Every finding on record at Lake Manassas Health & Rehabilitation Center

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide care in a timely manner to prevent serious injury and/or death to two of 12 residents in the survey sample, Residents #1 and #2, resulting in the identification of immediate jeopardy.The findings include:1. For Resident #1 (R1), on [DATE], the facility staff failed to assess and accurately identify signs and symptoms of sepsis (1) and to transfer the resident to the hospital in a timely manner. The resident's significant change of condition was identified on [DATE] at 7:30 a.m., the resident was not transferred to the local hospital for treatment until approximately 12:30 p.m., and the resident died at the hospital at 3:37 p.m. from sepsis. The delay in treatment put the resident at high risk of serious injury or death.R1 was admitted to the facility on [DATE] with diagnoses that included surgical repair of a hip fracture. On the admission MDS (minimum) assessment with an ARD (assessment reference date) of [DATE], he was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS (Brief Interview for Mental Status). He was coded as having no concerns with making his needs known or communicating. A review of provider and nursing assessments revealed R1 was consistently alert and oriented to person, place, time, and situation. R1 had a provider's order that he was a full code. A review of R1's clinical record revealed the following sequence of events: On [DATE] at approximately 11:00 p.m., R1 was documented as having no physical concerns; his blood pressure was 127/65, and no concerns were documented regarding his neurological status. On [DATE] at 6:27 a.m., the weekend on-call licensed provider was contacted about the resident's low blood pressure (documented as 84/49). The on-call provider ordered a hold on the resident's aspirin and medications to treat high blood pressure, a test for blood in the resident's stool, and hourly blood pressure checks. On [DATE] at 7:30 a.m., R1's blood pressure was recorded as 80/41, he was unresponsive to verbal stimuli, and his oxygen saturation was 84% on room air. R1's neurological status of being unresponsive never changed throughout the day. The resident's PCP (primary care physician) was notified and he gave orders for IV (intravenous) fluids to be given at 100 ml/hr (milliliters per hours). At 8:00 a.m., R1's blood pressure was 82/38 and O2 saturation was 93% on oxygen at 4 lpm (liters per minute). At 9:30 a.m., the PCP ordered additional IV fluids . At 10:00 a.m., R1's blood pressure was 85/43 and his heart rate was 132; his O2 saturation was 85-90% on 5 lpm. IV fluids continued. At 11:08 a.m., R1's blood pressure was 79/40 and his O2 saturation was 99% on 8 lpm. At 12:00 noon, R1's blood pressure was 81/41. The PCP gave an order for the resident to be transferred to the hospital.A review of the EMS (emergency medical services) call record revealed the facility placed a call for assistance with R1 on [DATE] at 12:23 p.m. This review revealed the following: Primary Impression: Sepsis.Signs and Symptoms Hypotension (low blood pressure) Primary.A review of R1's death certificate revealed his time of death at the hospital as 3:37 p.m., and sepsis as the resident's cause of death.On [DATE] at 9:27 a.m., LPN (licensed practical nurse) #1 was interviewed. LPN #1 worked the night shift taking care of R1 from 11:00 p.m. on [DATE] until 7:30 a.m. on [DATE]. He stated he had no memory of R1 or of any of the events that occurred around R1's change in condition between [DATE] and [DATE]. He stated he did not have access to the facility's electronic medical record and could not provide additional information.On [DATE] at 9:43 a.m., LPN #2 was interviewed. She was assigned to R1 on [DATE] from 7:00 a.m. until the resident was sent to the hospital. She stated she did not remember the resident or these events. After reviewing R1's progress notes, most of which were written by her, she stated it looked like she contacted the PCP. She stated that at the current time, she did not remember why she called the PCP instead of the weekend on-call provider. She stated that she told the PCP about R1's condition and vital signs, and she followed the orders the PCP gave (to administer IV fluids at 100 ml/hr and to continue to monitor the resident). She stated it was not her place to determine whether the PCP's orders were appropriate; it was her job to follow the orders. She stated that although she documented multiple times that the resident was unresponsive during her entire shift she did not remember anything about this. She stated she believed the PCP ordered the IV fluids in an effort to increase the resident's blood pressure. She stated she continued to monitor the resident's vital signs and to report them to the PCP, as was evidenced in the progress notes. She stated she believed she reported all vital signs and the resident's neurological status to the PCP each time she spoke with him. She stated she did not question the provider's orders, and she continued to follow the physician's orders and the facility protocol. During the interview, LPN #2 was given a scenario of a resident with low blood pressure, loss of consciousness, and decreasing respiratory status, and she was asked to identify what was likely to have been happening to the resident. She did not identify sepsis as a likely outcome. She added that as a nurse, she is only able to follow the physician's order. She stated: I can't just do something on my own. I cannot judge his decision. I cannot send the resident to the ER (emergency room) on my own. I always need an order. She stated she did not know who the facility's medical director was at that time or who it is at the present time.On [DATE] at 10:06 a.m., R1's Nurse Practitioner (NP) was interviewed. She stated the resident had at least one previous episode of low blood pressure, and her thinking was that the resident may have had some slight internal bleeding. She stated the resident had previously declined additional iv fluids to treat the low blood pressure, and she had ordered an iron supplement to boost the resident's red blood cell function. She stated every time she saw R1, the resident was alert, oriented, and talkative. The NP was not a part of any of the communication regarding R1's change in condition between [DATE] and [DATE]. She reviewed the clinical record, and stated it was too hard for her to know or to speculate if she would have done anything differently if she had been contacted. She stated: It's so hard. It depends on who's calling you and what information you are given. She stated that by the time the 10:00 a.m. vital signs were recorded, she would have been highly suspecting that the resident had sepsis. She stated sepsis is a life-threatening medical emergency and must be treated immediately, and that the window of time for successful treatment is very small.On [DATE] at 12:27 p.m., the PCP was interviewed. Before the surveyor could inform the PCP of which patient would be discussed, the PCP stated : First, I don't remember anything about this patient. He stated one of the facility nurses had already called him to alert him of the questions that were being asked about R1, and he had already reviewed the whole thing. He stated he did not remember anything about this resident, and he could not remember anything about any of the information he was given throughout the morning of [DATE]. He added: I wasn't even supposed to be working. I was not even on call that day. He explained that sometimes the nurses call him even when he is not on call, and he responds to the information he is given. He said that most likely the information he was given was only about the resident's blood pressure. He stated that he did not remember anyone telling him anything about the resident being unresponsive. He explained that these communications with the staff were two years ago and he was trying to put the events together based solely on the clinical record. He reiterated: I don't remember anything about the calls. Nothing. He stated if a nurse believes a resident should be sent to the ER, he has no problem with that. He stated: I tell them they are there, I am not. He completed the interview by saying if he had known the resident was unconscious and that his respiratory status was declining, he would have sent him to the ER immediately.On [DATE] at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She stated it would be very hard to say R1 was transferred to the hospital in timely manner. She stated the facility nurses have always had autonomy in using their nursing judgment to send a resident to the hospital even without a provider's order. She stated she could not speculate on the action of the PCP on [DATE].Reference(1) Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse. This information is taken from the website https://medlineplus.gov/sepsis.html?_gl=1*nte9oy*_ga*MTk0MjYwOTg2NS4xNzc2MDk1NTQ4*_ga_7147EPK006*czE3NzYwOTU1NDgkbzEkZzEkdDE3NzYwOTU1ODQkajI0JGwwJGgw*_ga_P1FPTH9PL4*czE3NzYwOTU1NDkkbzEkZzEkdDE3NzYwOTU1ODQkajI1JGwwJGgw. Sepsis is diagnosed through a medical assessment performed by a healthcare provider.They diagnose sepsis using physical findings, such as: Fever, Increased heart rate, Low blood pressure, Trouble breathing.Research shows that rapid, effective sepsis treatment includes: Giving appropriate treatment, including antibiotics, as soon as possible, Maintaining blood flow to organs, Sometimes surgery is required to remove tissue damaged by the infection. Healthcare providers should treat sepsis as soon as possible. This information is taken from the website https://www.cdc.gov/sepsis/about/index.html.2. For Resident #2 (R2), the facility staff failed to assess and accurately identify signs and symptoms of sepsis and to transfer the resident to the hospital in a timely manner. The resident's significant change of condition was identified on [DATE] at 9:00 p.m. and the resident was not transferred to the local hospital for treatment until approximately 10:30 p.m. that same evening. The delay in treatment put the resident at high risk for serious injury or death.On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], R2 was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as having no concerns with being understood or with understanding others. A review of provider and nursing assessments revealed R2 was consistently alert and oriented to person, place, time, and situation. R2 had a provider's order that she was a full code.A review of R2's clinical record revealed the following sequence of events: On [DATE] at 8:30 p.m., the resident was documented as alert, responsive, talking, and answering questions with facility staff. On [DATE] at 9:00 p.m., a CNA (certified nursing assistant) reported to the nurse that the resident's condition had changed. LPN (licensed practical nurse) #3 assessed the resident, whose blood pressure was 78/46, and who was documented to be in acute distress, including being lethargic and having respiratory congestion with labored breathing and intermittent gasping. On [DATE] at 9:52 p.m., LPN #3 contacted the on-call licensed provider service, who gave an order for the resident to be transferred to the hospital. The resident was sent to the emergency room around 10:30 p.m. on [DATE], per the facility documentation.The CNA who identified a change in R2's condition was not available for interview during the survey.On [DATE] at 1:41 p.m., LPN #3 was interviewed. She stated she did not know R2 very well at all. She stated she was told in report that the resident was ordinarily alert and oriented, and she remembered talking with the resident, including an exchange of light-hearted questions and answers at the beginning of her shift. She stated she identified R2's condition as possible sepsis. However, she was not allowed to send the resident to the hospital without a physician's order. She stated: We have to talk to the provider before sending them out. She stated she could not explain why she waited almost an hour between assessing the resident and contacting the provider.On [DATE] at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She stated it would be very hard to say R2 was transferred to the hospital in timely manner. She stated the facility nurses have always had autonomy in using their nursing judgment to send a resident to the hospital even without a provider's order.R2's hospital records were requested but not provided prior to the conclusion of the survey.A review of the facility policy, Significant Change of Condition, revealed, in part: A licensed nurse will assess the patient for signs and symptoms of change of condition.Potentially life-threatening conditions require nursing assessment critical thinking skills to determine whether a patient should be transferred to an acute care setting.This decision will be made by a licensed nurse when the patient's condition is so acute that time does not permit waiting for provider's response.The facility's deficient practice placed all residents in the facility at risk of serious injury and death due to a lack of identification of sepsis and delay in treatment. This resulted in a determination of Immediate Jeopardy (IJ), cited at level four isolated beginning on [DATE].On [DATE] at 1:15 p.m., the DON and Regional Director of Clinical Services (RDCS) were informed of these concerns, and informed that the facility was in immediate jeopardy.On [DATE] at 4:00 p.m., the facility's IJ Removal Plan was accepted by the SA (state agency) supervisor.Facility Removal PlanCorrective Action for those residents found to be affected by the deficient practice:1. Resident 1 and Resident 2 were sent out to the hospital and no longer reside in the facility.Corrective Actions taken for residents with potential to be affected by deficient practice:2. All residents have the potential to be affected by the deficient practice. All current residents will have their vitals obtained and reviewed by a Licensed Nurse who is educated on signs and symptoms of Sepsis to assess an emergent medical need.Systemic Changes put into place to ensure the deficient practice does not recur: 3. The Interdisciplinary Team (Director of Nursing, Assistant Director of Nursing, Director of Social Work, Dietary Manager, Business Office Manager, Director of Housekeeping and Laundry, Human Resources, Rehab Director and Unit Managers) will be educated by the Regional Director of Clinical Services on identification of change in condition and early identification of sepsis. The licensed nursing staff will be educated on the change of condition policy and signs and symptoms of sepsis as outlined by the CDC to include sending residents to the hospital in an emergent situation. [NAME] President of Operations will educate Medical Director on duties and responsibilities. Staff will not be allowed to work until educated, and all new licensed nursing staff will be educated upon hire. Monitoring of corrective action to ensure the deficient practice does not recur. 4.The DON or designee will review unplanned discharges 5 times a week for 4 weeks then weekly for 4 weeks to identify timely identification in change in condition, sepsis, and timely return to hospital, and following physician orders.5. The facility will be complete with a plan for removal of the Immediate Jeopardy on [DATE] at 11:59pm.On [DATE] at 6:30 a.m., the survey team began verification of the facility's removal plan. This verification process included staff interviews on all elements of the removal plan (interviews conducted with staff from all three shifts and with the medical director), and review of the facility's credible evidence. The survey team verified that the facility completed the removal plan on [DATE] at 11:59 p.m. Once the immediate jeopardy was removed, the scope and severity was reduced to a level three, isolated.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to implement an effective QAPI (Quality Assurance/Performance Improvement) process for one of one facility.The findings include:The facility failed to implement its QAPI plan following an incident in which a resident, who was displaying signs and symptoms of sepsis (1), was not transferred to the hospital in a timely manner.On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was contacted about the resident's low blood pressure (documented as 84/49). The on-call provider ordered a hold on the resident's aspirin and medications to treat high blood pressure, a test for blood in the resident's stool, and hourly blood pressure checks. On 9/1/24 at 7:30 a.m., R1's blood pressure was recorded as 80/41, he was unresponsive to verbal stimuli, and his oxygen saturation was 84% on room air. R1's neurological status of being unresponsive never changed throughout the day. The resident's PCP (primary care physician) was notified and he gave orders for IV (intravenous) fluids to be given at 100 ml/hr (milliliters per hours). At 8:00 a.m., R1's blood pressure was 82/38 and O2 saturation was 93% on oxygen at 4 lpm (liters per minute). At 9:30 a.m., the PCP ordered additional iv fluids. At 10:00 a.m., R1's blood pressure was 85/43 and his heart rate was 132; his O2 saturation was 85-90% on 5 lpm. IV fluids continued. At 11:08 a.m., R1's blood pressure was 79/40 and his O2 saturation was 99% on 8 lpm. At 12:00 noon, R1's blood pressure was 81/41. The PCP gave an order for the resident to be transferred to the hospital.A review of the EMS (emergency medical services) call record revealed the facility placed a call for assistance with R1 on 9/1/24 at 12:23 p.m. This review revealed the following: Primary Impression: Sepsis.Signs and Symptoms Hypotension (low blood pressure) Primary.A review of R1's death certificate revealed his time of death at the hospital as 3:37 p.m., and sepsis as the resident's cause of death.On 4/8/26 at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She stated it would be very hard to say R1 was transferred to the hospital in timely manner. She stated that she could not find specific evidence that the sequence of events surrounding R1's discharge from the facility was reviewed by the QAPI committee, or that a quality improvement plan was ever considered following R1's delay in treatment. She stated that the staff participates in a weekly risk management meeting, which is considered to be a part of the facility's QAPI process, during which all the previous week's discharges are discussed. However, she could not locate any evidence that this had occurred following R1's discharge on [DATE]. She stated she was not aware that any sort of action plan had been developed or implemented regarding R1's situation. She added the facility has improvements to be made in this regard.A review of the facility policy, QAPI, revealed, in part: The Administrator is responsible for directing the Center's Quality Assurance/Performance Improvement Program and for implementing a Quality Assurance/Performance Improvement Plan that focuses on Center specific indicators that measure quality of care, quality of life and patient choice. The QAPI plan will systematically identify actual or potential areas of risk or deficiency that will proactively pursue ongoing performance improvement.The QAPI committee is scheduled to meet a minimum of quarterly. The care and service standards of the Center are continuously tracked, reviewed, analyzed, monitored, and improved by the committee.In addition to Center established indicators and surveys, the Administrator and the QAPI committee are responsible for targeting and monitoring specific services and/or operational areas of ongoing studies within the Center.These are identified as a priority for high risk, high volume, or problem prone processes .or opportunities for improving dimensions of performance.On 4/8/26 at 10:48 a.m., the DON, Regional Director of Clinical Services, and [NAME] President of Operations were notified of these concerns. No additional information was provided prior to exit.Reference(1) Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse. This information is taken from the website https://medlineplus.gov/sepsis.html?_gl=1*nte9oy*_ga*MTk0MjYwOTg2NS4xNzc2MDk1NTQ4*_ga_7147EPK006*czE3NzYwOTU1NDgkbzEkZzEkdDE3NzYwOTU1ODQkajI0JGwwJGgw*_ga_P1FPTH9PL4*czE3NzYwOTU1NDkkbzEkZzEkdDE3NzYwOTU1ODQkajI1JGwwJGgw. Sepsis is diagnosed through a medical assessment performed by a healthcare provider.They diagnose sepsis using physical findings, such as: Fever, Increased heart rate, Low blood pressure, Trouble breathing.Research shows that rapid, effective sepsis treatment includes: Giving appropriate treatment, including antibiotics, as soon as possible, Maintaining blood flow to organs, Sometimes surgery is required to remove tissue damaged by the infection. Healthcare providers should treat sepsis as soon as possible. This information is taken from the website https://www.cdc.gov/sepsis/about/index.html.

Based on staff interview, physician interview, facility document review, and clinical record review, the facility staff failed to provide competent nursing staff for two of twelve residents in the survey sample, Residents #1 and #2.The findings include:1. For Resident #1 (R1), the facility nursing staff failed to demonstrate competence to recognize and respond to a significant change in condition, including signs and symptoms consistent with sepsis (1).R1 was admitted to the facility on [DATE] with diagnoses that included surgical repair of a hip fracture. On the admission MDS (minimum) assessment with an ARD (assessment reference date) of 8/16/24, he was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS (Brief Interview for Mental Status). He was coded as having no concerns with making his needs known or communicating. A review of provider and nursing assessments revealed R1 was consistently alert and oriented to person, place, time, and situation. R1 had a provider's order that he was a full code. A review of R1's clinical record revealed the following sequence of events: On 8/31/24 at approximately 11:00 p.m., R1 was documented as having no physical concerns; his blood pressure was 127/65, and no concerns were documented regarding his neurological status. On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was contacted about the resident's low blood pressure (documented as 84/49). The on-call provider ordered a hold on the resident's aspirin and medications to treat high blood pressure, a test for blood in the resident's stool, and hourly blood pressure checks. On 9/1/24 at 7:30 a.m., R1's blood pressure was recorded as 80/41, he was unresponsive to verbal stimuli, and his oxygen saturation was 84% on room air. R1's neurological status of being unresponsive never changed throughout the day. The resident's PCP (primary care physician) was notified and he gave orders for IV (intravenous) fluids to be given at 100 ml/hr (milliliters per hours). At 8:00 a.m., R1's blood pressure was 82/38 and O2 saturation was 93% on oxygen at 4 lpm (liters per minute). At 9:30 a.m., the PCP ordered additional iv fluids. At 10:00 a.m., R1's blood pressure was 85/43 and his heart rate was 132; his O2 saturation was 85-90% on 5 lpm. IV fluids continued. At 11:08 a.m., R1's blood pressure was 79/40 and his O2 saturation was 99% on 8 lpm. At 12:00 noon, R1's blood pressure was 81/41. The PCP gave an order for the resident to be transferred to the hospital.A review of the EMS (emergency medical services) call record revealed the facility placed a call for assistance with R1 on 9/1/24 at 12:23 p.m. This review revealed the following: Primary Impression: Sepsis.Signs and Symptoms Hypotension (low blood pressure) Primary.A review of R1's death certificate revealed his time of death at the hospital as 3:37 p.m., and sepsis as the resident's cause of death. On 4/7/26 at 9:43 a.m., LPN #2 was interviewed. She was assigned to R1 on 9/1/24 from 7:00 a.m. until the resident was sent to the hospital. She stated she did not remember the resident or these events. After reviewing R1's progress notes, most of which were written by her, she stated it looked like she contacted the PCP. She stated that at the current time, she did not remember why she called the PCP instead of the weekend on-call provider. She stated that she told the PCP about R1's condition and vital signs, and she followed the orders the PCP gave (to administer iv fluids at 100 ml/hr and to continue to monitor the resident). She stated it was not her place to determine whether the PCP's orders were appropriate; it was her job to follow the orders. She stated that although she documented multiple times that the resident was unresponsive during her entire shift she did not remember anything about this. She stated she believed the PCP ordered the iv fluids in an effort to increase the resident's blood pressure. She stated she continued to monitor the resident's vital signs and to report them to the PCP, as was evidenced in the progress notes. She stated she believed she reported all vital signs and the resident's neurological status to the PCP each time she spoke with him. She stated she did not question the provider's orders, and she continued to follow the physician's orders and the facility protocol. During the interview, LPN #2 was given a scenario of a resident with low blood pressure, loss of consciousness, and decreasing respiratory status, and she was asked to identify what was likely to have been happening to the resident. She did not identify sepsis as a likely outcome. She added that as a nurse, she is only able to follow the physician's order. She stated: I can't just do something on my own. I cannot judge his decision. I cannot send the resident to the ER (emergency room) on my own. I always need an order. She stated she did not know who the facility's medical director was at that time or who it is at the present time.On 4/8/26 at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She explained that new nurses should come to the facility with a basic understanding of sepsis, but that she does not always find this to be the case. She added: It is scary. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She added that newly hired nurses all receive some training in identifying sepsis when they are first hired, and that all staff receive refresher training on sepsis annually. She stated it would be very hard to say R1 was transferred to the hospital in timely manner. She stated the facility nurses have always had autonomy in using their nursing judgment to send a resident to the hospital even without a provider's order. On 4/8/26 at 10:48 a.m., the DON, Regional Director of Clinical Services, and [NAME] President of Operations were notified of these concerns. At this time, the [NAME] President of Operations stated the facility did not have a policy regarding competent nursing staff.No additional information was provided prior to exit.Reference(1) Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse. This information is taken from the website https://medlineplus.gov/sepsis.html?_gl=1*nte9oy*_ga*MTk0MjYwOTg2NS4xNzc2MDk1NTQ4*_ga_7147EPK006*czE3NzYwOTU1NDgkbzEkZzEkdDE3NzYwOTU1ODQkajI0JGwwJGgw*_ga_P1FPTH9PL4*czE3NzYwOTU1NDkkbzEkZzEkdDE3NzYwOTU1ODQkajI1JGwwJGgw. Sepsis is diagnosed through a medical assessment performed by a healthcare provider.They diagnose sepsis using physical findings, such as: Fever, Increased heart rate, Low blood pressure, Trouble breathing.Research shows that rapid, effective sepsis treatment includes: Giving appropriate treatment, including antibiotics, as soon as possible, Maintaining blood flow to organs, Sometimes surgery is required to remove tissue damaged by the infection. Healthcare providers should treat sepsis as soon as possible. This information is taken from the website https://www.cdc.gov/sepsis/about/index.html.2. For Resident #2 (R2), the facility nursing staff failed to demonstrate competence to recognize and respond to a significant change in condition, including signs and symptoms consistent with sepsis.A review of R2's clinical record revealed the following sequence of events: On 2/28/26 at 8:30 p.m., the resident was documented as alert, responsive, talking, and answering questions with facility staff. On 2/28/26 at 9:00 p.m., a CNA (certified nursing assistant) reported to the nurse that the resident's condition had changed. LPN (licensed practical nurse) #3 assessed the resident, whose blood pressure was 78/46, and who was documented to be in acute distress, including being lethargic and having respiratory congestion with labored breathing and intermittent gasping. On 2/28/26 at 9:52 p.m., LPN #3 contacted the on-call licensed provider service, who gave an order for the resident to be transferred to the hospital. The resident was sent to the emergency room around 10:30 p.m. on 2/28/26, per the facility documentation.On 4/7/26 at 1:41 p.m., LPN #3 was interviewed. She stated she did not know R2 very well at all. She stated she was told in report that the resident was ordinarily alert and oriented, and she remembered talking with the resident, including an exchange of light-hearted questions and answers at the beginning of her shift. She stated she identified R2's condition as possible sepsis. However, she was not allowed to send the resident to the hospital without a physician's order. She stated: We have to talk to the provider before sending them out. She stated she could not explain why she waited almost an hour between assessing the resident and contacting the provider.On 4/8/26 at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She explained that new nurses should come to the facility with a basic understanding of sepsis, but that she does not always find this to be the case. She added: It is scary. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She added that newly hired nurses all receive some training in identifying sepsis when they are first hired, and that all staff receive refresher training on sepsis annually. She stated it would be very hard to say R2 was transferred to the hospital in timely manner. She stated the facility nurses have always had autonomy in using their nursing judgment to send a resident to the hospital even without a provider's order. On 4/8/26 at 10:48 a.m., the DON, Regional Director of Clinical Services, and [NAME] President of Operations were notified of these concerns.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide required documents at the time of discharge for one of 12 residents in the survey sample, Resident #2.The findings include:For Resident #2 (R2), the facility staff failed to provide a written notice of bed hold to the resident or Resident Representative (RR) and failed to provide continuity of clinical care documents to the receiving hospital on 2/28/26.A review of R2's clinical record revealed that she was discharged to the hospital on 2/28/26 at approximately 10:30 p.m.Further review of R2's clinical record failed to reveal evidence that the resident (or Resident Representative) was notified in writing of the reasons for the discharge and no evidence that the facility provided clinical documentation regarding the resident's care plan goals and other information to the receiving hospital.On 4/8/26 at 7:05 a.m., the [NAME] President of Operations stated there was no bed hold or continuity of clinical care information for R2 on 2/28/26.On 4/8/26 at 8:52 a.m., LPN (licensed practical nurse) #9 was interviewed. She stated she communicates the critical clinical information to the receiving hospital by phone. She stated she also prints the resident's code status, medical history, allergies, vital signs, and other relevant information from the past seven days. She stated ordinarily she gives this paperwork to the EMS (emergency medical service personnel) to be handed over to the emergency room staff. She stated all of this is documented in the change of condition report in the electronic medical record.On 4/8/26 at 10:48 a.m., the Director of Nursing, Regional Director of Clinical Services, and [NAME] President of Operations were notified of these concerns.A review of the facility policy, Patient Transfer, revealed, in part: A Patient Transfer Form (eINTERACT) should be sent with the patient when transporting to a hospital or acute care setting.The Patient Transfer Form (eINTERACT) is completed by a licensed nurse when the patient is being transferred to the hospital for care and services. Generate the chart for the last 7 days and provide information to the receiving facility.A review of the facility policy, Bed Reserve, revealed, in part: Whenever any patient.is transferred from the Health and Rehabilitation Center is admitted for overnight hospitalization/observation.the patient and or the responsible representative (or hospital) must pay to hold the bed if the patient wishes to ensure that he/she can return to the bed he/she has been occupying.To make this arrangement, the patient and/or responsible representative must (1) promptly complete and sign a formal 'Voluntary Bed Retention Agreement' and (2) provide private payment to the Health and Rehabilitation Center for the requested days. This arrangement can be made at the time of transfer, or by the close of the business day on which the hospitalization occurs, but no later than 10:00 a.m. on the day following the hospitalization.No additional information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide physician supervision for one of 12 residents in the survey sample, Resident #1. The findings include:For Resident #1 (R1), the facility physician failed to provide adequate physician oversight and direction related to a significant change in condition on 9/1/24.R1 was admitted to the facility on [DATE] with diagnoses that included surgical repair of a hip fracture. On the admission MDS (minimum) assessment with an ARD (assessment reference date) of 8/16/24, he was coded as having no cognitive impairment, having scored 15 out of 15 on the BIMS (Brief Interview for Mental Status). He was coded as having no concerns with making his needs known or communicating. A review of provider and nursing assessments revealed R1 was consistently alert and oriented to person, place, time, and situation. R1 had a provider's order that he was a full code. A review of R1's clinical record revealed the following sequence of events: On 8/31/24 at approximately 11:00 p.m., R1 was documented as having no physical concerns; his blood pressure was 127/65, and no concerns were documented regarding his neurological status. On 9/1/24 at 6:27 a.m., the weekend on-call licensed provider was contacted about the resident's low blood pressure (documented as 84/49). The on-call provider ordered a hold on the resident's aspirin and medications to treat high blood pressure, a test for blood in the resident's stool, and hourly blood pressure checks. On 9/1/24 at 7:30 a.m., R1's blood pressure was recorded as 80/41, he was unresponsive to verbal stimuli, and his oxygen saturation was 84% on room air. R1's neurological status of being unresponsive never changed throughout the day. The resident's PCP (Primary Care Physician) was notified and he gave orders for IV (intravenous) fluids to be given at 100 ml/hr (milliliters per hours). At 8:00 a.m., R1's blood pressure was 82/38 and O2 saturation was 93% on oxygen at 4 lpm (liters per minute). At 9:30 a.m., the PCP ordered additional IV fluids. At 10:00 a.m., R1's blood pressure was 85/43 and his heart rate was 132; his O2 saturation was 85-90% on 5 lpm. IV fluids continued. At 11:08 a.m., R1's blood pressure was 79/40 and his O2 saturation was 99% on 8 lpm. At 12:00 noon, R1's blood pressure was 81/41. The PCP gave an order for the resident to be transferred to the hospital.A review of the EMS (emergency medical services) call record revealed the facility placed a call for assistance with R1 on 9/1/24 at 12:23 p.m. This review revealed the following: Primary Impression: Sepsis (1).Signs and Symptoms Hypotension (low blood pressure) Primary.A review of R1's death certificate revealed his time of death at the hospital as 3:37 p.m., and sepsis as the resident's cause of death.On 4/7/26 at 9:43 a.m., LPN #2 was interviewed. She was assigned to R1 on 9/1/24 from 7:00 a.m. until the resident was sent to the hospital. She stated she did not remember the resident or these events. After reviewing R1's progress notes, most of which were written by her, she stated it looked like she contacted the PCP. She stated that at the current time, she did not remember why she called the PCP instead of the weekend on-call provider. She stated that she told the PCP about R1's condition and vital signs, and she followed the orders the PCP gave (to administer iv fluids at 100 ml/hr and to continue to monitor the resident). She stated it was not her place to determine whether the PCP's orders were appropriate; it was her job to follow the orders. She stated that although she documented multiple times that the resident was unresponsive during her entire shift she did not remember anything about this. She stated she believed the PCP ordered the iv fluids in an effort to increase the resident's blood pressure. She stated she continued to monitor the resident's vital signs and to report them to the PCP, as was evidenced in the progress notes. She stated she believed she reported all vital signs and the resident's neurological status to the PCP each time she spoke with him. She stated she did not question the provider's orders, and she continued to follow the physician's orders and the facility protocol. During the interview, LPN #2 was given a scenario of a resident with low blood pressure, loss of consciousness, and decreasing respiratory status, and she was asked to identify what was likely to have been happening to the resident. She did not identify sepsis as a likely outcome. She added that as a nurse, she is only able to follow the physician's order. She stated: I can't just do something on my own. I cannot judge his decision. I cannot send the resident to the ER (emergency room) on my own. I always need an order. She stated she did not know who the facility's medical director was at that time or who it is at the present time.On 4/7/26 at 12:27 p.m., the PCP was interviewed. Before the surveyor could inform the PCP of which patient would be discussed, the PCP stated : First, I don't remember anything about this patient. He stated one of the facility nurses had already called him to alert him of the questions that were being asked about R1, and he had already reviewed the whole thing. He stated he did not remember anything about this resident, and he could not remember anything about any of the information he was given throughout the morning of 9/1/24. He added: I wasn't even supposed to be working. I was not even on call that day. He explained that sometimes the nurses call him even when he is not on call, and he responds to the information he is given. He said that most likely the information he was given was only about the resident's blood pressure. He stated that he did not remember anyone telling him anything about the resident being unresponsive. He explained that these communications with the staff were two years ago and he was trying to put the events together based solely on the clinical record. He reiterated: I don't remember anything about the calls. Nothing. He stated if a nurse believes a resident should be sent to the ER, he has no problem with that. He stated: I tell them they are there, I am not. He completed the interview by saying if he had known the resident was unconscious and that his respiratory status was declining, he would have sent him to the ER immediately.On 4/8/26 at 10:08 a.m., the PCP contacted the survey team. He asked if there was any way this [regulatory finding] could be reversed. He stated he was confident that the nursing staff did not tell him about R1's altered level of consciousness and declining respiratory status. He did not respond to concerns about how he could specifically remember what was or was not shared with him by the nurse during phone calls on 9/1/24 if he, as he stated the previous day, remembered nothing about the resident or the sequence of events other than what was included in the record. The PCP was reminded that the clinical record contained consistent documentation of all of the resident's vital signs and neurological status at each entry during the morning of 9/1/24.On 4/8/26 at 10:25, the Director of Nursing (DON) was interviewed. She stated that sepsis has been a hot topic for decades for nurses. She stated that the nursing standard in this facility is for nurses to be able to recognize early signs and symptoms of sepsis and to take immediate action. She stated it would be very hard to say R1 was transferred to the hospital in timely manner. She stated the facility nurses have always had autonomy in using their nursing judgment to send a resident to the hospital even without a provider's order. She stated she could not speculate on the actions of the PCP on 9/1/24.On 4/8/26 at 10:48 a.m., the DON, Regional Director of Clinical Services, and [NAME] President of Operations were notified of these concerns. At this time, the [NAME] President of Operations stated the facility did not have a policy regarding physician services/supervision.No additional information was provided prior to exit.Reference(1) Sepsis is your body's overactive and extreme response to an infection. Sepsis is a life-threatening medical emergency. Without quick treatment, it can lead to tissue damage, organ failure, and even death.It's important to get medical care right away if you think you might have sepsis or if your infection is not getting better or is getting worse. This information is taken from the website https://medlineplus.gov/sepsis.html?_gl=1*nte9oy*_ga*MTk0MjYwOTg2NS4xNzc2MDk1NTQ4*_ga_7147EPK006*czE3NzYwOTU1NDgkbzEkZzEkdDE3NzYwOTU1ODQkajI0JGwwJGgw*_ga_P1FPTH9PL4*czE3NzYwOTU1NDkkbzEkZzEkdDE3NzYwOTU1ODQkajI1JGwwJGgw. Sepsis is diagnosed through a medical assessment performed by a healthcare provider.They diagnose sepsis using physical findings, such as: Fever, Increased heart rate, Low blood pressure, Trouble breathing.Research shows that rapid, effective sepsis treatment includes: Giving appropriate treatment, including antibiotics, as soon as possible, Maintaining blood flow to organs, Sometimes surgery is required to remove tissue damaged by the infection. Healthcare providers should treat sepsis as soon as possible. This information is taken from the website https://www.cdc.gov/sepsis/about/index.html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure medications were available for administration for one of five residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to obtain Vancomycin for administration, the resident missed six doses of the medication. The physician order dated, 2/26/24 at 9:55 a.m. documented, Vancomycin HCL (hydrochloride) (1) Oral Capsule 125 MG (milligrams); Give 1 capsule by mouth four times a day for c-diff (clostridium difficile)(2). The February 2024 MAR (medication administration record) documented the above order. On 2/26/24 at the 1:00 p.m. dose a 9 was documented. A 9 indicates Other/See progress note. On 2/26/24 for the 5:00 p.m. and 9:00 p.m. dose a 5 was documented. A 5 indicates Hold/See progress note. On 2/27/24 for the 9:00 a.m. dose, it was documented as having been administered. On 2/27/24 for the 1:00 p.m. dose, a 9 was documented. Review of the nurse's notes revealed the following: On 2/26/24 at 2:07 p.m. - Medication is on the way, not given during this shift. 2/26/24 at 10:48 p.m. - medicine is on order. 2/26/24 at 11:27 p.m. - Called for pharmacy, they told us would send overnight. Not given two scheduled times. Need to adjust the order. 2/27/24 at 12:45 p.m. - Medication is on the way, not given. The pharmacy manifest documented the medication was delivered to the facility on 2/27/24 at 1:16 p.m. Review of the contents list of the Omnicell, failed to evidence the facility stocks Vancomycin Oral Capsules in the sysytem. An interview was conducted with LPN (licensed practical nurse) #2, on 2/19/25 at 9:28 a.m. When asked what a nurse is to do when a medication is not on the medication cart at the time it is to be administered, LPN #2 stated, First the nurse needs to look in the medication room. If not there go to the Omnicell (pharmacy storage unit in facility). Call the pharmacy that you are missing the medication. Notify the nurse practitioner and responsible party. When asked if the facility stocks Vancomycin Oral Capsules, LPN #2 stated she didn't believe so. LPN #2 further stated with a medication like that, the nurse should have called the pharmacy to have the medication sent from a local pharmacy. She stated if the nurse practitioner puts the order an order in the system in the morning, it generally is here on the afternoon delivery around 6:00 p.m. The facility policy, Medication Unavailability documented, A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered. 1. A licensed nurse will notify the provider of the unavailability of medication and discuss an alternative order, if necessary. 2. If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process and procedures. 3. A licensed nurse will document notification to the provider of the unavailability in the medical record. 4. A licensed nurse will notify the responsible party of any new orders and document notification in the medical record. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 2/19/25 at 2:15 p.m. No further information was provided prior to exit. References: (1) Vancomycin is used to treat colitis (inflammation of the intestine caused by certain bacteria) that may occur after antibiotic treatment. Vancomycin is in a class of medications called glycopeptide antibiotics. It works by killing bacteria in the intestines. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a604038.html. (2) C. diff is a bacterium that can cause diarrhea and more serious intestinal conditions such as colitis. You may see it called other names, such as Clostridioides difficile (the new name), Clostridium difficile (an older name), and C. difficile. This information was obtained from the following website: https://medlineplus.gov/cdiffinfections.html.

Based on resident interview, family interview, and clinical record review, it was determined the facility staff failed to provide incontinence care in a timely manner for one of five residents in the survey sample, Resident # 2. The findings include: For Resident #2 (R2), the facility staff failed to offer toileting or incontinence care for a period of three hours. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 12/16/24, the resident scored an 11 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section GG - Functional Status, the resident was coded as requiring substantial/maximum assistance for toilet transfers. In Section H - Bladder and Bowel, the resident was coded as being frequently incontinent of both bowel and bladder. On 2/18/25 at 10:30 a.m., An interview was conducted with R2 and her family. R2 stated, I had taken a shower around 7:00 a.m. to 7:15 a.m. The resident stated,I had not been offered to go to the bathroom or had her brief changed since that time. The family member stated, 'She has asked for a toileting schedule for R2. At 10:57 a.m. the resident's family member requested the resident be taken to the bathroom as she had to have a bowel movement. On 2/18/25 at 1:56 p.m. observation was made of the resident's bathroom call bell ringing. The resident was in the bathroom. Once brought out from the bathroom, the resident's family member and surveyor noted the resident had on a different pair of pants. The comprehensive care plan dated, 12/27/23, documented in part, Focus: (R2) is incontinent of bladder and bowel. Interventions: provide toileting hygiene with brief changes. On 2/18/25 at 2:15 p.m., An interview was conducted with CNA (certified nursing assistant) #1, CNA #1 stated, Residents should be checked on or toileted every two hours. She stated she had given R2 a shower at 7:00 a.m. in the morning. She stated she had not checked her until the nurse and unit manager had assisted her to the bathroom around 11:00 a.m. CNA #1 stated she didn't get back to the resident before then. When asked why the resident's pants had to be changed when she toileted her around 2:00 p.m. CNA #1 stated they were damp. CNA #1 stated the resident was not on a toileting schedule. On 2/19/25 at 10:43 a.m., An interview was with LPN (licensed practical nurse) #1, When asked if R2 was on a toileting schedule, LPN #1 stated, She was not. LPN #1 stated, The resident was better at telling them she needed to go to the bathroom before, but now she doesn't tell us as much. R2 is taken to the bathroom upon rising, then after lunch and before the shift ends around 2:45 p.m. LPN #1 stated the resident sometimes doesn't want to go to the bathroom between breakfast and lunch, but always goes after lunch and before the shift ends. On 2/19/25 11:25 a.m., An interview was conducted with ASM (administrative staff member) #2, the director of nursing, ASM #2 stated, R2 was not on a toileting schedule, but it is her expectation of her staff to do purposeful rounding every two hours that includes incontinence care or the offering of toileting. On 2/19/25 at 2:15 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the regional nurse consultant were made aware of the above findingsASM #3 stated the facility did not have a policy on toileting/incontinence care. No further information was provided prior to exit.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide care and services, for one of 40 residents in the survey sample, receiving dialysis services, Resident #76. The findings include: For Resident #76, the facility staff failed to evidence the monitoring of the resident's dialysis access, an arterial - venous fistula. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/30/2024, the resident scored a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section B - Hearing, Speech and Vision, the resident was coded as having highly impaired vision. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hemodialysis (1). The resident was admitted to the facility on [DATE]. Observation was made of Resident #76 on 4/16/2024 at 10:37 a.m. The resident was sitting on the side of the bed, working with therapy. A dressing was noted on their left wrist, the site of the fistula (2). The nurse's note dated, 3/22/2024 at 10:04 p.m. documented, Pt (patient) is noted with a fistular [sic] on his left arm. Further review of the nurse's notes failed to evidence any documentation related to the resident's fistula. Review of the MAR (medication administration record) and the TAR (treatment administration record) for March and April 2024, failed to evidence documentation related to the fistula. The physician order dated 4/16/2024, documented, Check for the presence of bruit/thrill. If present document YES. If not present document NO, enter progress note and notify MD (medical doctor) q (every) shift. An interview was conducted with RN (registered nurse) #3 on 4/17/2024 at 9:40 a.m. When asked how she checks and documents a resident with a dialysis access, RN #3 stated, she palpates the thrill and document it in a progress note. RN #3 was asked if she listens to the dialysis access, RN #3 stated, no. When asked how often this is to be done, RN #3 stated it's supposed to be checked after dialysis and check the site for bleeding and the thrill. The above order was read to RN #3. When asked how she checks the bruit, RN #3 stated she thought they were the same things as a thrill. The facility policy, Hemodialysis, documented in part, Procedure: 1. Palpate for the presence of the thrill over the shunt upon return from dialysis and daily. 2. Auscultate bruit per physician's order .5. Document findings daily on the Treatment Administration Record, and document any unusual findings and notification of physician/responsible party in the Nurses Note. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit. References: (1) Hemodialysis is the procedure used in which wastes and impurities are removed from the blood by a special machine. Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 266. (2) Fistula is a channel connecting an artery and vein for the use during dialysis. Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 228.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement physician's orders for one of 40 residents in the survey sample; Resident #61. The findings include: 1. For Resident #61, the facility staff failed to implement physician's orders for (1) obtaining daily weights and (2) notify the nurse practitioner or physician of more than three pounds of weight gain in one day or five pounds in a week. A review of the clinical record revealed a physician's order dated 3/20/24, documented, daily weight notify NP/MD (Nurse Practitioner / Medical Doctor) of more than 3 lbs (pounds) (of weight gain) in a day or 5lbs in a week for heart failure. A second physician's order, dated 3/20/24, documented, Fluid Restriction: 1500ml (milliliters) per day - Meals from kitchen = Breakfast 300ml; Lunch 420ml; Dinner 360ml. Nursing = Morning Meds 120ml; Afternoon Meds 120ml; Evening Meds 120ml; Night Shift 60ml. A third physician's order, dated 3/25/24, for Furosemide (1) Oral Tablet 20 MG (milligrams) Give 40 mg by mouth one time a day for Edema. A review of the MAR (Medication Administration Record) revealed the following: March 2024: On 3/29/24 the weight was documented as 118.7 pounds. On 3/30/24 the weight was documented as 127 pounds. This was a 8.3 pound weight gain in one day. A review of the progress notes failed to reveal any evidence that the physician was notified of the 8.3 pound weight gain in one day. April 2024: On 4/7/24 the weight was documented as 126.7 pounds. There was no daily weight obtained for 4/8/24. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/8/24. There was also no evidence that the physician was notified that the daily weight was not obtained. Then, on 4/9 the weight was documented as 139 pounds. This was a 12.3 pound weight gain between the above 4/7/24 weight and the 4/9/24 weight. A review of the progress notes failed to reveal any evidence that the physician was notified of the 12.3 pound weight gain in two days. On 4/14/24 there was no daily weight obtained. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/14/24. There was also no evidence that the physician was notified that the daily weight was not obtained. On 4/18/24 at 12:45 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). He stated that if there was no weight documented then it wasn't done and the order was not followed. He stated that if the physician was not notified per order then the order was not followed. A request was made for a policy regarding implementing physician's orders / obtaining daily weights as ordered. None was provided. On 4/18/24 at approximately 1:00 PM, ASM (Administrative Staff Member) #1 the Administrator, #2 the Director of Nursing, and #3 the [NAME] President of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Furosemide is a diuretic used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682858.html

Based on observation, resident interview, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed rail assessments and consents for three of 40 residents in the survey sample, Residents #4, #358 and #359. The findings include: 1. For Resident #4 (R4), the facility failed to evidence an assessment or consent for the use of bed rails. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/25/2024, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact to make daily decisions. The resident was coded as requiring partial/moderate assistance with rolling left and right and not having any limitation in range of motion to the upper extremities. On 4/15/2024 at approximately 3:26 p.m., an observation was made of R4 in bed with bilateral bar shaped bed rails in place. At this time an interview was conducted with R4 who stated they used the bed rails to turn and position themselves in the bed. An additional observation of R4 was made on 4/16/2024 at approximately 8:11 a.m. in bed with the bed rails in place. The comprehensive care plan for R4 documented in part, Device: [Name of R4] prefers to have bed rails in place while in bed. [Name of R4] uses wheelchair for locomotion. [Name of R4] uses air mattress for wound healing. Created on: 03/19/2024. Revision on: 03/20/2024. The Admission/Readmission Nursing Collection Tool for R4 dated 3/18/2024 documented in part, .Bed Side Rail Tool. Nursing Evaluation and Consent Tracking. Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? No . The additional questions of the bed side rail tool were observed to be blank. On 4/16/2024 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the bed rail assessment and consent for R4. On 4/17/2024 at approximately 8:00 a.m., ASM #1 provided a bed side rail tool evaluation for R4 dated 4/16/2024 documenting the resident utilizing bed rails. On 4/17/2024 at 9:49 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that bed rail assessments were completed during admission on the nursing admission assessment. She stated that some residents used the bed rails for turning and positioning if they preferred to have them and could use them. She stated that during the assessment they asked the resident if they wanted the rails and got the consent and did an assessment to make sure they could use them. She stated that if the assessment did not document use of bed rails they removed the rails from the bed. She stated that this was done because bed rails were not safe for all residents and an assessment had to be completed. The facility policy Restraints effective 11/01/19 documented in part, The Device Assessment will be completed to provide documentation of the needs, and risk factors involved in the use of a restraint or device used by the patient . The Device Assessment is used to provide documentation that the patient/responsible party has been informed of the purpose, benefits, and potential complications associated with the use of a device(s) . On 4/17/2024 at 11:35 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services, and ASM #6, the administrator in training were made aware of the findings. No further information was provided prior to exit. 2. For Resident #358 (R358), the facility failed to evidence an assessment or consent for the use of bed rails. The MDS (minimum data set) assessment was not due at the time of the survey. The Admission/Readmission Nursing Collection Tool for R358 dated 4/11/2024 documented the resident being alert and oriented to person, place, time and situation. The assessment documented in part, .Bed Side Rail Tool. Nursing Evaluation and Consent Tracking. Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? No . The additional questions of the bed side rail tool were observed to be blank. On 4/15/2024 at approximately 1:00 p.m., an observation was made of R358 in bed with bilateral bar shaped bed rails in place. At this time an interview was conducted with R358 who stated that the bed rails were on the bed when they were admitted and they used them to adjust themselves in bed. An additional observation of R358 was made on 4/15/2024 at approximately 4:04 p.m. in bed with the bed rails in place. The comprehensive care plan for R358 documented in part, Devices: [Name of R358] has bed rails in place for turning and repositioning. [Name of R358] uses a wheelchair for locomotion. Created on: 04/12/2024. On 4/16/2024 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the bed rail assessment and consent for R358. On 4/17/2024 at approximately 8:00 a.m., ASM #1 provided a bed side rail tool evaluation for R358 dated 4/16/2024 documenting the resident utilizing bed rails. On 4/17/2024 at 9:49 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that bed rail assessments were completed during admission on the nursing admission assessment. She stated that some residents used the bed rails for turning and positioning if they preferred to have them and could use them. She stated that during the assessment they asked the resident if they wanted the rails and got the consent and did an assessment to make sure they could use them. She stated that if the assessment did not document use of bed rails they removed the rails from the bed. She stated that this was done because bed rails were not safe for all residents and an assessment had to be completed. On 4/17/2024 at 11:35 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services, and ASM #6, the administrator in training were made aware of the findings. No further information was provided prior to exit. 3. For Resident #359 (R359), the facility failed to evidence an assessment or consent for the use of bed rails. The MDS (minimum data set) assessment was not due at the time of the survey. The Admission/Readmission Nursing Collection Tool for R359 dated 4/11/2024 documented the resident being alert and oriented to person and place. The assessment documented in part, .Bed Side Rail Tool. Nursing Evaluation and Consent Tracking. Does the resident need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? No . The additional questions of the bed side rail tool were observed to be blank. On 4/15/2024 at approximately 1:22 p.m., an observation was made of R359 in bed with bilateral bar shaped bed rails in place. At this time an interview was conducted with R359 and their power of attorney who stated that the bed rails had always been on the bed. R359 stated that they held onto them sometimes when they were receiving care. An additional observation of R359 were made on 4/16/2024 at approximately 8:09 a.m. and 4/16/2024 at approximately 2:12 p.m. in bed with the bed rails in place. The comprehensive care plan for R359 documented in part, Devices: [Name of R359] has bed rails in place for turning and repositioning. [Name of R359] uses a wheelchair for locomotion. Created on: 04/12/2024. On 4/16/2024 at approximately 4:00 p.m., a request was made to ASM (administrative staff member) #1, the administrator for the bed rail assessment and consent for R359. On 4/17/2024 at approximately 8:00 a.m., ASM #1 provided a bed side rail tool evaluation for R359 dated 4/16/2024 documenting the resident utilizing bed rails. On 4/17/2024 at 9:49 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that bed rail assessments were completed during admission on the nursing admission assessment. She stated that some residents used the bed rails for turning and positioning if they preferred to have them and could use them. She stated that during the assessment they asked the resident if they wanted the rails and got the consent and did an assessment to make sure they could use them. She stated that if the assessment did not document use of bed rails they removed the rails from the bed. She stated that this was done because bed rails were not safe for all residents and an assessment had to be completed. On 4/17/2024 at 11:35 a.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services, and ASM #6, the administrator in training were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to ensure one of 40 residents in the survey sample were free of unnecessary medications, Resident #156. The findings include: For Resident #156, the facility staff failed to hold a blood pressure medication when the blood pressure was below the physician ordered parameters. The physician order dated 4/10/2024, documented, Metoprolol Succinate ER (extended release) Oral Tablet Extended Release 24 hours 50 MG (milligrams); Give 1 tablet by mouth in the morning for HTN (high blood pressure)/Sick Sinus Syndrome. Hold for SBP (systolic blood pressure) < (less than) 130 or HR (heart rate) < 60. The April 2024 MAR (medication administration record) documented the above order. On 4/13/2024 the blood pressure was documented as 120/58. The medication was documented as having been administered. On 4/14/2024 the blood pressure was documented as 102/66. The medication was documented as having been administered. An interview was conducted with LPN (licensed practical nurse) #4 on 4/17/2024 at 8:20 a.m. When asked if a medication has parameters for administering it, what does the nurse do, LPN #4 stated that if a blood pressure or pulse is needed prior to giving the medication, you take the pulse or blood pressure. The computer triggers you to enter the vital sign that is required. You hold the medication based on the physician order. The above documentation was reviewed with LPN #4. LPN #4 stated the medication should have been held on those two days. The facility policy, Administration Procedures for All Medications, documented in part, 6. Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration .13. Notify the attending physician and/or prescriber of .b. Held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results or vital signs resulting in medication being held. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.

Based on staff interview and clinical record review, it was determined the facility staff failed to have a written agreement for services provided for one of one resident receiving dialysis services, Resident #76. The findings include: The facility failed to have a written agreement with the dialysis center that was providing dialysis services to Resident #76. On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/30/2024, the resident scored a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. In Section B - Hearing, Speech and Vision, the resident was coded as having highly impaired vision. In Section O - Special Treatments, Procedures and Programs, the resident was coded as receiving hemodialysis (1). The resident was admitted to the facility on [DATE]. The physician order dated, 3/23/2024, documented, Hemodialysis (1) 3X/week (three times per week) MWF (Monday, Wednesday, Friday) at (name, address and phone number of dialysis center). A request was made for the dialysis contracts during the entrance conference on 4/15/2024 at approximately 11:45 a.m. One contract was provided, it was for another dialysis center in a different town than the one that Resident #76 attended. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 4/17/2024 at 10:07 a.m. ASM #1 stated they do not have a contract with the dialysis center that Resident #76 goes to. They usually send residents to the local dialysis center. Resident #76's family wished to maintain Resident #76 at their normal center. ASM #1 stated she was on vacation when this happened. ASM #1, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit. References: (1) Hemodialysis is the procedure used in which wastes and impurities are removed from the blood by a special machine. Barron's Dictionary of Medical Terms, 5th edition, Rothenberg and [NAME], page 266.

Based on observation, staff interview, facility document review, it was determined the facility staff failed to ensure medications were not left at the bedside without an assessment for self-administration for one of 40 residents in the survey sample, Resident #25. The findings include: On the most recent MDS (minimum data set) assessment, an admission assessment, with an ARD (assessment reference date) of3/29/24, the resident scored a 15 out of 15 indicating the resident is not cognitively impaired for making daily decisions. Observation was made with LPN (licensed practical nurse) #4, on 4/16/2024 at 8:25 a.m. On the overbed table was a bottle of nasal saline spray and an albuterol inhaler. LPN #4 picked up the medications and stated they shouldn't be in the resident's room. When asked why the medications can't be in the resident's room, LPN #4 stated that the residents can't have medications in their room. If they see them in the room, they are to remove them. Review of the resident clinical record failed to evidence an assessment for the self-administration of medications. A request was made for the assessment, and none was provided prior to exit. The MAR (medication administration record) for April documented the physician order, dated 3/23/2024, Saline Mist Spray Nasal Solution 0.65% saline: 1 spray in each nostril every 4 hours for nose bleeds. The last documented time it was administered prior to the observation was on 4/16/2024 at 4:00 a.m. The physician order dated 3/27/2024, documented, Albuterol Sulfate HFA Aerosol Solution Inhalation 108 mcg (micrograms)/ (per) ACT (activation); 2 puffs inhale orally every 6 hours as needed for wheezing for 5 Days. There was no documentation on the MAR or in the progress notes of the administration of the Albuterol inhaler. The facility policy, Self-Administration of Medication at Bedside documented in part, Procedure: 1. The patient may request to keep medications at bedside for self-administration in a lock box. 2. Verify physician's order in the patient's chart for self-administration of specific medications under consideration. 3. Complete self-administration safety screen. 4. The interdisciplinary Team will review the assessment and will document during care plan. 5. Self-administration of meds must e reviewed by the Interdisciplinary team quarterly and PRN if change in status is noted .6. Medications that are ordered by a physician to be self-administered will be identified on the MAR (medication administration record). 7. A licensed nurse will monitor and chart self-administered drugs and will monitor for proper storage on each med pass. 8. When a patient becomes unable to self-administer meds, it must be brought to the attention of the appropriate staff via the Shift Report. 9. When a patient is unable to self-administer medications, the meds will be given by nursing staff until the patient can be reassessed by the Interdisciplinary Team. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to notify the physician and/or resident representative of a change in condition for two of 40 residents in the survey sample; Residents #61 and #155. The findings include: 1. For Resident #61, the facility staff failed to notify the physician of an increase in daily weights per order; and when daily weights were not obtained per order. A review of the clinical record revealed a physician's order dated 3/20/24, documented, daily weight notify NP/MD (Nurse Practitioner / Medical Doctor) of more than 3 lbs (pounds) (of weight gain) in a day or 5lbs in a week for heart failure. A second physician's order, dated 3/20/24, documented, Fluid Restriction: 1500ml (milliliters) per day - Meals from kitchen = Breakfast 300ml; Lunch 420ml; Dinner 360ml. Nursing = Morning Meds 120ml; Afternoon Meds 120ml; Evening Meds 120ml; Night Shift 60ml. A third physician's order, dated 3/25/24, for Furosemide (1) Oral Tablet 20 MG (milligrams) Give 40 mg by mouth one time a day for Edema. A review of the MAR (Medication Administration Record) revealed the following: March 2024: On 3/29/24 the weight was documented as 118.7 pounds. On 3/30/24 the weight was documented as 127 pounds. This was a 8.3 pound weight gain in one day. A review of the progress notes failed to reveal any evidence that the physician was notified of the 8.3 pound weight gain in one day. April 2024: On 4/7/24 the weight was documented as 126.7 pounds. There was no daily weight obtained for 4/8/24. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/8/24. There was also no evidence that the physician was notified that the daily weight was not obtained. Then, on 4/9 the weight was documented as 139 pounds. This was a 12.3 pound weight gain between the above 4/7/24 weight and the 4/9/24 weight. A review of the progress notes failed to reveal any evidence that the physician was notified of the 12.3 pound weight gain in two days. On 4/14/24 there was no daily weight obtained. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/14/24. There was also no evidence that the physician was notified that the daily weight was not obtained. On 4/18/24 at 12:45 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). He stated that if there was no note documenting that the physician was notified of a weight change, then it wasn't done. The facility policy, Documentation and Notification was reviewed. This policy documented, 1. The Charge Nurse is responsible for notifying the Physician (MD) and/or the Responsible Party (RP) whenever there is a change related to the care of the patient 3. The Unit Manger is ultimately responsible to ensure that notification of the MD/RP has occurred and has been documented accurately On 4/18/24 at approximately 1:00 PM, ASM (Administrative Staff Member) #1 the Administrator, #2 the Director of Nursing, and #3 the [NAME] President of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Furosemide is a diuretic used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682858.html 27660 2. The facility staff failed to notify the physician, per the physician order, of blood sugar reading that were over the prescribed parameter for Resident #155. The physician order dated, 4/12/2024, documented, Humulin R (regular) Injection Solution (used to treat diabetes) 100UNIT/ML (milliliter) (insulin Regular Human); inject as per sliding scale: if 180 - 200 = 1 (unit) 201 - 250 = 2 (units) 251 - 300 = 3 (units) 301 - 350 = 4 (units) 351 + = 5 (units) & notify NP (nurse practitioner)/MD (medical doctor) & recheck in one hour & document in nursing note, subcutaneously every 6 hours for DM (diabetes mellitus) & continuous TF (tube feeding) diet. The blood sugars were documented on the following dates and time: 4/13/2024 at 12:00 p.m. = 377 4/13/2024 at 6:00 p.m. = 371 4/14/2024 at 12:00 a.m. = 414 $/15/2024 at 6:00 p.m. = 369 4/16/2024 at 12:00 a.m. = 401 4/17/2024 at 12:00 a.m. = 387 For each of the above results, five units on insulin was documented as given. Review of the progress notes failed to evidence documentation of the NP/MD being notified of the results of the blood sugar. An interview was conducted with LPN (licensed practical nurse) #4, on 4/17/2024 at 9:28 p.m. The above order and blood sugar results were reviewed with LPN #4. When asked what steps the nurse should take when the blood sugar was above the physician prescribed parameters, LPN #4 stated the nurse should give the five units of insulin and then notify the nurse practitioner or doctor and then do the recheck in an hour. LPN #4 was asked where the recheck of the blood sugar is documented, LPN #4 stated there should be a progress note with all that you did. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required resident clinical information when a resident is transferred to the hospital, for three of 40 residents in the survey sample, Residents #72, #100 and #25. The findings include: 1. The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #72. Resident #72 was transferred to the hospital on 2/21/24. Resident #72 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD, intestinal fistula, afib (atrial fibrillation) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/4/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section GG-functional status coded the resident as requiring maximal assistance for bathing, transfer and hygiene; independent for eating and locomotion. A review of the comprehensive care plan dated 2/27/24 revealed, FOCUS: Resident has developed gastrointestinal infection. INTERVENTIONS: Observe resident for signs and symptoms of dehydration as a result of loose stools and possible malaise. Notify physician as needed. Obtain labs as ordered. There was no evidence of clinical documents sent with the resident to the hospital on 2/21/24. A review of the progress note dated 2/21/24 at 10:30 AM revealed, Patient was transferred out of facility by EMS (emergency medical services) via stretcher for excessive bleeding from her abdominal fistula to hospital. Patient states her dressing got changed around 4:30am and by 7:30am she needed it to be redone. Stated she woke up with blood all her abdomen and it was more than normal. Vitals were stable: blood pressure 101/69, heart rate 97, Oxygen saturation 96%, respirations 17, and temperature 98.7. No other complaints other than slight pain where fistula is and anxiety over the blood. Wound nurse checked out fistula. All morning medication was administered before she left. Report given to hospital. Family aware of transfer. Supervisor and NP (nurse practitioner) aware of transfer. An interview was conducted on 4/17/24 at 8:30 AM with LPN (licensed practical nurse) #2. When asked what documents are sent with the resident to the hospital, LPN #2 stated, the face sheet, care plan, physician orders, labs, history/physical, medication list and the eINTERACT (Interventions to Reduce Acute Care Transfer) form. When asked how that would be evidenced, LPN #2 stated, there would be initials on the eINTERACT form or it would be documented in the progress note. The eINTERACT form did not evidence any initials of documents sent. On 4/17/24 at 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training were made aware of the findings. A review of the facilities Patient Transfer Form policy revealed, A Patient Transfer Form (eINTERACT) must be sent with the patient when transporting to a hospital or acute care setting. This process will provide a format of all pertinent information regarding the patient's medical status when the patient requires additional hospital care and treatment. No further information was provided prior to exit. 31753 2. For Resident #100 (R100), the facility staff failed to evidence required information was provided to hospital staff and failed to evidence a physician note regarding transfer was documented when the resident was transferred to the hospital on 2/7/24. A review of R100's clinical record revealed the resident was transferred to the hospital on 2/7/24 and was admitted due to abdominal pain. Further review of R100's clinical record failed to reveal documentation of the information provided to the hospital staff and failed to reveal a physician's note regarding the transfer. On 4/17/24 at 9:37 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated she sends a copy of the care plan, a medication list, labs, a face sheet, a medication list, a list of allergies, and the resident's code status to the hospital when a resident is transferred but she does not document to evidence this is done. RN #3 stated she was not aware of the physician documenting a note regarding hospital transfers. On 4/17/24 at 11:38, ASM #1 (the administrator) and ASM # 2 (the director of nursing) were made aware of the above 27660 3. The facility staff failed to evidence the required clinical documents were sent with the resident upon transfer to the hospital, Resident #25. The nurse's note dated, 3/17/2023 at 9:24 a.m. documented, Patient was unresponsive to verbal and tactile stimuli. Blood pressure was 91/61, O2 (oxygen) was 54% on 4 L (liters), temp (temperature) was 97, heart rate was 81, blood sugar was 288. Patient was transferred to hospital via EMS (emergency medical services) at 0830 (8:30 a.m.). Emergency contact notified as well as (name of nurse practitioner). Further review of the clinical record failed to evidence that the required clinical documents were sent with the resident to the hospital. An interview was conducted with RN (registered nurse) #3 on 4/17/2024 at 9:40 a.m. When asked what documents she sends to the hospital with the resident upon transfer, RN #3 stated, she sends the reason why the resident is being sent, vital signs, code status, history, critical labs, and allergies. When asked if the care plan goals are sent, RN #3 stated we send a copy of the care plan. She stated they call the hospital with report. When asked if she writes a progress note of everything she has sent with the resident, RN #3 stated they used to have a check off list and they used to print everything but for some reason, it wasn't working out and taking too long to download so we don't do that anymore. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to evidence a bed hold notice was provided when one of 40 residents were transferred to the hospital, Resident #25. The findings include: The nurse's note dated, 3/17/2023 at 9:24 a.m. documented, Patient was unresponsive to verbal and tactile stimuli. Blood pressure was 91/61, O2 (oxygen) was 54% on 4 L (liters), temp (temperature) was 97, heart rate was 81, blood sugar was 288. Patient was transferred to hospital via EMS (emergency medical services) at 0830 (8:30 a.m.). Emergency contact notified as well as (name of nurse practitioner). Further review of the clinical record failed to evidence that a bed hold notice was sent with the resident to the hospital. A request was made for evidence that the bed hold notice was sent with the resident upon transfer and none was provided prior to exit. An interview was conducted with RN (registered nurse) #3 on 4/17/2024 at 9:40 a.m. When asked what documents she sends to the hospital with the resident upon transfer, RN #3 stated, she sends the reason why the resident is being sent, vital signs, code status, history, critical labs, and allergies. When asked if she sends a copy of a bed hold notice with the resident, RN #3 stated, no. The Bed Reserve Policy documented, The Admissions Director will ensure the proper documentation is executed for any patient desiring to voluntarily reserve a bed. Procedure: The Admissions Director must establish contact with the patient and/or responsible agent to determine bed retention arrangements once the patient's hospitalization has been confirmed. 2. The Admissions Director will inform the patient/responsible representative of the payment amount necessary for the requested accommodation of days. 3. The Admissions Director will establish a time for the signing of the Voluntary Bed Retentions Agreement and the collection of payment. 4. The Admissions Director will notify staff of the Voluntary Bed Retention Agreement once the agreement has been singed and the payment collected. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.

Based on observations, resident/staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop/implement the care plan for three of 40 residents in the survey sample, Residents #72, #155 and #64. The findings include: 1.The facility staff failed to develop the comprehensive care plan for PTSD (Post Traumatic Stress Disorder) for Resident #72. Resident #72 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), intestinal fistula, afib (atrial fibrillation) and CHF (congestive heart failure). The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 3/4/24, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section GG-functional status coded the resident as requiring maximal assistance for bathing, transfer and hygiene; independent for eating and locomotion. A review of the comprehensive care plan dated 2/27/24 revealed, FOCUS: Resident has developed gastrointestinal infection. INTERVENTIONS: Observe resident for signs and symptoms of dehydration as a result of loose stools and possible malaise. Notify physician as needed. Obtain labs as ordered. Care Plan was revised on 4/15/24 after entrance to include care plan for PTSD. A review of the facility Trauma Informed Screen dated 2/7/24 at 10:51 AM revealed, Patient has PTSD. Referral to mental health provider. Trauma Care Plan: Focus: the resident reported trauma during their trauma screening related to PTSD. Focus: the resident reported trauma during their trauma screening. Goal: the residents past traumatic experiences will not cause the distress thru the review period. Intervention: refer to psych services as indicated. An interview was conducted on 4/15/24 at 4:05 PM with Resident #72. When asked if she had PTSD, Resident #72 stated, yes, I do. An interview was conducted on 4/16/24 at 12:30 PM with LPN (licensed practical nurse) #2. When asked the purpose of the care plan, LPN #2 stated, it is to set out the care that the resident needs and the interventions needed to meet that care. When asked if PTSD should be on the care plan, LPN #2 stated yes, it should. When asked when it should be included, LPN #2 stated, if there was a diagnosis on admission, it should have been included on the admission care plan. On 4/17/24 at 1:00 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training were made aware of the findings. A review of the facilities Care Planning policy revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental and psychosocial well-being of the patient. The care plan will include, if deemed appropriate, behavioral health services which include, but are not limited to, the prevention and treatment of mental and substance use disorders. No further information was provided prior to exit. 27660 2. The facility staff failed to implement the care plan for the treatment of diabetes for Resident #155. The comprehensive care plan dated, 4/12/2024 documented in part, Focus: DIABETES MELLITUS: (Resident #155) is at risk for complications and blood glucose fluctuations related to diagnoses of diabetes mellitus. The Interventions documented in part, Administer medications as ordered. Labs (laboratory tests) as ordered. Observe fir signs and symptoms of hyper/hypoglycemia and notify MD (medical doctor) as indicated. The physician order dated, 4/12/2024, documented, Humulin R (regular) Injection Solution (used to treat diabetes) 100UNIT/ML (milliliter) (insulin Regular Human); inject as per sliding scale: if 180 - 200 = 1 (unit) 201 - 250 = 2 (units) 251 - 300 = 3 (units) 301 - 350 = 4 (units) 351 + = 5 (units) & notify NP (nurse practitioner)/MD (medical doctor) & recheck in one hour & document in nursing note, subcutaneously every 6 hours for DM (diabetes mellitus) & continuous TF (tube feeding) diet. The blood sugars were documented on the following dates and time: 4/13/2024 at 12:00 p.m. = 377 4/13/2024 at 6:00 p.m. = 371 4/14/2024 at 12:00 a.m. = 414 $/15/2024 at 6:00 p.m. = 369 4/16/2024 at 12:00 a.m. = 401 4/17/2024 at 12:00 a.m. = 387 For each of the above results, five units on insulin was documented as given. Review of the progress notes failed to evidence documentation of the NP/MD being notified of the results of the blood sugar. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. An interview was conducted with RN (registered nurse) #4 on 4/17/2024 at 1:43 p.m. When asked the purpose of the care plan, RN #4 stated it's how to care for the resident and each care plan is individualized to that resident. When asked if it should be followed, RN #4 stated, very much so. No further information was provided prior to exit. 42106 3. For Resident #64 (R64), the facility staff failed to implement the comprehensive care plan to administer medications as ordered. The Toprol XL (1) was administered on dates in February and March of 2024 when it should have been held according to the ordered blood pressure and pulse parameters set. The comprehensive care plan for R64 documented in part, Nursing Care Needs: [Name of R64] has nursing care needs r/t (related to) AFIB (atrial fibrillation), AKI (acute kidney injury), ETOH (alcohol) abuse, anxiety, heart failure, hyperlipidemia, hypertension, neuropathy, ulcer of left leg, venous insufficiency. Created on: 06/26/2022. Revision on: 11/01/2022. Under Interventions it documented in part, Administer medications/treatment as ordered. Created on: 06/26/2022 . The physician order dated 10/10/2023 documented, Toprol XL Oral Tablet Extended Release 24 Hour 25 MG (milligram) (Metoprolol Succinate) Give 1 tablet by mouth one time a day for A-fib (atrial fibrillation). Hold for SBP<120 (systolic blood pressure less than 120) or HR<60 (heart rate less than 60). The eMAR (electronic medication administration record) dated 2/1/2024-2/29/2024 documented the above order. The order was documented to be administered on 2/25/2024 with the blood pressure of 115/61 and on 2/28/2024 with the pulse of 56. The eMAR dated 3/1/2024-3/31/2024 documented the above order. The order was documented to be administered on 3/5/2024 with the blood pressure of 118/40, on 3/18/2024 with the blood pressure of 115/54 and on 3/27/2024 with the blood pressure of 113/48. On 4/17/2024 at 9:49 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that the purpose of the care plan was to keep a record of the overall care of the patient, provide continuity of care and be a communication tool between all the staff. She stated that the care plan was personalized and documented information specific to the resident like their preferences and behaviors. She stated that the care plan should be implemented to give the resident complete care because it included everything for the patients needs. She stated that medications were administered according to the physicians orders and that certain medications had parameters that should be followed which advised the nurses when to hold a medication according to the residents vital signs. She stated that the parameters were put into place to prevent any complications and prevent the blood pressure or heart rate from getting lower than they already were. RN #3 reviewed R64's eMAR and stated that according to the orders and the vital signs documented on the dates listed above, the Toprol XL should have been held. She stated that the eMAR documented the medications as being administered to R64 on those dates. On 4/17/2024 at 11:35 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services, and ASM #6, the administrator in training were made aware of the findings. No further information was provided prior to exit. Reference: (1) Toprol XL Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to treat chronic (long-term) angina (chest pain). Metoprolol is also used to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682864.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 40 residents in the survey sample; Resident #61. The findings include: 1. For Resident #61, the facility staff failed to review and revise the comprehensive care plan to include obtaining weights as ordered by the physician for a resident on a diuretic and fluid restriction with specific orders for daily weights and reporting changes to the physician. A review of the clinical record revealed a physician's order dated 3/20/24, documented, daily weight notify NP/MD (Nurse Practitioner / Medical Doctor) of more than 3 lbs (pounds) (of weight gain) in a day or 5lbs in a week for heart failure. A second physician's order, dated 3/20/24, documented, Fluid Restriction: 1500ml (milliliters) per day - Meals from kitchen = Breakfast 300ml; Lunch 420ml; Dinner 360ml. Nursing = Morning Meds 120ml; Afternoon Meds 120ml; Evening Meds 120ml; Night Shift 60ml. A third physician's order, dated 3/25/24, for Furosemide (1) Oral Tablet 20 MG (milligrams) Give 40 mg by mouth one time a day for Edema. A review of the MAR (Medication Administration Record) revealed the following: March 2024: On 3/29/24 the weight was documented as 118.7 pounds. On 3/30/24 the weight was documented as 127 pounds. This was a 8.3 pound weight gain in one day. A review of the progress notes failed to reveal any evidence that the physician was notified of the 8.3 pound weight gain in one day. April 2024: On 4/7/24 the weight was documented as 126.7 pounds. There was no daily weight obtained for 4/8/24. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/8/24. There was also no evidence that the physician was notified that the daily weight was not obtained. Then, on 4/9 the weight was documented as 139 pounds. This was a 12.3 pound weight gain between the above 4/7/24 weight and the 4/9/24 weight. A review of the progress notes failed to reveal any evidence that the physician was notified of the 12.3 pound weight gain in two days. On 4/14/24 there was no daily weight obtained. A review of the progress notes failed to reveal any evidence as to why the weight was not obtained on 4/14/24. There was also no evidence that the physician was notified that the daily weight was not obtained. A review of the comprehensive care plan revealed one dated 3/19/24 for Diuretics the resident is at risk for complications secondary to diuretic use due to diagnosis of CHF (congestive heart failure), Edema. This care plan contained the following interventions, all dated 3/19/24, were: 1. administer medications as ordered 2. auscultate lung sounds as needed 3. labs as ordered 4. observe for edema and notify MD as indicated 5. vitals as needed The interventions did not address the physician's ordered requirement to obtain daily weights and notify the nurse practitioner or physician of weight changes. On 4/18/24 at 12:45 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). He stated that for a resident with physician orders for obtaining daily weights, this is something that should be included on the care plan. The facility policy, Care Planning was reviewed. This policy documented, Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur On 4/18/24 at approximately 1:00 PM, ASM (Administrative Staff Member) #1 the Administrator, #2 the Director of Nursing, and #3 the [NAME] President of Operations were made aware of the findings. No further information was provided by the end of the survey. References: (1) Furosemide is a diuretic used to treat high blood pressure. Information obtained from https://medlineplus.gov/druginfo/meds/a682858.html

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 40 residents in the survey sample, Residents #99, #156, #155, #64. The findings include: 1. For Resident #99 (R99), the facility staff failed to ensure that a RN (registered nurse) pronounced the resident's death. A review of R99's clinical record revealed the resident presented with no vital signs on 3/3/24. Further review of R99's clinical record failed to reveal the resident's death was pronounced by a RN. On 4/17/24 at 11:31 a.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated a RN should pronounce a resident's death because it's a standard of practice ASM #1 and ASM #2 (the director of nursing) were made aware of the above concern . The facility policy titled,Record of Death-Virginia documented, Important note: Only a physician or an RN can pronounce death, 27660 2. For Resident #156, the facility staff failed to administer a nasal spray and an iron supplement per the physician orders. A. The physician order dated,3/28/2024 documented, Ferretts Oral Tablet 325 MG (milligrams) (106 Fe [iron]) (Ferrous Fumarate) (used to treat anemia); Give 1 tablet by mouth in the morning for anemia. The April 2024 MAR (medication administration record) documented the above order. On the following dates for the 9:00 a.m. dose a 15 was documented: 4/2/2024 4/5/2024 4/5/2024 4/7/2024 4/8/2024 4/10/2024 A 15 indicated that No coverage was required. On 4/13/2024 through 4/16/2024, it was documented as administered. An interview was conducted with LPN (licensed practical nurse) #4 on 4/17/2024 at 1:10 p.m. The above order was reviewed with LPN #4. When asked why the medication had not given for all the days, LPN #4 stated the facility only had Ferrous Sulfate and it had to be ordered. (OSM - other staff member) #3, the central supply clerk had to order it and we had to wait for the shipment. An interview was conducted with OSM #3 on 4/17/2024 at 11:20 a.m. When asked why the ferrous fumarate took so long to get, OSM #3 stated she had a bottle of long-acting iron in a medication room and gave it to the nurse. The nurse said that would be fine. On 4/17/2024 at 11:29 a.m. LPN #4 was asked to show the bottle of what she had administered to the resident as documented for the past two days. The bottle showed slow-release iron 45 MG. Under the ingredient label, it documented, ferrous sulfate. When asked if that was the same thing as the ferrous fumarate, LPN #4 stated no. The bottle of long-acting iron was shown to the nurse practitioner, ASM (administrative staff member) #4, on 4/17/2024 at 11:32 a.m. ASM #4 examined the bottle and stated that is not enough iron for this resident. It was not what she had ordered. ASM #4 stated she was not aware that the resident was not getting the ferrous fumarate that she had prescribed. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was obtained prior to exit. B. For Resident #156, the facility staff failed to administer Fluticasone Propionate Nasal Suspension (Flonase) per the physician order. The physician order dated 3/28/2024 documented, Fluticasone Propionate Nasal Suspension (Flonase) 50 MCG (micrograms)/ACT (activation); 2 sprays in both nostrils in the morning for nasal congestion. The MAR for April 2024 documented the above order. On the following dates for the 9:00 a.m. dose a 15 was documented: 4/2/2024 4/5/2024 4/6/2024 4/7/2024 4/8/2024 4/10/2024 4/11/2024 On 4/12/2024 a 9 was documented, indicating Other/See progress note. The progress notes were reviewed. The notes documented, Not available for each of the entries above. An interview was conducted with LPN (licensed practical nurse) #4 on 4/17/2024 at 11:10 a.m. When asked why the medication was not administered as prescribed, LPN #4 stated the medication was ordered on 3/28/2024 from the pharmacy, it never arrived, it was an over the counter medication. We didn't have it in the house. An interview was conducted with OSM #3 on 4/17/2024 at 11:20 a.m. When asked if Flonase is stocked in house, OSM #3 stated she always has it in stock as it is used frequently. On 4/17/2024 at 11:42 a.m. OSM #3 showed the stock room that contained two containers of Flonase. The manifest of deliveries was reviewed. The facility ordered two Flonase on 3/7/2024 and they arrived on 3/11/2024. The facility ordered two Flonase on 3/14/2024 and they arrived on 3/18/2024. The facility ordered four Flonase on 4/8/2024 and they arrived on 4/9/2024. OSM #3 stated that if we don't have an over-the-counter medication, the administrator sends her to the local pharmacy, Walmart or Walgreens, to purchase them. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit. 3. For Resident #155, the facility staff failed to implement the physician order for blood glucose monitoring. The physician order dated, 4/12/2024, documented, Humulin R (regular) Injection Solution (used to treat diabetes) 100UNIT/ML (milliliter) (insulin Regular Human); inject as per sliding scale: if 180 - 200 = 1 (unit) 201 - 250 = 2 (units) 251 - 300 = 3 (units) 301 - 350 = 4 (units) 351 + = 5 (units) & notify NP (nurse practitioner)/MD (medical doctor) & recheck in one hour & document in nursing note, subcutaneously every 6 hours for DM (diabetes mellitus) & continuous TF (tube feeding) diet. The blood sugars were documented on the following dates and time: 4/13/2024 at 12:00 p.m. = 377 4/13/2024 at 6:00 p.m. = 371 4/14/2024 at 12:00 a.m. = 414 $/15/2024 at 6:00 p.m. = 369 4/16/2024 at 12:00 a.m. = 401 4/17/2024 at 12:00 a.m. = 387 For each of the above results, five units on insulin was documented as given. Review of the progress notes failed to evidence documentation of the NP/MD being notified of the results of the blood sugar or evidence of the repeat blood sugar per the physician orders. An interview was conducted with LPN (licensed practical nurse) #4, on 4/17/2024 at 9:28 p.m. The above order and blood sugar results were reviewed with LPN #4. When asked what steps the nurse should take when the blood sugar was above the physician prescribed parameters, LPN #4 stated the nurse should give the five units of insulin and then notify the nurse practitioner or doctor and then do the recheck in an hour. LPN #4 was asked where the recheck of the blood sugar is documented, LPN #4 stated there should be a progress note with all that you did. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit. 42106 4. For Resident #64 (R64), the facility staff failed to follow physician orders to hold Toprol XL (1) according to blood pressure and pulse parameters set. The physician order dated 10/10/2023 documented, Toprol XL Oral Tablet Extended Release 24 Hour 25 MG (milligram) (Metoprolol Succinate) Give 1 tablet by mouth one time a day for A-fib (atrial fibrillation). Hold for SBP<120 (systolic blood pressure less than 120) or HR<60 (heart rate less than 60). The eMAR (electronic medication administration record) dated 2/1/2024-2/29/2024 documented the above order. The order was documented to be administered on 2/25/2024 with the blood pressure of 115/61 and on 2/28/2024 with the pulse of 56. The eMAR dated 3/1/2024-3/31/2024 documented the above order. The order was documented to be administered on 3/5/2024 with the blood pressure of 118/40, on 3/18/2024 with the blood pressure of 115/54 and on 3/27/2024 with the blood pressure of 113/48. On 4/17/2024 at 9:49 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated that medications were administered according to the physicians orders. She stated that certain medications had parameters that should be followed in the physician orders that advised the nurses when to hold a medication according to the residents vital signs. She stated that the parameters were put into place to prevent any complications and prevent the blood pressure or heart rate from getting lower than they already were. RN #3 reviewed R64's eMAR and stated that according to the orders and the vital signs documented on the dates listed above, the Toprol XL should have been held. She stated that the eMAR documented the medications as being administered to R64 on those dates. The facility policy Administration Procedures for All Medications revised 8/2020, documented in part, Medications will be administered in a safe and effective manner . Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration . On 4/17/2024 at 11:35 a.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services, and ASM #6, the administrator in training were made aware of the findings. No further information was provided prior to exit. Reference: (1) Toprol XL Metoprolol is used alone or in combination with other medications to treat high blood pressure. It also is used to treat chronic (long-term) angina (chest pain). Metoprolol is also used to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682864.html

Based on staff interview and clinical record review, it was determined the facility staff failed to provide showers in a timely manner for one of 40 residents in the survey sample, Resident #152. The findings include: For Resident #152, the facility staff failed to provide bathing for nine days after admission. On the MDS (minimum data set) assessment, an admission assessment, with the ARD (assessment reference date) of 3/2/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as not having any baths during the lookback period. The ADL (activities of daily living) record for February 2023, documented on 2/28/2023, the day of admission, the bathing activity did not occur. The ADL record for March 2023, documented the showers were to be given on 3/2/2023 and on 3/6/2023. On both dates, it was documented that the activity did not occur. The first documented shower given to Resident #152 was on 3/9/2023, nine days after admission. Review of the nurse's note failed to evidence documentation as to why the resident was not showered. An interview was conducted with CNA (certified nursing assistant) #4 on 4/17/2024 at 12:44 p.m. When asked how often a resident receives a shower or bath, CNA #4 stated twice a week. CNA #4 was asked what kind of bath, CNA #4 stated they offer a shower but some residents don't want a shower so we then give them a bed bath. It is documented in the computer. When asked if a resident has been in the facility for a week, how many shower/bed baths should they have received, CNA #4 stated at least one, depending on their shower days and when they came in. Administrative staff member (ASM) #1, the administration, ASM #3, the vice president of operations, ASM #5, the regional director of clinical services and ASM #6, the administrator in training, were made aware of the above concern on 4/17/2024 at 1:00 p.m. No further information was provided prior to exit.