Every finding on record at Louisa Health & Rehabilitation Center

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for one of eight residents in the survey sample (Resident #3, R3). The findings include: Medication Administration Record (MAR) was not documented on multiple times for the month of August 2024. Diagnoses for R3 included: Dementia, peripheral vascular disease, neuropathy, and diabetes. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/7/2025. R3 was assessed as being cognitively intact. Review of R3's medication orders documented an order dated 8/14/24 that read: Gabapentin Capsule 100 MG [milligrams] Give 2 capsules by mouth three times a day for Neuropathy. Review of R3's MAR for the month of August 2024 did not indicate the medication had been signed off as being given on 8/14/24 for the 2:00 p.m. dose and the 9:00 p.m. dose, and also not signed off as being given on 8/15/24 for the 9:00 a.m. dose and the 2:00 p.m. dose. On 5/28/25 at 12:00 p.m. the facility's nurse consultant (administrative staff, AS #2) was interviewed. AS #2 verbalized the nurse that was giving medications on the days in question was no longer employed at the facility. AS #2 was able to provide narcotic sign out sheet indicating that the medication in question was signed off for distribution for R3, however did agree that the medication was not signed off on the MAR indicating that it had been given. A policy titled General Guidelines for Medication Administration read in part: IV. Documentation 1. The individual who administers the medication dose records the administration the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure the necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications. On 5/28/25 at 1:30 p.m. the above information was presented to the administrator. No other information was presented prior to exit conference on 5/28/25.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the family/responsible party of a fall with injury for one of eight residents in the survey sample (Resident #5). The findings include: Resident #5 (R5) was admitted to the facility with diagnoses that included diabetes, chronic kidney disease, osteoporosis, hypertension, depression, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R5 with severely impaired cognitive skills. R5's clinical record documented a nursing note dated 4/4/25 stating, .Nurse was in the room across the hall performing wound care when Nurse was alerted to Resident being on the floor. Resident was observed on the floor on the right side of the bed in between the bed and the wall .upon assessment there was one skin tear on right elbow. Unit Manager notified, NP [nurse practitioner] notified new orders to cleanse Rt elbow skin tears with wound cleanser apply Xeroform and cover with bordered gauze QD [each day] . The clinical record documented no notification to the resident's responsible party regarding the fall. On 5/27/25 at 2:10 p.m., licensed practical nurse (LPN #4) caring for R5 on 4/4/25 was interviewed. LPN #4 stated R5 rolled out of bed on 4/4/25 and she assessed the resident following the fall with a skin tear on the right elbow. LPN #4 stated she notified the unit manager and the nurse practitioner and obtained orders for care of the skin tear. LPN #4 stated she thought the resident was her own responsible party and did not notify the resident's family member/emergency contact listed on the face sheet. On 5/27/25 at 2:15 p.m., the unit manager (LPN #5) on R5's unit was interviewed. LPN #5 reviewed the clinical record and stated there was no family notification regarding the 4/4/25 fall. LPN #5 stated concerning the notification, That wasn't handled the way it should have been. LPN #5 stated R5's family should have been called and notified immediately regarding the fall/injury. On 5/27/25 at 3:45 p.m., the administrator was interviewed about R5's fall on 4/4/25. The administrator stated LPN #4 did not reach out to the family about the incident and injury of 4/4/25. The administrator stated LPN #4 should have notified the family/responsible party regarding the fall. The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Notify provider and document in Progress Notes .Responsible party will be notified of a change in condition . On 5/28/25 at 1:15 p.m., the administrator and regional nurse consultant stated a plan of correction had been implemented in response to the failure to notify R5's family following the fall. The following plan of correction was presented. Problem -Nurse did not notify the responsible party of a fall. Actions taken included: - R5's responsible party was notified of the fall. A meeting was conducted on 4/7/25 with R5's family members and facility administration to discuss family concerns that included the notification failure. -All residents were identified to have the potential to be affected by failure to notify of changes in condition. - LPN #4 was educated and issued corrective action/warning on 4/15/25 regarding failure to notify R5's family of the fall. - In-service education was provided by director of nursing (DON) and/or designee to all nursing staff on 5/1/25 regarding notification to the physician and responsible party following falls and/or changes in condition. Additional training was conducted on 5/12/24 with all nursing staff that included requirements to notify family/responsible party of falls, incidents and changes in condition. - The DON or designee will complete responsible party notification audit during daily clinical meeting for 6 weeks and then randomly during clinical meetings to ensure prompt notifications to the responsible party. - Audit results will be reported to the monthly quality assurance committee for review/discussion until quality assurance committee deems actions taken ensure compliance. - Date of correction was 5/14/25. The survey team verified actions taken. R5's clinical record documented the family meeting was held on 4/7/25 with the notification failure discussed/reviewed with R5's family. Signature sheets documented education and corrective action warning with LPN #4 and all other nurses. Audits sheets were documented and ongoing from the daily clinical meetings regarding notifications. Two current residents that had experienced falls since the correction date of 5/14/25 were added to the survey sample (Residents #7 and #8). Notifications to the residents' family/responsible party were documented in the clinical record following the falls with no deficiency identified since the correction date. The survey team accepted the plan of correction and cited this deficiency as past non-compliance.

Based on staff interview, clinical record review and during a complaint investigation, the facility staff failed to ensure wound care orders were in place for one of 24 residents in the survey sample, Resident #75. Resident #75 did not have wound care orders for the treatment of two unstageable pressure ulcers that were present upon admission to the facility (06/20/22); physician orders for wound care were not obtained until 06/28/22, eight days after admission. Findings include: Resident #75 was admitted to the facility on [DATE]. Diagnoses for Resident #75 upon admission included, but were not limited to: unstageable pressure ulcer to the coccyx, unstageable pressure ulcer to the thoracic spine, retroperitoneal hematoma-probable abscess from PID [pelvic inflammatory disease], severe sepsis, acute kidney injury, high blood pressure, and protein malnutrition. The resident's most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance with most all ADL's (activities of daily living) with assistance from at least one staff person. This MDS also assessed the resident as being at risk for pressure ulcers and having two unstageable pressure ulcers (present upon admission). In Section M. M1200. Skin and Ulcer/Injury Treatments (check all that apply) none were checked. A complaint investigation regarding Resident #75 was completed on 01/24/23 through 01/26/23. An allegation within the complaint alleged that the resident did not have physician orders for wound care treatments upon admission. Resident #75's admission assessment dated [DATE] documented, .vertebrae (upper-mid) pressure 5 cm (centimeters) (length) by 2 cm (wide) .Sacrum pressure 0.5 cm X 0.5 cm . The resident's physician's orders were reviewed and revealed an order for, but not limited to: .(order date: 06/28/22) (start date: 06/29/22) Z-Guard paste to peri wound on coccyx and spine as needed for unstageable pressure ulcers, cleanse with wound cleanser. Apply Medi Honey to wound, then Z-guard paste to peri wound and then cover with bordered foam dressing daily and as needed if missing or soiled .WOUND CARE consult (order date: 06/20/22) The above orders were the only orders seen for wound care from 06/20/22 through 06/28/22. The resident's TARs (treatment administration records) were reviewed for June 2022. According to the June 2022 TAR the above treatment was started and administered on 06/29/22 and 06/30/22. A wound evaluation note by the wound NP dated 06/23/22 documented, .coccyx .100 % slough .unstageable .zinc barrier cream to peri wound .dressing change daily cleanse with wound cleanser .medihoney .bordered foam (dressing) . A wound evaluation note by the wound NP dated 06/23/22 documented, .mid thoracic spine .100% slough .unstageable .zinc barrier cream to peri wound .dressing change daily cleanse with wound cleanser .medihoney .bordered foam (dressing) . The resident was seen by the wound NP and wound treatments were completed on 06/23/22 and 06/27/22, not daily as indicated in the wound NP's wound evaluation assessments. There was no evidence of any wound care treatments for 06/20/22 (date of admission), 06/21/22, 06/22/23, 06/24/22, 06/25/22, 06/26/22 or 06/28/22. On 01/25/23 at approximately 10:30 AM, the above information was reviewed with the DON (director of nursing) and administrator. The DON and administrator were asked for assistance in locating wound care orders and/or wound care treatments for Resident #75 from admission through 06/28/22. On 01/25/23 at approximately 1:00 PM, the administrator and DON stated that the resident was seen by the wound care nurse as described above. There was no explanation by the DON and/or administrator as to why the resident did not have wound care orders upon admission and/or why the resident did not receive daily wound dressing changes as documented by the wound NP on the wound evaluation assessments. The resident's CCP (comprehensive care plan) documented, . (created on: 07/06/22) .unstageable pressure ulcer to: 1. Mid-thoracic spine 2. Coccyx .administer treatments as ordered and monitor for effectiveness (created on 07/06/22) .report dressing if not intact during care to nurse (created on: 07/06/22) . On 01/25/22 at approximately 5:00 PM, the administrator and DON were informed of concerns regarding Resident #75 not having initial physician's orders for care and treatment of pressure ulcers that were present upon admission and that according to the wound NP's documentation the resident should have been getting dressing changes daily, but was not. The DON and administrator stated that they would continue to look into this and get back with me tomorrow, but could not provide information as to why the resident didn't have orders and treatments daily per the wound NP. On 01/26/22 at approximately 9:15 AM, the DON again presented wound care documentation completed by the wound NP on 06/23/22 and 06/27/22. The DON stated that she did not know why wound orders were not put in for Resident #75 or why the resident wasn't getting daily wound care treatments as described by the wound care NP. No further information and/or documentation was presented prior to the exit conference on 01/26/23 at 12:15 PM.

Based on staff interview and clinical record review, the facility staff failed to ensure an as needed (prn) psychotropic medication was limited to 14-day use for one of twenty-four residents in the survey sample. Resident #44 had an order for the anti-anxiety medication lorazepam in use beyond 14 days without a documented rationale for the extended use or a designated duration for the order. The findings include: Resident #44 was admitted to the facility with diagnoses that included multiple sclerosis, asthma, atrial fibrillation, anxiety disorder, protein-calorie malnutrition, depression, hypothyroidism, insomnia, hypertension, failure to thrive and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #44 with severely impaired cognitive skills for daily decision making. Resident #44's clinical record documented a physician's order dated 12/22/22 for lorazepam (antianxiety medication) concentrate (2 milligrams/milliliter) 0.5 milliliters by mouth every 8 hours as needed for agitation related to anxiety disorder. The clinical record included no documented rationale for use of the prn lorazepam beyond 14 days or any designated stop date for the order. Resident #44's medication administration record (MAR) for January 2023 documented prn doses of the lorazepam were administered on 1/12/23, 1/17/23, 1/23/23 and 1/24/23. On 1/25/23 at 1:30 p.m., the licensed practical nurse (LPN #2) caring for Resident #44 was interviewed about the extended use of prn lorazepam. LPN #2 stated that the resident was on comfort care and she thought the prn lorazepam was a standing order for those on comfort measures. LPN #2 stated that she did not know why the order had no specified duration. On 1/25/23 at 1:45 p.m., the registered nurse unit manager (RN #2) was interviewed about Resident #44's prn lorazepam in use beyond 14 days. RN #2 stated the pharmacist usually sent recommendations about limited days of use or rationales for extended use. RN #2 stated she did not see any pharmacy recommendation about the prn lorazepam and did not know why the order had no designated duration. On 1/26/23 at 8:11 a.m., the director of nursing (DON) was interviewed about Resident #44' prn lorazepam. The DON stated that there was a pharmacy recommendation issued on 12/22/22 about limiting the order to 14 days unless there was a documented rationale and specified duration. The DON stated that the physician had not responded to the 12/22/22 pharmacy recommendation and the order had been in place since 12/22/22 without a designated duration and/or rationale for extended use. The DON stated that response to the pharmacy recommendation about Resident #44's prn lorazepam had been missed. The Nursing 2022 Drug Handbook on pages 908 through 910 describes lorazepam as an anxiolytic used for the treatment of anxiety and insomnia and precautions include, .Use cautiously in elderly, acutely ill, or debilitated patients . (1) This finding was reviewed with the administrator, director of nursing, and regional director of clinical services during a meeting on 1/25/23 at 4:50 p.m. (1) Woods, Anne Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022.

Based on family interview, resident council interview, staff interview and facility document review, the facility staff failed to promptly respond to call bells on one of two units (Residential unit). Residents and a family member reported extended wait times for staff response to call bells on the Residential unit. The findings include: On 1/24/23 at 4:13 p.m., Resident #56's family member was interviewed about quality of care/life in the facility. The family member stated she had witnessed extended response time by staff members to the call bell. The family member stated two weekends ago it took over one hour before a staff person responded to take Resident #79 to the bathroom. The family member stated that she pressed the call bell several times, got no response, and then went to the nursing station to request assistance. The family member stated it took another 15 minutes for a CNA (certified nurses' aide) to come and take Resident #79 to the bathroom. The family member stated the resident was wanting to go to a Bingo activity and was delayed because of slow staff response. The family member stated Resident #56 had a history of urinary tract infections, adding that it was not good for her to hold her urine for extended times. On 1/25/23 at 2:00 p.m., an interview was conducted with ten members of the facility's resident council. Resident #20 stated during this interview that the facility was frequently short of help and call bell response was slow, especially on the evening shift. After ringing the bell for assistance last week, Resident #20 stated that the wait for assistance was over one hour. When the aide came to assist her, Resident #20 stated, I was soaked. Resident #20 stated this delayed response required her to change clothing as well as her brief due to leakage. Resident #20 stated this had happened on another occasion with her waiting over 20 minutes for a staff person to change her brief. Resident #20 stated both extended responses were after 6:00 p.m. and on the Residential unit. Resident #20 stated there were problems when the CNAs had split assignments on more than one hall because the CNAs were not always able to see the call lights when on the other unit. Other residents during the council interview agreed that at times staff response to call bells was slow, especially in the evenings. Several residents stated that at times a staff person came to the room, said they were getting their assigned aide, but nobody returned to provide the care. Resident #20 stated lengthy call bell response had been communicated to the administration during prior council meetings. On 1/26/23 at 9:20 a.m., the administrator was interviewed about the family interview and resident council interview indicating extended call bell response. The administrator stated that she recognized that prompt call bell response with appropriate follow up was an issue. The administrator stated that sometimes staff initially responded to the call bell but did not always follow up to be sure the need was completely addressed. The administrator stated that all employees were responsible for responding to call bells, but the issue was making sure the need was met. The administrator stated she had met with the resident council and discussed the call bell issue. The administrator stated she had observed call bells answered but no follow up provided as stated by the residents. The administrator stated all call bells do not require a nurse or CNA. The administrator stated at times they did have split assignments between the two units and that could possibly create a problem for call light visibility due to the facility layout. The facility's policy titled Shift Responsibilities for CNA (effective 11/1/19) documented, .Perform shift responsibilities/assignments that promote quality of care; make rounds, identify and address any immediate patient needs, promptly respond to call lights and notify the licensed nurse of any pertinent patient findings . This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 1/25/23 at 4:50 p.m.

Based on observations, clinical record review, and staff interview, the facility staff failed to develop a baseline care plan for the immediate care needs identified upon admission for three of 24 residents. Findings include: 1. The facility failed to develop a baseline (initial) care plan within 48 hours of admission for Resident #225 to address the immediate care of diabetes, wound care, anticoagulant therapy, or pain management. Resident #225 was admitted to the facility on [DATE]. Diagnoses upon admission included, but were not limited to Stage III high grade serous primary peritoneal carcinoma/metastatic, DM (diabetes mellitus), high blood pressure, malignant neoplasm of the peritoneum, thrombocytopenia, major depressive disorder, oral mucositis - ulcerative (mouth sores) due to antineoplastic therapy, history of pulmonary emobolis (on anticoagulant medication), and stage III pressure ulcer (open wound) to the sacral region. Resident #225's most current MDS (minimum data set) was a five day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13, indicating the intact cognition for daily decision making skills. Resident #225 was also assessed as requiring supervision with most ADL's (activities of daily living) with assistance from at least one staff person. According to the MDS, Resident #225 required extensive assistance for transfers. Resident #225 was observed on 01/24/23 at approximately 11:15 AM, laying supine in bed with eyes closed. Observed again on 01/24/23 at approximately 2:00 PM., a person identified as the resident's sister was at the bedside. Stating that the resident had cancer and had recently been admitted to the LTC (long term care) facility, Resident 225's sister was tearful and stated that the resident's body was shutting down. The resident was again observed lying supine, eyes closed and was mouth breathing. The resident's sister stated that the resident has declined pretty rapidly and was no longer talking or really responding. The resident's baseline care plan was reviewed. The initial care plan was dated 01/07/23 and included the following: constipation, falls, urinary catheter, and malnutrition. There was no care plan for the specific care needs of the diabetes, pressure ulcers, anticoagulant therapy, pain medications, and oral/dental care until 01/17/23, which was 11 days after admission. On 01/25/23 at approximately 10:30 AM, the administrator was asked about the initial care plan develooment for Resident #225. On 01/25/23 at approximately 1:00 PM, the administrator stated that there was no initial care plan for immediate care of the resident in those areas until 01/17/23 (per the clinical record) and that it was not triggered on the resident's admission assessment. The administrator stated that those areas should have been included upon admission and triggered by the admission assessment. No further information and/or documentation was presented prior to the exit conference on 01/26/23 at 12:15 PM. 2. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #75 to address the immediate care of pressure ulcers or bladder incontinence. Resident #75 was admitted to the facility on [DATE]. Diagnoses for Resident #75 upon admission included, but were not limited to unstageable pressure ulcer to the coccyx, unstageable pressure ulcer to the thoracic spine, retroperitoneal hematoma-probable abscess from PID (pelvic inflammatory disease), severe sepsis, acute kidney injury, high blood pressure, and protein malnutrition. Resident #75's most current MDS (minimum data set) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15 out of 15, indicating the resident was intact for daily decision making skills. Resident #75 was also assessed as requiring extensive assistance with most all ADL's (activities of daily living), with support from at least one staff person. Section M documented that two unstageable pressure ulcers were present upon admission. In Section H. H0300 Urinary Continence, the resident was assessed as always incontinent under bladder function on this MDS. Resident #75's clinical records were reviewed, along with the resident's baseline care plan. The first baseline care plan developed for Resident #75 was dated 06/21/22 and was for nutrition and weight loss. Other care areas were added on 06/23/22. Further review revealed that the resident did not have any type of care plan developed for pressure ulcers and/or bladder incontinence until 07/06/22, which was 17 days after admission. On 01/25/23 at approximately 10:30 AM, the administrator was asked about the initial care plan development for Resident #75. On 01/25/23 at approximately 1:00 PM, the administrator stated that there was no initial care plan for the immediate care of Resident #75's pressure ulcers or incontinence care, until 07/06/22. The administrator stated that those care areas were documented upon admission and on the admission assessment, but were not marked to trigger the baseline care plan. No further information and/or documentation was presented prior to the exit conference on 01/26/23 at 12:15 PM. 29123 3. Resident #79's baseline care plan did not include interventions regarding his refusal of care and his resistance to having skin assessments completed. According to the closed record review, Resident #79 was admitted to the facility for Respite care after being discharged from a local hospital. At the time of his discharge from the hospital, his family/caretakers were sick with the flu and in his best interest, had him admitted to the facility until the family illness passed. His diagnoses included but were not limited to: dementia with agitation, severe protein-calorie malnutrition, type 2 diabetes mellitus, mild cognitive impairment, adult failure to thrive, coronary artery disease, alpha thalassemia minor, prostate cancer, and major depression. An admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2022, assessed Resident #79 as severely impaired with a cognitive summary score of 00 out of 15. Resident #79 had two skin assessment completed while in the facility. The first skin assessment dated [DATE] documented his skin as warm and dry with the following note: no impairments observed to sacrum or feet/heels, unable to examine entire body due to resident resisting care and refusing. resident stiffens arms and does not let staff remove clothes. The second skin assessment dated [DATE] documented bruising to Resident #79's abdomen, left upper arm, rib area on the left side and the right upper arm. His skin was described as warm and dry with the following note: Pt has bruisin (sic) on his left side front he upper arm down the left side to the abdomen and left hop. There is also a small bruise on his upper right arm. All are purplish with yellow and green beginning to fade. The progress note section was reviewed. There was documentation throughout the progress note section regarding Resident #79's behaviors, i.e. hitting staff, knocking medication out of nurse's hands, going into other patient rooms, wandering, refusing medications, requiring redirection from staff, urinating in trash cans and other inappropriate places. His aggressive behaviors escalated to the point that PRN (as needed) Haldol (antipsychotic medication) was ordered. There was no documentation in the progress note section regarding staff attempting to do skin assessments and Resident #79 refusing, or any documentation regarding the bruising documented on the skin assessment dated [DATE]. The care plan was reviewed. There were no interventions regarding Resident #79 refusing care, his behaviors, or the bruising noted on the skin assessment dated [DATE]. RN (Registered Nurse) #1 was interviewed on 01/25/2023 at 3:20 p.m. When asked about the bruising she had documented on the skin assessment sheet dated 11/12/2022, RN #1 stated that the first time she had seen the bruises was when she had entered the shower room with CNA #1 on 11/12/2022, to assist her with Resident #79's shower. RN #1 described the areas as yellowish, dark purple in the middle, yellow at the edges. Asked if she had updated base line care plan regarding the bruises, RN #1 stated, No. On 01/26/2023 at 10:00 a.m., LPN (licensed practical nurse) #1 who completed Resident #79's admission assessment was interviewed. LPN #1stated that Resident #79 was resistive to care. When asked if she had attempted to do skin assessments on Resident #79 at anytime other than his admission, LPN #1 stated, Yes, I did .I probably didn't communicate that it wasn't done and I probably should have. Asked about the lack of information on the care plan regarding resident #79 being resistive to care or refusing skin assessments, LPN #1 stated, I don't do the care plan .MDS used to do it, I'm not sure who does it now. When asked if the resistance to care and having skin assessments should be on the care plan, LPN #1 stated, Probably. When asked if she had observed any bruising on Resident #79's body, LPN #1 stated, No. On 1/26/2023 at 10:40 a.m., The DON was interviewed. When asked about the above interviews and findings, the DON stated, The care plan is triggered by the initial assessment, but it can have additional information added. When asked if Resident #79's behaviors, refusal of care & skin assessments, and the noted bruises should have been on the base line care plan, the DON stated, Yes. No further information was obtained prior to the exit conference on 01/26/2023.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to follow their abuse policies for reporting injuries of unknown origin (bruises) for one of 24 residents, Resident #79. Findings were: Added to the survey sample as a closed record review, Resident #79 was admitted to the facility for Respite care after being discharged from a local hospital. At the time of his discharge from the hospital, his family/caretakers were sick with the flu and in his best interest, had him admitted to the facility until the family illness passed. His diagnoses included but were not limited to dementia with agitation, severe protein-calorie malnutrition, type 2 diabetes mellitus, mild cognitive impairment, adult failure to thrive, coronary artery disease, alpha thalassemia minor, prostate cancer, and major depression. An admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2022, assessed Resident #79 as severely impaired with a cognitive summary score of 00 out of 15. The clinical record was reviewed on 01/24/2023. The initial admission assessment dated [DATE] was reviewed. Under the section 13, Skin Observations the following was observed: Did the head to toe skin assessment on admission reveal any skin conditions or impairments? NO; General Skin Condition: Warm, dry; Comments: (No entries were made regarding Resident #79's skin). The admission narrative note contained the following: resident arrived at facility via stretcher from [hospital] alert and oriented X 1. pureed diet, takes meds crushed in applesauce. fall risk, not compliant in using call light for assistance. Resident #79 had two skin assessments completed while in the facility. The first skin assessment dated [DATE] documented his skin as warm and dry with the following note: no impairments observed to sacrum or feet/heels, unable to examine entire body due to resident resisting care and refusing. resident stiffens arms and does not let staff remove clothes. Both the initial admission assessment and the first skin assessment were completed by LPN (Licensed Practical Nurse) #4. The second skin assessment written by RN (registered nurse) #1 and dated 11/12/2022 documented bruising to Resident #79's abdomen, left upper arm, rib area on the left side and the right upper arm. His skin was described as warm and dry with the following note: Pt has bruisin on his left side front he upper arm down the left side to the abdomen and left hop. There is also a small bruise on his upper right arm. All are purplish with yellow and green beginning to fade.(sic) A progress note dated 11/14/2022 and written by the DON was the first note to contain information regarding bruising to Resident #79: This morning between 10-10:15 am, the resident's daughter .approached the nurses station and reported that she would be taking her dad home tomorrow. It had been reported at the time of admission that he would be discharged home with his daughter when she got over the flu, so this came as no surprise. Shortly after going to his room, she requested someone come in the room with her. Upon entering the room, noted a CNA [Certified Nursing Assistant] in addition to [daughter's name] being in the room. [Daughter's name] was crying and hard to console. She stated that her dad had bruises and he was wet. DON assessed [Resident #79's] skin to fine [sic] that he had bruising to the LLQ [left lower quadrant of abdomen] of his abdomen radiating to his left hip, bruising to L [left] upper arm and also to right antecubital areas. She stated that she was taking her dad home today. She was visibly and verbally upset and accusatory. DON told her that an internal investigation will be initiated. The DON assisted with putting [Resident #79's] pants on and left the room. [Attending physician's name redacted]) was notified of [daughter's name] taking her dad home today. Hospice .was notified as well. On 01/24/2023 at approximately 4:00 p.m., the administrator was asked for any facility account completed regarding the above information. She presented a folder and stated, We identified that we did not document appropriately. The facility synopsis concluded, Staff interviews reveal that [Resident #79] was not cooperative with staff during initial skin assessment. Staff reports he would not allow them to visualize his upper body including but not limited to: his pelvic and pubic area, trunk area, upper arms, or back. He refused to remove his shirts and jacket Our internal investigation was completed which included record review and staff interviews. The [local police] were notified and have been in to investigate the incident .There are no documented falls since admission, the first time the bruises were visualized by our staff was on Monday, November 7th. Due to his unwillingness for our staff to look at his body, this was not recorded timely .At this time we cannot determine the true origin of these old and fading bruises, however we have no suspicion of abuse in this investigation. Staff who cared for Resident #79 during his time at the facility were interviewed on 01/25/2023 and 01/26/2023. Interviews revealed that several staff had observed the bruised areas of Resident #79. CNA #1 observed bruising to Resident #79 on 11/07/2022 and 11/12/2022. RN #1 observed bruising on 11/12/2022 and CNA #3 observed bruising on the weekend of 11/05/2022-11/06/2022. When questioned, CNA #1 stated, I gave him a shower over the weekend, [redacted Name of RN #1] came in there with me .he still had the bruises and she didn't say anything about them. When asked if bruising was something that should be reported, CNA #1 stated, Yes, I should have told the nurse when I saw them the first time. When questioned, RN #1 stated, Normally we report things like that to the doctor and the RP [responsible party] .I didn't look to see if it had already been reported or not. At approximately 4:00 p.m., RN #1 reported that she could not find the weekend report for November twelfth and did not know if the bruising had been reported on it or not. CNA #3 stated that she had reported the bruising to LPN #1, but LPN #1 stated in her interview that she had never seen the bruising and was not aware of it. When asked if she had attempted to do skin assessments on Resident #79 at anytime other than his admission, LPN #1 stated, Yes, I did .I probably didn't communicate that it wasn't done and I probably should have. Per the facility policy Abuse/Neglect/Misappropriation/Crime, A licensed nurse will immediately respond to all allegations and/or reasonable suspicions of staff to patient, patient to patient, and/or visitor to patient, abuse, neglect, mistreatment, exploitation, or an misappropriation of patient property or crime against a patient. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source .are to be reported immediately . The facility policy Injuries of Unknown Origin contained the following: Injuries of unknown origin will be handled the same as an allegation of mistreatment, neglect, or abuse and must be reported to the center Administrator. The DON was interviewed at 10:40 a.m. regarding the above interviews and findings. She was asked what should have occurred. The DON stated, Someone should have reported the bruises to me, the administrator or the unit manager. I didn't know about the bruises until the day his daughter was here. I knew he was agitated but I didn't know he wasn't allowing skin assessments while he was here .that should have been reported to me too. No further information was obtained prior to the exit conference on 01/26/2023.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician and the RP (responsible party) of a change in resident status for one of 24 residents, Resident #79. Findings were: Added to the survey sample as a closed record review, Resident #79 was admitted to the facility for Respite care after being discharged from a local hospital. At the time of the discharge from the hospital, Resident #79's family/caretakers were sick with the flu and in his best interest, had him admitted to the facility until the family illness passed. Resident #79's diagnoses included but were not limited to dementia with agitation, severe protein-calorie malnutrition, type 2 diabetes mellitus, mild cognitive impairment, adult failure to thrive, coronary artery disease, alpha thalassemia minor, prostate cancer, and major depression. An admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2022, assessed Resident #79 as severely impaired in daily decision making, with a cognitive summary score of 00, out of 15. The clinical record was reviewed on 01/24/2023. Resident #79 had two skin assessments completed while in the facility. The first skin assessment dated [DATE] documented his skin as warm and dry with the following note: no impairments observed to sacrum or feet/heels, unable to examine entire body due to resident resisting care and refusing. resident stiffens arms and does not let staff remove clothes.[sic] The second skin assessment, written by RN (registered nurse) #1 and dated 11/12/2022, documented bruising to Resident #79's abdomen, left upper arm, rib area on the left side, and the right upper arm. His skin was described as warm and dry with the following note: Pt has bruisin on his left side front he upper arm down the left side to the abdomen and left hop. There is also a small bruise on his upper right arm. All are purplish with yellow and green beginning to fade. [sic] There was no documentation in the clinical record that the physician or the RP had been notified of the bruises that were identified. On 01/24/2023 at approximately 4:00 p.m., the administrator was asked for any investigation completed regarding the above information. She presented a folder and stated, We identified that we did not document appropriately. The FRI (facility reported incident) was reviewed. The conclusion on the FRI was Staff interviews reveal that [Resident #79] was not cooperative with staff during initial skin assessment. Staff reports he would not allow them to visualize his upper body including but not limited to: his pelvic and pubic area, trunk area, upper arms, or back. He refused to remove his shirts and jacket Our internal investigation was completed which included record review and staff interviews. The [local police] were notified and have been in to investigate the incident .There are no documented falls since admission, the first time the bruises were visualized by our staff was on Monday, November 7th. Due to his unwillingness for our staff to look at his body, this was not recorded timely .At this time we cannot determine the true origin of these old and fading bruises, however we have no suspicion of abuse in this investigation. Staff who cared for Resident #79 during his time at the facility were interviewed on 01/25/2023 and 01/26/2023. Interviews revealed that CNA (certified nursing assistant) #1 observed bruising to Resident #79 on 11/07/2022 and 11/12/2022. RN #1 observed bruising on 11/12/2022 and CNA #3 observed bruising on the weekend of 11/05/2022 through 11/06/2022. CNA #3 reported that she had reported the bruising to LPN #1, but LPN #1 stated in her interview that she had never seen the bruising and was not aware of it. When asked if she had attempted to do skin assessments on Resident #79 at anytime other than his admission, LPN #1 stated, Yes, I did .I probably didn't communicate that it wasn't done and I probably should have. The bruising was not reported to the physician or the RP prior to the RP's arrival at the facility on 11/14/2022 when she observed the bruising first hand. The DON was interviewed at 10:40 a.m. regarding the above interviews and findings. Asked what should have occurred, the DON stated, Someone should have reported the bruises to me, the administrator or the unit manager. I didn't know about the bruises until the day his daughter was here. I knew he was agitated but I didn't know he wasn't allowing skin assessments while he was here .that should have been reported to me too. Asked if the physician and the RP should have been notified of the bruising and the resident's refusal to have skin assessments, the DON stated, Yes, they should have been notified when it first happened. No further information was obtained prior to the exit conference on 01/26/2023.

Based on staff interview, clinical record review and facility document review, the facility staff failed to report an injury of unknown origin to the administrator for one of 24 residents (Resident #79). Bruising that was observed on Resident #79's abdomen, hip, and arms by several nursing staff was not reported to the administrator or the DON (director of nursing) until the day of discharge from the facility. Findings were: Added to the survey sample as a closed record review, Resident #79 was admitted to the facility on [DATE] for Respite care, after being discharged from a local hospital. At the time of his discharge from the hospital, his family/caretakers were sick with the flu and in his best interest, had him admitted to the facility until the family illness passed. His diagnoses included but were not limited to: dementia with agitation, severe protein-calorie malnutrition, type 2 diabetes mellitus, mild cognitive impairment, adult failure to thrive, coronary artery disease, alpha thalassemia minor, prostate cancer, and major depression. An admission MDS (minimum data set) with an ARD (assessment reference date) of 11/10/2022, assessed Resident #79 as severely impaired for daily decision making, with a cogntive summary score of 00 out of 15. The clinical record was reviewed on 01/24/2023. On the initial admission assessment dated [DATE], under section 13. Skin Observations, the following documentation was observed, Did the head to toe skin assessment on admission reveal any skin conditions or impairments? NO; General Skin Condition: Warm, dry. Under Comments, no entries were made regarding Resident #79's skin. The admission narrative note contained the following: resident arrived at facility via stretcher from (hospital) alert and oriented X 1. pureed diet, takes meds crushed in applesauce. fall risk, not compliant in using call light for assistance. Resident #79 had two skin assessments completed during the 11/4/22-11/15/22 stay in the facility. The first skin assessment dated [DATE] documented his skin as warm and dry, along with this note: no impairments observed to sacrum or feet/heels, unable to examine entire body due to resident resisting care and refusing. resident stiffens arms and does not let staff remove clothes. Both the initial admission assessment and the first skin assessment were completed by LPN (Licensed Practical Nurse) #4. The second skin assessment written by RN (registered nurse) #1 and dated 11/12/2022 documented bruising to Resident #79's abdomen, left upper arm, rib area on the left side and the right upper arm. His skin was described as warm and dry with the following note: Pt has bruisin on his left side front he upper arm down the left side to the abdomen and left hop. There is also a small bruise on his upper right arm. All are purplish with yellow and green beginning to fade.[SIC] The progress note section was also reviewed. A medical note written on 11/05/2022 by the NP (nurse practitioner) described Resident #79's skin as Dry, intact. Throughout the progress note section regarding Resident #79's behaviors, i.e. hitting staff, hitting medication out of nurse's hands, going into other patient rooms, wandering, refusing medications, requiring redirection from staff, urinating in trash cans and other inappropriate places. His aggressive behaviors escalated to the point that PRN (as needed) Haldol was ordered. There was no documentation in the progress note section regarding staff attempting to do skin assessments and Resident #79 refusing, no documentation regarding the bruising documented on the skin assessment dated [DATE], and subsequently no documentation of this occurrence being reported. A progress note dated 11/14/2022 and written by the DON was the first note to contain information regarding bruising to Resident #79: This morning between 10-10:15 am, the resident's daughter .approached the nurses station and reported that she would be taking her dad home tomorrow. It had been reported at the time of admission that he would be discharged home with his daughter when she got over the flu, so this came as no surprise. Shortly after going to his room, she requested someone come in the room with her. Upon entering the room, noted a CNA in addition to [daughter's name redacted] being in the room. [Daughter's name redacted] was crying and hard to console. She stated that her dad had bruises and he was wet. DON assessed [Resident #79's name] skin to fine (sic) that he had bruising to the LLQ [left lower quadrant] of his abdomen radiating to his left hip, bruising to L [left] upper arm and also to right antecubital areas. She stated that she was taking her dad home today. She was visibly and verbally upset and accusatory. DON told her that an internal investigation will be initiated. The DON assisted with putting [Resident #79's name] pants on and left the room. [Attending physician redacted] was notified of [Resident's daughter] taking her dad home today. Hospice .was notified as well. (sic) On 01/24/2023 at approximately 4:00 p.m., the administrator was asked for any facility account completed regarding the above findings. She presented a folder and stated, We identified that we did not document appropriately. The facility synopsis concluded, Staff interviews reveal that [Resident #79] was not cooperative with staff during initial skin assessment. Staff reports he would not allow them to visualize his upper body including but not limited to: his pelvic and pubic area, trunk area, upper arms, or back. He refused to remove his shirts and jacket Our internal investigation was completed which included record review and staff interviews. The [local police] were notified and have been in to investigate the incident .There are no documented falls since admission, the first time the bruises were visualized by our staff was on Monday, November 7th. Due to his unwillingness for our staff to look at his body, this was not recorded timely .At this time we cannot determine the true origin of these old and fading bruises, however we have no suspicion of abuse in this investigation. Staff who cared for Resident #79 during his time at the facility were interviewed on 01/25/2023 and 01/26/2023. The following information was obtained: CNA #1 was interviewed at 2:55 p.m. on 01/25/2023. She was asked if she remembered Resident #79 and whether or not she had seen any bruising on his person. She acknowledged that she remembered the resident and had taken care of him. She stated, The first time I took care of him was on November seventh .I went in his room to help his roommate and [Resident #79] needed to go to the restroom. I helped him in there and I was able to get him fully undressed and get some clean clothes on him. I saw his bruises then. She was asked to describe what she saw. CNA #1 stated, They [the bruises] were on his lower abdomen and spread to his hip, they looked old to me, purplish-green color. They were also on his left arm I didn't ask him what happened, he didn't act like they hurt while I was cleaning him up. She was asked if she reported the bruising to anyone. She stated, I didn't ask anyone about it or tell anyone .I thought the nurses already knew about it because he had been here for a few days. CNA #1 also stated, I gave him a shower over the weekend, [redacted Name of RN #1] came in there with me .he still had the bruises and she didn't say anything about them. When asked if bruising was something that should be reported, CNA #1 stated, Yes, I should have told the nurse when I saw them the first time. RN #1 was interviewed at 3:20 p.m. She was asked about the bruising she had documented on the skin assessment sheet dated 11/12/2022. She stated that she had gone into the shower room with CNA #1 on 11/12/2022 to assist her with Resident #79's shower. She stated that was the first time she had seen the bruises. She described the areas as, yellowish, dark purple in the middle, yellow at the edges. When asked if she reported what she had observed, RN #1 stated, I don't know if I reported it or not .I was the weekend supervisor .I do a weekend report for the DON, the administrator, and the unit manager. I'll have to see if I put it on there. She was asked if the bruising had been reported previously. RN #1 stated, Normally we report things like that to the doctor and the RP [responsible party] .I didn't look to see if it had already been reported or not. At approximately 4:00 p.m., RN #1 reported that she could not find the weekend report for November twelfth and did not know if the bruising had been reported on it or not. The nurse practitioner (NP) who completed Resident #79's medical admission note on 11/05/2022 was interviewed over the telephone at approximately 4:00 p.m. Asked if during his assessment had he visualized Resident #79's abdomen, the NP stated, Yes, I assessed him. He was asked if he had observed any bruising. The NP stated, No, I did not see that, if I had, it would be documented, there was no bruising. On 01/26/2023 at 10:00 a.m., LPN #1 who completed the admission assessment on 11/04/2022 and the first skin assessment on 11/05/2022, was interviewed. She stated that Resident #79 was resistive to care. LPN #1 stated, He [Resident #79] wore a long jacket that came down below his brief .he held it down and wouldn't let you take it off of him .he didn't usually wear pants, just his brief but he kept his jacket pulled down. She was asked if she had attempted to do skin assessments on Resident #79 at anytime other than his admission. LPN #1 stated, Yes, I did .I probably didn't communicate that it wasn't done and I probably should have. When asked if anyone had told her about Resident #79's bruising, LPN #1 stated, No. Interviewed at 10:25 a.m., CNA #3 stated that she saw the bruises the weekend after Resident #79 was admitted , which she clarified was the weekend of November 5th-6th. CNA #3 stated, I saw the bruises when he was in the bathroom .they were on his side, I don't remember which side, maybe the left. I don't remember the color but they weren't dark. She was asked if she had reported her observation to anyone. She stated, Yes, I told [Name of LPN #1 redacted] .she said she would have the unit manager go look at his skin with her. The DON was interviewed at 10:40 a.m. regarding the above interviews and findings. She was asked what should have occurred. The DON stated, Someone should have reported the bruises to me, the administrator or the unit manager. I didn't know about the bruises until the day his daughter was here. I knew he was agitated but I didn't know he wasn't allowing skin assessments while he was here .that should have been reported to me too. A meeting was held with the DON and the administrator prior to the exit conference on 01/26/2023. Concerns were voiced that at least three staff members had observed bruising on Resident #79 and no one had reported it to the DON, the administrator, the physician, or the RP nor had anyone reported that Resident #79 was not allowing skin assessments. The DON presented information that nursing staff had been reeducated on skin assessments and all staff had been educated on abuse and reporting. The administrator was asked if residents in house had been assessed for skin impairments, reporting findings, etc. The DON stated, No, we just did some education. No further information was obtained prior to the exit conference on 01/26/2023.

Based on staff interview, facility document review and clinical record review, the facility staff failed to act upon pharmacy recommendations for two of twenty-four residents in the survey sample. Pharmacy recommendations for Residents #44 and #24 were not responded to and/or implemented. The findings include: 1. Resident #44's pharmacy recommendation regarding the use of the anti-anxiety medication lorazepam beyond 14 days was not responded to by the provider. Resident #44 was admitted to the facility with diagnoses that included multiple sclerosis, asthma, atrial fibrillation, anxiety disorder, protein-calorie malnutrition, depression, hypothyroidism, insomnia, hypertension, failure to thrive and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed Resident #44 with severely impaired cognitive skills for dialy decision making. Resident #44's clinical record documented a physician's order dated 12/22/22 for lorazepam (anti-anxiety medication) concentrate (2 milligrams/milliliter) 0.5 milliliters by mouth every 8 hours as needed (prn) for agitation related to anxiety disorder. A consultant pharmacist's recommendation dated 12/22/22 documented, The resident has an order to receive the following medication Lorazepam prn . all PRN psychotropic medication(s) are limited to 14 days of usage to limit their effect on the brain activities associated with mental processes and behavior .To extend the PRN order past the 14 days, the prescriber must document the rationale in the medical record and indicate the duration of the PRN order . The clinical record documented no physician response to the 12/22/22 pharmacy recommendation regarding the prn lorazepam order. Spaces on the recommendation sheet for physician response were blank and the clinical record documented no rationale or duration for the continued use of the prn lorazepam. On 1/25/23 at 1:45 p.m., the registered nurse unit manager (RN #2) was interviewed about Resident #44's prn lorazepam order in place for over 30 days. RN #2 stated that she saw no recommendation from pharmacy in the clinical record regarding the prn lorazepam. Questioned further, RN #2 stated that she did not know why the prn lorazepam was ordered beyond 14 days and with no end date. On 1/26/23 at 8:11 a.m., the director of nursing (DON) was interviewed about any response to the prn lorazepam pharmacy recommendation for Resident #44. The DON reviewed the clinical record and stated there had been no physician response to the pharmacy recommendation. The DON stated she usually received the recommendations monthly and forwarded any recommendations to the physician for response. Regarding Resident #44's recommendation of 12/22/22, the DON stated, This one was missed. The facility's policy titled Medication Regimen Review (effective 8/2020) documented regarding facility response to recommendations, .Resident-specific irregularities and/or clinically significant risks resulting from or associated with medication are documented in the resident's active record and reported to the Director of Nursing, Medical Director, and/or prescriber as appropriate .Recommendations are acted upon and documented by the facility staff and/or the provider .The prescriber accepts and acts upon recommendation or rejects provides an explanation for disagreeing . (sic) This finding was reviewed with the administrator, DON, and regional director of clinical services during a meeting on 1/25/23 at 4:50 p.m. 29123 2. Resident #24 was admitted to the facility with the following diagnoses, including but not limited to: generalized anxiety disorder, hypertension, dementia without behavioral disturbances, major depressive disorder, delusional disorder, and pressure ulcer of the sacral region. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/18/2022. Resident #24 was assessed as severely impaired in daily decision making, with a cognitive summary score of 04 out of 15. The clinical record was reviewed on 01/25/2023 at approximately 11:00 a.m. A Consultant Pharmacist Recommendation to Physician form with a medical record review date of 12/15/2022 contained the following: Federal guidelines state antipsychotic drugs should have an attempt at a gradual dose reduction (GDR) twice per year for the first year in 2 different quarters with at least 1 month between attempts, then annually thereafter. This resident has been taking ABILIFY 20 MG HS (hour of sleep) since 6/2022 without a GDR. Could we attempt a dose reduction at this time to 15 MG HS to verify the resident is on the lowest possible dose? If not, please indicate response below . Five choices were listed for the physician to choose as the response. Resident #24's physician chose: Reduce the dose of ABILIFY to: 15 mg. The form was signed by the physician on 01/19/2023. The physician order section of the clinical record was reviewed. Current orders for Abilify were: ARIPiprazole (generic ABILIFY) Tablet 10 MG Give 2 tablets by mouth at bedtime for psychosis related to GENERALIZED ANXIETY DISORDER; DELUSIONAL DISORDERS; MAJOR DEPRESSIVE DISORDER . The DON (Director of nursing) was interviewed on 01/25/2023 at approximately 1:00 p.m. regarding Resident #24's Abilify orders. After reviewing the form from the pharmacy and the physician response, the DON stated, I see what happened. The DON pointed to writing on the form that had been struck through and stated, He [the physician] got confused .he thought this resident had passed and he wrote passed on the form .when it came back to me I gave it back to him .the form is supposed to come back to me to write the orders .this one didn't .I will contact the doctor and let him know what happened. At approximately 2:00 p.m., the DON presented a progress note that contained the following: 01/25/2023 (Name of physician) notified of Abilify GDR not being completed on 01/19/2023. Order obtained to decrease Abilify to 15 mg on this date. Order placed in system .RP [responsible party] notified of new order. The DON also presented a new physician order summary that included the change of Abilify from 20 mg to 15 mg at bedtime. The above information was discussed during an end of the day meeting on 01/25/2023. Concerns were voiced that Resident #24 had received 20 mg of Abilify at HS for six nights instead of the reduction to the 15 mg dosage prescribed by the physician. No further information was obtained prior to the exit conference on 01/26/2023.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration on one of two medication carts inspected: Residential unit. A vial of expired Lantus insulin was observed in the medication cart. Findings include: On 1/25/23 beginning at 9:30 a.m., the medication cart on the Residential unit was inspected. LPN (licensed practical nurse) # 2 was present during the inspection. A vial of Lantus insulin with an open date of 12/1/22 was located in the medication cart. LPN # 2 was asked about the date, and how long the insulin could be on the cart after being opened. LPN # 2 stated It's good for 28 days once opened. LPN # 2 was asked if the new expiration date was recorded on the label and she stated I don't think so. On 1/25/23 at 9:45 a.m., the DON (director of nursing) was asked for a policy on insulin labeling and storage. The policy Medications With Shortened Expiration Dates was reviewed. For Lantus insulin, the policy directed Vial: once opened .product expires 28 days after first use or removal from refrigerator, whichever comes first. On 1/25/23 at 10:15 a.m., the Regional Clinical Coordinator (RCC) was interviewed. Presented with the policy, the RCC stated, I see where it says it expires after 28 days of opening; I think there's a label for staff to record not only the date opened, but the date it should be taken out of the cart. The RCC and I went to the medication cart and observed the label affixed to the insulin vial in question. Staff had recorded the open date, and there was also a place to record the new expiration date, but no date had been recorded. The RCC stated Well, there is a space to record an expiration date; not sure why staff aren't doing that I know they are to check before administration of medications with a shortened expiration date but since there's a space for that, it should be recorded so it's a quick reference . The above findings were shared with the administrator, DON, and Regional Clinical Coordinator during a meeting with facility staff beginning at 4:50 p.m. No further information was provided prior to the exit conference.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure a complete and accurate clinical record for one of 24 residents in the survey sample (Resident #23). The Findings Include: Resident #23 had incomplete documentation of the Treatment Administration Record (TAR) for several days in the month of January 2023. Diagnoses for Resident #23 included; Urinary tract infection, Osteomyelitis, multiple pressure ulcers and wounds, and quadriplegia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/28/22. Resident #23 was assessed with a cognitive score of 14 out of 15, indicating cognitively intact for daily decision making. On 1/25/23, Resident #23's physician orders were reviewed. There were multiple orders for wound dressings to be completed each night, which included dressing changes to Resident #23's left foot and toes, left lower hip, right hip, right below knee amputation site, left heel, and coccyx (all wounds were acquired prior to admission). The TAR for January 2023 was then reviewed and noted to have blanks for all treatments (no nurses initials indicating the treatment had been completed) for the 3rd, 5th, and 10th of January. Review of the progress notes for the dates in question, did not indicate Resident #23 was out of the facility. On 01/25/23 at 1:59 PM license practical nurse (LPN #1) was interviewed. LPN #1 said that she was assigned to Resident #23 on the day shift after the dates in question, and did not recall getting report that the dressings were not completed, as usually this would be reported in an end of shift report so that the next nurse can ensure to complete anything that was not done. LPN #1 went onto say that she felt that the dressing changes were being completed but not signed off as the nurses were good about letting each other know if something was not completed and also there was no documentation of refusals. On 01/25/23 at 3:00 PM, Resident #23 was interviewed regarding dressing changes. Resident #23 said that the nurses have been doing the dressing changes each night and to his knowledge had not missed any dressing changes. Resident #23 went onto say that the nurses and aides are taking good care of him. Resident #23's wife was in the room during the interview and agreed. On 01/25/23 at 5:00 PM, the above information was presented to the director of nursing (DON) and administrator during an end of day meeting and was asked for follow up on the concern. 01/26/23 08:20 AM, the DON and administrator was interviewed again. The DON verbalized that she was able to reach out to one of the night shift nurses working on the night in question but the nurse was unable to verify that she did or did not complete dressing changes. The DON went onto to say that Resident #23 chooses when he gets his dressing changes and prefers not to be awaken if sleeping, but then the nurse would have documented on the TAR that the resident had refused treatment. The DON stated that in terms of the documentation, she could not say for definite that Resident #23 did or did not get dressing changes, but felt that he did receive the dressing changes, although it was not documented on the TAR. When asked about documenting on the TAR, the administrator and DON agreed that it is the expectation of the nurses to document on the TAR if a dressing change was performed or not. The facility's policy titled Topical Medication Administration read in part 22. Note administration of the treatment by recording initials, date and time in the appropriate area on the MAR or TAR [ .]. No other information was presented prior to exit conference on 1/26/23.

Based on observation, interview, record review, review of facility policy, and review of disinfectant instructions for use, the facility failed to ensure the staff appropriately disinfected blood glucose (sugar) monitors between resident use for one of two residents (Resident (R) 38), and failed to prevent the potential for cross-contamination for two of two residents (R38 and R12) when the staff placed wax paper barriers on the potentially contaminated surfaces of two medication carts and on surfaces in resident rooms. The facility had 18 residents who received blood glucose monitoring. Findings include: Review of the facility's policy and procedure titled, Blood Test Monitoring, dated 11/01/19, revealed, Procedure: . 2. Manufacturer's guidelines will be followed for monitoring device preparation . 6. Device must be cleaned and disinfected between patients. Review of a document titled, Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, revised 12/17 revealed, The meter should be cleaned and disinfected after use on each patient . [An] Environmental Protection Agency (EPA) registered disinfectant product may be used to clean and disinfect the blood glucose meter. Review of the Product Literature Sheet, dated 2021, for PDI (Professional Disposables International, Inc.) Sani-Cloth Bleach Germicidal Disposable Wipe, retrieved online on 04/21/2021 at: https://pdihc.com/wp-content/uploads/2018/08/PDI-Sani-Cloth-Bleach-Clinical-Wipe-Sell-Sheet_ 201.pdf, revealed the Sani-Cloth Bleach Wipe Benefits included that the product was, Effective against [CONDITION(S)]-CoV-2 (Coronavirus), the virus that causes COVID-19. Review of the PDI Sani-Cloth Bleach Germicidal Disposable Wipe Wall Chart titled, General Guidelines for Use, dated 2019, retrieved online 04/21/2021 at: https://pdihc.com/wp-content/ uploads/2019/08/SaniClothBleachIFUCanisterWallchart 534.pdf revealed, . 4. Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous 4 minute [sic] wet contact time. 1. a. Observation on 04/21/2021 at 11:55 AM revealed Licensed Practical Nurse (LPN) 2 stood at her medication cart wiping all surfaces of glucometer #2 (a device used to measure the blood sugar levels) with a disposable wipe. The LPN identified the wipe as a PDI Sani-Cloth Bleach Germicidal Disposable Wipe. After wiping the device with the germicidal wipe, the LPN placed the glucometer on a piece of wax paper on the medication cart. Further observation revealed a second glucometer (glucometer #1) sat on a separate piece of wax paper uncovered and dry. LPN2 stated that she had also cleaned the glucometer #1 with a PDI Sani-Cloth Bleach Germicidal Disposable Wipe. Continued observation revealed at 12:03 PM, the LPN used glucometer #2, which she had wiped with the PDI Sani-Cloth Bleach Germicidal Disposable Wipe seven minutes prior, to complete a blood sugar test for R38. After completion of the test, LPN2 took the potentially contaminated glucometer back to the medication cart and used two PDI Sani-Cloth Bleach Germicidal Wipes to clean the glucometer. The LPN disposed of both wipes in the trash and placed the glucometer on a new piece of wax paper on the top of the medication cart. LPN2 stated, It [the glucometer] has to sit for four minutes before it can be used again to make sure it's disinfected. When asked about the PDI Sani-Cloth Bleach Germicidal Wipes instructions for use for cleaning and disinfecting glucometers after use, the LPN stated, I was told they [the glucometers] were supposed to dry for four minutes while the disinfectant worked. The LPN stated that she was unaware the glucometers needed to remain visibly wet with the germicide for at least four minutes in order to appropriately disinfect the devices. LPN2 did not recall who instructed her to allow the glucometers to air dry, nor when she received inservice training in infection control as it related to the disinfection of glucometers. b. Observation on 04/21/2021 at 11:55 AM revealed after LPN2 finished wiping the surface of glucometer #2 with PDI Sani-Cloth Bleach Germicidal Wipes, she placed the glucometer on a piece of wax paper that was in direct contact with the potentially contaminated top of the medication cart. At 12:03 PM, the LPN assembled additional blood sugar testing supplies, picked up glucometer #2 along with the wax paper underneath the device, entered R38's room, and placed the wax paper holding the glucometer on the potentially contaminated countertop of the resident's sink while she washed and dried her hands and applied gloves. LPN2 then placed the wax paper and glucometer on the resident's potentially contaminated bedside table. After completing the resident's blood sugar test, the LPN picked up glucometer #2 along with the wax paper underneath the device and placed the wax paper underneath the glucometer directly on the top of the medication cart potentially contaminating the cart top. When asked about the potential for cross-contamination of both the resident's room items and top of the medication cart, the LPN stated that she had not considered that possibility. 2. Observation on 04/21/2021 at 11:37 AM revealed LPN1 stood at her medication cart and placed a section of wax paper on the surface of the medication cart without first cleaning and disinfecting the cart top. LPN1 then retrieved a glucometer from a plastic bag storage and placed it and other supplies on the wax paper. LPN1 picked up the glucometer along with the wax paper underneath the device, entered R12's room, and placed the wax paper holding the glucometer on top of the potentially contaminated countertop of the resident's sink while she washed and dried her hands and applied gloves. LPN1 then placed the wax paper and glucometer on the resident's potentially contaminated bedside table. After completing the resident's blood sugar test, the LPN picked up the glucometer along with the wax paper underneath the device and returned to the medication cart. The LPN then disposed of the wax paper and without first cleaning and disinfecting the cart top, placed a new section of wax paper directly on the top. When asked about the potential for cross-contamination of both the resident's room items and top of the medication cart, the LPN stated that she had not considered that possibility. Review of an Inservice/Education Sign in Sheet, dated 2/27/20, revealed the training information presented related to cleaning of glucometers. The inservice Sign in Sheet revealed both LPN1 and LPN2 attended the training, which instructed the staff to keep, 2 [sic] glucometers on each [medication] cart top when one is in use the other is being cleaned. The attachment titled, Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, revised 12/17 revealed, The meter should be cleaned and disinfected after use on each patient. [An] Environmental Protection Agency (EPA) registered disinfectant product may be used to clean and disinfect the blood glucose meter. The training did not address that use of the PDI Sani-Cloth Bleach Germicidal Wipes required the glucometer to remain visibly wet with the germicidal agent for at least four minutes for adequate disinfection, nor did it address how to avoid sources of potential cross-contamination. During an interview on 04/21/2021 at 1:05 PM, LPN4, the facility's Certified Infection Preventionist, stated that the facility had no residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . follow protocol, standards of practice, and the facility's policies and procedures when performing blood sugar testing and for disinfecting the medication carts. This included cleaning and disinfecting the tops of the medication carts in between medication passes, cleaning and disinfecting the glucometers after each use as specified by the device's directions for use, and to use a protective barrier when using the glucometer, but to use a separate wax paper barrier in the resident's room, which is disposed of prior to leaving the resident's room to avoid possible cross-contamination. During an interview on 04/22/2021 at 12:15 PM the Director of Nursing and the Registered Nurse (RN) Consultant stated the staff were to follow the facility's policies and procedures and standards of clinical practice when performing blood sugar testing and for disinfecting the glucometers and medication carts.

Based on observation, interview, record review, and review of facility policies, the facility failed to develop comprehensive and individualized care plans that included person-centered interventions to meet the residents' medical needs for 3 of 17 sampled residents, (Resident (R) 6, R60 and R171). The facility failed to include individualized interventions on the care plan for R60 to prevent falls and potential for injury when the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy and procedure titled, Care Planning with an Effective Date of 11/01/19, 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. 1. Review of R60's Electronic Medical Record (EMR) under the Profile tab revealed the facility admitted the resident on 03/02/21 from an acute care hospital. Under the Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R60's Admission Assessment/Screening V.1.2 under the Assmnts (Assessments) tab in the EMR, dated 03/02/21 at 1:52 PM, revealed the resident was alert and oriented to person and situation. The assessment indicated the resident had fallen within the past month. A Falls Risk Assessment also under the Assmnts tab completed on 03/02/21 at 1:52 PM revealed the admitting nurse documented that R60's risk factors for falls included impaired vision with or without glasses and incontinence. The resident's most recent fall prior to admission occurred on 02/23 (no year documented). Review of the resident's Order Summary Report under the Orders tab for the dates 03/01/21 through 04/30/21 revealed no orders pertinent to the resident's risk for falls. Review of the resident's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/21, in the EMR under the MDS tab, revealed the answer codes for the Brief Interview for Mental Status (BIMS) assessment and summary score, and the staff assessment of the resident's mental status were all populated with dashes. The MDS assessment indicated that R60 had no behavioral symptoms, did not reject care, and did not exhibit wandering behavior. R60 was able to walk in her room with limited assistance of one person, was unsteady on her feet but able to stabilize herself without staff assistance but sustained a fall in the last month prior to her admission. Review of R60's care plan, dated 03/09/21, revealed a Focus or problem area created on 03/02/21 related to her fall risk that read, The resident is at risk for falls r/t [related to] confusion, deconditioning, gait/balance problems, diuretic therapy, [CONDITION(S)], [CONDITION(S)] [high blood pressure], [and] major depressive disorder. The staff documented the Goal for the resident's fall risk as, The resident will be free of falls through the review date [05/31/21]. The interventions developed by the staff to prevent R60 from future falls included only three preventative measures: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Keep environment free of trip hazards. The three interventions on R60's care plan for fall prevention were not person-centered and did not include the resident's fall history, impaired vision with or without glasses, and incontinence status. 2. Review of R171's EMR under the Profile tab revealed the facility admitted the resident on 04/09/21. Review of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R171's April 2021 Order Summary Report found under the Orders tab in the EMR revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Oxygen Therapy - Oxygen 3 liters per minute [3L/min] via nasal cannula [for] [CONDITION(S)] with an order date of 04/12/21; and Oxygen tubing and humidifier change weekly on Thursdays every night shift every 7 day(s) with an order date of 04/12/21. Review of R171's Admission MDS with an ARD of 04/15/21 found under the MDS tab in the EMR revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. The assessment revealed R171 experienced shortness of breath or trouble breathing with exertion and when lying flat. Observation on 04/19/21 at 11:45 AM revealed R171 received oxygen at 3L/min delivered via clear tubing applied to his nose and supplied by an oxygen concentrator at bedside. Additional observation revealed R171's oxygen tubing trailed off the left side of the resident's bed to the floor and continued along the contaminated floor approximately 2 feet to the oxygen concentrator where it joined to an empty humidifier bottle. Neither the oxygen tubing nor the humidifier bottle where initialed and dated with the last change of the respiratory equipment. During an interview on 04/19/21 at 11:45 AM, R171 stated the staff applied his oxygen tubing on admission and added the humidifier bottle, . the day after I got here and have not changed it out for a full bottle since then. Review of the resident's undated active Care Plan found under the Care Plan tab in the EMR revealed the staff did not include interventions for changing the resident's oxygen tubing and humidifier every seven days, for initialing and dating the oxygen tubing and the humidifier bottle when changed, or to ensure that the resident's oxygen tubing did not come into contact with the contaminated floor. 3. Review of R6's EMR Profile tab revealed the facility admitted the resident on 01/06/21. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's Significant Change in Status Assessment MDS with an ARD of 01/14/21 revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of R6's April 2021 Order Summary Report found under the Orders tab in the EMR revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/19/21 at 11:24 AM revealed R6 rested in bed and received oxygen at 2L/min delivered via clear tubing applied to his nose and supplied by an oxygen concentrator at bedside. Additional observation revealed R6's oxygen tubing trailed off the left side of the resident's bed to the floor and continued along the contaminated floor approximately 2.5 feet to the oxygen concentrator where it joined to a humidifier bottle with approximately 1/4 cup of fluid remaining in the bottle. Neither the oxygen tubing nor the humidifier bottle were initialed and/or dated with the last change of the respiratory equipment. Review of the resident's undated active Care Plan found under the Care Plan tab in the EMR revealed the staff did not include interventions for changing the resident's oxygen tubing and humidifier every seven days, to initial and date the oxygen tubing and humidifier when changed, or to ensure the resident's oxygen tubing did not come into contact with the contaminated floor. During an interview on 04/22/21 at 3:15 PM, the Director of Nursing (DON) stated that she expected the admitting nurse to begin the initial care plan for new admissions and is to include pertinent interventions according to the resident's specific risk factors and care needs.

Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to obtain physician orders for and offer two of five residents (Resident (R) 66 and R169) and/or their representative, reviewed for influenza/pneumonia vaccinations, the opportunity for the resident to be vaccinated in accordance with nationally recognized standards. The facility failed to offer R169 the opportunity to be vaccinated with PCV13 (pneumococcal vaccine) in accordance with CDC guidelines and failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident and/or their representative were unable to share in clinical decision making with the medical provider as they were not given information or offered the vaccinations. The failed practice had the potential to increase the risk for influenza and/or pneumonia for the two residents. Findings include: Review of the Centers for Disease Control and Prevention (CDC) website titled, Pneumococcal Vaccine Recommendations revealed, For adults [AGE] years or older who do not have an immunocompromising condition, [CONDITION(S)], or cochlear implant and want to receive PCV13 (Prevnar13®), AND PPSV23 (Pneumovax23®) . Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later. If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Retrieved online, 04/22/21, at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html Review of the facility policy Vaccinations and PPDs with an effective date of 11/01/19, read in part, Policy: After receiving a physician's order a licensed nurse will administer routine or standard vaccination to each patient unless medically contraindicated and will document accordingly. Procedure: 1. Annual flu vaccine will be administered to all patients by physician order. 2. A copy of vaccine related information/education that was provided to the patient of [sic] responsible party in the form of CDC Vaccination Information Statement will be placed in the patient's medical record. 3. [MEDICATION(S)] . will be administered as physician ordered. 5. Documentation of all vaccinations is to be documented on the Immunization Report. 1. Review of R66's Electronic Medical Record (EMR) under the Profile tab revealed the facility admitted the resident on 09/30/20 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/20, revealed the resident did not receive the influenza vaccine at the facility for the 2020 influenza season and that the facility did not offer the influenza vaccine to the resident. Review of the resident's Quarterly MDS assessments, with ARDs of 01/05/21 and 04/05/21 respectively, revealed the resident did not receive the influenza vaccine at the facility for the 2020 influenza season and that the facility did not offer the influenza vaccine to the resident. Review of R66's Physician Orders for April 2021, found under the Orders tab in the EMR, failed to contain an order to administer the influenza vaccine. Review of R66's EMR under the Immunizations tab revealed no documentation to indicate the resident received or was offered the influenza vaccine or did not receive the vaccines due to medical contraindications, previous vaccination, or refusal. 2. Review of R169's EMR under the Profile tab revealed the facility admitted the resident on 04/08/21 with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Admission MDS with an ARD of 04/14/21, revealed the section for Influenza Vaccine, was blank. The section for Pneumococcal Vaccine indicated the resident's pneumococcal vaccination was not up to date but provided no reason why the resident did not receive the pneumococcal vaccine. Review of R169's Physician Orders for April 2021, found under the Orders tab in the EMR failed to contain an order to administer the influenza or pneumococcal vaccines. Review of R169's EMR under the Immunizations tab revealed no documentation to indicate the resident was offered or received the [MEDICATION(S)] pneumococcal vaccine, the [MEDICATION(S)] 23 vaccine, or the influenza vaccine, or did not receive the vaccines due to medical contraindications, previous vaccination, or refusal. During an interview on 04/22/21 at 12:15 PM, the Director of Nursing (DON) and the Registered Nurse (RN) Consultant, the DON confirmed the facility had no documentation related to the influenza vaccination for R66 and had no documentation related to R169's influenza, [MEDICATION(S)], or [MEDICATION(S)] 23 vaccinations or documentation of previous administration.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide necessary respiratory care consistent with the physicians' orders, professional standards of practice, and the residents' care plans for two of two residents observed for oxygen use, (Resident (R) 6 and R171). The staff failed to date and initial R6's and R171's oxygen tubing and humidifiers, failed to ensure the residents' oxygen tubing did not come into contact with the contaminated floor, and failed to ensure that R171's humidifier bottle was replaced when empty. Findings include: Review of the facility's policy and procedure titled, Respiratory/Oxygen Equipment, with an Effective Date of 11/01/19, revealed that, Licensed staff will administer and maintain respiratory equipment, oxygen administration, and oxygen equipment per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Nasal cannulas, Simple masks, Venturi mask, and Oximizer must be changed every week, dated and initialed. 7. If [the] flow rate [of oxygen] is greater than 4 liters/minute, a pre-filled disposable humidifier bottle must be used. Humidifier bottles are to be dated and changed every 7 days. The policy and procedure failed to address that staff ensure oxygen tubing be kept off the floor. 1. Observation on 04/19/21 at 11:45 AM revealed R171 rested in bed and received oxygen at 3L/min delivered via clear tubing applied to his nose and supplied by an oxygen concentrator at bedside. Additional observation revealed R171's oxygen tubing trailed off the left side of the resident's bed to the floor and continued along the floor approximately 2 feet to the oxygen concentrator where it joined to an empty humidifier bottle. Neither the oxygen tubing nor the humidifier bottle were initialed and dated with the last change of the respiratory equipment. During an interview on 04/19/21 at 11:45 AM, R171 stated he was admitted to the facility . a week ago due to a worsening of his [CONDITION(S)] and an increase in [CONDITION(S)] (fluid retention) to both of his feet. When asked when the staff most recently changed his oxygen tubing and replaced his humidifier bottle, the resident stated the staff applied his oxygen tubing on admission and added the humidifier bottle, . the day after I got here and have not changed it out for a full bottle since then. Review of R171's Electronic Medical Record (EMR) under the Profile tab revealed the facility admitted the resident on 04/09/21. Review of the Med Diag [Medical Diagnosis] tab in the EMR revealed R171 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R171's April 2021 Order Summary Report found under the Orders tab in the EMR revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the R171's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/15/21 found under the MDS tab in the EMR revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The assessment revealed R171 experienced shortness of breath or trouble breathing with exertion and when lying flat. Review of the resident's undated active Care Plan found under the Care Plan tab in the EMR revealed it did not include interventions for changing the resident's oxygen tubing and humidifier every 7 days, to initial and date the oxygen tubing and humidifier when changed, nor to ensure the resident's oxygen tubing did not come into contact with the contaminated floor (Cross-reference F656 - Comprehensive Care Plans). Review of the resident's April 2021 Treatment Administration Record (TAR) found under the Orders tab in the EMR revealed an entry for: Oxygen tubing and humidifier change weekly on Thursdays every night shift every 7 day(s) with an order date of 04/12/21. Further review of the April 2021 TAR revealed the staff documented this task was most recently completed by the night shift staff on Monday, 04/19/21. However, the TAR entry did not include instructions for the staff to initial and date the respiratory equipment when changed and did not include an entry for the staff to ensure the resident's oxygen tubing did not come into contact with the contaminated floor. 2. Observation on 04/19/21 at 11:24 AM revealed R6 rested in bed and received oxygen at 2L/min delivered via clear tubing applied to his nose and supplied by an oxygen concentrator at bedside. Additional observation revealed R6's oxygen tubing trailed off the left side of the resident's bed to the floor and continued along the contaminated floor approximately 2.5 feet to the oxygen concentrator where it joined to a humidifier bottle with approximately 1/4 cup of fluid remaining in the bottle. Neither the oxygen tubing nor the humidifier bottle were initialed and dated with the last change of the respiratory equipment. Review of R6's EMR Profile tab revealed the facility admitted the resident on 01/06/21. Review of the Med Diag [Medical Diagnosis] tab in the EMR revealed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's April 2021 Order Summary Report found under the Orders tab in the EMR revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R6's significant change in status assessment MDS with an ARD of 01/14/21 revealed the resident had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of the resident's undated active Care Plan found under the Care Plan tab in the EMR revealed it did not include interventions for changing the resident's oxygen tubing and humidifier every 7 days, to initial and date the oxygen tubing and humidifier when changed, nor to ensure the resident's oxygen tubing did not come into contact with the contaminated floor (Cross-reference F656 - Comprehensive Care Plans). Review of the resident's April 2021 TAR found under the Orders tab in the EMR revealed an entry for: Oxygen tubing change weekly on Sunday, 7p-7a shift every night shift every Sun[day] with an order date of 03/03/21 and a discontinue date of 04/09/21. The April 2021 TAR revealed the staff documented this task was most recently completed by the night shift staff on Sunday, 04/04/21. Further review of the TAR revealed that although the resident had active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 04/21/21 at 1:05 PM, the facility's Certified Infection Preventionist, Licensed Practical Nurse (LPN) 4 stated that oxygen tubing should never be allowed to touch the floor due to infection prevention and control concerns. LPN4 stated that all staff were responsible for checking oxygen tubing placement and the water level in the humidifier bottles. All respiratory equipment should be changed every 7 days and labeled with the date of the change and initialed by the staff member who provided the change in the respiratory equipment.

Based on interviews, record review, and facility policy review, the facility failed to conduct an effective post-fall root-cause analysis per facility policy to develop appropriate person-centered fall prevention measures for one resident (Resident (R) 60) with repeated falls out of a sample of 17 residents. The failed practice put R60 at risk for further falls and injury. Findings include: 1. Review of R60's EMR under the Profile tab revealed the facility admitted the resident on 03/02/21 from an acute care hospital. Under the Medical Diagnosis tab the resident's diagnoses included [CONDITION(S)] (brain disease, disorder, or damage), generalized muscle weakness, altered mental status, mononeuropathy (damage to a single nerve that can cause a loss of sensation, movement, or function of the affected body part) of both legs, unspecified dementia without behavioral disturbance, unsteadiness on feet, and repeated falls. Review of R60's Admission Assessment/Screening V.1.2 under the Assmnts (Assessments) tab, dated 03/02/21 at 1:52 PM, revealed the resident was alert and oriented to person and situation. The assessment indicated the resident had fallen within the past month. A Falls Risk Assessment also under the Assmnts tab completed on 03/02/21 at 1:52 PM revealed the admitting nurse documented that R60's risk factors for falls included impaired vision with or without glasses and incontinence. The resident's most recent fall prior to admission occurred on 02/23 (no year documented). Review of the resident's Order Summary Report under the Orders tab in the EMR for the dates 03/01/21 through 04/30/21 revealed no physician orders pertinent to the resident's risk for falls. Review of the resident's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/21, found under the MDS tab in the EMR revealed the answer codes for the Brief Interview for Mental Status (BIMS) assessment and summary score, and the staff assessment of the resident's mental status were all populated with dashes. The MDS assessment indicated that R60 had no behavioral symptoms, did not reject care, and did not exhibit wandering behavior. R60 was able to walk in her room with limited assistance of one person, was unsteady on her feet but able to stabilize herself without staff assistance but had sustained a fall in the last month prior to her admission. Review of R60's Care Plan, dated 03/09/21, found under the Care Plan tab in the EMR revealed a Focus or problem area created on 03/02/21 related to her fall risk that read, The resident is at risk for falls r/t [related to] confusion, deconditioning, gait/balance problems, diuretic therapy, [CONDITION(S)], [CONDITION(S)] [high blood pressure], [and] major depressive disorder. The staff documented the Goal for the resident's fall risk as, The resident will be free of falls through the review date [05/31/21]. The interventions developed by the staff to prevent R60 from future falls included only three preventative measures: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Keep environment free of trip hazards. Review of R60's multidisciplinary Progress Notes under the Progress Notes tab in the EMR dated from 03/02/21 at 1:52 PM through 04/20/21 at 4:05 PM, a Falls Risk Assessment under the Assmnts tab dated 03/24/21 at 4:52 AM, and Post Fall Documentation notes also under the Assmnts tab from 03/24/21 at 12:28 PM through 03/29/21 at 4:28 AM, revealed that on 03/24/21 at 4:45 AM, the nurse documented the resident, . had to stay at the nursing station most of the night, until sleepy. [The] resident had a fall this shift at 0410 [4:10 AM] . Neuro checks were completed and skin check [sic]. Resident has not complained of any pain. Review of a Post Fall Documentation Note, dated 03/24/21 at 12:28 PM, revealed the resident had an unwitnessed fall in her room during the prior shift. The nurse documented the resident, . has a hx [history] of falls, confusion, and ambulating w/o [without] calling for assistance. [A] bruise [is] noted to resident's right temple next to [her] eye. [The] resident denies any pain r/t fall. Scattered bruising noted to BLUE [bilateral (both) upper extremities], and BLLE [bilateral lower extremities]. Vitals [vital signs] WNL [within normal limits]. No s/s [signs of symptoms] of distress or SOB [shortness of breath] noted. Resident does not indicate when transferring that she has pain, no facial grimacing or wincing, does not say ow or that hurts. Recommendations: Continue with current plan of care as it remains appropriate. Resident located in highly visible area to ensure residents safety at this time. Review of an Incident Note under the Progress Notes tab, which was completed on 03/24/21 at 3:44 PM by the facility's Certified Infection Preventionist and Unit Manager, Licensed Practical Nurse (LPN) 4 revealed, [The] resident was observed on floor next to her bed by staff wrapped in her blankets . Hx of falls, dementia [diagnosis] . Recommendations: Will place fall mats next to bed. Subsequent Post Fall Documentation notes under the Assmnts tab dated from 03/24/21 through 04/20/21 reflected the Recommendations included: Continue with current plan of care as it remains appropriate; frequent reminders, frequent checks, when awake is given activities to do in eye view of staff or has been talking with other residents in the hall; and Continue POC [Plan of Care]. During an interview on 04/21/21 at 1:05 PM, the facility's Certified Infection Preventionist and Unit Manager Licensed Practical Nurse (LPN) 4 stated that when a resident falls, the nurse performs a full head-to-toe assessment to determine if the resident has any injuries or is experiencing pain. LPN4 stated that she talks with the resident and the staff to try and determine the reason the resident fell . The resident's fall is then reviewed at least weekly by the Falls Management/Committee Meeting during which the team conducts a root-cause analysis if the resident's fall to determine and implement appropriate fall-prevention interventions. During an interview on 04/22/21 at 3:15 PM, the Director of Nursing (DON) provided a copy of a Falls Management/Committee Meeting Minutes form for R60's fall that occurred on 03/24/21. Review of the form's instructions for completion revealed the team is to, . Complete at least weekly during falls committee meeting. Minutes are to be completed anytime falls are discussed. The form included six sections for the team to complete: Medications, [CONDITION(S)], 'Vision, Mobility, Unsafe Behavior, and Other. Further review of the form completed in response to R60's fall on 03/24/21 revealed the Falls Management/Committee completed only one of the six sections, Unsafe Behavior, which reflected only that the resident, fell out of bed wrapped in blankets. Fall mats next to bed. The DON stated that the Falls Management/Committee team is to meet weekly after a resident falls to review the factors involved in the fall and update the resident's care plan with appropriate interventions to help prevent future falls. The DON then stated that the 03/24/21 Falls Management/Committee Meeting Minutes form for R60's fall was the only documentation the facility had for her fall. Further review of the meeting minutes provided no documentation reflective of a root-cause analysis by the committee of the resident's 03/24/21 fall and/or of her history of falls prior to admission to determine any common causes. Review of R60's care plan for fall risk revealed the care plan was not updated after the committee's meeting to reflect the addition of fall mats next to the resident's bed. Review of the facility policy titled, Falls Management Program, with an Effective Date of 11/01/19, revealed: The Center considers all patients to be at risk for falls and provides an environment as safe as practicable for all patients. The center utilizes a systems approach to a Falls Management Program that conducts multi-faceted, interdisciplinary assessments with evidence based [sic] interventions to develop individual care strategies. 2. Complete the Post-Fall Assessment to determine, to the extent possible, the cause of a patient fall. Follow-Up Responsibilities: 1. The Unit Manager will review the Incident Report and any post fall follow-up and communicate any necessary fall management interventions to direct caregivers . Falls Committee: . 2. Each fall will be reviewed for causative factors utilizing the Post Fall Assessment, Device Assessment, and Incident Report. 3.The committee will evaluate and recommend additional fall management strategies as indicated. 5. The Unit Manager verifies care plan revisions, patient monitoring, appropriate referrals, and communication to staff for all recommendations.

Based on observation, interview, record review, and review of facility policies, the facility failed to update the comprehensive care plan with person-centered interventions to prevent additional falls for 1of 17 sampled residents, (Resident (R) 60), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled, Falls Management Program, with an Effective Date of 11/01/19, revealed: The Center considers all patients to be at risk for falls and provides an environment as safe as practicable for all patients. The center utilizes a systems approach to a Falls Management Program that conducts multi-faceted, interdisciplinary assessments with evidence based [sic] interventions to develop individual care strategies. 2. Complete the Post-Fall Assessment to determine, to the extent possible, the cause of a patient fall. Follow-Up Responsibilities: 1. The Unit Manager will review the Incident Report and any post fall follow-up and communicate any necessary fall management interventions to direct caregivers. Falls Committee: . 2. Each fall will be reviewed for causative factors utilizing the Post Fall Assessment, Device Assessment, and Incident Report. 3.The committee will evaluate and recommend additional fall management strategies as indicated . 5. The Unit Manager verifies care plan revisions, patient monitoring, appropriate referrals, and communication to staff for all recommendations. Review of R60's Electronic Medical Record (EMR) under the Profile tab revealed the facility admitted the resident on 03/02/21 from an acute care hospital. Under the Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R60's Admission Assessment/Screening V.1.2 under the Assmnts (Assessments) tab in the EMR, dated 03/02/21 at 1:52 PM, revealed the resident was alert and oriented to person and situation. The assessment indicated the resident had fallen within the past month. A Falls Risk Assessment also under the Assmnts tab completed on 03/02/21 at 1:52 PM revealed the admitting nurse documented that R60's risk factors for falls included impaired vision with or without glasses and incontinence. The resident's most recent fall prior to admission occurred on 02/23 (no year documented). Review of the resident's Order Summary Report under the Orders tab for the dates 03/01/21 through 04/30/21 revealed no orders pertinent to the resident's risk for falls. Review of the resident's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/21, revealed the answer codes for the Brief Interview for Mental Status (BIMS) assessment and summary score, and the staff assessment of the resident's mental status were all populated with dashes. The MDS assessment indicated that R60 had no behavioral symptoms, did not reject care, and did not exhibit wandering behavior. R60 was able to walk in her room with limited assistance of one person, was unsteady on her feet but able to stabilize herself without staff assistance but sustained a fall in the last month prior to her admission. Review of R60's multidisciplinary Progress Notes under the Progress Notes tab dated from 03/02/21 at 1:52 PM through 04/20/21 at 4:05 PM, a Fall Risk Assessment under the Assmnts tab dated 03/24/21 at 4:52 AM, and Post Fall Documentation notes also under the Assmnts tab from 03/24/21 at 12:28 PM through 03/29/21 at 4:28 AM, revealed that on 03/24/21 at 4:45 AM, the nurse documented the resident, . had to stay at the nursing station most of the night, until sleepy. [The] resident had a fall this shift at 0410 [4:10 AM] . Neuro checks were completed and skin check [sic]. Resident has not complained of any pain. Review of a Post Fall Documentation note, dated 03/24/21 at 12:28 PM, revealed the resident had an unwitnessed fall in her room during the prior shift. The nurse documented the resident, . has a hx [history] of falls, confusion, and ambulating w/o [without] calling for assistance. [A] bruise [is] noted to resident's right temple next to [her] eye. [The] resident denies any pain r/t fall. Scattered bruising noted to BLUE [bilateral (both) upper extremities], and BLLE [bilateral lower extremities]. Vitals [vital signs] WNL [within normal limits]. No s/s [signs of symptoms] of distress or SOB [shortness of breath] noted. Resident does not indicate when transferring that she has pain, no facial grimacing or wincing, does not say ow or that hurts. Recommendations: Continue with current plan of care as it remains appropriate. Resident located in highly visible area to ensure residents safety at this time. Review of R60's Care Plan, dated 03/09/21, found under the Care Plan tab in the EMR revealed a Focus or problem area created on 03/02/21 related to her fall risk that read, The resident is at risk for falls r/t [related to] confusion, deconditioning, gait/balance problems, diuretic therapy, [CONDITION(S)], [CONDITION(S)] [high blood pressure], [and] major depressive disorder. The staff documented the Goal for the resident's fall risk as, The resident will be free of falls through the review date [05/31/21]. The interventions developed by the staff to prevent R60 from future falls included only three preventative measures: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Keep environment free of trip hazards. R60's care plan was not updated with new or revised person-centered interventions following the resident's fall on 03/24/21. Review of an Incident Note under the Progress Notes tab in the EMR, which was completed on 03/24/21 at 3:44 PM by the facility's Certified Infection Preventionist and Unit Manager, Licensed Practical Nurse (LPN) 4 revealed, [The] resident was observed on floor next to her bed by staff wrapped in her blankets . Hx of falls, dementia [diagnosis] . Recommendations: Will place fall mats next to bed. Subsequent Post Fall Documentation notes under the Assmnts tab dated from 03/24/21 at 12:28 PM through 03/29/21 at 4:28 AM reflected the Recommendations to prevent further falls included: Continue with current plan of care as it remains appropriate; frequent reminders, frequent checks, when awake is given activities to do in eye view of staff or has been talking with other residents in the hall; and Continue POC [Plan of Care]. During an interview on 04/21/21 at 1:05 PM, the facility's Certified Infection Preventionist and Unit Manager, Licensed Practical Nurse (LPN) 4 stated that she talks with the resident and the staff to try and determine the reason the resident's fall. The resident's fall is then reviewed at least weekly by the Falls Management/Committee Meeting during which the team conducts a root-cause analysis of the resident's fall to determine the appropriate fall-prevention interventions to add to the resident's care plan. During an interview on 04/22/21 at 3:15 PM, the Director of Nursing (DON) provided a copy of a Falls Management/Committee Meeting Minutes form for R60's fall that occurred on 03/24/21. The DON stated that the Falls Management/Committee team is to meet weekly after a resident falls to review the factors involved in the fall and update the resident's care plan with appropriate interventions to help prevent future falls. Review of the form's instructions for completion revealed the team is to, . Complete [the form] at least weekly during falls committee meeting. Minutes are to be completed anytime falls are discussed. The form included six sections for the team to complete: Medications, [CONDITION(S)], 'Vision, Mobility, Unsafe Behavior, and Other. Further review of the 03/24/21 Falls Management/Committee Meeting Minutes form completed in response to R60's fall revealed the Falls Management/Committee competed only one of the six sections, Unsafe Behavior, which reflected only that the resident, fell out of bed wrapped in blankets. Fall mats next to bed. The DON then stated that the 03/24/21 Falls Management/ Committee Meeting Minutes form for R60's fall was the only documentation the facility had for her fall. Review of the meeting minutes provided no documentation reflective of a root-cause analysis by the committee of the resident's 03/24/21 fall and/or of her history of falls prior to admission to determine any common causes. Review of R60's care plan for fall risk revealed the care plan was not updated after the committee's meeting to reflect the addition of fall mats next to the resident's bed or other person-centered interventions.

Based on observation, interview and facility policy review, the facility failed to ensure one resident (Resident (R) R21) was able to have her desired personal property. R21 was unable to have a television of the size she wanted in her room. This failure effected one of 36 sampled residents. Findings include: During interview on 04/19/21 at 2:48 PM, R21 stated she wanted a 40-inch television in her room but the facility told her she was only allowed to have a 32-inch television. R21 further stated she could not see the 32-inch television very well and thought a larger television would help. R21's television was observed, there was open space around the wall on her side of the room allowing for a larger television. During interview on 04/22/21 at 1:30 PM, the Maintenance Director stated the facility had a policy that residents could only have a 32-inch television or smaller. The Maintenance Director stated R21 had purchased her own television for her room. The Maintenance Director stated the same rules applied if the resident had purchased his/her own television. The Maintenance Director stated that R21 had stated to him that she wanted a 70-inch television and he informed her that she could only have a 32-inch television. During interview on 04/22/21 at 2:55 PM, the Maintenance Director stated there was not a written policy regarding television size in resident rooms but it varied by facility and for this facility they have always followed the 32-inch rule. During interview on 04/22/21 at 3:11 PM, Administrator 1 stated in the admission packet it stated that residents were able to have personal property as long as there was space in the room to accommodate the items. During interview on 04/22/21 at 3:50 PM, Administrator 1 stated R66's room would be able to accommodate a larger television. The Resident Handbook provided by the facility stated under Furnishings and Clothing, Residents are encouraged to bring personal furnishings within the space and safety limits of their room. Portable televisions on a movable stand are permissible. To ensure the safety, health, and well-being of all residents, any personal and electrical room furnishings must be approved by the Administrator. The Admission Packet provided by the facility stated under Resident Rights the right to retain and use his/her personal clothing and possessions as space permits unless to do so would infringe upon rights of other Residents and unless medically contraindicated as documented by his/her physician in his/her medical record.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, facility staff failed to ensure adequate monitoring of [MEDICATION NAME] levels prior to administering the medication, for two of nine residents in the survey sample, Residents #5 and #8, resulting in harm of Resident #5. Findings included: 1. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 06/15/2019. Resident #5 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #5's clinical record was reviewed on 11/04/2019 at 1:30 p.m. A discharge order sheet from the hospital's Infectious Disease Physician, dated 6/7/2019 included: Home IV (intravenous) Orders . 3. Antibiotic: .[MEDICATION NAME] 1 gram q12 hours IV 4. Lab each Monday: .Trough [MEDICATION NAME] level 5. Lab each Thursday: .Trough [MEDICATION NAME] level . 6. Fax lab to Dr. (Name) @(at) (phone number) . 8. Duration of therapy: last day of therapy should be July 17, 2019 Please call Dr. (Name) @ (phone number) before stopping therapy . 10. Pharmacy Consult for [MEDICATION NAME] dosing. Maintain trough between 15-20 . Included on the physician order [REDACTED]. According to the hospital discharge orders, [MEDICATION NAME] trough should have been drawn on Monday 06/10/2019. Resident #5 continued to receive [MEDICATION NAME] IV as ordered without these labs being completed. [MEDICATION NAME] lab was drawn on 06/12/2019 and was within normal limits at 18.4. The next [MEDICATION NAME] trough should have been drawn on Thursday 06/13/2019 and Monday 06/17/2019. The [MEDICATION NAME] trough was not done until 06/18/2019. During this time, Resident #5 continued to receive IV [MEDICATION NAME] as ordered without lab work being completed. The [MEDICATION NAME] lab result for 06/18/2019 was 46.0, which was annotated as HH meaning critically high. A progress note dated 06/19/2019 at 15:45 (3:45 P.M.) included: MD (Name-facility doctor) notified of vanc ([MEDICATION NAME]) trough level. Not a true trough as vanc was being administered at the time. Vanc trough reordered for 6*19*19. He is his own RP (responsible party) and aware. The [MEDICATION NAME] lab result for 06/19/2019 was 48.4, which was annotated as H meaning high. Review of the MAR (medication administration sheet), dated June 2019 included documentation that Resident #5 received IV [MEDICATION NAME] as ordered on [DATE], with the last dose being given at 7:55 p.m. The [MEDICATION NAME] lab result for 06/20/2019 was >50.00 (greater than 50). A progress note dated 06/20/2019 at 13:09 (1:09 p.m.) included: .Per pharm (pharmacy) [MEDICATION NAME] on hold until further notice . The doses scheduled for 6:00 p.m. on 06/20/2019 and 6:00 a.m. on 06/21/2019 were held. A Medical Note dated 06/20/2019 at 14:35 (2:35 p.m.) included: MD f/u (follow-up) patient-Labs noted with increased creatinine at 2.23 w/[MEDICATION NAME] >50-On 6/10/2019 creatinine at 0.87. MD reviewing orders for labs-apparently somehow not followed . A skilled progress note dated 06/20/2019 at 20:50 (8:50 p.m.) included: vanc trough results in, md (name-facility doctor) reviewed new order hold vanc, recheck trough 530am on sat 6/22/2019. pt own rp and is aware. (sic) Progress notes for Resident #5 also included the following: 06/15/2019 at 08:22 a.m.: noted rash like raised fluid blister located to shaft and head of penis. also noted to scrotum. pt c/o (complains of) burning itching. notify dr. (Name). pt won rp and is aware. (sic) 06/17/2019 at 03:53 a.m.: Patient .did complain of cast to right hand upon assessment I found it to be tight with good capillary refill 3 seconds but the exposed fingers and palm was red with several fluid filled blisters his left hand was also red with a few blisters he also complained of his Penis and scrotum being irritated it too was red somewhat swollen and had several blisters which erupted and draining slightly pink fluid . (sic) 06/17/2019 at 1:35 p.m.: .Family in to visit and concerned about blisters on his hands and penile area in which family and pt states has gotten better. MD (Name) not treating at this time and will assess . 06/17/2019 at 4:02 p.m.: Pt with new 'rash' to left hand. Appears to be multiple small blisters over palm and pinky of left hand. Pt. states they do not itch or hurt. He states that they appeared the night before .Pt. also has a new rash to the penis . 06/17/2019 at 5:33 p.m.: Medical Note: .Right palm w (with)/small blistering sore-believe directly related to edge of hard casting material-abrasion. Left palm and fingers with central palm displaying an approximate 0.75 cm (centimeter) blister, and adjacent to this an annular target violaceous lesion-flat, measuring approximately 1 cm. Small fluid filled blisters on several sides of digits. No other rash/blister noted on body .A/P (assessment/plan) - Unusual left palm annular lesion with small blisters forming-Nursing suggesting possible [MEDICATION NAME]. Area without pain/burning or stinging. MD concerned of drug reaction-though w/IV Vanc-systemic would suspect to see other signs over more of body surface . 06/18/2019 at 11:16 a.m.: Pt. left hand now red where blisters were yesterday. Appear to be reabsorbing. Still no complaints of pain or itching in the area. Spoke with pt wife who asked for us to call Dr. (Name) with Infectious Disease to make him aware of the situation. A call was placed .spoke with (Name). The situation was explained about the 'rash' and most recent Vanc trough results given . 06/19/2019 at 1:46 p.m.: .Unusual left palm annular lesion with small blisters forming-area without pain/burning or stinging. MD concerned of drug reaction-though w/IV Vanc-systemic would suspect to see other signs over more of body surface . 06/20/2019 at 2:35 p.m.: .Of acute concern-MD noting left palm with many more blisters and along side fingers. Additionally left toe now w/blister .Increasing blister/bullae-now showing signs of systemic spread-Urgent appointment to ID (infectious disease)-Nursing contacting office now . 06/21/2019 at 4:19 p.m.: Patient went out to a follow up appointment with ID Dr. (Name) at 1pm with family transport with concerns of medication interactions with multiple blisters to the left palm, right lower leg, toes, and back of bilateral thighs .He has been admitted to the hospital . Resident #5's hospital records included: .Hospital course: 1. acute [MEDICAL CONDITION], cr 3.0 on admission, suspect a combination of pre-renal (from volume depletion/dehydration) along with [MEDICATION NAME] toxicity (his vanc trough was >50) .4. Blister on both hand .skin biopsy: spongiotic [MEDICAL CONDITION] consistent with drug reaction .Discharge Diagnosis: [REDACTED].Allergic skin rash/spongiotic [MEDICAL CONDITION] . The facility Medical Director was interviewed on 11/04/2019 at 4:25 p.m. The Medical Director stated, Yes, if specific instructions are sent by the hospital physician I write those orders. It has been problematic with agency nurses. We definitely dropped the ball on this one. We met with the family and (Name) DON (director of nursing) came up with a plan so this doesn't happen again. The DON was interviewed on 11/04/2019 at 4:30 p.m. The DON stated regarding why the Infectious Disease Doctor's orders were not reviewed with the Medical Director and subsequent orders written, It would appear it didn't make it into PCC (computer order system). I do know two nurses are no longer here because of this. We did a root cause analysis and brought the family in to help. On 11/05/2019 at 9:25 a.m. the DON approached the conference room and stated, I want to make sure I didn't misspeak earlier. The pharmacy gives us recommendations for labs. We call Dr. (Name) and he gives us an order. We write the order to obtain the labs. Regarding the [MEDICATION NAME] level being drawn while medication was infusing, she stated I believe that was the lab. I don't know why they were drawing it then. Of course you would get an abnormal high level. That is why the order for labs was given for the next day. Yes, that is when we noticed inconsistencies with the labs. Regarding pharmacy protocols for [MEDICATION NAME] levels she stated, We have been told it is patient specific. Some have altered renalstatus and may need labs more frequently. There is no cookie cutter orders, like to obtain levels every Wednesday. Facility policy, Blood Sampling for Peak and Trough Values Revision Date: 05/01/16 documented the following: .Considerations: 1. Many medications must remain within a certain therapeutic range in the blood stream in order to achieve desired effects. In some cases the level of medication in the blood may go beyond an acceptable limit and symptoms attributable to drug toxicity can develop .2. The pharmacy can provide guidance of accepted clinical practice standards to physicians for .[MEDICATION NAME] therapy when provided accurate peak and trough serum levels from the facility .4. Proper dosing of [MEDICATION NAME] is important to achieve sustained serum concentrations and to prevent resistance, progression of infection and mortality. Guidance: .2. The trough is a measurement of drug in the blood right before the next dose is due to be administered and when it's at its lowest level concentration in the blood .6. The ACTUAL TIME a specimen is obtained and the ACTUAL TIME the medication was hung is CRITICAL to accurately interpret drug levels for dosing considerations. 7. To ensure accurate monitoring and dosing, all lab values must be faxed to the infusion pharmacy upon receipt. No further information was received prior to the exit conference on 11/06/2019. 2. Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a 5-day assessment with an ARD (assessment reference date) of 10/14/2019. Resident #8 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #8's record was reviewed on 11/04/2019 at 3:30 p.m. and again on 11/05/2019 at 10:30 a.m. Physician orders [REDACTED]. A progress note dated 10/14/2019 at 1:03 p.m. included: Patient receiving [MEDICATION NAME] for a 6 week course (10/2-11/13) with trough goal of 15-20. Vanc ([MEDICATION NAME]) trough drawn on 10/11 resulted 21.2, Pharmacy recommended to place on hold and redraw 10/12. Results from draw on 10/12 was 10.7. New recommendations to restart vanc 1.5G (grams) q24hr. (every 24 hours) and recheck vanc trough, BMP, and serum creat prior to administration of 4th dose. Reviewed with MD and new orders in system. A progress note dated 10/19/2019 at 7:02 a.m. included: Serum Creatinine, BUN, and Vanc trough to be drawn prior to the 4th dose of [MEDICATION NAME] after dose change. one time only for 1 Day Call for a STAT draw To be done on Monday and needs to be reschedule. (sic) A progress note dated 10/21/2019 at 3:22 p.m. included: .This nurse was not able to administer Vanc IV this morning as Vanc trough had not been drawn. This matter was reported to unit manager who has ordered STAT Vanc trough to be drawn today by lab . A progress note dated 10/21/2019 at 3:43 p.m. included: Vanc trough ordered stat during at 0800, company contact. No draw was done during shift. Company contact again and stated that there was no pending orders for resident, order was reentered by customer service agent and stated that someone would be here to draw it as soon as possible. Pharmacy made aware. A progress note dated 10/21/2019 at 6:04 p.m. included: .lab in to draw vanc trough . Review of the MAR (medication administration sheet) dated October 2019 included: [MEDICATION NAME] 750mg intravenously every 12 hours .Order Date: 10/08/2019 2001, Hold Date: from 10/11/2019 1850 to 10/12/2019 0800, D/C Date 10/14/2019 2345. Resident #8's IV [MEDICATION NAME] was held on 10/11/2019 at 9:00 p.m. and 10/12/2019 at 9:00 a.m. The medication was resumed 10/12/2019 at 9:00 p.m. A new order for [MEDICATION NAME] 1.5 Gms. in 150 ml of NS (normal saline) was written 10/14/2019 1245. Resident #8 received the first dose on 10/15/2019 at 9:00 a.m. The DON (director of nursing) was interviewed on 11/04/2019 at 4:50 p.m. regarding lab orders. The DON stated, We are at the mercy of the pharmacy for vanc level orders and dosing. On 11/05/2019 at 9:25 a.m. the DON stated, I want to make sure I didn't misspeak earlier. The pharmacy gives us recommendations for labs. We call Dr. (Name) and he gives us an order. We write the order to obtain the labs. Other #4 (pharmacist) was interviewed via phone on 11/05/2019 at 11:00 a.m. regarding [MEDICATION NAME] dosing and lab orders. Other #4 stated, We always do the dosing at the pharmacy. We have a guideline, but it is clinical judgment. Usually every three days or so. Our IV pharmacist takes care of dosing and labs. We go by the manufacturing recommended guidelines and clinical judgment. Depending on renal function, other labs, what we are treating, length of treatment, etc. Other #5 (IV pharmacist) was interviewed via phone on 11/05/2019 at 1:35 p.m. regarding [MEDICATION NAME] dosing and lab orders. Other #5 stated, Yes, we do have a policy in place for [MEDICATION NAME]. When someone is first admitted to the facility we get baseline labs and go from there. Regarding Resident #8, Other #5 stated, Originally she was getting vanc 750mg IV Q12H. Her vanc trough level on 10/11/19 was 21.2, so we held her dose and repeated the lab on 10/12/19. Generally, yes we hold [MEDICATION NAME] if the trough is greater than 20. The vanc was restarted on 10/12/19 the pm dose. On 10/14/2019 we recommended to change the [MEDICATION NAME] to 1.5 Gms. every 24 hours and to draw a vanc trough prior to the 4th dose administration. Resident #8 received the first dose of 1.5 Gms. on 10/15/2019. It is documented in our computer system to obtain labs before the fourth dose on the 18th. The DON and Corporate Nurse were interviewed on 11/05/2019 at 2:05 p.m. regarding pharmacy medication recommendations. The DON stated, We send the lab results to the pharmacy. They call us back with recommendations for dosing and labs. We call the physician with the recommendations and obtain an order. The order is written and the pharmacy sends out the medication. On 11/05/2019 at 2:30 p.m. the DON and Staff Development Coordinator (RN #1-registered nurse) were interviewed. They stated they reviewed the pharmacy recommendations for Resident #8 and her labs were missed on 10/18/2019. RN #1 stated, That is my fault. I miscalculated the date. They should have been drawn on the 18th. RN #1 stated, Pharmacy recommendations are faxed from the pharmacy and then facility staff notify the physician and write the order. No further information was received prior to the exit conference on 11/06/2019. This is a complaint deficiency.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide treatment and services for the prevention of, and subsequent development of pressure ulcers for two of nine residents, Resident #4 and Resident #9. This was identified as harm and is a complaint deficiency. Findings were: 1. Resident # 4 was originally admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an ARD (assessment reference date) 06/10/2019 assessed Resident #4 as moderately impaired in his cognitive status with a summary score of 12. He was coded as not having any pressure ulcers upon admission and was at risk for developing pressure ulcers. The clinical record was reviewed on 11/04/2019 beginning at approximately 1:00 p.m. The admission documentation dated 06/04/2019 contained the following information .has no major skin issues but has a healing laceration in his scalp . A nursing progress note dated 06/14/2019 documented: Patient has wound to right heel that is open with loose tissue with a foul odor there is no indication of any infection in terms of color it is semi dry with small drainage of no significance will continue to monitor and reassess. Another nursing progress note dated 06/18/2019 read: The wound to the right heel was present at time of admission and was too large to capture in photo therefore it was omitted yet present with skin breakdown and macerated wound edges it was varied in color and depth minus any true redness foul smell was present with slight pinkish drainage it was cleaned and redressed, on the right lateral ankle there was a red blood blister still intact and was gently cleaned and skin prep applied. The skin evaluation sheets were reviewed. There were no assessment sheets for either the heel wound or the blister on the ankle from the date of admission until 06/16/2019. The assessment on 06/16/2019 described the right heel as a Diabetic ulcer, present on admission, 3.8 cm X 6.6 cm; 50% of wound with granulation, 10% with slough and 40% eschar; light serosanguineous exudate, no odor. The physician was notified and orders were given for wet to dry dressing changes every day. An additional Skin and Wound Evaluation dated 06/16/2019 for the right ankle blister was observed and contained the following: Blister, in house acquired, 3.9 cm X 2.7 cm, intact serum filled blister. The physician ordered skin prep to the area every shift. Additional Skin and Wound Evaluation Sheets documented the following: Right Heel 07/04/2019: Diabetic, 5.1 cm X 3.4 cm, 10 % slough, 90% eschar, no exudate 07/31/2019: Diabetic, 4.3 cm X 4.3 cm, the wound bed was not described, light serosanguineous exudate 08/10/2019: Diabetic, 2.7 cm X 6.4 cm, 100 % eschar, no exudate 08/15/2019: Diabetic, 3.9 cm X 5.1 cm, 20% [MEDICATION NAME], 80 % eschar, no exudate 09/04/2019: Pressure, Unstageable: Obscured full thickness skin and tissue loss due to slough and/or eschar, 5.5 cm X 7.5 cm, eschar (no percentage documented), no exudate 09/12/2019: Pressure, Unstageable: Obscured full thickness skin and tissue loss due to slough and/or eschar, 3.4 cm X 6.8 cm, granulation/slough/eschar all checked as present without percentages documented, light serous exudate. 09/24/2019: Pressure, Unstageable: Obscured full thickness skin and tissue loss due to slough and/or eschar, 2.6 cm X 6.0 cm, granulation/slough/eschar all checked as present without percentages documented, exudate not documented. The DON (director of nursing) was interviewed on 11/04/2019 at approximately 3:00 p.m. The areas described above were discussed. She was asked if the area originally documented as a diabetic ulcer and then a pressure ulcer were the same area. She stated, Yes. She was asked what had been done with the area from the time of admission until 06/14/2019. She stated, I don't know. There is no documentation about the heel or ankle until the note on June 14th .there is no assessment of them nor any mention of any skin issues in the admission physician's note . The nurse who documented that information is no longer working here. She was asked why the wound description changed from diabetic to pressure. She stated, We identified that we had a problem with the wound assessments, I usually look at them on Mondays now, I didn't this week because of the survey. She was asked if the areas had been addressed by the admitting nurse and left for 10 days. She stated, I don't know if those areas were really present on admission or not. I really don't know what happened. The medical director was interviewed on 11/04/2019 at approximately 4:00 p.m. regarding Resident #4. He was asked about the area on Resident #4's heel that was identified in June. He stated, I don't believe that was a diabetic ulcer. His Hgb A1C was 7.1 at the time .I believe that was from pressure. He spent so much time on his back .He had [MEDICAL TREATMENT] three days a week and was gone a total of 7 hours every time, plus he had multiple appointments outside of the facility. He and the family were resistant to changing to a [MEDICAL TREATMENT] center that is down the street which would have greatly reduced the time he was out of the facility. On 11/05/2019 at approximately 10:30 a.m., the DON was interviewed. She stated, I reviewed (name of Resident #4) hospital discharge report and his notes from here. There isn't anything documented about any pressure areas or wounds at the time of his discharge from the hospital or on any of the physician notes here. I don't believe he came here with the wound described on his heel. I don't know why the nurse documented that .We also identified that the area was not a diabetic ulcer but was initially found as an unstageable pressure ulcer .we've made some changes regarding wound assessments since I have been here. She was asked how a wound would be found at that advanced stage and why the nurse had documented that it was present on admission. She stated, I don't know. The above information was discussed during an end of the day meeting with the facility staff on 11/05/2019. Concerns were voiced that an area had been discovered on Resident#4's heel at the level of an unstageable pressure ulcer with no prior assessment. No further information was obtained prior to the exit conference on 11/05/2019. This is a complaint deficiency. 2. Resident #9 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Dementia, [MEDICAL CONDITION] disease, and [MEDICAL CONDITION]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 09/20/2019. He was assessed as being severely impaired with both long and short term memory as well as being severely impaired with daily decision making skills. The clinical record was reviewed on 11/05/2019 beginning at approximately 9:30 a.m. The following progress notes were observed: 10/21/2019 13:12 (1:12 p.m.) Area of DTI (deep tissue injury) to left heel observed this am. Deep purple in color blistering in center and non blanchable redness surrounding purple. 4.2 (cm) X 5.3 (cm) MD (name) made aware. New orders for received for skin prep q (every) shift. New prevalon boots obtained for resident. Heel floater to be used when prevalon boots removed . 10/21/2019 19:07 (7:07 p.m.) MD informed today of pressure ulcer present-Deep tissue injury to left heel-describes as deep purple with blister at surrounding area-nonblanchable. MD discussed with UM (unit manager). Apparently developed with removal of prevalon boots (to wash-then return) . On 11/05/2019 at approximately 10:00 a.m., the unit manager was interviewed regarding the DTI to Resident #9's heel. She stated, It occurred over the weekend; they sent his prevalon boots to the laundry. Residents who have those have two pair so we can switch them out, if they aren't in the room there are two boxes of them in the therapy department. I don't know why no one got him another pair, maybe it was an agency nurse, I don't know. At approximately 11:00 a.m., Resident #9's right heel was observed. His prevalon boots were removed by the unit manager and his leg lifted up. The heel was dark purple in color, the area was closed. She was asked if there was any eschar. She stated, No. The above information was discussed during an end of the day meeting with the facility staff on 11/05/2019. No further information was obtained prior to the exit conference on 11/05/2019. This is as complaint deficiency.

Based on staff interview, clinical record review and during the course of a complaint investigation, the facility staff failed to ensure appropriate care and services for a gastrostomy tube to prevent dehydration and significant metabolic changes for one of 17 residents in the survey sample (Resident # 15), which resulted in actual harm. The facility failed to ensure Resident # 15 received adequate nutrition/hydration via a gastrostomy tube for the prevention of dehydration, as a result Resident # 15 was sent out emergently to the hospital via 911. Resident # 15 was admitted to the facility on [DATE] and discharged on [DATE], at which time he was admitted to the hospital MICU (medical intensive care unit), where the resident was diagnosed with [REDACTED]. Findings include: Resident # 15, (a [AGE] year old African American man) was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. mellitus), PEG tube (medical procedure where a tube is passed into a patient's stomach to provide a means of nutrition and hydration when unable to take oral intake) and cognitive communication deficit. The most recent full MDS (minimum data set) was a 5 day admission assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. The resident was also assessed as being totally dependent upon staff for all ADL's (activities of daily living) including feeding (nutrition/hydration). The resident was additionally assessed on this MDS to have a feeding tube (abdominal peg). In section K0700. Percent Intake by Artificial Route A. Proportion of total calories the resident received through tube feeding was documented as, 51% or more and for B. Average fluid intake per day by IV (intravenous) or tube feeding was documented as, 501 cc/day (cubic centimeters) or more. The resident was also assessed as receiving insulin injections for the previous 7 days and as receiving diuretics (medication that induces excretion of fluid from the body) for the previous 6 days. The resident did trigger in the CAAS (care area assessment summary) section of this MDS for nutrition, feeding tube, and dehydration; all of these areas were marked to address in the resident's comprehensive care plan (CCP). A complaint regarding Resident # 15, was investigated during the survey process on 08/09/16 through 08/11/16. The complaint alleged that Resident # 15 was transferred to the hospital on [DATE] where he was found to be severely dehydrated, with [MEDICAL CONDITION] (high sodium level). During clinical record review, Resident # 15's facility admission physician orders were reviewed. The orders included, but were not limited to, keep the resident NPO (nothing by mouth), and to have tube feeding ([MEDICATION NAME] 1.5) at 95 cc/hour for 14 hours via PEG tube to start at 6:00 p.m. and stop at 10:00 a.m., and to flush feeding tube with 100 cc of water every 6 hours. The resident was also order [MEDICATION NAME] (a diuretic) 25 mg (milligrams) every morning. A BMP (Basic Metabolic Panel) was also ordered to be drawn on 03/03/16. All of the above orders had an order date of 03/02/16. The resident's CCP (comprehensive care plan) was then reviewed. The CCP dated 03/02/16 documented: .PEG TF (tube feed), risk for aspiration/dehydration r/t [MEDICAL CONDITION]/ICH ([MEDICAL CONDITION]/[MEDICAL CONDITION]), NPO (nothing by mouth) status,[MEDICAL CONDITION] place, dependence on staff for nourishment/hydration .Provide diet/fluid as ordered. Monitor intake and record ., weekly weights . A Nutritional assessment dated [DATE] and timed 2:51 p.m. documented, XXX[AGE] year old male .[MEDICAL CONDITION] and peg place on 2/6/16 .Diet: NPO .ProStat SF BID (twice daily), provides 220 kcal (kilo calories) .labs: none since admission .Per hospital records Na+ (sodium) downtrending to most recent level 131 .Pertinent Meds: [MEDICATION NAME] (diuretic), [MEDICATION NAME], Insulin, [MEDICATION NAME] .Height: 67 inches (5'6) .Weight: 213 (97 kg) .adjusted weight 180 (82 kg) .Estimated nutritional needs .2300-2450 kcal .2300-2450 ml fluid, 28-30 ml/kg .1013 ml fluid + 600 ml flush = 1613 ml fluid .Suspect fluid restricted d/t (due to) .[MEDICAL CONDITION] (low sodium). will follow labs and adjust flushes as needed .signature of RD (Registered Dietitian). The physician's order for fluid and the RD note above did not match, as far as the resident's fluid/hydration needs. The resident's I&O (intake and output) records in the clinical record were then reviewed and no information was documented. The corporate nurse was asked on 08/10/16 at approximately 10:30 a.m., where I&O records are kept and/or documented. The corporate nurse voiced that the information was on enteral flow sheet, which is part of the MARs (medication administration records) where the tube feeding is listed. The resident's MARs and TARs (treatment administration records) for the entire month of March 2016 were reviewed. The following feeding and fluid intake records for Resident # 15 documented what the resident had on the following days. 03/02/16 = 855 ml of intake. 03/03/16 = 190 ml of intake. 03/04/16 = 855 ml of intake. 03/05/15 = no information found. 03/06/16 = 1040 ml of intake. 03/07/16 = 1000 ml of intake. 03/08/16 = 650 ml of intake. 03/09/16 = 650 ml of intake. 03/10/16 = 650 ml of intake. 03/11/16 = 650 ml of intake. 03/12/16 = 560 ml of intake. 03/13/16 = 940 ml of intake. The above documentation indicated that the resident did not receive an adequate amount of feeding and/or hydration on the above days and never met the minimum requirement that was ordered by the physician for fluid and feeding. No other information was located throughout the clinical record regarding intake for Resident # 15. Weight records were then reviewed for Resident # 15 from admission (03/01/16) through discharge (03/14/16), the last recorded weight was on 03/08/16, which documented a weight of 174.5. No weight records were located from 03/09/16 through 03/14/16, to evidence that Resident # 15 was getting daily weights as directed by the resident's CCP. A BMP (basic metabolic panel ) laboratory test was drawn on 03/03/16 for Resident # 15. The BMP was reviewed and documented, the resident had a high glucose level of 427 (reference range: 65-99), BUN (blood urea nitrogen-used to determine kidney function) was high at 39 (reference range: 8-27), the resident's eGFR (if African American) is a test to estimate glomerular filtration rate for African Americans and is used to detect early kidney damage, the resident's reading was 100 (reference range: greater than 59) a normal value, the resident's BUN/Creatinine Ration, which is used to assess kidney function was 49 (reference range: 10-22), well above normal, the resident's sodium level was slightly low at 133 (reference range: 134-144). No documentation could be located throughout the clinical record to evidence that the above lab results were reported to the physician or that the RD had reviewed. A nursing note dated 03/05/16 and timed 5:44 a.m., documented: vomited large amount of TF (tube feeding) appearing curdled with a brownish colored mucus and hiccups .low grade temp 99.2 .no residual TF obtained. TF held at this time, suction via yonker (sic) [MEDICAL CONDITION](sic) to ensure no aspiration .MD (medical doctor) notified .(signature of LPN (Licensed Practical Nurse) # 3). No information or documentation was found to evidence the physician was actually made aware of the above. No physician's orders were found to hold the TF for any time. The above nursing note did not document how long the TF was actually held. The resident's MARs for 03/05/16 (evening/night shift) was reviewed and no information and/or documentation at all was documented to indicate how much enteral feeding/fluid the resident received, if any. A nursing note dated 03/06/16 and timed 6:01 a.m. documented, .pain, hiccups and vomiting .temp 100.0, hiccups at same time as yesterday with vomiting to follow. MD returned call (no time) with new orders to decrease tf (tube feeding) to 80 cc hour and extending hang time to 1700 (5:00 p.m.) to 1100 (11:00 a.m.) .monitor for any changes .signature of LPN # 3. A physician's order dated 03/06/16 (no time) documented to change the tube feeding to 80 cc per hour for 16 hours and gave a start time of 5:00 p.m. and stop at 11:00 a.m. NOTE: oth physician's orders for the tube feeding were not clear and concise the first tube feeding order was ordered to run at 95 ml/hr for 14 hours, but had a start time of 6:00 p.m. and stop time of 10:00 a.m., which is actually 16 hours (not 14). The second physician's order for the tube feed was ordered to run at 80 ml/hr for 16 hours, but had a start time of 5:00 p.m. and stop time of 11:00 a.m., which is 18 hours (not 16). Neither orders were clarified. A physician's progress note dated 03/08/16 (1 week after the resident's admission) was reviewed and documented: .Nurses report patient had an episode of vomiting 03/5/16 and now with thick green sputum [MEDICAL CONDITION] .otherwise continue present care plan . The physician's progress note did not address or acknowledge the resident's BMP (Basic Metabolic Panel) laboratory test results from 03/03/16. A physician's order dated 03/02/16 (order date) for a [MEDICAL CONDITIONS] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) one time only for 1 day was reviewed. The start date for this order was 03/04/16. A nursing note dated 03/09/16 and timed 2:09 a.m. documented: .100.4 (temp) .[MEDICAL CONDITION] results positive [MEDICAL CONDITION]. Lab results sent to MD .(signature of LPN # 3). The above lab result was not reported to the physician until 5 days after lab test was completed, Resident # 15 was started on antibiotics for the above infection on 03/11/16. A physician's order dated 03/09/16 (no time) for laboratory tests, including a CMP (comprehensive metabolic panel), CBC (complete blood count), UA (urinalysis) C/S (culture and sensitivity) STAT to rule out infection was found in the clinical record. The CMP dated 03/09/16 for Resident # 15 was reviewed. The collection time was documented as 10:45 a.m., with a result time of 5:35 p.m. The CMP lab results documented that the resident had an HH (High Alert) BUN of 125 (reference range: 8-27), this was a significant increase from the BUN of 39 on 03/03/16; the resident's eGFR had significantly decreased from 100 (a normal value) on 03/03/16 to 54 a low, below normal value (reference range: greater than 59), the resident's BUN/Creatinine ratio was significantly higher at 87 (reference range: 10-22) compared to the result on 03/03/16, which was 49. The resident's sodium level was 150 on 03/09/16 in comparison to the 03/03/16 labs where the resident's sodium level was 133 (reference range: 134-144). No evidence could be located throughout the clinical record to evidence that the physician was actually notified of the CMP critical lab values dated 03/09/16. No physician's orders were found to evidence that any type of action had been taken to address the critical CMP lab results for Resident # 15 and no physician correspondence of any kind could be located to evidence that the physician was informed/notified and/or received the CMP critical lab information for Resident # 15. A nursing note dated 03/10/16 and timed 4:03 a.m. documented, that the resident was on antibiotic [MEDICAL CONDITION] infection (sputum). Resident # 15's antibiotic for [MEDICAL CONDITION] infection did not actually start until 03/11/6 at 8:00 a.m. A Nutrition assessment dated [DATE] and timed 9:10 a.m. documented, .updated with current weight XXX[AGE] year old male .[MEDICAL CONDITION] and peg place on 2/6/16 .NPO .labs: none since admission .Per hospital records Na+ (sodium) downtrending to most recent level 131 .Pertinent Meds: [MEDICATION NAME] (diuretic), [MEDICATION NAME], Insulin, [MEDICATION NAME] .Height: 67 inches .Weight: 3/8/16=174.5 (79 kg) .adjusted weight 161 (73 kg) .Estimated nutritional needs .2000-2200 kcal .2300-2450 ml fluid, 28-30 ml/kg .1013 ml fluid + 600 ml flush = 1613 ml fluid .Suspect fluid restricted d/t (due to) .[MEDICAL CONDITION] (low sodium). will follow labs and adjust flushes as needed .signature of RD (Registered Dietitian). There was no evidence throughout the clinical record that the RD reviewed the resident's laboratory test results from 03/03/16 or 03/09/16, no evidence was found that the physician and/or RD communicated or collaborated in response to Resident # 15's critical lab results or that the resident's nutritional and hydration needs were confirmed. A nursing note dated 03/10/16 and timed 2:46 p.m. documented, .Resident .lethargic .CMP returned with alert BUN level of 125 .Creatinine 1.44 .MD made aware via nurse, awaiting new order .started on [MEDICATION NAME] yesterday .presumed UTI (urinary tract infection) . A nursing note dated 03/10/16 and timed 11:08 p.m. documented, that the resident was being treated with [MEDICATION NAME] for infection and Bactrim was started on 03/11/6 [MEDICAL CONDITION] in the trach, the nursing note also documented, that the resident's free water was increased to 150 ml every 6 hours. No other interventions or physician's orders were found or located to indicate that the resident's critical CMP lab results were addressed. It could not be evidenced by the resident's clinical record or by the intake records, that Resident # 15 received the increase in fluids. An order was identified on the resident's POS (physician's order sheet) dated 03/11/6 (no time) for a CBC and CMP one time only for 1 day, the order date was documented as 03/11/16, the start date was documented as 03/17/16 (3 days after the resident had been discharged to the hospital). No other lab test were drawn on Resident # 15 until 03/14/16. The CMP lab results dated 03/14/16, with a time collection of 1:00 a.m. and a result time of 2:10 p.m. were reviewed. The CMP was marked and flagged as critical. The resident's BUN was now 219, the eGFR was now 21, the Creatinine was now at 3.20, the BUN/Creatinine was now 68, and the Sodium was now 166. A nursing note dated 03/14/16 and timed 5:04 p.m., documented, .Change of Condition .Abnormal lab results .this started on 03/07/16 during the afternoon .notified (Physician # 2 on) 03/13/16 6:00 p.m Orders obtained: Blood tests .(signature of RN # 1). A nursing note dated 03/14/16 and timed 6:04 p.m. documented, .MD notified of lab result: .MD orders to send resident out 911 to ER (emergency room ) .signature of RN # 1. All of the above concerns were shared with the administrator, DON (director of nursing), and the corporate nurse in a meeting with the survey team on 08/09/16 at 3:00 p.m. The facility staff were informed of the complaint investigation and any and all assistance was requested for any additional information or documentation to evidence that the resident received adequate fluids and nutrition and that the physician was actually notified, and/or notified in a timely manner regarding the critical labs results and any further information to evidence that the lab results were acted upon appropriately. The facility staff were also made aware of concerns regarding the resident's CCP, which included interventions for daily weights and for monitoring/recording the resident's intake. No evidence of daily weights were found after 03/08/16, which was the last recorded weight for Resident # 15. Limited evidence was found regarding Resident # 15's nutrition/hydration monitoring and recording. The staff were made aware that the resident's fluid intake did not ever meet the minimum requirements, as ordered by the physician or recommended by the RD and that the resident's lab values were showing signs of decline (dehydration) from admission up to the time of discharge without adequate and/or appropriate intervention from facility staff. The DON, administrator and corporate nurse were again made aware of serious concerns in a end of day meeting with the survey team on 08/10/16 at 5:00 p.m., again the facility staff were ask to provide any additional information or documentation to evidence the resident received adequate fluids and/or nutrition for the prevention of dehydration. On 08/11/16 at 8:50 a.m., RN (Registered Nurse) # 1 was interviewed in a meeting with the survey team. The RN was asked about the note written on 03/14/16 and timed 5:04 p.m. (the date of discharge for Resident # 15), the RN voiced that she could not remember what exactly happened on 03/14/16. The RN was asked about the change in condition note that was written, and asked specifically what was the change. RN # 1, voiced that she didn't remember and asked to see a copy of the note. RN #1 viewed a copy of the note and voiced the labs, that is why I notified the physician (physician # 2). It was pointed out to the RN that she notified physician #2 on 03/13/16 at 6:00 p.m. and was asked how she could notify physician # 2 of critical lab results that had not been drawn yet (referring to labs drawn on 03/14/16 1:00 a.m.). RN # 1 voiced that she notified the physician of the Resident's critical lab work from 03/09/16 and further voiced that the results were abnormal. RN # 1 voiced that it is documented in her note (dated 03/14/16) that she notified physician # 2 on 03/13/16 at 6:00 p.m. and as a result of that notification, that physician ordered blood tests (for 03/14/16) to be drawn, those labs were drawn at 1:00 a.m. on 03/14/16. The RN voiced noticing everything going down starting on 03/07/16 (referring to resident and labs). The RN voiced the 03/14/16 lab results were documented to have been drawn at 10:45 a.m. and reported to the facility at 5:35 p.m. RN #1 voiced that after the labs came back from 03/14/16 and the best she could remember was that she contacted the physician around 6:00 p.m. and the doctor gave an order to send out to hospital by 911. The RN was made aware that according to the lab results dated 03/14/16, that the results had been called back to LPN # 5 at 3:23 p.m. and was asked why it took 2 1/2 hours for physician #2 to be notified of those results. RN #1 voiced uncertainty and went on to say the resident was sent to the hospital via 911 at 6:20 p.m. The facility's medical director, also known as physician # 1 was interviewed at 9:45 a.m. on 08/11/16, in a meeting with the survey team. Physician #1 voiced that he is the medical director and has a partner, who is physician #2. The physician was asked if he was familiar with Resident #15 and the physician voiced, yes. The physician was made aware of the above concern regarding Resident #15 and was asked if he was notified of the resident's lab work on 03/03/16 or 03/09/16. The physician voiced that he did not remember. The physician was given the labs results from both dates to review. The physician voiced, clearly there was a change in his labs and voiced the resident's BUN and Creatinine were high. Physician #1 voiced that the labs could have been reported to the physician's office, that facility staff send them via fax, physician #1 voiced that he was not sure if he was notified directly, but voiced physician #2 was probably the one notified, since his name was on the lab results. Physician #1 was asked how the facility ensures that lab results are in fact reported by fax, phone or in person, and if the nurse documented that the physician was notified, how is it ensured that the labs are actually being validated to ensure that the physician has actually received results. Physician #1 voiced that when he comes into the facility he will initial (the labs) as having checked them and I call back to address if they come to the office and then initial when he comes back to the facility. Physician #1 asked this surveyor if the labs in question were initialed. The surveyor let physician #1 look at the copies of the lab results, none of which had any initials. Physician #1 voiced that he could not speak for physician #2, and could not answer whether the labs were seen, but when the 03/14/16 labs were drawn and I was notified, it was obvious there was a significant change and immediately sent him to the hospital. The physician voiced that he would expect the nurses to contact and alert the physicians with all lab results. Hospital records for Resident #15 were reviewed and documented, .DEPARTMENT OF MEDICINE MICU (medical intensive care unit) - history and physical examination [REDACTED].the ambulance picked him up and since then he has had labored breathing .concerned that the nursing home may not have been giving him his tube feeds and that is why he is dehydrated .chronically ill appearing .dry mucous membranes, [MEDICAL CONDITION] in place .peg in place .4 L (liters) NS (normal saline) given in ED (emergency department) .[MEDICAL CONDITION] 166 on admission .Free water deficit calculated to 7 L (liters) .No indication for urgent HD ([MEDICAL TREATMENT]) currently .admitted with [DIAGNOSES REDACTED] to 38 .of imminent or life threatening deterioration .severe [MEDICAL CONDITION] .septic shock which is refractory to aggressive volume resuscitation and requires multiple pressors for hemodynamic stabilization .Continue aggressive volume resuscitation .overall prognosis is incredibly grave The facility staff were again met with in a meeting with the survey team on 08/11/16 at approximately 11:40 a.m., and were asked if any additional information or documentation was found regarding the major concerns related to Resident # 15's fluid/nutrition/hydration status. The facility staff voiced that they (facility) did not have any additional information to present. No further information or documentation was presented by facility staff prior to the exit conference on 08/11/16 at 12:30 p.m., to evidence Resident # 15 received adequate nutrition and/or hydration for the prevention of dehydration and failed to evidence that the physician was notified, with appropriate intervention for lab work that was showing significant change with decline of the resident. Complaint Deficiency

Based on observation, staff interview, and clinical record review the facility staff failed to ensure adequate supervision and assistance to prevent an accident for two of 16 Residents, Resident #'s 7 and 12. 1. Resident #7 was improperly transferred and suffered a fracture. 2. Staff failed to ensure that all staff were aware that Resident #12 required two person assist when transferring. Resident # 12 was transferred by one staff member resulting in pain. Findings include: 1. Resident #7 was admitted to the facility on [DATE] with a readmission of 4/27/12, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly with an assessment reference date of 7/1/12, Resident #7 was assessed as being cognitively intact with a score of 15 of 15. Review of Resident #7's clinical record, conducted on 9/12/12, revealed a hospital "Discharge Summary" dated 2/5/12, that read in part "...Admission Diagnoses: [REDACTED]. Nursing notes were also reviewed at this time and revealed a note dated and timed 02-02-12 5:06 p.m. that read "... (name of nurse writing note) this patient had fallen from hoyer lift pad to floor (about 3 feet). CNA (name of CNA, certified nursing assistant) states her and (other name of CNA) had just finished showering patient and were attempting to transfer patient back to bed from hoyer, when pad came loose and patient fell to ground. On assessment, patient lying on her back, alert and oriented; crying with right leg/hip pain..." The care plan for Resident #7 was then reviewed for that time period and revealed a "Fall Potential for fall r/t (related to) debilitation." with interventions that stated "...Use vanderlift (hoyer) and 2 staff members for transfers..." An MDS was then reviewed closest to the time period of Resident # 7's incident, ARD of the MDS was 1/3/12. Under section "G" titled "Functional Status" subsection "B. Transfer", Resident #7 was coded as a 3 (Self-Performance) and 3 (Support), indicating Resident #7 needed extensive assistance with two plus person physical assistance. Also under section "G Functional Status" subsection "G 0120. Bathing", Resident #7 was coded as a "4" indicating "Total Dependence". On 9/12/12 at 9:50 a.m. an observation was made of a hoyer lift transfer. The transfer demonstrated proper technique as CNA #1 controlled the hoyer lift and CNA #2 (CNA #2 was also the CNA named in the nursing notes during the transfer when Resident #7 fell ) guided and balanced the resident. After the transfer observation, both CNA's were asked what could potentially go wrong when transferring a resident. CNA #1 verbalized that there should always be two assistants during a transfer, make sure the lift pad is properly positioned and equal on both sides of the resident, and make sure that all four support loops are hooked and tension is applied prior to lifting the resident. On 9/12/12 at 10:25 a.m. CNA #2 was interviewed regarding Resident #7's fall from the hoyer lift. CNA #2 verbalized that she and another CNA were transferring Resident #7 back to bed from the shower when one of the support loops came off and Resident #7 fell to the ground. The surveyor asked CNA #2, if the resident was having any behavior issues such as jerking or kicking during the transfer or was the hoyer lift or transfer pad broken or in ill repair. CNA #2 verbalized that there were no issues with Resident #7's behavior or any problems with the hoyer lift. This surveyor then asked CNA #2 what she thought might have caused the fall. CNA #2 verbalized, she felt that one of the support loops was not properly hooked. On 9/12/12 at 1:45 p.m. the director of nursing (DON) was interviewed concerning the above finding and was asked what Made Resident #7 a two person assist with hoyer lift status? The DON verbalized Resident #7 was non-weight bearing and debilitated in the lower extremities and also weighed over 150 pounds. On 9/12/12 at 2:40 p.m. the administrator was interviewed concerning this finding. The administrator verbalized that an investigation was done and the hoyer lift was inspected and found to be in proper operational order. The administrator went on to say that the facility's finding was the support loop was not properly hooked and summarized the incident as human error. The administrator then presented a five point plan of correction the facility implemented with a completion date of 2/10/12. On 9/12/12 at 4:45 p.m. during an end of day facility staff/survey meeting, this surveyor informed the administrator, DON, and nurse consultant that a past non-compliance deficiency could not be determined until the end of the survey process. On 9/13/12 at 10:20 a.m. Resident #7 was interviewed concerning the fall from the hoyer lift. Resident #7 verbalized that there were two CNA's helping her back to bed when the lift tilted to one side resulting in falling to the floor. Resident #7 also verbalized she was not sure what happened. On 9/13/12 at 2:30 p.m. during a facility/surveyor meeting, this surveyor informed the administrator due to new findings in the same deficient area after the POC date, the POC would be impacted. No further information was given concerning the above finding prior to exit conference on 9/13/12. 2. Resident #12 was admitted to the facility on [DATE] with a readmission of 7/29/09, with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly with an assessment reference date of 8/1/12, Resident #12 was assessed as having short and long-term memory problems and being severely cognitively impaired. Resident #12's clinical record was reviewed on 9/13/12 and revealed a nursing note dated 7/9/12 10:50 p.m. that read "...CNA reported that when getting resident up to wheelchair from bed she (CNA) heard a "pop" sound from residents L (left) arm. Resident started crying and c/o (complained of) L arm pain.... ROM (range of motion) WNL (within normal limits). No bruising or visible trauma noted...Xray scheduled for 7/10/12." Resident # 12's X-ray was reviewed and revealed no abnormalities found. Resident #12's care plan was then reviewed and revealed a fall care plan dated 5/23/12 with interventions that included "Total assistance with transfers." Resident #12's MDS's with ARD dates of 5/9/12 and 8/1/12 were reviewed. On the MDS dated [DATE] under section "G" Functional status, subsection "B" Transfer, Resident #12 was coded as a 4 (self performance) and 3 (support), indicating Resident # 12 was totally dependant of staff (full staff performance every time) with two plus persons physical assist. On the MDS dated [DATE] under section "G" Functional status subsection "B" Transfer, Resident #12 was coded as a 3 (self performance) and 3 (support), indicating Resident # 12 needed extensive assistance with staff providing weight-bearing support and totally dependant of staff with two plus persons physical assist. On 9/13/12 at 9:30 a.m. Resident #12's room was observed. Resident #12 did not have a bed frame, only a mattress on the floor with fall mats were observed. According to nursing notes this was in place due to multiple falls. This surveyor then asked for an incident report for the above finding. An incident report dated 7/10/12 was reviewed and repeated the nursing note dated 7/9/12. This surveyor then asked for any investigation report concerning the above finding. The DON showed an investigation report hand written and signed by the DON and stating "2 person assist under arms as always, no different in type of transfer performance. Staff denies change of normal routine." On 9/13/12 at 11:00 a.m. the DON was interviewed concerning the reasoning of a two person transfer for Resident #12. The DON verbalized Resident #12 is a two person transfer due to non weight bearing and leg contractors. The DON was also asked to find any documentation stating Resident was a two person transfer. On 9/13/12 at 11:05 a.m. CNA #3 was interviewed concerning how Resident #12 is transferred from the bed to wheel chair. CNA #3 verbalized that she gets Resident #12 up by herself by putting Resident #12 in the sitting position on the mattress (mattress is on the floor), CNA #3 then bends down and has Resident#12 put her arms around the CNA's neck, then she (CNA #3) hugs Resident #12 around Resident #12's body and stands Resident #12 up and pivots Resident #12 to the chair. On 9/13/12 at 11:10 a.m. CNA #4 was interviewed and asked how she got Resident #12 from the mattress to the wheel chair. CNA #4 verbalized that she would get the help of another CNA and stand Resident #12 up by raising her from under the arms. On 9/13/12 at 11:15 a.m. CNA #5 was asked the same previous question that was asked to CNA's #3 and #4. CNA # 5 verbalized that she gets Resident #12 up by herself by bending down and hugging Resident #12 under the arms, raising Resident #12 up and pivoting to chair. On 9/13/12 at 11:45 a.m. the DON was interviewed concerning the above finding and the investigation carried out by the DON. The surveyor asked who were the CNA's involved at the time of Resident #12 transfer resulting in pain. The DON was able to identify one of the CNA's involved (CNA #6). The DON was unable to positively identify the other CNA but gave two other possibilities (CNA #7 and CNA #8). The DON was asked if there was any other investigation or missing part to the investigation that would identify the CNA involved in the transfer? The DON replied "No." The DON was asked if there were any written statements from the CNA's involved in the transfer? The DON replied "No." The surveyor then pointed out the nursing note of the incident and verbalized that the note indicated only one CNA reported to the nurse. The DON verbalized that she was sure there was another CNA involved in getting Resident #12 up as Resident #12 was a two person assist. The DON also verbalized that her investigation notes could have been better and should have included written statements from all parties involved. The surveyor asked the DON for documentation that indicated Resident #12 was a two person assist. The DON verbalized that the facility goes by what the MDS's coded the resident for transfers. Multiple attempts to contact CNA's #6, #7, #8 were made via telephone, however, contact was not made. On 9/13/12 at 2:10 p.m. CNA #3 was again interviewed concerning transferring Resident #12. CNA #3 was asked if she had ever been told by a nurse that Resident #12 was a two person transfer. CNA #3 stated "Yes." CNA #3 was asked when was she told this. CNA #3 replied today (9/13/12) after being interviewed the first time. CNA #3 was also asked, how do staff know how to transfer residents. CNA #3 verbalized they (CNAs) get their information from other CNAs and nurses verbally. On 9/13/12 at approximately 2:15 p.m., this surveyor went to CNA #5 and asked the same questions. CNA #5 also verbalized that she was told today not to transfer Resident #12 by herself. CNA #5 verbalized that the nurse working the floor told her this after being interviewed earlier. On 9/13/12 at 2:15 p.m. license practical nurse (LPN #2) was interviewed concerning Resident #12's transfer status. LPN #2 was asked what prompted her to tell CNA's #3 and #5 that Resident #12 was a two person assist for transfers. LPN #2 verbalized that the DON talked to her earlier and told her (LPN #2) to inform the CNA's that Resident #12 is a two person assist for transfers. LPN #2 was also asked by this surveyor if she was aware that the CNA's were getting Resident #12 up by without help from another CNA. LPN #2 replied "Yes." On 9/13/12 at 2:30 p.m. during a facility/surveyor meeting the above information was brought to the attention of the administrator, DON and nurse consultant. The nurse consultant verbalized that the MDS's were only for a seven day look back period. At this time this surveyor reiterated what the DON verbalized earlier, that Resident #12 is a two person assist for transfers and that was also written on the investigation report. At this time the administrator was asked if she thought it was safe for one staff member to transfer Resident #12. She stated it was not a good idea. The administrator was then asked if she felt that Resident #12 should be a two person transfer for safety reasons. The administrator replied "yes" and the DON agreed. No other information was provided concerning this finding prior to exit conference on 9/13/12.

Based on staff interview, family interview, clinical record review, facility document review, and during the course of a complaint investigation, the facility staff failed to ensure one of 19 residents was free of an accident that resulted in injury, Resident # 1. Resident # 1 was not provided adequate supervision or assistive devices to prevent a fall, which resulted in the resident sustaining "a broken neck." Findings include: Resident #1 was admitted to the facility originally on 07/28/03, with the most current readmission on 06/03/11. [DIAGNOSES REDACTED]. The most recent full MDS (minimum data set) was an annual assessment dated [DATE]. Resident # 1 was assessed as having short and long term memory impairment and severe impairment in daily decision making skills. Resident # 1 was also assessed as a 3/3 for bed mobility, which indicated the resident required extensive assistance from staff, with staff providing weight bearing support of 2+ persons physical assistance. Resident # 1 was also assessed as having impairment on one side (upper extremity) and impairment on both sides (lower extremity's) for functional limitations in range of motion. Resident # 1's last documented weight in the clinical record was 265 lbs on 01/28/2010. During clinical record review on 09/20/11, physician's orders [REDACTED]. The most recent admission orders ...Bariatric Bed-long bariatric bed /c (with) bilateral 1/2 siderails per manufacturer to enhance bed mobility and assist /c (with) turning and repositioning q (every) shift...Trapeze bar-check q shift..." This physician's orders [REDACTED]. A physician's orders [REDACTED]. The order was dated 05/27/11, included the attending physician's name, and documented, "discontinue Bariatric Bed." The order was signed by the physician on 06/16/11. Nursing notes were then reviewed from 05/20/11 through 06/03/11. The nursing notes documented the following: ? On 05/20/11 at 6:44 a.m., it was documented that the resident received Ativan at 12:40 a.m. for agitation and yelling out. ? On 05/26/11 at 5:00 a.m., it was documented that Resident #1 was yelling out, crying out "I don't know...help me." Complained of hurting all over; Ativan and Tylenol was given at 12:30 a.m. ? On 05/29/11 at 6:51 a.m., it was documented that Resident # 1 was "very agitated" yelling and crying out. Ativan and Tylenol were given at 3:45 a.m. ? On 05/29/11 at 7:17 a.m., it was documented that blisters were found on the resident's right upper side and the CNA (certified nursing assistant) was instructed to keep resident off of right side. ? On 05/29/11 at 1:50 p.m., it was documented that Resident # 1 had remained off of right side. ? On 05/30/11 at 2:54 a.m., it was documented that the resident was "agitated and yelling out repetivitely (sic)" Ativan and Tylenol given at 12:30 a.m. ? On 06/02/11 at 12:00 p.m., a nursing note documented: "Resident rests on right side of edge of bed and will pull self over to the edge of bed. Resident heard yelling help, and resident found on floor next to roommates bed...send to ER (emergency room )...c/o (complained of) severe neck pain..." ? On 06/02/11 at 5:28 p.m., it was documented: "Resident has new order for long bariatric bed with bilateral 1/2 siderails per manufacturer to aid in turning & (and) repositioning..." On 09/21/11 at approximately 11:30 a.m., LPN (Licensed Practical Nurse) # 1 was interviewed regarding Resident # 1's fall. LPN # 1 stated that Resident # 1 was in a regular bed without a trapeze bar when he fell ; the resident was heard yelling, staff went to check on the resident and Resident # 1 was on the floor on a fall mat/rug. LPN # 1 voiced that the resident was assessed for injury and was found to have an abrasion on the right side of the forehead and complained of severe neck pain. LPN # 1 voiced that the resident had been "in the regular bed for awhile." The resident was sent out to the hospital after the fall. On 09/21/11 at approximately 3:00 p.m., LPN # 3 was interviewed regarding Resident # 1's fall. LPN # 3 stated that there was a malfunction in Resident # 1's bed (bariatric bed w/trapeze) that prevented the head of the bed from elevating. LPN # 3 stated that the day the bed broke, the DON (director of nursing) instructed the LPN (with assistance from staff) to obtain a weight on Resident # 1. The LPN voiced that the DON stated that if the resident was less than 300 lbs to write an order for [REDACTED]. The LPN voiced that the weight was obtained on the resident and that the weight was, "like 252..." LPN # 3 was asked if this weight was documented and LPN # 3 stated, "No." The LPN was then asked if the physician was notified and who gave the order for the regular bed. LPN # 3 voiced that the DON instructed to write the order for the regular bed and the physician was notified. LPN # 3 was then asked if this information was documented; LPN # 3 stated, "No." LPN # 3 further voiced that she (LPN # 3) thought the bed had been broken for approximately a week or two prior to the actual discontinuation of the bariatric bed on 05/27/11. Resident # 1's discharge summary dated 06/03/11 was reviewed. A weight of 264 pounds was documented on the summary for Resident # 1. It was also documented that the resident sustained [REDACTED]. On 09/21/11 at approximately 4:30 p.m. the DON (director of nursing) and Other Staff (OS) # 6 were interviewed in a meeting with the survey team regarding Resident # 1's fall. The DON stated, "...at the time we (facility staff) felt like a regular (bed) could hold him." The DON stated that the bed (Bariatric) was broken at least the shift before it was actually discontinued and that she (DON) had instructed staff to obtain a weight on Resident # 1 and if he was less than 300 pounds he could use the regular bed. The DON also voiced that she instructed LPN # 3 to get an order to discontinue the bariatric bed. The DON further stated, that the resident had plenty of room in the regular bed. The DON was interviewed regarding the order that was written by LPN # 3 to discontinue the bed. The DON stated that she could not say 100% that the Dr. was notified prior to the bed being discontinued. CNA (certified nursing assistant) # 4 was interviewed at approximately 4:45 p.m. on 09/21/11. CNA # 4 stated that she recalled asking the administrator if the resident would be getting the bed (Bariatric) back, because "he needed it, he was hard to turn, and it scared me..." The CNA could not remember when this conversation took place, but did state that the resident's bed (bariatric) was broken for a couple of weeks. On 09/21/11 at 5:15 p.m., the survey team conducted a meeting with the administrator, DON, and the nurse consultant informing them of the concerns regarding Resident # 1's fall and the concerns regarding the resident's bed. The facility staff were interviewed at this time regarding any type of assessment for the bariatric bed for Resident # 1, to determine the need/rationale for the use of this specialty bed. The facility staff informed the survey team that Resident # 1 had been using this bed for "a long time" and would try to locate any information. The facility staff were asked at this time if the resident had been assessed by PT or OT (Physical therapy or Occupational therapy) to determine the resident's need or continued need for this specialized equipment. The facility staff stated that the Resident # 1 had not been seen by therapy for at least a year or more, but would also attempt to locate this information. The facility's fall policy was requested at this time, in addition to the investigation on Resident # 1's fall. On 09/22/11, a fall risk assessment was observed dated 10/12/10. The assessment was marked as a "quarterly" assessment. The fall assessment documented, "Last fall occurred: 01/27/10." Resident # 1 was assessed on this document as having a fall risk score of "12." The assessment documented that a score of 10 or more indicated the resident was assessed as a high risk for falls. The assessment form also documented that if the the score is 10 or more, develop appropriate care plan interventions. Comments listed at the bottom of the assessment documented, "Resident unable to weight bear. Mechanical lift required to lift. Resdient (sic) incontinent of bowel and bladder..." Another fall risk assessment was observed dated 01/13/11. This assessment was also marked as a "quarterly" assessment. The fall assessment documented, "Last fall occurred: 01/27/10." Resident # 1 was assessed on this document as having a fall risk score of "16." The assessment documented that a score of 10 or more indicated the resident was assessed as a high risk for falls. The assessment form also documented that if the the score is 10 or more, develop appropriate care plan interventions. Comments listed at the bottom of the assessment documented, "Resident unable to weight bear. Mechanical lift required to lift. Resdient (sic) incontinent of bowel and bladder..." A final fall assessment was observed dated 09/13/11, this assessment was also marked as a "quarterly" assessment. This assessment was three months after the resident's last fall (06/02/11) and was nine months after the last fall risk assessment, which was 01/13/11. Resident # 1's care plan dated 01/28/10 was reviewed (one day after the resident's fall on 01/27/10). The care plan documented, "Self care deficit r/t (related to) debilitation from obesity, recent fall with left ankle fracture...Provide extensive care with ADL's (activities of daily living)...Impaired Cognition with mood and behavior...psych consult as needed...Actual fall with injury d/t (due/to) dementia and poor safety awareness, risk for further falls." The "Fall" section of the care plan further documented "Monitor for medication side effects, keep wheels on bed locked, call bell functional and within reach, fall mat, bed alarm, and chair alarm as safety measure, long bariatric bed with 1/2 SR (side rails) per manufacturer to enhance bed mobility and assist with turning and positioning, encourage res to keep bed in low position as safety measure..." The care plan dated 03/29/11 was reviewed. The care plan documented, "...impaired mobility...turn and position for comfort...Actual fall with injury d/t (due to) dementia and poor safety awareness, risk for further falls." The "Fall" section of the care plan further documented "Long bariatric bed with 1/2 SR (side rails) per manufacturer to enhance bed mobility and assist with turning and positioning, call bell functional and within reach, keep wheels on bed locked, Monitor for medication side effects, Vanderlift and staff assist of 2 with all transfers..." To the right of the fall approaches (in the "evaluation" section) was an entry that documented, "...06/02/11...roll to fall mat this am. To ER for eval." This care plan was discontinued on 06/09/11. The care plan dated 06/09/11, after the resident's fall on 06/02/11 was reviewed. In the "Fall" section of the care plan it was documented, "...Frequent bed checks, anticipate resident needs, Vanderlift and 2 staff members for all transfers, assistive devices as indicated half siderails x (times) 2 per manufacturers guidelines for bariatric bed. Fall mat, ..." The facility's fall policy was reviewed and documented: "...Falls Risk Assessment 1. A fall risk assessment will be completed upon admission, readmission, quarterly, and significant change of condition...3. Incorporate identified interventions into the comprehensive care plan as applicable...5. Review and re-evaluate initial fall risk assessment and Device Assessment during the initial weekly fall meeting and the initial care plan meeting after admission. 6. Refer the resident to PT/OT for screening, evaluation, and treatment as indicated. 7. Consult Maintenance personnel for any necessary adaptations...complete a post fall assessment to determine, to the extent possible the cause of a resident fall..." A post fall assessment was observed dated 06/03/11. The assessment documented the date of the fall as "06/02/11" and the time of the fall as "10:30 AM." At the top of the form, a question documented: "What was the resident attempting to do at the time of the fall?" The answer provided was, "At 2:00 AM, the resident observed lying on floor at bedside. When asked what happened, resident stated his legs gave out." It was documented at the bottom of this post fall assessment that the resident had a fall mat at the bedside. The post fall assessment was observed dated 01/25/10. The assessment documented the date of the fall as "01/25/10" and the time of the fall as "2:15 AM." At the top of the form, a question documented: "What was the resident attempting to do at the time of the fall?" The answer provided was, "At 2:00 AM, the resident observed lying on floor at bedside. When asked what happened, resident stated his legs gave out." The exact description as documented on the 06/02/11 post fall assessment. On 09/22/10 at 2:15 p.m., the administrator and DON presented a folder with various documents. The folder was reviewed by the surveyor in the presence of the survey team and administrative staff. The folder contained three documents titled, "Device/Restraint Assessment." The first assessment, dated 05/08/08 documented: "...3/4 x (times) 2 assist bars...trapeze...to facilitate bed mobility..." The second assessment dated , 06/05/08 documented: "...Trapeze...siderails 1/2 long per manufacturer assembly. Assists resident with bed mobility secondary cervical fusion Trapeze to facilitate bed mobility secondary cervical fusion..." The third and last assessment dated , 04/15/09 documented: "...cervical stenosis...cervical diskectomy with fusion...Long Bariatric bed with bil. (bilateral) 1/2 SR (siderails) X (times) 2; over bed Trapeze...Alternative: Regular standard bed...Resident Response: Uncomfortable secondary obesity, uncomfortable secondary arthritis & (and) obesity...to help facilitate bed mobility, aid with TAP (turn and positioning) d/t (due to) decreased physical/bed mobility r/t (related to) cervical [DIAGNOSES REDACTED] with cervical stenosis...over bed trapeze bar to help facilitate bed mobility and aid with TAP..." Under the "physician's orders [REDACTED]." Under this column all of the following were marked: "To prevent injury from fall, prevent injury to self/others, provide necessary treatment, maintenance of body alignment, increased sense of safety/security." The administrative staff were asked if this was their investigation. The DON stated that no investigation was completed because the staff did not suspect any type of abuse. No further information or documentation was provided regarding the assessed need/rationale of the bariatric bed with trapeze for Resident # 1. On 9/22/11 at 2:30 p.m., LPN # 1 was again interviewed regarding Resident # 1's fall in June. When asked if the resident was attempting to get up out of bed when he fell she stated "No, he never tried to get out of bed." On 09/22/11 at 2:50 p.m., this surveyor and the maintenance director went to Resident # 1's room. Resident # 1 was not present at the time. The resident's Bariatric bed was observed, in comparison to the roommates bed (a standard bed). The maintenance director measured the length of the 1/2 side rail on right side of the bed (the side that staff voiced and documented the resident was partial too). The side rail on the Bariatric bed measured 30 1/2 inches in length. The maintenance director then measured the siderails on the standard bed (the same type of bed Resident # 1 was in on 06/02/11-the date of the fall). The siderails on the standard bed were measured; the length of one siderail measured 10 inches in length. A difference of 20 1/2 inches in length between the bariatric siderail and the regular bed siderail. On 9/22/11 at 4:17 p.m., the resident's family member was interviewed in the presence of the survey team. When asked about Resident # 1's bed, she stated she had "concern back in June during lunch." She stated she when she came into Resident # 1's room during lunch she saw his "feet up in the air and head of the bed was down to he floor." She further stated she came back the following day and (the bed) was still broken. When asked how long she thought it had been broken she stated "more than a week, probably a week to a week and a half." She stated they put him in a regular bed and he fell and broke his neck and prior to him coming back to the facility got a rental bed. She stated she spoke with the DON regarding the rental bed. She further stated that the fall in June was the "second fall since he's been here." She stated she didn't "blame the first one (fall in January 2010) on them, but he (the resident) could get up (at that time)." On 09/22/11 at approximately 5:40 p.m., the survey team met with the administrative staff (DON, administrator, and nurse consultant) and again informed them of the concerns regarding Resident # 1's fall that resulted in a neck fracture and that the resident was in a regular bed at the time of the fall. The administrative staff voiced that the facility does not use restraints and that side rails are considered restraints and can't be used to help keep someone from falling out of the bed. The administrative staff were made aware at this time of the resident's Fall care plan related to the bariatric bed. The facility staff again informed the survey team that the facility did not use side rails to keep a resident from falling. The administrative staff were also informed at this time that the resident had not been assessed for bed mobility and the use of the bariatric bed had not been addressed since 2009 to determine if the resident had a continued need for the bed or was safe to use a regular bed. The facility staff confirmed that the resident had not been assessed since the documented assessment (2009) to determine the continued use of the bariatric bed. No further information or documentation was provided prior to the exit conference on 09/22/11 at 8:15 p.m. to evidence that a regular bed was appropriate for Resident # 1, which subsequently the resident fell out of and sustained a "broken neck." No further information or documentation was provided prior to the exit conference to evidence that the original purpose of the bariatric bed was not used as an intervention to prevent the resident from falling out of the bed, as documented.