Every finding on record at Louisville Healthcare LLC

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a person-centered comprehensive care plan for a resident with chronic pain (Resident #39) and a resident dependent on staff for nail care (Resident # 22) for two (2) of 16 care plans reviewed. Resident #22 and #39 Findings Include: Review of the facility policy titled Care Plans-Comprehensive revealed under, Policy Statement: An individual (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Resident #22 Record review of Resident #22's Care Plan Report revealed that he required assistance with his ADL's (Activities of Daily Living) related to confusion and cognitive impairment and had interventions initiated on 10/24/22 that included, Nail care as needed or scheduled. An observation on 4/14/25 at 2:43 PM revealed Resident #22 sitting up in his wheelchair in the room and his fingernails on both hands were long. They were approximately one-half to three-fourths inch long and there was a brown substance underneath them. An observation and interview on 4/15/25 at 9:20 AM with Licensed Practical Nurse (LPN) #1, confirmed that Resident #22 had long, dirty fingernails and she revealed that they should have been taken care of. An interview on 4/15/25 at 2:50 PM with the Minimum Data Set (MDS) Coordinator revealed that they developed a patient specific personalized care plan, so the staff knew how to care for the individualized needs of the residents. She confirmed that Resident #22's ADL care plan which includes his nail care was not followed. Record review of Resident #22's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Unspecified Dementia, Age-Related Physical Debility, and Unspecified Depression 47874 Resident #39 Record review of the Care Plan Report for Resident #39 revealed under, Focus: Resident has intermittent episodes of chronic pain . and listed under, Goals: Resident will verbalize full relief from pain with interventions provided by staff . Also revealed under, Interventions: Monitor for worsening pain symptoms and report to physician if indicated. Date initiated 4/3/25. An observation and interview on 4/14/25 at 2:48 PM with Resident #39 revealed she was sitting in a chair in her room and she stated that she was newly admitted to the facility and explained that she had been out of her pain medication (Lyrica) for almost a week. The resident revealed she came into the facility taking it for neuropathy pain for her lower legs and feet. She stated, I cannot even walk due to the leg pain. The resident explained that she had Tylenol that she could take, but it was not effective for her nerve pain in her legs and feet. Record review of the Pain assessment dated [DATE] revealed Resident #39 frequently experienced pain in the last 5 days with a pain intensity scale rated 7 on a scale of 1-10. An interview with Licensed Practical Nurse (LPN) #1 on 4/15/25 at 2:10 PM, while in the room with Resident #39, confirmed that the resident was currently reporting pain in her feet and legs and rated the pain 8 on a scale from 1 to 10 with 10 being the worst pain. The resident stated, It hurts to even touch my feet and to stand. She revealed that Lyrica helped with her nerve pain and explained that without the medication, the pain was constant and intense with the faintest touch. An interview with the MDS Nurse on 4/16/25 at 10:29 AM revealed the purpose of the care plan was to develop a plan of care for the direct care staff to follow so they can provide the best care needed. She then confirmed that the pain care plan was not followed because the staff had failed to administer medications to relieve the resident's pain. An interview with the Physical Therapy Assistant (PTA) on 4/16/25 at 8:55 AM revealed occupational therapy (OT), and she had been working with Resident #39 to build strength and endurance, but that they had to modify her therapy because she was in pain during therapy sessions. Record review of the Order Listing for Resident #39 revealed an order dated 4/02/25, Lyrica (nerve pain) Oral Capsule 200 MG (milligrams) (Pregabalin) Give 1 (one) capsule by mouth three times a day related to other chronic pain, with a discontinued date of 4/10/25. Record review of the Admission Record revealed the facility admitted Resident #39 on 4/02/25 with medical diagnoses that include Chronic Pain, Anxiety Disorder, Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Record review of the MDS with an Assessment Reference Date (ARD) of 4/08/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #39 was cognitively intact.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure effective pain management for one (1) of sixteen (16) sampled residents (Resident #39), when staff failed to provide continued access to prescribed pain medication (Lyrica) and failed to implement appropriate interventions. This resulted in the resident experiencing uncontrolled neuropathic pain, impaired mobility, disruption in therapy services, and a decline in quality of life. Findings Include: Review of the facility policy titled Pain Assessment/Management with a revision date of 9/10 revealed, It is the policy of this facility to provide guidelines in the identification and treatment of residents at risk for acute and chronic pain. Each residents pain will be assessed in an approach designed to increase comfort and promote dignity through administering alternative interventions or medications. On 4/14/25 at 2:48 PM an observation and interview with Resident #39 revealed that she was newly admitted to the facility and explained that she had been out of her pain medication (Lyrica) for almost a week. The resident revealed she came into the facility taking it for neuropathy pain in her lower legs and feet. She explained that staff told her that they contacted the facility doctor, but he would not refill it for her. She stated that she has an upcoming appointment with her pain specialist this Thursday, but she would rather not wait that long and stated, I cannot walk anymore due to the leg pain. The resident explained that she had Tylenol that she could take, but it was not effective for her nerve pain in her legs and feet. An interview with the Director of Nursing (DON) on 4/14/25 at 3:10 PM revealed Resident #39 was a new admission to the facility on [DATE] and had a contract with the pain clinic and could not get pain medication prescribed by anyone besides with them. She explained that the resident has an appointment to have a drug screen on 4/17/25 and will have a telehealth visit through the pain clinic after the drug test to get her refills. She confirmed that the resident was admitted to the facility on Lyrica for pain management and revealed that the order was discontinued after the facility medical director was contacted about refilling it. The DON explained that he refused to refill the medication and told them that the resident must get her pain medications refilled by her pain management physician. She stated, If he was not willing to refill the Lyrica, that was the physician's order from him to discontinue the medicine. Record review of the Order Listing for Resident #39 revealed an order dated 4/02/25, Lyrica (nerve pain) Oral Capsule 200 MG (milligrams) (Pregabalin) Give 1 (one) capsule by mouth three times a day related to other chronic pain, with a discontinued date of 4/10/25. Record review of the April 2025 Medication Administration Record (MAR) revealed Resident #39 last received a dose of Lyrica 200 mg on 4/10/25 at 1400 (2:00 PM), and the order was discontinued. Record review of the Pain assessment dated [DATE] revealed Resident #39 frequently experienced pain in the last 5 days with a pain intensity scale rated 7 on a scale of 1-10. An interview with Licensed Practical Nurse (LPN) #1 on 4/15/25 at 2:10 PM, while in the room with Resident #39, confirmed the resident had been out of the Lyrica. She revealed that the resident was currently reporting pain in her feet and legs and rated the pain 8 on a scale from 1 to 10 with 10 being the worst pain. LPN #1 revealed stopping the medication abruptly could cause a recurrence of pain symptoms and withdrawal side effects. The resident stated, It hurts to even touch my feet and to stand. She revealed that Lyrica helped with her nerve pain and explained that without the medication, the pain was constant and intense with the faintest touch. The resident explained that the facility's Medical Director saw her last week and told her he could not prescribe pain medications to her because it would void her contract with the pain clinic. She stated, I don't know what to do. An interview with the Director of Nursing (DON) on 4/15/25 at 2:19 PM revealed the staff had contacted Resident #39's pain clinic for the Lyrica refill, but they were told the resident must come in. She explained there was nothing they could do since the medical director would not refill it. A telephone interview with the facility Medical Director (MD) on 4/15/25 at 2:35 PM revealed Resident #39 has chronic pain and currently has rib fractures due to a fall at home. He confirmed he saw the resident last week in the facility, and revealed the staff did not tell him the resident was out of Lyrica. He explained that the staff did ask him about refilling her medications, and he told them that she would need to get it refilled by her pain specialist. The MD stated, There was a misunderstanding because I was never told that she was out of the medicine. He further elaborated, It was not my intention for her to go without. He acknowledged that he had no problem with giving the resident enough medication until she got back in with the pain clinic, but would not want to do it on a long-term basis. The MD confirmed this medication should not be abruptly stopped and would cause a recurrence of pain for the resident. An interview with the Administrator on 4/15/25 at 2:55 PM revealed Resident #39 should not be in pain and confirmed the facility was responsible for ensuring the resident had the medications available to manage her pain. She revealed her expectations were for the Medical Director to provide the medication until the resident was able to see her pain specialist. An interview with the Physical Therapy Assistant (PTA) on 4/16/25 at 8:55 AM revealed occupational therapy (OT), and she had been working with Resident #39 to build strength and endurance. She revealed they had previously been walking and doing exercises, but explained that the resident complained of pain in her feet yesterday and could not stand and we had to modify her therapy treatment plan to adapt due to the pain. Record review of the PT (Physical Therapist) Flowsheet revealed the following entries: Dated 4/14/25 . Pt (patient) reported not feeling well and needing to sit with c/o (complaints of) rib pain and foot nerve pain. PTA transitioned activity to dynamic sitting activity . Dated 4/15/25 . dynamic sitting balance activity requiring pt to reach across midline to challenge trunk stability needed for daily tasks. Pt reported not feeling well with LE (lower extremity) pain. No standing on this day date related to pain. Record review of Resident #39's April 2025 Medication Administration Record revealed under, Pain scale-evaluate pain per pain scale (0-10) Q (every) shift and PRN (as needed). If pain is present document interventions and follow up on effects. Notify MD of persistent pain unrelieved by intervention with zeros (0) documented on all shifts from 4/10/25 until 4/16/25 indicating the resident had no pain. An interview with LPN #1 on 4/16/25 at 9:45 AM confirmed that she did not document Resident #39's pain level correctly on her shift. She revealed the resident complained of pain in both feet rated 8/10 and explained that she gave the resident two (2) Tylenol 325 milligrams (MG) at 245 PM yesterday, and upon follow-up the resident stated, It helped a little bit but not much. She confirmed that she failed to document the pain or that Tylenol was given because she forgot. LPN #1 confirmed that the resident had told her that her pain was an 8 on a scale of 1-10. Record review of the Admission Record revealed the facility admitted Resident #39 on 4/02/25 with medical diagnoses that include Chronic Pain, Anxiety Disorder, Peripheral Vascular Disease and Type 2 Diabetes Mellitus. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/08/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #39 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure that resident call lights were within reach, which limited residents' ability to request assistance as needed for two (2) of 54 residents observed. Resident #1 and Resident #47 Findings include: Review of the facility policy titled Call Lights: Accessibility and Timely Response dated 8/12/2019 revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. 5. Staff will ensure the call light is within reach of resident and secured, as needed.6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room. Resident #1 An interview and observation in Resident #1's room on 4/14/25 at 10:35 AM revealed the door was closed. The resident was lying in bed and stated, I want to get up, and revealed that she had told the staff. The call light was observed unreachable, and the button was clipped to the upper portion of the cord coming from the wall unit with a silver clip. An interview with Registered Nurse (RN) #1 on 4/14/25 at 10:42 AM confirmed Resident #1's call light was inaccessible. She revealed the call lights should always be in reach of the residents in case they needed somebody or were distressed. She revealed that without the call light, the resident could not call to get help. An interview with the Director of Nursing (DON) on 4/14/25 at 12:15 PM confirmed the call lights should be accessible to the residents. She revealed the charge nurse was responsible for making daily rounds and ensuring the call lights were in reach. She revealed she also made rounds once or twice weekly and had checked for this. The DON revealed that without the call light, the resident could not alert the staff of the need for assistance. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/12/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 11, which indicated Resident #1 was moderately cognitively impaired. Record review of the Admission Record revealed the facility admitted Resident #1 on 2/20/09 with a medical diagnosis that included Unspecified Dementia. 46013 Resident #47 An observation and interview on 4/14/25 at 10:30 AM, revealed Resident #47 lying in bed with his call light secured and hanging behind a positioning bar, rendering the call light out of reach. Resident #47 stated, I can't reach my call light. It doesn't do any good when you can't push it if you need anything. During an interview on 4/14/25 at 11:37 AM, RN #1 confirmed that she had noticed earlier that several call lights were not within reach of the residents. She revealed she went around to ensure all of them were put where the residents could reach them. RN #1 emphasized that the call light is in place to allow residents to request assistance for their needs. In an interview on 4/14/25 at 11:55 AM, the DON revealed that it is the facility's expectation that all residents always have access to their call lights. She revealed the charge nurse was responsible for making rounds each shift to ensure call lights are accessible, and all staff must make sure the call light is within reach before exiting a resident's room. A review of Resident #47's Admission Record revealed he was admitted to the facility on [DATE] with diagnoses that include a history of falling, Chronic Respiratory Failure, and Anxiety Disorder. Record review of the MDS with an ARD of 01/14/25 revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to provide a clean homelike environment for residents in four (4) of forty-eight rooms observed during the survey. Rooms 209, 210, 212, and 216. Findings include: Record review of the facility policy Safe and Homelike Environment revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . room [ROOM NUMBER] An observation on 4/14/25 at 10:45 AM and on 4/15/25 at 8:45 AM in the bathroom of room [ROOM NUMBER] revealed a strong foul odor. An interview on 4/15/25 at 9:10 AM with the Housekeeping Supervisor revealed that they had a hard time keeping the urine smell out of the bathroom in room [ROOM NUMBER]. She revealed that they cleaned and mopped it once daily and within an hour of cleaning it, the smell was back. She explained that the residents were bad to urinate on the floor, and urine ran out into the rooms. The Housekeeping Supervisor revealed that there were four men sharing that one bathroom and she thought that the urine was down underneath the tile. She confirmed the strong, foul smell and stated, It's always like this. She agreed that the strong odor in the bathroom was not ideal and that she would not want to smell it in her home. An observation and interview on 4/15/25 at 9:18 AM with Licensed Practical Nurse (LPN) #1, revealed that the bathroom in room [ROOM NUMBER] had a foul odor and stated, It smells like urine in here. LPN #1 confirmed that with the strong, urine smell present, this was not a clean, homelike environment for the residents. An interview on 4/15/25 at 9:20 AM with the Administrator (ADM), revealed that the facility has had some issues in the past with a resident urinating in the air conditioner unit and with the urine odors in the bathroom in room [ROOM NUMBER]. She confirmed the foul odor in the bathroom in room [ROOM NUMBER] and revealed that they might have to take the floor up and replace it to fix the issue. She agreed that the strong foul odor in the bathroom needed to be fixed to provide the residents with a clean homelike environment. Rooms #209, #212, #216 - Walls An observation on 4/14/25 at 11:05 AM in room [ROOM NUMBER] revealed that the upper right corner of the air conditioner unit was pulled out from the wall and the ground outside the facility was visible. There was an opening measuring approximately one inch by one inch at the right upper corner of the air conditioner unit with daylight visible, and warm air felt entering the room from the outside. An observation also revealed a hole in the wall measuring approximately six inches by six inches above and to the left of the sink faucet in room [ROOM NUMBER]. An observation on 4/14/25 at 2:55 PM in room [ROOM NUMBER] revealed a hole in the wall to the left of the sink faucet which measured approximately seven inches by seven inches. An observation on 4/14/25 at 3:00 PM in room [ROOM NUMBER] revealed a hole in the wall above the sink faucet which measured approximately seven inches by seven inches. An observation and interview on 4/15/25 at 9:25 AM with the ADM revealed the facility had contractors come in and replace the sink faucets, closets, and overbed tables in the resident rooms about a year ago. She revealed that the contractors removed the built-in soap dishes, and it left the holes in the walls. The ADM revealed that the contractors had started at one end of the building repairing the walls and never made it to that end of the building on 200 wing. She revealed that the contractors had not been back to the facility in a while. She acknowledged that there were holes in the walls in rooms #209, #212, and #216 and confirmed that they needed to follow up to get them fixed. An observation and interview on 04/15/25 at 9:45 AM with the Maintenance Director confirmed the air conditioner unit in room [ROOM NUMBER] was pulled away from the wall on the right upper corner with exposure to the outside. He revealed that leaving the air conditioner loose like that could allow bugs, dust, hot or cold air, and other unwanted pest or rodents to get into the facility from the outside.

Based on observation, interview, record review and facility policy review, the facility failed to provide nail care for one (1) of sixteen sampled residents reviewed. Resident #22. Findings Include: Record review of the facility policy, ADL (Activities of Daily Living) Care Policy revealed It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis . On 4/14/25 at 2:43 PM an observation revealed Resident #22 sitting up in his wheelchair in the room and his fingernails on both hands were long and approximately one-half to three-fourths inch past his fingertips. There was a brown substance underneath each of them. An observation and interview on 4/15/25 at 9:14 AM with Certified Nursing Assistant (CNA) #1, revealed that Resident #22 had long fingernails with brown substance underneath. She confirmed that Resident #22 had long, dirty fingernails and revealed that this could cause a lot of health problems, the spread of germs, and could cause infections. She revealed that they were supposed to clean fingernails every day as needed. An interview on 4/15/25 at 9:20 AM with Licensed Practical Nurse (LPN) #1, revealed that Resident #22 was prone to have dirty fingernails, and they were supposed to check his fingernails and clean them every day if needed. She revealed that the aides were to check fingernails during resident bath/shower times, and they trimmed and cleaned them as needed. LPN #1 confirmed that Resident #22 had long, dirty fingernails and she revealed that they should have been taken care of. Record review of Resident #22's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Unspecified Dementia, Age-Related Physical Debility, and Unspecified Depression. Record review of Resident #22's Minimum Data Set (MDS) with Assessment Reference Date of 1/08/25 under Section C revealed, a Brief Interview for Mental Status (BIMS) Score of 99 which indicated that he had severe cognitive deficits.

Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possibility of the spread of infection as evidence by not removing a mask after exiting a COVID-19 isolation room (Resident #2) and failed to clean a wound during wound care (Resident # 28) for two (2) of seven (7) resident care observations. Resident #2 and Resident #28 Findings Include Review of the facility policy titled Standard Precautions Infection Control with no revision date revealed under, Policy Explanation and Compliance Guidelines: #2. Using Personal Protective Equipment (PPE) .c. Before leaving the patient's room or cubicle, remove and discard PPE into the appropriate receptable. Review of the facility policy titled, Infection Prevention and Control Program with no revision date revealed under Policy .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. This review was revealed under, Policy Explanation and Compliance Guidelines: #2 All staff are responsible for following all policies and procedures related to the program. Review of the facility policy titled, Hand Sanitizing Procedure with a revision date of 4/2015 revealed under the Procedure for Handwashing .#2 Apply one squirt of soap. Using friction, rub hands together, cleaning under nails and between fingers thoroughly. Wash up to your wrist as well. Do this for at least 10 seconds. Resident #2 An interview on 9/12/23 at 9:18AM, with the Administrator confirmed the facility was in a COVID19 outbreak that began on 9/11/23 and that they currently have two nurses and two resident's that are positive. An observation on 09/12/23 at 9:32 AM, of the hall outside Resident #2's room revealed a red barrel and a yellow barrel sitting outside the resident's room door. An observation on 9/12/23 at 10:00 AM, revealed Certified Nurse Assistant (CNA) #1 exit Resident #2's room with her PPE on which included gown, hair net, shoe covers and N95 mask. This observation revealed that CNA #1 removed all her PPE except her N95 mask, she put the removed PPE in the red barrel in the hallway outside the resident's room door, walked to the nurse's station with the N95 mask on and began a conversation with other staff members. An interview on 9/12/23 at 10:15AM, with CNA #1 revealed that she must put a gown, shoe covers, hair net and mask on when she goes into the COVID-19 positive resident rooms, remove it when she leaves the resident's room and put it in the red barrel outside the resident's room door. She stated that the PPE goes into the red barrel and the dirty linen goes into the yellow barrel. She confirmed that she did not remove her mask when she left Resident #2's room but should have. She stated that she knows better than that. An interview on 9/12/23 at 10:55AM, with the Administrator and the Director of Nurses (DON) confirmed that the staff caring for the positive COVID-19 residents should remove all PPE when they leave the residents room, hand sanitize and put on a new mask. The DON confirmed that the barrels for PPE and dirty linen should be inside the resident's room so that the PPE can be removed and disposed of before leaving the resident's room and this should be done to prevent the possible spread of infection. An observation and interview on 9/12/23 at 1:35 PM with Resident #2 confirmed there were no barrels inside the resident's room for disposal of PPE or dirty linens. An interview on 9/13/23 at 3:40 PM with CNA #1 confirmed that she should have removed the mask when she left Resident #2's room, performed hand hygiene, and put on a clean mask to prevent the spread of infection. An interview on 9/13/23 at 3:50 PM with Licensed Practical Nurse (LPN) confirmed that when a resident is in isolation for COVID-19 then you have to put your gown, N95 mask, shoe covers, hair cover and gloves on before entering the resident's room, remove it all before you leave their room, hand sanitize and put on a clean mask after leaving their room. Record review of the facilities in-services revealed the following: In-service training 10/31/22 with PPE handout attended by nursing staff that included CNA #1. In-service training 2/6/23 regarding donning and doffing of PPE was attended by nursing staff that included CNA #1. In-service training 6/26/23 regarding don/doff PPE attended by nursing staff. Record review of testing for the facilities current COVID-19 outbreak revealed the following: Resident #2-tested positive 9/11/23. Record review of Resident #2's Physician's Orders revealed the following: Order dated 9/11/23; Airborne isolation for COVID-19 x 5 days. Record review of Resident #2's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that include Unspecified Hypothyroidism. Record review of Resident #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 08, which indicated the resident was moderately cognitively impaired. Resident #28 Record review of the Order Listing Report revealed an order dated 8/10/23, Clean stage 2 sacral pressure ulcer with normal saline, pat dry, apply resinol to entire wound bed & (and) cover with foam dressing. Change daily and PRN (as needed) for soiled or dislodged dressing. An observation and interview during wound care for Resident #28 on 9/13/23 at 11:00 AM, with the Wound Care Nurse, observed the resident did not have a wound dressing intact at the beginning of wound care. The Wound Nurse stated, I'm not going to clean the wound because she just had a bath. Observed that the Wound Nurse did not clean the wound before she applied the resinol to the wound. In an interview with the Wound Nurse on 9/13/23 at 11:10 AM, confirmed that she did not clean the wound for Resident # 28. She stated, No, I didn't because she had just got a bath and the area was clean. She acknowledged that she should have but was nervous and messed up. During an interview with the Director of Nursing (DON) on 9/13/23 at 2:20 PM, confirmed that the Wound Nurse should have cleaned the wound for Resident # 28 according to the physician's order regardless that the resident had just received a bath to prevent the spread of infection. An interview with the Administrator on 9/14/23 at 10:15 AM, revealed that Resident # 28's wound should have been cleaned according to the physician's order because anything could have happened between getting a bath and the provided wound care. Record review of the Admission Record revealed Resident # 28 was admitted to the facility on [DATE] with diagnoses that include Diffuse Traumatic Brain Injury, Paraplegia, Type 2 Diabetes Mellitus and Pressure Ulcer of Sacral Region, Stage 2. Record review of the MDS with an ARD of 8/08/23 revealed under Section C a BIMS score of 08, which indicated Resident #28 is moderately cognitively impaired. Also revealed under Section M, the resident has one (1) stage 2 pressure ulcer that was present upon admission/entry or reentry to the facility. 47874

Based on observation, resident and staff interview, record review and facility policy review, the facility failed to provide nail care to a resident for 1 (one) of 48 residents reviewed for activities of daily living (ADL) care. Resident #8 Findings include: Review of the facility policy titled, Fingernails/Toenails, Care of, undated, revealed, Policy The purposes of this policy is to clean the nail bed, to keep nails trimmed, and to prevent infections. Procedure .4. Nails can be partially cleaned during the bath .6. Nail care includes daily cleaning and regular trimming. 7. Proper nail care can aid in the prevention of skin problems around the nail bed. 8. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . On 09/12/23 at 10:07 AM, an observation and interview revealed Resident #8's fingernails were long and dirty and the nails on both hands had brownish material under them. Resident #8 confirmed that he had already had his bath this morning and he would have liked his nails cut. On 09/13/23 at 8:37 AM and 3:40 PM, an observation and interview revealed the resident stated his fingernails have not been cut and are still dirty. He stated his nails had not been cut in about a month. On 09/13/23 at 3:45 PM, during an observation and interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the resident's fingernails were long and dirty. The ADON stated that she cut the residents fingernails on Saturday week before last. He was in the hospital last Saturday so they would be due for a cut this Saturday. The ADON stated that dirty nails could cause possible infection issues. The DON confirmed the resident's fingernails were dirty and review of the bath schedule confirmed he got bath on Tuesday. She stated that she would think the resident's nails should not be dirty if he got a bath on Tuesday. An interview on 09/14/23 at 10:10 AM, with the lead Certified Nursing Assistant (CNA) #2 revealed that personal care for diabetic residents concerning nail care is that the nurse cuts the nails, but the CNAs should wash the residents hands with a bath cloth or soak them during bathing and get dirt out from under the nails. Review of the Admission Record resident information sheet revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominate hand, Acquired Absence of right and left leg above knee, Type 2 Diabetes Mellitus, Heart Failure. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #8 was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASARR) for a resident with a new mental health diagnosis for one (1) of four (4) PASARRs reviewed. Resident #23. Findings Include: A review of the facility policy title, PASARR (Pre-admission Screening and Resident Review) dated 6/27/2023 revealed, .Procedure (2) The nursing facility must submit a Change in Status Request whenever a Significant Change in Condition occurs for an individual with a PASARR identified condition (i.e. Serious Mental Illness (SMI), Intellectual and/or Developmental Disability (ID/DD) and/or Related Condition (RC) This includes residents previously identified by PASARR to have a mental illness, intellectual disability or a condition related to an intellectual disability who: *Demonstrate increased behavioral, psychiatric, or mood-related symptoms . Record review of Resident #23's Admission Record revealed that she was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, Major Depressive Disorder, and Insomnia. Record review of Resident #23's Medical Diagnosis revealed diagnoses of Auditory Hallucinations/other Hallucinations dated 3/12/2023 and Schizophrenia dated 4/17/2023 were added to the list of diagnoses. An interview on 09/13/23 at 8:45 AM, the Social Services Director revealed she was responsible for submitting the PASARR and was aware that with any new mental illness diagnoses she was required to submit a new change of status form for a Level 2 PASSR. She confirmed that she did not do that because she wasn't aware of the new diagnoses for Resident #23. An interview on 09/13/23 at 8:55 AM, with the Director of Nurses (DON) revealed Resident #23 started having some issues and received a new diagnosis for hallucinations and schizophrenia. She revealed we usually discuss changes during our weekly Utilization Review meeting and morning meetings, but I'm not sure if we didn't meet that week or what, but it obviously got missed. The DON confirmed the resident should have had a change in status done for her Level 2 evaluation. An interview on 09/13/23 at 2:23 PM, with the Administrator (ADM) revealed the purpose of the Level 2 evaluation is to make sure the resident gets the proper psychiatric care that they may need. She revealed she was unaware of a new mental health diagnosis for Resident #23 and that a Level II change in status had not been completed. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 08/02/2023 revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact.

Based on observations, resident and staff interviews, record review and facility policy review the facility failed to implement a comprehensive care plan related to nail care (Resident 8) and wound care (Resident 28) for 2 (two) of 13 care plans reviewed. Findings include: Review of the facility care plan policy titled, Care Plans - Comprehensive, dated 10/2016, revealed, Policy Statement An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. Policy interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or resident representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; .f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and /or functional level . Resident #8 Review of the care plan for Resident #8 revealed, Focus: Resident requires assistance with his ADLs (Activity of Daily Living) related to bilateral above the knee amputations, hemiplegia, and bilateral upper extremity contractures .Revision on: 10/05/2022 Goal: Resident's needs will be met every shift with assistance from staff through the next review date . Interventions: .Nail care as needed or scheduled by registered nurse only. Assist with . personal hygiene .daily & as needed or requested . An observation on 09/12/23 at 10:07 AM, revealed that Resident 8's fingernails were long and dirty and the nails on both hands had brownish material under them. He stated that his nails need to be cut and cleaned. Resident #8 confirmed that he had already had his bath this morning. An observation on 09/13/23 at 8:37 AM and 3:40 PM, revealed the resident stated his fingernails have not been cut and were still dirty. He stated his nails had not been cut in about a month. An observation and interview on 09/13/23 at 3:45 PM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the resident's fingernails were long and dirty. An interview, on 09/14/23 at 11:00 AM with the DON confirmed Resident #8's care plan was not followed for cleaning his nails. Review of the Admission Record resident information sheet revealed Resident #8 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting left dominate hand, Acquired Absence of right and left leg above knee, Type 2 Diabetes Mellitus, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #8 was cognitively intact. 47874 Resident #28 Record review of Resident # 28's care plan revealed, Clean Stage 2 pressure injury to sacrum with normal saline, apply resinol to the entire area, and cover with foam border dressing; change daily and PRN (as needed). An observation of sacral wound care for Resident # 28 and interview with the Wound Care Nurse on 9/13/23 at 11:00 AM, revealed the resident did not have a wound dressing intact at the beginning of wound care. The Wound Nurse stated, I'm not going to clean the wound because she just had a bath. The Wound Nurse did not clean the wound before applying resinol to the wound and covering it with a foam dressing. On 9/13/23 at 11:10 AM, during an interview with the Wound Nurse confirmed that she did not clean the wound for Resident # 28. She stated, No, I didn't because she had just gotten a bath and the area was clean. She acknowledged that she did not follow the physician's order for treatment or the care plan for treatment of the wound and acknowledged that she should have. An interview on 9/14/23 at 8:35 AM, with Registered Nurse (RN) #2 revealed the purpose of the care plan was to identify the problems with the resident and to give the staff a guideline to provide the needed care. She confirmed that Resident #28's care plan was not followed related to wound care. An interview with the Director of Nursing (DON) on 9/14/23 at 9:55 AM, revealed the purpose of the care plan was to try to provide a guideline to provide individualized care for the resident. She confirmed that Resident #28's care plan was not followed for wound care. Record review of the Admission Record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses that include Diffuse Traumatic Brain Injury, Paraplegia, Type 2 Diabetes Mellitus and Pressure Ulcer of Sacral Region, Stage 2. Record review of the MDS with an ARD of 8/08/23 revealed under Section C a BIMS score of 08, which indicated Resident # 28 is moderately cognitively impaired. Also revealed under Section M, the resident has one (1) stage 2 pressure ulcer that was present upon admission/entry or reentry to the facility.

Based on observations, staff interviews, record review and facility policy review, the facility failed to clean a residents wound as prescribed by the physician for one (1) of four (4) residents observed for wound care. Resident # 28 Findings include: Review of the facility policy titled Wound Care updated 1/2015 revealed under, Policy: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Also revealed under, Procedure: . After cleaning wound as ordered, clean the tissue around the wound that is usually covered by the dressing, tape or gauze with normal saline and pat dry. Record review of the Order Listing Report revealed an order dated 8/10/23, Clean stage 2 sacral pressure ulcer with normal saline, pat dry, apply resinol to entire wound bed & (and) cover with foam dressing. Change daily and PRN (as needed) for soiled or dislodged dressing. An observation and interview with the Wound Care Nurse of sacral wound care for Resident # 28 on 9/13/23 at 11:00 AM, revealed the resident did not have a wound dressing intact at the beginning of wound care. The Wound Nurse stated, I'm not going to clean the wound because she just had a bath. Observed that the Wound Nurse did not clean the wound before she applied the resinol to the wound and covered it with a foam dressing. An interview with the Wound Nurse on 9/13/23 at 11:10 AM, confirmed that she did not clean the wound for Resident # 28 as ordered by the physician. She stated, No, I didn't because she had just got a bath and the area was clean. She acknowledged that she did not follow the physician's order for treatment of the wound and acknowledged that she should have but was nervous and messed up. She confirmed that failure to clean the wound as ordered by the physician could affect the healing status of the wound. An interview with the Director of Nursing (DON) on 9/13/23 at 2:20 PM, confirmed that the Wound Nurse should have cleaned the wound for Resident # 28 per the physician's order. She acknowledged that failure to clean the wound according to the physician's order could influence wound healing. An interview with the Administrator (ADM) on 9/14/23 at 10:15 AM, revealed the Wound Nurse should have cleaned Resident # 28's wound according to the physician's order. She stated, Anything could come in contact with the wound between the time of bathing and the wound care. Record review of the Admission Record revealed Resident # 28 was admitted to the facility on [DATE] with diagnoses that included Diffuse Traumatic Brain Injury, Paraplegia, Type 2 Diabetes Mellitus and Pressure Ulcer of Sacral Region, Stage 2. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/08/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 08, which indicated Resident # 28 is moderately cognitively impaired. Also revealed under Section M, the resident has one (1) stage 2 pressure ulcer that was present upon admission/entry or reentry to the facility.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possible spread of infection as evidenced by staff not performing hand hygiene in between residents when passing meal trays and when assisting residents with a meal for two (2) of three (3) halls observed. Findings Include: Review of the facility policy titled, Infection Prevention and Control Program with a revision date of 8/2017 revealed Policy: It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Policy Explanation and Compliance Guidelines: .4. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated object, after PPE (Personal Protective Equipment) removal, before/after eating, before/after toileting, and before going off duty. b. Staff shall wash their hands before and after performing resident care procedures. c. Hands shall be washed in accordance with our facility's established hand washing procedure . Review of the facility policy titled, Standard Precautions Infection Control with no revision date revealed .Policy Explanation and Compliance Guidelines:1 . e. Perform hand hygiene: . i. Before having direct contact with patients . v. After contact with inanimate objects in the immediate vicinity of the patient. On 02/22/22 at 11:55 AM, an observation of the noon meal tray pass in the day room of the Memory Care unit by Certified Nurse Assistant (CNA) #3 revealed CNA #3 did not perform proper hand hygiene between resident's tray pass and set up. The CNA removed the plastic covering from the residents cup, opened milk, opened silverware then continued on to the next resident. On 02/23/2022 at 1:30 PM, an interview with CNA #3 confirmed that she did not utilize hand hygiene between the meal tray pass for the residents at the noon meal on 02/22/22. She revealed that sometimes she does use hand gel and that she should have cleaned her hands between delivering and setting up each of the resident's meal trays. CNA #3 voiced that by not using hand hygiene between tray delivery could cause contamination to spread. CNA #3 confirmed that she had been in-serviced on infection control including hand hygiene. An observation on 02/22/22 at 11:48 AM, revealed Certified Nurse Assistant (CNA) #2 took Resident #42's lunch tray, set it on his overbed table and opened his milk and utensils without performing hand hygiene. CNA #2 then retrieved Resident #22 lunch tray, set it on her overbed table without performing hand hygiene. CNA #2 then put on gloves and began feeding Resident #22 without performing hand hygiene between lunch tray set up of the two residents. An interview on 02/22/22 at 1:45 PM, with the Staff Development Nurse revealed that hand hygiene should be performed in between residents when passing meal trays or ice to the residents and that she has had a recent in-service regarding hand hygiene. An interview on 02/23/22 at 8:05 AM, with CNA #2 revealed she did not use hand sanitizer between residents when passing trays to Residents #42 and #22. CNA #2 stated, I just forgot, and confirmed that she needed to use hand sanitizer to prevent contamination between residents and that she had been in serviced on hand hygiene. An interview on 2/24/22 at 9:45 AM with the Director of Nurses (DON) revealed that hand hygiene should be performed between residents when passing meal trays and assisting with feeding the resident. The DON confirmed that hand hygiene should be performed between residents to prevent cross contamination and the spread of germs. Record review of an In-Service Training dated 2/21/22, revealed under Title and Detailed Content of In-service, hand hygiene was included. CNA #2 and CNA #3 signed the attendance record.

Based on staff interview and record review the facility failed to obtain a Level ll Preadmission Screening and Resident Review (PASRR) for a resident with a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33. Findings include: An interview on 02/24/22 at 9:45 AM, with the Social Services Director (SSD) revealed that the facility does not have a policy on PASRR but, they follow the state guidelines. Record review revealed there was not a PASRR Level 2 on the medical record. An interview, on 02/23/22 at 2:20 PM, with the SSD revealed that she was aware that residents should be referred for a Level 2 evaluation if they have a new mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview, on 02/24/22 at 1:20 PM, with the Director of Nursing (DON) revealed that she understands a PASRR is done on admission and that a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that Social Services is responsible for PASRRs. An interview, with the Administrator (ADM) on 2/24/22 at 1:30 PM, revealed that Social Services is responsible for PASRRs. The ADM stated that prior to this survey, they had no specific person to notify Social Services of a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated that new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #33's Admission Record revealed that he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #33 had a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 1/5/22 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 03, indicating the resident has severely impaired cognitive skills.

Based on staff and pharmacy consultant interviews, record review and facility policy review the facility failed to have stop dates on [CONDITION(S)] and anti-psychotic as needed (PRN) medications for two (2) of five (5) residents medications reviewed. Resident #23 and #33. Findings include: Review of the facility policy titled, Monitoring of Antipsychotic Medication Therapy revised 06/2015 revealed, It is the policy of this facility to monitor the effectiveness and side effects for any resident that is taking an antipsychotic medication . Procedure .5. The pharmacy consultant will review these meds monthly and make dose reduction recommendations as indicated per CMS (Centers for Medicare and Medicaid Services) guidelines. These recommendations will be forwarded to the physician for their response within 7 days . Resident #33 Record review of the Order Summary Report revealed Resident #33 had a physician's order dated 12/30/2020 for [MEDICATION(S)] Solution 5 mg/ml (milligrams/milliliter). Inject 5 mg/ml intramuscularly (IM) every 8 hours as needed for generalized anxiety disorder. The physicians order did not have an end date. An interview, on 02/24/22 at 11:45 AM, with the Director of Nursing (DON) confirmed that [MEDICATION(S)] is an antipsychotic medication, and the order does not have an end date. She stated that she is not aware of the regulation concerning it. The DON revealed that Resident #33 has a [CONDITION(S)] and she screams out uncontrollable at times like she is hallucinating. She revealed the new guidelines for antipsychotic medications were discussed with the doctors when the regulations came out in 2019. A phone interview on 2/24/2022 at 12:25 PM, with the Consultant Pharmacist revealed that he does assess orders for stop dates and addresses it on the [CONDITION(S)] dashboard given to the DON after his monthly medication reviews. He confirmed that PRN antipsychotic medications such as [MEDICATION(S)] should have a 14 day stop date and a physician evaluation before it is reordered. He stated that antipsychotic medications should be reordered every 14 days according to the federal regulations. He stated that he sends a dashboard every month with information concerning [CONDITION(S)] medications. An interview with the Administrator (ADM) on 02/24/22 at 1:40 PM, revealed that antipsychotic medications should be evaluated by the doctor and the pharmacist. PRN (as needed) antipsychotic meds should have a 14-day deadline and should be reordered. The ADM stated that for a PRN [MEDICATION(S)] order dated 12/2020, that's a long time, there should be a lot of documentation. An interview with the ADM on 2/24/22 at 3:07 PM, revealed that his review of Resident #33's record confirmed the documentation required for continuing the [MEDICATION(S)] was not present. Review of the Medication Administration History for Resident #33 revealed [MEDICATION(S)] 5 mg/ml had been administered on 9/17/21, 10/19/21, 11/9/21, and 01/12/22. Record review of the February 2022 Interdisciplinary Team [CONDITION(S)] Dashboard for the facility revealed Resident #33's name was listed with the following: [MEDICATION(S)] 5 mg IM Q (every) 8H (hours) PRN was highlighted in blue with a notation that [CONDITION(S)] PRN orders must have a 14 day stop time and patient must be evaluated prior to continuing the order. Review of the Admission Record revealed that Resident #33 was admitted to the facility on [DATE]. Diagnoses included Malignant Neoplasm of the Brain, Generalized Anxiety Disorder, [CONDITION(S)] Disorder, and Major Depressive Disorder. Resident #23 Record review of the electronic medical record revealed the following physician's order dated 02/03/22; [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet by mouth every 4 hours as needed for Anxiety related to Anxiety Disorder, Unspecified, End Date: Indefinite. An interview on 02/24/22 at 12:30 PM, with the Pharmacy Consultant revealed he reviewed the residents PRN (as needed) [MEDICATION(S)] in November 2021 and [MEDICATION(S)] would need to be re-evaluated by the physician every 14 days. The Consultant Pharmacist revealed It should have a stop date. He confirmed that an end date of indefinite is not appropriate for PRN [MEDICATION(S)] and the physician should not write an end date of indefinite. An interview on 02/24/22 at 1:46 PM, with the Director of Nurses (DON) confirmed that there was no stop date on the residents PRN [MEDICATION(S)]. The DON revealed that if there is no stop date on PRN [MEDICATION(S)] then the nurse would not be aware when the 14 days is up and that re-evaluation would be needed per the regulations. An interview on 02/24/22 at 1:52 PM, with the Administrator confirmed that there needs to be a stop date on the antipsychotic medications so that the facility can flag the Medication Administration Record (MAR) for the medication nurse to be aware that it is time for this medication to be reviewed. The Administrator revealed he reviewed the antipsychotic medication policy and confirmed it does not address putting an end date on antipsychotic medications. Review of the February 2022 Interdisciplinary Team [CONDITION(S)] Dashboard for the facility revealed Resident #23's name was listed with the following: [MEDICATION(S)] 1 mg Q4H PRN was notated that [CONDITION(S)] PRN orders must have a 14 day stop time and patient must be evaluated prior to continuing the order. Record review of the Admission Record revealed Resident #23 was admitted to the facility on [DATE]. Record review revealed a diagnosis of Anxiety Disorder, Unspecified with a date of 6/25/21. Record review of the Minimum Data Set, dated dated dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #23 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to ensure medications and supplies were available for administration and resident use in two (2) of two (2) medication rooms. Findings include: Review of the facility policy titled, Checking Stock Medications and Supplies for Manufacturer Expiration Dates dated 4/2017, directed Policy: It is the policy of this facility to check for medications and medical supplies expiration dates monthly. The facility will check the manufacturer's expiration dates once a month and as needed prior to dispensing medications or using supplies for resident care. Procedure: When nursing staff are performing the End of Month Medication Order Review each month, all stock medication will be checked for the manufacturers (sic) expirations dates. These medications include all stock medications that are maintained on any facility med (medication) cart, as well as any stock room medications that have yet to be placed on a cart. During this process, if any medication is found to be expired, it will immediately be removed from the med cart or stock room and given to the Director of Nursing for proper disposal in accordance to the 'Destruction on Non-Controlled Medication' policy. Also, during every medication pass, the nurse dispensing medications will check the bottle for the manufacturers (sic) expiration on all stock medications individually prior to administering to a resident. All medical supplies used for resident care (that have expiration dates) will be checked monthly for the manufacturers (sic) expiration dates immediately following the medication expiration checks. Any supply that has an expired manufacturers (sic) expiration date will be immediately removed from use and give to the Director of Nursing for proper disposal. On 5/14/19 at 4:20 PM, the Main Hall Medication Storage Room was inspected with Registered Nurse (RN) #2. The following expired supplies were found in the cupboard above the sink: One (1) package containing 35 green top vacutainer tubes with an expiration date of 4/4/2019. There were 11 vacutainer tubes missing from the package. An interview with RN #2 during the inspection revealed the facility had just received the package of vacutainer tubes from the hospital last week. RN #2 stated the package of vacutainer tubes was missing several tubes when the package was delivered to the facility. Further observation in the Medication Storage Room revealed the following expired supplies in the blood draw basket: One (1) green top vacutainer tube with an expiration date of 4/4/19, and three (3) blue top vacutainer tubes with an expiration date of 2/28/19. Further observation in the Medication Storage Room revealed the following expired supplies in the drawer: Ten (10) blue top vacutainer tubes with an expiration date of 1/31/19; One (1) Novofine Autocover 0.3 x 8.0 millimeter (mm) needle with an expiration date of 1/2019; one (1) bottle of low control solution yellow top with an expiration date of 10/2017; and one (1) bottle of high control solution red top with an expiration date of 9/2017. Interview on 5/14/19 at 4:36 PM, with RN #2 revealed the nurses goes through the medication room for expired medications and supplies once a week. On 5/14/19 at 4:38 PM, Hall 2 medication room was reviewed with RN #2. The following expired medications were found in the cupboard: Nine (9) packages of Blephadex eye lid wipes (a medication to help relieve the symptoms of inflamed, red, itchy or dandruff-like scales to the eye lids) eyelid wipes with an expiration date of 4/2019 and one (1) bottle of [MEDICATION NAME] powder (for wounds delivers controlled release antimicrobial silver into the wound bed) five (5) grams with an expiration date of 1/2019. In an interview on 5/14/19 at 4:55 PM, the Director of Nursing (DON) stated that the expired control solutions are for a glucometer machine the facility does not use or have. On 5/15/19 9:20 AM, in an interview, the DON stated the medications and supplies come in either Wednesday or Thursday and at this time the nursing staff check for outdates and restock the medications and supplies. The DON stated the package of green top vacutainers tubes had come from the local hospital last week. The package of green top vacutainer tubes arrived from the hospital to the facility with several missing tubes. The DON stated the facility had not drawn any residents blood or used the expired green top vacutainer tubes.

Based on observation, interview, record review, and facility policy review, the facility failed to implement and follow the care plan treatment interventions, including air mattress settings to promote healing and failure to keep wounds covered, to meet the resident's needs for one (1) resident (Resident #29) out of 30 resident care plans reviewed. This deficient practice had the potential to result in wound infection and improper healing of the wound. Findings include: The facility provided the policy titled, Care Plans - Comprehensive dated 10/2016, which directed the care plan should, 3e. Reflect treatment goals, timetables and objectives in measurable outcomes; 3g. Aid in preventing or reducing declines in the resident's functional status and/or function levels; 3i. Reflect currently recognized standards of practice for problem areas and conditions. 5. Care plan interventions are designed after careful consideration of the relationship between he resident's problem areas and their causes . The facility provided the policy titled Following the Care Plan Policy dated 1/2011, which directed, Policy. It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan. Procedure .all employees will follow the written care plan that is developed in order to assure the residents needs are met. Resident #29's care plans included the following directions to staff: - Resident has surgical wound to left ischium, dated 5/1/19. The interventions included the following directions to staff: Cleanse surgical wound to left ischium with wound cleanser - pat dry - apply Solosite gel to wound bed - apply Resinol to wound borders - pack with saline moistened gauze - cover with proximal silicone foam dressing daily. Maintain pressure reducing mattress. Practice good infection control. Keep wound clean and dry. -Resident has surgical wound to left lower buttock, dated 4/12/19. The interventions included the following directions to staff: Maintain pressure reducing mattress. Practice good infection control. Keep wound clean and dry. Wound treatment as ordered. Re-evaluate for effectiveness. Notify MD if treatment ineffective. -Alternating pressure mattress to bed for maximum pressure relief due to skin breakdown, dated 4/12/19. The interventions directed staff: Maintain pressure reducing mattress through next review. Air mattress settings checked every shift. Based on resident's weight mattress setting is soft. Settings are based on resident's weight. Nine (9) observations over three (3) days revealed Resident #29's air mattress settings were set at less than 150 pounds, when the resident weighed 169 pounds, and the air mattress was set at static pressure. - 5/14/19 at 10:53 A.M. - 5/14/19 at 2:11 P.M. - 5/14/19 at 4:48 P.M. - 5/15/19 at 9:09 A.M. - 5/15/19 at 9:34 A.M. - 5/15/19 at 11:33 A.M. - 5/15/19 at 2:48 P.M. - 5/16/19 at 9:50 A.M. - 5/16/19 at 11:30 A.M. Wound care observation on 5/14/19 at 2:11 PM, revealed neither of the wounds (left ischium and left buttocks) were covered with a dressing upon removal of the resident's brief. It was determined that the two (2) surgical wounds were not covered for a period of over two (2) hours. Interview at that time with Certified Nursing Assistant (CNA) #1 revealed she was changing the resident's brief and then informed the nurse that the dressings were not on the wounds. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #29's Annual Minimum Data Set ((MDS) dated [DATE] recorded the resident required total assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, personal hygiene, and bathing, did not walk, was always incontinent of bowel and bladder, and did not have pressure ulcers, but did have skin tears. During an interview on 5/16/19 at 11:49 AM, Licensed Practical Nurse (LPN) #2, stated the care plan was not followed because the setting parameters were in the care plan, but not followed. LPN #2 further stated the wounds should never be uncovered, with the possible outcome of infection. LPN #2 stated, The current wounds are moist, if they are not covering them or packing them, it could cause deterioration of the granulation tissue. During an interview on 5/16/19 at 11:58 AM, Registered Nurse (RN) #2 stated the wounds should not ever be uncovered, except when doing the treatment, to keep them from getting infected, and it could prevent healing. RN #2 stated the care plan was not being followed correctly, because the setting parameters were in the care plan, but not followed. During an interview on 5/16/19 at 12:40 PM, the Director of Nursing (DON) stated she expected them (nursing staff) first of all make sure the air mattress is working and functioning. The proper functioning, they should follow the care plan. For all care they should look at the care plans. The DON further stated she expects the CNAs to tell the nurse if a dressing is not in place. The CNA should tell the nurse to remove the dressing if soiled and have the nurse re-dress the wound. The DON stated the possible outcomes of no dressing for over two (2) hours for a bowel incontinent resident, the Possibility of getting infected.

Based on observation, record review, interview, and review of facility policy, the facility failed to implement proper air mattress settings to promote healing of wounds and failed to follow the physician's orders [REDACTED].#29, of four (4) residents sampled for wounds. Findings Included: Review of a facility policy titled Wound Treatment Management, dated (YEAR), which directed, To promote wound healing of various types of wounds it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Review of the manufacturer's User Manual for the Med-Aire Essential 8 Alternating Pressure & Low Air Loss Mattress System, dated 2014, which directed, Intended Use: The Med-Aire Essential pump and mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort. Pressure Adjust knob adjustable by patient's weight: Turn the Pressure Adjust Knob to set a comfortable pressure level by using the weight scale as a guide. (The User Manual included a graphic of the Pressure Adjust Knob indicating the setting at 'Weight of Patient'). Step 9. Turn the Pressure Adjust Knob to set a comfortable pressure level using the weight scale as a guide. 10. Press the static button to set it in static mode, and the Static indicator will come on. The static mode will be started within approximately 6 minutes. Press the Static button again to switch back to alternating mode. Observations of Resident #29 on the following dates and times revealed the resident's air mattress settings were as follows: - 5/14/19 at 10:53 AM revealed the resident in bed, turned to the left. The air mattress setting was less than 150, the other settings were static and normal pressure. - 5/14/19 at 2:11 PM, revealed the resident in bed, turned to the left. The air mattress setting was less than 150, approximately one-third of the way down toward 125, and the other settings were static and normal pressure. - 5/14/19 at 4:48 PM revealed the resident in bed, turned to the left. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/15/19 at 9:09 AM revealed the resident in bed on his right side. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/15/19 at 9:34 AM revealed the resident in bed turned to the right. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/15/19 at 11:33 AM revealed the resident in bed turned to the left. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/15/19 at 2:48 PM revealed the resident in bed turned to the right. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/16/19 at 9:50 AM revealed the resident in bed. The air mattress setting was less than 150, and the other settings were static and normal pressure. - 5/16/19 at 11:30 AM revealed the resident in bed. The air mattress setting was less than 150, and the other settings were static and normal pressure. On 5/14/19 at 2:11 PM, wound care observation revealed Certified Nursing Assistant (CNA) #1 and CNA #2 removed the resident's brief for wound care. Observation of the inside of the brief revealed one (1) balled up gauze (which appeared to be wound packing) and neither of the wounds (left ischium and left buttocks) were covered with a dressing. Both CNAs and Registered Nurse (RN) #1 as well as Licensed Practical Nurse (LPN) #2 verified there were no dressings on the left buttock wound or the left ischium wound, and there were no dressings in the resident's brief. During an interview at that time, CNA #1 stated she changed the resident's brief about 9:00 AM and the two (2) wounds were covered with dressings. CNA #1 stated the Hospice CNA came in about 11:00 AM to give the resident a bed bath. CNA #1 stated she saw the Hospice CNA leave the building about 12:00 noon. CNA #1 further stated the Hospice CNA did not report to her that the resident's wounds were uncovered and had no dressings. Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Weekly Body Audit assessment, dated 3/26/19, recorded two (2) of the findings included a raised area on the left lateral hip (left ischium), and a blister on the left buttock. Record review of the Physician's Notes dated 3/16/19, 4/4/19, and 4/30/19, recorded the left ischium wound and the left buttock wound originated from [DIAGNOSES REDACTED] blisters ([DIAGNOSES REDACTED] disorder) and were not pressure ulcers or pressure injuries. The 4/4/19 physician's note recorded, Keep covered at all times with Duoderm/[MEDICATION NAME]. Review of Resident #29's care plans documented the following: Resident has surgical wound to left ischium dated 5/1/19. The interventions directed staff: - Cleanse surgical wound to left ischium with wound cleanser - pat dry - apply Solosite gel to wound bed - apply Resinol to wound borders - pack with saline moistened gauze - cover with proximal silicone foam dressing daily. - Maintain pressure reducing mattress. - Practice good infection control. Keep wound clean and dry. Resident has surgical wound to left lower buttock dated 4/12/19. The interventions directed staff: -Ensure adequate hydration and nutrition. Dietary to assess for nutritional needs. -Maintain pressure reducing mattress. -Practice good infection control. Keep wound clean and dry. -Wound treatment as ordered. Re-evaluate for effectiveness. Notify MD if treatment ineffective. Alternating pressure mattress to bed for maximum pressure relief due to skin breakdown, dated 4/12/19. The interventions directed staff: - Maintain pressure reducing mattress through next review. - Air mattress settings checked every shift. - Based on resident's weight mattress setting is soft. - Settings are based on resident's weight. Review of the Treatment Administration Record (TAR) dated 5/1/19-5/31/19 recorded, Alternating pressure mattress to bed for maximum relief every shift, start date 4/9/19. Review of the hospital records dated 4/15/19 - 4/29/19 recorded the two (2) [DIAGNOSES REDACTED] wounds were debrided surgically before the resident readmitted to the facility. The resident had been admitted to the hospital for an upper respiratory infection. Upon return to the facility, the Weekly Wound Observation Reports dated 5/3/19, documented the left ischium wound measured 3.0 cm (centimeters) long x (by) 3.5 cm wide x 2.0 cm deep. The left buttock wound measured 6.0 cm long x 4.0 cm wide x 3.8 cm deep. Review of the resident's weight record to determine the correct air mattress settings revealed weights were done monthly since (MONTH) 2008 with weights ranging from 159-191 pounds. The most current weight was recorded on 5/9/19 the resident weighed 169 pounds. The order for the air mattress dated 4/9/19, recorded, Alternating pressure mattress to bed for maximum relief. Every shift. During an interview on 5/15/19 at 9:34 AM, the Hospice CNA stated she gave the resident a bed bath yesterday and was there from about 11:00 AM - 12:00 Noon. The CNA further stated she reported to two (2) nurses at the desk that the resident had soiled dressings which she removed during the bath, and the resident currently did not have dressings on the two (2) wounds. During an interview on 5/16/19 at 11:35 AM, CNA #3 stated CNAs were supposed to look at the air mattress setting and report to the nurse if it isn't right. CNA #3 stated that for Resident #29, He has wounds, so if the air mattress isn't set right for his weight it could affect his wounds, like not let them heal right, or he might get new ones. During an interview on 5/16/19 at 11:38 AM, LPN #1 stated air mattress settings are set by the resident's weight. I look at it to make sure it's working and turned on, and functioning. LPN #1 further stated the treatment nurse was the one responsible for the setting, and LPN #1 only checks to see if the air mattress is functioning every shift. At 11:42 A.M., observation of Resident #29's air mattress setting with LPN #1 revealed the setting less than 150. LPN #1 stated, It's under 150. It should be at 169 which is his weight. LPN #1 verified there were no weights under 150 pounds recorded in the medical record. LPN #1 stated, The air mattress is supposed to relieve pressure from current wounds. It's a prevention help to keep him from getting wounds. During interview on 5/16/19 at 11:49 AM, LPN #2 stated the air mattress setting was based on weight and was a [MEDICATION NAME] intervention to prevent pressure areas and deep tissue injuries. LPN #2 stated for the resident's current wounds, it helps alleviate some of the pressure that he might have, and everyone is responsible to check the settings, including the CNAs and the charge nurse should check it whenever she goes in the room. LPN #2 stated the care plan was not followed because the setting parameters are in the care plan. LPN #2 further stated the wounds should never be uncovered, with the possible outcome of infection. LPN #2 stated, The current wounds are moist, if they are not covering them or packing them, it could cause deterioration of the granulation tissue. During an interview on 5/16/19 at 11:58 AM, RN #2 stated the air mattress was to keep pressure off the resident's bony prominences to prevent more wounds. For current wounds it keeps them from getting worse. Air mattress settings, we were taught to go by the resident's weight. Any nurse going in should check it during the day. If the air mattress is too soft, I would think it would defeat the purpose of support. The wounds should not ever be uncovered, except when doing the treatment, to keep them from getting infected, and it could prevent healing. RN #2 stated the care plan was not being followed correctly, because the setting parameters are in the care plan. During interview on 5/16/19 at 12:40 PM, the Director of Nursing (DON) stated the air mattress should relieve pressure to prevent increased further issues or more wounds from forming and should be set by weight. All nursing staff was responsible to monitor the settings every shift according to the TAR, and there was no setting in the TAR. The orders say alternating air mattress, no settings described. The DON stated she expects them (nursing staff) first of all make sure it's on, working and functioning. The proper functioning, they should follow the care plan. For all care they should look at the care plans. The DON further stated she expects the CNAs to tell the nurse if a dressing was not in place, and the hospice CNA should do the same. The DON stated that the CNA should tell the nurse to remove the dressing if soiled and have the nurse re-dress the wound, also the hospice CNA should do the same. The DON stated the possible outcomes of no dressing for two (2) or more hours for a bowel incontinent resident, the Possibility of getting infected. During interview on 5/16/19 at 2:27 PM, Resident #29's physician (MD) stated the air mattress should off load some parts of the body and alternating that. The MD further stated the resident's setting needs to be corrected, and stated, I think it should be done right. If unchecked longer than four (4) days, (the resident) could have worsened wounds, poor wound healing, and progressing wounds. I think they'll get septic eventually and die from that. When asked about the uncovered wounds, the MD stated, They should never be opened, always covered. They shouldn't be open, only during wound care twice a day and any time they are (incontinent). (Resident #29's) wounds should be packed and covered at all times. I'm not speculating on the outcomes. The CNA should have reported it right away. The facility failed to properly set the air mattress according to the resident's weight and on an alternating status and failed to keep the wounds covered with a dressing for more than two (2) hours.

Based on observation, interview, and review of facility emergency menus, it was determined the facility failed to follow the approved menu for 50 of 55 residents in the facility. Findings include: A review of the facility's emergency food supply policy revised on 10/17, and titled Emergency and Disaster Planning documented the intent of the policy as Emergency and disaster plans for interruption of service that are available and are followed to ensure that adequate nourishment will be provided to residents and staff. Basic safety and sanitation principles for storage, preparation and service of food and securing food and supplies from appropriate sources are followed. Procedures: Section 3 Planning for an emergency: a. The DM shall keep on hand at all times: A minimum of three (3) day's supply of non-perishable food. Stock is rotated as necessary; A minimum of three (3) day's supply of disposable meal service items; and Disaster supplies (see suggestions for foods to keep on hand for an emergency in Appendix). b. The DM shall keep on hand during hurricane and winter storm seasons a minimum of five (5) day's supply of non-perishable food. Section 7: Menu Planning for an emergency a. Plan menus in advance to use foods that are perishable, other potentially hazardous foods, and foods on hand that are designated as disaster food supply. b. Menus should include familiar and acceptable items, especially comfort foods. An adequate amount of coffee for residents, staff, family members and volunteers especially important. c. Menus should include modifications for special needs, diabetes mellitus, [MEDICAL TREATMENT], those who need a sodium restriction. Liberalize diets as much as possible during an emergency period. The following list of foods was included in the policy to meet the minimum requirements of the three (3)-day menu for 100 people: Fruit juice 13, 48oz. (ounce) box Dry cereal 18 ¾ quarts Instant grits (two) 2 bulk packages Vegetable Beef Soup 20, #50 cans Chicken Noodle Soup 12, #50 cans Tomato Soup 12, #50 cans Tuna (four) 4, #10 cans Cheese 6 ½ pounds Ravioli (four) 4, #10 cans Green Beans (four) 4, #10 cans Green Peas (four) 4, #10 cans Beets (four) 4, #10 cans Peach Slices (four) 4, #10 cans Pear Halves (four) 4, #10 cans Pineapple Slices (four) 4, #10 cans Fruit Cocktail (four) 4, #10 cans Peanut Butter 18 ¾ pounds Jelly (nine) 9 cups Rice (six) 6 pounds Crackers 600 (two) 2-pack Bread 30 loaves (32 oz) Dry Milk 10 gallons On 5/13/19 at 3:10 PM, an inspection of the facility's emergency food supply revealed the following: no designated area for storage of the emergency food supply. In an interview with the Dietary Manager (DM) during this inspection she stated that she had just started to gather some food for the facility's emergency supply. She stated they had to use some of the ravioli and had not yet replaced it. The menu for the emergency supply was requested with the policy/protocol for the facility's emergency supply requirements. During an inspection of the emergency food supply on 5/14/19 at 10:35 AM, the following items were observed in the food storage: Eight (8) - #50 cans of Tomato soup with a serving size of 12 (1/2 cup) Seven (7) - #50 cans of Cream of Chicken soup with a serving size of 12 (1/2 cup) Twelve (12) - #50 cans of Cream of Mushroom soup with a serving size of 12 (1/2 cup) One (1) - #50 can of Cream of Celery soup with a serving size of 12 (1/2cup) Three (3) - #10 cans of Ravioli with a serving size of 12 (1cup) Two (2) - five (5) pound (lb.) tubs of Peanut Butter In an interview on 5/15/19 at 10:35 AM, with the DM, she revealed that she could not locate or was not sure where to find the emergency supply policy. She stated that she was sure they had one provided by the consulting company that provided their menus. The DM also stated that would be the policy they would be using to implement their emergency menus. An interview with the Registered Dietitian (RD) on 5/15/19 at 11:45 AM, revealed that she was not aware that there was not a designated emergency food supply. She stated that the policy for the emergency food supply was in the dietary office and she would make sure the DM knew where to locate it. The facility failed to meet the requirements of the emergency menu that would provide adequate nourishment as required by their policy.

Based on interview and record review the facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed. This deficient practice had the potential to effect 50 of 55 residents who received meals in the facility. Findings include: During the initial tour of the kitchen on 5/13/19 at 8:50 AM, the Dietary Manager (DM) was asked if she was certified as a Dietary Manager. She stated that she did not have the credentials yet and had just recently signed up for the classes to get her credentials because she thought she had five (5) years to obtain it. The DM also stated she had been employed at the facility for [AGE] years as the cook and had been designated as the Dietary Manager in (MONTH) of (YEAR). She stated that the Registered Dietitian was not full-time and came to the facility on ce a month but will come twice a month to help her with her classes she had signed up for. She was asked to provide verification of registration for the courses. A review of the registration provided by the DM revealed confirmation dated 4/25/19, for her courses at Auburn University offices of continuing education for the Dietary Manager Independent Study Program. The confirmation contained information about accessing module 1-24 and her student ID number. In an interview conducted with the Registered Dietitian (RD) on 5/15/19 at 11:45 AM, she stated she was employed as a contractor by an outside company and was scheduled for one (1) day a month at the facility. The RD stated she had been consulting at this facility since (MONTH) (YEAR). She also stated she was aware that the DM was not currently credentialed and was past the deadline. She further stated she had been encouraging enrollment in the courses and confirmed she will be increasing time at the facility to preceptor the DM in her courses. She also stated that the program was typically a two (2)-year program. On 5/16/19 at 10:00 AM, in an interview with the Administrator, he stated that he was aware the DM was not certified and was enrolled in the courses. He also stated he was told by the consulting company that she would have five (5) years to obtain her certification because she had been employed by the facility for [AGE] years. He did confirm that she had been designated as the DM in (MONTH) of (YEAR), which would put her in a 1-year window of completion to be completed by (MONTH) of (YEAR). During this interview the Administrator and surveyor checked the Association of Nutrition and Foodservice Professionals (ANFP) website. The following information was confirmed; As of (MONTH) 28, (YEAR), newly-hired Food Service Directors must meet the qualifications specified in the regulations and are no longer within the one-year window for obtaining certification. The Certified Dietary Manager, Certified Food Protection Professional (CDM, CFPP) credential is now listed as the primary qualification for the Director of Food and Nutrition Services in the absence of a full-time dietitian. The regulation was also reviewed with the Administrator for clarification of the required deadline which states; (i) For designations prior to (MONTH) 28, (YEAR), meets the following requirements no later than five (5) years after (MONTH) 28, (YEAR), or no later than 1 year after (MONTH) 28, (YEAR), for designations after (MONTH) 28, (YEAR). The Administrator confirmed that the DM had been designated in her current position in (MONTH) of (YEAR).

Based on record review, staff interview and facility policy review, the facility failed to complete a comprehensive assessment for a significant change in status; Resident #7, for one (1) of 15 records reviewed. Findings include: Review of the facility's policy entitled Minimum Data Set (MDS) Assessment dated 05/06, revealed it is the facility's policy to follow the Resident Assessment Instrument (RAI) process as set forth by the Center for Medicare and Medicaid Services (CMS). Review of the Center for Medicare and Medicaid Services (CMS) 3.0 Manual revealed a significant change is a comprehensive assessment for a resident that must be completed when the interdisciplinary team has determined that a resident meets the significant change guidelines for either improvement or decline. A significant change is a decline or improvement in a resident's status that will not normally resolve itself without intervention, impacts more than one area of the resident's health status and requires interdisciplinary review and/or revision of the care plan. Resident #7 A review of Resident #7's admission MDS assessment with an Assessment Reference Date (ARD) of 09/11/16 revealed this resident required extensive assistance with Activities of Daily Living (ADL) and was frequently incontinent of bowel and bladder. A comparison review of the quarterly MDS assessments with an ARD of 12/10/16 and 03/06/17 revealed this resident was coded as being independent with ADL care and continent of bowel and bladder which indicated an improvement. Interview on 03/21/17 at 10:00 AM with Registered Nurse (RN) #1 revealed she was the MDS nurse responsible for completing the assessments for Resident #7. RN #1 revealed Resident #7 was admitted with indicators of Depression and required maximum assistance from staff with ADL care. RN #1 stated the resident had a 360 degree turnaround. RN #1 confirmed that she should have completed a significant change assessment. RN # revealed she calls the corporate MDS consultant for assistance and also uses the MDS 3.0 manual as a reference guide. Review of the Face Sheet revealed the facility initially admitted Resident #7 on 09/07/16 with [DIAGNOSES REDACTED]. A review of the most recent quarterly MDS assessment with an ARD of 003/06/17 revealed Resident #7 scored 14 on the Brief Interview of Mental Status (BIMS) which indicated cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow physician orders [REDACTED].#8 and #10 for two (2) of 13 residents reviewed for physician orders. Findings Include: Review of the facility's policy titled, Transcribing Physician Orders, dated 2/27/12, revealed under Policy: the facility's policy is to transcribe and follow the attending physician's orders [REDACTED]. Under Procedure: Orders will be followed and medications will be administered according to the prescribed physician's instruction and according to state regulation. Observation and interview on 3/22/17 at 10:55 AM revealed Registered Nurse (RN) #1 stated the orders for Resident #10's wound care were to clean the resident's Stage II sacral wound with normal saline (N/S), apply Laniseptic and cover with border gauze. Observation revealed that during preparation of supplies, RN #1 poured Sterile Water into a 30 milliliter (ml) plastic medication cup. RN #1 explained she only had Sterile Water on her cart and used it in place of N/S. RN #1 preformed would care using sterile water instead of N/S for wound cleanser. Record review revealed a handwritten phone physician's orders [REDACTED].#10's pressure ulcer to sacrum with normal saline, pat dry. Apply Laniseptic and cover with bordered gauze daily until healed. An interview with RN #1 on 3/22/17 at 11:00 AM revealed RN #1 stated she knew the difference between sterile water and normal saline. She stated she got nervous and knows not to use sterile water when the order reads normal saline. She said these were her mistakes and she unstood physician orders [REDACTED]. On 3/22/17 at 3:00 PM, an interview with the Director of Nurses (DON) revealed RN #1 had expressed to the DON her errors were from nervousness, and she was unaware the facility had normal saline wipes available. Review of the facility's face sheet revealed, the facility admitted Resident #10 on 12/24/15. Resident #10's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) revealed a Brief Interview of Mental Status (BIMS) score of two (2) indicating Resident #2 was severely cognitively impaired. Resident #8 Observation on 3/22/17 at 8:55 AM revealed during wound care Registered Nurse (RN) #1 cleansed the wound on Resident #8's right heel with sterile water. Record review of the Physician order [REDACTED]. Interview on 3/23/17 at 10:00 AM with RN #1 confirmed she cleaned the wound with sterile water instead of normal saline (NS). RN #1 stated we have both and confirmed she should have looked at the bottle label the same as she would a medication to be sure she had the right thing. Interview on 3/23/17 at 11:55 AM with Director of Nurses (DON) revealed the facility has normal saline wipes and bottled sterile water. The DON confirmed RN #1 should have checked the order and checked the label to ensure she had the proper solution to clean the wound. Review of the facility face sheet revealed the facility admitted Resident #8 on 11/15/16 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/17 revealed a Brief Interview of Mental Status (BIMS) score of 04 that indicated Resident #8 had severely impaired cognition.

Based on policy/procedure review, record review, and staff interview, the facility failed to use the shoulder restraint seatbelt of the facility van during a van transport, which caused an avoidable fracture for one (1) of six (6) residents reviewed. (Resident 1). Resident #1 was a bilateral above the knee amputee (AKA), and was only secured in his wheelchair in the facility van by the lap seatbelt. A majority of Resident #1's weight was in his upper body. The seatbelt system is a two (2) piece system, and the shoulder seatbelt was not used. On 7/14/15, Resident #1 was loaded into the facility van by facility staff while sitting in his wheelchair, and taken to a doctor's visit. On the transport back to the facility, the resident was sitting in his wheelchair, and only had the vehicle lap seatbelt restraint in place. Each wheel chair wheel was fastened, and the lap seatbelt was fastened, but the shoulder seatbelt restraint was not used. Resident #1 fell forward during the transport, falling with his upper body going down towards the floor. The lap seatbelt restraint ended up between the resident's upper legs, his arms on the floor, and his head resting on his arms. The facility's failure to follow their policy for identifying risks, and the failure to heed the manufacturer's recommendations for the use of safety restraints caused Resident #1 to suffer a fractured left hip. Findings include: A review of the facility's policy entitled, Fall Risk, revised 5/2005, stated: It is the policy of this facility to evaluate and provide least restrictive intervention when a resident is at risk for falls. A review of the manufacturer's instructions/facility policy entitled, Q Straint Wheelchair Passenger Safety Solutions, revised 10 August, stated: Attach Shoulder Belt-Extend shoulder belt over passenger's shoulder and across upper torso and fasten pin connector onto lap belt. Review of the facility's Reportable Incident Form dated 7/15/15, revealed the date of occurrence was, 7/14/15 at 3:00 PM. Resident #1 was returning from an appointment in the facility van accompanied by two (2) facility Certified Nursing Assistants (CNAs). Resident #1 was secured in his wheelchair in the van. The CNAs reported the resident was demanding to get out of the van, threatened to throw himself out of the wheelchair, and propelled himself onto the van floor. His upper body hung onto the floor, and his lower body was secured by the seatbelt. The CNAs assisted the resident back up into the wheelchair, he denied pain/discomfort, said he was alright. Hours later, the resident began to complain of pain in his left leg, and was transported to the local emergency room where it was discovered he had a left hip fracture. Review of the witness statement, written by Certified Nurses Aide #1 (CNA), revealed, We heard a noise and (Resident #1) said, 'help me'. He wasn't fully on the floor. I saw that the seatbelt was between his legs. I took off the seatbelt, put it back around him and tightened it back. We asked him was he ok, and he said yes. Review of the witness statement, written by CNA #2, revealed, We were less than a mile away from the facility as (Resident #1) complained of wanting to get out of the van. He was secured in his wheelchair in the back of the van. He then propelled himself forward out of the wheelchair. He was hanging forward in the wheelchair with his arms and head on the floor of the van. His lower body was still in the wheelchair held up by the seatbelt. We assisted Resident #1 back into an upright position. We asked if he was ok and he said yes. Review of the Xray report for Resident #1 dated, 7/14/15 revealed, The bones are diffusely demineralized. There is a left femoral neck fracture with slight impaction. Interview with the Director of Nurses (DON) on, 8/4/15 at 9:30 AM, revealed the facility had their own van, and it was used to transport residents, and staff were sent with the residents. Interview with the Staff Development Coordinator nurse on, 8/4/15 at 4:00 PM, revealed the faciity had obtained the van late last year. The Staff Development Coordinator reported an annual training on the van was done early in July; it was not a hands on training, but after the incident the facility included a hands on training for the use of the van. Interview with CNA #2 on, 8/4/15 at 10:45 AM, revealed she did not drive the van, she was the passenger there to assist the resident. CNA #2 reported she went with Resident #1 all the time, and he had threatened before to throw himself out of the wheelchair. He did not like to sit up. CNA #2 stated it was an accident. The vehicle was moving, and he said, I fell . I turned around and he was on the floor. We got him back in the chair, asked him if he was alright, and he said, 'yeah'. There was no injuries that I saw. He didn't hit his head. His head was resting on a blanket. I told the charge nurse (RN #2) immediately when we got back to the facility. I had already put him to bed, he had no complain of pain. Transferred him to bed with the hoyer lift. CNA #1 stated, No, he didn't hit his head. He had a blanket that was under his head, and his arm. He had one leg caught in the seat, that was what was holding him into his chair. He said he didn't hit his head and it was resting on his arm and a blanket. Interview with CNA #1 on, 8/4/15 at 11:15 AM, revealed she drove the facility van, and worked the floor also. CNA #1 stated, I don't know if you could call it a fall, he did not completely hit the floor. The vehicle was in motion when it happened. I heard a little bang sound, and the resident say, help me. The other CNA (#2) said girl, he done fell . I stopped, turned on the emergency lights, and when we made it to him, his hips were still in the chair, his butt was not completely on the seat, it was up a little bit. He still had the waist seat belt on. When we picked him up, it was between his legs. He was half in, and half out of the seat belt. His head and arms were on the floor. His head was laying on his jacket. I did not see any redness, bruising, knots, or anything on him. Because some part of him hit the floor, is why I called it a fall. He had complained of his back and bottom hurting that morning before we left. After we picked him up, we asked him if he was hurting, and he said his back still hurt. The seat belt was on top of his left leg, and under the right leg. It had loosened. He had asked us if we could get him out of the chair, and throw him on the side of the road earlier in the trip. About 30 miles away from the facility, he did say he was going to jump out of the wheelchair. CNA #2 brought him into the building, while I parked the van. CNA #2 and myself reported the incident to the Registered Nurse (RN) #2, how it happened, where it happened, where the seat belt was. I never saw him after CNA #2 got him out of the van. The wheelchair was strapped in, it was stable, it had not moved. He had the waist belt on. There was a shoulder belt to use, I did not know about it at that time. I just started drivng the bus/van about three (3) months ago. CNA #1 reported the Staff Development Coordinator nurse showed her the shoulder belt after this incident. Interview with Registered Nurse (RN) #2 on, 8/4/15 at 11:45 AM, revealed, CNA #2 and CNA #1 stopped me in the front lobby. They both told me he was very upset on the trip home, cussing saying he was going to throw himself out of his wheelchair if they didn't get him out of it. They said he loosened his seatbelt and went forward. I was under the impression he leaned forward, not a fall is how I interpreted it. He was already in his bed. I went and assessed him, asked him if he was in pain, he denied it. I saw no redness, bruising, swelling or tenderness anywhere. A son came to me and said daddy is saying he fell out of his chair. I told him I was under the impression he went forward, but did not come out of the chair. I got CNA #2, she said he was cussing and threatened to throw himself out of the chair, he loosened his seatbelt and the top portion of his body went forward. I asked her if his top portion was on the floor. She said, 'yes, the top portion of his body did'. It was almost 7pm and I went and filled out the incident report. I got a call about 9:00 pm with the Licensed Practical Nurse saying Resident #1 was yelling out in pain and asked me to come back. She also said she noticed a bruise coming up on his stomach. I came back about 9:00 pm, saw him immediately; he said he was hurting on his lower left leg. I started my assessment, and he would yell out anywhere I touched him on his left leg. During my assessment I did see a bruise on the right of his navel and slight redness to the left hip area. I told him we needed to send him out. I don't want to go to the damn hospital. I talked him into it and called the on call dr. I explained what happened and asked, can I send him to the ER for xrays or eval. He said ok. We took him in our van. I followed up on the incident report again and left about 11:30 pm. At 12:45 am, the facility called me saying he had a left hip fracture and was being shipped to Columbus. An interveiw with the DON on, 8/5/15 at 8:55 AM, revealed the seat belt copy she provided for the surveyor is what came with the van, and it is in the van today. The DON, stated she did not know if it was in the van prior to today, she would have to check with the Administrator. The DON reported the Administrtor gave her a copy of it last night so she could start her inservices. An interview on, 8/5/15 at 1:04 PM, with the Administrator reveaeld the plastic QRT Series User Instructions were in his office, and would now plan to place it in the van. The Administrator reported he did not know he had this until he was going through paperwork in his office last PM, and it had been in his desk all that time. The Administrator stated he trained from the Vehicle Anchorage and Accessories for the four (4) point wheelchair securement system. The Administrator stated he read this, and instructed from it for the 2014 inservice. Review of the facility's Admission Record revealed the facility admitted the resident on 7/12/11, with the included [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/6/15, revealed Resident #1's Basic Interview for Mental Status (BIMS) score was nine (9), which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required total, two (2) person assist with transfers, total one (1) person assist with locomotion on and off the unit, extensive to total one (1) person assist with dressing/personal hygiene, and had bilateral limited range of motion (ROM) to the lower extremities.

Based on facility policy review, record review, and staff interview, the facility failed to identify, address or develop a plan of care for the specific requirements for transportation of a resident with special needs, for one (1) of six (6) residents reviewed. (Resident #1). Resident #1 was a bilateral above the knee [MEDICAL CONDITION] (AKA), and sustained a left [MEDICAL CONDITION] while on a transport in the facility van related to the shoulder seat belt restraint was not in use at the time of the transportation. Resident #1 was able to fall forward while sitting in his wheelchair, and sustained a fracture to his left hip. Findings include: Review of the facility's policy entitled, Care Plans-Comprehensive, revised 6/2015, documented, Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Based on thorough assessment incorporate identified problem areas, reflect treatment goals, timetables, and objectives in measurable outcomes. Identify professional services responsible for each element of care. Identify problem areas, and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and complex decision making. A review of Resident #1's fall risk care plan revealed the resident had not been care planned for the important use of the shoulder and lap seat belt restraints to be used during vehicle transport related to the resident being a bilateral above the knee [MEDICAL CONDITION]. A majority Resident #1's weight was in his upper body. An interview with Registered Nurse #1, Director of Nurses (DON), on 8/6/15 at 1:15 PM, revealed, Yes, we care plan each resident individually. She confirmed the care plan for Resident #1, a bilateral above the knee [MEDICAL CONDITION], did not address the requirements for the use of the shoulder, and lap seat belts during transport for Resident #1 . The DON stated the Minimum Data Set (MDS) nurse was not at the facility at this time for an interview. Review of the facility's Admission Record revealed the facility admitted the resident on, 7/12/11, with the included [DIAGNOSES REDACTED]. Review of the Quarterly MDS with an Assessment Reference Date (ARD) of 7/6/15, revealed Resident #1's Basic Interview for Mental Status (BIMS) score was nine (9), which indicated moderate cognitive impairment. Further review of the MDS revealed Resident #1 required total, two (2) person assist with transfers, total one (1) person assist with locomotion on and off the unit, extensive to total one (1) person assist with dressing/personal hygiene, and had bilateral limited range of motion (ROM) to the lower extremities.