24 at 9:02 AM, R43 was in bed, the nebulizer equipment was assembled, uncovered, resting on the bedside table without a barrier with visible droplets in the equipment. The face mask was visibly dirty with smudges. During an observation on 10/07/24 at 12:07 PM, R43 was sitting on the side of his bed. R43's oxygen tubing was draped over the handle of a wheelchair in his room, not secured in a plastic bag. Resident #48 (R48) Review of an Admission Record reflected R48 originally admitted to the facility on [DATE] with diagnosis that included end stage renal disease, dependence on renal dialysis, and Congestive Heart Failure (CHF). Review of a Care Plan initiated on 9/30/2024 reflected R48 had altered respiratory status/difficulty breathing related to atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung). Interventions in the care plan described oxygen settings and monitoring but did not specify care and maintenance of the oxygen equipment. During an observation and interview on 10/7/24 at 3:51 PM, R48 was seated in his wheelchair, oxygen tubing was draped over the oxygen supply in the wall over R48's bed. R48 was not wearing supplemental oxygen during the interview. Review of a policy Respiratory Therapy Equipment: Oxygen and Nebulizer Administration dated 11/02/2023 reflected, It is the policy of this center that residents receiving oxygen or nebulizer therapy will have appropriate treatment. Only trained licensed staff will administer respiratory therapy. Respiratory equipment used to provide therapy will be maintained appropriately. The procedure outlined steps that included 7. Change oxygen cannula and tubing every seven (7) days and as necessary. 8. Keep oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. Directions outlined for nebulized medication specified: 3. After completion of therapy: Remove nebulizer container; Rinse container with fresh tap water; Dry with clean paper towel or gauze sponge. 4. Reconnect to administration set-up. 5. Use caution not to contaminate internal nebulizer tubes. 6. Wipe mouthpiece with damp paper towel or gauze sponge. 7. Store circuit in plastic bag, marked with date and resident's name, between uses. 8. Wash hands. 9. Discard administration set-up every seven days. Review of a policy Oxygen Administration Revised October 2010 reflected equipment and supplies included 6. Clear plastic bag for storage.

Based on observation, interview, and record review, the facility failed to ensure licensed personnel followed medication administration policy and procedures when a nurse pre-poured medications for eight residents (R9, R27, R30, R31, R35, R39, R50) and documented the administration of medications that had not been given to residents. Findings: During an observation on 10/7/24 at 7:33 AM, Licensed Practical Nurse (LPN) Q was asked to complete a medication pass. LPN Q was asked to open the top drawer of the medication cart for inspection, and it was discovered medications had been preset for 8 residents on the unit (R9, R27, R30, R31, R35, R39, R50). Pills, tablets and capsules were noted in plastic medication cups, a smaller paper medication cup was placed over the medications in each plastic cup with a number written on each paper cup. LPN Q said the numbers were rooms on the unit. LPN Q reported there were no controlled substances in any of the preset medication cups. A narcotic count was conducted to verify that no controlled substances had been preset that morning. During an interview and observation on 10/7/24 at 7:55 AM, the Director of Nursing (DON) and Unit Manager (UM), LPN K observed the medication cups in the top drawer of the medication cart. The DON reported that the facility did not allow nurses to preset resident's mediations. The DON said the medications would be wasted in a drug buster (a container with a mixture used to destroy medications that need to be wasted) and each medication pass would be administered correctly. Review of Medication Administration Records (MARS) for the residents identified during the observation on 10/7/24 at 7:33 AM indicated LPN Q had already documented the medications that had been preset had been administered. During a follow-up interview on 10/7/24 at 10:30 AM, UM/LPN K reported that she and the DON had re-pulled and administered the morning medication pass for the residents on LPN Q's assignment. LPN K said that she interviewed each resident identified as having preset medications to confirm they did not receive their medication. LPN K reported that she and the DON would then delete LPN Q's initials from the electronic MAR and enter their own initials as proof the medications had been administered. Review of a policy Medication Administration dated 01/01/2023 reflected 3. Medications are administered at the time they are prepared. Review of Policies and Procedures Pharmacy Services for Nursing Facilities dated September 1, 2023, reflected When medications are administered by mobile cart taken to the resident's location (room, dining area, etc.) medications are administered at the time they are prepared. Medications are not pre-poured either in advance of the med pass or for more than one resident at a time. Review of a policy Documentation of Medication Administration dated July 2023 reflected The facility shall maintain a medication administration record to document all medications administered. 2. Administration of medication must be documented immediately after it is given.

Based on observation, interview, and record review, the facility failed to ensure two Residents (R20 and R26) of five residents reviewed for medication were properly assessed and monitored for self-administration of medication and failed to securely store and document medication self-administration after use. Findings: R20 R20 admitted to the facility [DATE] with pertinent diagnoses that included asthma and respiratory failure. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 13 which indicted R20 is cognitively intact. On [DATE] at 11:40 AM an observation and interview were conducted in the room of R20. An albuterol 90 micrograms (mcg) multi-dose inhaler in an aero chamber and a bottle of Flonase were observed on the over-the-bed table of R20. R20 reported she has had immediate access to both medications since admission. The policy provided by the facility titled Self-Administration of Medications, last revised [DATE] was reviewed. The Policy Statement reflected Residents have the right to self-administer medications if the interdisciplinary team had determined that it is clinically appropriate and safe for the resident to do so. This indicated a resident would be assessed to determine a resident's ability to self =-administer medication. Under Policy Interpretation and Implementation number 12 reflected 'Nursing staff will review the self-administration medication and as necessary will transfer pertinent information to the medication administration record (MAR) appropriately noting that the doses were self-administered. Review of the Electronic Medical Record (EMR) for R20 did not reflect any documentation that the interdisciplinary team had discussed self-administration of medication or that a self-administration assessment was documented. Review of the EMR Physician Orders reflected a current order for Albuterol Sulfate Inhalation Aerosol Solution 90 mcg 2 puffs every 4 hours as needed for wheezing with a start date of [DATE]. The order did not reflect that R20 may keep medications at bedside or had been approved for self-administration. On [DATE] at 9:43 AM a follow-up interview was conducted with R20 in her room. R20 reported that a nurse had removed her albuterol inhaler and the Flonase from her room that morning. R20 reported that she had been using the albuterol inhaler several times a day since her admission. R20 reported that nursing had never asked her if she had used the inhaler or how often. Review of the MAR for September and [DATE] reflected one dose was documented on ,d+[DATE] and one dose on ,d+[DATE] from [DATE] to the date of review on [DATE]. On [DATE] at 9:57 AM an interview was conducted with Licensed Practical Nurse (LPN) D. LPN D reported she had retrieved the albuterol inhaler and the Flonase from R20 that morning. LPN D reported the medications were in a locked area in the room of the Resident. LPN D indicated R20 would be given the medication to use when she asked for it. On [DATE] at 11:35 AM the Director of Nursing (DON) was informed of the medication found at the bedside of R20 and that no self-administration assessment had been found in the EMR. The DON indicated if a resident had been assessed for self-administration documentation of this should be present in the EMR notes and on the MAR. The DON indicated she would review the EMR and provide any pertinent information. As of survey exit no additional information had been provided by the facility. 29073 Resident #26 (R26) Review of an Admission Record Reflected R26 admitted to the facility with diagnoses that included chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen. Review of the Electronic Medical Record (EMR) revealed a Self-Administration of Medication Evaluation had been completed on admission ([DATE]) and again on [DATE]. R26 was deemed safe to self-administer inhaled (nebulizer & inhalation) medications. During an observation on [DATE] at 11:28 AM, an Albuterol Sulfate 90 mcg (microgram) inhaler was observed on R26's over-the-bed table. R26 said she keeps the inhaler at the bedside and uses it up to four times a day. During an observation on [DATE] at 12:11 PM, the Albuterol Sulfate 90 mcg inhaler was again observed on R26's over-the-bed table. During an observation on [DATE] at 10:18 AM, the Albuterol Sulfate 90 mcg inhaler and a Incruse Elipta 62.5 mcg were noted on R26's over-the-bed table. No licensed nurses were in R26's room. R26 reported she does not document when she uses the albuterol inhaler, and the nurses do not ask her when or how often she uses it. R26 said she uses the albuterol about four times a day and uses the Incruse Elipta once a day. R26 said she does not rinse her mouth after administration of either medication. Review of the Medication Administration Record (MAR) for September and [DATE] revealed an order for Ventolin HFA Inhalation Aerosol Solution 108 (90 Base) MCT/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for SOB (short of breath)/Wheezing no sooner than 4 hours between all sources of Albuterol. The records did not indicate R26 had ever taken a PRN (as needed) dose of the medication. Further review of all orders reflected on the MAR's did not indicate R26 had a physician order to self-administer inhaled medications. Review of a policy Self-Administration of Medications revised [DATE], reflected 1. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for ensuring that medications were taken. 2. Self-administered medications must be stored in a safe and secure place. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 3. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. 4. The facility will reorder self-administered medications in the same manner as other medications, if requested by the resident. 5 .The nursing staff will routinely check self-administered medications and will remove expired, discontinued, or recalled medications. 6. Nursing staff will review the self-administered medication and as necessary will transfer pertinent information to the medication administration record (MAR), appropriately noting that the doses were self-administered. 7. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on observation, interview, and record review, the facility failed to assess, monitor and notify the physician of clinical changes in condition for 1 resident (Resident #48) out of 13 residents reviewed for quality care from a total sample of 13 residents. Findings: Resident #48 (R48) Review of an Admission Record reflected R48 originally admitted to the facility on [DATE] with diagnosis that included end stage renal disease, dependence on renal dialysis, and Congestive Heart Failure (CHF). Review of a Minimum Data Set (MDS) admission assessment dated [DATE] reflected R48 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 15/15. Review of a Care Plan initiated on 9/16/24 indicated R48 has altered cardiovascular status r/t (related to) hypertension, hypotension, pacemaker, HLD (hyperlipidemia), CAD (coronary artery disease). The goal of the care plan was that R48 would be free from signs and symptoms of complications of cardiac problems. Interventions included Vital signs as tasked. Notify nurse/physician of any abnormal readings; Monitor/document/report to MD changes in lung sounds on auscultation (i.e. crackles), edema and changes in weight. Review of a hospital Transfer of Care Document indicated R48 was hospitalized from 9/20/24-9/24/24 for Acute on chronic systolic heart failure. Discharge instructions indicated This is a heart failure patient. Plan for managing heart failure at sub-acute rehab: Order: Standing daily weights first thing in the morning after patient empties his/her bladder. Monitor the patient daily and notify facility provider for the following: Weight gain of 2-3 pounds in 1 day or 5 pounds in 1 week. Increased shortness of breath with activity, sleeping, or at rest. Unable to lay flat at night. Complaints of abdominal fullness, nausea, or change in appetite. Increased swelling. Increased 02 (oxygen) needs from baseline or new oxygen requirement. Unable to tolerate medications (beta-blocker, diuretics, ACE/ARB/ARNI-Entresto). Systolic blood pressure of less than 90 or over 140 for more than three consecutive readings. Review of a Late Entry progress note dated 10/01/24 indicated the Registered Dietitian (RD) S spoke w/ (with) provider about pt's (patient's) fluid retention. Pt's dry weight is 220-pounds w/ hospital getting him down to 215 pounds. Pts' weight is at 228.8 pounds. Provider will add abdominal girth daily, and pt is to see his cardiologist today as well. RD will continue to follow. Review of a Late Entry Nursing Progress Note dated 10/3/24 reflected R48 underwent Paracentesis (a procedure that removes fluid from the abdomen with a needle or tube) and 3 liters of fluid were removed. Review of a Practitioner Short Progress Note dated 10/3/2024 indicated R48 had 3 liters of fluid drained after paracentesis on 10/3/24. The note specified Ascites s/p (status post) paracentesis today with 3L off per patient. Monitor for need of repeat paracentesis, daily abdominal girth measurements ESRD (end stage renal disease) on HD (hemodialysis). Review of R48's October 2024 Treatment Administration Record (TAR) reflected AM-Standing daily weight, standing weight if applicable, if not explain in progress note, and obtain weight by wheelchair, in the morning for monitoring weight to ensure H20 (water) retention is not occurring. Try to get this before breakfast for a more accurate capture of dry weight. -Start Date- 9/28/24. Review of weights recorded on the October 2024 TAR reflected R48 gained over 3 pounds between 10/1/24 and 10/2/24. R48's weight on 10/5/24 was 227.4; on 10/6/24 R48 weighed 233.8 pounds, a 6.4-pound weight gain in one day. On 10/7/24 R48 weighed 240.2, a 6.4-pound weight gain in one day. R48 gained a total of 12.8 pounds in 2 days between 10/5/24 and 10/7/24. The October 2024 TAR also reflected the order Measure and record abdominal girth daily one time a day for Ascites (fluid buildup in the abdomen)-Start Date-10/2/24. The documentation reflects R48's abdominal girth was never measured between 10/2/24 and 10/7/24. During an observation and interview on 10/7/24 at 3:51 PM, R48 was seated in his wheelchair, oxygen tubing was draped over the oxygen supply in the wall over R48's bed. R48 was not wearing supplemental oxygen during the interview. R48 reported that nursing staff have not been measuring his abdominal girth. During an interview on 10/7/24 at 4:00 PM, Registered Nurse (RN) T reviewed R48's electronic medical record, including treatment orders and progress notes and reported there was no evidence nursing staff had notified the provider of R48's weight gains. RN T said there was not another system to document physician notification such as a binder on the nurse station. RN T also confirmed that R48's abdominal girth had not been measured. During an interview on 10/7/24 at 4:21 PM, RD S reported she monitors resident weights Monday - Friday and notifies the provider if there is a 2-pound weight gain in one day or a 5-pound change in a week. RD S showed the surveyor a spreadsheet of residents being monitored. R48's weight gain of over 12 pounds was not noted on the form, indicating that as of 4:21 PM, RD S had not noted R48's 12.8-pound weight change. During an interview on 10/7/24 at 4:30 PM, the Director of Nursing (DON) reported that she does not know why staff are not measuring R48's abdominal girth. The DON did not know why nursing staff were not notifying the provider of R48's weight gains. During a follow-up interview on 10/8/24 at 9:14 AM, R48 was seated on the edge of his bed, supplemental oxygen in place. R48 was pursed-lip breathing (a breathing technique that can help with shortness of breath) as he attempted to work his pants over his knees while seated on the edge of the bed, taking breaks while he spoke to the surveyor. R48 reported he was waiting on staff to weigh him before he ate his breakfast which was sitting on his over-bed table. Review of a policy Change of Condition dated 1/1/2023 reflected It is the policy of this center to inform the resident, the resident's physician and if indicated the resident's responsible party of change of condition including: . 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications. The policy also specified 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 3. The attending physician and Responsible Party/family will be notified of the significant change in condition in a timely manner. Unless it is an emergency situation the center has up to 24 hours to make the notification. If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician), or the emergency room physician. Review of a policy Physician Orders dated 1/1/2023 reflected It is the policy to follow written and verbal orders given by the physician, dentist, APN (Advanced Practice Nurse) or PA (Physician Assistant). Review of a policy Heart Failure - Clinical Protocol revised February 2023 indicated As part of the initial assessment, the physician will help identify individuals with a history of heart failure (HF) and will clarify, as much as possible, its severity and underlying causes. Monitoring and follow-up listed in the protocol indicated Vital signs, including weight monitoring will be completed in accordance with the Physician orders. Changes in vital signs and weights will be reported to the Physician in accordance with Physician Orders., if specific orders are present in the resident's clinical record, or in accordance with facility policy and procedures.

Based on interview and record review, the facility failed to ensure antipsychotic medications were prescribed to treat a condition as diagnosed and documented with rationale in the clinical record for 1 resident (Resident #24) out of 5 residents reviewed for unnecessary medications. Findings: Review of an Admission Record reflected R24 admitted to the facility on [DATE] with diagnoses that included Covid-19, acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and cognitive communication deficit. Review of a Minimum Data Set (MDS) assessment dated [DATE] reflected R24 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8/15. Review of a Preadmission Screening(PAS)/Annual Resident Review(ARR) Level I Screening dated 9/5/2024 reflected R24 did not have a mental illness or dementia and was prescribed oral trazadone (an antidepressant) for delirium in the hospital. No chronic behavioral health diagnoses. Review of a hospital After Visit Summary reflected R24 was prescribed RisperiDONE 0.5 mg (milligram) disintegrating tablet commonly known as RisperDAL M-TABS Take I tablet (0.5 mg total) by mouth at bedtime for 2 days. Review of an Order Audit Report reflected R24 was prescribed 0.5 mg Risperidone upon admission to the facility on [DATE]- 9/12/24. R24 did not take the mediation for 2 days from 9/12/24-9/14/24. Risperidone 0.5 mg tablet, give 0.5 mg by mouth in the evening for agitation for 14 days was started again on 9/14/24-9/28/2024. R24 did not take Risperidone for two days, then the medication was restarted on 9/30/2024-10/14/2024. Review of a Care Plan initiated on 9/16/2024 indicated I (R24) use anti-psychotic medications. No diagnoses associated with the use of anti-psychotic medications were documented. The Goal of the care plan was that R24 would maintain the lowest effective dosage of my antipsychotic medication without significant side effects . Review of Nursing Progress Notes dated 9/12/24 reflected R24 was on droplet precautions due to being Covid-19 positive and would wander in the halls and be re-directed without distress. Review of a Late Entry Nursing Progress Note dated 9/14/24 reflected R24 was a 1:1 due to increased confusion; staff encouraged R24 to stay in her room due to Covid-19 droplet precautions. Review of a Nursing Infection Note dated 9/16/24 indicated R24 was removed from droplet precautions. Review of a Nursing Progress Note dated 9/18/24 reflected R24 was noted to wander around unit. Patient (R24) very pleasant and easily redirected . Review of a Nursing Progress Note dated 10/02/24 indicated R24 had wandering behaviors and was pleasant and cooperative with cares, No behaviors noted. Review of all Practitioner Short Progress Notes for the dates 9/12/24, 9/17/24, 9/19/24, 9/20/24, and 10/7/24 did not reflect a discussion of R24's behaviors or prescribed antipsychotic medications. During an interview on 10/08/24 at 1:29 PM Licensed Practical Nurse (LPN) Unit Manager (UM) R reviewed R24's Electronic Medical Record (EMR) and explained the provider asked her to enter a verbal order for Risperidone after not having it for two days on 9/14/24. LPN/UM R reported there was no behavior monitoring in place. LPN/UM R reviewed the progress notes and reported that R24 would have wandering behaviors and was not very compliant with remaining in her room when she was in Covid-19 droplet precautions due to being unfamiliar with the facility, which was understandable. LPN/UM R reported staff increased supervision for R24, who was redirectable and without behavioral concerns. LPN/UM R confirmed there was not an order for a consultation with behavioral health providers. Review of a policy Behavior Management-Psychoactive Medication-Antipsychotic Drug Therapy dated 1/1/2023 reflected It is the policy of this center to use antipsychotic medications per CMS (Centers for Medicare and Medicaid Services) guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety. The policy specified 4. Specific conditions for which antipsychotic drugs may be used: Schizo-affective disorder; delusional disorder; psychotic mood disorders (including mania and depression with psychotic features); acute psychotic episodes brief reactive psychosis; Schizophreniform disorder; atypical psychosis; Tourette's disorder; Huntington's disease, Organic mental syndromes (including dementia and delirium) with associated psychotic and/or agitated behaviors: which have been quantitatively (number of episodes) and objectively (biting, kicking, scratching) documented, which are not caused by preventable reasons, which are causing the resident to 1) present a danger to her/himself or to others, 2) Continuously scream yell or pace if these specific behaviors cause an impairment in functional capacity, 3) Experience psychotic symptoms (hallucinations, paranoia, delusions) not exhibited as dangerous behaviors or as crying, screaming, yelling, or pacing but which cause the resident distress or impairment in functional capacity; Short term (seven day) symptomatic treatment of hiccups, nausea, vomiting, or pruritus. 5. Conditions for which antipsychotic drugs should NOT be used (as an only indication): wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, agitated behaviors which do not represent danger to the resident or others.

Based on observation, interview, and record review, the failed to ensure proper use of Personal Protective Equipment (PPE) for residents in Enhanced Barrier Precautions for 1 resident (Resident #37) of 13 residents reviewed for infection control. Findings include: Review of an Admission Record revealed Resident #37 (R37) admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disorder and peripheral vascular disease. Review of a Minimum Data Set (MDS) assessment for R37, with a reference date of 8/1/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R37 was cognitively intact. Further review of same MDS assessment revealed R37 required assistance with toileting, transferring, and repositioning. Review of a current impairment to skin integrity Care Plan intervention for R37, initiated 8/13/2024, directed staff to maintain enhanced barrier precautions (gown and glove use) during high contact cares such as dressing, bathing, transferring, changing linens, providing hygiene, toileting, device care, and wound care. Further review directed staff to practice proper infection control interventions. Review of R37's active Physician's Orders, started 8/13/2024, revealed an order to maintain enhanced barrier precautions (gown and glove use) during high contact care such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care, and wound care. In an observation and interview on 10/7/2024 at 2:22 PM, Lead Certified Nursing Assistant (CNA) I entered R37's room, transferred R37 from the bedside chair to her bed using a sit to stand lift, positioned her on her side, and pulled her brief down without donning a gown or gloves and using bare hands. Signage on the door indicated R37 required enhanced barrier precautions for high contact care such as transfers and toileting. Lead CNA I reported enhanced barrier precautions were only required for R37 during wound care. In an interview on 10/7/2024 at 3:06 PM, Licensed Practical Nurse (LPN) Unit Manager E reported gown and glove use is required for residents on enhanced barrier precautions during transfers and all high contact cares and not only during dressing changes. Review of facility policy/procedure Enhanced Barrier Precautions, reviewed 12/2020, revealed .It is the policy of this facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms . enhanced barrier precautions refer to the use of gown and gloves for certain residents during specific high-contact resident care activities that have been found to increase risk for transmission of multidrug-resistant organisms . An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds and/or indwelling medical devices . High-contact resident care activities- dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care .

This citation pertains to M100142556, M100143537, and M100143672. Based on interview and record review, the facility failed to provide residents a list of pertinent contact information to the State Agencies (SA), advocacy groups and the like, a description of the requirements and procedures for establishing eligibility for Medicaid, and Medicare/Medicaid coverage, and how to file a complaint with the SA, how to file a grievance, and resources for information regarding returning to the community for 4 (Resident #1, Resident #5, Resident #11, Resident #12) of 4 residents reviewed. This deficient practice affects all 54 residents who reside at the facility. Resident #1 (R1) Review of a Face Sheet revealed R1 admitted to the facility on [DATE]. In an interview on 5/14/24 at 10:28 AM, the Power of Attorney (POA) O for R1 reported the facility was to assist them in finding long-term care placement and was in the process of getting Medicaid which they were approved for. R1 had an acute condition and had to go to the hospital and the facility refused to accept him back. POA O was confused why the facility would not accept him back. She felt it was insurance related concerns because the facility would not accept him. POA O reported she did not receive an admission packet when R1 admitted to the facility that had any information regarding procedures for Medicaid/Medicare coverage or to any State Agency/advocacy groups. She was not aware of any bed hold policies. Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE]. In an interview on 5/15/24 at 9:28 AM, Designated Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources, costs/ fees, or bed hold policies. This lack of information caused her to not have the resources to apply for Medicaid timely, be informed about bed hold policies in advance of a transfer to the hospital, or contact/resource information to State Agencies, to help prepare for the needs of the resident. DPOA J reported the process of R5's financial journey has been stressful. DPOA J reported she did not receive any information when R5 was admitted to the facility regarding Medicaid insurance procedures, how to file a grievance or any other pertinent information. When R5 went to the hospital, the facility refused to let him come back to the Facilty. She was not aware of any bed hold policies. R11 Review of an Admissions, Discharges and Transfer report revealed R11 admitted to the facility on [DATE]. In an interview on 5/16/24 at 10:10 AM, R11 reported she did not receive a bed hold policy when she admitted to the facility and did not know what it was. R12 Review of an Admissions, Discharges and Transfer report revealed R12 admitted to the facility on [DATE]. In an interview on 5/16/24 at 10:20 AM, R12 reported she did not receive a bed hold policy when she admitted to the facility and did not remember receiving any documents when she admitted . In an interview on 5/16/24 at 10:31 AM, the Nursing Home Administrator (NHA) reported he has very limited beds and all the beds at the facility are dually certified. The NHA reported R5 was pending Medicaid and to re-admit the resident back to the facility, they would not have had a payor source and would have to do an authorization to admit him back. The NHA reported the facility does not have a policy on permitting residents to return to the facility after hospitalization s and does not give the residents admission packets upon admission to the facility. There is no information given to the residents other than the Admission Agreement.

This citation pertains to intakes M100143672 AND M100142556. Based on interview and record review, the facility failed to have an admission policy and procedure and provide admission packets for 3 (Resident #5, Resident #11, Resident #12) of 3 residents reviewed, resulting in residents being uninformed of their rights and resources, and the absence of written information available to the resident/responsible party regarding costs, policies, procedures, and services. This deficient practice affects all residents admitted to the facility. Findings include: In an interview on 5/15/24 at 9:28 AM, Designated Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources, costs/ fees, or bed hold policies. This lack of information caused her to not have the resources to apply for Medicaid timely, be informed about bed hold policies in advance of a transfer to the hospital, or contact/resource information to State Agencies, to help prepare for the needs of the resident. DPOA J reported the process of R5's financial journey has been stressful. There was a lack of assistance and timing of his Medicaid application that cost her money out of her pocket and did not know there was such a thing as a bed hold policy. When he went to the hospital on 3/25/24, he was not allowed back to the facility. Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, congestive heart failure, and cognitive communication deficit. Review of the MDS dated [DATE] revealed R5 was moderately cognitively impaired and required substantial to maximum assistance for most Activities of Daily Living (ADLs) and dependent for toileting, bathing, and mobility. Review of the Electronic Medical Record (EMR) for R5 revealed no Consent to Treat or Admission Agreement on file. In an interview on 5/16/24 at 10:00 AM, the Nursing Home Administrator (NHA) reported the facility did not have an admission policy and did not provide the residents with an admission packet that informs them of their rights, bed hold policies, costs, contact information, facility information, services and fees, and other pertinent information. The NHA reported they have a Consent to Treat & Admission Agreement only. The NHA reported they currently did not have a Business Office Manager and he was stepping in until they hire a new one. He reported that the facility was a Sub-Acute Rehab (SAR) and that was what this building was made for. The NHA reported all the beds at the facility were dually certified. Resident #11 (R11) Review of an Admissions/Discharge Summary revealed R11 admitted on [DATE]. In an interview on 5/16/24 at 10:10 AM, R11 reported when she admitted to the facility, she did not receive an admission packet. Review of the electronic medical records for R11 revealed no Consent to Treat or Admission Agreement on file. Resident #12 (R12) Review of an Admissions/Discharge Summary revealed R12 admitted on [DATE]. In an interview on 5/16/24 at 10:20 AM, R12 reported she did not receive an admission packet when admitted to the facility and looked around in her room to make sure. Review of the electronic medical records for R12 revealed no Consent to Treat or Admission Agreement on file. Review of a Notice of Bed Hold Policy revealed ***This document must be signed by the patient upon discharge to the hospital or therapeutic leave*** If unable to sign, notification from the patient and/or family/DPOA (Designated Power of Attorney) must be documented. Complete top section upon admission with resident or responsible party. This NOTICE OF BEDHOLD POLICY is provided to _______ on the effective date of admissions as well as upon any subsequent transfer to a hospital for a therapeutic leave, the date of which is applicable, is __________

This citation pertains to intakes M100142556, 143537, and 143672. Based on interview and record review, the facility failed to prepare for discharges, provide a safe home discharge, and allow a readmission post hospitalization for 2 (Resident #4 and Resident #5) of 3 residents reviewed for discharges, resulting in both residents needing to find placement at another long-term care facility. Findings include: Resident #4 (R4) Review of a Face Sheet revealed R4 admitted to the facility on [DATE] with pertinent diagnoses of acute kidney failure, muscle weakness and cognitive communication deficit. Review of the Minimum Data Set (MDS) dated [DATE] for R4 revealed he was moderately cognitively impaired and required partial to moderate assistance with mobility. Review of the discharge MDS dated [DATE] revealed R4 required supervision or touching assistance with some mobility. He was dependent for bathing, ambulation greater than 150 feet or walking 10 feet on uneven surfaces and picking up objects. He had a manual wheelchair. Review of the discharge MDS dated [DATE] for R4 revealed he required the same assistance documented on the 1/3/24 assessment. Review of an email correspondence reported to the State Agency revealed R4 was discharged home and could not care for himself. When the outpatient home care services arrived at his home the next day on 3/15/24, they sent him back to the hospital and reported R4 was not discharged home safely. In an interview on 5/20/24 at 10:09 AM, the Home Healthcare Agency Director (HAD) N reported they had a Physical Therapist (PT) visit R4 on 3/15/24, the day after he was discharged from the facility. When the PT arrived, the resident was not able to care for himself and the Home Care did not admit him. His sister told them they had a hard time getting him from the car to the house a fell a couple times getting to the door after he was discharged from the facility. His sister could not toilet him, transfer him or meet his needs. Review of a Hospital Progress note for an admission of 3/15/24 for R4 revealed: [R4] presented to [Emergency Department] via EMS (emergency medical services) due to concern for weakness and inability for him to care for himself. Patient presented with his sister and brother-in-law who stated he was discharged from rehab the day prior to presentation. They dropped him off at home and when home nursing came the next morning, he was still in the same position stating he could not get up. Admission diagnoses was Generalized weakness and urinary tract infection. R5 was discharged to another long-term care facility. Review of the Hospital Physical Therapy Progress notes dated 3/16/24 for the 3/15/24 hospital admission for R4 revealed: At baseline, patient is independent with mobility prior to last rehab stay and typically uses 4WW (wheeled walker) for mobility. Pt (patient) reports that prior to rehab was completing all basic cares independently but sister was helping with grocery laundry and meal prep as well as providing transport. At this time, patient is requiring increase level of assist and shows moderate balance and coordination deficits impacting pt safety with activity. Pt shows mild cognitive deficits and safety awareness deficits that are impacting independence with mobility at this time as well indicating that further skilled Physical Therapy is required. Clinical Impression: per pt presentation pt shows potential to progress with continued skilled therapy but level of family assist may be a barrier to return home due to safety concerns. Otherwise pt shows good potential to improved with balance and strength to improve functional independence. (sic) Review of the Notice of Medicare Non-Coverage (NOMNC) for R4 revealed his services were scheduled to end on 3/13/24 and he signed the form on 3/11/24. The Business Office Manager at the time witnessed his signature. In an interview on 5/15/24 at 2:30 PM, Social Worker (SW) B reported R4 was able to appropriately answer questions and had no concerns of his cognitive status even though his BIMS (Brief Interview for Mental Status) showed he was moderately cognitively impaired. SW B did remember the resident wanted to go home. R5 was independent and lived at home alone. Review of Discharge Instructions and Recap of Stay for R4 with an effective date of 3/11/24 and discharge date of [DATE] revealed he discharged to home with his sister because his condition improved. Nursing services recap of medical stay included R5 needing assistance with ADLs (Activities of Daily Living) and medication administration. Rehabilitation recap of stay included At discharge, resident functioning with Supervision utilizing wheeled walker for all self-care and ambulatory tasks utilizing wheeled walker. Review of the Physical Therapy (PT) Discharge Summary from the facility for R4 revealed he was discharged from services on 3/13/24. Upon discharge, he required supervision or touching assistance with bathing, grooming/hygiene, and the assistance of 1 CGA (contact guard assistance), posterior lean for stand pivot transfers with a walker. He was dependent walking 10 feet on uneven surfaces. Discharge instructions: continue PT with home health care and 24-hour care recommended. Review of the Care Plan for R4 revealed a Focus: I am in the facility for a short term stay for acute kidney failure. I have the potential for difficulty with ADL functioning and pain, initiated 3/4/24. Focus: I wish to return to my home in the community. My current needs are assistance with ADL's, initiated 3/4/24. No Focus for discharge planning. Review of a Care Plan for R4 revealed a Focus: I have an ADL Self Care Performance Deficit [related to] Chronic Vertigo, [hypertension], weakness, initiated 2/23/34 and canceled 3/19/24. Interventions included: Bathing- 1 person assist, Bed Mobility-1 person assist, personal hygiene- staff participation, dressing- staff participation, toileting- 1 staff participation, mobility- wheeled walker, transfers- 1 person assist. In an interview on 5/16/24 at 2:13 PM, the Regional Business Office Manager Consultant (RBOM) K reported R4's NOMNC showed his last covered day as 3/13/24 and went home on 3/14/24. The facility was designed to be and Sub-Acute Rehab (SAR) meaning a short-term rehab facility and then the residents are to go home. Resident #5 (R5) Review of a Face Sheet revealed R5 admitted to the facility on [DATE] with pertinent diagnoses of Parkinsons disease, congestive heart failure, and cognitive communication deficit. Review of the MDS dated [DATE] revealed R5 was moderately cognitively impaired and required substantial to maximum assistance for most Activities of Daily Living (ADLs) and dependent for toileting, bathing, and mobility. In an interview on 5/15/24 at 9:28 AM, Durable Power of Attorney (DPOA) J reported she did not get an admission packet for R5 when he admitted to the facility informing her of pertinent information related to insurance and Medicaid resources, costs/ fees, or bed hold policies. This lack of information caused her to not have the resources to apply for Medicaid timely, be informed about bed hold policies in advance of a transfer to the hospital, or contact/resource information to State Agencies, to help prepare for the needs of the resident. DPOA J reported the process of R5's financial journey has been stressful. DPOA J reported the facility tried to discharge R5 home on 1/8/24 when his Medicare insurance ran out. She got to the facility just in time when the ambulance showed up to take him home and told the facility there was no way he could go home by himself. The Social Worker told her R5 was a 2 person assist and in order to keep him there at the facility, it would cost $500 a night and the facility needed 30 days pay in advance. She had to make an on-the-spot decision and the facility let her pay $1500 to keep him there, then offered for him to apply for Medicaid. She did not sign a NOMNC form and did not recall being told she could appeal the decision. DPOA J reported she did not know there was such a thing as a bed hold policy when R5 went to the hospital for a urinary tract infection on 3/25/24. The hospital asked her if she signed one when the facility would not let him go back. She was told by the facility that since he was released from Physical Therapy, insurance will no longer cover his care because he was not getting any better. The Social Worker at the hospital was able to find him placement at another long-term care nursing facility and that is where he is now. Review of the NOMNC for R5 revealed his Medicare services ended 1/7/24 and was not signed by the DPOA. A note at the bottom of the form has a handwritten note that the previous acting Social Worker notified the DPOA on 1/5/24 and explained her rights to appeal the process. Review of a Practitioner Short Progress Note dated 3/25/24 for R5 revealed: abrupt onset of peripheral vision, light-headedness, cervicalgia, send out to ED (emergency department). Review of a Social Worker Progress note dated 3/25/24 for R5 revealed DPOA J was informed that the facility will not be accepting R5 back from the hospital since he will be needing long term care replacement and a rehab not being the appropriate setting. [DPOA J] expressed frustration with the lack of communication per the progress note. In an interview on 5/15/24 at 2:31 PM, the Social Worker (SW) B reported the Nursing Home Administrator (NHA) had input on why R5 could not return to the facility while R5 was pending Medicaid. R5 no longer qualified for therapy and met his max potential. Therefore, he would no longer be a candidate for SAR (Sub-acute Rehab). If residents need long term care, they contact a company to assist them in finding an open bed for the residents to transfer to. However, the facility does have some long-term care residents. Review of a Business Office Manager (BOM) progress note dated 3/26/24 for R5 revealed: I let (DPOA J) know that once [R5] was admitted to the hospital his Medicaid pending turned to private pay, and in order to readmit into the facility that it would have to be paid. In an interview on 5/16/24 at 10:31 AM, the Nursing Home Administrator (NHA) reported he is filling in as the BOM since the previous one is no longer there. He reported he has very limited beds and all the beds at the facility are dually certified. He reported R5 did go to the hospital and when it was time for the resident to be discharged from the hospital back to the facility, the NHA reported he told the hospital he was not a good Sub-Acute Rehab (SAR) referral because he needed long term care (LTC). The NHA emphasized this facility was built for SAR not for LTC. The NHA reported R5 was pending Medicaid and to re-admit the resident back to the facility, they would not have had a payor source and would have to do an authorization to admit him back. The NHA reported the facility does not have a policy on permitting residents to return to the facility after hospitalization s and does not give the residents admission packets upon admission to the facility. In an interview on 5/16/24 at 2:13 PM, the Regional Business Office Manager Consultant (RBOM) K reported R5's NOMNC showed his last covered day as 1/7/24. The facility was designed to be and Sub-Acute Rehab (SAR) meaning a short-term rehab facility. All the beds at the facility are dually certified to help accommodate those whose insurance runs out and assists residents applying for Medicaid. The company they use to assist in finding open beds at other long term care facilities cannot place residents until they get approved for Medicaid. R5 was pending Medicaid when he went to the hospital and fell off the radar. Review of an unsigned Discharge Instructions and Recap of Stay for a discharge date of [DATE] for R5 revealed R5 was able to make his needs known. No concerns or barriers to discharge. [R5] and his sister/patient advocate discussed desire to move to the ALF (Assisted Living Facility) side of (Independent Living Facility) and will be coordinating with (Assisted Living Facility) to have this evaluation and move POST discharge. They are agreeable to discharging home and utilizing HHC (Home Health Care) services. -Summary of Medical stay: Assist with ADL's, medication administration, catheter care and management. -Rehabilitation-Recap of Stay: Resident received physical, occupational and speech therapies. At discharge, resident functioning with Maximum assistance for all self-care and transfer tasks utilizing wheeled walker/wheelchair. Speech focusing on attention to task and safety awareness. -Physician summary: He lives in [Independent Living] . He has continued to progress well with therapy and is stable for discharge to [Independent Living] today. He is instructed to follow up with his PCP (primary care physician) within 1-2 weeks of discharge, signed 1/8/24. Review of the Care Plan for R5 revealed he had an indwelling urinary catheter; he required a 2-person assistance with ADL's. No Focus for discharge planning included in the Care Plan. Review of an undated policy titled Transfer or Discharge, Preparing a Resident for referencing the old survey tag revealed: Our facility shall prepare a resident for a transfer or discharge. 1. When a resident is scheduled for transfer or discharge, the business office will notify Nursing Service of the transfer or discharge so that appropriate procedures can be implemented. Responsibilities of Nursing Services 2. Nursing Services will be responsible for: 1. Packing and collecting personal possessions (if the resident is not expected to return); 2. Assisting with transportation as applicable (i.e., calling for an ambulance); 3. Escorting the resident to transportation; 4. Preparing the discharge summary and post-discharge plan; 5. Preparing medications (as permitted by law); 6. Forwarding charge slips to the business office; 7. Directing the resident or representative (sponsor) to the business office prior to the transfer or discharge; 8. Providing the resident or representative (sponsor) with required documents; and 9. Forwarding completed records to the business office. The business office will be responsible for: 1. Informing appropriate departments of the resident's transfer or discharge; 2. Informing the resident, or his or her representative (sponsor) of our facility's readmission appeal rights, bed-holding policies, etc.; and 3. Others as appropriate or as necessary. Review of a Discharge: Notice of Intent Transfer of Discharge policy dated 1/1/23 revealed: is the policy of this center that residents and/or responsible parties will be notified prior to transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Office of the State Long-Term Care Ombudsman will be notified via written communication of discharge or transfer. discharged residents will have documentation related to discharge or transfer in clinical record. Procedure: 2. Notify the resident and the responsible party of the transfer or discharge and reasons for the move in writing and in a language and manner they understand. 3. The written notice will include: a) Notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged b) Notice must be made as soon as practicable before transfer or discharge when the safety of individuals in the facility would be endangered. The health of individuals in the facility would be endangered. The resident's health improves sufficiently to allow a more immediate transfer or discharge. An immediate transfer or discharge is required by the resident's urgent medical needs. A resident has not resided in the facility for 30 days 5. The facility will send a monthly listing, may be written or electronic notification, of residents discharged to the Office of the State Long-Term Care Ombudsman which will include reason for transfer or discharge, date and receiving entity 7. Discharges that are initiated by the resident or resident representative, either in writing or verbally, do not require notification of transfer or discharge. However, the resident or resident representative desire or intent to leave the facility must be documented in the resident medical record. Review of a Notice of Bed Hold Policy revealed ***This document must be signed by the patient upon discharge to the hospital or therapeutic leave*** If unable to sign, notification from the patient and/or family/DPOA (Designated Power of Attorney) must be documented. Complete top section upon admission with resident or responsible party. This NOTICE OF BEDHOLD POLICY is provided to _______ on the effective date of admissions as well as upon any subsequent transfer to a hospital for a therapeutic leave, the date of which is applicable, is __________

Based on observation, interview and record review, the facility failed implement an effective discharge planning process and properly coordinate services to meet the discharge needs of 1 (Resident #14), who is dependent and discharged to home, resulting in essential supplies/medications being unavailable, lack of coordination in care for a dependent resident, mental stress, compromised physical well-being, and rehospitalization . Findings include: Review of a Face Sheet revealed Resident #14 is a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Entry tracking Minimum Data Set (MDS) dated [DATE] revealed Resident #14 admitted to the facility. Review of the Discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #14 discharged from the facility. Review of the Entry tracking Minimum Data Set (MDS) dated [DATE] revealed Resident #14 admitted to the facility. Review of the Admission Minimum Data Set (MDS) dated [DATE] for Resident #14 revealed a Brief Interview for Mental Status (BIMS) indicated she is moderately cognitively impaired and required extensive assistance of 1 staff for transfers and care. She has limited range of motion on one side of her lower extremity and uses a wheelchair. The Care Assessment Areas (CAAs) triggered were Cognitive Loss/Dementia, ADL (activities of daily living) Functional/Rehabilitation Potential, Urinary Incontinence, and Indwelling Catheter, Falls, Dehydration/fluid Maintenance, Pressure Ulcer and [CONDITION(S)] Drug use. In an interview on 7/13/21 at 11:19 a.m., Resident #14 was in her room with a Resident Care Associate (RCA) BB assisting her back to bed after toileting. The resident has a wound vac attached to her right leg stump and required assistance to transfer with the wound vac machine. The RCA plugged the wound vac back into the wall after the transfer back to bed. Resident #14 reported she recently had her leg amputated and the wound on her stump has an infection and has been on antibiotics since then. The wound vac is to assist with the healing and has some pain at the site. She reported she is diabetic and some other wounds on her body too. Resident #14 reported the facility kicked her out after a few days of being there when her insurance ran out. She went home and fell that same day when she tried to self-transfer out of bed. She ended up back at the hospital that night and then returned to the nursing facility. She did not have assistance at home because her son was at the hospital expecting a baby. Resident #14 reported her son found out she did have the State Insurance. The resident reported she was waiting for Therapy to start again for this admission so she could improve her balance. She reported she did get therapy for 20-30 days this admission. Resident #14 reported staff are not always timely when she needs assistance to go to the bathroom and will sometimes soil herself while waiting for assistance, which makes her feel embarrassed. Short staffing happens at different times and one night there was only one staff person for the whole floor. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for Bilat groin wounds: Wash with soap and water, pat dry, apply single layer Xeroform gauze, apply gauze pad and tape daily. Every evening shift for wound care, start date 6/8/21, discontinue 6/11/21. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for Bilat groin wounds: Wash with soap and water, pat dry, apply single layer Xeroform gauze, apply gauze pad and tape daily. Every day shift for wound care, start date 6/12/21 and discontinue date 7/2/21. The resident received treatment on 6/12/21 and did not receive treatment again until 6/16/21 after she readmitted to the facility with the same orders. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for right leg stump ulcers: cleanse with normal saline or wound cleanser, replace bordered gauze or [MEDICATION(S)] every day shift for wound care, start date 6/12/21 at 6:00 a.m. and discontinue date 7/4/21. The resident received treatment on 6/12/21 and did not receive another treatment until 6/16/21 after she readmitted to the facility. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for right leg stump wound vac replace black [MEDICATION(S)], cover with wound vac drape and apply vac at -125 mmhg every evening shift every Mon, Wed, Fri for wound care, start date 6/9/21 and discontinue date 6/11/21. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for right leg stump wound vac replace black [MEDICATION(S)], cover with wound vac drape and apply vac at -125 mmhg every day shift for wound care, start date 6/12/21 at 0600, discontinue date 6/15/21. Resident received treatment on 6/12/21 only prior to discharge. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for right leg stump wound vac replace black [MEDICATION(S)], cover with wound vac drape and apply vac at -125 mmhg every day shift for wound care, start date 6/17/21 after the resident readmitted to the facility. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for Right medial thigh wound: wash with soap and water, pat dry, apply Santyl Oint cover with gauze pad and wrap with roll gauze daily. Every day shift for wound care, start date 6/8/21 and discontinue on 6/11/21. Review of the June Treatment Administration Record (TAR) for Resident #14 revealed orders for Right medial thigh wound: wash with soap and water, pat dry, apply Santyl Oint cover with gauze pad and wrap with roll gauze daily. Every day shift for wound care, start date 6/12/21. The resident received treatment on 6/12/21 and did not receive care until 6/16/21 after she readmitted to the facility with the same orders. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Pain documented greater than a 5 on a 0-10 scale several times prior to discharge on 6/12/21. Interventions: Avoid use of aspirin or NSAIDS (non-steroid anti-[CONDITION(S)] drug). Review of a Care Plan for Resident #14 revealed on 6/12/21 and cancelled on 6/15/21 a Care Plan was initiated for I Wish to Return to the Community. My Current needs are: heal and gain strength. The Goal: My goal for discharge is: be strong enough to go home. Interventions: Coordinate with the IDT (interdisciplinary team) to determine caregiver skill and availability to perform required care upon discharge. Evaluate and discuss with me/responsible party the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits and needs for maximum independence. Include me in the discharge planning process and re-evaluate my situation as needed. Review of a Care Plan for Resident #14 revealed a Focus of I am Anticoagulant therapy: [MEDICATION(S)] r/t (related to): History of DVT (deep vein thrombosis), PVD (peripheral vascular disease), initiated 6/8/21. Review of a Care Plan for Resident #14 revealed on 6/8/21 a Focus of I am at risk for impaired skin integrity r/t risk for immobility, nutritionally at risk, history of venous/stasis ulcer, diabetic [CONDITION(S)], require assistance with my ADLs, Cardiovascular Disease, CHF, PVD, Diabetes, history of smoker, Complaints of lower extremity pain was resolved on 6/9/21. Review of a Care Plan for Resident #14 revealed on 6/8/21 a Focus of I have an ADL Self Care Performance Deficit cancelled on 6/15/21. Interventions: I use a wheelchair for locomotion. I wear glasses to aid in my vision. TRANSFERRING- w/w +2 person Assist. Moderate fall risk (initiated 6/7/21 and revised 6/12/21). BED MOBILITY-(no entry) then initiated 1 assist as needed on 6/17/21. Toileting - (no entry) then initiated on 6/17/21 as 1 assist as needed. Review of a Care Plan for Resident #14 revealed on 6/8/21 a Focus of I am at an increased risk for falls r/t was cancelled on 6/15/21. No mention of her amputation, comorbidities, or wound vac. Review of a Care Plan for Resident #14 revealed on 6/8/21 a Focus of I have acute/chronic pain r/t extensive surgical history related to PVD and skin grafting, ischemic [CONDITION(S)], wound to right stump cancelled on 6/16/21. In an interview on 7/20/21 at 4:24 p.m., Physical Therapy Director (PT) N reported Resident #14 would have been safe to go home if her son would be there with her. PT N reported the resident's insurance was cut which is why she was discharged . Usually residents who get discharged to home are discharged with therapy. In an interview on 7/20/21 at 4:47 p.m., Social Worker (SW) O reported the Administrator arranged for Resident #1 to be discharged to her daughter's house. The daughter had step to go up to the bathroom that was not easy for the resident, and she ended up back at her sons' house but not sure how she got there. The resident and her son have trailers that are back to back. The son just had a baby 2 days prior to the residents' discharge and was at the hospital. He was not able to at his home to care for Resident #14. She was only given a few days to be at the facility per her insurance and not sure why because a person who is an [CONDITION(S)] usually stays longer. The Business Office Manager (BOM) had no proof of insurance and then ran Medicaid after she discharged from the facility and found out she did have Medicaid. SW O reported the Nursing Home Administrator (NHA) did the discharge for her and planned for her to go home with her daughter. Resident #14 was at the facility form 6/7/21 to 6/12/21 on a 5 day authorization. SW O reported the nursing care was the most important thing for Resident #14 because she had a wound vac and felt therapy could have waited until the following week. SW O reported she was not sure if Resident #14 had supplies to go home with or if services were set up. SW O reported that according to the emails, a response from a person to provide care did not get the memo until the following Monday (after discharge) because the email was sent after hours on Friday. SW O felt there was no safe solution for Resident #14 to be discharged . In an interview on 7/20/21 at 4:49 p.m., Business Office Manager (BOM) P reported Resident #14 had private insurance upon admission and the benefits maxed out after 5 days. BOM reported she did a screening for Medicaid but there was no insurance coverage noted in the system and the resident did not tell her she had Medicaid and the hospital did not have a secondary insurance listed. BOM P suggested Resident #14 to call the Elder Law Office and communicated information to the Social Worker and the NHA. In an interview on 7/20/21 at 6:03 p.m., the NHA reported Resident #14 had a ramp at her son's house and was aware the son was expecting a baby to be delivered. Resident #14 wanted to go to her daughter's house because she was unwilling to pay private pay and expressed those concerns to her daughter. Resident #14 wanted to go to her son's house first to get her belongings, then go to her daughters. Resident #14 was discharged on a Saturday and wound care was ordered for every other day and would have been there on Tuesday and felt there would not have been a gap in care since she was discharged on the weekend. NHA reported the residents Medicaid was ran and showed inactive and her daughter was not sure of the residents Medicaid status. The DON reported as she was reading the notes in the computer that Resident #14 did not want to go home. The BOM entered the room at this time and reported she was not sure if she could provide proof of a lack insurance for the resident. The NHA reported he was not sure of the Ombudsman was notified the resident was discharged from the facility. Review of an email dated 7/20/21 at 6:08 p.m. from the NHA revealed (Resident #14) is her responsible party. Since we gave her alternative options to stay, ensured she had home health service, informed daughter as well, we did not consider this as a facility initiated discharge and did not notify Ombudsman. Review of Occupational Therapy notes for Resident #14 revealed she received services from 6/8/21 and discharged from services on 6/11/21. Document indicated the resident required partial to moderate assistance for ADLs. Assessment and Summary of Skilled Services: D/C Location= Patient discharged to home w/support from others. Discharge Recommendations: HHC, 24 hours care/sup, ramp for entrance for house. Review of Physical Therapy notes for Resident #14 revealed she received services from 6/8/21 to 6/11/21 and was discharged because her benefits were exhausted. She was discharged to home with support from others. Patient would benefit from continued therapy and increased assistance at home to 24 hours due to increased pain, wounds, and decreased mobility. The document revealed Resident #14 was dependent for 1 step (curb), 4 steps, car transfer, and required some supervision and partial to moderate assistance for mobility. Review of a late entry Social Service Progress Note dated 6/10/21 at 10:18 for Resident #14 revealed: It was stated in morning meeting that (Resident #14) is to change to Medicaid pending on Saturday rather than needing to discharge. I had not been informed of this previously so I went to speak to her about this and that she would be able to stay longer. (Resident #14) was very please to hear this news and I left her in happy tears. Review of a Practitioner Progress Note dated 6/10/21 at 5:08 p.m. for Resident #14 revealed: (stump wound) Aerobic culture revealed a few Citrobacter and Enterobacter (bacteria's) . Skin: Patient has multiple wounds. Patient has 2 stage III decubiti on her ischium bilaterally and a small stage II decubitus on her right thigh which she states is from her prosthesis. Patient has a pale yellowish color to her skin. Review of a late entry Physical Medicine and Rehabilitation Progress not dated 6/10/21 at 10:43 p.m. for Resident #14 revealed: . Continued rehabilitation at the subacute level was recommended before discharge to home. pain averaging 5-7/10 of her residual limb . The pain seems to be worse . with wound VAC changes. Continue fall and safety precautions, family training and energy conservation techniques. ADL and mobility dysfunction . Fall risk. R AKA with wound vac. Disposition/Discharge Planning: At this point, we will continue to follow with the discharge plan yet to be determined based on the patient's response to therapy measures. Will continue with discussion with therapy team and SW. Review of a late entry Social Service Progress Note dated 6/11/21 at 10:20 a.m. for Resident #14 revealed: I had been informed earlier that after speaking with (R #14) the BOM does not feel she will qualify for Medicaid and needs to be discharged Saturday as originally planned. Spoke with (Resident #14) about this and tried to determine where she might be able to go since her son's girlfriend is supposed to be induced today and may end up needing a C-section. This means there will likely be no one home to assist her this weekend. She doesn't think going to her daughters will work due to her not being able to help much. Review of a Social Services Progress Note dated 6/11/21 at 2:15 p.m. for Resident #14 revealed: . told me she cannot manage the private pay rate . will be going to daughter's home tomorrow. He (NHA) will arrange transportation for her via (cab), they will change her dressing before she leaves facility on Saturday and then will not need the dressing changed again until Tuesday. I also received a message from Therapy that asked to call (Resident #14's) son since he was very concerned that his mother would be alone at his house over the weekend. I called to inform him of the administrator's plan and he was g going to go to his sisters house to see what they could figure out about the steps since the ramp evaluation was not possible at this late time nor could it probably be afforded at this time. Review of an email thread provided by the facility regarding Resident #14 revealed on 6/11/21 a medical service provider reached out to the Social worker inquiring about orders, supplies and services needed and who will be providing supplies for the wound vac. SW O responded The aide is not critical if you can proved (sic) the rest.If you can't get the wound vac supplies I will probably try to order them from (medical supplier). She is a new [CONDITION(S)] . As far as the specific with the wound vac please call the building . since I can't see those specifics of Nursing. At 1:49 p.m., the medical service provider replied: . Also, her insurance requires a 10% coinsurance per visit per discipline, which would be about $14.00 to $25.00, is the patient willing to accept those costs? Review of an Administrative Progress note dated 6/11/21 for Resident #14 revealed: Per DON (name), resident did not want to go home so I had a detailed discussion with the resident and her daughter .I explained to (Resident #14) that it is not about insurance extension and in fact she ran out of her benefit days. I also explained to (Resident #14) that based on the information we have, she does not qualify for Medicaid. I also gave her private pay option with installments, but she denied that offer. At the end of the conversation, (Resident #14) decided to go to her daughters house, so she called her daughter (name) to discuss about the DC plan. (Daughter) had some concerns but understood the situation. She planned on working with her mom to get MCD coverage. Patient's wound Vac and dressing will be changed Saturday to allow enough time for Home Care services to resume the care. At 5:07 p.m. the SW responded: That is certainly cheaper than her having to stay here private pay and really therapy can wait but the nursing can't. she will be going to her daughter's house not her son's at least for a few days. She is planning to discharge tomorrow and will have her wound vac changed here before she goes. She will not need another change until Tuesday. On 6/14/21 at 9:51 a.m., the medical service provider responded: Good morning, sorry for the delayed response, the email came in after hours on Friday. Where does the patient's son live at? Also, has the patient had supplies and someone set up to come yet? At 12:48 p.m. SW replied: She actually discharged to her daughter's house which I don (sic) not have an address for. I doubt supplies got ordered but I will try to get them . Do you know what the typical items would be? Review of a Nursing Progress Noted dated 6/12/21 at 4:44 p.m. for Resident #14 revealed: patient was discharged at 3:45 p.m. with her daughter, meds and discharge instructions were gone over with patient, no meds were ordered from pharmacy at this time. Review of an Administrative Progress note dated 6/12/21 for Resident #14 revealed: Resident initially wanted to go to her daughter's address but later changed her mind to going home to collect her belongings and eventually go to her daughter's house. She said her son will be busy this weekend, so her daughter will be available to help. Review of Discharge Instructions and Recap of Stay document for Resident #14 revealed she was discharged on [DATE] at 1:15 p.m. to her daughter's home via Ambu-cab. Reason for discharge: Other. 2. Social Work-Recap of Stay: Barriers (emotional, cognitive, financial, literacy concerns, transportation-appointments/items for daily living, safety, psychological) to discharge and steps taken for discharge: going home on wound Vac since insurance ended her length of stay. 3. Nursing Services-Recap of Stay: Brief summary of medical stay: Pt with wound vac and several wounds, Signed by the nurse on 6/16/21. 4. Dietary-Recap of Stay: Continue to eat a high protein diet to aide in healing.6. Patient received PT/OT skilled services with focus on gait and ADL training. At discharge, patient functioning with MinPA for all self care and ambulation tasks utilizing w/w. In-Home Care or Services: 1. Referrals made to HHC (Home Health Care) Agency. Medical Equipment Arrangements: (Oxygen supplier) and ramp evaluation. Prevention and Disease Management Education: N/A. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . No indication the resident received a copy of her medication list, medications, or prescriptions. No signature indicating the resident received this document. Review of Hospital Emergency Department Records dated 6/14/21 for Resident #14 revealed: . Physical Exam: . comments: Right AKA (above the knee amputation) stump is examined- see pictures. Wound dressing in place (no current VAC in place). Patient presented to the emergency department for evaluation after having a fall. Patient recently was discharged home from rehabilitation. Patient is currently living with her son. However, she states that he is busy and cannot always care for her. Last evening she was transferring from her wheelchair to the toilet when she lost her balance and fell . Patient could not remember if she hit her head or had loss of consciousness. Patient did not feel safe to be discharged home and requested to be admitted for possible placement. Infectious Disease recommended continued double-strength [MEDICATION(S)] .

This citation pertains to intake M 1197. Based on observation, interview and record review, the facility failed to assess, monitor, document and provide treatment per professional standards of care for 2 (Resident #137, Resident #139), resulting in a lack of assessments and follow up care for a resident with dysphagia and [CONDITION(S)] post hospitalization , lack of investigating care, treatments and services prior to unexpected deaths in the facility, preparing staff for emergency code procedures, and lack of necessary supplies on the crash cart. Findings include: Review of a policy titled Cardiopulmonary Resuscitation (CPR) - Adult last revised ,d+[DATE] revealed: Appropriate cardiac and respiratory function will be maintained until a definitive treatment can be given. CPR will be initiated on all residents with an Advanced Directive stating CPR-Full Resuscitation except in circumstances where you are responding to an emergency (drowning, choking, fall, or electrocution). (Facility) has set American Heart Association as our standard of BLS Care. 1. In the event a resident is identified unresponsive and upon a thorough assessment determines that there is no pulse or respiratory activity, and the resident has declared a full-code status, a BLS certified staff member will: a. Simultaneously with the initiation of chest compressions direct a staff member to immediately retrieve the emergency cart. b. Continue to administer chest compressions and rescue respirations per the American Heart Association recommendations. c. Direct a staff member to contact the Emergency Response Team (911) immediately to inform them of a full code requiring life support interventions and possible transportation to the emergency department d. Direct a member of the response team to contact the attending physician and responsible party/DPOA/guardian. This staff member shall also complete a hospital transfer sheet including a copy of advance directives/code status and make these documents available to Emergency Response Personnel. e. Identify a member of the response team to be responsible for documenting the time of each intervention and resulting response. Documentation should include but not limited to: 1) Date and time of arrest and name(s) of person(s) assisting with CPR, including the recorder. 2) Medications given. 3) Treatments performed. 4) Results of resuscitation. 5) Time AED was placed and whether or not shock advised if available. 6) Date and time family and doctor notified. 7) Assessment done. 8) Where resident was transferred to (i.e., EMS Agency or Mortuary). 9) A debriefing with staff involved in the code response as needed. Record review of the 'Nursing Clinical Skills, Perry, Potter and Ostendorf, 9th edition 2014, Chapter 28-Emergency Measures for Life Support, Page 739, Skill 28.2- Using an Automatic External Defibrillator noted the following: The AED (Automatic External Defibrillator) is a defibrillator that incorporates a rhythm analysis system. The device attaches to a patient by two adhesive pads and a connecting cable. Most AED's are stand-alone boxes with a very simple three-step function and verbal prompts to guide the responder. All AED's offer automatic rhythm analysis, whereby the rhythm is compared to thousands of other rhythms stored in the AED computer software. On rhythm identification, some AED's automatically provide the electrical shock after a verbal warning . Page 740 clinical decision point: If the AED is immediately available, attach it to patient as soon as possible. The faster defibrillation is delivered the better survival rate (Kleinman et al. 2015). Review of a Potter and Perry documentation provided by the facility regarding Palliative Care- Care of a Body After Death revealed: Recording and Reporting, Record time of death in the nurses' notes in electronic health record (EHR) or chart, describe any resuscitative measures taken (if applicable), and note the name of the professional certifying the death. Record names of mortuary and names of family members consulted at the time of death . Record on appropriate form personal articles left on the body . Record time the body was transported and its destination. Resident #137 Review of a Face Sheet revealed Resident #137 was a [AGE] year old male admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident died at the facility. Resident #139 Review of the Minimum Data Set revealed Resident #139 was an [AGE] year old female admitted to the facility on [DATE] and died at the facility on [DATE]. Resident #137 In an interview on [DATE] at 10:56 a.m., the Nursing Home Administrator (NHA) reported there were no incident accident reports or investigations for Resident #137. In an interview on [DATE] at 12:10 p.m., Social Worker (SW) O reported she entered Resident #137's room and found him unresponsive and shook his arm and looked around and saw his food tray and realized there may be something going on. SW O reported he felt warm to the touch and shook him harder and was still unresponsive. He was lying in bed in the middle with his legs hanging over the side and his meal tray in front of him, eyes closed and looked restful laying down with his hands by his side or on this stomach. At that time she called for the Occupational Therapist Assistant (OTA) EE who was nearby, and he entered the room and she left to get help. SW O reported she ran to the nurses' station where to staff members were and one ran to Resident #137's room and the other went to find a nurse. SW O also looked for the UM then saw LPN W trekking down the hall to the resident's room. She remembered someone hollered to call 911. SW O reported she called 911 and went back to the residents' room and saw LPN W and UM Q were in the room working on him and the crash cart was there. SW O reported it was mentioned by someone to call a code blue on the overhead paging system, but nobody knew how to do it. Then she went downstairs to meet EMS to let them in and heard the code blue called overhead. Once EMS came, they took over the scene. Not sure which EMS responded but confirmed the police and the fire department arrived as well. SW O does not recall any post incident education/investigation/debriefing occurred post code event for Resident #137. In an interview on [DATE] at 12:45 p.m., CNA DD reported the day Resident #137 coded, she was at the nurses' station when the SW came down the hall to tell her the resident was unresponsive and CNA DD then went to get help and found LPN W who went to his room and started compressions and CNA who was in the room told her to get the AED while LPN C brought the crash cart. CNA DD reported she then went to the 3rd floor to tell UM G there was a code on the second floor and see if there was anyone else who could help and that is when the staff on the 3rd floor called a code blue overhead. In an interview on [DATE] at 1:00 p.m., CNA FF reported the last time she saw Resident #137 was at 8:15 when she sat him up for breakfast. She reported she called a code blue 3 times overhead. She remembered that OTA EE was there in the room the entire time and LPN W passed off compressions when LPN C was in there. CNA FF reported she was the one who got the crash cart and took it to the room. In an interview on [DATE] at 8:07 a.m., OTA EE reported the day Resident #137 coded, he was passing by his room when SW O said the resident was not responding and OTA knew he gets really tired after [CONDITION(S)]. OTA EE reported when he entered Resident #137s room, he had a pale skin tone that looks like when you throw up and he was warm. His tray was tilted slightly off the table, and he looked like was sitting on the edge of the bed. He told the SW to get the nurse now and he repositioned the resident on the bed properly in a linear position then LPN W entered the room. That is when LPN W and OTA EE started CPR. OTA EE reported he did not do a finger sweep but did not visibly see anything in his mouth. They did not suction the resident but did stat with an ambu bag. OTA EE reported the switched off CPR with other staff who were in the room. OTA EE reported they were all paying attention to the clock but did not write anything down. They continued CPR efforts until EMS arrived. He reported he received his CPR certification last year. Review of the CPR Certificate for OTA EE revealed he received a Healthcare Provider BLS Course on [DATE] from a non-accredited institute that offers an online course in CPR. In an interview on [DATE] at 8:33 am., LPN W reported she was in another resident's room when she heard someone call faintly help and thought it was odd and was not sure what she really heard. Then she heard a blood curdling yell for help and immediately left the room when the CNA told her Resident #137 was not responsive. She then sprinted to his room and saw OTA EE shaking the resident and grabbed his arms. The resident was then slumped over in bed with his legs over the edge of the bed and his head at an able near the head of the bed. She grabbed his legs and put him in bed. She reported the resident's food tray passed at 8:15 a.m. and was doing CPR at 8:20 a.m. LPN W reported she was the one who initiated CPR and the CNAs grabbed the AED and the crash cart. She reported the AED gave one shock, did about 10 minutes of CPR and the AED analyzed him about 5 times with no shock advised. After the first shock she swept his mouth and there were tons of food in there. LPN W reported she swept his mouth 3 times and food was everywhere. She reported using the Ambu bag and the resident's chest never raised and did not go in even after repositioning, then EMS arrived and took over. LPN W reported a code blue was called about 3 ½ minutes after CPR was initiated because not all the phone paged overhead and there was a newer CNA who did not know how to pave overhead. LPN W reported the night shift is to check the crash cart and reported the code minutes documentation was overlooked that day. There is no paper on the cart for documenting minutes and it would be helpful if there was. In a second interview on [DATE] at 11:48 a.m., LPN W reported she did a head to toe assessment when she first entered Resident #137s room and felt he was gray, non-responsive, and dead. She repeated information from the first interview and reported there is a code button at the nurses' station that alerts everyone on the floor of a code, then the overhead paging lets the rest of the building know there is a code. LPN W proceeded to say the OTA EE checked the residents' pulse and said there was not a pulse. He was gray, cold and dead, and was only unsupervised for 5 minutes. LPN W reported she did 5 sets of 30 chest compressions with the bed flat. LPN W reported she, OTA EE, UM Q and UM G all took turns with compressions, but LPN C did not assist. LPN W reported everything should have been documented during the code. The facility did not provide education or debriefing after the code and was just educated today after the surveyors entered the building about how to fill out a form after the code. LPN C acknowledged there was not an ambu bag on the crash cart when surveyors entered the building but was just replaced yesterday. In an interview on [DATE] at 10:07 a.m., Regional Consultant (RC) S reported her expectations is for the night shift nurse to monitor the crash cart daily and weekly go through the whole cart to make sure everything is there. If there is a code blue, she expects the cart to be restocked of any used supplies. RC S acknowledged the nurse did not complete the inventory form but did order the supplies. When queried about any recent codes, the DON reported she heard there was a code but did not know who it was or what happened. The RC S was able to find that it was Resident #139 who coded recently on the second floor. The DON reported LPN V was the night shift nurse who ran that code. The DON reported LPN V has the code book with the minutes in it from that code but does not know where it is. When queried about documenting the minutes during a code, the DON reported nobody stood in the room taking notes but feels they are capable of putting together a timeline of what happened. The DON reported she also responded and assisted with the code blue for Resident #137. The DON reported she did a timeline right after EMS came in and thinks she gave the timeline to EMS. The DON reported she wanted to have a form on the crash cart but has not implemented one yet. When queried about extra AED pads not on the cart, the DON reported if there are no AED pads on the floor, the staff can go to other floors that have an AED to find them or go to the maintenance office in the basement. RC S asked if I had received the incident/accident reports for the codes of Resident #137 and Resident #139, this surveyor reported the NHA said there were no reports and only received a progress note. At this time RC S provided the reports. Review of the Incident Accident Report provided to this surveyor on [DATE] for Resident #137 revealed he was found unresponsive, CPR initiated, EMS arrived, and resident declared dead at 9:15 a.m. Three unidentified staff provided brief statements. No investigation done. The Incident Audit Report revealed on [DATE] the incident was created and closed by the Administrator on [DATE]. Review of the Death Certificate for Resident #137 revealed the resident died from a. Aspiration of food while eating, b. CHF, c. Hypertensive Heart Disease. Review of Progress notes for Resident #137 from the time of Admission on [DATE] to discharge on [DATE], no documentation indicating the resident went to [CONDITION(S)]. Pre/post [CONDITION(S)] assessments not documented Review of a Physical Medicine and Rehabilitation Initial Evaluation note dated [DATE] for Resident #137 revealed: Patient hypoxic on RA, treated with NC O2 (nasal cannula oxygen). Patient sitting at edge of bed, coughing frequently while eating, NAD, well developed and well nourished. No new orders noted. Review of a Nursing Progress Note dated [DATE] at 6:59 a.m. for Resident #137 revealed: Pt displayed aggressive behavior this am, writer went in to administer am medication at 0655 and pt yelled at nurse that he did not sleep last night . Review of a written statement provided by the facility from the Dietary Manager dated [DATE] for Resident #137 revealed: No stated chewing or swallowing difficulties in initial patient interview with nutrition services. Charted BIMS of 14 on [DATE]. Due to this (Resident #137) would not have triggered for a SLP (speech therapy) eval/screen. Review of the Order Summary for Resident #137 revealed: May use O2 (oxygen) as needed to maintain oxygen saturation >= 89% as needed for Emergency use per Standing orders, start date is [DATE]. Resident requires services at ([CONDITION(S)] Center). Treatment days are Mon, Wens (sic), Friday. PU 545 am. Monitor fistula to right arm site for bruit and thrill. Document in PN (progress notes) and notify MD of any abnormal findings: . every shift, start [DATE]. ST (speech therapy) to evaluate and treat as needed for evaluation, start [DATE]. Review of the Electronic Health Records (EHR) for Resident #137 revealed no documentation for continuity of care. No respiratory assessments and interventions. Review of the Care Plan for Resident #137 revealed a Focus for ADL (activities of daily living) self-care deficit related to [CONDITION(S)], below the knee amputation, and pleural effusion initiated on [DATE] revealed: RESOLVED: EATING-Independent, initiated [DATE] and resolved [DATE]. No care plan interventions for oxygen noted. Resident #139 In an interview on [DATE] at 9:45 a.m., UM Q reported she had Resident #139's death certificate in her office and was holding on to it in case it needed to be refaxed. She said the family gave her permission to release the body to the funeral home not the physician, but the physician signed the death certificate. UM Q does not know why there is a lack of documentation regarding Resident #139 and does not know who was on duty when she coded or who participated, and then started guessing who could have been there. When queried about what happened to Resident #139, UM Q reported she was just found unresponsive. UM Q reported she arrived at the facility between ,d+[DATE]:30 a.m. and at that time the police were there. Does not know who saw the resident last then said she should have followed up with the nurses to see if the orders were done. In an interview on [DATE] at 11:24 a.m., LPN V reported the night Resident #139 died , the Resident Care Associate (RCA) U did rounds that night and came running down the hall and said she didn't think the Resident #139 was breathing. LPN V said she grabbed the crash cart and ran to the room. When she got to the room, the resident was nonresponsive, then checked for a pulse, called 911, and started compressions right away. RCA U looked for another nurse and went to the 3rd floor. She was not sure how long it took but LPN B then came from the 3rd floor to assist. The resident was still warm but did not obtain vital signs. When the AED arrived there was no shock advised and the resident was still not breathing. EMS arrived in about 5 minutes after the code was called. When queried about the airway, LPN V reported the resident had a nasal canula on, but she immediately put on a non-rebreather (that is in a bag in the crash cart) and cranked the oxygen all the up while she was trying to take the Ambu bag out of a bag that was at the bottom of the cart. When queried about ambu bags being in a bag, LPN V could not remember if ambu bags were in bags or why she used a nonrebreather first instead of an ambu bag. No minutes were recorded by staff while performing CPR on the resident. When EMS arrived, there was no pulse detected. LPN V reported the police arrived, and somebody came in and took pictures and not sure if it was the coroner. Not sure who the CNA was because she was new. LPN V reported the last time she saw Resident #139 was around 4:30 a.m. to assist toileting her in the bathroom by herself because she was a 1 assist. LPN V reported the night shift nurse is to check the crash cart to make sure all the supplies are on the cart. She reported that when she works at night and has 26 patients to herself and one CNA, she forgets to check the crash cart. She reported she filled the form out but did not sign it because she did not have all the supplies and there were no supplies available to stock the cart. There were no ambu bags in central supply or on the second floor. LPN V reported the UM had her fill out a risk management form but is not aware of anyone investigating the situation. LPN V reported there was a pad of paper on top of the crash cart and did notes and transcribed the minutes but said there should be more documentation. In an interview on [DATE] at 1:06 p.m. Resident Care Associate (RCA) U started working in the facility in May and reported she found Resident #139 around 5:,d+[DATE]:45 a.m. The last time RCA U saw Resident #139 was to assist the resident toileting by using a bed pan around 2:30 a.m. but did not chart that she urinated because she did not urinate. The facility did not have a functioning call light system but did utilize a hand bell. Does not think anyone else had seen her before she found her unresponsive. RCA U reported she went to Resident #139's room for morning rounds and she appeared to be sleeping. She wanted to wake the resident up to see if she needed to use the bathroom. When RCA U walked in the room and saw her, she said she was cold, and her mouth was open and tried to feel if she was breathing. Her nasal cannula was on her shoulder by the pillow but not sure how much oxygen she was to be on, her knees were bent, and she was sitting upward. RCA U reported she put the oxygen back in her nose and she tried to shake the resident for a response then RCA U reported she ran to the nurses' station to tell LPN V. LPN V then headed to the residents' room and instructed RCA U to get LPN B who works on the 3rd floor. When RCA U went to the 3rd floor, she grabbed the AED to take to the second floor and not sure why she did not grab the AED on the second floor. She took the AED to LPN V and went back upstairs to the 3rd floor to grab the ambu bag. The crash cart on the second floor did not have an ambu bag at the time Resident #139 coded so RCA U reported that is why she had to go back upstairs. When queried how she got to the 3rd floor, RCA U reported she first tried to take the stairs but could not remember the code to get through the door, so she took the elevator two different times to get upstairs. RCA U reported she did not get any education for what to do during a code until last night. RCA U reported after the nurses had the defibrillator and the ambu bag, they called 911. The dayshift nurse who just arrived at the facility to start her shift into Resident #139's room, applied the AED to Resident #139 and no shock was advised. In an interview on [DATE] at 2:34p.m. LPN B reported the night Resident #139 died ; she was coming upstairs from the basement when RCA U told her about Resident #139 not being responsive. LPN B immediately went to the second floor and when she got to Resident #139s room the crash cart was there but there was no ambu bag. The resident had her nasal cannula in her nostrils. At that time she took out a nonrebreather oxygen mask and put that on her because that was the only thing on the crash cart to get her oxygen. Resident #139 was cool but not stiff. LPN B reported she sent RCA U to the 3rd floor to get the AED because the AED on the second floor did not have pads on it. LPN B reported they had to wait a couple minutes for the ambu bag. LPN B clarified that RCA U had to go upstairs twice, once for the ambu bag, then for the AED. LPN B reported it is the 3rd shifts responsibility to make sure they have supplies and stock the crash cart. LPN B reported that when a resident codes, the attending nurse will start CPR and the other staff on the floor will get help. The overhead paging works but is not activated because not everyone knows how to activate it. The ambu bags need to be on the crash carts along with extra AED pads. LPN B reported her concerns to the NHA and the DON because she did not have a messaging system for the maintenance or the central supply person. She was then told that Maintenance had extra pads in his office but did not have keys to his office and was told to call the ESM E when the AED pads needed to be replaced. Review of Hospital records for Resident #139 revealed she admitted to the hospital on [DATE] for [CONDITION(S)], acute congestive heart failure and [CONDITION(S)], and discharged on [DATE]. Discharge instructions included Standing daily weights first thing in the morning after patient empties bladder. Monitor the patient daily and notify facility provider for the following: weight gain of ,d+[DATE] pounds in 1 day or 5 pounds in 1 week. Increased shortness of breath with activity, sleeping or at rest. Unable to lay flat at night. Complaints of abdominal fullness, nausea or change in appetite. Increased swelling. Increased O2 needs from baseline or new oxygen requirement. Unable to tolerate medications (beta-blocker, diuretics, ACE/[NAME]/ARNI-entresto). Systolic blood pressure of less than 90 over 140 for more than three consecutive readings.The patient is required to have follow-up with cardiology within ,d+[DATE] days of discharge form your facility Discharge diet: Tube feeds as per nutrition. Review of a document titled Admission/Readmission Assessment for Resident #139 revealed she was admitted to the facility on [DATE] from the hospital for shortness of breath and weakness and on 2 liters of oxygen via nasal cannula. Review of an Order Summary for Resident #139 revealed no orders for daily weights, no orders for tube feeding or diet. Orders for ST to evaluate and treat as needed for evaluation ordered [DATE]. ST Clarification: ST evaluation completed and POC established for 5x/wk (5 times a week) for 4 weeks for dysphagia to include education/training for pt/caregivers on safe swallow strategies and determine least restrictive diet level. One time only for 4 weeks, ordered [DATE]. Review of a Speech Therapy Note dated [DATE] for Resident #139 revealed: Pt. seen this date for continued dysphagia tx. Pt seen post lunch meal with daughter present . Liquids via straw noted to have poor swallowing affects post swallow with belching occurring suspected from coordinating breath support to swallow as pt showing SOB this date as well as possible air ingestion . Pt daughter also reported no chest x-ray given since admission and advocating for this. Therapist in agreement . Recommended this to nursing to order. Review of a Laboratory document for Resident #139 revealed on [DATE] she had a High Sensitivity Troponin lab that had an abnormal, high, and critical results. Review of a Physician Assistant progress note with a Late Entry date of [DATE] at 8:27 a.m. for Resident #139 revealed: Chief complaint: Mobility and ADL dysfunction secondary to [CONDITION(S)] and NSTEMI (type of heart attack), now with increased weakness, debility, gait disturbance, acute on chronic neck and back pain. Today the patient reports upper back/neck pain, acute on chronic.Pain ,d+[DATE] with standing straight. Increased SOB and DOE, on 3L NC O2. At baseline, on NC O2 2.5L only at night. Patient seen lying in bed, appears uncomfortable and fatigued. NC O2 in nose at 3L. Increased work of breathing noted. No interventions for the shortness of breath noted and no acknowledgement of the critical troponin labs collected on [DATE]. Review of the Electronic Health Records (EHR) for Resident #139 revealed no documentation for continuity of care. No respiratory assessments and interventions noted, no daily weights noted. No follow up to elevated troponin levels. Review of the Care Plan for Resident #139 revealed on [DATE] a Focus of: I have altered respiratory status/Difficulty Breathing r/t SOB (shortness of breath), CHF (congestive heart failure). Goal: I will have no s/sx (signs or symptoms) of poor oxygen absorption through the review date. No interventions noted. A Focus of: I have altered cardiovascular status r/t CHR initiated [DATE] revealed interventions of Assess for shortness of breath and cyanosis. Report changes to the physician, resolved on [DATE]. I have a pacemaker. Follow up with cardiologist as ordered, resolved on [DATE]. Monitor/document/report to MD changes in lung sounds on auscultation (i.e. crackles), [CONDITION(S)] and changes in weight, resolved on [DATE]. Focus: I have the potential for a nutritional/hydration problem . initiated on [DATE], interventions: Feeding Techniques I require tube feeding and PO (oral), initiated on [DATE], monitor my weight, coordinate my care with speech therapy as needed, . my diet orders are: General, initiated [DATE], Fluid intake between meals initiated [DATE]. The Care Plan did not reflect person centered care. Care plan did not reflect a person centered care plan. Review of an Incident Report for Resident #139 dated [DATE] at 6:44 a.m. revealed: 0545 CNA (U) doing rounds found patient unresponsive. (CNA U) came and got this nurse. This nurse brought crash cart down to patient's room and immediately started CPR. CPR compressions started at 0545. 0550 (EMS) paramedics arrived and took over CPR. No investigation initiated or completed. During an observation and an interview on [DATE] at 9:08 a.m., Unit Manager (UM) Q reported when there is a code blue at the facility, any CPR (cardiopulmonary resuscitation) documentation minutes should be under the Risk Management tab in the electronic health records that the surveyors do not have access to. UM Q reported that Licensed Practical Nurse (LPN) W and LPN C did chest compressions on Resident #137 after Social Worker (SW) O found the resident unresponsive. UM Q reported Certified Nursing Assistant (CNA) DD then grabbed the AED (automated external defibrillator) and entered the room as the UM Q followed her in there. Once UM Q entered the room, she reported she took over control and designated staff to call a code and EMS (emergency medical services.) UM Q reported when she entered the room, LPN W had the air bag (ambu bag), but his tongue was protruding and had food coming out (of his mouth) and air was not going in and didn't realize he had food in his throat. The crash cart was there and heard LPN W swept Resident #137's mouth a couple times. At this time we reviewed the current crash cart on the second floor that did not have a tag on it to seal it, the log sheet was not filled out and several items were missing off the cart including the Ambu-bag. No document available to fill out in case there is a code. UM Q reported there is usually someone who records the minutes (minute by minute documentation of actions done during a code blue). When queried how they obtain the paper to do so if not on the crash cart, UM Q reported staff can grab it from the printer at the nurses' station or use paper in their pockets and reported not all staff carry paper in their pockets. UM Q reported there is a new form to be used for codes that has not been implemented yet and not available for use. When questioned about why the crash cart was not locked and stocked, she reported they were ordering supplies. She was unable to find the June log for the crash cart at this time but said she will continue to look. In an interview on [DATE] at 9:49 a.m., Environment Service Manager (ESM) E reported he stores extra AED pads in his locked office in the basement and the AEDs on the floors have one set inside the box. He reported managers have a key to his office and get another set if needed. He reported he keeps the extras in his office for inventory control and they would not get misplaced. When expressed concerns of not having an extra set readily available, ESM E acknowledged it would be beneficial to have extra available on the floor. In an interview on [DATE] at 10:05 a.m., UM Q reported she did not have the inventory logs for the crash cart on the second floor. In an interview on [DATE] at 9:24 a.m., the DON reported she could not find information on where the deceased bodies of Resident #137 and Resident #139 went or the orders to release the bodies. The DON reported the UM Q was here and did not like her answer. UM Q could not find the death certificate for Resident #139 either. The DON reported the documentation for Resident #139 is vague and questioned the nurse on duty because the documentation does not clarify the events that happened. The DON then reported a nurse called her one night before Resident #139 went to the because she was having some chest pain and the DON told him to call the on call (physician) and she was sent to the hospital and came back. When queried about the lack of assessments, documentation for transfers, and care, the DON reported she expects staff to do an E-interact when someone is sent out to the hospital and who they spoke to and document the progress notes. The DON then clarified the nurse called the on call physician first before calling her. During an observation and an interview on [DATE] at 3:04 p.m., ESM E reported the call system had not been working completely for 2 weeks. The lights worked but there was no noise. If the call light is pulled out of the wall, it will activate a red light and loud noise when it is completely working. The system wiped out the call log for call lights and the code alert system. During a tour of the facility, the code blue light is noted behind the nurses' desk which alerts staff on the floor, and the phones on the desk will allow for overhead paging for the whole

Based on observation, interview, and record review, the facility failed to assess, monitor, measure and ensure effective treatments for 1 (Resident #25) reviewed for pressure ulcers. The deficient practice resulted in Resident #25 sustaining a delay to have Stage 3 pressure ulcers assessed, measured, monitored, and treated with the potential for non-healing, infection, and further decline to occur. Findings include: Resident #25 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #25 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 9 out of 15 which represents Resident #25 had moderate cognitive impairment. According to the facility's Admission assessment dated [DATE], Section F reflected bruising to both arms, a chronic ulcer to the left forearm that measured 3.5 x 1.0 x 0.1, an abrasion to the left lower back that measured 4.0 x 1.0 x 0.1, an abrasion to the left upper posterior thigh that measured 5.0 x 1.0 x 0.1, a [CONDITION(S)] to the right upper abdomen area, a scab to the tip of the penis, and a Stage 3 wound to the coccyx (sacral area) that measured 1.0 x 1.0 x 0.1. Section F, #7 and #8 reflected no initiation of a care plan or interventions for the identified skin issues. According to the MDS dated [DATE], Section M reflected that Resident #25 was admitted with one Stage 3 pressure ulcer and one unstageable pressure ulcer. According to the Care Area Assessment (CAA) portion of the MDS, it triggered the need to develop a comprehensive care plan and indicated that the care plan was developed for the pressure ulcers. During an observation and interview on 7/14/21 at approximately 10:00 AM, the Wound Physician Assistant (Wound PA) M and the Clinic Care Coordinator (CCC) were observed as Resident #25's wounds were assessed and measured, while he was turned onto his left side in bed. Resident #25 had a dressing to the right buttock, no dressing to the open wound on the left buttock and a dressing to the sacral area that had the date of 7/6 (7/6/21) and time of 2000 (8:00 PM) written on the dressing. The Wound PA M and CCC G confirmed the date and time written on the dressing as 7/6 and 2000. The initials were smeared and unable to determine whom had placed the dressing. When asked if the pressure ulcer to the left buttock should have had a dressing on it, the Wound PA M stated, Yes. Resident #25 complained of discomfort during the mechanical debridement process and the Wound PA M was limited in the amount of [MEDICATION(S)] that could be accomplished. There was a healing wound (not open) noted to the left upper back, and according to the Wound PA M did not require treatment. The Wound PA M's notes from 6/22/21 - 7/14/21 were reviewed and summarized as follows: Sacral 6/30/21 - 1.0 x 3.1 x 0.1 unstageable pressure ulcer 7/7/21 - 1 x 2.8 x 0.2 unstageable pressure ulcer 7/14/2 - 0.7 x 2.0 x .07 unstageable pressure ulcer Right buttock 6/30/21 - 2.1 x 3.5 x 0.1 unstageable pressure ulcer 7/7/21 - 2.1 x 3.6 x 0.1 unstageable pressure ulcer 7/14/21 - 1.5 x 0.5 x 0.0 Stage 3 pressure ulcer Left buttock 6/30/21 no information about a left buttock wound 7/7/21 - 1.2 x 0.5 x 0.1 Stage 3 pressure ulcer 7/14/21 - 1.4 x 0.7 x 0.1 Stage 3 pressure ulcer (larger than the previous week) According to the Wound PA M's weekly notes the first time the left buttock was assessed and measured was 7/7/21 (15 days after admission) which reflected, Wound #4 Left Buttock is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 1.2cm length x 0.5cm width x 0.1cm depth .Per nursing staff this wound was present on admission. There was no other documentation to support that the left buttock Stage 3 pressure ulcer was being assessed, monitored, and measured during this period. According to the Treatment Administration Record (TAR) for June 2021, reflected a treatment start date of 6/22/21 for [MEDICATION(S)] Paste ([MEDICATION(S)]) applied to the sacral coccygeal region three times daily. The order did not reflect a cover dressing for the Stage 3/unstageable open pressure ulcer. There were no treatments recorded for the left and right Stage 3 pressure ulcers upon admission. On 6/28/21 the June TAR reflected the first cover dressing orders for the Stage 3 pressure ulcers to the sacral, right buttock and left buttock were initiated. The new orders reflected to cleanse the wounds with normal saline, apply treatment ointment and cover with dressing which started on 6/28/21 (6 days after admission). An interview and record review was conducted on 7/20/21 at 9:30 AM with the Director of Nursing and the Corporate Consultant AA. The surveyor asked how many pressure ulcers did Resident #25 have upon his admission from the hospital and after review of the hospital discharge summary, the Corporate Consultant AA stated that he had one to the left upper back that has currently healed, one to the sacrum, one to the right buttock and one to the left buttock. The surveyor asked when the first treatment order was obtained for the pressure ulcer to the sacral area and the DON stated that [MEDICATION(S)] was ordered on 6/22/21. The DON stated the wound was open and should have had an absorbent dressing ordered which did get ordered on 6/28/21 (6 days after admission). According to the admission assessment there was no indication of a pressure ulcer to the right buttock or measurements noted. When asked when the first measurement of the right buttock was done, the DON stated it was done by the Wound PA on 6/30/21 (8 days after admission) that measured 2.2 x 3.3 x 0.1. The surveyor asked when the first measurement of the pressure ulcer to the left buttock was documented and the DON stated, The first one I see was on 7/7/21 (15 days after admission). It measured 1.2 x 0.5 x 0.1. The surveyor asked when the first dressing order for the pressure ulcers to the right and left buttock were initiated and the DON stated 6/28/21 (6 days after admission). The DON stated that she spoke with Resident #25's nurse, and she reported that she was applying a wound dressing, but it was not documented anywhere. The DON was unable to locate or provide a baseline care plan for the pressure ulcers that were present upon admission. During a review of the electronic health record version of the pressure ulcer care plan, it was noted by this surveyor and the DON that the first pressure ulcer care plan was initially created on 7/13/21 (21 days after admission to the facility).

This citation pertains to MI 299, MI 654, MI 652, MI 643, MI 48 Based on interview and record review, the facility failed to develop and implement interventions to prevent pressure ulcers, weight loss and dehydration for 3 residents (Residents #1, #3 and #7), out of 7 residents reviewed for quality of care, resulting in stage IV pressure ulcer/unstageable pressure ulcer, weight loss and dehydration requiring hospitalization . Findings include: Resident #1 According to a facility face sheet dated 8/3/2020 at 5:25 PM, Resident #1 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Review of facility Braden Skin Risk Scores for Resident #1 reflected on 1/4/2020 the score was 8 indicating Resident #1 was a high risk for skin break down. Review of a Minimum Data Set Admission assessment dated [DATE] reflected Resident #1 was a 1 indicating she was dependent for functional cognition and self-care such as bathing, dressing, toileting prior to her admission. This assessment also reflected she used a manual or motorized wheelchair. Section M of this assessment reflected Resident #1 had preexisting pressure ulcers. Section G of this assessment reflected Resident #1 required maximum assistance of 2 persons for bed mobility get to and from a lying position and turning side to side. Resident #1 lower extremities had impairment on both sides. Review of facility documents titled, Wound Assessment for Resident #1 reflected: 1/4/2020 at 2:22 PM, Type of wound: Pressure Ulcer .present on admission .1.3 cm length by 1.1 cm width, no documentation of depth. Wound location: Other (please specify) fifth metatarsal on right foot - pressure injury . There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. There also was not documentation noted regarding the staging of this pressure area. 1/4/2020 at 3:53 PM, Type of wound: Other, present on admission .length 2.1 cm, width 1.8 cm, no documentation of depth. Location: Other (specify) left heel - open blister). There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. This document did not specify the type of wound this was. 1/4/2020 at 3:54 PM, Type of wound: pressure ulcer, length 6 cm, width 3.6 cm, no documentation of depth. Location: sacrum (lower back area above the gluteal cleft) non blanchable red area and with some excoriation on the left buttock. There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. There also was not documentation noted regarding the staging of this pressure area. 1/6/2020 at 1:58 PM, Type of wound: pressure, DTI (deep tissue injury), present on admission .length 1.3 cm by 1.1 cm, no depth was noted .Right toe(s) plantar portion of the right foot near 5th digit (toe). 100% eschar (dead tissue). 1/6/2020 at 3:17 PM, Type of wound: pressure, St 2 (stage 2) .present on admission .length 2.1 cm, width 1.8 cm, (no depth was indicated) Location: left heel, non-blanchable .granulation 100% (healing tissue) .mushy. 1/6/2020 at 2:04 PM, Type of wound: pressure, present on admit .length 2.8 cm by 1.3 cm (no depth was recorded). Location: left buttock non blanchable red area surrounded by blanchable red area. [MEDICATION NAME] (healing tissue) 70% and granulation tissue (healing tissue) 30%. 1/13/2020 at 11:44 AM, Type of wound: pressure, acquired in house .length 1.2 cm by 1.2 cm (no depth noted). NO location noted .100% scabbed. 1/13/2020 at 10:53 AM, Type of wound: pressure .length 1.2 cm by 1.4 cm (no depth recorded). Location: left heel, area is dark in color and scabbed over. There was no documentation if the wound was [MEDICATION NAME], granulation, slough, or eschar tissue. 1/13/2020 at 10:49 AM, Type of wound, pressure stage 2 .length 6 cm, 7 cm width, depth 0.1 cm. Location: Coccyx (tailbone area in between the gluteal clefts or buttocks) has superficial open area with pinkish/reddish base. 100% granulation (healing tissue). Review of medical records for Resident #1 from the specialty wound clinic dated 1/7/2020 at 2:30 PM (3 days later) reflected, Notes: [AGE] year-old .presents to the (name of the clinic) with chief c/o (complaint of) pressure ulcers to bilateral feet and sacrum (area of lower back above the cleft of the buttocks) recently admitted from (name of local hospital) from 12/27/19 to 1/4/2020 for hypothermia (low body temperature), multiple press ulcers noted on admission. Misc. culture obtained from the right plantar foot ulcer (12/27) showed Acinetobacter calcoaceticus-baumannil complex, Corynebacterium and staph coag neg(ative) (multiple bacteria present) .Wound 1: status is open. Original cause of the wound was pimple. The wound is currently classified as a Category/Stage III (3) wound with etiology of pressure ulcer and is located on the left calcaneus (heel). The wound measures 1.1 cm (centimeters) length x (by) 1 cm width x 0.1 cm depth .There is a fat layer (subcutaneous tissue) exposed. There is no tunneling, or undermining noted. There is a medium amount of serosangenous (bloody fluid) drainage noted. There is medium (34 to 66% percent) red granulation tissue within the wound bed. There is a medium (34 - 66%) amount of necrotic (dead) tissue within the wound bed including adherent slough (dead tissue). Wound 2 status open. Original cause of wound was pressure injury. The wound is currently classified as a category/stage III wound with etiology as pressure ulcer and located on the right plantar metatarsal head fifth (fifth toe). The wound measures 0.5 cm length x 0.9 cm width x 0.2 cm depth; .There is a fat layer (subcutaneous tissue) exposed .There is no tunneling or undermining noted. There is a medium amount of serosangenous drainage noted .There is a medium (34-66%) amount of necrotic tissue within the wound bed including adherent slough .Wound 3 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound etiology of pressure ulcer is located on the left gluteus (buttock). The wound measures 4 cm length x 3.5 cm width x 0.1 cm depth .There is a fat layer (subcutaneous) exposed .There is no tunneling, or undermining noted. This medium amount of serosangenous drainage noted .There is a small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough . This documentation goes on to reflect that a debridement (removal of tissue) was completed for all 3 wounds. The Director of Nursing (DON) revealed on 8/6/2020 at 9:38 AM, that Resident #1 had missed a wound clinic appointment on 1/14/2020 due to an emergency room visit. Review of medical records for Resident #1 from the specialty wound clinic dated, 1/21/2020 at 1:00 PM reflected, Wound 1: status is open. Original cause of the wound was pimple. The wound is currently classified as a Category/Stage III (3) wound with etiology of pressure ulcer and is located on the left calcaneus (heel). The wound measures 2 cm (centimeters) length x (by) 4.7 cm width x 0.1 cm depth .There is a fat layer (subcutaneous tissue) exposed. There is no tunneling, or undermining noted. There is a medium amount of serosangenous (bloody fluid) drainage noted. There is medium (34 to 66% percent) red granulation tissue within the wound bed. There is a medium (34 - 66%) amount of necrotic (dead) tissue within the wound bed including eschar and adherent slough (dead tissue). Wound 2 status healed. Original cause of wound was pressure injury. The wound is currently classified as a category/stage III wound with etiology as pressure ulcer and located on the right plantar metatarsal head fifth (fifth toe) .Wound 3 status is open. Original cause of wound was pressure injury. The wound is currently classified as a unstageable/unclassified wound etiology of pressure ulcer is located on the left gluteus (buttock). The wound measures 5 cm length x 7.5 cm width x 0.3 cm depth .There is a fat layer (subcutaneous) exposed .There is no tunneling, or undermining noted. There is a medium amount of serosangenous drainage noted. The wound margin is indistinct and non-visible. There is a small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including eschar and adherent slough . Wound 3 was debrided (dead tissue removed) at this appointment. Directions in the document reflected, Offloading: assure no contact of wound with surfaces, use wheelchair cushion . turn every 2 hours, limit side lying to 30 degree tilt, limit head of bed elevation to 30 degrees, limit time sitting up to meals only, for no more than 30 minutes per time for a total than no more than 1.5 hours per day sitting up. No laying on your back - you need to be on your side far enough to take pressure off the wounds .strict bed rest. This is essential to healing - your wounds are much worse this week and now stage 4 pressure ulcers. Please eat meals in bed - be sure to lower the head of the bed as soon as your meal is done .continue heel offloading. Lengthy discussion regarding sacral wound with considerable regression noted since .last appointment. Needs 24/7 bed rest if .is to heal. No chair time unless absolutely necessary. Change dressings to gent([MEDICATION NAME] an antibiotic) TID (three times a day) d/t (due to ) pseudomonas (a bacterial infection). Will start trending [MEDICAL CONDITION] markers in a few weeks with eventual imaging to r/o (rule out) osteo (osteo[DIAGNOSES REDACTED] an bone infection) if indicated . Review of facility documents titled, Wound Assessment for Resident #1 reflected: 1/21/2020 at 6:00 AM, Type of wound: pressure, present on admission. Length 6 cm by 9.3 cm, (no depth was documented). Location: Sacrum (earlier noted as a coccyx or left buttock wound), non-blanchable red area. Granulation 75% and Slough 25% .Education provided: turn every 2 hours . There also was not documentation noted regarding the staging of this pressure area. 1/22/2020 at 10:33 AM, Type of wound: other deep tissue injury. Length 0.4 cm, width 0.4 cm (no depth was documented. Location: other (specify) bottom of foot near fifth metatarsal. There was no documentation of the wound base. There was no documentation about education provided. This wound had been documented on 1/21/2020 at the wound clinic as healed. 1/22/2020 at 10:21 AM, Type of wound: pressure, present on admission .length 4 cm, width 3 cm (no depth was documented). Location: left heel, non-blanchable red area. [MEDICATION NAME] tissue (healing tissue) 100% No education was documented. There also was not documentation noted regarding the staging of this pressure area. 1/27/2020 at 3:51 PM, Type of wound: pressure right plantar (bottom of foot). Onset was not documented. Length 0.2 cm, width 0.2 cm, depth 0.1 cm. This area had been documented as healed by the wound clinic notes on 1/21/2020. There was no documentation on the wound bed or the stage of the wound. This may have reflected a reoccurance of a pressure area. 1/27/2020 at 3:42 PM, Type of wound, pressure coccyx area (earlier noted as sacrum or left buttock). Length 8 cm, width 8 cm, depth was documented as a question mark .Other information: see above regarding dark areas- ddep (sic deep) tiisue (sic tissue) injury . There was no documentation noted on the type of wound base. No teaching was documented as being done. On 8/5/2020 at 3:27 PM, during record review and an interview with the Director of Nursing (DON) she was asked when Resident #1 was first seen after facility admission in the wound clinic, what were the wound measurements? The DON revealed that the measurements had not been sent by the wound clinic and revealed she would get the documentation from them. When the DON was asked about wound assessments, she agreed that the facility Wound Assessment documentation did not contain an assessment of the staging of pressure ulcers nor did they have wound clinic measurements to correlate with. She also agreed that there was conflicting information regarding pressure area of the sacrum, coccyx, or left buttock. The DON was asked if the facility was aware of the recommendations of the wound clinic in their notes dated 1/21/2020? The DON read them out loud. When asked if Resident #1 had been placed on bed rest she agreed that she did not see this intervention was added to the plan of care. The DON was asked about the facility assessment completed 1/27/2020 at 3:42 PM of the coccyx area, the DON agreed that this documentation reflected that the wound was not open. The DON agreed that the Wound Clinic now staged this coccyx/sacrum/left buttock wound as a stage 4 pressure ulcer. When asked what tasks the Certified Nurse's Aides were given in their care plans the DON reflected it was roho cushion (pressure relieving cushion to a wheelchair, air mattress to bed, and foam boots on the feet. She agreed there was no task such as strict bed rest and up ½ hour during meals only, turning the resident side to side, keeping the resident off her back, keeping the head of the bed below 30 degrees when not eating and it also did not reflect to turn Resident #1 every 2 hours. Category/Stage I: Non-blanchable usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 2: Partial thickness: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration, or excoriation. Bruising indicates deep tissue injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 3: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 4: Full thickness tissue loss: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of head) and malleolus (ankle) do not have (adipose/fat) subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Unstageable/Unclassified: 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 3 or 4. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) According to the Wound Ostomy and Continence Nursing Society, The staging system, as recommended by the NPUAP and WOCN, does not support down-staging or reverse staging of granulating pressure ulcers. Down staging or reverse staging of granulating pressure ulcers is not appropriate, because the full-thickness repair process involves replacement of the lost normal tissue with granulation tissue (NPUAP, 2000). For example, a granulating Stage 4 pressure ulcer should not be down-staged to a Stage 3, because a Stage 3 pressure ulcer, by definition, is one with exposed subcutaneous tissue. Therefore, a granulating Stage 4 pressure ulcer is most appropriately classified as a granulating Stage 4 or healing Stage 4 . If the Stage 4 pressure ulcer is completely healed, it can be classified as a healed Stage 4, which conveys the pressure ulcer is now filled with granulation tissue and resurfaced with epithelium . (http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf ( ) ( )) A nursing care plan contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and a plan for evaluation. Over the course of the patient's stay, the plan is updated with any changes and new information as it presents itself. (https://nurse.org/articles/what-are-nursing-care-plans/) According to The Fundamentals of Nursing (Potter and Perry, 6th Edition, 2005), Nursing interventions are prioritized to provide safe and efficient care .The client's mobility problem is an obvious priority because of its influence on skin integrity and risks for falls. The nurse plans individualized interventions based on the severity of risk factors and the client's developmental stage, level of health, lifestyle, and culture .nursing interventions are directed toward maintaining the client's safety in all types of settings. Nursing measures for providing a safe environment include health promotion, developmental interventions, and environmental interventions .To promote an individual's health, it is necessary for the individual to be in a safe environment to practice a lifestyle that minimizes risk of injury. This citation pertains to intakes: MI 652, MI 654, MI 643 and MI 648. Resident #3 Review of Resident #3's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] for short term rehabilitation following the amputation of her right leg above the knee. She also had the following Diagnoses: [REDACTED]. Review of Resident #3 Brief Interview of Mental Status (BIMS) score on 5/27/20 was 7 out of 15 indicating moderate cognitive impairment. Review of Resident #3's, Nutritional Assessment/Status 3.0, dated 5/23/20 at 3:47 PM (2 day after admission) revealed, the facility was to document daily food acceptance, weight was 119.6 on 5/21/20 at 6:22 PM, she needed daily weights, significant weight changes would be reported to the resident and physician, she did not have any chewing or swallowing difficulty, she had a good appetite/intake of 75 to 100% of most meals, she required 1350 - 1620 calories daily and 1350 to 1620 ml of fluid a day. This note was electronically signed by Dietary Manager (DM) V Review of Resident #3's Nutrition/Fluid Intake record revealed, 5/21 (0), 5/22 (480), 5/23 (600), 5/24 (120), 5/25 (250), 5/26 (290), 5/27 (360), 5/28 (120), 5/29 (480), 5/30 (240), 5/31 (240), 6/1 (360), 6/2 (450), 6/3 (0), 6/4 (340), and 6/5 (60). Review of Resident #3's food intake record revealed, 5/21 all day (0), 5/22 9:00 (bites of food), 1300 (bites of food), 1800 (100%), 5/23, 9:00 (100%), 1300 (50%), 1800 (0), 5/24 9:00 75%, 1300 (0), 1800 (0), 5/25 9:00 (25%), 1300 (0), 1800 (100%), 5/26 all day (0), 5/27 9:00 100%, 1300 (75%), 1800 (0), 5/28 all day (0), 5/29, 9:00 (25%), 1300 (25%), 1800 (50%), 5/30, 9:00 (50%), 5/31, 9:00 (50%), 1300 (0), 1800 (50%), 6/1 9:00 (50%), 1300 (0), 1800 (50%), 6/2 9:00 (50%), 1300 (f50%), 1800 (0), 6/3 all day (0), 6/4 9:00 (50%0, 1300 (25%), 1800 (25%), 6/5, 9:00 (25%), 1300 (0), 1800 (0). Three of the 15 days no meals accepted, only 3 meals of the 15 days did Resident #3 accept 75% to 100 % of her meal which was assessed to be her baseline in the assessment completed on 5/23/20. (Progress notes did not mention lack of eating or why Resident #3 was not accepting food). Review of Resident #3's ADL (Activity of Daily Living and Nutrition/hydration care plan did not reveal any indication Resident #3 required any assistance with eating or drinking. Review of Resident #3's Admission, Minimum Data Set (MDS), dated [DATE] indicated she only required supervision and set up with meals. (No indication in the medical record as to why Resident #3 was not eating 75 % to 100 % of meals as she was prior to her admission). Review of Resident #3's weights revealed her weight on 5/21/10 (admission) was 119.6 lbs. (pounds)on 5/26/20 was 113 lbs., on 5/27/20 was 110.8 lbs., on 5/30/20 was 103.6 lbs., on 5/31/20 was 103.5 lbs., on 6/1/20 was 103.5 lbs., on 6/2/20 was 106.0 lbs., on 6/4/20 was 101.6 lbs. and on 6/5/20 it was 102.2 lbs. Review of Resident #3's care conference notes, progress note, and physician note revealed the resident, residents responsible party and Resident #3's physician were not notified of Resident #3 significant loss of weight until she was discharged . Daily weights were not located for 5/22/20, 5/23/20, 5/24/20, 5/25/20, 5/28/20, 5/29/20 and 6/3/20 (nutritional assessment documented Resident #3 was to have daily weights.) Resident #3 lost over 17 pounds in 15 days. During an interview with the facility Registered Dietitian (RD) D on 8/4/20 at 11:40 AM, RD D confirmed Resident #3 lost 8.8 pounds from admission to the first care conference on 5/27/20 and a total of 17.4 pounds from admission on 5/21/20 to discharge on 6/5/20. RD D said Resident #3 was not eating well and she had anticipated some weight loss due to water loss after having an amputation. RD D was not able to locate any information in Resident #3's medical record that indicated Resident #3's physician or responsible party with notified of the significant weight loss and poor food intake. RD D was not able to locate any interventions being placed for the weight loss that was documented the day of the care conference 5/27/20. RD D recalled she was not at the care conference but if she had been, she would have discussed it at the care conference and notified the physician. RD D said she would see what staff attended the care conference and look for interventions and notification. RD D returned after the interview with two interventions highlighted in the physician orders: 1) Med Pass 2.0 (nutritional supplemental drink provided by the medication nurse) on 6/5/20 at 6:00 PM. (just prior to resident being sent to the hospital that day). RD D was not able to see Med Pass was ever provided. 2) [MEDICATION NAME] Tablet 7.5 MG (also known as [MEDICATION NAME] an antidepressant medication which is also used to stimulate appetite). There was no indication in Resident #3 medical record that Resident #3's responsible party was notified of these medication changes or the amount of weight loss. There was no documentation Resident #3's physician was informed of the amount of weight loss. RD D confirmed she was not able to find any documentation that the facility had notified Resident #3's responsible party or physician of the significant weight loss. During an interview with the facility Social Worker (SW) M on 8/5/20 at 10:52 AM, SW M reviewed Resident #3's medical record. SW M confirmed Resident #3's first care conference was on 5/27/20 with Resident #3's responsible party. SW M said Dietary Manager (DM) V was at the care conference and would have discussed weight concerns. DM V came to the interview, reviewed Resident #3's medical record. DM V confirmed the weight loss but was not able to locate any information that she had placed interventions for further weight loss, notification of the physician or responsible party. During an interview with a Confidential Complainant (CC) Z on 8/5/20 at 3:53 PM Z said he was a Registered Nurse (RN) and was familiar with Resident #3 prior to her admission to the facility. CC Z said he became concerned about Resident #3's condition on 6/5/20 when he became aware of Resident #3 decline in mental condition and severe weight loss. CC Z said he contacted Resident #3's family and recommended Resident #3 be transferred to the hospital for evaluation. During a telephone interview with Resident #3's Responsible Party (RP) Y on 8/10/20 at 8:15 AM, she said she received a call from CC Z on 6/5/20. RP Y said the facility had not informed her that Resident #3 had severe weight loss since admission. RP Y said she had multiple problems with being able to communicate with Resident #3 since COVID-19. RP Y said she had provided Resident #3 with a phone and an iPad but Resident #3 could not use these items without assistance. RP Y said she spoke with multiple nurses, the Director of Nursing (DON and the Nursing Home Administrator about wanting to have face time visits with Resident #3 on a routine basis but this never got set up. RP Y said she was able to see Resident #3 in the lobby for 15 minutes on 6/4/20 and she was concerned about the bruise she saw on Resident #3 but was told bruise were present on admission and Resident #3 could not even hold up her head. RP Y said she did not know about the severe weight loss until she received a call from CC Z. When RP Y found out about the severe weight loss she called the facility to have Resident #3 transferred to the hospital. On 8/13/20 at 7:07 AM the NHA was asked what was the facility expectation when a resident refuses oral intake for 2 or 3 consecutive meals and if the facility electronic medical record gives her or nursing any alerts for meal refusals or weight loss? The NHA responded at 9:23 AM by email, The patient in question did not have a significant weight loss. She weighed 118.8 prior to her surgery. She had a right above knee amputation, and we have provided the calculations for approximated weight of 102.4 post amputation and her [MEDICAL CONDITIONS] diagnosis. We have provided supporting documentation. When a patient does not eat, we offer an alternate meal. The documentation proof of alternate was included in the documentation provided yesterday. Residents have the right to refuse to eat or refuse meals and the patient's refusal of meals and alternates is included in the documentation provided yesterday. We have also attached a copy of her fluid intake. Our nurses complete daily skilled assessments monitoring skin turgor, mucous membranes, and other indicator of potential dehydration. There was not sign or symptoms of dehydration that would indicate the need for alternate interventions. (Facility did not acknowledge a significant weight loss (over 17 pounds in 15 days while Resident #3 was in the facility and did not acknowledge the need to assess the reason for weight loss. No interventions were placed to improve nutrition for 13 days with documented significant weight loss). During an interview with Registered Dietitian (RD) D on 8/17/20 at 12:15 PM, RD D said the electronic medical record (EMR) provides and alert for her and nursing when a resident has a significant when loss. RD D said a significant weigh loss is 3% or greater. RD D said the physician and the residents responsible party are notified of any significant weight loss. Resident #3 weighted 119.6 on admission. Resident #3 was supposed to have a daily weights documented; however, she was not weighted again until 5/26/20 (5 days later). On 5/26/20 Resident #3 weight 113 pound (over 5% of body weight loss documented). There was no indication Resident #3's responsible party or physician were notified of this significant weight loss. Resident #3 continued to lose weight for the remainder of her stay in the facility and there was no indication her responsible party or physician were ever notified. Review of Resident #3's care plan revealed, I have the potential for a nutritional/hydration problem r/t (related to); Right AKA (above knee amputation), [MEDICAL CONDITIONS] DM II (diabetes mellitus II), Acute kidney failure, dementia, CKDS ([MEDICAL CONDITION] stage 3), [MEDICAL CONDITION] [MEDICAL CONDITION] (weakness one side),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] (high fats or lipids in the blood), Depression, A-fib (abnormal heart beat),[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), anxiety and weakness, initial date 5/25/20 (4 days after admission and no weights had been obtained for the last 3 days). All interventions on this care plan were dated 5/25/20. Facility weights documented a 6.6-pound weight loss on 5/26/20 (day 5), this was an 5.5 % weight loss in 5 days. Resident #3 continued to lose weight throughout her stay. On discharge 6/5/20 she was down to 102.2-pounds a 17.4-pound weight loss since admission. Resident #3 lost 14.5 % of her admission weight in 15 days. The facility did not respond to the electronic medical record alerts of a 3% or greater weight loss and did not make any alterations to her care plan to prevent this significant weight loss. Review of Resident #3's progress notes, revealed a Discharge EMERGENT note dated 6/5/20 at 7:45 PM, signed by the Director of Nursing (DON), Reason for discharge: family request, name of Responsible Party requested. Review of Resident #3's Emergency Department noted, dated 6/5/20 at 6:58 PM revealed, Resident #3 was admitted with a 20-pound weight loss and fatigue. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#3's admission to the facility on [DATE]. Review of Resident #3's Emergency Department Supervisor Note dated 6/5/20 at 6:58 PM revealed Resident #3 had a 20-pound weight loss in the last 2 weeks and had an altered mental status. Several laboratory investigations were obtained that showed she is markedly dehydrated. Review of Resident #3's Hospital Course (page 79) revealed, Resident #3, was admitted with toxic/metabolic [MEDICAL CONDITION]ly 2/2 nutritional state, also uremia (kidneys not filtering properly), patient had creatinine of 1.4 when baseline .7 mg/dl. Patient AKI w/elevated BUN of 104 and noted to have Metabolic acidosis with BHB elevated 2/2 starvation ketoacidosis and was started on [MEDICATION NAME] gtt with D5 (medical treatment for [REDACTED].

This citation pertains to MI 299 Based on interview and record review, the facility failed to assess pressure ulcers, collaborate with consulting wound clinic and implement interventions to prevent worsening of pressure ulcers for 2 residents (Resident #1 and #7) out of 4 residents reviewed for pressure ulcers resulting in inability to accurately assess and treat pressure ulcers and subsequent worsening of existing pressure ulcers. Findings include: Resident #1 According to a facility face sheet dated 8/3/2020 at 5:25 PM, Resident #1 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Review of facility Braden Skin Risk Scores for Resident #1 reflected on 1/4/2020 the score was 8 indicating Resident #1 was a high risk for skin break down. Review of a Minimum Data Set Admission assessment dated [DATE] reflected Resident #1 was a 1 indicating she was dependent for functional cognition and self-care such as bathing, dressing, toileting prior to her admission. This assessment also reflected she used a manual or motorized wheelchair. Section M of this assessment reflected Resident #1 had preexisting pressure ulcers. Section G of this assessment reflected Resident #1 required maximum assistance of 2 persons for bed mobility get to and from a lying position and turning side to side. Resident #1 lower extremities had impairment on both sides. Review of facility documents titled, Wound Assessment for Resident #1 reflected: 1/4/2020 at 2:22 PM, Type of wound: Pressure Ulcer .present on admission .1.3 cm length by 1.1 cm width, no documentation of depth. Wound location: Other (please specify) fifth metatarsal on right foot - pressure injury . There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. There also was not documentation noted regarding the staging of this pressure area. 1/4/2020 at 3:53 PM, Type of wound: Other, present on admission .length 2.1 cm, width 1.8 cm, no documentation of depth. Location: Other (specify) left heel - open blister). There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. This document did not specify the type of wound this was. 1/4/2020 at 3:54 PM, Type of wound: pressure ulcer, length 6 cm, width 3.6 cm, no documentation of depth. Location: sacrum (lower back area above the gluteal cleft) non blanchable red area and with some excoriation on the left buttock. There was no documentation regarding the wound base such as granulation tissue, eschar (scabbing), slough or healing [MEDICATION NAME] tissue. There also was not documentation noted regarding the staging of this pressure area. 1/6/2020 at 1:58 PM, Type of wound: pressure, DTI (deep tissue injury), present on admission .length 1.3 cm by 1.1 cm, no depth was noted .Right toe(s) plantar portion of the right foot near 5th digit (toe). 100% eschar (dead tissue). 1/6/2020 at 3:17 PM, Type of wound: pressure, St 2 (stage 2) .present on admission .length 2.1 cm, width 1.8 cm, (no depth was indicated) Location: left heel, non-blanchable .granulation 100% (healing tissue) .mushy. 1/6/2020 at 2:04 PM, Type of wound: pressure, present on admit .length 2.8 cm by 1.3 cm (no depth was recorded). Location: left buttock non blanchable red area surrounded by blanchable red area. [MEDICATION NAME] (healing tissue) 70% and granulation tissue (healing tissue) 30%. 1/13/2020 at 11:44 AM, Type of wound: pressure, acquired in house .length 1.2 cm by 1.2 cm (no depth noted). NO location noted .100% scabbed. 1/13/2020 at 10:53 AM, Type of wound: pressure .length 1.2 cm by 1.4 cm (no depth recorded). Location: left heel, area is dark in color and scabbed over. There was no documentation if the wound was [MEDICATION NAME], granulation, slough, or eschar tissue. 1/13/2020 at 10:49 AM, Type of wound, pressure stage 2 .length 6 cm, 7 cm width, depth 0.1 cm. Location: Coccyx (tailbone area in between the gluteal clefts or buttocks) has superficial open area with pinkish/reddish base. 100% granulation (healing tissue). Review of medical records for Resident #1 from the specialty wound clinic dated 1/7/2020 at 2:30 PM (3 days later) reflected, Notes: [AGE] year-old .presents to the (name of the clinic) with chief c/o (complaint of) pressure ulcers to bilateral feet and sacrum (area of lower back above the cleft of the buttocks) recently admitted from (name of local hospital) from 12/27/19 to 1/4/2020 for hypothermia (low body temperature), multiple press ulcers noted on admission. Misc. culture obtained from the right plantar foot ulcer (12/27) showed Acinetobacter calcoaceticus-baumannil complex, Corynebacterium and staph coag neg(ative) (multiple bacteria present) .Wound 1: status is open. Original cause of the wound was pimple. The wound is currently classified as a Category/Stage III (3) wound with etiology of pressure ulcer and is located on the left calcaneus (heel). The wound measures 1.1 cm (centimeters) length x (by) 1 cm width x 0.1 cm depth .There is a fat layer (subcutaneous tissue) exposed. There is no tunneling, or undermining noted. There is a medium amount of serosangenous (bloody fluid) drainage noted. There is medium (34 to 66% percent) red granulation tissue within the wound bed. There is a medium (34 - 66%) amount of necrotic (dead) tissue within the wound bed including adherent slough (dead tissue). Wound 2 status open. Original cause of wound was pressure injury. The wound is currently classified as a category/stage III wound with etiology as pressure ulcer and located on the right plantar metatarsal head fifth (fifth toe). The wound measures 0.5 cm length x 0.9 cm width x 0.2 cm depth; .There is a fat layer (subcutaneous tissue) exposed .There is no tunneling or undermining noted. There is a medium amount of serosangenous drainage noted .There is a medium (34-66%) amount of necrotic tissue within the wound bed including adherent slough .Wound 3 status is open. Original cause of wound was pressure injury. The wound is currently classified as an unstageable/unclassified wound etiology of pressure ulcer is located on the left gluteus (buttock). The wound measures 4 cm length x 3.5 cm width x 0.1 cm depth .There is a fat layer (subcutaneous) exposed .There is no tunneling, or undermining noted. This medium amount of serosangenous drainage noted .There is a small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including adherent slough . This documentation goes on to reflect that a debridement (removal of tissue) was completed for all 3 wounds. The Director of Nursing (DON) revealed on 8/6/2020 at 9:38 AM, that Resident #1 had missed a wound clinic appointment on 1/14/2020 due to an emergency room visit. Review of medical records for Resident #1 from the specialty wound clinic dated, 1/21/2020 at 1:00 PM reflected, Wound 1: status is open. Original cause of the wound was pimple. The wound is currently classified as a Category/Stage III (3) wound with etiology of pressure ulcer and is located on the left calcaneus (heel). The wound measures 2 cm (centimeters) length x (by) 4.7 cm width x 0.1 cm depth .There is a fat layer (subcutaneous tissue) exposed. There is no tunneling, or undermining noted. There is a medium amount of serosangenous (bloody fluid) drainage noted. There is medium (34 to 66% percent) red granulation tissue within the wound bed. There is a medium (34 - 66%) amount of necrotic (dead) tissue within the wound bed including eschar and adherent slough (dead tissue). Wound 2 status healed. Original cause of wound was pressure injury. The wound is currently classified as a category/stage III wound with etiology as pressure ulcer and located on the right plantar metatarsal head fifth (fifth toe) .Wound 3 status is open. Original cause of wound was pressure injury. The wound is currently classified as a unstageable/unclassified wound etiology of pressure ulcer is located on the left gluteus (buttock). The wound measures 5 cm length x 7.5 cm width x 0.3 cm depth .There is a fat layer (subcutaneous) exposed .There is no tunneling, or undermining noted. There is a medium amount of serosangenous drainage noted. The wound margin is indistinct and non-visible. There is a small (1-33%) red granulation within the wound bed. There is a large (67-100%) amount of necrotic tissue within the wound bed including eschar and adherent slough . Wound 3 was debrided (dead tissue removed) at this appointment. Directions in the document reflected, Offloading: assure no contact of wound with surfaces, use wheelchair cushion . turn every 2 hours, limit side lying to 30 degree tilt, limit head of bed elevation to 30 degrees, limit time sitting up to meals only, for no more than 30 minutes per time for a total than no more than 1.5 hours per day sitting up. No laying on your back - you need to be on your side far enough to take pressure off the wounds .strict bed rest. This is essential to healing - your wounds are much worse this week and now stage 4 pressure ulcers. Please eat meals in bed - be sure to lower the head of the bed as soon as your meal is done .continue heel offloading. Lengthy discussion regarding sacral wound with considerable regression noted since .last appointment. Needs 24/7 bed rest if .is to heal. No chair time unless absolutely necessary. Change dressings to gent([MEDICATION NAME] an antibiotic) TID (three times a day) d/t (due to ) pseudomonas (a bacterial infection). Will start trending [MEDICAL CONDITION] markers in a few weeks with eventual imaging to r/o (rule out) osteo (osteo[DIAGNOSES REDACTED] an bone infection) if indicated . Review of facility documents titled, Wound Assessment for Resident #1 reflected: 1/21/2020 at 6:00 AM, Type of wound: pressure, present on admission. Length 6 cm by 9.3 cm, (no depth was documented). Location: Sacrum (earlier noted as a coccyx or left buttock wound), non-blanchable red area. Granulation 75% and Slough 25% .Education provided: turn every 2 hours . There also was not documentation noted regarding the staging of this pressure area. 1/22/2020 at 10:33 AM, Type of wound: other deep tissue injury. Length 0.4 cm, width 0.4 cm (no depth was documented. Location: other (specify) bottom of foot near fifth metatarsal. There was no documentation of the wound base or whether it was the right or the left foot. There was no documentation about education provided. This wound had been documented on 1/21/2020 at the wound clinic as healed. 1/22/2020 at 10:21 AM, Type of wound: pressure, present on admission .length 4 cm, width 3 cm (no depth was documented). Location: left heel, non-blanchable red area. [MEDICATION NAME] tissue (healing tissue) 100% No education was documented. There also was not documentation noted regarding the staging of this pressure area. 1/27/2020 at 3:51 PM, Type of wound: pressure right plantar (bottom of foot). Onset was not documented. Length 0.2 cm, width 0.2 cm, depth 0.1 cm. This area had been documented as healed by the wound clinic notes on 1/21/2020. There was no documentation on the wound bed or the stage of the wound. This may have reflected a reoccurence of a pressure area. 1/27/2020 at 3:42 PM, Type of wound, pressure coccyx area (earlier noted as sacrum or left buttock). Length 8 cm, width 8 cm, depth was documented as a question mark .Other information: see above regarding dark areas- ddep (sic deep) tiisue (sic tissue) injury . There was no documentation noted on the type of wound base. No education was documented as being done. On 8/5/2020 at 3:27 PM, during record review and an interview with the Director of Nursing (DON) she was asked when Resident #1 was first seen after facility admission in the wound clinic, what were the wound measurements? The DON revealed that the measurements had not been sent by the wound clinic and revealed she would get the documentation from them. When the DON was asked about wound assessments, she agreed that the facility Wound Assessment documentation did not contain an assessment of the staging of pressure ulcers nor did they have wound clinic measurements to correlate with. She also agreed that there was conflicting information regarding pressure area of the sacrum, coccyx, or left buttock. The DON was asked if the facility was aware of the recommendations of the wound clinic in their notes dated 1/21/2020? The DON read them out loud. When asked if Resident #1 had been placed on bed rest she agreed that she did not see this intervention was added to the plan of care. The DON was asked about the facility assessment completed 1/27/2020 at 3:42 PM of the coccyx area, the DON agreed that this documentation reflected that the wound was not open. The DON agreed that the Wound Clinic now staged this coccyx/sacrum/left buttock wound as a stage 4 pressure ulcer. When asked what tasks the Certified Nurses Aides were given in their care plans the DON reflected it was roho cushion (pressure relieving cushion to a wheelchair, air mattress to bed, and foam boots on the feet. She agreed there was no task such as strict bed rest and up ½ hour during meals only, turning the resident side to side, keeping the resident off her back, keeping the head of the bed below 30 degrees when not eating and it also did not reflect to turn Resident #1 every 2 hours. According to a facility policy titled, Skin and Pressure Ulcer Risk Assessment and Prevention reviewed/revised 7/18 reflected, It is our policy to perform skin assessment and pressure injury risk assessment as part of our systematic approach to injury prevention and management .(name of organization) utilizes the Perry and Potter Clinical Nursing Skills techniques and National Pressure Ulcer Advisory Panel. A skin assessment will be conducted by a licensed or registered nurse upon admission/readmission and weekly thereafter. Category/Stage I: Non-blanchable usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 2: Partial thickness: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration, or excoriation. Bruising indicates deep tissue injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 3: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Category/Stage 4: Full thickness tissue loss: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of head) and malleolus (ankle) do not have (adipose/fat) subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) Unstageable/Unclassified: 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 3 or 4. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) According to the Wound Ostomy and Continence Nursing Society, The staging system, as recommended by the NPUAP and WOCN, does not support down-staging or reverse staging of granulating pressure ulcers. Down staging or reverse staging of granulating pressure ulcers is not appropriate, because the full-thickness repair process involves replacement of the lost normal tissue with granulation tissue (NPUAP, 2000). For example, a granulating Stage 4 pressure ulcer should not be down-staged to a Stage 3, because a Stage 3 pressure ulcer, by definition, is one with exposed subcutaneous tissue. Therefore, a granulating Stage 4 pressure ulcer is most appropriately classified as a granulating Stage 4 or healing Stage 4 . If the Stage 4 pressure ulcer is completely healed, it can be classified as a healed Stage 4, which conveys the pressure ulcer is now filled with granulation tissue and resurfaced with epithelium . (http://c.ymcdn.com/sites/www.wocn.org/resource/collection/E3050C1A-FBF0-44ED-B28B-C41E CCC/Position_Statement_-_Pressure_Ulcer_Staging_(2011).pdf ( ) ( )) Accurate wound assessment is a critical component of effective wound management. A skilled nurse who can accurately assess a wound, plays a vital role in determining the appropriate management of a wound to promote healing and avoid secondary complications .Begin the assessment by documenting the anatomic location of the wound, using landmarks to define the position . (https://www.rn.com/nursing-news/secrets-of-accurate-wound-assessment/) Pressure ulcers are the common conditions among patients hospitalized in acute and chronic care facilities and impose significant burden on patients, their relatives and caregivers. Pressure ulcers have been described as one of the most costly and physically debilitating complications since the 20th century. The pain and discomfort due to pressure ulcer prolongs illness, rehabilitation, time of discharge and even contribute to disability and death. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 66/) This citation pertains to intakes: MI 652, MI 654, MI 643 and MI 648. Resident #3 Review of Resident #3's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] for short term rehabilitation following the amputation of her right leg above the knee. She also had the following Diagnoses: [REDACTED]. Review of Resident #3 Brief Interview of Mental Status (BIMS) score on 5/27/20 was 7 out of 15 indicating moderate cognitive impairment. Review of Resident #3's admission skin assessment revealed she had no skin issues on her buttock. Review of Resident 3's skin assessment completed on 6/5/19, with an effective date of 6/1/20 at 6:00 AM, Resident #3 had MASD (moisture - associated skin damage) with excoriation noted on her sacrum. This note was electronically signed by the Director of Nursing (DON). During an interview with the DON on 8/5/20 at 2:26 PM the DON said she did a head to toe skin assessment on Resident #3 prior to her discharge to the hospital on [DATE] and the DON denied Resident #3 had any pressure ulcers on her buttock. Review of Resident #3 care plan revealed a care plan, I am at risk for alteration of skin integrity r/t (related to) at risk for moisture: (incontinent for bladder, at risk for decreased activity: chair fast, at risk for immobility, Assist with ADLS (activities of daily living), contributing [DIAGNOSES REDACTED]. The goal was for skin to remain intact through the next review. No new interventions were placed with the facility identified Resident #3 had MASD with excoriation to her buttock on 6/1/20. Review of Resident #3's Emergency Department note, dated 6/5/20 at 6:58 PM revealed, Resident #3 was admitted with a 20-pound weight loss and fatigue. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#3's admission to the facility on [DATE]. Resident #7 Review of Resident #7's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Resident #7 was her own responsible party. Review of Resident #7's Brief Interview of Mental Status (BIMS) score dated 5/31/20 revealed she had a score of 15/15 (normal cognition). Resident #7 was observed in the bathroom in her room on 8/4/20 at 9:12 AM, Resident #7 had gripper style socks on (heels in contact with the floor/no pressure relief). Certified Nurse Aides (CNA) : G and F assisted Resident #7 get clean and stand when she was done using the toilet. When Resident #7 stood and transferred off the toilet her heels were in full contact with the floor in the bathroom. Resident #7 was asked about any open areas on her skin and she said she had sores on her heels. Resident #7 was asked how she got the sores on her heels and she said, I could not keep my feet on the pillows in bed, but they just gave me a blue thing that is in my closet to keep my heals off the bed. Resident #7 walked in her room with a walker with the assistance of Occupational Therapist (OT) J on 8/4/20 at 12:53 PM, OT J said the Physician Assistant (PA) working with Resident #7 was aware she was walking without a device to off load pressure from her heels. OT J was asked about pressure relieving devices that Resident #7 was using and she said she recently provided a bridge to be used in bed. OT J went to Resident #7's closet and showed a blue padded device. OT J said she was not aware of any other device and OT J was aware Resident #7 had pressure ulcers on both heels. Resident #7 was assisted to bed on 8/4/20 at 1:15 PM by OT J and CNA H. When Resident #7 was placed in bed both of her heels were in contact with the mattress and Resident #7 told CNA H and OT J her heels hurt. CNA H went to get Licensed Practical Nurse (LPN) G. OT J continued to talk to Resident #7 and after about 5 minutes Resident #7 again reported her heels hurt. OT J went to the closet and put the blue padded device under Resident #7 legs (heels off mattress). Resident #7 thanked OT J and said that stopped the pain. Resident #7 required physical assistance to lift both legs. LPN G completed dressing changes on both of Resident #7's heels on 8/4/20 at approximately 1:20 PM. Resident #7's heels were only a few inches off the bed so the entire open areas were not visible, but open areas were observed on both heels. Review of Resident #7's care plan dated 2/23/20 revealed, I am at risk for alteration of skin integrity r/t (related to) Assists with ADLS (activities of daily living). Intervention review revealed, I require pressure relieving boots to be on both feet at all time while out of bed as tolerated, initiated on 7/30/20 and revised on 8/4/20 and resolved 8/4/20. Elevate heels off the bed with blue heel off loading device initiated on 7/30/20 and resolved 8/4/20. (these were the only items list to keep pressure off of Resident #7's heels). Review of Resident #7's care plan dated 4/19/20 revealed, I have actual impairment to skin integrity r/t (related to) - unstageable PU (pressure ulcer) left heel - DM(diabetes mellitus) Ulcer to right heel x 2. I have [MEDICAL CONDITIONS] and DM (diabetes mellitus with [MEDICAL CONDITION] and toe amputation. Hx (history) of diffuse arterial calcification in feet and in-compressible thigh/calves bilaterally due to calcified vasculature. Positive Covid-19 on 4-8-20. No interventions for pressure relief for Resident #7's heels were located. Review of Resident #7's Admission Physician history and physical dated 2/8/20 revealed she was admitted with a right 3rd toe acute [DIAGNOSES REDACTED] with right foot [MEDICAL CONDITION] and required intravenous antibiotics and pain management. Resident #7 had the 3rd digit on her right foot removed at the hospital. Resident #7 required 6 weeks of antibiotic treatment related to this infection and removal of her 3rd digit on her right foot. There was no indication of any skin issues on Resident #7's heels. Review of the facility timeline for Resident #7's heel ulcers revealed, Resident #7 developed a left heel ulcer on 4/14/20 (in house) and a left heel ulcer developed on 6/22/20 (in house). Review of Resident #7's Wound assessment dated on set 4/16/20 revealed she had an unstageable left heal ulcer that measured 3.1 cm x 3.6 that was black in color. This was signed by the Director of Nursing (DON) on 4/17/20. Review of Resident #7's skin sweep dated 4/21/20 revealed she had a deep tissue injury to her left heel that started on 4/16/20 that measured 4.9 cm x 2.9 cm. (increased in size from start and no care plan for pressure relief located). Review of Resident #7's skin sweep dated 4/30/20 revealed she had a deep tissue injury to her left heel that started on 4/16/20 that measured 4.9 cm x 2.9 cm. (increased in size from the start and no care plan for pressure relief located). During an interview with the DON on 8/4/20 at 3:00 PM, the DON said the facility did identify wound documentation issues that involved not documenting the body part on wound assessments on 5/3/20. The DON said they are still working on a process of improvement. The DON said she would provide all documentation related to Resident #7's heel ulcers. The document the DON provided by email at 3:15 PM, on 8/4/20 was missing any recent wound assessments and measurements from Resident #7's medical record. The only measurements that were provided after 4/30/20 were from her timeline (not in Resident #7's medical record). The timeline documented the left heel ulcer measured 1.3 x 5.0 x 0.1 on 8/1/20 and the right heel ulcer measured 1.6 x 0.1 on 8/1/20. On 8/4/20 around 4:30 PM the DON provided additional paper copies of wound assessments for Resident #7. The last wound assessment for Resident #7's right heel was dated 7/30/20 and it measured 2.1 x 1.8 x 0.2. The last wound document for the left heel was a skin sweep dated 6/15/20 and documented it measured 1.8 x 2.4 x 0.3. The DON did not clarify where she was getting her wound measurements from. Several wound documents reviewed in Resident #7's medical record did not include what body part was being assessed. Review of Resident #7's physician orders [REDACTED]. Apley Medhoney to wound bed. Cover with nonstick dressing and cover with allyven heel protector wrap kerlix around allyven to hold in place. Review of Resident #7's physician orders [REDACTED]. Apley [MEDICATION NAME] to wound bed. Cover with nonstick dressing and cover with allyven heel protector. Wrap [MEDICATION NAME] around allyven ONLY to hold in place

This citation pertains to MI 382 Based on interview and record review, the facility failed to provide supervision to prevent a fall for two residents (Resident #5 and 11), out of 3 residents reviewed for falls, resulting in falls with major injuries. Findings include: Resident #5 According to a facility face sheet dated [DATE] at 5:26 PM, Resident #5 was a [AGE] year-old admitted into the facility on [DATE] with the Diagnoses: [REDACTED].). Resident #5 had fallen downstairs in her home prior to their stay at the facility and fractured their right arm and leg. Resident # 5 suffered from Riley-Day Syndrome. Riley-Day syndrome, also called familial [DIAGNOSES REDACTED], an inherited disorder .that is caused by abnormal functioning of the autonomic nervous system. Riley-Day syndrome is characterized by emotional instability, decreased tear production, low blood pressure upon standing up (postural [MEDICAL CONDITION]), excessive sweating and blotchiness of the skin during excitement and eating, difficulty in swallowing, insensitivity to pain, [MEDICAL CONDITION], vomiting, breath-holding, and poor motor coordination. (https://www.britannica.com/science/Riley-Day-syndrome) On [DATE] at 3:54 PM, Resident #5's fall risk score was 13 indicating she was at risk for a fall. According to a facility timeline review, incident/accident and investigation review and interview with the Director of Nursing (DON) on [DATE] at 10:15 AM, Resident #5 had experienced 4 falls during her stay in the facility. [DATE] at 4:20 PM Resident #5 was observed on the bedroom floor, her blood sugar level was low, and the [DIAGNOSES REDACTED] policy was initiated. New intervention to prevent a fall was to have her physician evaluate her diabetic regimen. This fall was not observed and there did not appear to be injury. Resident #5 had a cast on her right lower leg. [DATE] at 2:55 PM Resident #5 was trying to readjust herself in bedside chair for comfort and slid to the floor. New intervention to prevent a fall was to place a dycem (nonskid pad) to the bedside chair. This fall was unwitnessed and there did not appear to be any injury. The call light was on. [DATE] at 6:02 PM Resident #5 fell in room by sink due to syncopal episode. She had stood up to reach for something and fell . Intervention to prevent another fall was to educate her on safety measures. Antibiotics were changed and labs were obtained. Resident #5 was moved to a room closer to the nurse's station. The call light was not on but was within her reach. Resident #5 stated her call light was on the floor. This fall was also unwitnessed and there did not appear to be injury. [DATE] at 10:30 PM Resident #5 was in her room getting out of bed to change her clothing and had another syncopal episode. This fall was witnessed. Staff was unable to get to the resident in time and she fell . Resident #5 was sent to the emergency room for an evaluation. The call light was not on. During an interview with Family Member (FM) E on [DATE] at 1:28 PM, FM E revealed that Resident #5 was legally blind and had a Siri device to help her make phone calls. FM E stated Resident #5 called the late evening of [DATE]. When Resident #5 called (through Siri) she was crying she was in pain and was going to throw up. Resident #5 stated she wanted to get up but could not find her call light. FM E told Resident #5 not to get up. Resident #5 wanted Family Member E to call her facility nurse. When the FM E called the facility nurses' desk, FM E was told to tell Resident #5 to use the call light. FM E revealed a male nurse argued with her about pain medication and had told her this. When she got a return phone call, she was told Resident #5 had fallen. An interview on [DATE] at 9:22 AM with Licensed Practical Nurse (LPN) S revealed he worked the afternoon shift of [DATE]. He recalled he talked on the phone a couple of times to FM E. LPN S stated Resident #5 had confusion at the beginning of the shift and they were trying to see if a pain medication was the cause of the confusion. FM E first had called to tell LPN S that Resident #5's pain was not tolerable, and that the resident was not being truthful about her pain. LPN S revealed he told FM E to have Resident #5 report her pain accurately and not be self-conscious. FM E told him Resident #5 reported hallucinating, but he revealed that Resident #5 was behaving normally. The second phone call from FM E was during the end of shift change report. LPN S revealed that FM E might have said something about Resident #5 not being able to find her call light and that Resident #5 wanted to get out of bed. LPN S revealed he does not remember sending staff into check on Resident #5 related to this phone call because he was concentrated on this phone call with FM E. LPN S stated shortly after the call, an aide had reported that Resident #5 had fallen. During an interview with Certified Nurse's Aide (CNA) U on [DATE] at 10:37 AM she stated she was working the night shift the evening of [DATE]. CNA U stated that Resident #5 was known to be a fall risk and that Resident #5 had been in the common area before bed to be able to watch more closely. She revealed that Resident #5 had been restless that night. CNA U stated they put Resident #5 to bed. Less than 10 min later, a coworker said that Resident #5 was up in her room. CNA U denies having nursing tell her that she needed to check on Resident #5. Review of documents from the emergency room of the local hospital dated [DATE] (no time noted) reflected, .[DIAGNOSES REDACTED].recurrent falls . This document also reflected, Chief complaint: confusion (from rehab fractures on right side) . Patient is a [AGE] year-old .with history of recurrent falls, numerous over the past week as well as type 2 diabetes, diabetic retinopathy, recent right shoulder and right ankle fracture status [REDACTED]. Resident #11 According to a facility face sheet dated [DATE], Resident #11 was a [AGE] year old admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. Resident #11's Brief Interview for Mental Status upon admission score was 14 out of 15 indicating she was cognitively intact. An assessment for ambulatory needs on [DATE] reflected Resident #11 needed to have assist of one person with a hemi (partial) walker. Stand by assist was defined as, Help provided to a person who cannot complete an activity of daily living on his own, e.g., the prevention of falls and injuries. (https://medical-dictionary.thefreedictionary.com/stand-by+assistance) A Fall Risk assessment on [DATE] for Resident #11 reflected a score of 11 meaning Resident #11 was at risk for a fall. On [DATE] at 9:30 AM during an interview with Resident #11 in their room, Resident #11 stated she had been in the facility since [DATE]. She revealed she had fallen here while standing at the side of her bed waiting for the therapy personnel to bring her wheelchair out of the bathroom because she was not feeling well. Resident #11 confirmed that she did have a gait belt (belt used to grasp by staff if they become unsteady or need to be steadied ). Resident #11 stated she fell and hit the side of the bed and required stitches at the hospital to close a large cut. Review of a facility document titled, Fall for Resident #11 dated [DATE] (no time noted) reflected, Observed on floor with large pool of blood on ground. Large heavy bleeding laceration (cut) on right buttock skin tear on LUE (left upper extremity). Sitting on her but holding herself up with left arm. Was working the PT (Physical Therapy) in the room and patient states stepping backwards while therapy getting wheelchair and hit her arm on the bed enabler and fell to her buttocks . This document also reflected a witness statement from Occupational Therapy (COTA) AA on [DATE] (no time noted), Therapist and Pt (patient) were about to go on a short walk in front of bed pt. ask (sic) therapist to go get w/c (wheelchair) pt. stated 'woah'. Therapist turned around to get w/c and she (Resident #11) was stepping backward and hit enabler bar (bar on the side of the bed) with arm . This document also listed a predisposing physiological factor gait imbalance which is a deviation from a person's normal way of walking. A facility document titled, Post Fall Evaluation dated [DATE] at 3:00 PM for Resident #11 reflected a witnessed fall. Contributing factors: stated stepped back and lost balance. Documentation of the resident's vital signs were not documented in this evaluation and the physical findings reflected no for change in blood pressure. On [DATE] at 11:49 AM, during an interview and review of a care plan for Resident #11 with COTA AA, he revealed he was assisting Resident #11 to walk out of her bathroom toward her bed with a gait belt on. He was going to take her for a walk. He assisted her to be close to her bed and then went to get the wheelchair in the resident's bathroom. He stated as he got the wheelchair, Resident #11 fell . COTA AA was asked if residents that require stand by assistance should be left unattended while getting a wheelchair and COTA AA said, No. When asked what new intervention was placed to prevent another fall such as this, he stated staff was to make sure Resident #11 was seated before leaving her side. The care plan for Resident #11 reflected this intervention. Review of a facility policy titled, Fall Reduction Policy dated reviewed/revised ,[DATE] reflected, Our residents have the right to be free from falls, or to sustain minimal injury from falls .the facility utilizes a standardized risk assessment for determining a resident's fall risk. Upon admission, quarterly, in conjunction with the RAI, upon significant change and post fall and/or intercepted fall. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care .when a resident experiences a fall, the facility will: assess the resident, complete a post fall assessment, complete an incident report, notify physician and family, IDT (interdisciplinary team) review the resident's care plan and update as indicated, document assessments and actions, obtain witness statements as needed.

This citation pertains to intakes: MI 652, MI 654, MI 643 and MI 648. Based on interview and record review, the facility failed to monitor for weight loss (Resident #1), involve the physician to prevent further weight loss and implement intervention to prevent weight loss (Resident #3) for two residents out of 3 residents reviewed for weight loss resulting in the inability to assess if weight has been lost, lack of physician collaboration to prevent further weight loss and lack of interventions to prevent further weight loss and ongoing weight loss. Resident #3 Review of Resident #3's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] for short term rehabilitation following the amputation of her right leg above the knee. She also had the following Diagnoses: [REDACTED]. Review of Resident #3 Brief Interview of Mental Status (BIMS) score on 5/27/20 was 7 out of 15 indicating moderate cognitive impairment. Review of Resident #3's, Nutritional Assessment/Status 3.0, dated 5/23/20 at 3:47 PM (2 days after admission) revealed, the facility was to document daily food acceptance, weight was 119.6 on 5/21/20 at 6:22 PM, she needed daily weights, significant weight changes would be reported to the resident and physician, she did not have any chewing or swallowing difficulty, she had a good appetite/intake of 75 to 100% of most meals, she required 1350 - 1620 calories daily and 1350 to 1620 ml of fluid a day. This note was electronically signed by Dietary Manager (DM) V Review of Resident #3's Nutrition/Fluid Intake record revealed, 5/21 (0), 5/22 (480), 5/23 (600), 5/24 (120), 5/25 (250), 5/26 (290), 5/27 (360), 5/28 (120), 5/29 (480), 5/30 (240), 5/31 (240), 6/1 (360), 6/2 (450), 6/3 (0), 6/4 (340), and 6/5 (60). Review of Resident #3's food intake record revealed, 5/21 all day (0), 5/22 9:00 (bites of food), 1300 (bites of food), 1800 (100%), 5/23, 9:00 (100%), 1300 (50%), 1800 (0), 5/24 9:00 (75%), 1300 (0), 1800 (0), 5/25 9:00 (25%), 1300 (0), 1800 (100%), 5/26 all day (0), 5/27 9:00 100%, 1300 (75%), 1800 (0), 5/28 all day (0), 5/29, 9:00 (25%), 1300 (25%), 1800 (50%), 5/30, 9:00 (50%), 5/31, 9:00 (50%), 1300 (0), 1800 (50%), 6/1 9:00 (50%), 1300 (0), 1800 (50%), 6/2 9:00 (50%), 1300 (50%), 1800 (0), 6/3 all day (0), 6/4 9:00 (50%), 1300 (25%), 1800 (25%), 6/5, 9:00 (25%), 1300 (0), 1800 (0). Three of the 15 days no meals accepted, only 3 meals of the 15 days did Resident #3 accept 75% to 100 % of her meal which was assessed to be her baseline in the assessment completed on 5/23/20. (Progress notes did not mention lack of eating or why Resident #3 was not accepting food). Review of Resident #3's ADL (Activities of Daily Living) and Nutrition/hydration care plan did not reveal any indication Resident #3 required any assistance with eating or drinking. Review of Resident #3's Admission, Minimum Data Set (MDS), dated [DATE] indicated she only required supervision and set up with meals. (No indication in the medical record as to why Resident #3 was not eating 75 % to 100 % of meals as she was prior to her admission). Review of Resident #3's weights revealed her weight on 5/21/10 (admission) was 119.6 lbs. (pounds) on 5/26/20 was 113 lbs., on 5/27/20 was 110.8 lbs., on 5/30/20 was 103.6 lbs., on 5/31/20 was 103.5lbs., on 6/1/20 was 103.5 lbs., on 6/2/20 was 106.0 lbs., on 6/4/20 was 101.6 lbs. and on 6/5/20 it was 102.2lbs. Review of Resident #3's care conference notes, progress note, and physician note revealed the resident, residents responsible party and Resident #3's physician were not notified of Resident #3 significant loss of weight until she was discharged . Daily weights were not located for 5/22/20, 5/23/20, 5/24/20, 5/25/20, 5/28/20, 5/29/20 and 6/3/20 (nutritional assessment documented Resident #3 was to have daily weights). Resident #3 lost over 17 pounds in 15 days. During an interview with the facility Registered Dietitian (RD) D on 8/4/20 at 11:40 AM, RD D confirmed Resident #3 lost 8.8 pounds from admission to the first care conference on 5/27/20 and a total of 17.4 pounds from admission on 5/21/20 to discharge on 6/5/20. RD D said Resident #3 was not eating well and she had anticipated some weight loss due to water loss after having an amputation. RD D was not able to locate any information in Resident #3's medical record that indicated Resident #3's physician or responsible party with notified of the significant weight loss and poor food intake. RD D was not able to locate any interventions being placed for the weight loss that was documented the day of the care conference 5/27/20. RD D recalled she was not at the care conference but if she had been, she would have discussed it at the care conference and notified the physician. RD D said she would see what staff attended the care conference and look for interventions and notification. RD D returned after the interview with two interventions highlighted in the physician orders: 1) Med Pass 2.0 (nutritional supplemental drink provided by the medication nurse) on 6/5/20 at 6:00 PM. (just prior to resident being sent to the hospital that day). RD D was not able to see Med Pass was ever provided. 2) [MEDICATION NAME] Tablet 7.5 MG (also known as [MEDICATION NAME] an antidepressant medication which is also used to stimulate appetite). There was no indication in Resident #3 medical record that Resident #3's responsible party was notified of these medication changes or the amount of weight loss. There was no documentation Resident #3's physician was informed of the amount of weight loss. RD D confirmed she was not able to find any documentation that the facility had notified Resident #3's responsible party or physician of the significant weight loss. During an interview with the facility Social Worker (SW) M on 8/5/20 at 10:52 AM, SW M reviewed Resident #3's medical record. SW M confirmed Resident #3's first care conference was on 5/27/20 with Resident #3's responsible party. SW M said Dietary Manager (DM) V was at the care conference and would have discussed weight concerns. DM V came to the interview, reviewed Resident #3's medical record. DM V confirmed the weight loss but was not able to locate any information that she had placed interventions for further weight loss, notification of the physician or responsible party. During an interview with a Confidential Complainant (CC) Z on 8/5/20 at 3:53 PM Z said they were a Registered Nurse (RN) and was familiar with Resident #3 prior to her admission to the facility. CC Z said they became concerned about Resident #3's condition on 6/5/20 when they became aware of Resident #3's decline in mental condition and severe weight loss. CC Z said they contacted Resident #3's family and recommended Resident #3 be transferred to the hospital for evaluation. During a telephone interview with Resident #3's Responsible Party (RP) Y on 8/10/20 at 8:15 AM, she said she received a call from CC Z on 6/5/20. RP Y said the facility had not informed her that Resident #3 had severe weight loss since admission. RP Y said she had multiple problems with being able to communicate with Resident #3 since COVID-19. RP Y said she had provided Resident #3 with a phone and an iPad but Resident #3 could not use these items without assistance. RP Y said she spoke with multiple nurses, the Director of Nursing (DON) and the Nursing Home Administrator about wanting to have face time visits with Resident #3 on a routine basis but this never got set up. RP Y said she was able to see Resident #3 in the lobby for 15 minutes on 6/4/20 and she was concerned about the bruise she saw on Resident #3 but was told bruise were present on admission and Resident #3 could not even hold up her head. RP Y said she did not know about the severe weight loss until she received a call from CC Z. When RP Y found out about the severe weight loss she called the facility to have Resident #3 transferred to the hospital. On 8/13/20 at 7:07 AM the NHA was asked what was the facility expectation when a resident refuses oral intake for 2 or 3 consecutive meals and if the facility electronic medical record gives her or nursing any alerts for meal refusals or weight loss? The NHA responded at 9:23 AM, The patient in question did not have a significant weight loss. She weighed 118.8 prior to her surgery. She had a right above knee amputation, and we have provided the calculations for approximated weight of 102.4 post amputation and her [MEDICAL CONDITIONS] diagnosis. We have provided supporting documentation. When a patient does not eat, we offer an alternate meal. The documentation proof of alternate was included in the documentation provided yesterday. Residents have the right to refuse to eat or refuse meals and the patient's refusal of meals and alternates is included in the documentation provided yesterday. We have also attached a copy of her fluid intake. Our nurses complete daily skilled assessments monitoring skin turgor, mucous membranes, and other indicator of potential dehydration. There was not sign or symptoms of dehydration that would indicate the need for alternate interventions. During an interview with Registered Dietitian (RD) D on 8/17/20 at 12:15 PM, RD D said the electronic medical record (EMR) provides and alert for her and nursing when a resident has a significant when loss. RD D said a significant weight loss is 3% or greater. RD D said the physician and the resident's responsible party are notified of any significant weight loss. Resident #3 weighted 119.6 on admission. Resident #3 was supposed to have a daily weight documented; however, she was not weighed again until 5/26/20 (5 days later). On 5/26/20 Resident #3 weighed 113 pounds (over 5% of body weight loss documented). There was no indication Resident #3's responsible party or physician were notified of this significant weight loss. Resident #3 continued to lose weight for the remainder of her stay in the facility and there was no indication her responsible party or physician were ever notified. Review of Resident #3's progress notes, revealed a Discharge EMERGENT note dated 6/5/20 at 7:45 PM, signed by the Director of Nursing (DON), Reason for discharge: family request, (name of Responsible Party) requested. Review of Resident #3's Emergency Department note, dated 6/5/20 at 6:58 PM revealed, Resident #3 was admitted with a 20-pound weight loss and fatigue. [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#3's admission to the facility on [DATE]. Review of Resident #3's Hospital Course (page 79) revealed, Resident #3, was admitted with toxic/metabolic [MEDICAL CONDITION]ly 2/2 nutritional state, also uremia (kidneys not filtering properly), patient had creatinine of 1.4 when baseline .7mg/dl. Patient AKI w/elevated BUN of 104 and noted to have Metabolic acidosis with BHB elevated 2/2 starvation ketoacidosis and was started on [MEDICATION NAME] gtt with D5 (medical treatment for [REDACTED]. Nutrition was consulted and patient was diagnosed with [REDACTED]. Abdominal Xray showed gas but no significant stool burden. She had extreme tenderness on AKA right stump and vascular was consulted and noted some necrosis at the suture line and did not note any secondary infection and recommended f/u w/wound care. MRI of the brain did not note any acute ischemic stroke and neuro signed off. [MEDICAL CONDITION] meds were d/c as this could also be the cause of her [MEDICAL CONDITION], but no noted improvement. Her metabolic acidosis and acute kidney injury resolved. During her LOS (length of stay), patient continued to be AOx1 and SLP recommended that patient be NPO except meds: Family did not wish to have feed tubes placed. Palliative Care was on board for GOC and patient was transitioned to hospice, however on 6/11., patient's mentation improved and was back to baseline and Family requested home with home care w/RN, PT, OT and SLP. (Kidney and brain function returned to baseline with hydration and nutrition). Review of Resident #3's Emergency Department Supervisor Note dated 6/5/20 at 6:58 PM revealed (Resident #3) had a 20-pound weight loss in the last 2 weeks and had an altered mental status. Several laboratory investigations were obtained that showed she is markedly dehydrated. This citation pertains to MI 223 Resident #1 According to a facility face sheet dated 8/3/2020 at 5:25 PM, Resident #1 was a [AGE] year-old admitted into the facility on [DATE] with the pertinent Diagnoses: [REDACTED]. Resident #1 resided in the facility from [DATE] to 1/28/2020, a little over 3 weeks. According to a facility policy titled, Weight Monitoring dated reviewed/revised on 2/20 reflected, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise .Weight will be obtained upon admission, readmission and weekly for the first four weeks after admission and at least monthly unless ordered by the physician . Review of facility documented reflected under the electronic medical records Weights and Vital Signs for Resident #1, 1/4/2020 at 3:57 PM 210.9 LBS (pounds). There was no further documentation of weights for Resident #1. During an interview on 8/4/2020 at 11:19 AM with Registered Dietician (RD) D, she revealed that Resident #1 had a UTI (urinary tract infection) upon admission [MEDICAL CONDITION] (blood infection), and that Resident #1 had [MEDICAL CONDITION]. Resident #1's weight on admission was 210 pounds. Resident #1 was discharged on [DATE]. RD D revealed that weekly weights were protocol upon admission but agreed that had not been done. RD D stated that nursing was responsible to make sure this was completed. Resident #1's usual body weight was 185 to 195 pounds. Resident #1 had hyperosmolality so had [MEDICAL CONDITION] (swelling), and Resident #1 was over hydrated. RD D stated Resident #1 ate well, but was full of fluid, and the RD D expected a weight loss. RD D stated Resident #1's skin was impaired upon admission.