Every finding on record at Lawrence Memorial Hospital SNF

The facility identified a census of nine residents. The sample included eight residents. Based on record review and interviews, the facility failed to establish and implement an admissions agreement that protected the residents' right to personal property. This deficient practice had the risk of loss of personal property, including property of monetary and/or sentimental value, and loss of dignity and personal right to property for residents admitted to the facility. Findings included: - A review of the facility's Consent to Treatment Authorizations/Agreements/Insurance assignments revealed under the section titled Personal Belongings documented the facility maintained a safe for the storage of patient valuables and recommends that residents place any valuables in the safe during their stay. All personal belongings not placed in the safe were solely the resident's responsibility and the facility would not be liable for any resulting loss or damage of such property. On 10/14/24 at 03:51 PM Administrative Nurse D stated the Health Information Management department reviewed admission agreements. She stated the facility completed an admission log with the resident's belongings on admission and the resident signed the log. She stated if belongings went missing that were not on the log, the resident reported it to the nurse who reported it electronically. Administrative Nurse D stated risk management worked with the resident on resolving the missing belongings. Administrative Nurse D declined to address the admission agreement waiving facility liability for resident belongings and stated she would need to check with risk management. The facility did not provide a policy related to admission agreements upon request. The facility failed to establish and implement an admissions agreement that protected the residents' right to personal property. This deficient practice had the risk of loss of personal property, including property of monetary and, or sentimental value, and loss of dignity and personal right to property for residents admitted to the facility.

The facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to post the required information including a list of names, addresses (mailing and e-mail), and telephone numbers of all pertinent State Agencies and advocacy groups. This deficient practice placed all residents at risk for impaired resident rights. Findings included: - On 10/14/24 at 01:48 PM, an empty resident room had a posting that directed if a resident had a concern, the resident could call the facility's patient advocate and listed the phone number. On 10/14/24 at 02:29 PM, a bulletin board in the hallway displayed thank you cards from residents and families over most of the board. Towards the bottom of the board, a laminated posting of Important Phone Numbers revealed phone numbers for various State Agency (SA) departments and the State Long-Term Care Ombudsman (LTCO) but did not contain the addresses (mailing and e-mail) for the agencies. A laminated posting of Questions/Concerns/Complaints revealed the LTCO and SA phone numbers but no addresses (mailing or e-mail). The tour of the unit lacked the required posting with the required information, accessible to residents and their representatives. On 10/14/24 at 02:49 PM, Administrative Nurse D stated risk management cleared information for the whole hospital and that was the information that was available in the skilled nursing unit. On 10/14/24 at 03:51 PM, Administrative Nurse D stated residents received the LTCO and SA's phone numbers in their admission packet. She stated residents have internet and most know how to use a phone. The facility did not provide a policy on required postings. The facility failed to post the required information of a list of names, addresses (mailing and e-mail), and telephone numbers of all pertinent State agencies and advocacy groups. This deficient practice placed all residents at risk for miscommunication of their resident rights and impaired resident rights.

The facility identified a census of nine residents. The sample included eight residents. Based on record review and interviews, the facility failed to develop a facility assessment that accurately reflected the required sections of a facility assessment including services provided, staff required, staff competencies, and religious practices. This deficient practice placed the residents at risk for unidentified care needs and inadequate care and services. Findings included: A review of the facility-provided Facility Assessment revealed an undated, half-page document, titled Transitional Care Unit Facility Assessment provided by the facility on 10/14/24. The document contained the following items in its entirety: Transitional Care Unit Facility Assessment Capacity: 14 Avg daily census: 10-14 Average LOS: 14 days Common diagnosis: orthopedic, infection, respiratory, CHF, HTN dysrhythmia, CVA, HOH, Diabetes Also: CPAP, O2, IV, TPN, PEG, Trach, radiation, transfusion Activity level: CGA-dependent Staffing: Evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs and CMS regulation. Refer: see matrix The facility assessment lacked the following required sections: staff competencies necessary to provide the level and types of care needed for the resident population, the physical environment, equipment, services, and other physical plant considerations necessary to care for the resident population; and any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services. The facility's resources, equipment, services provided, contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The facility provided a TCU Eligibility Requirements Policy with an original date of January 2007 and a Skilled Nursing Facility Structure Standards policy with a revised date of July 2009. On 10/14/24 at 03:51 PM Administrative Nurse D stated their facility assessment was updated at least annually. Administrative Nurse D stated the facility was always adequately staffed to care for the patients they admitted . Administrative Nurse D stated the residents the facility can provide care for, were addressed in the two policies that were provided, and one of those policies contained the diagnoses the facility was allowed to admit. Administrative Nurse D stated the staff competencies required to care for the residents the facility admitted and to provide the type of care required, would have been checked by the facility and the required education would have been provided by the facility. Administrative Nurse D stated any education related to ethical, cultural, or religious factors that may impact care would have been provided by the facility as well and was part of the facility's annual education. Administrative Nurse D stated she believed the discussed areas were not covered in the facility assessment as they would have been covered in the policies and therefore were not encompassed in the facility assessment. The facility did not provide a policy related to facility assessment upon request. The facility failed to develop a facility assessment that accurately reflected the required sections of a facility assessment including services provided, staff required, staff competencies, and religious practices. This deficient practice placed the residents at risk for unidentified care needs and inadequate care and services.

The facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 10/14/24 at 01:48 PM an inspection of the facility revealed a posting in an empty resident room that directed if a resident had a concern, they were to call the facility's patient advocate. A Resident Rights poster was located near the nurse's station; however, it did not have directions on how to file anonymous grievances. The inspection revealed there was no submission box or method for filing anonymous grievances. On 10/14/24 at 02:36 PM Resident (R)1 stated they had not been told how to file a grievance and did not know how to file a grievance anonymously. On 10/14/24 at 02:44 PM Licensed Nurse (LN) G stated there was a booklet with patient rights in it, how to file a complaint, and the facility had a patient advocate. LN G stated information was also posted in the dining room and outside the nurse's station. LN G stated residents could probably file a grievance anonymously through the phone number listed or on the website. On 10/14/24 at 03:51 PM Administrative Nurse D stated generally residents would call the patient advocate number to report a grievance. Administrative Nurse D stated most of the time if there was an issue, the resident would report it on the spot. Administrative Nurse D stated usually, after a grievance was reported, the advocate brought the information to someone such as the Director of Nursing (DON) then they may need to gather more information. Administrative Nurse D stated information on how to report grievances was in the admission information and on the website. Administrative Nurse D stated she believed residents knew there was a website and she believed residents could probably file grievances online anonymously. The facility's Customer Complaints and Grievances policy, with an approval date of 05/03/22, documented patients, their families, patient representatives, physicians, and community members have the right to express concerns about care and services without fear of reprisal and have hospital staff respond to them in a confidential, professional, and timely manner. It is the responsibility of every staff member to identify and document concerns as they arise. Staff members are empowered to resolve concerns as they occur or, when that is not possible, to refer them to the appropriate department leader for resolution. Complaints and grievances received by anyone in the organization will be documented and forwarded to the Risk Management Department where it will be logged for trending along with the follow-up and maintained in a central database. The facility failed to implement a system to allow residents and/or their representatives, to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility identified a census of nine residents. The sample included eight residents with five residents reviewed for pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on observations, record review, and interviews, the facility failed to administer a pneumococcal vaccination to Resident (R) 107 after he consented to receive it on 09/26/24. This deficient practice placed R107 at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - R107 admitted to the facility on [DATE] and discharged from the facility on 10/11/24. R107 consented to receive the pneumococcal vaccination on 09/26/24. A review of R107's Medication Administration Record (MAR) during his stay revealed that R107 did not receive the pneumococcal vaccination before he was discharged from the facility. On 10/14/24 at 08:09 AM, Administrative Nurse D stated the nurse asked every resident who was admitted if they wanted immunizations during the admission process then the pharmacist talked to the resident. On 10/14/24 at 09:36 AM, Administrative Nurse D stated the facility made sure the resident received the immunization before they were discharged . On 10/14/24 at 02:52 PM, Licensed Nurse (LN) G stated during the admission process, she asked residents what immunizations they received and if they wanted immunizations, including pneumococcal. She stated if the resident wanted the pneumococcal vaccination, she clicked they were interested in the EMR, and the notification went to the pharmacy to signal a resident wanted a vaccination. LN G stated she gave the immunization and documented it in the MAR. On 10/14/24 at 02:59 PM, Consultant HH stated if staff indicated a resident wanted a vaccination, it flagged for the pharmacist as a task. She stated the pharmacist reviewed the resident and based on the review, if the resident wanted the vaccination and qualified for it, staff usually gave vaccinations in the morning. Consultant HH stated she spoke to R107's representative who stated he received the pneumococcal vaccination at a previous facility, and she told Consultant HH she would get the information from the previous facility before R107 was discharged and if she did not, then R107's representative would follow-up with the previous facility after his discharge. Consultant HH stated she did not document the conversation with R107's representative or why the facility did not give R107 the pneumococcal vaccination before his discharge. The facility's Inpatient Immunizations policy, approval date of 07/20/23, directed if a resident met clinical criteria per Centers for Disease Control (CDC) guidelines, the pharmacist ordered and dispensed the appropriate vaccines. The facility failed to administer pneumococcal vaccination to R107 after he consented to receiving it on 09/26/24. This deficient practice placed R107 at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility identified a census of nine residents. The sample included eight residents with one resident reviewed for hospitalization . Based on record review and interviews, the facility failed to establish a bed hold policy and provide written notification of the bed hold policy to Resident (R) 3 or his representative. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R3. Findings included: - R3 admitted to the facility on [DATE] and discharged to the hospital on 07/30/24. R3's Electronic Medical Record (EMR) documented diagnoses of impaired mobility, impaired cognition, and atrial fibrillation (rapid, irregular heart beat). The Admission Minimum Data Set (MDS) dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The Functional Ability Care Area Assessment (CAA) dated 07/26/24, documented R3 had a significant decline in mobility and daily function from post-hospital admission due to multiple medical issues. R3's Care Plan dated 07/30/24, documented R3 had activity intolerance, impaired functional mobility, activities of daily living (ADL) deficit, impaired swallowing, and impaired communication. The plan directed staff to ensure the usage of assistive devices, planned rest periods to maximize energy, and increased ADL independence as tolerated. R3's EMR revealed the following: A Nursing Clinical Note on 07/30/24 at 06:49 PM, documented R3 transferred to the hospital inpatient care. Staff contacted Consultant GG earlier in the morning discussing R3's increased respiratory rate and increased fatigue. Staff continued to monitor R3 through the afternoon and Consultant GG made the decision to admit R3 to a higher level of care treatment due to the new onset of atrial fibrillation. A Skilled Nursing Facility (SNF) Final Case Summary on 07/30/24 at 08:42 PM, documented R3 repeated an aspiration event in the morning and despite supportive care, R3's respiratory rate continued consistently high in the 30's to 40's and R3 was uncomfortable. Consultant GG documented he discussed with R3's representative and palliative care and planned to admit R3 and monitor for atrial fibrillation with morphine given for air hunger. R3's medical record lacked evidence the facility sent a written notification of transfer to R3 or his representative for his transfer on 07/30/24. Upon request, the facility did not provide written notification of the bed hold policy for R3's transfer on 07/30/24. On 10/14/24 at 11:02 AM, Administrative Nurse D stated she did not think the facility sent a written notification of the bed hold policy to the resident or representative. On 10/14/24 at 02:44 PM, Licensed Nurse (LN) G stated when a resident transferred to the hospital, she notified the provider involved, the resident's family, and Administrative Nurse D. She stated she did not send a written bed hold policy to the resident or their representative. On 10/14/24 at 03:40 PM, Social Services X stated the facility did not have a bed hold policy. On 10/15/24 at 01:13 PM, Administrative Nurse D stated because the facility was not licensed with Medicaid a bed hold policy had never been brought up. She said the facility did not have a bed hold policy. The facility did not provide a policy on the bed hold notifications. The facility failed to establish a bed hold policy and provide written notification of the bed hold policy to R3 or his representative. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R3.

The facility identified a census of nine residents. The sample included eight residents with one resident reviewed for hospitalization . Based on record review and interviews, the facility failed to provide written notification within a practicable timeframe of a facility-initiated transfer to Resident (R) 3 or his representative. The facility further failed to notify the State Long Term Care Ombudsman (LTCO) of facility-initiated transfers/discharges for R3. This deficient practice had the risk of miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R3, and placed R3 at risk for impaired rights. Findings included: - R3 admitted to the facility on [DATE] and discharged to the hospital on 07/30/24. R3's Electronic Medical Record (EMR) documented diagnoses of impaired mobility, impaired cognition, and atrial fibrillation (rapid, irregular heartbeat). The Admission Minimum Data Set (MDS) dated [DATE], documented R3 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. The Functional Ability Care Area Assessment (CAA) dated 07/26/24, documented R3 had a significant decline in mobility and daily function from post-hospital admission due to multiple medical issues. R3's Care Plan dated 07/30/24, documented R3 had activity intolerance, impaired functional mobility, activities of daily living (ADL) deficit, impaired swallowing, and impaired communication. The plan directed staff to ensure the usage of assistive devices, planned rest periods to maximize energy, and increased ADL independence as tolerated. R3's EMR revealed the following: A Nursing Clinical Note on 07/30/24 at 06:49 PM, documented R3 transferred to hospital inpatient care. Staff contacted Consultant GG earlier in the morning discussing R3's increased respiratory rate and increased fatigue. Staff continued to monitor R3 through the afternoon and Consultant GG made the decision to admit R3 to a higher level of care due to the new onset of atrial fibrillation. A Skilled Nursing Facility (SNF) Final Case Summary on 07/30/24 at 08:42 PM, documented R3 repeated an aspiration event in the morning and despite supportive care, R3's respiratory rate continued consistently high in the 30's to 40's and R3 was uncomfortable. Consultant GG documented he discussed with R3's representative and palliative care and planned to admit R3 and monitor for atrial fibrillation. R3's medical record lacked evidence the facility sent a written notification of transfer to R3 or his representative for his transfer on 07/30/24. Upon request, the facility did not provide a written notification of transfer for R3. Upon request, the facility did not provide documentation of LTCO notification of R3's transfer on 07/30/24. On 10/14/24 at 11:02 AM, Administrative Nurse D stated the facility did not notify the LTCO of discharges or transfers and she did not think the facility sent a written notification of transfer to the resident or family. On 10/14/24 at 02:44 PM, Licensed Nurse (LN) G stated when a resident transferred to the hospital, she notified the provider involved, the resident's family, and Administrative Nurse D. She stated she did not send a written notification of transfer to the resident or their representative. On 10/14/24 at 03:40 PM, Social Services X stated she did not send a written notification of transfer to the resident or their representative with facility-initiated transfers. She stated she did not send any notifications to the LTCO. On 10/14/24 at 03:44 PM, Administrative Nurse E stated she did not send any notifications to the LTCO. The facility did not provide a policy on transfer notifications. The facility failed to provide a written notification of transfer to R3 or his representative. The facility further failed to notify the State LTCO of transfers/discharges for R3. This deficient practice had the risk of miscommunication between the facility and resident/representative and possible missed opportunities for healthcare services for R3, and placed R3 at risk for impaired rights.

The facility identified a census of nine residents. The sample included eight residents. Based on observation, record review, and interviews, the facility failed to post, in a place readily accessible to residents, family members, or legal representatives, the results of the most recent survey of the facility; failed to have the last three years of survey results available; and failed to post a notice of the availability of such reports in areas of the facility that were prominent and accessible to the public. This deficient practice placed the residents at risk for impaired resident rights. Findings included: - On 10/14/24 at 01:48 PM, a tour of the skilled nursing facility (SNF) lacked survey results from the most recent survey, three years of survey reports, and/or a posted sign directing where to find survey results. On 10/14/24 at 04:27 PM, Administrative Nurse D showed the surveyor a binder in the dining room area, on the railing of the other unit, not the SNF unit, that had survey results in it. The last survey results in the binder were dated 2020. On 10/14/24 at 02:36 PM, Resident (R) 1 stated she did not know how to find the survey results in the facility. On 10/14/24 at 01:48 PM, Licensed Nurse (LN) G stated survey results were on a website, probably the state's website. On 10/14/24 at 03:51 PM, Administrative Nurse D stated if a resident wanted to see the last survey results, she directed them to go online. On 10/14/24 at 04:27 PM, Administrative Nurse D stated she did not print out the survey results and update the binder because the results were located online. The facility did not provide a policy on survey results. The facility failed to post, in a place readily accessible to residents, family members, or legal representatives, the results of the most recent survey of the facility; failed to have the last three years of survey results available; and failed to post a notice of the availability of such reports in areas of the facility that were prominent and accessible to the public. This deficient practice placed the residents at risk for impaired resident rights.

The facility identified a census of ten residents. The sample included eight residents with five reviewed for medication administration. Based on observations, record review, and interviews, the facility failed to follow sanitary infection control practices while performing blood glucose checks on Resident (R)108. This deficient practice placed R108 at risk for complications related to infections. Findings Included- - On 06/20/23 08:12 AM Licensed Nurse (LN) G entered R108's room, already wearing gloves, carrying the glucometer (instrument used to calculate blood glucose) and other supplies in her hand. LN G announced herself and told R108 she would be checking R108's blood sugar. LN G walked over to R108's bedside table and placed the glucometer and other supplies down, directly on the bedside table with no clean barrier or sanitization of the table. LN G then picked up the glucometer from the table to scan R108's wristband. LN G placed the glucometer back on the bedside table, opened the bottle with the test strips and grabbed one test strip and inserted the strip into the glucometer. LN G picked up the lancet (a small needle used to poke the skin to get a small drop of blood) and alcohol wipe and opened the alcohol wipe package and wiped R108's finger and poked R108's finger. LN G picked up the glucometer and, holding the machine in her hand, placed the lancet back on the table and placed a drop of blood from R108's finger onto the test strip. LN G grabbed a cotton ball from the table and wiped R108's finger. LN G picked up the used supplies from the bedside table and removed the test strip from the glucometer and placed the lancet and test strip in the sharp's container (a safety container used to dispose of needles and syringes). LN G doffed her gloves and did hand hygiene upon leaving room. On 06/21/23 at 11:23 AM Administrative Nurse E stated staff completed annual in-service training related to hand hygiene, equipment cleaning, and infection control practices to prevent the spread of infections. She stated staff training was also provided as needed trainings to correct discovered issues related to infection control. She stated the facility's Quality Assurance and Performance Improvement (QAPI) team review identified concerns and provided education to improve staff performance. On 06/21/23 at 01:25 PM Certified Nurse Aide (CNA) M stated an aide or the nurse can get the blood glucose and a barrier should be put down on the table and/or surface prior to placing clean equipment used on the residents. On 06/21/23 at 01:28 PM LN H stated a clean barrier should be used if placing items for resident care use, such a glucometers, on unsanitized surfaces. On 06/22/23 at 01:00 PM Administrative Nurse D stated she was aware that LN G had not used a barrier while she performed a blood sugar check. Administrative Nurse D stated LN G had been reeducated yesterday on the appropriate procedures to obtain the blood glucose. A review of the facility's Infection Prevention and Control policy revised 09/2022 indicated staff would ensure safe/sanitary handling of the medical devices and equipment used for patient care. The policy indicated equipment should be disinfected and remain protected from contamination. The policy indicated reusable equipment will be consistently disinfected and used in a manner that maintained sanitary handling to prevent the spread of infections. The facility failed to follow sanitary infection control practices while performing blood glucose checks on R108. This deficient practice placed R108 at risk for complications related to infections.

The facility reported a census of 16 residents. The sample contained 10 residents. Based on observations, interviews, and record reviews the facility failed to ensure the use of standard infection control precautions (infection prevention practices which include but are not limited to hand hygiene and use of gloves) while performing care for Resident (R) 113's peripherally inserted central catheter (PICC- a form of intravenous access that can be used to a prolonged period of time or for administration of substances that should not be done peripherally). The facility failed to provide proper disinfection technique for glucometer (medical device for determining the approximate concentration of glucose in the blood) use with R59. Findings include: - Observation on 02/24/20 at 11:01 AM revealed Licensed Nurse (LN) I used an alcohol wipe and cleaned R113's PICC line port. LN then picked up and opened a saline flush syringe, secured the port in her ungloved hand then connected the syringe to the PICC line port. LN flushed the line with normal saline, disconnected the syringe after the flush then connected intravenous tubing to the port for antibiotic administration. LN I did not wear gloves throughout the procedure. Interview on 02/26/20 at 10:02 AM with Administrative Nurse D stated she expected the nursing staff to follow the hand hygiene policy and standard precaution policy. Staff should use a disinfecting cap (alcohol-containing caps that twist onto ports for disinfection and protection) or the tubing with PICC line cares. Administrative Nurse D stated the facility's policy did not address the use of gloves during the procedures, but believed most people would wear gloves, especially with the administration of a medication. Observation on 02/24/20 at 12:22 PM revealed Certified Nurse Aide (CNA) O placed the glucometer directly on to R59's bedside table without a barrier for protection underneath it. CNA O then laid a clean piece of gauze and an unused lancet needled device used to obtain blood) between R59's legs on the recliner. CNA O then cleaned R59's finger, used lancet to prick the skin of R59's finger then obtained a blood glucose reading from R59's finger and applied the piece of gauze to the finger to stop the bleeding. In an interview on 02/26/20 at 10:02 AM, Administrative Nurse D stated the facility cleaned glucometer machines between patients so there was little risk of transmission from setting the glucometer on the bedside table. The facility policy IV (intravenous-through the veins) Access Peripheral Procedure last approved 02/19/19 documented IV access procedures required strict adherence to the Hand Hygiene policy. The facility's policy Hand Hygiene last approved 02/14/2019 documented hand hygiene was accepted as the single most important measure to prevent transmission of infections, advised staff to perform hand hygiene before direct contact with patients, and before donning gloves for a clean/sterile procedure. The facility failed to ensure nursing staff wore gloves during management of a PICC line for R113 and failed to ensure nursing staff practiced disinfecting practices for glucometer use when blood glucose readings were obtained for R59. These deficient practices had the potential for transmission and/or development of infections among the residents and staff.

The facility identified 16 residents. The sample included 10 residents. Based on observations, record reviews, and interviews the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)7. Findings included: -- The Admission MDS dated [DATE] documented R7 received an anticoagulant (medication which inhibits the coagulation of blood) seven of the seven day look back period. The Activities of Daily Living Care Area assessment dated [DATE] documented R7 required staff assistance. The physician's orders [REDACTED]. On 02/25/20 at 03:00 PM Administrative Nurse F stated she researched medications through a computer program when unsure of their classifications. The facility failed to complete an accurate MDS which had the potential of ineffective identification of her care plan needs.

The facility identified a census of 16 residents. The sample included 10 residents with one Resident (R) sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interviews the facility failed to obtain measurements on R60's pressure ulcers. Findings included: - R60's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) was not completed. The Interdisciplinary Care Plan for Skin dated 02/10/20 documented R 60 was at risk for skin breakdown and the facility implemented standard skin care breakdown prevention interventions. The staff assisted R60 with repositioning at least every two hours. She had a reddened area to her buttock. The staff assessed her skin twice daily. The care plan revision dated 02/25/20 documented the staff continued to assess R60's skin daily. A barrier cream (an ointment applied to the skin to prevent excess moisture associated irritation to the skin) was applied to R60's buttocks, where it was noted to have a pressure ulcer. The Braden Assessment (a measurement tool used to assess skin impairment risk) tab of the EMR dated 02/10/20 documented R60 had a risk for skin breakdown and she currently had skin breakdown. Review of the Skin Assessment tab of the EMR reviewed from 02/10/20 to 02/25/20 documented the following skin impairments: R 60 had a flat linear pink area on her coccyx. The staff applied a barrier cream to the area on 02/16/20. On 02/25/20 the area was pink and barrier cream was still applied to the area. A pressure ulcer to the left buttock on 02/10/20 was documented as a hot pink, poorly defined area with the surrounding tissue intact. A [MEDICATION NAME] dressing (an absorbent foam bandage which minimizes trauma to the wound) was applied. The 02/25/20 assessment documented the area was dry with [DIAGNOSES REDACTED] (redness to the skin) and was blanchable (area of redness which takes on a whitish appearance when pressed). A rough spot with poorly defined edges and dryness on R60's right heel was documented on 02/10/20. On 02/20/20 the area presented as a pressure ulcer scar. No wound measurements were documented by the facility since admission. An observation on 02/25/20 at 07:45 AM revealed R60's heels had no redness or open areas but were soft. Her left buttock had a white unopened area (approximately the size of a dime) surrounded by a dark red area (approximately the size of a small orange). Her coccyx had no redness or open areas noted. 02/19/20 at 02:40 PM R60's representative stated R60 developed a pressure sore on her bottom since she admitted to the facility. On 02/24/20 at 10:30 AM Wound Nurse Consultant GG stated she had not been consulted about R60's wounds. On 02/25/20 at 11:18 AM Licensed Nurse H stated nurses perform skin assessments each shift. Wound measurements were done by the wound care nurse. When redness on a bony prominence was seen the area was measured by the nurse, who then notified the wound nurse. On 02/250/20 at 12:50 PM Administrative Nurse [NAME] stated skin assessments were performed daily. The wound nurse was consulted when the wound required more than basic wound care, such as barrier cream. A reddened skin area wound would not necessarily be measured. She saw no measurements documented for R60's wounds in the EMR. The facility's Wound Care Management Procedure policy dated 04/17/17 documented a basic goal of wound care management was to use standardized measurement and assessment methods to facilitate planning for wound care and evaluating outcomes. Measurements were made for the length as the distance, in centimeters, in the direction of head to feet and the width as the distance, in centimeters in direction of side to side. The facility failed to obtain measurements on R60's wounds. This practice had the potential for inaccurate wound assessments to identify if the wound was improving or declining.

The facility identified a census of 17 residents. The sample included 16 residents. Based on record reviews and interviews the facility failed to provide the notifications and obtain resident and/or legal representative signatures on the notice of Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage CMS- (SNFABN) Medicare non-coverage form for 3 (#64, #65, and #66) of 3 residents sampled for non-coverage liability notices. Findings included: - Review of resident #64's medical record indicated his/her Medicare Part A services ended on 1/11/19. The resident's medical record lacked documentation of an ABN notification summary. Review of resident #65's medical record indicated his/her Medicare Part A services ended on 1/31/19. The resident's medical record lacked documentation of an ABN notification summary. Review of resident #66's medical record indicated his/her Medicare Part A services ended on 2/8/19. The resident's medical record lacked documentation of an ABN notification summary On 2/28/19 at 8:03 AM social services staff X stated the facility staff reviews residents' care and potential for discharge from skilled services weekly. The facility does not provide residents with an ABN form since they are not a community based long term care facility. On 2/28/19 at 10:15 AM administrative staff D stated the facility lacks a policy for ABN notification and refers to the Centers for Medicare and Medicaid Services (CMS) website for guidance. The CMS guidelines indicate facility's provide residents with the SNFABN form to inform residents and/or their beneficiaries information regarding skilled services that may not be paid for by Medicare. The facility failed to provide these residents with the ABN notification and therefore the residents could not make an informed decision regarding their choice to assume financial responsibility and continue skilled services. .

The facility identified a census of 17 residents. The sample included 16 residents. Based on record review, interviews, and observation the facility failed to provide timely assessments for 1 (#163) of 1 resident reviewed for [MEDICAL TREATMENT] (a process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood). Findings included: - The resident's Electronic Medical Record (EMR) dated 2/26/19 listed [DIAGNOSES REDACTED]. The 5- day Minimum Data Set ((MDS) dated [DATE] was in progress. The [MEDICAL TREATMENT] care plan dated 2/23/19 documented on Mondays, Wednesdays, and Fridays; the resident had [MEDICAL TREATMENT] treatments. The staff should continue to monitor the resident's medical condition. The physician's orders [REDACTED]. On 2/26/19 at 4:32 PM the resident sat on the edge of his/her bed with a [MEDICAL TREATMENT] (used for [MEDICAL TREATMENT]) visible on his/her left arm. The access site had no signs of infection. On 2/28/19 at 8:34 AM licensed staff G stated he/she checked the resident's [MEDICAL TREATMENT] daily for bruit (audible vascular sound associated with turbulent blood flow usually heard with the stethoscope that may occasionally also be palpated as a thrill) and thrill (palpable vibration). On 2/28/19 at 10:30 AM the resident stated the facility staff do not always check his/her [MEDICAL TREATMENT] shunt for bruit and thrill. On 2/28/19 at 12:21 administrative staff A verified the facility staff did not consistently monitor the resident for bruit and thrill. The facility's [MEDICAL TREATMENT] policy dated 4/26/16 documented the facility staff checks [MEDICAL TREATMENT] for bruit, thrill, and signs of infection twice daily and as needed. The facility failed to provide timely assessments ensure the proper functioning and prevention of infection for this resident with [MEDICAL CONDITION].

The facility identified a census of 13 residents. The facility included one main kitchen and one satellite kitchen. Based on observation and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions in both kitchens. Findings included: During the initial tour of the satellite kitchen on 3/21/16 at 8:07 AM, observation revealed the following: 1. A bottle of opened, undated cranberry/apple juice in the refrigerator. During the initial tour of the main kitchen on 3/21/16 at 8:30 AM, observation revealed the following: 1. Numerous items in the reach-in refrigerators were opened and undated. 2. The certified dietary manager wore a hair net, but it did not cover all of his/her hair. On 3/22/16 at 11:30 AM, two dietary staff wore hair nets, but their hair was not fully contained. One dietary staff wore a ball cap, but his/her ponytail, approximately 4 inches long, was flowing freely from the cap. On 3/24/16 at 11:28 AM, dietary director DD stated the chef was responsible for dating all items when opened. Staff DD stated all dietary staff were expected to have all of their hair contained. The facility's Employee Handbook, undated, noted staff were to wear an approved uniform hat or hairnet, but did not address full containment of the hair. The facility failed to prepare, distribute, and serve food under sanitary conditions.

The facility identified a census of 13 residents. Based on observation, record review and staff interview, the facility failed to utilize precautions to minimize transmission of infection within the facility. Findings included: - On 3/22/16 at 10:12 AM, housekeeping staff X sprayed diluted CrewNA Bowl and Bathroom Disinfectant Cleaner into the water in the toilet bowl. On 3/22/16 at 10:16 AM (4 minutes later), housekeeping staff X brushed the inside of the toilet bowl, flushed the toilet, and resprayed the cleaner into the toilet bowl. Review of the manufacturer's label for CrewNA Bowl and Bathroom Disinfectant Cleaner documented to clean toilet bowls, empty the bowl and apply undiluted solution to exposed surfaces, swab thoroughly, allow remaining wet for 10 minutes, and then flushing the toilet. On 3/22/16 at 10:22 AM, housekeeping staff X stated he/she sprayed the CrewNA cleaner into the toilet bowl, brushed it 10 minutes later, and flushed. He/she said he/she sprayed more of the cleaner into the bowl and left it until the resident or staff flushed the toilet. On 3/24/16 at 10:46 AM, housekeeping manager Y stated the CrewNA toilet cleaner needed a contact time of 10 minutes to kill most germs. The facility's policy General Cleaning of Restrooms reviewed on February 2016 noted to begin cleaning of the toilet, swab the inside of the toilet with the solution and let stand. It failed to give specific information about the CrewNA Bowl and Bathroom Disinfectant Cleaner. The facility failed to utilize precautions to minimize transmission of infection within the facility.

The facility reported a census of 13 residents. The sample included 5 residents. Based on observation, record review and staff interview, the facility failed to identify the lack of monitoring for black box warnings in the care plan for 3 of the 5 (#76, #78, #79) residents sampled for unnecessary medications. Findings included: - Review of the physician's orders [REDACTED].#79 listed [DIAGNOSES REDACTED]. (chromosomal abnormality characterized by varying degrees of mental [MEDICAL CONDITION] and multiple defects), [MEDICAL CONDITION] (condition characterized by decreased activity of the [MEDICAL CONDITION]), and [MEDICAL CONDITION] reflux disease (backflow of stomach contents to the esophagus). The facility did not provide a Minimum Data Set (MDS) for this resident. Record review revealed the resident was admitted to the facility on [DATE]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] (a medication that increases muscle contractions in the upper digestive tract), 5 mg (milligrams), by mouth, daily for bowel motility. Review of the physician's orders [REDACTED]. [MEDICATION NAME] (a non-narcotic medication that relieves pain), 200 mg, by mouth, daily for pain. Review of the resident's care plan, dated 3/22/2016, revealed no BBW for [MEDICATION NAME] or [MEDICATION NAME]. According to fda.gov (Food and Drug Administration), a BBW is a warning of serious or life-threatening risks located on the label of a prescription drug. According to fda.gov, [MEDICATION NAME] may cause tardive dyskinesia, a serious movement disorder that is often irreversible. According to fda.gov, [MEDICATION NAME] may cause an increased risk of serious cardiovascular events or stroke, and an increased risk of serious gastrointestinal events including bleeding, and perforation of the stomach. Observation, on 3/22/2016 at 2:09 P.M., revealed the resident laying in his/her bed, looking up with his/her eyes open, and oxygen tubing in his/her nares. The resident appeared clean and groomed, but with a flat affect. In an interview, on 3/22/2016 at 10:55 A.M., administrative nursing staff D stated BBWs are documented as a pharmacist note, but not in the care plans. In an interview, on 3/22/2016 at 2:19 P.M., Direct Care Staff P stated he/she did not know what BBWs are, because he/she did not give residents any medications. In an interview, on 3/24/2016 at 8:18 A.M., Direct Care Staff Q stated he/she did not know what BBWs are, and did not know which possible medication side effects to monitor for this resident. The facility failed to provide medication monitoring for side effects for this resident. - The physician's orders [REDACTED].#76 had [DIAGNOSES REDACTED]. The 14 Day Minimum Data Set ((MDS) dated [DATE] revealed resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitive intact. The resident received insulin, anticoagulants and diuretics during the last 7 days. The care plan dated 3/24/16 lacked of identification of the resident at risk for fall due to impaired mobility. The care plan lacked the black box warning for the medication. The physician's medication order identified the resident with the following black box warning medications: [REDACTED]. Review of INR (international normalized ratio) results revealed following lab results: 1.73 on 3/8/16, 1.7 on 3/12/16, and 1.73 on 3/14/16. According to FDA (U.S. food and drug administration), the INR range should be between 2.0 and 3.0, and when the result was lower than 2.0, the risk for developing a blood clot increased. On 03/22/2016 at 9:44 AM direct care staff O stated he/she would report anything abnormal to the nurse. He/she did not know how to access to residents care plans or what a black box warning was. On 03/22/2016 at 3:29 PM direct care staff P stated he/she did not know what the black box warning was and he/she did not have access to look in the residents Skilled Nursing Facility Notes or MAR (medication administration record). On 03/22/2016 at 10:55 AM administrative nursing staff D stated the black box warnings were documented in Skilled Nursing Facility Note and MAR but not in the care plan. The facility failed to monitor the side effects of black box warning medications for this the resident, who received [MEDICATION NAME], placing the resident at increased risk for bleeding. - The physician's orders [REDACTED].#78 had [DIAGNOSES REDACTED]. The 14 Day Minimum Data Set ((MDS) dated [DATE] revealed the resident received an antidepressant on 7 out of 7 days. The CAAs (care area assessments) dated 3/21/16 revealed the resident was on [MEDICATION NAME] 10mg daily for depression prior admission. The care plan dated 3/24/16 revealed the resident with depression and staff were to manage it with medication. The care plan lacked identification of black box warning monitoring for [MEDICATION NAME] or [MEDICATION NAME]. Review of physician medication order dated 3/18/16 revealed this resident had the following black box warning medications: [REDACTED]. According to FDA (U.S food and drug administration) drug guide line, the following medications have the following BBW ' s: [MEDICATION NAME] would increase the risk for tardive dyskinesia (abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs and trunk) and [MEDICATION NAME] would increase the risk for suicidal thinking and behavior. On 03/22/2016 at 9:44 AM direct care staff O stated he/she would report anything abnormal to the nurse. He/she did not know how to access to residents' care plans or what a black box warning was. On 03/22/2016 at 3:29 PM direct care staff P stated he/she did not know what the black box warning was and he/she did not have access to look in the residents' Skilled Nursing Facility Notes or MAR (medication administration record). On 03/22/2016 at 10:55 AM administrative nursing staff D stated the black box warnings were documented in Skilled Nursing Facility Note and MAR but not in the care plan. The facility failed to monitor the side effects of black box warning medications for this cognitively impaired resident.

The facility identified a census of 13 residents. Based on record review and interview, the facility failed to post the nurse staffing data, at the beginning of each shift, in a prominent place, readily accessible to residents and visitors. Findings included: - On 3/21/16 at 10:00 AM, the nurse staffing was posted, located behind the nurse's desk and not visible to residents or visitors. The actual hours worked were blank. The posting sheets for shifts on 1/1/16, 1/2/16, 1/3/16, 1/4/16, 1/5/16, and 1/16/16 were not provided as requested. Review of staffing records dated 1/6/16 to 2/25/16, revealed six 12 hour shift postings with the actual hours worked left blank. Review of staffing records dated 3/16/16 to 3/21/16, revealed two 12 hour shift postings with the actual hours worked left blank. During an interview on 3/24/16 at 11:17 AM, administrative nursing staff D stated the unit secretary, the charge nurse, or he/she were responsible to fill out the posting sheets. The facility failed to post the nurse staffing data at the beginning of each shift, in a prominent place, readily accessible to residents and visitors.

The facility reported a census of 8 residents. The sample included 8 residents and 1 closed record. Based on record review and interview resident #53's (closed record) pressure ulcer increased in size and stage. Findings included: - The 5 day Minimum Data Set ((MDS) dated [DATE] revealed resident # 53 had a stage 3 pressure ulcer upon admission that measured 2.0 (centimeters) cm (x) by 1.1 cm x 0.1 cm. The resident required extensive assistance of two staff members for bed mobility, transfers and toilet use. The Pressure ulcer Care Area assessment dated [DATE] revealed a stage 3 pressure ulcer on coccyx present upon admission. The discharge MDS dated [DATE] revealed the resident had a stage 3 pressure ulcer that was present on admission which measured 2.5 cm x 1.5 cm x 0.2 cm. Interview on 12/3/14 at 9:59 A.M. administrative nursing staff D revealed he/she completed the MDS process and voiced the 5 day, admission and discharge assessment were coding incorrectly. Resident #53 came into the facility with a stage 2 pressure ulcer and while in facility became a stage 3 pressure ulcer. The care plan revised on 8/12/14 revealed the resident had a stage 3 pressure ulcer on the coccyx, and staff were to assist the resident every 2 hours with repositioning. Initial wound assessment on 7/15/14 upon entry of facility revealed the resident had a stage 2 pressure ulcer on the coccyx which measured 2.1 cm x 1.5 cm x 0.5 cm. Wound assessment dated [DATE] revealed the coccyx wound was a stage 3 pressure ulcer which measured 2.5 cm x 1.5 cm x 0.2 cm. Wound assessment dated [DATE] revealed the coccyx wound was a stage 3 pressure ulcer which measured 2.9 cm x 1.4 cm x 0.15 cm. The dietitian's assessments revealed on 7/25/14 a recommendation of ensure 2 times daily and again on 8/4/14 weight has declined and intake declined continue ensure two times daily. Review of the physician progress notes [REDACTED]. The record lacked documentation that the facility had notified the physician of the residents pressure ulcer worsening from a stage 2 to a stage 3 pressure ulcer. The record did document a change in treatment requested when the wound got worse. Interview on 12/3/14 at 9:59 A.M. administrative nursing staff D revealed he/she was the wound nurse and charted on wounds at least weekly, which was not done on resident # 53. He/she stated the physician would be notified if a wound increased in size. Administrative nursing staff D revealed he/she could not find documentation the physician was notified of the increase in size of the pressure wound, neither did she document a request for a wound consult which they normally do. The policy and procedure for wound care management dated 4/28/14did not addresswhat to do whane a pressure wound that got worse. The clinical record lacked evidence to show the worsening of the pressure ulcer was unavoidable. The record also lacked evidence the physician was notified that the pressure ulcer got larger and increased in stage.

The facility had a census of 8 residents. Based upon observation and interviews the facility failed to ensure linens were hygienically cleaned. Findings included: - On 12/4/14 housekeeping staff X stated the facility only laundered privacy curtains after residents with a [DIAGNOSES REDACTED]. Housekeeping staff X stated all other laundry was processed off site. On 12/4/14 at 9:05 A.M. the water temperature of the facility's washer measured 123.4 degrees. On 12/4/14 at 9:15 A.M. maintenance staff Z stated the facility did not send out water greater than 120 degrees. Housekeeping staff Y present at that time stated the facility used bleach when washing the curtains to ensure the curtains were hygienically cleaned. On 12/4/14 at 9:20 A.M. housekeeping Y stated the facility placed bleach in the dispensing unit of the washer when washing the curtains but he/she did not know the amount of bleach staff placed. Housekeeping staff Y stated the facility did not have a policy regarding processing of on-site laundry nor did the facility have anything from the manufacturer of the washer regarding appropriate methods to use to produce hygienically clean products. The facility failed to ensure the privacy curtains were hygienically cleaned.