Every finding on record at Lynchburg Health & Rehabilitation Center

Based on facility documentation reviews, staff interviews and observations, the facility staff failed to maintain an accurate record of the narcotic count record for on-coming and off-going staff for two out of nine medication carts. The findings included: Facility staff failed to sign the medication cart narcotic count record for on-coming and off-going shifts.On 7/13/26 at 1:56 pm, an observation was conducted with a licensed practical nurse (LPN #3). The narcotic count sheets were observed with LPN #3 which showed multiple areas not signed off on the narcotic count record for on-coming and off-going nurses. LPN#3 also reviewed the narcotic record and stated that she was not sure why the narcotic count sheets were not signed off for on-coming and off-going staff. LPN #3 stated that when giving narcotic medications, she makes sure it is the right dose, right route, right patient, verifies on the computer the medication administration record (MAR), pulls the medication, signs the narcotic book, then gives the medication to the resident. LPN #3 stated that at the end of the shift, narcotics are counted with the on-coming nurse, and both nurses verify. After verifying that the count is correct the on-coming nurse will sign off on the narcotic sheet. LPN #3 stated that the on-coming nurse is going to count and make sure count is correct, then sign. On 7/13/26 at 2:15 pm, an interview was conducted with the assistant director of nursing (ADON). The ADON stated that the nurses are supposed to sign on-coming and off-going narcotic count record verifying the count in the medication cart. ADON stated that she will educate staff. On 7/13/26 at 2:43 pm, an observation with LPN #3 was conducted. LPN #3 did a narcotic count. LPN #3 stated that the narcotic count record was to count the number of narcotic cards on the medication cart and the resident individual count sheet was for counting the resident's pills on the card, making sure the pills on the card for each resident were correct. On 7/14/26 at 8:49 am, an interview was conducted with a licensed practical nurse (LPN #4). LPN #4 stated the purpose of signing the narcotic count record with on-coming and off-going is to make sure the cart is accurate because once you take the cart you are saying the count for the cart and the book are correct.On 7/14/26 at 9:40 am, a facility documentation review was conducted. The facility policy titled, Shift Change Report, read in part, [.] Licensed nurses from the incoming and out-going shift will count and verify all narcotic medications at each shift change.On 7/14/26 at 2:52 pm, a meeting was held with the administrator, regional clinical consultant and interim director of nursing was conducted and made aware of above findings. No additional information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to develop a care plan for one of two residents in a survey sample.The Findings Include: Resident #1 (R1) did not have a care plan for noncompliance to medications, treatments, hygiene, and incontinence care. R1diagnoses include paraplegia, osteomyelitis, urinary tract infection, indwelling catheter, and MRSA (methicillin-resistant-Staphylococcus aureus. The most recent MDS (minimum data set) was a significant change dated 7/24/25 and indicated R1 was cognitively intact. Review of R1's clinical record including medication administration records, treatment administration record, nursing progress notes, physician progress notes, and activity of daily living (ADL) tool indicated R1 was refusing care and treatments, and medications at times. Interviews conducted on 11/12/25 with license practical nurse (LPN #2, unit manager) and certified Nursing assistant (CNA #2) indicated R1 was noncompliant with hygiene, incontinence, and treatments for wound care and catheter care. LPN #2 verbalized R1 would sign out and leave the building for hours at a time and would refuse treatments or medications that were scheduled during the time away from the facility. On 11/13/25 at 10:00 a.m. the facility physician (other staff, OS #3) was interviewed and verbalized R1 would refuse hygiene after being soiled and would refuse wound treatments. On 11/13/25 at 10:50 a.m. the wound care nurse practitioner (OS #2) was interviewed. OS #2 verbalized R1 was noncompliant with dressing changes to the sacrum. Review of R1's care plan indicated R1 had behaviors with rejecting wound treatments and medications, however the care plan did not address interventions for missing treatments or medications and did not address hygiene or incontinence care. On 11/13/25 at 11:45 a.m. the MDS coordinator (RN #2) was interviewed. RN #2 reviewed R1's care plan and agreed that there should have been more specific interventions put in place for refusal of care. On 11/13/25 at 12:15 p.m. the above information was presented to the director of nursing (DON). No other information was provided prior to exit conference on 11/13/25.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of care regarding skin assessments for one of two residents in the survey sample (Resident #2).The findings include:Resident #2 (R2) was admitted to the facility with diagnoses that included traumatic wounds to neck/chest, pneumothorax, paraplegia, vertebra fractures, neurogenic bladder/bowel, spinal stenosis, and emphysema. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact.R2's care plan (revised 11/3/25) documented the resident had traumatic wounds and was at risk of developing additional wounds and skin breakdown due to immobility related to paraplegia. Interventions to prevent further skin breakdown included skin assessments as indicated.R2's clinical record documented weekly skin assessments on 9/17/25, 9/24/25, 9/25/25. There were no documented skin assessments during week ending 10/4/25, 10/11/25 or 10/18/25. Weekly skin assessments resumed on 10/24/25 with the most recent assessment on 11/13/25. The clinical record made no mention of the resident's skin condition during the weeks of 10/4/25, 10/11/25 or 10/18/25 and provided no mention of resident refusal or explanation of why the audits were not performed.On 11/13/25 at 11:05 a.m., the licensed practical nurse unit manager (LPN #1) caring for R2 was interviewed about skin assessments. LPN #1 stated all residents were supposed to have weekly skin audits to identify any new wounds or skin conditions. LPN #1 stated the floor nurses were responsible for weekly skin assessments. LPN #1 stated the skin assessments were triggered in the electronic health record, prompting the nurse when the audits were due. LPN #1 reviewed R2's clinical record and stated she did not find skin assessments for weeks ending 10/4/25, 10/11/25 or 10/18/25. LPN #1 stated if the resident refused, nurses should have documented a note explaining why the audit was not performed. LPN #1 stated she did not know why R2's skin assessments were not completed weekly as required.On 11/13/25 at 11:40 a.m., the director of nursing (DON) was interviewed about R2's missing skin assessments. The DON stated she did not know why R2's skin assessments were not performed. The DON stated facility protocol required weekly skin assessments for all residents and the audits were scheduled in the electronic health record when residents were admitted .The facility's policy titled Skin Assessments (effective 1/29/24) documented, .Skin assessments will be completed for all patients .The Skin Observation Tool will be completed on admission, and at least every 7 days thereafter .This finding was reviewed with the regional nurse consultant and DON on 11/13/25 at 11:50 a.m. with no further information presented regarding R2's missing skin assessments prior to the end of the survey.

Based on resident interview, staff interview and clinical record review, the facility staff failed to administer medication as ordered by the physician for one of two residents in the survey sample (Resident #2)The findings include:Resident #2 (R2) was admitted to the facility with diagnoses that included traumatic wounds to neck/chest, pneumothorax, paraplegia, vertebra fractures, neurogenic bladder/bowel, spinal stenosis, and emphysema. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact.On 11/13/25 at 9:20 a.m., R2 was interviewed about quality of care in the facility. R2 stated that several weeks ago, multiple doses of the medication gabapentin were not administered as ordered. R2 expressed concern that it took several days to get the medication refilled.R2's clinical record documented a physician's order dated 9/16/25 for gabapentin 300 milligrams (mg) with instruction to administer three times per day for pain management. The medication administration record (MAR) documented R2's gabapentin was scheduled each day at 9:00 a.m., 2:00 p.m. and 9:00 p.m.R2's October 2025 MAR documented the resident missed eleven scheduled doses of gabapentin from 10/17/25 through 10/21/25. The MAR documented the gabapentin was not administered on 10/17/25 at 9:00 p.m., 10/18/25 at 2:00 p.m. and 9:00 p.m., 10/19/25 and 10/20/25 at 9:00 a.m., 2:00 p.m. and 9:00 p.m. and on 10/21/25 at 9:00 a.m. and 2:00 p.m. A nurse documented in a note on 10/20/25 that the gabapentin was ordered on hold due to pharmacy delivery. On 11/13/25 at 11:05 a.m., the licensed practical nurse unit manager (LPN #1) caring for R2 was interviewed about the missed doses of gabapentin. LPN #1 stated she thought there had been an issue getting the required script to the pharmacy for prompt delivery of the gabapentin. On 11/13/25 at 11:40 a.m., the director of nursing (DON) was interviewed about R2's missed doses of gabapentin in October 2025. The DON stated there had been a problem with faxes getting to the pharmacy after a new fax/printer installation and that the pharmacy did not get the required script timely. The DON stated gabapentin was kept in the back-up supply (Omnicell) and that nurses should have accessed the back-up supply to prevent missed doses. The facility's protocol titled Omitted Medications (undated) documented, .Medication are to be administered per the provider's order .In the event you do not have a medication you are to do the following .Check Omnicell for medication (check with another nurse or call nurse manager if you cannot access the Omnicell) .If medication is not available in Omnicell, you must contact the provider and ask for an appropriate alternative .Notify the pharmacy of the need for the medication and ask when it should be expected to arrive .This finding was reviewed with the regional nurse consultant and DON on 11/13/25 at 11:50 a.m. with no further information provided prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of two residents in a survey sample. The findings include:The treatment administration record (TAR) was not initialed to indicate treatments was or wasn't performed for Resident #1 (R1). R1 diagnoses include paraplegia, osteomyelitis, urinary tract infection, indwelling catheter, and MRSA (methicillin-resistant-Staphylococcus aureus. The most recent MDS (minimum data set) was a significant change dated 7/24/25 and indicated R1 was cognitively intact. Review of R1's TAR for the month of August 2025 evidenced blank spaces (no staff initials) to indicate if treatments had been performed or refused. The treatments in question were a nightly dressing change to the left heel that was not signed off on 8/2/25, 8/3/25, 8/14/25, and 8/17/25, and a nightly dressing change to a sacral wound on 8/2/25, 8/3/25, 8/7/25 and 8/17/25. On 11/12/25 at 2:30 p.m. the DON (director of nursing) and administrator were informed of the concern and was asked to show evidence of the treatments had or had not been performed. The administrator verbalized awareness regarding staff not signing off on treatments and medications. On 11/13/25 at 10:30 a.m. the DON showed evidence that treatment was not performed on 8/7/25 due to R1 refusing. The DON verbalized that staff are being educated on this concern and documentation should be completed on the TAR indicating if the residents had treatments performed or not. No other information was provided prior to exit on 11/13/25.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices during dressing changes for one of two residents in the survey sample (Resident #2).The findings include:Resident #2 (R2) was admitted to the facility with diagnoses that included traumatic wounds to neck/chest, pneumothorax, paraplegia, vertebra fractures, neurogenic bladder/bowel, spinal stenosis, and emphysema. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact.R2's clinical record documented a physician's order dated 10/23/25 for Enhanced Barrier Precautions due to the resident's wounds and urinary catheter. R2's clinical record documented a physician's order dated 11/5/25 for cleansing the right heel with normal saline, Xeroform dressing with bordered gauze daily. R2's clinical record documented a physician's order dated 11/10/25 to cleanse the upper back wound with normal saline, apply Betadine and a dry dressing each day shift.On 10/13/25 at 10:30 a.m., accompanied by registered nurse (RN #1) and with R2's permission, dressing changes to the resident's upper back wound and right heel were observed. RN #1 and a certified nurse's aide (CNA #1) washed their hands and put on new gloves prior to interacting with R2 for the dressing change with appropriate privacy provided. RN #1 placed the dressing change supplies (cleanser, Betadine, gauze/dressings) on the over-bed table. RN #1 did not clean/sanitize the bed table or provide any type of barrier prior to placing the supplies. RN #1 washed his hands, put on clean gloves and then removed the previous dressing from the resident's upper back wound. RN #1 discarded the dirty dressing, removed gloves and without hand hygiene, put on new gloves. RN #1 then applied Betadine and a clean dressing to the upper back wound. RN #1 removed gloves and returned to the treatment cart for supplies needed for the right heel wound. RN #1 placed the supplies on the resident's bed linens without a barrier underneath. RN #1 then washed hands, put on clean gloves and removed the old dressing from the right heel. RN #1 removed gloves and without hand hygiene, put on clean gloves, cleansed the heel with saline spray, dried the area with gauze, applied Xeroform dressing and covered the heel with bordered gauze. RN #1 discarded used supplies, removed gloves and washed hands. RN #1 and CNA #1 had no gowns in use during repositioning the resident or during either dressing change.On 11/13/25 at 10:50 a.m., RN #1 was interviewed about personal protective equipment required since the resident was on enhanced barrier precautions. RN #1 stated he thought the resident was on enhanced precautions because of the urinary catheter. When asked about the signage that indicated gowns/gloves were required for direct contact and wound care, RN #1 stated he was not sure about that and again stated he thought the precautions were for catheter care. When asked about hand hygiene between glove changes, RN #1 stated he washed his hands twice and that he thought he washed his hands after the glove changes. When asked about a clean barrier for supplies, RN #1 stated he used a washcloth.On 11/13/25 at 11:05 a.m., the licensed practical nurse unit manager (LPN #1) caring for R2 was interviewed about the dressing change observation. LPN #1 stated enhanced barrier precautions were in place for all residents with wounds and invasive devices and that a gown and gloves were required for direct care. LPN #1 stated the nurse should have provided a clean surface for placement of supplies and that hand hygiene should be performed between glove changes.On 11/13/25 at 11:40 a.m., the director of nursing (DON) was interviewed about R2's wound observation. The DON stated gowns and gloves were required for residents on enhanced barrier precautions, a clean field was required for supplies and that hand hygiene was required between glove changes.The facility's policy titled Enhanced Barrier Precautions (effective 3/26/24) documented, Employees providing high-contact patient care activities will follow Enhanced Barrier Precautions (EBPs) for patients who meet criteria .EBPs require the use of gown and gloves by staff during high-contact patient care activities as defined below .Wound care for chronic wounds .The facility's policy titled Handwashing Requirements (effective 2/6/20) documented, .Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections .Hand hygiene can consist of handwashing with soap and water or use of an alcohol based hand rub .The following is a list of some situations that require hand hygiene .Before and after changing a dressing .After any contact with potentially contaminated materials (used wound/treatment dressings) .This finding was reviewed with the regional nurse consultant and DON on 11/13/25 at 11:50 a.m. with no further information provided prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the responsible party of a change in condition for one of four residents in the survey sample (Resident #3). The findings include: The facility provided no notification to Resident #3's responsible party regarding a change in condition and subsequent transfer to the hospital. Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented the resident was transported to the hospital on 2/25/25 due to a change in condition. The clinical record documented no notification to the resident's emergency contact/responsible party regarding the change in condition and transport. On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about notification to R3's responsible party (RP) regarding the resident's change in condition and transfer to the hospital on 2/25/25. The DON stated nursing assessed R3 with low blood pressure and altered mental status around 6:00 a.m. on 2/25/25. The DON stated R3 was sent to the hospital due to change of condition. The DON stated there was no notification to R3's responsible party regarding the resident's change and transfer. The DON stated she talked with the resident's RP later in the day on 2/25/25 and the RP reported that nobody had called informing her of the change/transfer. The DON stated nurses were expected to notify the listed emergency contact regarding changes in condition and the notification should have been documented in the clinical record. On 4/8/25 at 8:30 a.m., the registered nurse (RN #3) who was unit manager during R3's stay was interviewed. RN #3 stated the resident was sent to the hospital around 6:00 a.m. on 2/25/25. RN #3 stated when she arrived at work, she noted that R3 had been sent to the emergency room. RN #3 stated she was not aware notification had not been made to the RP. On 4/9/25 at 11:00 a.m., RN #1 that cared for R3 on 2/25/25 at the time of transfer was interviewed. RN #1 stated around 5:50 a.m., R3 was assessed with a low blood pressure and oxygen saturations varying from 83% to 90%. RN #1 stated he attempted to call the on-call provider with no answer and then called the on-call nurse manager who instructed him to send the resident to the emergency room. RN #1 stated emergency services were called, and the resident was transported to the emergency room prior to 6:30 a.m. RN #3 stated he did not call or notify the resident's listed RP of the change in condition/transfer. RN #3 stated he communicated R3's transfer during shift change and thought the day shift nurses would make notification to the RP. The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Responsible party will be notified of a change in condition . This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility document review, the facility staff failed to ensure a clean, homelike room environment for one of four residents in the survey sample (Resident #3). The findings include: Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about R3's room cleanliness. The DON stated R3's family member reported on 2/13/25 that the bed had not been made, and the room was not clean. The DON stated she went to R3's room and had the bed made/cleaned. On 4/8/25 at 4:15 p.m., the housekeeping supervisor (other staff #4) was interviewed about any issues/concerns with the cleanliness of R3's room during February 2025. The housekeeping supervisor stated on 2/13/25, R3's family member reported the resident's room was not clean with trash in the floor, bed not made and sticky floors. The housekeeping supervisor stated he and two housekeepers went to R3's room. The housekeeping supervisor he observed the bed not made, trash in the floor and the floor was sticky. The housekeeping supervisor stated the housekeeper assigned to this room had reported she cleaned the room but had not. The housekeeping supervisor stated R3's room cleanliness was not up to standards. The housekeeping supervisor stated that nursing aides were responsible for making beds and providing clean linens. The housekeeping supervisor stated all resident rooms were supposed to the cleaned daily and that cleaning including mopping, emptying trash and cleaning the bathroom. The housekeeping supervisor stated rooms were cleaned as needed if there was an incident. The housekeeping supervisor again stated R3's room on 2/13/25 was not up to standards. The facility's policy titled Method of Cleaning (undated) documented, .general cleaning practices, routine, and systems need to be in place and followed .Restrooms - address the same as a room, paying careful attention to the sink and commode .Check privacy curtain, linens and the overall condition of the room . Remove all debris from floors, counters, and edges .Remove all trash and replace liners as needed .mop floors using disinfecting neutral floor cleaner or quaternary disinfectant cleaner . This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of quality for one of four residents in the survey sample (Resident #3). The findings include: Assessments and interventions implemented regarding a change in condition for Resident #3 were not recorded/documented. Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented the resident was transferred to the hospital on 2/25/25 due to a change in condition. R3's clinical record included no documentation regarding the 2/25/25 change in condition or any assessments, interventions, communications leading to the transfer to the emergency department. A nursing note dated 2/25/25 at 8:57 a.m. documented the resident was sent to the emergency department on the prior shift. On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about any documentation of R3's change in condition/transfer that occurred on 2/25/25. The DON stated R3 experienced altered mental status and was transferred to the emergency department on 2/25/25 around 6:00 a.m. The DON stated the nurse caring for R3 at the time of the transfer did not document assessments of the resident, interventions or communications regarding the change in condition and transfer. The DON stated it was an expectation that nurses document in the clinical notes regarding any changes in condition, any assessments conducted and significant events such as hospital transfer. On 4/9/25 at 11:00 a.m., registered nurse (RN) #1 that cared for R3 during the early morning shift on 2/25/25 was interviewed. RN #1 stated he assessed R3 on 2/25/25 around 12:30 a.m. with oxygen saturation at 93% and he applied the resident's oxygen. RN #1 stated he asked R3 about pain and the resident stated he had no pain. RN #1 stated the other vital signs were nothing unusual but he did not remember the vital sign readings other than the oxygen saturation. RN #1 stated he checked on R3 multiple times during the shift. RN #1 stated another set of vitals signs were obtained mid-shift and they were ok with improved oxygen saturation. RN #1 stated he did not remember the vital sign readings and he did not record them in the clinical record. RN #1 stated around 5:50 a.m., R3's blood pressure was assessed as low at 100/50, and oxygen saturations were varying between 83% to 90%. RN #1 stated he attempted to call the nurse practitioner but got no answer so informed the on-call nurse manager. RN #1 stated the nurse manager instructed him to send R3 to the emergency room due to the change in condition. RN #1 stated he did not document the vital signs taken during the shift, did not document the attempted communication to the provider or the call to the nurse manager. RN #1 stated he did not document any nursing notes about R3's change in condition or transfer. RN #1 stated after EMS transferred R3 to the hospital, he administered medications before the end of his shift at 7:00 a.m. RN #1 stated he communicated R3's change/transfer to the day shift at shift change. RN #1 stated he left at the end of his shift and stated, I just didn't document it. When asked if he considered a late entry of the events, RN #1 stated he was an agency nurse and had not worked at the facility since 2/25/25. On 4/9/25 at 1:40 p.m., the regional nurse consultant (administration staff #4) was interviewed about lack of documentation regarding R3's change of condition/transfer. The regional nurse consultant stated nurses were supposed to document any assessments and changes in condition in the clinical record at the time of the events. The regional nurse consultant stated standards of practice included timely documentation of changes and events. The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Notify provider and document in Progress Notes . The Lippincott Manual of Nursing Practice 11th edition on page 15 documents regarding common departures from standards of nursing care, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . (1) This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey. (1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide a complete and accurate clinical record for one of four residents in the survey sample (Resident #3). The findings include: Resident #3's clinical record did not include documentation regarding assessments and interventions implemented related to a change in condition with subsequent transfer to the hospital. Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented the resident was transferred to the hospital on 2/25/25 due to a change in condition. R3's clinical record included no documentation regarding the 2/25/25 change in condition or any assessments, interventions, communications leading to the transfer to the emergency department. A nursing note dated 2/25/25 at 8:57 a.m. documented the resident was sent to the emergency department on the prior shift. On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about any documentation of R3's change in condition/transfer. The DON stated R3 experienced altered mental status and was transferred to the emergency department on 2/25/25 around 6:00 a.m. The DON stated the nurse caring for R3 at the time of the transfer did not document assessments of the resident, interventions and/or communications regarding the change in condition and transfer. The DON stated nurses should document in the clinical notes regarding any changes in condition, any assessments conducted and significant events such as hospital transfer. On 4/9/25 at 11:00 a.m., registered nurse (RN) #1 that cared for R3 during the early morning shift on 2/25/25 was interviewed. RN #1 stated he assessed R3 on 2/25/25 around 12:30 a.m. and his oxygen saturation was at 93% and he reapplied the resident's oxygen. RN #1 stated he asked R3 about pain and the resident stated he had no pain. RN #1 stated the other vital signs were nothing unusual but he did not remember the vital sign readings other than the oxygen saturation. RN #1 stated he checked on R3 multiple times during the shift. RN #1 stated around 5:50 a.m., R3's blood pressure was low at 100/50, and oxygen saturations were varying between 83% to 90%. RN #1 stated he attempted to call the nurse practitioner but got no answer so informed the on-call nurse manager. RN #1 stated the nurse manager instructed him to send R3 to the emergency room due to the change in condition. RN #1 stated he did not document the vital signs taken during the shift, did not document the attempted communication to the provider or the call to the nurse manager. RN #1 stated he did not document any nursing notes about R3's change in condition or transfer. RN #1 stated after EMS transferred R3 to the hospital, he administered medications before the end of his shift at 7:00 a.m. RN #1 stated he communicated R3's change/transfer to the day shift at shift change. RN #1 stated, I just didn't document it. When asked if he considered a late entry of the events, RN #1 stated he was an agency nurse and had not worked at the facility since 2/25/25. On 4/9/25 at 1:40 p.m., the regional nurse consultant (administration staff #4) was interviewed about lack of documentation regarding R3's change of condition/transfer. The regional nurse consultant stated nurses were supposed to document any assessments and changes in condition in the clinical record. The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Notify provider and document in Progress Notes . This finding was reviewed with the administrator, assistant administration and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility documentation review, the facility staff failed to implement a bed safety program for the entire facility affecting all residents residing on 3 of 3 units. The findings included: On 9/11/24, in the afternoon an interview was conducted with the facility's maintenance director. When asked about the bedrails on Resident #49's (R49) bed, the maintenance director stated that he had put the railings on the bed not long after he started working at the facility, approximately two months ago. The maintenance director was asked to provide a copy of the maintenance work order where that was done. On 9/11/24, the facility staff was asked to provide any evidence of an inspection being conducted on R49's bed and bedrails. On 9/12/24, the regional director of clinical services (RDCS) reported to the survey team that they were not able to locate the maintenance work order regarding the application of bedrails for R49. The RDCS also showed the survey team a 3-ring binder that was the bed safety program and said, I'm not going to even open it, indicating it was not complete. On 9/12/24 at approximately 11 a.m., the surveyor reviewed the bed management binder and there was what appeared to be a bed inventory listing dated April 2023, that listed bed frame model numbers. There was no indication of an actual inspection being conducted. When the surveyor asked the corporate team who was in the office, the RDCS confirmed that was accurate, there was no indication of any inspections being performed. Review of the facility policy titled; Bed System Audits was conducted. This policy read in part, 1. Maintenance will identify each center bed by number and will conduct a full bed audit on each bed a minimum of annually. The audit will include the frame, the deck, the headboard, the footboard, the mattress, and any installed bed rails and/or assistive devices . 4. Annual and intermittent bed audits will reference the FDA's Seven Zones of Entrapment, the dimensional criteria as established by the HBSW (Hospital Bed Safety Workgroup) guidelines, and other areas of potential safety risk within the bed system . No additional information was provided.

Based on observation, staff interviews, resident interviews, clinical record reviews, and facility documentations the facility staff failed to provide trauma informed care for six residents, (Resident #30-R30, Resident #39-R39, Resident #105-R105, Resident #134-R134, Resident #149-R149 and Resident #367-R367) out of a survey sample of 33 residents. The findings included: 1. The facility staff failed to identify triggers related to trauma and did not provide interventions to address trauma-informed care on the care plans for R39, R105, R134 and R149. 1a. According to the clinical record R39 had diagnosis of psychotic disturbance, mood disturbance, and anxiety disorder. On 9/11/24 at 8:29 a.m. an interview was conducted with R39. R39 stated that she has increased anxiety with the way some staff speak to her at times. R39 stated, When the staff are rude with me or raise their voice, I become anxious. On 9/11/24, a clinical record review was conducted for R39. R39 had a trauma screen that was completed on 10/27/23, which identified trauma areas of physical abuse, homicide attempt, and domestic violence. The trauma screen documented that R39's ex-boyfriend tried to kill her by smashing her head. The care plan documented that R39 had reported trauma during their trauma screening related to past relationships and abuse. Care plan interventions were listed as referred to psych services as indicated and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma and/or trauma-informed care were noted. 1b. According to R134's clinical record, they had a diagnosis of anxiety disorder, borderline personality disorder, and major depressive disorder. On 9/11/24 at 9:24 a.m., an interview was conducted with R134. R134 stated that their triggers included, mean people and things upset me. On 9/11/24 a clinical record review was conducted for R134. R134 had a trauma screen that was completed on 7/16/24, which identified trauma areas of physical abuse, domestic violence, and a traumatic divorce. The care plan documented that R134 reported trauma during their trauma screening related to having an alcoholic father, a traumatic divorce, and a violent car accident. Care plan interventions were listed as referred to psych services as indicated and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/ to avoid and there were no interventions for staff related to trauma-informed care. 1c. R149's clinical record noted diagnoses of anxiety disorder, borderline personality disorder and psychoactive substance abuse. On 9/11/24 at 10:44 a.m. an interview with R149 was conducted. R149 stated that,Loud noises and violence on television are the things that bother me. On 9/11/24 a clinical record review was conducted for R149. R149 had a trauma screen that was completed on 7/24/24, which identified trauma areas of physical abuse, gun violence, stalking, and abuse of drugs. The trauma screen documented that R149 had been shot with a gun. The care plan documented that R149 reported trauma during their trauma screening related to being physically, sexually, and mentally abused. Care plan interventions were listed as to have familiar staff to take care of R149, to refer to psych services as indicated, and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma trauma-informed care. 1d. According to R367's record, their diagnoses included anxiety disorder and major depressive disorder. On 9/11/24 at 9:08 a.m. an interview was conducted with R367. R367 stated, Medical procedures and being held down is a trigger. On 9/11/24 a clinical record review was conducted for R367. R67 had a trauma screen that was completed on 9/6/24, which identified trauma areas of physical abuse, homicide attempt, suicide attempt, and domestic violence. R367's care plan had no reference to the trauma screening. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma-informed care. On 9/11/24 at 9:34 a.m., an interview was conducted with the regional social work and discharge planning specialist (RSWDCP). The RSWDCP stated, We give [residents] the option to talk about their trauma and we try to be sensitive I agree, it should be more on the trauma screening and more options should be addressed on the care plan. The RSWDCP stated, I was not aware that the diagnosis of post-traumatic stress disorder had to be addressed on the care plan, with goals and triggers, for staff to know what triggers the patient. 2. The facility staff failed to identify triggers related to post traumatic stress disorder and failed to provide trauma-specific interventions on the care plan. According to the clinical record, R105 had diagnosis to include major depressive disorder, bipolar disorder, and post-traumatic stress disorder. On 9/11/24 at 8:33 a.m. an interview was conducted with R105. R105 stated, I have very bad anxiety at times. The way staff speaks and the way they act will make me escalate with my anxiety and I have nightmares at times. Just some things make me more anxious than others. On 9/11/24 at 9:34 a.m., an interview was conducted with the regional social work and discharge planning specialist (RSWDCP). The RSWDCP stated, We give [residents] the option to talk about their trauma and we try to be sensitive I agree, it should be more on the trauma screening and more options should be addressed on the care plan. The RSWDCP stated, I was not aware that the diagnosis of post-traumatic stress disorder had to be addressed on the care plan, with goals and triggers, for staff to know what triggers the patient. On 9/11/24, a clinical record review was conducted for R105. R105 had a trauma screen that was completed on 9/21/23, which identified trauma areas of physical and emotional abuse. Care plan interventions for R105 included psychiatry referral, familiar staff, and trauma screening as indicated. No triggers were identified on the care plan related to her post traumatic stress disorder for staff to be aware of or to avoid and there were no trauma-informed care interventions for staff. On 9/11/24 at 4:35 p.m. an end of day meeting was conducted with the administrator, regional director of clinical services, the director of nursing, and the vice president of operations. The above findings were discussed, and the regional director of clinical services stated that an 100% audit of the trauma screening, post-traumatic stress disorder management, and care plans has been initiated. No new information was provided. 41449 3. For resident #30 (R30) who had a history of trauma, the facility staff failed to provide trauma-informed care. On 9/9/24 and 9/10/24, R30 was visited in their room, but appeared to be asleep and did not actively engage in conversation with the surveyor. On 9/10/24 a clinical record review was conducted. According to hospital records dated 4/10/24, that were under the documents tab of the chart, R30 was hospitalized with suicidal ideation prior to admission to this facility. According to a trauma screen completed 4/22/24, R30 had suffered sexual assault. According to the form it indicated, resident was sexually assaulted by father at a young age. The trauma screen also indicated that R30 .feels fears and anxieties stemming from the sexual abuse committed against her . According to the clinical record, R30 had only been seen by psychiatric services three times since her admission to the facility in April. The visits occurred on 5/21/24, 7/31/24 and 8/14/24. Each of the notes revealed the only mention of the prior suicidal ideation was in the past medical history and read, suicidal behavior onset 1/24/24, with attempted self-injury . The prior sexual assault trauma was not noted. The focus of the visit was to address, .concern of intermittent refusal of care. The note did indicate that R30 denied suicidal and/or homicidal ideations at that time. Diagnosis included bipolar disorder, dementia with behavioral disturbance, major depressive disorder- recurrent- moderate, and insomnia. Recommendations included, but were not limited to: . maintain a quiet stress-free environment, encourage participation in planned activities and social gatherings, gentle redirection and reassurance, identify, address and eliminate underlying causes for distress, and approach the patient in a way that doesn't escalate distress or result in behavioral dysregulation . According to R30's care plan, trauma was addressed with interventions, which read as, refer to psych services as indicated and trauma screen as indicated. There was no indication that the facility staff had talked with the resident to identify triggers that increase the resident's fears or anxiety, nor steps the facility staff were to take to minimize re-traumatization. The care plan did not address the prior suicidal ideation. On 9/11/24 at approximately 3:30 p.m., R30 was interviewed by the surveyor. R30 did acknowledge that she had been sexually abused previously but was not willing to discuss it with the surveyor. R30 only acknowledged the abuse had not occurred in the facility. On 9/12/24 at 9 a.m., an interview was conducted with the registered nurse (RN #5), who was a care plan coordinator for the facility. RN #5 reported that the care plan is developed by assessment, talking with the resident, family and staff to get the best plan of care for the residents. It helps staff know task involved and serves as a guide. Review of the facility policy titled; Trauma Informed Care was conducted. The policy read in part, . 2. Through available medical records review and by interviewing the patient, indicate any diagnosis of PTSD or any history of trauma on the Trauma Informed Screen Assessment. 3. If a patient is diagnosed with PTSD, or indicates a history of trauma, encourage the patient to disclose known systems, triggers, and coping mechanisms so that the center can best accommodate those needs in a way that makes the patient feel safe and respected. a. Symptoms may include but are not limited to agitation, anxiety, nightmares, isolation, decreased interest in activities. b. Triggers may include but are not limited to sounds, lights, smells. c. Coping mechanisms may include but are not limited to attending group meetings, deep breathing, mindfulness, physical activity. Immediately update the care plan to reflect information about trauma gathered from the patient and alert the IDT of identified symptoms, triggers, and coping mechanisms. On 9/12/24, the above concerns were discussed with the facility administration and corporate staff. No other information was provided prior to exit.

Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts and failed to allow residents to readily access their trust funds, affecting all 140 residents with trust accounts. The findings included: On 9/10/24, an interview was conducted with Resident #14- R14. During the interview, R14 expressed that he doesn't get any kind of statement regarding his trust account. On 9/10/24 at 2 p.m., a group interview was conducted with eight residents (Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38).When asked about trust account statements, the residents reported that they did not receive any kind of statement regarding their trust fund accounts. These residents also verbalized concerns that they can only withdraw funds from their trust account for two hours, Monday through Friday, and no longer have weekend access. On 9/10/24 at approximately 4:28 p.m., observations noted a sign posted near the front reception desk that read, Bank Hours: Monday-Friday 10am-12pm. Closed Saturday and Sunday. Thank you, Business Office. On 9/10/24 at approximately 4:30 p.m., an interview was conducted with other employee #9 (OE9), who was the front office assistant and who distributed resident's trust funds. OE9 explained that residents can access their money Monday through Friday from 10 a.m., until 12 noon. When asked about weekend access, OE9 said that they no longer do that and that they had sent out a letter to notify the residents. During the interview with OE9, the business office manager (BOM) walked up and joined in the conversation. When asked about account statements, OE9 stated that when residents withdraw money, she can let them know how much they have left. The BOM added that the statements go directly to the residents from the resident fund management system (RFMS). The BOM stated that the facility doesn't send out any statements. On 9/11/24 at 11:26 a.m., a telephone call was placed to RFMS, and the surveyor spoke with a representative regarding statements. The RFMS representative stated that each facility can choose if they receive the statements monthly or quarterly. The RFMS representative accessed their records and reported that this facility was set up to receive the statements quarterly. When asked if RFMS sends the statements to the residents, the RFMS representative said, They are made available to the facility and if the residents receive a copy is up to the facility. We don't mail them out to residents or families. On 9/11/24 at 11:40 a.m., an interview was conducted with the business office manager (BOM). The BOM was asked about the banking hours changing and why they decided on two hours per day Monday through Friday. The BOM said, It had a lot to do with speaking with other facilities and how their banking is handled. We were also trying to manage resident funds and the money we receive. We have residents that come daily and get their max out. [OE9's name redacted] is the guard-dog on that and keeps track of who comes daily and for their safety and to keep them from having the money we were going through doing it 7 days a week. We were doing it to manage the money better because we were constantly running out of money. During the above interview with , When asked if the facility had met with the residents and gotten their input on this change, the BOM stated, No, to be honest, we did not. And as residents came up, we were notifying them. The BOM was asked to provide the surveyor with a copy of the letter that was sent out. The BOM went on to say, We also had some staffing challenges, we had part-timers, and we were trying to limit how many hands were in the money. The clinical record for R14 was reviewed. There was no evidence that the resident had received a trust account statement. A review of the facility policy titled, Quarterly PFA [personal fund account] Statements, dated 6/1/22, was conducted. This policy read in part, A quarterly written Patient Trust Fund and Burial Trust Fund, if applicable, statement is issued to the patient or to his or her designated representative . The facility policy dated 6/1/22, which was titled, Banking Hours was reviewed. This policy read in part, 1. The center will establish banking hours to allow patients to have access to their patient funds for at least two hours during regular business working hours, and for a reasonable time on Saturdays and Sundays . 4. The center will establish a secure procedure for Saturday and Sunday patient access to cash withdrawals. On 9/10/24, during an end of day meeting, the facility Administrator, director of nursing, and corporate staff were made aware of the above findings. No additional information was received.

Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of thirty-three residents in the survey sample (Residents #49, #66, #30 and #131). The findings include: 1. Resident #131's plan of care of was not revised with interventions in place for trauma related care. Resident #131 (R131) was admitted to the facility with diagnoses that included urinary tract infection, major depressive disorder, post-traumatic stress disorder, diabetes, spinal stenosis, anxiety and anemia. The minimum data set (MDS) dated [DATE] assessed R131 as cognitively intact. R131's clinical record documented a trauma assessment 4/19/24 indicating the resident had history of physical abuse, verbal abuse and misappropriation of personal property by an ex-boyfriend. The trauma assessment documented no other source of trauma and identified the resident's trauma was related to fear that the ex-boyfriend would enter the facility and harm her. R131's plan of care (revised 8/21/24) documented the resident reported history of trauma related to an ex-boyfriend that had assaulted her and stole her money. The care plan identified the trigger related to the resident's trauma history was that the ex-boyfriend would enter the facility and cause harm. The care plan interventions to prevent/minimize distress/anxiety from past traumatic experiences included refer to psych service as needed, schedule familiar staff with resident and trauma screen as indicated. The plan of care included no individualized interventions about preventing the ex-boyfriend from entering the facility or visiting the resident. On 9/10/24 at 2:11 p.m., the certified nurses' aide (CNA #1) caring of R131 was interviewed about any interventions related to the trauma history. CNA #1 stated she was aware the resident had an ex-boyfriend that was not supposed to visit. CNA #1 stated the ex-boyfriend's picture and name were posted at the reception desk and staff were not supposed to let him in the facility. On 9/10/24 at 2:23 p.m., the licensed practical nurse unit manager (LPN #8) was interviewed about interventions related to R131's traumatic stress disorder. LPN #8 stated the ex-boyfriend was not permitted to visit the resident or enter the facility. LPN #8 stated the ex-boyfriend's picture was posted at the front desk so staff could identify him and prevent his entrance. LPN #8 stated the interdisciplinary team was responsible for updating care plans. LPN #8 stated he was not sure why the interventions in place were not on the care plan. On 9/10/24 at 2:30 p.m., R131 was interviewed about interventions implemented by facility staff to prevent stress/fear related to her trauma history. R131 stated the ex-boyfriend tried to visit her once since her admission and this person was stopped at the front desk and denied entrance. R131 stated the ex-boyfriend had made no further attempts to contact or visit her. R131 stated, Staff have done a good job keeping him [ex-boyfriend] away. R131 stated she felt safe in the facility and relieved that she no longer had to deal with the ex-boyfriend. On 9/11/24 at 8:19 a.m., the service ambassador (other staff #6) working at the entrance desk was interviewed about interventions regarding R131's ex-boyfriend. The service ambassador was aware that R131's ex-boyfriend was not to enter the facility or visit the resident. The service ambassador pointed to a picture with name posted on the front desk. The service ambassador stated if this person attempted to enter the facility, she was to ask him to leave and if he would not leave, she was to call the police. On 9/11/24 at 8:36 a.m., the regional registered nurse (RN #2) responsible for MDS/care planning, was interviewed about R131's care plan not listing interventions in place regarding trauma care. RN #2 stated the interdisciplinary team was responsible for updates to care plans. RN #2 stated that social services was usually responsible for the trauma related care plan interventions. On 9/11/24 at 8:38 a.m., the social worker (other staff #3) was interviewed about R131's care plan not including interventions in place regarding trauma care. The social worker stated the care plan should be updated to include the interventions in place to prevent trauma related stress. The social worker stated R131's trauma assessment was last completed on 4/19/24 and the last formal care plan meeting took place on 7/10/24. The social worker stated the interventions in place should be on the plan of care. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey. 41449 2. For resident #49 (R49), the facility staff failed to review and revise the care plan to reflect a fall and bed rails that were in use. On 9/9/24 and 9/10/24m R49 was visited in his room. R49 was noted to be non-verbal and did not respond to verbal stimuli. R49 was noted to be on an air mattress and had 1/8 length bed rails to both sides of the bed. On 9/10/24, a clinical record review was conducted. This review revealed R49 had diagnosis which included, but were not limited to persistent vegetative state, obstructive hydrocephalus, cerebral palsy, and cerebral infarction due to unspecified intracranial injury with loss of consciousness of unspecified duration. According to a nursing note entry dated 7/26/24, R49 sustained a fall. The notes for that day read in part, Resident was lying in between the beds on his left side. No signs of pain or discomfort at this time, and This writer spoke with [R49's father's name redacted] to notify him of [R49's name redacted] fall. This writer informed patient's father that there were no injuries noted at this time but aware of new orders for x-rays. This writer also asked father if he consents to bed side rails. RP [responsible party] agreed. Review of R49's care plan was conducted. The care plan did not indicate that R49 had fallen on 7/26/24 and did not indicate the bed rails. On 9/12/24 at 9 a.m., an interview was conducted with the registered nurse (RN #5), who was a care plan coordinator for the facility. RN #5 reported that the care plan is developed by assessment, talking with the resident, family and staff to get the best plan of care for the residents. It helps staff know task involved and serves as a guide. RN#5 stated that falls are discussed daily during a clinical meeting and then the care plan is updated. She stated, we need to put interventions on the care plan as part of the care of the patient, it's how to keep them safe and what to look for. On 9/12/24, during a late morning meeting with the facility administrator, director of nursing and corporate staff, the above concerns were discussed. No additional information was provided. 3. For resident #30, R30, who had mental health diagnosis, the care plan was not revised to indicate that a level 2 pre-admission screening for mental health had been halted and not completed. On 9/10/24, a clinical record review was conducted of R30's chart. This review revealed diagnosis that included, but were not limited to, suicidal ideation, bipolar disorder, major depressive disorder, anxiety disorder, and Alzheimer's disease. On 9/10/24 a clinical record review was conducted. According to hospital records dated 4/10/24, that were under the documents tab of the chart, R30 was hospitalized with suicidal ideation prior to admission to this facility. According to the pre-admission screening, the level 1 screening for mental illness, intellectual disability or related conditions, indicated that a level 2 assessment was warranted. According to R30's care plan, it noted, Resident has a Level II PASRR. However, the level II PASRR was not able to be located within the chart. On 9/11/24, the facility administration was notified during an end of day meeting and again on the morning of 9/12/24, that the survey team wanted to see R30's level II pre-admission screening resident review form. On 9/12/24 at approximately 10:30 a.m., the survey team was provided with a letter from the department of behavioral health and developmental services division with the Commonwealth of Virginia that indicated the level II screening for R30 had been halted. The reason noted was the individual has a primary diagnosis of an organic disorder, dementia (including Alzheimer's disease) and does not have a diagnosis of ID [intellectual disability]. The letter was dated 9/11/2020. Upon being handed the document, the regional director of clinical services confirmed that the document had not been a part of R30's clinical chart and they had called to get the information faxed to the facility. On 9/12/24 at approximately 11 a.m., during a meeting held with the facility administration and corporate staff, the above findings were reviewed. No additional information was provided. 28106 4. Resident #66's care plan was not revised to reflect the intervention of heel protectors (bunny boots) for skin integrity. The findings include: Diagnoses for R66 included; Dementia, diabetes, osteoarthritis, and failure to thrive. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/8/24. R66 was assessed with a cognitive score of 00 indicating severe cognitive impairment. Review of R66's clinical record evidenced a physicians order dated 8/8/24 for Bunny boots bilaterally while in bed. R66's care plan was also reviewed and did not evidence interventions for bunny boots. On 9/10/24 multiple observations were made between 8:30 a.m. and 10:30 a.m. of R66 lying in bed without bunny boots in place. The bunny boots were observed on the bed-side dresser. On 9/10/24 at 10:39 a.m. license practical nurse (LPN #1) was asked to observe R66's heels while R66 was still in bed. LPN #1 observed R66 without heel protectors and when asked LPN #1 verbalized unawareness of the heel protector order. It was explained to LPN #1 the possible reason for not knowing about the order was because the order did not indicate documentation was needed (on the TAR, Treatment Administration Record) to ensure the bunny boots were in place. On 9/10/24 at approximately 2:00 p.m. review of R66's orders indicated the bunny boot order had been updated and entered in a way that the order transferred to the TAR. Review of R66's care plan also was updated to include bunny boots. On 9/10/24 at 3:29 p.m. registered nurse (RN #2, MDS coordinator) was interviewed regarding the intervention of bunny boots added to the care plan on 9/10/24. RN #2 reviewed the care plan and verbalized that it appeared that the director of nursing (DON) had updated the skin integrity care plan to include bunny boots on 9/10/24 and the care plan should have been updated when the order was placed on 8/8/24. On 9/11/24 at 4:41 p.m. the above finding was presented to the administrator, DON and nurse consultant. No other information was presented prior to exit conference on 9/12/24.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for five of thirty-three residents in the survey sample (Residents #66, #159, #99, #149, and #92). The findings include: 1. Resident #66's heel protectors (bunny boots) were not applied as ordered. The findings include: Diagnoses for R66 included; Dementia, diabetes, osteoarthritis, and failure to thrive on hospice. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/8/24. R66 was assessed with a cognitive score of 00 indicating severe cognitive impairment. Review of R66's clinical record evidenced a physicians order dated 8/8/24 for Bunny boots bilaterally while in bed. The order indicated no documentation was needed. On 9/10/24 multiple observations were made between 8:30 a.m. and 10:30 a.m. of R66 lying in bed without bunny boots in place. The bunny boots were observed on the bed-side dresser. On 9/10/24 at 10:39 a.m. license practical nurse (LPN #1) was asked to observe R66's heels while R66 was still in bed. LPN #1 observed R66 without heel protectors and when asked LPN #1 verbalized unawareness of the heel protector order. When it was explained to LPN #1 the possible reason for not knowing about the order was because the order did not indicate documentation was needed (on the TAR, Treatment Administration Record) to ensure the bunny boots were in place, LPN #1 agreed. R66's heels were assessed at this time and showed dry, peeling skin to the right heel with a finger-tip size dark area. The left heel showed dry skin. On 9/10/24 at approximately 2:00 p.m. review of R66's orders indicated the bunny boot order had been updated and entered in a way that the order transferred to the TAR, requiring documentation. On 9/10/24 at 5:06 p.m., the above finding was presented to the administrator, DON, and nurse consultant. No other information was presented prior to exit conference on 9/12/24. 2. Resident #159's feeding tube was not anchored as ordered. The Findings Include: Diagnoses for R159 included; Displacement of esophageal anti-reflux device (tracheostomy), chronic obstructive pulmonary disease, esophageal obstruction, cellulitis of abdominal wall, feeding tube. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/2/24, which assessed R159 with a cognitive score of 15 out of 15, indicating intact cognition. Review of R159's clinical record evidenced a physicians order, dated 6/21/24, to Anchor feeding tube every shift. On 9/10/24 at 2:30 p.m., R159 was interviewed regarding an anchor being applied to the feeding tube. R159 verbalized that an anchor was not being used and showed that the feeding tube was not anchored. On 9/10/24 at 2:45 p.m., registered nurse (RN #1, assistant director of nursing) joined the surveyor to observe R159's feeding tube, that was without a feeding tube anchor. RN #1 said that she thinks the anchor is the balloon that holds the tube in. On 9/10/24 at 5:05 p.m., RN #1 reported that she had found the anchors for the feeding tubes and verbalized being unaware that the facility had them. On 9/10/24 at 5:06 p.m., the above finding was presented to the administrator, DON, and nurse consultant. 21875 3. Resident #99 was administered two tablets of acetaminophen ER (extended release) 650 mg (milligrams) when the physician's order required two tablets of acetaminophen 325 mg. A medication pass observations was conducted on 9/10/24 at 7:51 a.m. with licensed practical nurse (LPN) #4 administering medications to Resident #99 (R99). Among the medications administered were two tablets of acetaminophen ER 650 mg. R99's clinical record documented a physician's order dated 8/2/24 for acetaminophen 325 mg with instructions to give two tablets every 4 hours as needed for pain/headache. On 9/10/24 at 8:45 a.m., LPN #4 was interviewed about the incorrect dose of acetaminophen administered to R99. LPN #4 stated she was nervous and pulled the wrong bottle of Tylenol (acetaminophen). LPN #4 stated she was not used to being watched. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/10/24 at 5:15 p.m. with no further information presented prior to the end of the survey. 49456 4. For Resident #149, the facility staff failed to follow a physician's order to apply ted hose every morning. Resident #149 (R149) was admitted to the facility on [DATE]. R149's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/28/24 coded R149 with no cognitive impairment. On 9/9/24 at 3:33 p.m. an observation was made of R149 sitting outside without ted hose on bilateral extremities. R149 was wearing ankle socks and tennis shoes. On 09/10/24 at 11:00 a.m. an observation was made of R149. R149 was walking around the nursing units at the facility and was not wearing her ted hose. R149 was wearing bedroom slippers. On 9/11/24 at 10:44 a.m. an observation was made of R149. R149 was observed walking around the facility hallways with flip flops on and her ted hose were not being worn. On 09/12/24 at 8:25 a.m. an interview was conducted with a licensed practical nurse, LPN # 2 (LPN2). LPN2 stated, the resident can put the ted hose on independently and she typically likes things a certain way. LPN2 walked with the surveyor to R149's room and there was no ted hose in R149's room. On 9/12/24 at 8:25 a.m. an interview was conducted with R149 concerning her ted hose. R149 stated that she could put the ted hose on by herself, but sometimes she needed help. R149 stated that she only had the black socks that the supply clerk gave her because she was unable to find ted hose at the store, so the supply clerk bought these socks. On 9/12/24 at 8:45 a.m. an interview was conducted with the supply clerk. The supply clerk stated that she did not have the correct size for R149, so she went to the store and bought the black socks and was not aware the socks were not ted hose. The supply clerk stated she has had R149's size in the ted hose for 2 weeks and will give the ted hose to R149 today. On 9/12/24 a clinical record review was conducted. R149 had a physician's order dated 7/29/24 to apply ted hose in the am and remove in the pm written by the nurse practitioner. On 9/12/24 a review of a facility policy was conducted. The facility's policy titled, Physician's Orders, read in part, .Admission Physician's orders must be provided for every patient at the time of admission to activate a medical plan of care. Other orders indicated by patient's condition with specific directions. On 9/12/24 at 10:25 a.m. the administrator and regional nurse consultant was made aware of the above concerns. No new information was provided. 41449 5. For resident #92 (R92), the facility staff failed to obtain a valproic acid level lab in accordance with the physicians orders. On 9/10/24, a clinical record review was conducted. This review revealed that according to the diagnosis tab of the chart, R92 had a diagnosis of epilipsy. R92's medications included Depakote delayed release, which was indicated as being for siezure disorder. According to a physician order dated 8/9/24, it read, Valproic acid level one time only for labs until 08/10/2024. A review of R92's results tab of the chart revealed that on 8/10/24, a uric acid level lab had been obtained. On 9/11/24, during an end of day meeting, the facility administrator, director of nursing and coproate staff were made aware of the above findings. On 9/12/24, the survey team was provided a copy of the lab slip which was completed by a nurse at the facility, and they stated, the wrong test was noted on the lab sheet.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a therapeutic diet as ordered by the physician for four residents (Resident #139, #55, #9, and #30), in a survey sample of 33 residents. The findings included: 1. For Residents #139, 55, and 9, all who had therapeutic diets ordered, the facility kitchen failed to provide the appropriate diet. On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west unit. It was noted that R139's meal ticket indicated she was to receive chopped meats. R139's meal tray included a whole/intact pork chop, which nursing staff had to cut up into bite size pieces, which was not a chopped consistency. R139 was observed to not eat the pork chop and verbalized several times, it's too tough. R24 and R9's meal ticket indicated they were to receive pureed foods. The meat on the tray was not a smooth consistency and appeared more like ground meat. Several staff members, to include LPN #6, LPN #3 and CNA #4 all agreed the pureed meat was not a pureed consistency. LPN #6 took R9's tray back to the kitchen to get a replacement. CNA #4 was assisting to feed R55, confirmed the resident was not only to receive pureed foods but was to receive double portions and none of his meal items were double portions. On 9/9/24 at approximately 1:05 p.m., the unit manager, LPN #3 was asked to accompany the surveyor into the restorative room where residents were eating. LPN #3 was shown each of the resident's trays, R139, 55 and 9. LPN #3 confirmed the above findings. LPN #3 went on to stay she had spoken to the kitchen previously for the same concerns with regards to portion sizes and therapeutic diets not being served. On 9/9/24, clinical record reviews were conducted for each of the residents named above. The records revealed the following: R9's diet order dated 7/17/24, read, Regular diet Dysphagia Pureed texture, Thin Liquids consistency, magic cup with lunch, large portions of dessert. R55's diet order dated 7/17/24 read, Regular diet Dysphagia Pureed texture, Thin Liquids consistency, Large portions. R139's diet order from the physician dated 7/17/24, read, Regular diet Regular texture, Thin Liquids consistency, Chopped meats. 2. For Resident #30 (R30), who had experienced weight loss, the facility staff failed to provide nutritional supplements as ordered. On 9/11/24, R30's breakfast meal was observed. According to the meal ticket, R30 was to receive a health shake with breakfast. The shake was not on the tray. When asked, R30 said she likes the strawberry shakes, not the chocolate, but doesn't get them often. On 9/11/24, other employee #13 (OE13), who conducted daily rounds on R30's room was asked to step into the room. OE13 confirmed that R30's meal ticket indicated she was to receive a health shake at breakfast, but it was not present. On 9/11/24 at approximately 9 a.m., the unit manager, LPN #3 was shown the above, that R30 did not receive the health shake. LPN #3 and the surveyor went to the kitchen and LPN #3 notified the kitchen staff R30 did not get her shake. The kitchen staff immediately provided LPN #3 with a health shake that she then took to R30. The dietary manager was asked why R30 wasn't provided the health shake on the tray as ordered, and she didn't have an answer. According to R30's physician order dated 7/30/24, it read, Regular diet Regular texture, Thin Liquids consistency, large portions at lunch and dinner, health shake at breakfast for to prevent malnutrition/promote wt. [weight] maintenance. The facility provided the survey team with the requested facility policy titled, Therapeutic Diets. The policy read in part, .3. Diets will be offered as ordered by the physician or designee . On 9/11/24, all the above findings were reviewed with the facility administrator, director of nursing and corporate staff. No additional information was provided.

Based on observation, staff interview, and facility document review, the facility staff failed to maintain effective pest control. The findings include: Flies were observed during the survey on the [NAME] unit dining/day room and in the main kitchen during food preparation. On 9/9/24 at 11:32 a.m., lunch preparation was observed in the main kitchen. Flies were observed in the kitchen near the handwashing sink located beside an exit door. Several flies were observed near the convection ovens. Kitchen staff members were observed exiting and re-entering through the exit door multiple times during meal preparation/service. An air curtain positioned over the exit door did not activate when the door was opened. The dietary manager was interviewed at this time about the flies and air curtain. The dietary manager stated the air curtain at the exit door did not come on automatically when the door was opened. The dietary manager stated she had to turn on the air curtain at the breaker box. The dietary manager stated she usually turned the air curtain on when the door stayed open for deliveries. The dietary manager stated she did not routinely run the air curtain during meal prep. On 9/9/24 at approximately 12:00 p.m., residents on the [NAME] unit were observed eating lunch in the day room. Multiple flies were observed in the day room while residents were eating and/or being fed lunch. On 9/9/24 at 4:26 p.m., Resident #55 (R55) was observed seated in a wheelchair in the [NAME] unit day room. Several flies were observed on and/or around the resident. Flies were observed flying/landing on the resident's shirt, the resident's head/forehead, and on R55's hands/forearms. On 9/11/24 at 10:23 a.m., the assistance maintenance director (other staff #1) was interviewed about the observed flies and the facility's pest control. The assistant maintenance director stated that a pest control vendor came each month and treated the facility for pests including flies. The assistant maintenance director stated he was not aware that flies were in the [NAME] unit day/dining room. The assistant maintenance director stated the air curtain in the main kitchen was not working properly. The assistant maintenance director stated he did not know what was wrong with the air curtain and that the air curtain was supposed to come on automatically when the door was opened to prevent flying insects from entering. The assistant maintenance director presented monthly reports from a contracted pest control vendor. The most recent report dated 8/28/24 documented treatment for ants, glue boards for flies and treatment for fruit flies in the kitchen. The report made no mention of the non-functional air curtain in the kitchen or of any targeted treatment for flies in the kitchen and/or [NAME] unit dining room. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.

Based on observation, staff interview, and resident interview, the facility failed to accommodate the resident's preference to dine in the dining room affecting multiple residents on three of three units. The findings included: The facility staff failed to have their main dining room available for the residents to have their meals. On 9/9/24, during the initial tour of the facility, the main dining room was observed to be used as a storage area and not being used for residents dining. On 9/10/24, at 2:00 p.m., during a resident council meeting conducted with eight residents, all of the residents in attendance were complaining about not having the dining room open for use during mealtimes. Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38 were complaining about how long the dining room had been closed off to the residents and that it was being used as a storage area. On 9/10/24 at 3:15 p.m, Resident #64 stated,It was nice when we all could get together and talk in the dining room at meals, but now it is just a warehouse. On 9/10/24 at 3:15 p.m., Resident #69 stated, I miss being with everyone in the dining area and it is a shame they just put boxes and things in there where we cannot use it anymore For about 3 months, it's been this way. On 9/10/24 at 3:325 p.m., the director of nursing and regional director of clinical services were asked about the lack of resident access to the dining room. It was stated that arrangements were being made to have the boxes removed from the dining area and it would be opened back up as soon as the boxes and equipment were moved out of the area. 09/10/24 05:02 p.m., an end of day meeting was held with regional director of clinical services, vice president of operations, administrator, and the director of nursing, during which the above concerns were discussed with the administration staff of the facility. On 9/11/24 at 10:44 a. m, Resident #149 stated, I really think we need a place to eat other than our room for socialization. It can get depressing, just staying in your room all the time. On 9/12/24, the facility provided the survey team with evidence that they had ordered a shipping container to have onsite to store the items that were currently being stored in the dining room. Throughout the four days of survey, the dining room was observed to be unaccessible for the residents to use. No additional information was provided.

Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner from the main kitchen and on one of three units (West unit). The findings include: a) The walk-in refrigerator and freezer in the main kitchen had out-of-date and/or unsealed food items. Stainless prep pans were stored nested and wet. The bench mounted can opener was dirty with accumulated debris. Flies were observed in the kitchen during meal prep near the exit door beside the handwashing sink. On 9/9/24 at 10:41 a.m., accompanied by the dietary manager (other staff #2), the main kitchen was inspected during the initial tour of the facility. Stored in the walk-in refrigerator was a package of sliced turkey labeled with a use by date of 9/5/24. There was an opened 46-ounce carton of thickened cranberry cocktail with no label indicating when opened. A package of slice turkey, with no manufacturer's label was stored and available for use. There was no identification on the packaged turkey indicating a use by or expiration date. A box with 18 pasteurized eggs was stored with a use by date of 7/11/24. In the walk-in freezer was stored an unsealed bag of frozen sausage patties and an unsealed bag of frozen French fries. Seven stainless quarter-sized pans were observed stored nested and wet. The bench mounted manual can opener near the 3-compartment sink was dirty with accumulated black/brown debris on the blade and bracket. The dietary manager (other staff #2) was interviewed at the time of the observations about the out-of-date and unsealed food items stored in the refrigerator and freezer. The dietary manager stated all food items were supposed to be labeled with a date opened and a discard date. The dietary manager stated foods were supposed to be stored in sealed containers. The dietary manager stated the package of slice turkey with no identification should not have been removed from the original box/packaging. The dietary manager stated the prep pans were supposed to air dry on a rack prior to nesting. The dietary manager stated the can opener needed to be soaked and cleaned. On 9/9/24 at 11:32 a.m., lunch preparation was observed. Flies were observed in the kitchen near the handwashing sink located beside an exit door. Several flies were observed near the convection ovens. Kitchen staff members were observed exiting and re-entering the through the exit door, multiple times during meal preparation/service. An air curtain positioned over the exit door did not activate when the door was opened. The dietary manager was interviewed at this time about the flies and the non-functioning air curtain. The dietary manager stated the air curtain at the exit door did not come on automatically when the door was opened. The dietary manager stated she had to turn the air curtain on at the breaker box. The dietary manager stated she usually turned the air curtain on when the door stayed open for deliveries. The dietary manager stated she did not routinely run the air curtain during meal prep. On 9/9/24 at 11:55 a.m., a warming oven in use was inspected. The front of the unit was dirty with drips, fingerprints, and smudges on the glass door. The bottom of the unit had accumulated crumbs, spills, and debris. The control panel near the floor was dirty with crumbs and debris. b) On 9/10/24 at 2:53 p.m., accompanied by licensed practical nurse (LPN) #4, the [NAME] unit nutrition/snack refrigerator was inspected. Stored in the refrigerator was an opened 32-ounce carton of Med Pass supplement. There was no date or label indicating when the Med Pass was opened. LPN #4 was interviewed at this time. LPN #4 stated she was not sure how long the Med Pass had been opened because there was no label indicating the date opened. LPN #4 stated nurses were supposed to label supplements when opened. The facility's policy titled Food Storage: Cold (Oct. 2019) documented, .It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code .The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . The facility's food storage chart (referencing Food Code 2017) documented that ready-to-eat foods and leftovers may be stored for up to 7 days after preparation or opening. The facility's policy titled Ware Washing (policy 22) documented, .It is the center policy that all dishware and service ware will be cleaned and sanitized after each use . The Dining Services Director ensures that all dishware is air dried and properly stored . The facility's policy titled Equipment (policy 27) documented, .It is the center policy that all food service equipment is clean, sanitary, and in proper working order .The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials .The Dining Service Director will ensure that all food contact equipment is cleaned and sanitized .The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed . This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/10/24 at 5:15 p.m. with no further information presented prior to the end of the survey.

Based on observation and staff interview, the facility staff failed to distribute meals in a manner to maintain and enhance a residents dignity affecting several residents on one of three units. The findings included: The facility staff failed to distribute meal trays in a manner to uphold resident's dignity. On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west wing. It was noted that R22 was sitting at a table with resident #9 (R9). R9 was served her meal and began eating. All the other residents in the dining room were served, including a tray sat between R22 and R9 for another resident who was not present in the dining room. CNA #4 was the only staff member remaining in the dining room after the trays had been served, and she was sitting to assist in feeding resident #55. The surveyor identified several concerns with regards to the consistency of pureed foods. LPN #6 was asked to verify that residents who were served pureed foods were not given a pureed consistency of food. LPN #6 then removed R9's tray to take it to the kitchen to be prepared at the correct consistency. In doing so, it left R9 and R22 in the dining room with all the other residents eating their meal with no food for them to eat. R22 was then observed to remove the coffee from the meal tray sitting between him and R9, as he had no beverages or food items. A few minutes later, R9 then removed the lid from the plate of food that had been put on the table between her and R22. CNA #4 came over and recovered the plate of food. The surveyor asked where R22's food was and CNA #4 said, it wasn't on the cart. At 1:18 p.m., R22 was served his meal tray that had been taken onto the unit in the meal cart. On 9/9/24 at 1:22 p.m., the resident whose tray had been sat on the table between R22 and R9 came into the dining room and was assisted to the table where his food that had been sitting since 12:58 p.m. This was the same tray that R22 had removed the coffee from and R9 had removed the cover from. On 9/10/24, during an end of day meeting with the facility administrator, director of nursing and corporate staff, the above findings were reviewed.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure safety while providing incontinence care for one of five residents in the survey sample. Resident #2, dependent upon staff for all mobility and personal care needs, fell from the bed when turned by a staff member during provision of incontinence care. Staff failed to follow the resident's plan of care for two-person assistance and failed to safely turn the resident in bed when the fall occurred. The resident experienced a goose egg and a bleeding abrasion/laceration to the forehead from the fall. The findings include: Resident #2 was admitted to the facility with diagnoses that included cerebral infarction, right hand contracture, [CONDITION(S)] with gastrostomy, dysphagia, adult failure to thrive, Alzheimer's disease, diabetes, major depressive disorder, hypertension, [CONDITION(S)], dysarthria and constipation. The minimum data set (MDS) dated [DATE] assessed Resident #2 with short and long-term memory problems and moderately impaired cognitive skills. This MDS listed the resident as non-verbal with impaired range of motion in both upper extremities and was assessed as totally dependent upon staff for hygiene and requiring the extensive assistance of one person for bed mobility. Resident #2's closed clinical record documented a nursing note dated 6/11/22 stating, This writer entered room and observed resident lying supine on the floor mat in between the two beds, writer observed raised area roughly the size of a quarter on the left side of forehead near eyebrow, and abrasion to left side of forehead. Resident was calm, no s/s [signs/symptoms] of distress or pain .chest rise ready and regular. CNA [certified nurses' aide] instructed to hold pressure to abrasion that was bleeding while writer call the on call MD [physician] and nursing manager. At 1850 [6:30 p.m.] new order to send resident to ER [emergency room ] was obtained .EMS [emergency medical services] arrived at 1855 [6:35 p.m.] and assumed care of resident . (Sic) A change in condition communication form dated 6/11/22 documented Resident #2's vital signs after the fall were: blood pressure 142/81; pulse rate 104; respiration rate 20; temperature 97.2; blood glucose 140 and pulse oximetry 95.0%. A transfer form dated 6/11/22 documented the resident as a high fall risk with wounds listed as, .bleeding coming from her head and a goose egg. The emergency room physician's note dated 6/11/22 documented, .pt [patient] arrived from [facility] via EMS after a witnessed fall. Per EMS the pt was responsive on arrival, but became unresponsive and pulseless during transport . The ER physician's note documented, .The patient presents with a heart rate of 40 with pulseless electrical activity. There were no palpable pulses and no organized cardiac activity on bedside ultrasound .We decided to terminate the resuscitation .Patient was pronounced dead at 1944 [7:44 p.m.] . The ER report listed the resident was assessed with an unspecified fall, unspecified head injury and cardiac arrest upon arrival. The report documented no cause of death. A facility reported incident form dated 6/12/22 documented Resident #2 rolled from the bed while CNA #2 was providing incontinence care on the evening of 6/11/22. The facility's investigation dated 6/17/22 documented, .Primary CNA was interviewed and stated the following: resident turned over onto left side while in bed due to bowel movement that needed to be addressed, resident was noted to hold onto the grab bar with right hand. When CNA went to reach for wipes to clean resident, [Resident #2] adjusted her grip on the bar and momentum carried her forward and over the side of the bed. A fall mat was present on the floor in between resident's bed, resident was observed supine on the floor, a raised area to the left forehead and a laceration with a moderate amount of bleeding was present to forehead as well . The facility's investigation included written statements from staff members caring for the resident and/or working on the resident's unit at the time of the fall. A written statement dated 6/11/22 by CNA #2 who was providing care for Resident #2 at the time of the incident documented, .CNA assisted Resident onto her left side to be cleaned. Resident grabbed the left railing and gripped it tightly. When resident grabbed railing she rolled over the left side of the bed onto the floor mat. CNA was on the right side of the bed and was placing brief under resident until fall. CNA called for help and checked on resident . A written statement dated 6/11/22 by licensed practical nurse (LPN) #5 working on Resident #2's unit at the time of the fall documented, .I heard the CNA [#2] .yell and I saw another CNA run down the hall .I came out and went into [Resident #2's] room and saw her lying on the floor mat in between both beds .resident was alert and awake .I noticed blood coming from her head and a goose egg showing up on her forehead .I called 911 and they got here fast . A written statement dated 6/11/22 by TNA [temporary nurses' aide] #3 who was working on Resident #2's unit at the time of the fall documented, .CNA called my name asking for help looking frantic so I ran down the hallway and enter room .CNA was holding the end of the bed looking red in the face. Then the nurse came in asking what happened and that's when CNA [#2] said that [Resident #2] had fell off the bed so I went around and seen . that her body was on the floor mat while her head was under her roommate's bed. Then I went toward [Resident #2] and removed her head from under the bed and seen a pool of blood so I asked the CNA to give me a washcloth so the injury could be compressed to stop further bleeding . (Sic) Resident #2's clinical record documented the resident was at risk of falls due impaired mobility and cognitive impairment. A fall risk assessment dated [DATE] documented the resident's fall risk factors included impaired vision, inability to stand or ambulate, inability to perform range of motion, incontinence, improper positioning while in a chair (slouching, leaning), requirement for two-person assistance with transfers and use of a Geri (reclining) chair when out of bed. Occupational therapy (OT) evaluated and treated Resident #2 from 5/24/22 through 6/3/22 due to impaired upper extremity mobility. The OT evaluation dated 5/24/22 documented the resident as .Non-verbal, cooperative at times, moderately resistive to RUE PROM (right upper extremity passive range of motion), significantly resistive to LUE PROM (left upper extremity passive range of motion) exercises, unable to follow one-step commands . The OT evaluation listed the resident had a contracture of the right hand, was dependent upon staff for oral hygiene, toileting, bathing and upper and lower body dressing with severely impaired decision-making and impaired safety awareness. Resident #2's plan of care (reviewed/revised 6/8/22) documented the resident had ADL self-care deficit due to history of stroke and Alzheimer's dementia. Interventions to maintain ADLs documented a requirement for two-person assistance for bed mobility and two-person assistance with transfers using a mechanical lift. The care plan documented the resident was always incontinent of bowel/bladder and required total assistance for dressing and hygiene. The care plan listed the resident was non-verbal and likes to chew on her fingers . Interventions to meet basic needs were listed as, Anticipate and meet needs. The care plan documented the resident was at risk of falls and was unaware of safety needs. Interventions to prevent falls included, Anticipate and meet The resident's needs .Assist bars & Geri-chair . Be sure The resident's call light is within reach and encourage the resident to use it .Fall Education .Keep environment free of trip hazards . (Sic) The requirement for two-person assistance with bed mobility listed under ADL care had been in place and was last revised on 6/3/19. On 7/5/22 at 12:40 p.m., CNA #2 that was with Resident #2 at the time of the fall on 6/11/22 was interviewed. CNA #2 stated around 6:30 p.m. on 6/11/22, she rolled Resident #2 onto her left side to provide a brief change. CNA #2 stated the resident was only able to move her hands and described the resident's body as very stiff. CNA #2 stated after she positioned the resident onto her side, with her hand on the resident's hip, she reached back 180 degrees to get the wipes. CNA #2 stated the resident then gripped the bed rail and this moved the resident toward the rail. CNA #2 stated the resident continued in motion and rolled off the bed onto the floor mat. CNA #2 stated she was on the opposite side of the bed facing the resident's backside and stated concerning the fall, I could not stop her. CNA #2 stated after the fall, the resident's forehead had a goose egg and was bleeding. CNA #2 stated there were no other staff members in the room at the time of the fall and TNA #3 and LPN #5 came to the room after she called for help. When asked what assistance was required when turning Resident #2 in bed, CNA #2 stated she mostly changed the resident by herself. CNA #2 stated the resident was very stiff and if a staff person was not familiar with the resident or not strong enough, two people would be needed to provide safe care. CNA #2 stated again, I usually do her by myself. CNA #2 stated she was familiar with Resident #2 and that her trainer told her she could provide care for Resident #2 with one person. CNA #2 did not remember the name of her CNA trainer. CNA #2 stated she used two people for transfers because the resident required a mechanical lift. CNA #2 described the resident as non-verbal and as dependent upon staff for moving and turning in bed. CNA #2 stated the resident was total care and did nothing for herself. CNA #2 stated the resident's right hand was contracted and she sometimes put a washcloth in the hand to help with moisture. On 7/5/22 at 1:09 p.m., TNA #3 working on Resident #2's unit at the time of the fall was interviewed. TNA #3 stated on the evening of 6/11/22, CNA #2 came in the hall and asked for help. TNA #3 stated she and LPN #5 went to Resident #2's room and found her on the floor on her back beside the bed. TNA #3 stated the resident's forehead was bleeding and she put pressure on the wound with a cloth to stop the bleeding. TNA #3 stated she had worked in the facility about three months and had previously cared for Resident #2. TNA #3 stated the resident was totally dependent for care and required two people for bed mobility and transfers. TNA #3 stated Resident #2 did not move and was non-verbal. TNA #3 stated she previously cared for Resident #2 and stated, I used two persons always with her. On 7/5/22 at 2:50 p.m., the physical therapy assistant (PTA)/assistant rehab manager (other staff #3) was interviewed about Resident #2. The PTA stated the resident was evaluated and treated in May 2022 for impaired range of motion focusing on the right shoulder and elbow. The PTA stated Resident #2 was unable to straighten her right arm even after therapy. On 7/5/22 at 4:25 p.m., the director of nursing (DON), administrator and corporate nursing consultant (administration staff #3) met with the survey team about Resident #2's fall of 6/11/22. The nursing consultant stated they had reviewed the incident and the only issue identified was that the care plan had not been updated to indicate the resident required one-person assistance for bed mobility. The nursing consultant stated the reason the care plan needed updating was so the required bed mobility assistance would match the MDS. The survey team asked for a rationale of why the required amount of assistance for Resident #2 would be decreased and if there had been an improvement in her condition that changed her needs. There were no reasons provided by the nursing consultant or DON about why the resident's mobility assistance needed to change from two-person to one-person other than to match the MDS. On 7/5/22 at 4:45 p.m., CNA #4 that routinely cared for Resident #2 was interviewed. CNA #4 described Resident #2 as non-verbal and non-moving. CNA #4 stated two people were always required when performing incontinence care or transferring Resident #2. CNA #4 stated she got information about resident needs at shift change from other CNAs. CNA #4 stated she always changed Resident #2's brief with one person on one side of the bed and another staff person on the opposite side of the bed. On 7/5/22 at 4:55 p.m., LPN #3 that routinely cared for Resident #2 was interviewed. LPN #3 described Resident #2 as total care. LPN #3 stated the resident required a mechanical lift for transfers and required two people for bed mobility during incontinence care. LPN #3 stated the resident's body frequently stiffens up when moved making it more difficult to turn her in bed. On 7/6/22 at 8:38 a.m., LPN #4 that routinely cared for Resident #2 was interviewed. LPN #4 stated she had cared for Resident #2 for years and was familiar with her needs. LPN #4 stated the resident was total care and a high fall risk. LPN #4 stated the resident could sometimes grab the bed rail but required assistance from staff for turning and was transferred with a mechanical lift. LPN #4 stated if one person provided incontinence care you would have to use good body mechanics. When asked to explain, LPN #4 stated that meant pulling the resident toward you and not away from you. LPN #4 stated if the resident's foot, leg or upper body went over the bedside the resident was not able to hold herself or stop herself for falling. LPN #4 stated she always pulled the resident toward her when turning to prevent the resident from rolling or falling from bed. On 7/6/22 at 8:40 a.m., the registered nurse unit manager (RN #1) was interviewed about Resident #2 and the fall on 6/11/22. RN #1 stated the resident's care plan required for two-person assistance with bed mobility and transfers and that requirement had been in place since 2019. RN #1 stated staff members including CNAs were expected to follow the plan of care for all residents. RN #1 stated, The care plan states how we are supposed to care for residents. RN #1 stated Resident #2 at times nodded her head but had no upper body control or ability to manage movements in bed. RN #1 stated it was a standard of care to roll patients toward you and not away from you when rolling/turning in bed to ensure safety and prevent falls. RN #1 stated she did not know why CNA #2 turned the resident toward the opposite side of the bed on 6/11/22. RN #1 stated if unfamiliar with Resident #2, two staff persons were required to safely turn the resident for incontinence care. On 7/6/22 at 8:50 a.m., the facility's TNA instructor (RN #2) was interviewed about the proper protocol for turning residents in the bed with one-person assistance. The TNA instructor stated if one person was providing care for a dependent resident, they should pull the patient toward them so that the patient's body movement could be controlled and falls prevented. The TNA instructor stated the resident was also supposed to be in the center of the bed and not near the edge when positioned laterally for care. The TNA instructor stated the only time it would be appropriate to roll a resident away from your body was with a staff person on each side of the bed to ensure safety. The TNA instructor stated this technique for turning residents safely was part of her instruction manual for nurse aides and was included on the examination for nurse aide certification. On 7/6/22 at 9:08 a.m., the TNA instructor provided a copy of procedure 5-6 from her CNA instruction manual titled Turning a Resident from Supine to Side-Lying for Personal Care (undated). The procedure documented steps for turning a resident to their side with one staff person as, .Help the resident bend their knees and place their feet flat on the bed .Place one hand on the resident's shoulder that is farthest from you .Place you other hand on the hip farthest from you .On the count of three, help the resident roll toward you .Some residents may be more comfortable guiding the turn by holding on to the side rails . On 7/6/22 at 9:17 a.m., the DON and corporate nursing consultant met with the survey team regarding Resident #2's fall of 6/11/22. The nursing consultant stated CNA #2 did nothing wrong when Resident #2 fell from the bed on 6/11/22. The nursing consultant stated the resident was a one-person assist for bed mobility according to the MDS but the care plan had not been updated to reflect the one-person requirement. When asked if staff members were expected to follow the plan of care for residents, the nursing consultant stated CNAs went by the reports from nurses, reports from other CNAs, nursing assessments, shift reports, current status of resident and care given last. The nursing consultant stated, Things change rapidly. When asked if there was anything identified as needing correction and/or improvement based on investigation of Resident #2's fall, the nursing consultant stated, Everything was done right. The nursing consultant stated if a resident had plenty of room and could hold the bed rail, he had no problem rolling/pushing the resident away from him during care as long as the legs and arms were secured. When asked who was supposed to ensure safety for Resident #2 when she was turned in bed, the nursing consultant stated it was the responsibility of all staff members in the facility to keep residents safe. The nursing consultant stated nothing was identified that should have been done differently and described the incident as an unfortunate accident. On 7/6/22 at 10:35 a.m., the survey team met with the administrator, DON and corporate nursing consultant. During this meeting the survey team reviewed the additional interviews obtained with the unit manager (RN #1), TNA instructor (RN #2) and other staff members (CNA #4, LPN #3, LPN #4) that routinely cared for Resident #2. The nursing consultant stated these interviews were staff members just talking to a surveyor. The nursing consultant stated the unit manager's (RN #1's) response that two people were required with Resident #2 and that residents should be pulled toward you and not away when turned was speculating. The nursing consultant stated, This was just her (RN #1) talking to a surveyor. The nursing consultant stated he did not know where the information about how to turn a resident to side-lying position presented by the TNA instructor came from. The administrator and DON offered no further information or comment about Resident #2's fall on 6/11/22. CNA #2's most recent in-service education was dated 4/6/22 and included requirements for mandated reporting related to abuse/neglect, protocols for standard precautions/blood borne pathogens, a fall prevention in-service quiz, a test about use of positioning devices and a fall facts quiz. These findings were reviewed with the administrator, DON and corporate nursing consultant during a meeting on 7/6/22 at 10:40 a.m. This is a complaint deficiency.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility failed to ensure one of fifty-eight residents in the survey sample did not have a significant weight loss, and failed to ensure six of fifty eight residents received tube feeding and flushes for hydration as ordered by the physician. Resident #204 lost a total of 57.7 pounds (23.89%) from the time of admission on 08/07/2021 until his hospital admission on 10/24/2021. The significant weight loss was not identified by facility staff and no nutrition interventions were put into place to prevent further loss, resulting in harm. Residents #208, #209, #210, #247, #201 and #222 did not receive tube feedings or flushes for hydration from 7:00 p.m. on 02/07/2022 until 07:00 a.m. on 02/08/2022. Findings were: 1. Resident #204 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/07/2021 assessed Resident #204 as severely impaired with a cognitive summary score of 05. Under section K0200 Height and Weight Resident #204's height was listed as 70 inches, no weight was recorded, and section K0300 Weight Loss was coded as No or unknown. Resident #204's clinical record was reviewed on 02/08/2022 beginning at approximately 2:00 p.m and included the following: An admission assessment dated [DATE] which included, F. Cardiac/Circulation and assessed Resident #204's Pulse as Regular rate and rhythm. Also, under Section F were questions regarding [CONDITION(S)]: [CONDITION(S)] present, Location of [CONDITION(S)], Pitting, none of those questions were marked as present. Resident #204's capillary refill was documented as (symbol meaning less than or equal to) 3 sec (seconds) -Normal. A Rehabilitation Services Screen was completed by the speech language patholigist on 08/09/2021. A speech therapy evaluation was not recommended. The current diet order was Heart Healthy diet Level 7 - Regular texture, Regular Liquids consistency. No fluid restriction was ordered. The current care plan included, Nutrition Risk r/t (related to) recent hospitalization , medical dxs (diagnoses), therapeutic diet d/t [CONDITION(S)] (due to hypertension) and [CONDITION(S)], elevated BMI. Focus: Resident will avoid significant weight change through next review. Interventions included: Weights per protocol, Monitor/document/report PRN (as needed) s/sx of dysphagia (difficulty swallowing) . The following weights were recorded: 08/07/2021 242.88 lbs (pounds) 09/01/2021 241.2 lbs 10/04/2021 198.3 lbs The weight from 10/04/2021 had been stricken through and a note from the RD (registered dietitian) was written on 10/07/2021 indicating, Incorrect Documentation. There were no other weights in the clinical record. A Malnutrition Universal Screening Tool was completed for Resident #204 on 08/09/2021, 08/24/2021, and 09/06/2021. All three tools documents were identical using the admission weight from 08/07/2021. Resident #204 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] > 5 days? was marked as No. All three documents were completed by the RD. There was no other nutrition assessment or documentation by the RD. The following note was written on 10/07/2021, Culinary Director spoke to resident at bedside about the dining program and reviewed food preferences. Dietary management system updated and IDT (inter-disciplinary team) will honor resident's preferences and requests. Culinary Director if available to follow up with resident to review food preferences as consulted or requested. A note written on 10/21/2021 documented, Ate 50% or less for 2 or more meals in one day. Offered a snack after meal. There were no other notes in the clinical record regarding meal/ fluid intake or weights. At approximately 2:30 p.m. on 02/08/2022, the DON (director of nursing) was interviewed about the weight protocol used by the facility. She stated, We weigh everyone within 24 hours of admission, weekly for four weeks, and everyone is weighed at least monthly unless they refuse .if they refuse we document that in the progress notes. Then we notify the physician and the RP (responsible party) and of course we try again later or the next day. Resident #204 was sent to a local hospital on 10/24/2021 after being observed by the nursing staff as very lethargic, cold to touch with shallow breathing. A progress noted in the clinical record dated 10/25/2021 documented: Resident admitted for AKI (acute kidney injury), [CONDITION(S)], septic shock, dehydration, elevated troponins, chronic [CONDITION(S)]. Hospital records were reviewed. The emergency department note written on 10/24/2021 documented that Resident #204 weighed 84 kilograms (185.18 pounds) at the time of arrival to the emergency room . A difference of 57.7 pounds (23.8%) since his admission to the facility on [DATE]. On 02/10/2022 at 10:45 a.m., the RD was interviewed regarding Resident #204. He was asked why he had marked through the weight recorded in the clinical record on 10/04/2021. He stated, I am sure we discussed that as a team. I marked through it because it is very unlikely that someone would lose that much weight in a month .it was likely to be inaccurate. We usually weigh the residents on Monday and then we meet on Thursdays .he should have been reweighed before that meeting. The RD was asked if he had asked for a reweigh on Resident #204. He stated, No, I don't ask for reweights. He was asked if he felt marking through a licensed nurse's documentation and labeling it as inaccurate without discussing it with the nurse was appropriate. He stated, The resident's weight was stable for the first month, it is unlikely that he lost 50 pounds in one month. The RD was informed of Resident #204's weight at the time of admission to the hospital. He stated, I don't know that I would have done anything differently .the policy states the weight will be verified within five days when there is a variance of five pounds .nursing should have reweighed him. The RD was asked how he knew whether or not the weight he struck was a reweight. He stated, That's a good point. The nurse practitioner that cared for Resident #204 was interviewed on 02/10/2022 at 11:45 a.m. She was asked if she had noticed Resident #204 losing weight. She stated, I only saw him acutely when something happened .I saw him in August for behaviors, in September because he broke his glasses and he had a sore on his nose, and again because he had a fall. I did his recert in October and I used the weight from September .I didn't notice that his weight didn't look right .If I see someone for weights it is because it has been brought to my attention by the nursing staff or the RD. I don't remember anyone mentioning that. On 02/10/2022 at 12:10 p.m., during a meeting with the DON, the administrator and two corporate nurse consultants, the above information was discussed. Concerns were voiced that Resident #204 had lost 23.8% of his body weight while at the facility; weights were not obtained per facility protocol; and weights had been marked through in the clinical record by the RD without follow-up. There was no documentation in the clinical record regarding Resident #204 refusing to eat, refusing to be weighed, or any interventions to monitor his weight and/or prevent weight loss. The DON was asked what should have happened. She stated, He should have been weighed per our policy, a reweight should have been obtained. LPN #1 who documented the weight on 10/04/2021 that was marked through by the RD was interviewed on 02/10/2022 at approximately 2:40 p.m. She was asked if she remembered Resident #204. She confirmed that she did. She was asked about the weight obtained on 10/04/2021 and if a reweight had been obtained due to the difference of 44 pounds since the previous weight. She stated, I am sure that was the reweight. She was asked if Resident #204 had been refusing to eat. She stated, He fed himself, I don't remember him refusing to eat. On 02/20/2022, at approximately 2:45 p.m., CNA (certified nursing assistant) #2 was interviewed about Resident #204. She stated, I never took care of him .but I remember him. He drank his drinks, sometimes he refused to eat. She was asked if the nursing staff had been notified that he refused to eat and how often that happened. She stated, I'm not sure how often it happened, I don't know if anyone told the nurses or not. At 3:00 p.m. on 02/10/2022 two additional CNAs were interviewed about Resident #204. CNA #4 stated that she had taken care of Resident #204, He fed himself, he hardly ate . CNA #5 stated, He was mean, he ate a lot of fruit. The policy Weight Monitoring and Tracking dated 11/01/2019 contained the following: The Director of Nursing is responsible for ensuring patients are weighed in a timely manner .Nursing staff is responsible for recording weight in the patient medical record; All patients will be weighed on admission/readmission and weekly X 4 weeks, or until the interdisciplinary team determines weight is stable, then monthly thereafter if weight is stable; Weights will be verified within five days when a weight variance of 5 # (pounds) from last weight and/or significant weight change is identified. No further information was obtained prior to the exit conference on 02/10/2022. 2. Resident #208 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: dysphagia, [CONDITION(S)], acute kidney failure, depression, and hypertension. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/20/2021, assessed Resident #208 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #208's clinical record included the following physician orders: Enteral Feed Order every 4 hours 220 ml H2O flush via PEG tube Enteral Feed Order every 4 hours [MEDICATION(S)] 1.5 @ 237 ml bolus feed via PEG tube The care plan was reviewed and included, The resident requires tube feeding r/t (related to) dysphagia, swallowing problem. He is at risk for aspiration with lowering HOB (head of bed) . Interventions included: Provide TF (tube feeding) per order; Provide water flushes per MD order. Review of Resident #208's February MAR (medication administration record) documented water flushes were not provided at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/022, for a total of 660 cc of water not given. Resident #208 also did not receive [MEDICATION(S)] 1.5 bolus feedings at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/2022, for a total of 711 cc (1066.5 calories) of tube feeding not provided. 3. Resident #209 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: cerebral infarct, [CONDITION(S)], [CONDITION(S)], and hypertension. A quarterly MDS with an ARD of 12/23/2021, assessed Resident #209 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #209's clinical record included the following physician orders: Enteral Feed Order every 4 hours 200 ml H2O flush via PEG tube Enteral Feed Order every 4 hours [MEDICATION(S)] 1.5 @ 237 ml bolus feed via PEG tube The care plan was reviewed and included, The resident requires tube feeding r/t dysphagia. Interventions included: Provide TF per order; Provide water flushes per MD order. Review of Resident #209's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #208 also did not receive [MEDICATION(S)] 1.5 bolus feedings at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/2022, for a total of 711 cc (1066.5 calories) of tube feeding not provided. 4. Resident #210 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: cerebral infarct, Alzheimer's, adult failure to thrive, and dysphagia. A quarterly MDS with an ARD of 11/29/2021, assessed Resident #210 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #210's clinical record included the following physician orders: Enteral Feed Order every 4 hours 300 ml H2O flush via PEG tube Enteral Feed Order 4 times per day for nutrition [MEDICATION(S)] 1.5 Cal @ 237 ml bolus via PEG tube The care plan was reviewed and included,The resident requires tube feeding r/t inability to consume adequate po (by mouth) to maintain weight, and adequate nutritional status d/t (due to) feeding problems r/t dx (diagnoses) dementia, multiple [CONDITION(S)] (cerebral vascular accidents), slightly elevate BMI. Interventions included: Provide TF per order; Provide water flushes per order. Review of Resident #210's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #210 also did not receive [MEDICATION(S)] 1.5 Cal bolus feedings at midnight and 6:00 a.m. on 02/08/2022, for a total of 474 cc (711 calories) of tube feeding not provided. 5. Resident #247 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Peripheral vascular disease, hypertension, [CONDITION(S)], and dysphagia. An annual MDS with an ARD of 11/18/2021 assessed Resident #247 as moderately impaired with a cognitive summary score of 10. Resident #247's clinical record included the following physician orders: Enteral Feed Order every 6 hours 275 ml H2O flush via PEG tube The care plan was reviewed and included,The resident requires tube feeding r/t swallowing problem. Interventions included: Provide water flushes per MD order. Review of Resident #247's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The above information was discussed with the director of nursing, the administrator, and both nurse consultants, during a meeting at approximately 12:15 p.m. on 02/10/2022. No further information was obtained prior to the exit conference on 02/10/2022. 6. Resident #201 was admitted to the facility on [DATE] with a readmission on 1/12/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #201 with severely impaired cognitive skills. Resident #201's clinical record documented current physician orders for the following enteral feedings/flushes to meet the resident's nutritional and hydration needs: 7/10/21 - Enteral feed order - [MEDICATION(S)] 1.5 @ 474 ml (milliliters) bolus three times per day 7/10/21 - Flush feed tube with 250 ml of water every 4 hours 1/13/21 - Flush feed tube with 20 to 30 ml of water before and after each medication pass Resident #201's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This amount was 1/3 of the resident's daily feeding formula requirement (711 calories). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications scheduled for 2/7/22 at 8:00 p.m., 9:00 and on 2/8/22 at 6:00 a.m. were not administered and therefore no water was provided with medication passes. Resident #201's plan of care (revised 2/1/22) documented the resident was at risk of dehydration, was at nutritional risk due NPO (nothing by mouth) status and requirement for tube feeding due to dysphagia and [CONDITION(S)] dysmotility. Interventions to prevent dehydration, prevent weight loss and avoid tube feeding complications included, .Monitor/document report PRN s/sx (signs/symptoms) of dehydration .the HOB (head of bed) elevated 30-45 degrees at all times .Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 500 cc aspirate .Monitor/document/report PRN (as needed) s/sx of: Aspiration .Provide TF (tube feeding) as ordered .Provide water flushes per MD order .Provide Tube Feeding and water flushes per order . 7. Resident #222 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #222 as comatose with cognitive skills unable to be assessed. Resident #222's clinical record documented current physician orders for the following enteral feedings/flushes to meet the resident's nutritional and hydration needs: 12/2/20 - Enteral feeding of [MEDICATION(S)] 1.0 at 70 ml/hour via PEG (percutaneous endoscopic gastrostomy) 6/18/20 - Water flushes 150 ml every 4 hours via PEG tube Resident #222's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in 450 ml out of the ordered 900 ml daily water (50%) not administered. Resident #222's plan of care (revised 12/2/21) documented the resident was at risk of dehydration due to tube feeding, required tube feeding due to dysphagia, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions to prevent dehydration, weight loss and complications from tube feeding included, .Administer medications as ordered .Monitor/document/report PRN any s/sx of dehydration .observe for further episodes of vomiting and observe for signs of aspiration .the HOB elevated 30-45 degrees during and thirty minutes after tube feed .Check tube for placement and gastric contents/residual volume per facility protocol and record .Provide TF and flushes as ordered . On 2/8/22 at 3:35 p.m., the administrator, DON and corporate consultant (administration staff #3) met with the survey team and reported that no physician ordered medications and/or treatments were administered to any of the residents on the West unit from 2/7/22 at 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated LPN #2 was the house supervisor that evening and could have reassigned the nurses working on the facility's three units (East, South and West). The DON stated LPN #2, LPN #3 and LPN #4 worked in the building on the evening of 2/7/22 until 11:00 p.m. The DON stated LPN #2 and LPN #4 left on 2/7/22 at 11:00 p.m. with two nurses scheduled for the building starting at 11:00 p.m. The DON stated LPN #3 was on the East unit, LPN #5 was assigned to South unit and the two nurses were supposed to split the West unit. On 2/8/22 at 4:45 p.m., the administrator, DON and corporate consultant met again with the survey team. The DON stated last night (2/7/22) that two nurses (LPN #3 and LPN #5) were the only nurses in the building from 11:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated when only two nurses worked the building that they (nurses) knew to split the West unit. The DON stated there was no house supervisor on the night shift. On 2/8/22 at 5:10 p.m., the DON again stated that all prescribed medications and treatments were not administered on West unit on the 2/7/22 from 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated, There was a miscommunication at shift change. These findings were reviewed with the administrator, director of nursing and corporate consultant during a meeting on 2/9/22 at 3:00 p.m. No further information was provided to the survey team regarding the missed enteral feedings and flushes.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility failed to ensure one of fifty-eight residents in the survey sample did not have a significant weight loss, and failed to ensure six of fifty eight residents received tube feeding and flushes for hydration as ordered by the physician. Resident #204 lost a total of 57.7 pounds (23.89%) from the time of admission on 08/07/2021 until his hospital admission on 10/24/2021. The significant weight loss was not identified by facility staff and no nutrition interventions were put into place to prevent further loss, resulting in harm. Residents #208, #209, #210, #247, #201 and #222 did not receive tube feedings or flushes for hydration from 7:00 p.m. on 02/07/2022 until 07:00 a.m. on 02/08/2022. Findings were: 1. Resident #204 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/07/2021 assessed Resident #204 as severely impaired with a cognitive summary score of 05. Under section K0200 Height and Weight Resident #204's height was listed as 70 inches, no weight was recorded, and section K0300 Weight Loss was coded as No or unknown. Resident #204's clinical record was reviewed on 02/08/2022 beginning at approximately 2:00 p.m and included the following: An admission assessment dated [DATE] which included, F. Cardiac/Circulation and assessed Resident #204's Pulse as Regular rate and rhythm. Also, under Section F were questions regarding [CONDITION(S)]: [CONDITION(S)] present, Location of [CONDITION(S)], Pitting, none of those questions were marked as present. Resident #204's capillary refill was documented as (symbol meaning less than or equal to) 3 sec (seconds) -Normal. A Rehabilitation Services Screen was completed by the speech language patholigist on 08/09/2021. A speech therapy evaluation was not recommended. The current diet order was Heart Healthy diet Level 7 - Regular texture, Regular Liquids consistency. No fluid restriction was ordered. The current care plan included, Nutrition Risk r/t (related to) recent hospitalization , medical dxs (diagnoses), therapeutic diet d/t [CONDITION(S)] (due to hypertension) and [CONDITION(S)], elevated BMI. Focus: Resident will avoid significant weight change through next review. Interventions included: Weights per protocol, Monitor/document/report PRN (as needed) s/sx of dysphagia (difficulty swallowing) . The following weights were recorded: 08/07/2021 242.88 lbs (pounds) 09/01/2021 241.2 lbs 10/04/2021 198.3 lbs The weight from 10/04/2021 had been stricken through and a note from the RD (registered dietitian) was written on 10/07/2021 indicating, Incorrect Documentation. There were no other weights in the clinical record. A Malnutrition Universal Screening Tool was completed for Resident #204 on 08/09/2021, 08/24/2021, and 09/06/2021. All three tools documents were identical using the admission weight from 08/07/2021. Resident #204 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] > 5 days? was marked as No. All three documents were completed by the RD. There was no other nutrition assessment or documentation by the RD. The following note was written on 10/07/2021, Culinary Director spoke to resident at bedside about the dining program and reviewed food preferences. Dietary management system updated and IDT (inter-disciplinary team) will honor resident's preferences and requests. Culinary Director if available to follow up with resident to review food preferences as consulted or requested. A note written on 10/21/2021 documented, Ate 50% or less for 2 or more meals in one day. Offered a snack after meal. There were no other notes in the clinical record regarding meal/ fluid intake or weights. At approximately 2:30 p.m. on 02/08/2022, the DON (director of nursing) was interviewed about the weight protocol used by the facility. She stated, We weigh everyone within 24 hours of admission, weekly for four weeks, and everyone is weighed at least monthly unless they refuse .if they refuse we document that in the progress notes. Then we notify the physician and the RP (responsible party) and of course we try again later or the next day. Resident #204 was sent to a local hospital on 10/24/2021 after being observed by the nursing staff as very lethargic, cold to touch with shallow breathing. A progress noted in the clinical record dated 10/25/2021 documented: Resident admitted for AKI (acute kidney injury), [CONDITION(S)], septic shock, dehydration, elevated troponins, chronic [CONDITION(S)]. Hospital records were reviewed. The emergency department note written on 10/24/2021 documented that Resident #204 weighed 84 kilograms (185.18 pounds) at the time of arrival to the emergency room . A difference of 57.7 pounds (23.8%) since his admission to the facility on [DATE]. On 02/10/2022 at 10:45 a.m., the RD was interviewed regarding Resident #204. He was asked why he had marked through the weight recorded in the clinical record on 10/04/2021. He stated, I am sure we discussed that as a team. I marked through it because it is very unlikely that someone would lose that much weight in a month .it was likely to be inaccurate. We usually weigh the residents on Monday and then we meet on Thursdays .he should have been reweighed before that meeting. The RD was asked if he had asked for a reweigh on Resident #204. He stated, No, I don't ask for reweights. He was asked if he felt marking through a licensed nurse's documentation and labeling it as inaccurate without discussing it with the nurse was appropriate. He stated, The resident's weight was stable for the first month, it is unlikely that he lost 50 pounds in one month. The RD was informed of Resident #204's weight at the time of admission to the hospital. He stated, I don't know that I would have done anything differently .the policy states the weight will be verified within five days when there is a variance of five pounds .nursing should have reweighed him. The RD was asked how he knew whether or not the weight he struck was a reweight. He stated, That's a good point. The nurse practitioner that cared for Resident #204 was interviewed on 02/10/2022 at 11:45 a.m. She was asked if she had noticed Resident #204 losing weight. She stated, I only saw him acutely when something happened .I saw him in August for behaviors, in September because he broke his glasses and he had a sore on his nose, and again because he had a fall. I did his recert in October and I used the weight from September .I didn't notice that his weight didn't look right .If I see someone for weights it is because it has been brought to my attention by the nursing staff or the RD. I don't remember anyone mentioning that. On 02/10/2022 at 12:10 p.m., during a meeting with the DON, the administrator and two corporate nurse consultants, the above information was discussed. Concerns were voiced that Resident #204 had lost 23.8% of his body weight while at the facility; weights were not obtained per facility protocol; and weights had been marked through in the clinical record by the RD without follow-up. There was no documentation in the clinical record regarding Resident #204 refusing to eat, refusing to be weighed, or any interventions to monitor his weight and/or prevent weight loss. The DON was asked what should have happened. She stated, He should have been weighed per our policy, a reweight should have been obtained. LPN #1 who documented the weight on 10/04/2021 that was marked through by the RD was interviewed on 02/10/2022 at approximately 2:40 p.m. She was asked if she remembered Resident #204. She confirmed that she did. She was asked about the weight obtained on 10/04/2021 and if a reweight had been obtained due to the difference of 44 pounds since the previous weight. She stated, I am sure that was the reweight. She was asked if Resident #204 had been refusing to eat. She stated, He fed himself, I don't remember him refusing to eat. On 02/20/2022, at approximately 2:45 p.m., CNA (certified nursing assistant) #2 was interviewed about Resident #204. She stated, I never took care of him .but I remember him. He drank his drinks, sometimes he refused to eat. She was asked if the nursing staff had been notified that he refused to eat and how often that happened. She stated, I'm not sure how often it happened, I don't know if anyone told the nurses or not. At 3:00 p.m. on 02/10/2022 two additional CNAs were interviewed about Resident #204. CNA #4 stated that she had taken care of Resident #204, He fed himself, he hardly ate . CNA #5 stated, He was mean, he ate a lot of fruit. The policy Weight Monitoring and Tracking dated 11/01/2019 contained the following: The Director of Nursing is responsible for ensuring patients are weighed in a timely manner .Nursing staff is responsible for recording weight in the patient medical record; All patients will be weighed on admission/readmission and weekly X 4 weeks, or until the interdisciplinary team determines weight is stable, then monthly thereafter if weight is stable; Weights will be verified within five days when a weight variance of 5 # (pounds) from last weight and/or significant weight change is identified. No further information was obtained prior to the exit conference on 02/10/2022. 2. Resident #208 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: dysphagia, [CONDITION(S)], acute kidney failure, depression, and hypertension. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 12/20/2021, assessed Resident #208 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #208's clinical record included the following physician orders: Enteral Feed Order every 4 hours 220 ml H2O flush via PEG tube Enteral Feed Order every 4 hours [MEDICATION(S)] 1.5 @ 237 ml bolus feed via PEG tube The care plan was reviewed and included, The resident requires tube feeding r/t (related to) dysphagia, swallowing problem. He is at risk for aspiration with lowering HOB (head of bed) . Interventions included: Provide TF (tube feeding) per order; Provide water flushes per MD order. Review of Resident #208's February MAR (medication administration record) documented water flushes were not provided at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/022, for a total of 660 cc of water not given. Resident #208 also did not receive [MEDICATION(S)] 1.5 bolus feedings at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/2022, for a total of 711 cc (1066.5 calories) of tube feeding not provided. 3. Resident #209 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: cerebral infarct, [CONDITION(S)], [CONDITION(S)], and hypertension. A quarterly MDS with an ARD of 12/23/2021, assessed Resident #209 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #209's clinical record included the following physician orders: Enteral Feed Order every 4 hours 200 ml H2O flush via PEG tube Enteral Feed Order every 4 hours [MEDICATION(S)] 1.5 @ 237 ml bolus feed via PEG tube The care plan was reviewed and included, The resident requires tube feeding r/t dysphagia. Interventions included: Provide TF per order; Provide water flushes per MD order. Review of Resident #209's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #208 also did not receive [MEDICATION(S)] 1.5 bolus feedings at 8:00 p.m. on 02/07/2022, or at midnight and 4:00 a.m. on 02/08/2022, for a total of 711 cc (1066.5 calories) of tube feeding not provided. 4. Resident #210 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: cerebral infarct, Alzheimer's, adult failure to thrive, and dysphagia. A quarterly MDS with an ARD of 11/29/2021, assessed Resident #210 as having problems with both long and short term memory and severely impaired with daily decision making skills. Resident #210's clinical record included the following physician orders: Enteral Feed Order every 4 hours 300 ml H2O flush via PEG tube Enteral Feed Order 4 times per day for nutrition [MEDICATION(S)] 1.5 Cal @ 237 ml bolus via PEG tube The care plan was reviewed and included,The resident requires tube feeding r/t inability to consume adequate po (by mouth) to maintain weight, and adequate nutritional status d/t (due to) feeding problems r/t dx (diagnoses) dementia, multiple [CONDITION(S)] (cerebral vascular accidents), slightly elevate BMI. Interventions included: Provide TF per order; Provide water flushes per order. Review of Resident #210's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #210 also did not receive [MEDICATION(S)] 1.5 Cal bolus feedings at midnight and 6:00 a.m. on 02/08/2022, for a total of 474 cc (711 calories) of tube feeding not provided. 5. Resident #247 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Peripheral vascular disease, hypertension, [CONDITION(S)], and dysphagia. An annual MDS with an ARD of 11/18/2021 assessed Resident #247 as moderately impaired with a cognitive summary score of 10. Resident #247's clinical record included the following physician orders: Enteral Feed Order every 6 hours 275 ml H2O flush via PEG tube The care plan was reviewed and included,The resident requires tube feeding r/t swallowing problem. Interventions included: Provide water flushes per MD order. Review of Resident #247's February MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The above information was discussed with the director of nursing, the administrator, and both nurse consultants, during a meeting at approximately 12:15 p.m. on 02/10/2022. No further information was obtained prior to the exit conference on 02/10/2022. Surveyor: Wood, Norma 6. Resident #201 was admitted to the facility on [DATE] with a readmission on 1/12/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #201 with severely impaired cognitive skills. Resident #201's clinical record documented current physician orders for the following enteral feedings/flushes to meet the resident's nutritional and hydration needs: 7/10/21 - Enteral feed order - [MEDICATION(S)] 1.5 @ 474 ml (milliliters) bolus three times per day 7/10/21 - Flush feed tube with 250 ml of water every 4 hours 1/13/21 - Flush feed tube with 20 to 30 ml of water before and after each medication pass Resident #201's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This amount was 1/3 of the resident's daily feeding formula requirement (711 calories). The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Medications scheduled for 2/7/22 at 8:00 p.m., 9:00 and on 2/8/22 at 6:00 a.m. were not administered and therefore no water was provided with medication passes. Resident #201's plan of care (revised 2/1/22) documented the resident was at risk of dehydration, was at nutritional risk due NPO (nothing by mouth) status and requirement for tube feeding due to dysphagia and [CONDITION(S)] dysmotility. Interventions to prevent dehydration, prevent weight loss and avoid tube feeding complications included, .Monitor/document report PRN s/sx (signs/symptoms) of dehydration .the HOB (head of bed) elevated 30-45 degrees at all times .Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than 500 cc aspirate .Monitor/document/report PRN (as needed) s/sx of: Aspiration .Provide TF (tube feeding) as ordered .Provide water flushes per MD order .Provide Tube Feeding and water flushes per order . 7. Resident #222 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #222 as comatose with cognitive skills unable to be assessed. Resident #222's clinical record documented current physician orders for the following enteral feedings/flushes to meet the resident's nutritional and hydration needs: 12/2/20 - Enteral feeding of [MEDICATION(S)] 1.0 at 70 ml/hour via PEG (percutaneous endoscopic gastrostomy) 6/18/20 - Water flushes 150 ml every 4 hours via PEG tube Resident #222's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in 450 ml out of the ordered 900 ml daily water (50%) not administered. Resident #222's plan of care (revised 12/2/21) documented the resident was at risk of dehydration due to tube feeding, required tube feeding due to dysphagia, had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions to prevent dehydration, weight loss and complications from tube feeding included, .Administer medications as ordered .Monitor/document/report PRN any s/sx of dehydration .observe for further episodes of vomiting and observe for signs of aspiration .the HOB elevated 30-45 degrees during and thirty minutes after tube feed .Check tube for placement and gastric contents/residual volume per facility protocol and record .Provide TF and flushes as ordered . On 2/8/22 at 3:35 p.m., the administrator, DON and corporate consultant (administration staff #3) met with the survey team and reported that no physician ordered medications and/or treatments were administered to any of the residents on the West unit from 2/7/22 at 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated LPN #2 was the house supervisor that evening and could have reassigned the nurses working on the facility's three units (East, South and West). The DON stated LPN #2, LPN #3 and LPN #4 worked in the building on the evening of 2/7/22 until 11:00 p.m. The DON stated LPN #2 and LPN #4 left on 2/7/22 at 11:00 p.m. with two nurses scheduled for the building starting at 11:00 p.m. The DON stated LPN #3 was on the East unit, LPN #5 was assigned to South unit and the two nurses were supposed to split the West unit. On 2/8/22 at 4:45 p.m., the administrator, DON and corporate consultant met again with the survey team. The DON stated last night (2/7/22) that two nurses (LPN #3 and LPN #5) were the only nurses in the building from 11:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated when only two nurses worked the building that they (nurses) knew to split the West unit. The DON stated there was no house supervisor on the night shift. On 2/8/22 at 5:10 p.m., the DON again stated that all prescribed medications and treatments were not administered on West unit on the 2/7/22 from 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated, There was a miscommunication at shift change. These findings were reviewed with the administrator, director of nursing and corporate consultant during a meeting on 2/9/22 at 3:00 p.m. No further information was provided to the survey team regarding the missed enteral feedings and flushes.

Based on resident interview, staff interview and clinical record review, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to fifty-four of 58 residents in the survey sample. Residents residing on the West unit that included Residents #201, #203, #205, #207 through #228 and #230 through #258, were not provided physician ordered medications and/or treatments during twelve consecutive hours starting on the evening of 2/7/22 due to no nurse working the unit. Resident #207 experienced significant pain after missing scheduled doses of narcotic medication when no nurse worked or came to the unit to administer medications, resulting in harm. The findings include: Resident #207 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #207 as cognitively intact. Resident #207's clinical record documented current physician orders that included the following medications and treatments. [MEDICATION(S)] 150 mg at bedtime for depression [MEDICATION(S)] 900 mg three times per day for [CONDITION(S)] [MEDICATION(S)] 2.5 mg every 8 hours for pain [MEDICATION(S)] 30 mg four times per day for pain [MEDICATION(S)] diaper rash cream 15% to bilateral inner thighs topically each day and evening shift for chaffing Resident #207's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was scheduled to be administered on 2/7/22 at 9:00 p.m., [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were scheduled for 2/8/22 at 12:00 a.m. and an additional dose of [MEDICATION(S)] was scheduled for 2/8/22 at 6:00 a.m. On 2/8/22 at 2:05 p.m., the licensed practical nurse (LPN) #1 working on Resident #205's unit (West unit) was interviewed. LPN #1 stated she worked on 2/7/22 from 7:00 a.m. until 7:00 p.m. LPN #1 stated there was no nurse on the West unit when she left on 2/7/22 around 7:30 p.m. and she gave a verbal report to the unit manager on East unit prior to leaving the building. LPN #1 stated there was no nurse on the West unit when she arrived this morning (2/8/22) at 7:00 a.m. LPN #1 stated she did not know who was scheduled to work the evening and night shifts on West unit. LPN #1 stated there was currently no unit manager for the West unit. On 2/8/22 at 2:10 p.m., the director of nursing (DON) was interviewed about medications not administered to residents on the West unit on the evening of 2/7/22 and early morning of 2/8/22. The DON stated nurses had 24 hours to clarify and sign off a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON had no explanation why the residents did not receive medications on the evening of 2/7/22 and stated she would research and clarify. The DON stated, We did have agency nurses last night. The DON stated LPN #2, LPN #3 and LPN #4 worked the evening shift. The DON stated that LPN #2 was the East unit manager and house supervisor on the 2/7/22 evening shift. On 2/8/22 at 3:35 p.m., the administrator, DON and corporate consultant (administration staff #3) met with the survey team and reported that no physician ordered medications and/or treatments were administered to any of the fifty-four residents on the West unit from 2/7/22 at 7:00 p.m. until 2/8/22 at 7:00 a.m. The corporate consultant stated LPN #1 reported to the East unit manager (LPN #2) that all the evening medications on the West unit had been given when she left on 2/7/22 around 7:30 p.m. The DON stated LPN #2 was the house supervisor that evening and could have reassigned the nurses working on the facility's three units (East, South and West). The DON stated LPN #2 did not give medications on West during the evening shift because LPN#1 reported that all the medications on the unit had been given. The DON stated, There was a miscommunication at the shift change. The DON stated LPN #2, LPN #3 and LPN #4 worked in the building on the evening of 2/7/22 until 11:00 p.m. The DON stated LPN #2 and LPN #4 left on 2/7/22 at 11:00 p.m. with two nurses scheduled for the building starting at 11:00 p.m. The DON stated there was a call out on 2/7/22 prior to the night shift (11:00 p.m. to 7:00 a.m.) leaving LPN #3 as the only nurse in the building. The DON stated agency was contacted and LPN #5 reported to work on 2/7/22 at 11:00 p.m. The DON stated LPN #3 was on the East unit, LPN #5 was assigned to South unit and the two nurses were supposed to split the West unit. On 2/8/22 at 3:45 p.m., the East unit manager (LPN #2) was interviewed. LPN #2 stated she was working on East unit on 2/7/22 for 3:00 p.m. to 11:00 p.m. shift. LPN #2 stated that on 2/7/22 around 7:30 p.m., LPN #1 from West reported to her that she was leaving and all the medications on West unit had been given. LPN #2 stated she did not go to the West unit prior to leaving her shift at 11:00 p.m. LPN #2 stated, I couldn't do nothing. I was giving meds (medications) on East. LPN #2 stated there was no nurse on the West unit on 2/7/22 after 7:30 p.m. when LPN #1 went home, and she thought LPN #1 had given all the evening medications. LPN #2 stated, Nobody reported to me they didn't get meds. I wasn't aware. LPN #2 stated she and LPN #4 left the building on 2/7/22 at 11:00 p.m. leaving LPN #3 working the East unit until 2/8/22 at 7:00 a.m. LPN #2 stated an agency nurse was called in and reported to South unit on 2/7/22 around 11:00 p.m. to work the night shift. On 2/8/22 at 4:45 p.m., the administrator, DON and corporate consultant met again with the survey team. The DON stated on 2/7/22, that two nurses (LPN #3 and LPN #5) were the only nurses in the building from 11:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated when only two nurses worked the building that they (nurses) knew to split the West unit. The DON stated there was no house supervisor on the night shift. On 2/8/22 at 5:10 p.m., the DON stated that all prescribed medications and treatments were not administered on West unit on the 2/7/22 from 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated again, There was a miscommunication at shift change. LPN #3 stated she was assigned to work the East unit and helped out on the South unit after 7:00 p.m. LPN #3 stated on 2/7/22 at 11:00 p.m. she went back to the East unit, as LPN #5 came in to cover South after the scheduled nurse called out. LPN #3 stated she was not assigned to work the West unit. LPN #3 stated there were two nurses on West unit on 2/7/22 until 7:00 p.m. LPN #3 stated again she was never assigned to West unit on 2/7/22 and she was not aware there was no nurse on West unit until around 11:30 p.m. when Resident #207 called her on the phone and asked for her [MEDICATION(S)] pain medication. LPN #3 stated, I didn't know there was no nurse back there (West unit) until then. LPN #3 stated she told Resident #207 that she could not give her the medication because it was a narcotic and she did not count the narcotics on that unit at shift change. LPN #3 stated she was not comfortable giving narcotics on that unit because it might come back on me if the counts were wrong. LPN #3 stated after 2/7/22 at 11:00 p.m., she and LPN #5 were the only nurses in the building along with three CNAs. LPN #3 stated she did not check on residents on the West unit because she was working East. LPN #3 stated she told the CNA working on West to let her know of any problems. On 2/8/22 at 5:35 p.m., Resident #207 was interviewed about any missed medications on the evening of 2/7/22. Resident #207 stated she did not get any of her medications on 2/7/22 after 7:00 p.m. until 2/8/22 at 11:00 a.m. Resident #207 stated that on 2/7/22 she missed a 9:00 p.m. dose of [MEDICATION(S)], on 2/8/22 at 12:00 a.m. missed a dose of [MEDICATION(S)], [MEDICATION(S)] and a psych med and missed another dose of [MEDICATION(S)] scheduled for 2/8/22 at 6:00 a.m. Resident #207 stated that on 2/7/22 around 11:30 p.m., she reported to the CNA (certified nursing assistant) #5 that she needed a nurse to get her scheduled pain medications. Resident #207 stated CNA #5 checked with the nurse on East unit and reported to her that she was out of luck as there was no nurse on the unit (West). Resident #207 stated she called on her cell phone to the East unit and asked LPN (licensed practical nurse) #3 if she would come and give her the pain medications. Resident #207 stated LPN #3 told her no and that she was not her assigned nurse. Resident #207 stated when she asked who her assigned nurse was, LPN #3 told her she did not have a nurse this shift. Resident #207 stated she then called the other unit (South). Resident #207 stated whoever answered the phone on South stated the nurse was in with a resident. Resident #207 stated she reported that she needed her pain, psych meds and asked for the nurse to call her when possible. Resident #207 stated she did not know who answered the phone but that person told her if the nurse could come she would and if not, she (nurse) won't. Resident #207 stated she never got a visit or a call from either nurse. Resident #207 stated there was a CNA working the unit on the evening/night of 2/7/22 but she saw no nurse after 7:00 p.m. until the day shift reported the next morning (2/8/22). Resident #207 stated she was in a lot of pain due to missed doses of [MEDICATION(S)] and [MEDICATION(S)]. Resident #207 stated she had pain in her arms and lower back and rated pain during the early morning of 2/8/22 as a 9 almost 10 (on scale of 0 = no pain, 10 = worst pain). Resident #207 stated she almost called 911 to go to the emergency room because nobody was here to care for her. Resident #207 stated she could not sleep due to the pain, was up and down all night and even emailed the corporate nursing consultant (administration #3) around 2:00 a.m. about not getting her medications. Resident #207 stated she last saw a nurse (LPN #1) on 2/7/22 around 7:00 p.m. and did not see another nurse until 2/8/22 around 11:00 a.m. when the day shift nurse brought her medications. On 2/8/22 at 8:30 p.m., CNA #1 working on West unit was interviewed. CNA #1 stated he worked the West unit on the evening of 2/7/22 until 11:00 p.m. CNA #1 stated two CNAs from day shift stayed over and worked the unit with him until 7:00 p.m. CNA #1 stated the nurses on the unit left on 2/7/22 around 7:30 p.m. CNA #1 stated after 7:30 p.m. there was no nurse on the entire unit and he was the only CNA. CNA #1 stated he saw no nurses come to the unit and check on residents from 7:30 p.m. until 11:00 p.m. CNA #1 stated most all the residents were in bed by 7:00 p.m. and he did his best to answer call lights. When asked if any residents needed a nurse during his shift, CNA #1 stated Resident #207 asked to see a nurse about her medications and Resident #257 asked to see a nurse I think about an earache. CNA #1 stated he told them a nurse would come as soon as possible because, I didn't want to say there was no nurse. CNA #1 stated on the evening of 2/7/22, he was answering lights, checking on residents and, Next thing I know I'm the only one here. On 2/9/22 at 3:00 p.m., the DON was interviewed again about medications/treatments not administered with no nurse working the West unit. The DON stated LPN #3 was aware when only two nurses were in the building that the nurses had to split the West unit. The DON stated she talked with unit manager LPN #2 and LPN #3 by telephone during the evening on 2/7/22. The DON stated LPN #2 was upset because she had to work the East medication cart and LPN #3 was upset because there were only two nurses for the night shift. The DON stated she told them everyone was frustrated and that they all had to work together as a team. The DON stated nobody called or reported to her that Resident #207 needed pain medications or about residents not getting medications/treatments on West. The DON stated she was aware there were only two nurses working the building after 11:00 p.m. but thought the nurses knew to split the West unit. On 2/10/22 at 2:40 p.m., CNA #2 was interviewed. CNA #2 stated she and another CNA worked the day shift on West on 2/7/22 and stayed on the unit until 7:00 p.m. CNA #2 stated the two nurses on the unit left on 2/7/22 at 7:00 p.m. CNA #2 stated she and the other CNA had all the residents in the bed by 7:00 p.m. except Resident #201. CNA #2 stated she gave report to CNA #1 and left the building at 7:00 p.m. CNA #2 stated there were no nurses on West unit when she left on 2/7/22 at 7:00 p.m. and CNA #1 was the only aide on the unit after 7:00 p.m. The clinical records for all residents on the West unit were reviewed by the survey team regarding missed medications and/or treatments on the evening of 2/7/22 and early morning of 2/8/22 when no nurse provided care and services on the unit. In addition to Resident #207, fifty-three other residents on the unit (#201, #203, #205, #208 through #228 and #230 through #258) missed scheduled medications and/or treatments that included enteral tube feedings/flushes, blood sugar checks for diabetic management, tubing changes/site care related to enteral feedings/oxygen administration, and care for a urinary catheter. Medications that were not administered included a variety of prescriptions and over-the counter medicines for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician ordered treatments not provided to the West unit residents on the evening of 2/7/22 and early morning of 2/8/22 included topical medications/creams for dry/chaffed skin, joint pain, skin tears/wounds and pressure ulcer prevention/care. Quality of care deficiencies were cited for the fifty-four West unit residents that were not provided medications/treatments on the evening of 2/7/22 and early morning of 2/8/22. Care related deficiencies were cited at F684, F686, F690, F692, F693, F695 and F697. These findings were reviewed with the administrator, director of nursing and corporate nursing consultant on 2/9/22 at 3:00 p.m.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to ensure fifty-four of 58 residents in the survey sample were free from neglect. Residents residing on the West unit that included Residents #201, #203, #205, #207 through #228 and #230 through #258, were not provided physician ordered medications and/or treatments during twelve consecutive hours starting on the evening of 2/7/22 due to no nurse working the unit. Facility staff, aware that no nurse was on the unit, made no attempt to ensure any medications/treatments were provided to the West unit residents during this 12-hour period. A nurse refused to administer Resident #207's pain medicines in response to the resident's verbal request for the medication. Resident #207 experienced significant pain during this time after missing scheduled doses of narcotic medication, resulting in harm. The findings include: Resident #207 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #207 as cognitively intact. Resident #207's clinical record documented current physician orders that included the following medications and treatments. [MEDICATION(S)] 150 mg at bedtime for depression [MEDICATION(S)] 900 mg three times per day for [CONDITION(S)] [MEDICATION(S)] 2.5 mg every 8 hours for pain [MEDICATION(S)] 30 mg four times per day for pain [MEDICATION(S)] diaper rash cream 15% to bilateral inner thighs topically each day and evening shift for chaffing Resident #207's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was scheduled to be administered on 2/7/22 at 9:00 p.m., [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were scheduled for 2/8/22 at 12:00 a.m. and an additional dose of [MEDICATION(S)] was scheduled for 2/8/22 at 6:00 a.m. On 2/8/22 at 2:05 p.m., licensed practical nurse (LPN) #1, working on the West unit was interviewed. LPN #1 stated she worked on 2/7/22 from 7:00 a.m. until 7:00 p.m. LPN #1 stated there was no nurse on the West unit when she left on 2/7/22 around 7:30 p.m. and she gave a verbal report to the unit manager on East unit prior to leaving the building. LPN #1 stated there was no nurse on the West unit when she arrived on 2/8/22 at 7:00 a.m. LPN #1 stated she did not know who was scheduled to work the evening and night shifts on West unit. LPN #1 stated there was currently no unit manager for the West unit. On 2/8/22 at 2:10 p.m., the director of nursing (DON) was interviewed about medications not administered to residents on the West unit on the evening of 2/7/22 and early morning of 2/8/22. The DON stated nurses had 24 hours to clarify and sign off a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON had no explanation why the residents did not receive medications on the evening of 2/7/22 and stated she would research and clarify. The DON stated, We did have agency nurses last night. The DON stated LPN #2, LPN #3 and LPN #4 worked the evening shift. The DON stated that LPN #2 was the East unit manager and house supervisor on the 2/7/22 evening shift. On 2/8/22 at 3:35 p.m., the administrator, DON and corporate consultant (administration staff #3) met with the survey team and reported that no physician ordered medications and/or treatments were administered to any of the fifty-four (54) residents on the West unit from 2/7/22 at 7:00 p.m. until 2/8/22 at 7:00 a.m. The corporate consultant stated LPN #1 reported to the East unit manager (LPN #2) that all the evening medications on the West unit had been given when she left on 2/7/22 around 7:30 p.m. The DON stated LPN #2 was the house supervisor that evening and could have reassigned the nurses working on the facility's three units (East, South and West). The DON stated LPN #2 did not give medications on West during the evening shift because LPN#1 reported that all the medications on the unit had been given. The DON stated, There was a miscommunication at the shift change. The DON stated LPN #2, LPN #3 and LPN #4 worked in the building on the evening of 2/7/22 until 11:00 p.m. The DON stated LPN #2 and LPN #4 left on 2/7/22 at 11:00 p.m. with two nurses scheduled for the building starting at 11:00 p.m. The DON stated there was a call out on 2/7/22 prior to the night shift (11:00 p.m. to 7:00 a.m.) leaving LPN #3 as the only nurse in the building. The DON stated agency was contacted and LPN #5 reported to work on 2/7/22 at 11:00 p.m. The DON stated LPN #3 was on the East unit, LPN #5 was assigned to South unit and the two nurses were supposed to split the West unit. On 2/8/22 at 3:45 p.m., the East unit manager (LPN #2) was interviewed. LPN #2 stated she was working on East unit on 2/7/22 for 3:00 p.m. to 11:00 p.m. shift. LPN #2 stated that on 2/7/22 around 7:30 p.m., LPN #1 from West reported to her that she was leaving and all the medications on West unit had been given. LPN #2 stated she did not go to the West unit prior to leaving her shift at 11:00 p.m. LPN #2 stated, I couldn't do nothing. I was giving meds (medications) on East. LPN #2 stated there was no nurse on the West unit on 2/7/22 after 7:30 p.m. when LPN #1 went home, and she thought LPN #1 had given all the evening medications. LPN #2 stated, Nobody reported to me they didn't get meds. I wasn't aware. LPN #2 stated she and LPN #4 left the building on 2/7/22 at 11:00 p.m. leaving LPN #3 working the East unit until 2/8/22 at 7:00 a.m. LPN #2 stated an agency nurse was called in and reported to South unit on 2/7/22 around 11:00 p.m. to work the night shift. On 2/8/22 at 4:45 p.m., the administrator, DON and corporate consultant met again with the survey team. The DON stated on 2/7/22, that two nurses (LPN #3 and LPN #5) were the only nurses in the building from 11:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated when only two nurses worked the building that they (nurses) knew to split the West unit. The DON stated there was no house supervisor on the night shift. On 2/8/22 at 5:10 p.m., the DON stated that all prescribed medications and treatments were not administered on West unit on the 2/7/22 from 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated again, There was a miscommunication at shift change. On 2/8/22 at 5:20 p.m., LPN #3 was interviewed by telephone about the evening/night of 2/7/22. LPN #3 stated she reported to work on 2/7/22 at 3:15 p.m. and worked until 2/8/22 at 7:00 a.m. LPN #3 stated she was assigned to work the East unit and helped out on the South unit after 7:00 p.m. LPN #3 stated on 2/7/22 at 11:00 p.m. she went back to the East unit, as LPN #5 came in to cover South after the scheduled nurse called out. LPN #3 stated she was not assigned to work the West unit. LPN #3 stated there were two nurses on West unit on 2/7/22 until 7:00 p.m. LPN #3 stated again she was never assigned to West unit on 2/7/22 and she was not aware there was no nurse on West unit until around 11:30 p.m. when Resident #207 called her on the phone and asked for her [MEDICATION(S)] pain medication. LPN #3 stated, I didn't know there was no nurse back there (West unit) until then. LPN #3 stated she told Resident #207 that she could not give her the medication because it was a narcotic and she did not count the narcotics on that unit at shift change. LPN #3 stated she was not comfortable giving narcotics on that unit because it might come back on me if the counts were wrong. LPN #3 stated after 2/7/22 at 11:00 p.m., she and LPN #5 were the only nurses in the building along with three CNAs. LPN #3 stated she did not check on residents on the West unit because she was working East. LPN #3 stated she told the CNA working on West to let her know of any problems. On 2/8/22 at 5:35 p.m., Resident #207 was interviewed about any missed medications on the evening of 2/7/22. Resident #207 stated she did not get any of her medications on 2/7/22 after 7:00 p.m. until 2/8/22 at 11:00 a.m. Resident #207 stated that on 2/7/22 she missed a 9:00 p.m. dose of [MEDICATION(S)], on 2/8/22 at 12:00 a.m. missed a dose of [MEDICATION(S)], [MEDICATION(S)] and a psych med and missed another dose of [MEDICATION(S)] scheduled for 2/8/22 at 6:00 a.m. Resident #207 stated that on 2/7/22 around 11:30 p.m., she reported to the CNA (certified nursing assistant) #5 that she needed a nurse to get her scheduled pain medications. Resident #207 stated CNA #5 checked with the nurse on East unit and reported to her that she was out of luck as there was no nurse on the unit (West). Resident #207 stated she called on her cell phone to the East unit and asked LPN (licensed practical nurse) #3 if she would come and give her the pain medications. Resident #207 stated LPN #3 told her no and that she was not her assigned nurse. Resident #207 stated when she asked who her assigned nurse was, LPN #3 told her she did not have a nurse this shift. Resident #207 stated she then called the other unit (South). Resident #207 stated whoever answered the phone on South stated the nurse was in with a resident. Resident #207 stated she reported that she needed her pain, psych meds and asked for the nurse to call her when possible. Resident #207 stated she did not know who answered the phone but that person told her if the nurse could come she would and if not, she (nurse) won't. Resident #207 stated she never got a visit or a call from either nurse. Resident #207 stated there was a CNA working the unit on the evening/night of 2/7/22 but she saw no nurse after 7:00 p.m. until the day shift reported the next morning (2/8/22). Resident #207 stated she was in a lot of pain due to missed doses of [MEDICATION(S)] and [MEDICATION(S)]. Resident #207 stated she had pain in her arms and lower back and rated pain during the early morning of 2/8/22 as a 9 almost 10 (on scale of 0 = no pain, 10 = worst pain). Resident #207 stated she almost called 911 to go to the emergency room because nobody was here to care for her. Resident #207 stated she could not sleep due to the pain, was up and down all night and even emailed the corporate nursing consultant (administration #3) around 2:00 a.m. about not getting her medications. Resident #207 stated she last saw a nurse (LPN #1) on 2/7/22 around 7:00 p.m. and did not see another nurse until 2/8/22 around 11:00 a.m. when the day shift nurse brought her medications. Resident #207's plan of care (revised 12/23/21) documented the resident had musculoskeletal pain, low back pain, lumbar [CONDITION(S)] joint disease and chronic pain due to physical disability. Interventions to eliminate and/or minimize pain included, Anticipate and meet needs .Medications as ordered .Administer [MEDICATION(S)] per order .Encourage to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation .Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities . The plan of care documented the resident had depression and altered psychosocial well-being due to [CONDITION(S)] disorder. Interventions to prevent sad mood, depression and promote psychosocial well-being included, Administer medications as ordered .Allow the resident time to answer questions and to verbalize feelings perceptions, and fears .Increase communication between resident/family/caregivers about care .Monitor/document resident's usual response to problems . On 2/8/22 at 8:30 p.m., CNA #1 working on the West unit was interviewed. CNA #1 stated he worked the West unit on the evening of 2/7/22 until 11:00 p.m. CNA #1 stated the nurses on the unit left on 2/7/22 around 7:30 p.m. CNA #1 stated after 7:30 p.m. there was no nurse on the entire unit and he was the only CNA. CNA #1 stated he saw no nurses come to the unit and check on residents from 7:30 p.m. until 11:00 p.m. When asked if any residents needed a nurse during his shift, CNA #1 stated Resident #207 asked to see a nurse about her medications and Resident #257 asked to see a nurse I think about an earache. CNA #1 stated he told them a nurse would come as soon as possible because, I didn't want to say there was no nurse. On 2/9/22 at 3:00 p.m., the DON was interviewed again about medications/treatments not administered with no nurse working the West unit. The DON stated LPN #3 was aware when only two nurses were in the building that the nurses had to split the West unit. The DON stated she talked with unit manager LPN #2 and LPN #3 by telephone during the evening on 2/7/22. The DON stated LPN #2 was upset because she had to work the East medication cart and LPN #3 was upset because there were only two nurses for the night shift. The DON stated she told them everyone was frustrated and that they all had to work together as a team. The DON stated nobody called or reported to her that Resident #207 needed pain medications or about residents not getting medications/treatments on West. The DON stated she was aware there were only two nurses working the building after 11:00 p.m. but thought the nurses knew to split the West unit. On 2/10/22 at 2:40 p.m., CNA #2 was interviewed. CNA #2 stated the two nurses on the unit left on 2/7/22 at 7:00 p.m. CNA #2 stated there were no nurses on West unit when she left on 2/7/22 at 7:00 p.m. The clinical records for all residents on the West unit were reviewed by the survey team regarding missed medications and/or treatments on the evening of 2/7/22 and early morning of 2/8/22 when no nurse provided care and services on the unit. In addition to Resident #207, fifty-three other residents on the unit (#201, #203, #205, #208 through #228 and #230 through #258) missed scheduled medications and/or treatments that included enteral tube feedings/flushes, blood sugar checks for diabetic management, tubing changes/site care related to enteral feedings/oxygen administration, and care for a urinary catheter. Medications that were not administered included a variety of prescriptions and over-the counter medicines for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician ordered treatments not provided to the West unit residents on the evening of 2/7/22 and early morning of 2/8/22 included topical medications/creams for dry/chaffed skin, joint pain, skin tears/wounds and pressure ulcer prevention/care. Quality of care deficiencies were cited for the fifty-four West unit residents that were not provided medications/treatments on the evening of 2/7/22 and early morning of 2/8/22. Care related deficiencies were cited at F684, F686, F690, F692, F693, F695 and F697. The facility's policy titled Ancillary Nursing Care and Services (effective 11/01/19) documented, Nursing personnel will provide basic nursing care and services following accepted standards of practice guidelines recognized by state boards of nursing as informed by national nursing organizations and as evidenced by hiring individuals who graduate from an approved nursing school and/or nurse aide curriculum and have successfully passed a licensing and/or certification examination. The facility's abuse/neglect prevention policy titled Patient Protection (effective 1/23/20) documented, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient .Patients of the Center have the legal right to be free from verbal, sexual, mental and physical abuse .All employees are responsible for immediately reporting to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation and/or mistreatment . These findings were reviewed with the administrator, director of nursing and corporate nursing consultant on 2/9/22 at 3:00 p.m.

Based on staff interview, family interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide necessary care and treatment to promote the healing of a pressure ulcer, for one of four residents, Resident #1. The consultant wound nurse practitioner assessed the wound on 11/02/2021 and deemed it a Stage II pressure injury. Recommendations were not implemented, and further assessment was not conducted on the wound after two staff members identified a change, or prior to discharge to the hospital on 11/07/2021. At the time of admission to the hospital the wound was identified as a Stage III pressure ulcer. Findings were: Resident #1 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 09/21/2021, assessed Resident #1 as moderately impaired with a cognitive summary score of 10. Section G, Functional Status, coded Resident #1 as needing extensive assistance of 2+ person's physical assist for bed mobility, extensive assistance of one person for toilet use, was totally dependent on staff with one person physical assist for personal hygiene and bathing. Section H, Bowel and Bladder assessed Resident #1 as always incontinent of urine and bowel. Section M, Skin Conditions, assessed Resident #1 as not being at risk for the development of pressure ulcers/injuries, with the use of a pressure reducing device for his bed. On 11/29/2021 at approximately 10:00 a.m., Resident #1's family member was interviewed. She stated, Thank you .I can't believe the shape he was in when he left there .his bedsore was as big as my fist. The wound center at the hospital looked at it .they said it probably wouldn't heal. Weekly skin assessments for October and November were reviewed. The evaluation on 10/27/2021 documented the following: Skin intact without impairment? No; Wound(s) present: Yes; Are any wounds pressure related? No; Site: Right buttock; Type: Other MASD; Stage: II Site: Left buttock; Type: Other MASD; Stage: II Resident with Stage II to left and right buttock, measuring 5 X 5 cm circular areas with skin off, wound be [sic] red, with small amount of bloody drainage, no odor, cleanse with soap [a]nd water pat dry, applied [MEDICATION(S)] Cream to areas, reposition with pillow for relief off sacrum. Wound: Location of Wound: Right buttock .Date acquired: 10/27/2021; Visible Observation of Tissue: granulation tissue present (beefy red), Moist. Percentage of Wound involvement: 100% .Drainage present/Tunneling/Undermining/description of periwound: Not answered. Describe wound edges: Irregular shape .Special equipment: Specialty bed mattress .Wound: Location of Wound: Left buttock .Date acquired: 10/27/2021; Visible Observation of Tissue: granulation tissue present (beefy red), Moist. Percentage of Wound involvement: Not Answered; Drainage: Yes; Type of Drainage: Sanguineous: bloody drainage; Amount: Small; Tunneling: No; Undermining: No; Description of periwound: Dry intact; Describe wound edges: irregular . A nursing progress note dated 10/28/2021 at 12:52 a.m., documented: Resident with stage 2 to left and Right Buttocks measuring 5 X 5 cm circular shape, skin off wound bed beefy red, with small amount of bloody drainage, cleaned with soap and water pat dry, applied [MEDICATION(S)] Ointment. Pericare administered, ointment applied, reposition with pillow underneath back side. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Ointment 0.44-20.6% ([MEDICATION(S)]-[MEDICATION(S)]) Apply to right/left buttocks topically every shift for stage 2 r/t (related to) MASD for 14 days. The wound care nurse practitioner, OS (Other staff) #3 assessed Resident #1 on 11/02/2021 and documented the following, .Chief Complaint: Comprehensive skin and wound evaluation for Pressure Injury to sacrum .Review of systems: .patient is obese, morbidly obese .Genitourinary: Heavily incontinent .Wounds: Large stage 2 pressure injury to sacrum that extends to bilateral buttocks. See TA (tissue analytics) for full wound assessment details .PRIMARY diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Wound plan of care: Patient is at high risk for this wound overcompensating due to his [CONDITION(S)], heavy incontinence, and immobility. See Tissue Analytics Documentation for full wound description and plan of care. Plan of Care Assessment & Plan - Patient has a pressure injury; Pressure reduction and turning precautions discussed with staff at time of visit recommended, including heel protection and pressure reduction to bony prominences. Staff educated on all aspects of care. Factors Affecting Healing: Patient has frequent incontinence which can decrease healing rate of wound. Recommend providing incontinence care as needed, PRN (as needed). Increased moisture at wound site can promote poor prognosis of wound healing. Please keep wound site covered and avoid contamination with feces at all times. Other elements of Patient Evaluation: Staff made aware that wound rounds were completed and of any changes in treatment plan. The Tissue Analytics referred to in OS #3's note was located in the clinical record and contained the following: Length: 4.72 cm Width: 5.51 cm LXW [Length x width]: 26.01 cm Depth: 0.10 cm Total: 12.04 cm Date Wound Acquired: 11/02/2021 % epithelization: 100 Depth (cm): 0.10 Other: [MEDICATION(S)] barrier cream Wound status: New Acquired in House: Yes Etiology: Pressure Ulcer-Stage 2 Drain Amount: Moderate Drain Description: Serosanguinous Odor: No odor Periwound: Fragile Dressing change frequency: Daily Cleanse Wound With: Wound Cleanser Pressure Reduction/Offloading: Ensure compliance with turning protocol, Elevate legs regularly, Wedge/foam cushion for offloading, Wheelchair Cushion, Mattress Overlay Secondary Dressing: See notes PUSH Score: 16 Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for heel protectors, mattress overlay, wheelchair cushion, or a turning protocol. The care plan included the following focus area dated 10/28/2021: Resident has actual skin impairment to left/right buttocks Stage 2 r/t MASD was observed, with interventions of, Keep skin clean and dry. Moisture barrier cream as needed for protection of skin. Weekly skin assessment. The care plan also included a focus area for .Incontinence r/t immobility with the goal, Resident will remain free from skin breakdown due to incontinence and brief use, and intervention of, Ensure the resident has an unobstructed path to the bathroom. INCONTINENT: Peri-care as needed . There were no other interventions listed on the care plan for turning frequency, the use of a wedge/foam cushion to off load pressure areas, heel protectors, or a mattress overlay. An additional weekly skin evaluation completed by the facility staff and dated 11/03/2021 contained the following: Skin intact without impairment? No; Wound(s) present: Yes; are any wounds pressure related? Yes; Site: Sacrum Resident currently has a Stage II wound on sacrum. Treatment in place. No other areas of the evaluation were completed. A tour of the wing where Resident #1 had resided was conducted on 11/29/2021 at approximately 11:40 a.m. CNA (certified nursing assistant) #1 was interviewed and asked if he had worked with Resident #1 when he was a resident at the facility and if so how often. He stated, Yes, I took care of him, but not a lot .it just depends on how many we have working, if it's five of us then I have the lower hall, if it's just four then I have his room too. He was asked if he had taken care of Resident #1 the day he left the facility to go to the hospital. He stated, Oh, yes. I had him .his daughter was here the day before to visit him (Resident #1) and he was a mess. She was mad. CNA #1 was asked what he meant by the He was a mess. He stated, .He was soaked, his skin was all scaly and dry. He had a hole in his butt. He was asked if he had stated to Resident #1's daughter that she should see his ass. He stated, Yeah, I told her that .he had a big hole back there. He was asked if he had told the nursing staff about the hole on Resident #1's bottom, and if so who he had reported it to. He stated, Yes, I told them, I don't remember who was working that day. He was asked how often Resident #1 had been changed and repositioned. He stated, When I would come in his room in the mornings, he would be soaked, his bed would be wet. He was a large man, they don't want to turn him and change him because it's hard work. CNA #1 was asked if Resident #1 had an air mattress on his bed while he was at the facility. He stated, I don't remember, he had one of those big beds. At approximately 12:30 p.m., the wound care nurse practitioner, OS #3 was interviewed over the phone regarding Resident #1. She stated she had only seen the resident one time on 11/02/2021. She stated, I am looking at my notes now .he had a stage two pressure injury, it was from his sacrum to his bilateral buttocks, it wasn't full thickness and it was superficial 4.72 centimeters in length, 5.51 centimeters in width, there wasn't any depth. It was pink. She was asked if there were any open areas, she stated, No, he had an indentation the size of my finger. She was asked if the indentation was an open area. She stated, No, there wasn't an opening .I think it was part of his anatomy .I am looking at a picture that I took of the area now .the facility has access to that and can show you what I am talking about. She was asked what she thought had caused his areas on his buttocks. She stated, From what I remember he had an air mattress, he was incontinent, obese, he wasn't getting up .when I saw the patient he really wasn't able to participate in the exam. She was asked if the pressure injury was avoidable. She stated, I don't know if they were completely avoidable, I only saw him once .he was heavily incontinent .I've never been asked that before .from what I saw he had an air mattress and turning protocol .I ordered the barrier cream .he may have had some scarred tissue there that is more fragile than the original skin .I really don't know enough about him to answer that question. At approximately 12:45 p.m., Admin #4, one of the corporate nurse consultants was asked if she could access the picture taken by OS #3. At approximately 1:30 p.m. the photograph was reviewed. Observed on the photograph were two areas in a butterfly pattern on the left and right buttocks both pink in color. In the center of the two pink areas was a dark area, darker than the resident's skin. Admin #4 was asked if the area was the indentation described by OS #3. She stated, I don't know. OS #3 was contacted by Admin #4 and asked to come to the facility to clarify what was being seen on the photograph. OS #3 arrived at the facility at approximately 2:00 p.m. She looked at the photograph and stated, I was looking at it on an IPad, I don't see an indentation on this photograph. OS #3 was asked if there had been any open areas when she examined Resident #1. She stated, No. On 11/29/2021 at approximately 4:00 p.m., a meeting was held with the DON (director of nursing) and the administrator. The pressure reducing mattress coded on the quarterly MDS was discussed. The DON stated, That is just our regular mattress, everyone has that. On 11/30/2021 at 9:00 a.m., LPN #2 was interviewed, as she was the last nurse to document a dressing change on the TAR (treatment administration record) for 11/7/21. She was asked what the wound looked like that day. She stated, I had never seen it before .I put cream on it after I cleaned if off with wound cleanser it was pink there was an open area at the sacrum, the center of it was pink it was open, it wasn't black or anything . She was asked if she had measured the area or looked at the previous wound assessment so she would know if the area had changed. She stated, I didn't measure it .I don't think there was that much depth .they had told me it was getting better, but I don't know. The daughter was in there jumping up and down, and screaming. I was just trying to get it done and get out of there and calm her down. She was asked if there had been an air mattress or a wedge for positioning on the bed. She stated, No, I don't remember that. On 11/30/2021 at 9:20 a.m., OS #2, another nurse practitioner at the facility was interviewed regarding Resident #1. She was asked if she had seen Resident #1's wound. She stated, Yes, I ordered the cream for it and we consulted wound care. She was asked if there was an air mattress on his bed and if so was something that had to be ordered. She stated, I don't remember if there was or not and I don't know who makes the decision on those .the wound care team comes in and writes orders. The staff is responsible for putting them in the computer. She was shown the tissue analytics paperwork and asked if those were the wound care orders. She stated, Yes, I think so but I know she (OS #3) has had some concerns about the orders in the past and I encouraged her to talk to (name of the administrator). OS #2 was asked if the areas on Resident #1's buttocks were avoidable. She stated, With proper turning and changing diapers regularly it would be .the urine is acidic and if it lays on the skin it breaks it down. The skin is red at first and if treatment is put in place, it doesn't progress. On 11/30/2021 at approximately 9:30 a.m , Admin #3, another corporate nurse consultant and OS #3 were interviewed. OS #3 was asked about documentation on the tissue analytics paperwork were her orders for care. She stated, Those are my recommendations, I make the same ones on everyone I see. The facility can decide what they want to use. Admin #3 was asked about the recommendations made by OS #3 for heel protectors, mattress overlay, etc. He stated, It should be on the care plan if it was in place. Admin #3 was asked about the weekly skin evaluation dated 11/03/2021 that did not have measurements or additional information documented. He stated, When we hired this company to do wounds, the nurses don't have to do measurements anymore based on the agreement we have with the wound company .but if there is a change they should document it. The discharge transfer summary dated 11/07/2021 documented that Resident #1 had a stage 2 pressure injury at the time of discharge. LPN #3 who completed the form was interviewed at approximately 10:50 a.m. She was asked if she had done a visual wound assessment prior to Resident #1 leaving the facility. She stated, No, he was already up in the chair. I didn't see the area. Review of the TAR (treatment record) indicated that LPN #3 had not provided wound care to Resident #1 since 11/01/2021, six days prior to his transfer. She was asked if she had based her documentation on 11/07/2021 on the wound appearance on 11/01/2021. She stated, Yes. LPN #3 was asked about the DTI (deep tissue injury) on Resident #1's right foot identified on the transfer summary. She state, Yes, it was just a little purple area, I put it on there. On 11/30/2021, hospital records for Resident #1 were obtained. The admission history and physical report documented, Daughter mentioned a likely decubitus ulcer for which will need wound care . A hospital wound care progress note dated 11/08/2021 contained the following information: .patient's first wound is a sacral pressure injury stage III. The wound bed is pink and there is a scant amount of odorous drainage. Orders have been placed for a dressing of: Cleanse with normal saline, apply [MEDICATION(S)] ag to wound bed ONLY, top with an bad and secure with [MEDICATION(S)], daily . The hospital discharge summary contained the following: Discharge Diagnosis .Sacral decubitus ulcer, Stage III .present on admission and seen by wound care . A meeting was held on at approximately 12:15 p.m., with the administrator, the DON, and Admin #3. The above information was discussed. Admin #3 was asked if the LPN #3 should have assessed Resident #1's wounds prior to transferring him to the hospital. He stated, Yes, that is how we train. He was asked if there was any policy or procedure regarding assessments of wounds. He stated, We don't have a policy on that, that's how we train our staff. That is what they are supposed to do. Concerns were voiced that two staff members, CNA #1 and LPN #2 had both identified an opened area described by one as a hole and the other as an open area with depth, on Resident #1's sacrum, without any further assessment or documentation regarding the area. Recommendations made by the wound care nurse practitioner were not implemented or care planned, there was no evidence provided that an air mattress was in place for Resident #1, and when he was transferred to the local hospital, his pressure injuries were not assessed prior to leaving the facility. Upon arrival to the local hospital he was assessed as having a Stage III to his sacrum. The administrator, the DON, and Admin #3 were informed that harm was identified. No further information was obtained prior to the exit summary on 11/30/2021.

Based on resident interview, staff interview and clinical record review, the facility staff failed to administer medications and/or treatments for pain management for sixteen of 58 residents in the survey sample. Resident #202, residing on the East unit, and Residents #207, #211, #212, #213, #218, #220, #221, #223, #224, #231, #233, #241, #246, #248, and #257, residing on the West unit, were not provided physician ordered medications and/or treatments for pain management on 2/7/22. Resident #207 experienced significant pain after nurses refused to administer scheduled pain medications and failed to provide any assessment and/or response to the resident's verbal requests for the medication, resulting in harm. The findings include: 1. Resident #207 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #207 as cognitively intact. Resident #207's clinical record documented current physician orders that included the following medications for pain management: [MEDICATION(S)] 2.5 mg every 8 hours for pain [MEDICATION(S)] 30 mg four times per day for pain Resident #207's MAR documented the [MEDICATION(S)] and [MEDICATION(S)] were not administered on 2/8/22 at 12:00 a.m. and an additional dose of [MEDICATION(S)] was not administered on 2/8/22 at 6:00 a.m. as scheduled. Resident #207's plan of care (revised 12/23/21) documented the resident had musculoskeletal pain, low back pain, lumbar [CONDITION(S)] joint disease and chronic pain due to physical disability. Interventions to eliminate and/or minimize pain included, Anticipate and meet needs .Medications as ordered .Administer [MEDICATION(S)] per order .Encourage to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation .Monitor/record/report to Nurse any s/sx (signs/symptoms) of non-verbal pain .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities . On 2/8/22 at 5:20 p.m., LPN #3 was interviewed by telephone about the evening/night of 2/7/22. LPN #3 stated there were two nurses on West unit on 2/7/22 until 7:00 p.m. LPN #3 stated she was never assigned to West unit on 2/7/22 and she was not aware there was no nurse on West unit until around 11:30 p.m. when Resident #207 called her on the phone and asked for her [MEDICATION(S)] pain medication. LPN #3 stated, I didn't know there was no nurse back there (West unit) until then. LPN #3 stated she told Resident #207 that she could not give her the medication because it was a narcotic and she did not count the narcotics on that unit at shift change. LPN #3 stated she was not comfortable giving narcotics on that unit because it might come back on me if the counts were wrong. LPN #3 stated she did not check on residents on the West unit because she was working East. On 2/8/22 at 5:35 p.m., Resident #207 was interviewed about any missed medications on the evening of 2/7/22. Resident #207 stated she did not get any of her medications on 2/7/22 after 7:00 p.m. until 2/8/22 at 11:00 a.m. Resident #207 stated that on 2/7/22 she missed a 9:00 p.m. dose of [MEDICATION(S)], on 2/8/22 at 12:00 a.m. missed a dose of [MEDICATION(S)], [MEDICATION(S)] and a psych med and missed another dose of [MEDICATION(S)] scheduled for 2/8/22 at 6:00 a.m. Resident #207 stated that on 2/7/22 around 11:30 p.m., she reported to the CNA (certified nursing assistant) #5 that she needed a nurse to get her scheduled pain medications. Resident #207 stated CNA #5 checked with the nurse on East unit and reported to her that she was out of luck as there was no nurse on the unit (West). Resident #207 stated she called on her cell phone to the East unit and asked LPN (licensed practical nurse) #3 if she would come and give her the pain medications. Resident #207 stated LPN #3 told her no and that she was not her assigned nurse. Resident #207 stated when she asked who her assigned nurse was, LPN #3 told her she did not have a nurse this shift. Resident #207 stated she then called the other unit (South). Resident #207 stated whoever answered the phone on South stated the nurse was in with a resident. Resident #207 stated she reported that she needed her pain, psych meds and asked for the nurse to call her when possible. Resident #207 stated she did not know who answered the phone but that person told her if the nurse could come she would and if not, she (nurse) won't. Resident #207 stated she never got a visit or a call from either nurse. Resident #207 stated there was a CNA working the unit on the evening/night of 2/7/22 but she saw no nurse after 7:00 p.m. until the day shift reported the next morning (2/8/22). Resident #207 stated she was in a lot of pain due to missed doses of [MEDICATION(S)] and [MEDICATION(S)]. Resident #207 stated she had pain in her arms and lower back and rated pain during the early morning of 2/8/22 as a 9 almost 10 (on scale of 0 = no pain, 10 = worst pain). Resident #207 stated she almost called 911 to go to the emergency room because nobody was here to care for her. Resident #207 stated she could not sleep due to the pain, was up and down all night and even emailed the corporate nursing consultant (administration #3) around 2:00 a.m. about not getting her medications. Resident #207 stated she last saw a nurse (LPN #1) on 2/7/22 around 7:00 p.m. and did not see another nurse until 2/8/22 around 11:00 a.m. when the day shift nurse brought her medications. On 2/8/22 at 8:30 p.m., CNA #1 working on West unit was interviewed. CNA #1 stated he worked the West unit on the evening of 2/7/22 until 11:00 p.m. CNA #1 stated he saw no nurses come to the unit and check on residents from 7:30 p.m. until 11:00 p.m. When asked if any residents needed a nurse during his shift, CNA #1 stated Resident #207 asked to see a nurse about her medications. CNA #1 stated he told Resident #207 a nurse would come as soon as possible because, I didn't want to say there was no nurse. On 2/9/22 at 3:00 p.m., the DON was interviewed again about medications/treatments not administered with no nurse working the West unit. The DON stated LPN #3 was aware when only two nurses were in the building that the nurses had to split the West unit. The DON stated she talked with unit manager LPN #2 and LPN #3 by telephone during the evening on 2/7/22. The DON stated LPN #2 was upset because she had to work the East medication cart and LPN #3 was upset because there were only two nurses for the night shift. The DON stated she told them everyone was frustrated and that they all had to work together as a team. The DON stated nobody called or reported to her that Resident #207 needed pain medications. The DON stated she was aware there were only two nurses working the building after 11:00 p.m. but thought the nurses knew to split the West unit. The Nursing 2022 Drug Handbook on page 945 describes [MEDICATION(S)] as an opioid [MEDICATION(S)] used for the management of severe pain. Page 948 of this reference documents regarding nursing considerations with use of [MEDICATION(S)], .Don't stop abruptly; withdraw slowly and individualize gradual taper plan to prevent signs and symptoms of withdrawal, worsening pain, and psychological distress in physically dependent patients . (1) The Nursing 2022 Drug Handbook on page 1004 describes [MEDICATION(S)] as an opioid [MEDICATION(S)] used for the management of severe pain requiring continuous, around-the-clock opioid. Page 1008 of this reference documents regarding nursing considerations with use of [MEDICATION(S)], .Don't stop abruptly; withdraw slowly and individualize gradual taper plan to prevent signs and symptoms of withdrawal, worsening pain, and psychological distress in physically dependent patients . (1) (1) Woods, Anne Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022. 2. Resident #211 was admitted to the facility on [DATE] with a readmission on 5/9/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #21 with moderately impaired cognitive skills. Resident #211's clinical record documented current physician orders that included the following medications for pain: [MEDICATION(S)] ER 15 mg three times per day for pain [MEDICATION(S)] gel 1% cream apply 4 grams transdermal every shift for leg pain Resident #211's clinical record documented the above medications/treatments were not administered on the evening of 2/7/22. The [MEDICATION(S)] was scheduled for 8:00 p.m. and the [MEDICATION(S)] gel was scheduled for 9:00 p.m. Resident #211's plan of care (revised 11/22/21) documented the resident had leg pain. Interventions to minimize and/or eliminate pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 3. Resident #212 was admitted to the facility on [DATE] with readmission on 4/2/21. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #212 with moderately impaired cognitive skills. Resident #212's clinical record documented current physician orders that included the following pain medication: [MEDICATION(S)]-acetaminophen 10-325 mg four times per day for chronic back pain Resident #212's MAR documented the [MEDICATION(S)]-acetaminophen was not administered on 2/7/22 at 8:00 p.m. as scheduled. Resident #212's plan of care (revised 2/1/22) documented the resident had pain. Interventions to decrease and/or eliminate pain included, Attempt non-pharmacological interventions as needed .Encourage relaxation techniques and provide diversional activities .Position resident for comfort .Premedicate in anticipation of painful procedures . 4. Resident #213 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #213 with moderately impaired cognitive skills. Resident #213's clinical record documented physician orders that included the following pain medication: [MEDICATION(S)]-acetaminophen 5-325 mg three times per day for polyosteoarthritis Resident #213's MAR documented the [MEDICATION(S)]-acetaminophen was not administered on 2/7/22 at 8:00 p.m. as scheduled. Resident #213's plan of care (revised 2/10/22) documented the resident had pain due to arthritis. Interventions to decrease pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Position for comfort . 5. Resident #218 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #218 with severely impaired cognitive skills. Resident #218's clinical record documented current physician orders that included the following pain medication: [MEDICATION(S)] 50 mg three times per day for pain Resident #218's MAR documented the [MEDICATION(S)] was not administered on 2/7/22 at 9:00 p.m. as scheduled. Resident #218's plan of care (revised 11/4/21) documented the resident had potential for pain. Interventions to decrease and/or eliminate pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 6. Resident #220 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #220 with moderately impaired cognitive skills. Resident #220's clinical record documented current physician orders that included the following pain treatment: Aspercreme [MEDICATION(S)] patch 4% to right should topically every 12 hours for arthritis pain Resident #220's MAR documented the Aspercreme was not administered on 2/7/22 at 9:00 p.m. as scheduled. Resident #220's plan of care (2/1/22) documented the resident had pain. Interventions to decrease and/or eliminate pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 7. Resident #221 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #221 with short and long-term memory problems and moderately impaired cognitive skills. Resident #221's clinical record documented current physician orders that included the following pain medication: Tylenol 650 mg three times per day for generalized pain Resident #221's MAR documented the Tylenol was not administered on 2/7/22 at 9:00 p.m. as scheduled. Resident #221's plan of care (revised 1/24/22) documented the resident experienced pain. Interventions to decrease and/or eliminate pain included, Attempt non-pharmacological interventions as needed .Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 8. Resident #223 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #223 with severely impaired cognitive skills. Resident #223's clinical record documented current physician orders that included the following pain medication: [MEDICATION(S)] gel 1% apply 2 grams transdermal every day and evening shift for pain, apply to bilateral knees and shoulders Resident #223's MAR documented the [MEDICATION(S)] gel was not administered during the evening shift on 2/7/22 as scheduled. Resident #223's plan of care (revised 1/31/22) documented the resident experienced pain. Interventions to decrease and/or eliminate pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 9. Resident #224 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #224 with short and long-term memory loss and severely impaired cognitive skills. Resident #224's clinical record documented current physician orders that included the following pain treatment: Biofreeze gel 4% apply to right knee topically every day and evening shift for pain Resident #224's MAR documented the Biofreeze was not administered on the evening of 2/7/22. Resident #224's plan of care (revised 1/31/22) documented the resident had right knee pain. Interventions to minimize pain included, Medicate as ordered .Notify MD for pain not relieved with medication . 10. Resident #231 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #231 with severely impaired cognitive skills. Resident #231's clinical record documented current physician orders that included the following pain medication: Tylenol 8 hours arthritis extended release one tablet three times per day for arthritis pain Resident #231's MAR documented this medication was not administered on 2/7/22 at 9:00 p.m. as scheduled. Resident #231's plan of care (revised 1/6/22) documented the resident experienced pain. Interventions to decrease and/or eliminate pain included, Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 11. Resident #233 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #233 with moderately impaired cognitive skills. Resident #233's clinical record documented a current physician orders that included the following medication for pain: Tylenol 650 mg three times per day for right knee pain. Resident #233's MAR documented the Tylenol was not administered on 2/7/22 at 9:00 p.m. as scheduled. Resident #233's plan of care (revised 1/31/22) documented the resident experienced pain. Interventions to decrease and/or eliminate pain included, Attempt non-pharmacological interventions as needed .Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 12. Resident #202 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #202 with moderately impaired cognitive skills Resident #202's clinical record documented a current physician's order dated 5/10/21 for [MEDICATION(S)]-acetaminophen 5-325 mg three times per day for pain. Resident #202's MAR documented this medication was not administered on 2/7/22 at 8:00 a.m. Resident #202's narcotic count sheet for the [MEDICATION(S)]-acetaminophen documented no dose was removed from the cart for the 8:00 a.m. dose on 2/7/22. Resident #202's count sheet for [MEDICATION(S)]-acetaminophen matched the amount left on the pharmacy supply card. On 2/7/22 at 3:20 p.m., LPN #6 caring for Resident #202 was interviewed about the [MEDICATION(S)]-acetaminophen not administered. LPN #6 reviewed the resident's MAR and supply of [MEDICATION(S)]-acetaminophen and stated the 8:00 a.m. dose for 2/7/22 was not signed out or administered. LPN #6 stated she did not know why the medication was not given as ordered. Resident #202's plan of care (revised 1/12/22) documented the resident experienced pain. Interventions to decrease and/or eliminate pain included, Attempt non-pharmacological interventions as needed .Encourage relaxation techniques and provide diversional activities .Medicate as ordered .Notify MD for pain not relieved .Position resident for comfort .Premedicate in anticipation of painful procedures . 13. Resident #241 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: [CONDITION(S)], hypertension, anxiety, depressive disorder, convulsions and dementia. A quarterly MDS with an ARD of 01/23/2022 assessed Resident #241 as having problems with both long and short term memory as well as being severely impaired with daily decision making skills Resident #241's clinical record included the following physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Tylenol Tablet 325 mg .Give 2 tablets by mouth three times a day for back pain. Review of Resident #241's February MAR documented the above medication, was not given as ordered at 9:00 p.m. on 02/07/2022. The care plan was reviewed and included a focus area Pain. Interventions included: Medicate as ordered, Notify MD is pain is not relieved with medication or with new complaints of pain. 14. Resident #246 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Breast cancer, hypertension, major depressive disorder, and dysphagia. A quarterly MDS with an ARD of 12/30/2021 assessed Resident #246 as moderately impaired with a cognitive summary score of 09. Resident #246's clinical record included the following physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Tylenol 325 mg Give 325 mg by mouth three times a day for pain. Review of Resident #246's February MAR documented the above medication, was not given as ordered at 8:00 p.m. on 02/07/2022. The care plan was reviewed and included a focus area Pain. Interventions included: Medicate as ordered, Notify MD is pain is not relieved with medication or with new complaints of pain. 15. Resident #248 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Other mental disorders due to known physiological condition, dementia, delusional disorder, depressive disorder and dementia. A quarterly MDS with an ARD of 01/29/2022 assessed Resident #248 as having problems with both long and short term memory as well as being moderately impaired with daily decision making skills Resident #248's clinical record included the following physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] Tylenol 325 mg .Give 2 tablet by mouth four times a day for PAIN MGT (management). Review of Resident #248's February MAR documented the above medication, was not given as ordered at 9:00 p.m. on 02/07/2022. The care plan was reviewed and included a focus area Pain. Interventions included: Medicate as ordered, Notify MD is pain is not relieved with medication or with new complaints of pain. 16. Resident #257 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: dysphagia, major depressive disorder, [CONDITION(S)], [CONDITION(S)], unspecified [CONDITION(S)], and hypertension. An annual MDS with an ARD of 12/08/2021 assessed Resident #257 as moderately impaired with a cognitive summary score of 09. Resident #257's clinical record included the following physician orders: [MEDICATION(S)] Capsule Give 300 mg by mouth three times a day for [CONDITION(S)] Biofreeze Gel 4% .topical [MEDICATION(S)] Apply to left shoulder AND HAND topically every shift for pain Review of Resident #257's February MAR documented the above medication was not given as ordered at 9:00 p.m. on 02/07/2022. Review of the February TAR (treatment administration record) documented the Biofreeze Gel was not applied as ordered during the night shift on 02/07/2022. The care plan was reviewed and included the focus area Pain with interventions that included: Medicate as ordered, Notify MD is pain is not relieved with medication or with new complaints of pain. Also, The resident has pain r/t (related to) [CONDITION(S)], with the intervention: Meds as ordered. On 2/8/22 at 2:10 p.m., the director of nursing (DON) was interviewed about medications not administered to residents on the West unit on the evening of 2/7/22 and early morning of 2/8/22. The DON stated nurses had 24 hours to clarify and sign off a medication administration record (MAR) or treatment administration record (TAR). The DON had no explanation why the residents did not receive medications on the evening of 2/7/22 and stated she would research and clarify. On 2/8/22 at 3:35 p.m., the administrator, DON and corporate consultant (administration staff #3) met with the survey team and reported that no physician ordered medications and/or treatments were administered to any of the residents on the West unit from 2/7/22 at 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated LPN #2 was the house supervisor that evening and could have reassigned the nurses working on the facility's three units (East, South and West). The DON stated LPN #2, LPN #3 and LPN #4 worked in the building on the evening of 2/7/22 until 11:00 p.m. The DON stated LPN #2 and LPN #4 left on 2/7/22 at 11:00 p.m. with two nurses scheduled for the building starting at 11:00 p.m. The DON stated LPN #3 was on the East unit, LPN #5 was assigned to South unit and the two nurses were supposed to split the West unit. On 2/8/22 at 4:45 p.m., the administrator, DON and corporate consultant met again with the survey team. The DON stated last night (2/7/22) that two nurses (LPN #3 and LPN #5) were the only nurses in the building from 11:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated when only two nurses worked the building that they (nurses) knew to split the West unit. The DON stated there was no house supervisor on the night shift. On 2/8/22 at 5:10 p.m., the DON again stated that all prescribed medications and treatments were not administered on West unit on the 2/7/22 from 7:00 p.m. until 2/8/22 at 7:00 a.m. The DON stated, There was a miscommunication at shift change. All of the above information was discussed with the director of nursing, the administrator, and both nurse consultants, during a meeting at approximately 12:15 p.m. on 02/10/2022. No further information was obtained prior to the exit conference on 02/10/2022.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure glucose-monitoring devices were calibrated and accurate on three of three units. A total of twelve glucose monitoring devices were located on nine medication carts and available for use on all three units. Review of the calibration logs for the devices revealed calibration had not been completed on a nightly basis per facility policy. All twelve devices were calibrated for accuracy by facility staff, and nine devices were out of range. Staff observed conducting the calibration of the devices did not follow manufacturer instructions for correctly performing the calibrations, and control solutions for the testing of high and low values were expired. Thirty-two (32) residents were identified as requiring insulin and blood sugar monitoring. Thirteen (13) of those residents (Residents # 27, 95, 113, 108, 249, 384, 42, 97, 69, 84, 88, 236, and 247) were included in the survey sample and the extended survey sample. Four of the thirteen residents (#27, 108, 249, and 69) were identified as having concerns related to glucose monitoring. Staff were performing blood sugar tests and administering insulin based on blood sugar readings obtained on equipment that had not been calibrated. This was identified as Immediate Jeopardy (IJ) in the area of Quality of Care [DATE] at 4:55 p.m., with resulting SQC (substandard quality of care). The Immediate Jeopardy was abated on [DATE] at 1:10 p.m., and the Scope and Severity was lowered to Level II, pattern. The facility staff also failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #56 was not provided support hose as ordered by the physician. Resident #71 was not started on antibiotics as ordered by the physician until four days after admission. Residents #32 and #42 did not have physician ordered weights obtained by staff. Findings include: 1. On [DATE] at 9:45 a.m., accompanied by the licensed practical nurse (LPN #6), the medication carts were inspected on the East unit. The January, February, and [DATE] blood glucose monitoring calibration sheets for the East unit glucometers were blank with no entries or control checks completed on the unit's three medication carts. There were no blood glucose monitoring calibration sheets for the glucometers for April, May, or [DATE]. On [DATE] at 10:15 a.m., accompanied by the East unit manager (LPN #6), three blood glucose monitors were checked with the manufacturer's control solution. The acceptable high range was labeled as ,d+[DATE] and the acceptable low range was ,d+[DATE]. Cart #1 included two glucometers. The first glucometer had a high reading of 233 and a low reading of 96 with both readings within range. The second glucometer had a high reading of 243 and a low of 94 with both readings within range. Cart #2 included two glucometers. There was no test solution for Cart #2. LPN #6 stated she would use the solution from cart #3. One of the glucometers from Cart #2 had a high reading of 258 and a low reading of 88, with the high reading out of range. The second glucometer on Cart #2, had a high reading of 237 and a low reading of 94, both readings were within range. Cart #3 included two glucometers. One of the glucometers from Cart #3 had a high reading of 359 and a low reading of 79, both readings were out of range. The second glucometer on Cart #3 had a high reading of 223 and a low reading of 91, both readings were within range. LPN #6 stated at the time of the cart inspections that there was no documentation of which glucometer was used with which resident. 2. On [DATE] at 10:18 AM, medication storage and labeling was observed on the South wing. Medication cart B was observed. This cart had one glucometer; the glucometer was labeled with a permanent marker, Cart B #1.' LPN (Licensed Practical Nurse) # 3 stated that the device is cleaned before and after each use, and provided the cleaning protocol with demonstration. LPN #3 was asked if the glucometer had been calibrated. LPN #3 stated, I'll have to get an answer for that and stated, I don't do it. LPN #3 had a new bottle of test strips dated [DATE]. There was no control solution on this medication cart to do a calibration test. At 10:28 AM, LPN #3 asked LPN #2 about the glucometers being calibrated. LPN #2 stated that they should be calibrated every night on 3rd shift. LPN #2 stated that the 3rd shift nurse has a checklist with things to do and that is one of them. LPN #2 was asked how many glucometers were on the South unit. LPN #2 stated that Cart A has two glucometers, Cart B has one glucometer and Cart C has one glucometer, for a total of four glucometers on the South unit. The glucometers were labeled as Cart A #1 and #2, Cart B #1, and Cart C #1. At approximately 10:30 AM, LPN #3 asked LPN #1 where the calibration/control solution to test the glucometers was located. LPN #1 stated that they do the calibration test to see if the glucometers are operating correctly and then document in the book. LPN #1 stated that this is done every night on the glucometers. LPN #1 was asked to perform a control test. LPN #1 and LPN #3 both stated that they did not have any control solution on their carts [Cart B and Cart C]. LPN #1 was then asked to review the book with quality control tests. LPN #1 went to the nurse's station and pulled a binder book with glucometer control testing results. Inside the book were sheets titled, blood glucose monitoring meter checks quality control record. LPN #1 stated that there is a sheet for each glucometer on the unit. Each sheet had 13 columns, each column labeled as follows: the date, station/shift, operator initials, meter cleaned, check strip result, test strip lot #, expiration date, code #, Level 1 control range , Level 1 control result, Level 2 control range, Level 2 control result, and Corrective Action column [last]. The glucometers were counted on the South wing unit by staff and verified that four glucometers were on the South wing [2 glucometers on Cart A, 1 on Cart B, and 1 Cart C]. The quality control logs located in the book were reviewed for the last three months, [DATE] through present [[DATE]], the following was revealed: Cart A glucometer #1 only had one log sheet for June. The dates tested were [DATE]th, 25th, 28th, and 29th. It was documented that this glucometer was in range on those dates. There was no log for Cart A glucometer #2, although there were two glucometers on Cart A. There was no documentation for Cart A #1 or #2 glucometers for the months of April and May to evidence any testing. Cart B glucometer #1 log sheet for June documented testing dates were [DATE]th, 25th, 28th, and 29th. There was no documentation for April or [DATE] to evidence any testing. Cart C glucometer #1 log sheet for June documented testing dates were [DATE]th, 25th, 28th, and 29th. There was no documentation for April or May to evidence any testing. At approximately 10:40 AM, LPN #2 stated that she had control solution on her cart, Cart A. At 10:42 AM, LPN #2 and LPN #3 gathered their assigned glucometers and supplies to perform the control tests, which included Cart A glucometers #1 and #2, and Cart B glucometer #1. All the supplies gathered [test strips, control solution] were verified by lot number, not expired, and not past an open date. Cart A glucometer #1 was tested and did not pass the control test for the level 2 test. The level 2 test range was listed on the bottle as ,d+[DATE]. The actual result for glucometer #1 was 345. Cart A glucometer #2 was tested and did not pass the control test for the level 2 test. The level 2 test range was listed on the bottle as ,d+[DATE]. The actual result for glucometer #2 was 349. Cart B glucometer #1 was tested and did not pass the control test for level 2 test. The level 2 test range was listed on the bottle as ,d+[DATE]. The actual result for glucometer #1 was 362. According to the control logs, all four glucometers were last tested on [DATE] and all four passed the control test [level 1 and level 2]. At 11:05 AM, LPN#1 was asked to test Cart C glucometer #1. LPN #1 stated, I don't have any controls [solution] on my cart because it expired and the facility doesn't have anymore. LPN #1 stated that she had thrown them away this morning. LPN #1 stated that she only had one glucometer on her cart. The control solution was borrowed from Cart A to perform the control test. Cart C glucometer #1 was tested and did not pass the control for the level 2 test. The level 2 test range was listed on the bottle as ,d+[DATE]. The actual result for glucometer #1 was 348. All four glucometers on the South wing were found out of calibration and none of the glucometers were removed from service. At approximately 11:45 AM, LPN #2 performed a blood glucose check on Resident #108 with glucometer #2 from Cart A. This glucometer was checked at approximately 10:45 AM and was found out of calibration [failed the level 2 test]. The resident's blood glucose result on this glucometer was 259. Resident #108 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) for Resident #108 was a five day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13. Resident #108 was assessed in Section N. [Medications] as receiving 3 injections of insulin in the last three days [with one order for insulin]. Resident #108's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Accuchecks AC and HS before meals and at bedtime for for DM Notify MD for BS less than 60 or greater than 400 .Hold meal insulin for blood sugars less than 100 .Insulin [MEDICATION(S)] .inject 50 units subcutaneously in the morning .Insulin [MEDICATION(S)] .inject 15 units subcutaneously with meals for Diabetes Hold meal time insulin for blood sugars less than 100 . Resident #108's care plan was reviewed and documented, .has Diabetes Mellitus .medication as ordered by doctor. Monitor/document for side effects .dietary consult .educate regarding medications .compliance .podiatry consult as needed . Resident #108's MARS [medication administration records] were then reviewed. According to the resident's MARS the resident was given 15 units of [MEDICATION(S)] by LPN#2 on [DATE] at noon. The resident was also given [MEDICATION(S)] 15 units at 5:00 PM, the blood glucose reading was 173. 3. On [DATE] at 4:13 PM, glucometer calibration tests were performed on the west wing by registered nurse, (RN) #4. Test solution and test strips were not expired. The results were as follows: Glucometer labeled west C cart was tested . The bottle of test strips indicated the range for low side (Level 1) should be ,d+[DATE]. The bottle also indicated the range for high side (level 2) should be ,d+[DATE]. The test was run for low side with the results being 79 (indicating out of parameter). The test was completed for the high side with the results being 355 (indicating out of parameter). B cart glucometer was tested . The bottle of test strips indicated the range for low side should be ,d+[DATE]. The bottle also indicated the range for high side should be ,d+[DATE]. The test was run for low side with the results being 90 (indicating within parameter). The test was completed for the high side with the results being 357 (indicating out of parameter). A cart glucometer was tested . The bottle of test strips indicated the range for low side should be ,d+[DATE]. The bottle also indicated the range for high side should be ,d+[DATE]. The test was run for low side with the results being 83 (indicating within parameter). The test was completed for the high side with the results being 350 (indicating out of parameter). RN #4 stated that she would take the glucometers out of service and get a new one. Glucometer calibration logs were then reviewed with the unit manager (license practical nurse, LPN #4). Documentation showed each cart glucometers (A, B, and C) were last tested on [DATE] with only one test done prior on [DATE]. LPN #4 stated that tests on the glucometers are supposed to be run on every night shift. Resident #27 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #27 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] Resident #27's medical record was reviewed. A progress noted dated [DATE] documented a call from the facility contracted lab indicating Resident #27 had a critical glucose result of 24 from a lab that was taken earlier in the morning. The lab report dated [DATE] documented that the lab test was taken at 5:38 AM on [DATE] and also documented the glucose lab was confirmed by a repeat analysis. Resident #27's blood sugar test flow sheet was then reviewed and documented a blood sugar test had been obtained on [DATE] at 5:51 AM with results being 83 (13 minutes after the lab had drawn blood). 4. Resident #69 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: end stage renal disease, dementia, hypertension, schizoeffective disorder, and diabetes mellitus. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #69 was assessed as cognitively intact with a summary score of 12. The clinical record was reviewed on [DATE] at approximately 4:00 p.m. The following progress notes were observed: [DATE] 23:37 [11:37 p.m.] Resident blood sugar at 2154 [9:54 p.m.] was 67. Resident was alert and stated he did not feel like his blood sugar was low. Went and got a coke and snacks from vending machine for resident. Resident was eating snacks and drinking his coke when leaving room. Went to recheck bs [blood sugar] at 2230 [10:30 p.m.] and resident was in the floor between the two beds, Resident was laying on his left side. Resident had spilled his coke and was laying in the coke on the floor. Resident would open his eyes but was unresponsive. Resident was breathing and had a pulse. Call for nursing assistants and called 911 from the room. Attempted several times to get a BS and got reading all over the place. One read HI, one read 85, one read 247, last one read 54. Gave resident glucose since he was being [beginning] to be a little more alert. However, resident would just cough and not swallow glucose. 3 emts [emergency medical technicians] arrived and assisted resident to stretcher . [DATE] 01:55 [a.m.] Received report from [Name] in ER [emergency room ] who states when resident got to hospital he was alert and answering correctly. She noted he had urinated on himself and she walked him to the bathroom and cleaned him. His BS was 226. His white blood cells are up @ 21.8 she states. He was DX [diagnosed ] with [CONDITION(S)] [urinary tract infection .States he is returning back to the facility via car and wife. The following note was a late entry created [DATE] at 2:36 a.m.: [DATE] 02:09 During report, evening shift nurse stated resident had had a low BS at bedtime. She asked to stop report and recheck up on him. This nurse was the third nurse in to see resident. He was laying in the floor. He was on his left side with a small amount of white froth noted at the corners of his mouth. He barely had his eyes open but they weren't focused. He could not answer or response to stimuli by nurses. His skin was very cold and clammy. He had his coke spilled all over him. He was making the snoring noises diabetics make when they are trying to slip into a coma. All nurses were called to the room and crash cart brought in. No code performed r/t [related to] he has a heart beat and he is breathing at this time. 911 was called. Evening nurse unable to obtain an accurate blood sugar r/t [related to] spilled coke on his hands. Staff stayed at bedside until EMTs arrived and took him to the ambulance around 2348 [11:48] pm. Ambulance remained in the lot for 20 minutes before leaving for the hospital. [DATE] 15:20 [3:20 p.m.] MEDICAL NOTE: ProMedical Progress Note CC: Okay .S: Patient is being evaluated today for hospital follow-up. On [DATE], patient had an episode of [CONDITION(S)]. Nursing staff found the patient laying on the floor on his left side with a small amount of white frothy at the corners of his mouth. Patient barely can keep his eyes open and focus. He cannot answer or respond to stimuli by nurses. Patient was very cold and clammy. Patient was sent to the emergency department for further evaluation. CT scan of the head and neck were unremarkable. There was concern for [CONDITION(S)] and patient was started on [MEDICATION(S)]. On [DATE], patient was evaluated for [CONDITION(S)]. Patient's blood sugars were 64 and 87 and insulin was held. At the time he was thought this could have been an isolated incident. An A1c was checked. On [DATE], patient was evaluated to follow-up on diabetes to follow-up on the results of the A1c. A1c was 9.9 on [DATE]. Patient was currently taking [MEDICATION(S)] 8 units with meals, [MEDICATION(S)] insulin 50 units daily and a sliding scale as needed for blood sugars greater than 200. [MEDICATION(S)] was increased from 50 units to 55 units daily. [MEDICATION(S)] was increased to 10 units with meals. Since [DATE], blood sugar ranges have been between 95 and 472. Patient states that he is eating all of his meals. He denies any changes in his diet. He is on a diabetic diet .A: This is a [AGE] year-old male with a history of diabetes being evaluated for a fall that occurred on [DATE] and an episode of [CONDITION(S)] resulting in a hospital follow-up. P: Consulted for mechanical ground-level fall with no significant injuries. There was questionable loss of consciousness due to [CONDITION(S)]. Medications were evaluated and no changes are indicated at this time. We will follow-up with patient in 2 weeks. The hospital records from the emergency room documented the following: Basic information Chief complaint: Pt (patient) sent for suspected syncopal episode from [name of facility] d/t [due to] [CONDITION(S)]. Pt stated, I don't know what I was doing but I was lightheaded and then it all went blank. Pt was hypoglycemic upon EMS arrival, blood sugar rose w/ [with] D10 . History of Present Illness: 58- year-old male with history of end stage renal disease now status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient reports he ate a full dinner of a cheeseburger, fries, tea, and coffee. He then went back to his room and his blood sugar was checked and found to be in the 50s. Staff immediately brought him things to eat. He does remember drinking a coke but then had a syncopal episode and fell from the bed .daughter reports that he has very labile blood sugars and has had syncopal episodes from [CONDITION(S)] in the past .states this event appears very similar to past events. Laboratory data from the emergency room showed a Glucometer POCT [point of contact testing] reading on [DATE] at 23:58 [11:58 p.m.] of 226. A routine Chemistry lab test dated [DATE] and resulted at 00:57 [12:57 a.m.] showed a blood glucose level of 254. Concerns were voiced to the DON, administrator, the corporate nurse consultant on [DATE] at approximately 4:50 p.m., that the blood glucose monitors in the facility were not calibrated per facility policy and when tested with the control solution were testing out of range. Documentation in Resident #69's record indicated that blood sugar readings were all over the place. 5. Resident #249 had scheduled insulin and insulin administered before meals and at bedtime each day with dosages determined by blood sugar readings (sliding scale). These readings were obtained with glucometers that either had not been calibrated, were calibrated with out of date solution or were found out of calibration (not meeting manufacturer's specifications for calibration). Resident #249 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] assessed Resident #249 as cognitively intact. Resident #249's clinical record documented the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Insulin Lispro100 units/milliliter (ml), inject per sliding scale subcutaneously before meals and at bedtime. Sliding scale listed: blood sugar 200 to 299 give 5 units, 300 to 399 give 10 units, 400 to 401 give 15 units, above 400 call physician. NPH [MEDICATION(S)] & regular suspension insulin pen (,d+[DATE]) 100 units/ml, inject 20 units subcutaneously each evening and 30 units each morning. Accuchecks (blood sugar) before meals and at bedtime each day. The record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #249's clinical record documented the insulin was administered as ordered. Blood sugar checks were documented before meals and at bedtime each day, with insulin administered per sliding scale. A nursing note dated [DATE] at 1:17 p.m. documented, .rsd [resident's] BS [blood sugar] was 61 @ [at] 1230 pm gave rsd. teddy grams and graham crackers. rsd. alert and verbal at this this time stated she felt okay and didn't feel like her BS was low. recheck BS at 1245 pm it was 59 gave rsd 1 IM [intramuscular] [MEDICATION(S)] rechecked BS at 105 pm bs 149 . (Sic) On [DATE] at 2:15 p.m., the director of nursing (DON) was interviewed about calibration of the facility's glucometers. The DON stated the night shift (11:00 p.m. to 7:00 a.m.) nurses were responsible for calibrating the glucometers each night. The DON stated any glucometers found out of calibration were supposed to be taken out of service and replaced with a meters meeting control checks. The DON stated any problems with glucometer calibrations were supposed to be reported to her or the unit managers. The DON stated she had not been made aware of any issues with glucometers out of calibration in the facility. The facility was determined to be in immediate jeopardy on [DATE] at 4:55 p.m. regarding a system failure with glucometers on all nursing units found without recent calibrations, found out of calibration or had been calibrated with out of date solution. There was no system to track which glucometers were used with which residents and glucometers were found without accurate date setup for historical reference of blood sugar readings. The facility staff presented the following plan of correction that was accepted by the survey team on [DATE] at 6:37 p.m.: 1) New blood glucose meters will be purchased immediately, calibrated per manufacturer's guidelines and documented on the Blood Glucose Monitoring Control Log. 2) An audit will be conducted to identify all residents with current blood glucose monitoring orders. All identified residents will have their blood glucose level checked immediately with a one-time order. We will use the new glucometers post calibration to obtain blood glucose levels. 3) All licensed staff will be educated by the Director of Nursing or designee on the manufacturer's guidelines for calibrating blood glucose monitors and appropriate documentation. Calibration and documentation will be completed once a shift. By tomorrow ,d+[DATE] at 1200 will educate remaining nursing staff before their shift is scheduled. 4) Blood Glucose Monitoring Control Log will be audited daily for 4 weeks and weekly thereafter. 5) Step 1 will be completed by [DATE] at 1900. Step 2 will be completed by [DATE] at 2100. Step 3 will be completed by [DATE] at 1200. On [DATE] at 6:40 PM, LPN #2 was interviewed and was asked if glucometer #1 and glucometer #2 for Cart A had been taken out of service and if the information regarding the failed control tests for both of these glucometers had been reported. LPN #1 stated that they had not been taken out of service and the information had not been reported to anyone. LPN #2 was then asked if Resident #108 received any insulin after the glucose reading. LPN #1 stated that she did administer the resident 15 units of [MEDICATION(S)] [with lunch per order] based on the blood glucose reading from the glucometer that failed the control test. On [DATE] at 6:50 PM, LPN #3 was interviewed and was asked if glucometer #1 for Cart B had been taken out of service and if the information regarding the failed control test the glucometer had been reported. LPN #3, No, you took the book. LPN #3 was asked again, if the failed test had been reported to anyone. LPN #3 stated, No. On [DATE] at 8:22 a.m., the licensed practical nurse (LPN #2) that administered the [MEDICATION(S)] to Resident #249 on [DATE] was interviewed. LPN #2 stated the unit glucometers were used for blood sugar checks and administration of scheduled and sliding scale insulin. LPN #2 stated she did not think Resident #249 was checked with an out of range glucometer but there was no record of which glucometers were used with the resident. On [DATE] at 8:57 AM, Resident #27 was interviewed regarding the hypoglycemic event on [DATE]. Resident #27 said he has been a diabetic most of his adult life and knows when his blood sugar is getting low. Resident #27 stated he could not remember what day the lab technician drew labs but had not been feeling that his blood sugars had been low lately. Resident #27 said he did not remember eating anything after the labs test were taken but did eat breakfast. On [DATE] at approximately 9:00 AM, the glucometer control solution test information was reviewed for the [name of glucometer] that were being used by the facility. The glucometer manual, [Name of glucometer] blood glucose monitoring system .Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within the range, the meter and test strip are working correctly. Do not use system if control solution is out of range. Healthcare professionals: Record result in quality logbook . On [DATE] at 10:00 AM, the DON (director of nursing), the administrator and nurse consultant were again made aware of the serious concerns regarding staff not performing glucometer control checks and using glucometers after failing the control tests and administering insulin based on a test result from a glucometer that had failed control tests. The DON stated that they did not have a policy, but stated that the glucometer control tests are done every night by night shift and that the glucometer manual is the policy and stated that is what we go by. On [DATE] at 11:30 a.m., in-service education records were presented by the facility documenting staff education regarding: blood glucose meter control logs; completion of the calibration logs; blood glucose meter calibration protocol per manufacturer's guidelines; visual, verbal and return demonstrations of performing calibration; use of control solutions; and logging results in calibration test book. All current nursing staff were educated and a system was in place to educate any unavailable staff prior to their next scheduled shift. Glucometer checks were documented on all residents with current orders for blood sugar checks (30 residents) using newly purchased and successfully calibrated glucometers. On [DATE] at 12:08 p.m., the survey team inspected all glucometers in use on the three nursing units. All glucometers in use had been calibrated and were documented as meeting manufacturer's calibration requirements. Nurses on each unit demonstrated to surveyors the calibration protocol using testing solutions and demonstrated competency in calibration performance and documentation in logbooks. Staff were interviewed at the time of the demonstrations and all verified participation in staff education concerning glucometers, calibration protocols, documentation of calibrations and steps to take glucometers out of service if found out of calibration. On [DATE] at 1:09 p.m., the survey team informed the administrator, director of nursing and corporate consultant that the survey team had verified implementation of their plan of removal of immediate jeopardy. The Immediate Jeopardy was abated on [DATE] at 1:10 p.m., and the Scope and Severity was lowered to Level II, pattern. No further information was provided prior to exit. 6. Resident # 42 was admitted to the facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was quarterly review dated [DATE] had Resident # 42 coded 15 out of 15 for cognition, indicating cognitively intact. The clinical record was reviewed [DATE] at 2:45 p.m. There was an order written [MEDICAL RECORD OR PHYSICIAN ORDER] .call cardiovascular if wts greater than ,d+[DATE] pounds . The MAR (medication administration record) and TAR (treatment administration record) were reviewed but no daily weights were located on the records. The Weights and Vitals tab of the record was then reviewed, but no daily weghts were recorded. On [DATE] 3:30 p.m. the DON (director of nursing) was asked for assistance in locating the daily weights. On [DATE] at 8:24 a.m. the DON was asked if any documentation for the daily weights had been found. She stated I didn't see any daily weights. The DON was asked if that meant the weights were not done, and she replied Yes. The administrator, DON, and nurse consultant were made aware of the findings [DATE] at 1:15 p.m. during a meeting with facility staff. No further information was provided prior to the exit conference. 7. Resident #56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed the resident with moderately impaired cognitive skills. On [DATE] at 2:52 p.m., Resident #56 was interviewed about quality of care in the facility. Resident #56 stated that he had ongoing swelling in his feet and legs. The resident stated he wore support hose prior to coming to the facility and was told several times hose would be provided by the facility. Resident #56 stated he did not currently have support hose and had not had a pair since his admission. The resident was observed at this time with no hose or socks in use. Resident #56's clinical record documented assessment of lower extremity [CONDITION(S)] by the nurse practitioner (NP). A NP progress note dated [DATE] documented, .Patient states he noticed last couple days he has had increased swelling to bilateral lower extremities. He states when he was at home he had TED hose but he forgot to bring them with him .1+ [CONDITION(S)] noted bilateral lower extremities .We will order TED hose in a.m. and off in p.m. as needed for [CONDITION(S)] . Resident #56's clinic [TRUNCATED]

Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to prevent a significant decline in ROM (range of motion) for one of 24 residents in the survey sample (Resident # 23). Resident #23 did not receive range of motion exercises and/or interventions for the prevention of contractures and had a significant decline in range of motion in both lower extremities, resulting in harm. Resident # 23 was not provided restorative nursing ROM as recommended by therapy and was not provided physician ordered leg brace(s) for an extended period of time to prevent a significant decline in bilateral lower extremities mobility; the restorative nursing ROM recommendations were included in the resident's CCP (comprehensive care plan) beginning in January 2016, but was not implemented until August of 2016, a result the resident suffered irreversible bilateral (crossed) leg contractures. Findings include: Resident # 23, a [AGE] year old female was admitted originally to the facility on [DATE]. The resident had a readmission to the facility on [DATE], with the most current readmission being on 04/02/16; the resident was discharged from the facility on 11/10/16 and did not return to the facility. Admitting [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE], which assessed Resident # 23 as being in a persistent vegetative state. This MDS also assessed the resident as requiring extensive assistance for all ADL's (activities of daily living). The resident's functional limitation in ROM (upper and lower extremities) was assessed as having no impairment in the upper extremities and as having impairment on both sides for lower extremities. A quarterly MDS assessment was reviewed for comparison, dated 06/22/16. This MDS assessed the resident as being in a persistent vegetative state and also assessed the resident as requiring extensive assistance for all ADL's (activities of daily living). The resident's functional limitation in ROM (upper and lower extremities) was assessed as having no impairment in the upper or lower extremities. A PT (physical therapy) evaluation and plan of treatment (dated 02/28/16) was reviewed and documented, .patient will safely wear a knee extension splint on left knee for up to 5 hours w/minimal s/s (signs and symptoms) of redness, swelling, discomfort or pain . will achieve normal anatomical alignment of the left knee . using a knee extension splint in order to prevent contractures and in order to reduce tone/promote mobility . Patient demonstrates good rehab potential as evidenced by strong family support and supportive caregivers/staff . Reason for Referral: Patient referred . increased need for assistance from others, joint instability, decreased coordination . decrease in range of motion indicating the need for PT to increase functional activity tolerance, increase coordination, improve tone in LE (lower extremity), facilitate motor control and establish and instruct in compensatory strategies .RLE (right lower extremity) ROM (within functional limits) (involuntary muscle movement noted) LLE (left lower extremity) (within functional limits) (spastic hamstrings resulting in left knee limited knee extension ROM) .To prevent BLE (bilateral lower extremity) contracture, decrease BLE spasm with use of dynamic knee brace, BLE PROM (passive range of motion) to increase ROM, and positioning to prevent contracture, bed ulcers and increase quality of life . A PT treatment encounter note dated 02/28/16 documented, physician's orders [REDACTED]. techniques to prevent contractures and techniques to normalize tone . A PT therapy progress report dated 03/11/16, documented that the resident is tolerating the knee extension brace without any discomfort or redness on LE (lower extremity) . patient have (sic) demonstrated wearing tolerance from 30 minutes to 2.5 hours . is tolerating the knee extension brace without any discomfort or redness . building wearing tolerance then educate and train staff on proper donning (put on) and doffing (take off) . A physician's orders [REDACTED]. The leg brace was documented as applied on the TAR (treatment administration orders) for March 24th through March 28th, 2016. The PT discharge summary dated 03/28/16 documented: .Patient now able to tolerate . 8-12 hours without any signs of redness or discomfort, left knee muscle tissue is demonstrating decrease muscle spasm activity and pt is able to relax and hold leg down in place without knee flexing maximally . Pt and caregiver training: caregiver education and training focused on proper positioning in bed for comfort, gentle PROM to LLE and donning and doffing of the left knee brace and skin inpection (sic) to monitor for redness and any adverse reaction. Unit Manager was educated and task demonstrated to her on the process of donning/doffing. She is in agreement and has signed the inservice form accordingly . discharge recommendations: .to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNP (restorative nursing program) has been completed with the IDT (interdisciplinary team): ROM (passive) and knee brace care The resident was discharged to the hospital for UTI (urinary tract infection)[MEDICAL CONDITION] on 03/29/16 and was readmitted back to the facility on [DATE]. The hospital history and physical dated 3/29/16 documented, .she (resident) has braces for contractures on both upper extremities on the wrists and hands as well as on the left knee . she moves all extremities but again does not follow commands . The hospital discharge summary dictated 04/01/16 documented, .pt has returned back to baseline status and she is felt stable for discharge back to (name of long term care facility). The patient will resume previous care there . The resident was readmitted back to the long term care facility on 04/02/16. A physician's progress note dated 04/04/16 (no time) documented, .[MEDICAL CONDITIONS]/persistent vegetative state . chronic trach/peg/foley-total care . cognitive impairment -[MEDICAL CONDITIONS] and unable to answer questions . weakness . unresponsive exc (except) for some non-purposeful movements . total care . care plan/treatment/therapy: Total Care .(signature of physician). A nursing note dated 05/27/16 (3:32 a.m.) documented, .extremely fidgety and screaming out. Both legs and hands are contracted .NP (nurse practitioner) notified to assess resident . 05/27/16 (6:30 p.m.) NP gave instructions to medicate with PRN (as needed) Tylenol as pain persist. A physician's progress note dated 05/29/16 (no time) documented, .60 day recert . hospitalized from 03/29 -04/02 UTI (urinary tract infection)[MEDICAL CONDITION]. Stable since readmission (04/02/16) .eyes closed and unresponsive to verbal stimuli exc (except) moves extremities a little only . total care with trach/peg/foley .(signature of physician). No other information and or documentation could be located throughout Resident # 23's clinical record to indicate that the resident had any prior issues with bilateral leg contractures prior to the nursing note dated 05/27/16. No information could be located to evidence the resident was assessed by the physician and/or the NP for documented concerns related to contractures on 05/27/16. TARs (treatment administration records) and Restorative records were reviewed for the months of April and May of 2016. According to the restorative records, Resident # 23 did not receive any restorative ROM exercises for either month and no records could be located for the leg/knee brace for the either month. On 04/13/17 at 9:30 a.m., the corporate nurse consultants were made aware of the above information and was asked for assistance in locating records for the use of the leg/knee brace for Resident # 23 for April and May (2016). The corporate nurse stated that if you don't have them in the copies that were presented to you, then they are not there and further stated that it (the leg/knee brace) starts back up in June (2016). The corporate nurse was asked if the resident went without the leg/knee brace for over 2 months. No further information or response was provided at this time. The resident's CCP (comprehensive care plan) from readmission (January 2016) to discharge (November 2016) was then reviewed and documented that the resident had, limited physical mobility and for staff to provide gentle range of motion as tolerated with daily care (this was created on 12/16/15). The CCP also documented for, nursing rehab/restorative care to provide passive ROM with passive ROM to all extremities to include 5 sets of 10 repetitions, 6-7 times per week (this was created on 01/19/16). Resident # 23's restorative nursing records were reviewed from January 2016 through November 2016. The restorative records included the following: Nursing rehab/restorative Passive ROM to all extremities 5 sets of 10 reps 6-7 times per week . The restorative records had slots for day, evening and night shifts to initial as completed; none were marked from January 2016 through July 2016, all were blank. According to the restorative records, the resident did not receive any ROM exercises from January 2016 through July 2016. The resident began receiving restorative passive ROM on August 15, 2016 according to the documentation. Further review of Resident # 23's clinical record revealed Resident # 23 was seen again by PT therapy on 06/03/16. The PT evaluation and plan of treatment (dated 06/03/16) documented, .Short-term Goals will achieve and maintain good anatomical alignment while in bed using a side wedge and inclined wedge place between feet/ankles . will achieve anatomical alignment of the right ankle, right knee and right hip . using a knee extension splint in order to reduce tone/promote mobility and in order to prevent contractures . will safety wear a knee extension splint on left foot, left hip, left knee and left ankle . in order to reduce tone/promote mobility and in order to prevent contractures . Long-term Goals Patient will be positioned in bed using cushion placed between fee/ankles . maintain joint integrity and prevent contractures . As documented above, the resident went from wearing one leg/knee brace in March which was for the left knee, to now requiring two braces, one on each leg. The PT eval and treat (dated 06/03/16) also documented the reason for the referral as, Pt referred to PT secondary to decreased ROM in BLE (bilateral lower extremities), BLE muscle stiffness and contractures in all joints . increase LE (lower extremity) ROM and prevent and decrease joint contracture . A PT therapy progress note dated 06/15/16 documented, .Pt and caregiver training: instructed . primary caregivers in splinting/orthodic schedule in order to prevent decline from current level of skill performance with variable carryover demonstrated by caregivers . Patient is compliant with POT (plan of treatment) and patient's condition is improving as a result of skilled therapy services . Patient demonstrates good rehab potential as evidenced by strong family support and supportive staff . A physician's progress note dated 06/20/16 documented, .no subsequent visits since last recertification (05/29/16) . vegetative state . lower and upper extremity contractures noted. Spastic movement noted . continue current treatment plan . continues to require skilled nursing and rehab services .(signature of NP). The resident's PT discharge summary dated 06/24/16 documented, .Contracture management . instructed . primary caregivers in splinting/orthodic schedule in order to preserve current level of function . patient tolerated PROM and gentle passive stretching of bilateral hamstrings, ankle PF/DF (plantar flexion/dorsal flexion) and hip aB/aD (abduction/adduction) well . Recommend con't (continued) use and application of bilateral dynamic knee braces to prevent or reduce significant BLE contractures . RNP (restorative nursing program) . facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNP had been completed with the IDT (interdisciplinary team): ROM (Passive) and splint brace care . Resident # 23's physician's orders [REDACTED]. Order # 1- dated 06/23/16 documented, Bilateral leg braces every evening shift for prevention remove leg braces at bedtime. This was documented on the TAR as evening and it was initialed from 06/23/16 through 06/29/16, there was not area to document the removal at bedtime. Order # 2-dated 06/24/16 documented, Bilateral leg braces one time a day for prevention apply bilateral leg braces on in AM and off in PM. This was documented on the TAR as 8:30 a.m. and was initialed from 06/24/16 through 06/29/16, there was no place on the TAR to document the removal of the braces in the PM. Order # 3- dated 06/30/16 documented, Bilateral leg braces every shift for prevention Bilateral leg braces on at all times. This was documented on the TAR as day/evening/night (every shift) and it was initialed for every shift from 06/30/16 through 08/14/16. According to the clinical records, Resident # 23 did not have the leg braces from 04/02/16 (readmission) through 06/23/16, there was not documentation that the resident had the leg braces for April and May. The leg braces were started again on June 23, 2016. The clinical record did not evidence that consistent restorative nursing services were provided until 08/15/16, after being recommended by therapy on two separate occasions. Clinical records revealed and demonstrated the formation of contractures for Resident 23 between 04/02/16 and 05/27/16 (identified by nurse) and was not seen by therapy again until 06/23/16. A nursing note dated 07/24/16 (timed 10:27 a.m.) documented, .prepare to put patients braces on . opened eyes and started grimacing giving Tylenol for pain and will go back and apply braces to extremities . A nursing note dated 07/24/16 (timed 1:59 p.m.) documented, .patient was very contracted . massaged legs and got them straightened out a lot . A physician's progress note dated 07/28/16 documented, .seen due to staff request muscle relaxer to help with rigidity . lower and upper contractures noted . Contractures/[DIAGNOSES REDACTED]: Will start [MEDICATION NAME] 5 mg (milligrams) TID (three times daily), can increase every 3 days, Max 80mg/day . (signature of NP). A nursing note dated 08/15/16 (timed 11:26 p.m.) documented, .resident's braces to bilateral legs have been discontinued . According to the clinical record documentation (TARs), the leg braces were not applied from 08/14/16 to 10/24/16 due to the wound. Restorative nursing was started on 08/15/16. A nursing note dated 10/01/16 (timed 2:47 p.m.) documented, .patient has been tightening up muscles and moaning when going to apply braces to hands and legs are getting harder to move pillows between legs and heels . A nursing note date 10/24/16 (timed 7:49 p.m.) documented, Knee braces on at all times except when taking a shower. every shift for prevention removed (sic). A nursing note dated 10/28/16 (timed 2:41 p.m.) documented, .new order for Ortho consult on 11/03/16 at 12:30 p.m An Ortho consult dated 11/03/16 documented, .patient presents for evaluation of bilateral arm and bilateral leg pain . the patient has experienced bilateral upper and lower extremities contractures . has utilized braces of her lower extremities, which seemed to cause wounds on both heels. Her legs are fixed in a crossed position. She has increased pain when trying to move her . discussed patient's issue with . nurse . explained that any surgical intervention is a large undertaking . do not recommend this . bilateral lower extremity: fixed flexion contracture, no passive ROM . (signature of physician). The Lippincott Manual of Nursing Practice 10th edition states on pages 172 and 173 concerning complications of immobility, The goal of frequent position changes is to prevent contractures, stimulate circulation and prevent pressure sores, prevent [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, promote lung expansion and prevent pneumonia, and decrease [MEDICAL CONDITION] of the extremities . The recommendation is to change body position at least every 2 hours, and preferably, more frequently in patients who have no spontaneous movement . The goals of therapeutic exercise are to develop and retrain deficient muscles, to restore as much normal movement as possible to prevent deformity, to stimulate the functions of various organs and body systems, to build strength and endurance, and to promote relaxation .Perform passive range-of-motion (ROM) exercise . Carried out without assistance from the patient . The purpose is to retain as much joint ROM as possible and to maintain circulation . Move the joint smoothly through its full ROM . Do not push beyond the point of pain . (1) The facility staff were informed of the above information regarding Resident # 23 in a meeting with the survey team on 04/13/17 at approximately 9:00 a.m. The facility staff were made aware that the resident's CCP included interventions from therapy for restorative nursing ROM exercises and there was no evidence that the exercises were being completed regularly until August of 2016, after the fact the resident had already acquired bilateral leg contractures. The facility staff were also made aware that according to the clinical record, the resident did not have any type of therapy and/or restorative nursing services from 04/02/16 through 06/23/16, when a nursing note had identified that the resident had contractures on 05/27/16. Assistance was requested from facility staff for any information and/or documentation to evidence that the resident had received appropriate care/services and interventions from facility staff for the prevention of contractures. At approximately 11:00 a.m., in a meeting with the survey team, the facility staff were again informed of serious concerns regarding Resident # 23 and the potential for harm for the resident who had suffered a significant decline in ROM. The facility staff stated that they were aware of the concerns and stated that they (staff) did do exercises with the resident, but failed to document it. The facility staff was asked to present any information and/or documentation to evidence Resident #23 was receiving the care and services to prevent contractures. No further information and/or documentation was presented prior to the exit conference on 04/13/16 at 12:30 p.m., to evidence that Resident # 23 was receiving adequate interventions for the preventions of contractures. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. This is a complaint deficiency.

Based on staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to implement interventions for the prevention of pressure related ulcers for one of 24 residents in the survey sample (Resident # 23), as a result Resident #23 acquired pressure related areas resulting in harm to the resident. Resident # 23 had bilateral leg/knee braces for the prevention of contractures, the leg/knee braces were not removed daily for skin inspections and the resident acquired pressure related areas in the following locations: 1) Area to the right knee cap 2) Area to right heel 3) Area to left heel 4) Area to top of right foot On 11/10/16, Resident #23 was sent to the Emergency Department due to wounds not improving and a heavy odor associated with the areas. Findings include: Resident # 23, a [AGE] year old female was admitted originally to the facility on [DATE]. The resident had a readmission to the facility on [DATE], with the most current readmission being on 04/02/16; the resident was discharged from the facility on 11/10/16 and did not return to the facility. Admitting [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with CAAS (care area assessment summary) was a significant change assessment dated [DATE], which assessed Resident # 23 as being in a persistent vegetative state. This MDS also assessed the resident as requiring extensive assistance for all ADL's (activities of daily living). This MDS assessed the resident with 2 unstageable pressure ulcers that were suspected DTI (deep tissue injury). A quarterly MDS assessment was reviewed for comparison, dated 06/22/16. This MDS assessed the resident as being in a persistent vegetative state and also assessed the resident as requiring extensive assistance for all ADL's (activities of daily living). This MDS assessed the resident as having no pressure ulcers or skin impairment. A PT (physical therapy) evaluation and plan of treatment (dated 02/28/16) was reviewed and documented, .patient will safely wear a knee extension splint on left knee for up to 5 hours w/minimal s/s (signs and symptoms) of redness, swelling, discomfort or pain .will achieve normal anatomical alignment of the left knee . using a knee extension splint in order to prevent contractures and in order to reduce tone/promote mobility . Patient demonstrates good rehab potential as evidenced by strong family support and supportive caregivers/staff . Reason for Referral: Patient referred . increased need for assistance from others, joint instability, decreased coordination . decrease in range of motion indicating the need for PT to increase functional activity tolerance, increase coordination, improve tone in LE (lower extremity), facilitate motor control and establish and instruct in compensatory strategies . RLE (right lower extremity) ROM (within functional limits) (involuntary muscle movement noted) LLE (left lower extremity) (within functional limits) (spastic hamstrings resulting in left knee limited knee extension ROM) . To prevent BLE (bilateral lower extremity) contracture, decrease BLE spasm with use of dynamic knee brace, BLE PROM (passive range of motion) to increase ROM, and positioning to prevent contracture, bed ulcers and increase quality of life . A PT therapy progress report dated 03/11/16, documented that the resident is tolerating the knee extension brace without any discomfort or redness on LE (lower extremity) . patient have (sic) demonstrated wearing tolerance from 30 minutes to 2.5 hours . is tolerating the knee extension brace without any discomfort or redness . building wearing tolerance then educate and train staff on proper donning (put on) and doffing (take off) . The PT discharge summary dated 03/28/16 documented: .Patient now able to tolerate . 8-12 hours without any signs of redness or discomfort, left knee muscle tissue is demonstrating decrease muscle spasm activity and pt is able to relax and hold leg down in place without knee flexing maximally . Pt and caregiver training: caregiver education and training focused on proper positioning in bed for comfort, gentle PROM to LLE and donning and doffing of the left knee brace and skin inpection (sic) to monitor for redness and any adverse reaction . The resident was discharged to the hospital for UTI (urinary tract infection)[MEDICAL CONDITION] on 03/29/16 and was readmitted back to the facility on [DATE]. The hospital history and physical dated 3/29/16 documented, .she (resident) has braces for contractures on both upper extremities on the wrists and hands as well as on the left knee . she moves all extremities but again does not follow commands . The hospital discharge summary dictated 04/01/16 documented, .pt has returned back to baseline status and she is felt stable for discharge back to (name of long term care facility). The patient will resume previous care there . The resident was readmitted back to the long term care facility on 04/02/16. A physician's progress note dated 04/04/16 (no time) documented, .[MEDICAL CONDITIONS]/persistent vegetative state . chronic trach/peg/foley-total care . cognitive impairment -[MEDICAL CONDITIONS] and unable to answer questions . weakness . unresponsive exc (except) for some non-purposeful movements . total care . care plan/treatment/therapy: Total Care . (signature of physician). A physician's progress note dated 05/29/16 (no time) documented, .60 day recert . hospitalized from 03/29 -04/02 UTI (urinary tract infection)[MEDICAL CONDITION]. Stable since readmission (04/02/16) . eyes closed and unresponsive to verbal stimuli exc (except) moves extremities a little only . total care with trach/peg/foley . (signature of physician). The resident's CCP (comprehensive care plan) from readmission (January 2016) to discharge (November 2016) was then reviewed and documented that the resident has potential for pressure ulcer development related to immobility, the resident will have intact skin, free of redness, blisters or discoloration (this was created on 04/12/16). The intervention to this problem was to educate the resident/family/caregivers as to causes of skin breakdown; including transferring/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning . Further review of Resident # 23's clinical record revealed Resident # 23 was seen again by PT therapy on 06/03/16 for bilateral leg braces related to contracture development. The PT evaluation and plan of treatment (dated 06/03/16) documented, .to increase LE ROM and prevent and decrease joint contracture, increase functional activity tolerance . improve tone LE and facilitate motor control in order to enhance patient's quality of life by improving ability to relieve pressure for decreased risk of skin breakdown and exhibit preserved skin integrity . due to documented physical impairments and associated functional deficits, the patient is at risk for: . increased dependency on caregivers . limited functional movement . [MEDICAL CONDITION] and pressure sores . A PT therapy progress note dated 06/15/16 documented, .Pt and caregiver training: instructed . primary caregivers in splinting/orthodic schedule in order to prevent decline from current level of skill performance with variable carryover demonstrated by caregivers . Patient is compliant with POT (plan of treatment) and patient's condition is improving as a result of skilled therapy services . Patient demonstrates good rehab potential as evidenced by strong family support and supportive staff . Resident # 23's physician's orders [REDACTED]. Order # 1- dated 06/23/16 documented, Bilateral leg braces every evening shift for prevention remove leg braces at bedtime. This was documented on the TAR as evening and it was initialed from 06/23/16 through 06/29/16, there was not area to document the removal at bedtime. Order # 2-dated 06/24/16 documented, Bilateral leg braces one time a day for prevention apply bilateral leg braces on in AM and off in PM. This was documented on the TAR as 8:30 a.m. and was initialed from 06/24/16 through 06/29/16, there was no place on the TAR to document the removal of the braces in the PM. Order # 3- dated 06/30/16 documented, Bilateral leg braces every shift for prevention Bilateral leg braces on at all times. This was documented on the TAR as day/evening/night (every shift) and it was initialed for every shift from 06/30/16 through 08/14/16. The TAR was documented as continuous use of the leg braces for all three shifts from 06/30/16 through 08/014/16. 1) A nursing note dated 08/14/16 (timed 4:00 a.m.) documented, .this nurse observed the resident moaning and grimace on face . made assessment and found . bruise to her right kneecap . removed the brace from the (sic) her legs . bed bath . reported to the next shift nurses . A nursing note dated 08/14/16 (timed 1:03 p.m.) documented, Resident noted with wound to the right knee cap. Appearing as a blood filled blister/bruise . braces were removed from legs at nurse's discretion last night, as the wound has began by the knee braces rubbing against skin . MD (medical doctor) notified, order received for skin prep every shift to wound . Nurse explained to sister (of resident) how the wound was started on the knee and why the braces were removed. Sister states 'That's because they've been leaving them on too long' moonboots and positioning pillows remain in place A nursing note dated 08/14/16 and time 4:19 p.m. documented, Braces removed on 11-7 shift this morning due to right knee wound . A nursing note dated 08/14/16 and timed 7:13 p.m. documented, .wound appears as a bruise/blood filled blister measuring 3.8 cm (centimeters) in Width, 1.7 cm in Length . Resident had braces ordered by therapy for both legs due to contractures. Nurse attempted to explain to (name of family member) how braces could have been improperly placed . A nursing noted dated 08/15/16 and timed 4:47 a.m. documented, resident has had a skin tear at the right knee cap, appears swollen and redden (sic) . A nursing note dated 08/15/16 (timed 11:03 a.m.) documented, .concerns (from sister of resident) told (nurse) that patient has a sore on her right knee and that she believes that it came from staff not taking off her brace . has a circular area to right knee that appears as a skin tear . A nursing note dated 08/15/16 (timed 11:26 p.m.) documented, resident continues with blister to right knee. Residents braces to bilateral legs have been discontinued . A wound record dated 08/14/16 documented, that the resident's wound to the right knee was 'acquired . blood filled blister . purple/maroon . 1.7 by 3.8 . irregular (wound edges) . first observation . The resident's CCP was reviewed and documented, .resident has an abrasion to the right knee . identify potential causative factors and eliminate/resolve when possible . A physician's progress note dated 08/22/16 documented, .total care . doesn't respond to verbal commands . arm extended above head. Legs flexed under buttocks, no [MEDICAL CONDITION], moving around in bed non-purposeful . one open area right knee now . orders reviewed/approved- no change . According to the clinical record documentation (TARs), the leg braces were not applied from 08/14/16 to 10/24/16 due to the wound. Restorative nursing was started (signed of as completed) on 08/15/16 for PROM to all extremities 5 sets of 10 reps 6-7 times per week. A nursing note dated 10/01/16 (timed 2:47 p.m.) documented, .patient has been tightening up muscles and moaning when going to apply braces to hands and legs are getting harder to move pillows between legs and heels . 2 and 3) A nursing note dated 10/17/16 and timed 4:57 p.m. documented, Resident noted to have SDTI (suspected deep tissue injury) to bilateral heels . A nursing note dated 10/24/16 and timed 2:30 p.m. documented, Residents R (right) heel SDTI pressure ulcer observed with blood from ulcer . verbal order received to steri-strip skin that is still observed (sic) to heel, cover . continues with pressure ulcer to left heel as well, skin intact, purple in color . A nursing note date 10/24/16 (timed 7:49 p.m.) documented, Knee braces on at all times except when taking a shower. every shift for prevention removed (sic). Wound records dated 10/16/16 documented for the right and left heel, both acquired and both pressure, both SDTI and this was the first observation. A nursing note dated 10/28/16 (timed 2:41 p.m.) documented, .new order for Ortho consult on 11/03/16 at 12:30 p.m 4) A nursing note dated 11/01/16 and timed 2:32 p.m. documented, .Left heel with top layer of skin peeled back, slight odor . also observed new wound to top of residents right foot, measured 2 cm X 2 cm X 0 cm depth, no tunneling/undermining . An Ortho consult dated 11/03/16 documented, .patient presents for evaluation of bilateral arm and bilateral leg pain . the patient has experienced bilateral upper and lower extremities contractures . has utilized braces of her lower extremities, which seemed to cause wounds on both heels. Her legs are fixed in a crossed position. She has increased pain when trying to move her . discussed patient's issue with . nurse . explained that any surgical intervention is a large undertaking . do not recommend this . bilateral lower extremity: fixed flexion contracture, no passive ROM . Eschar size of silver dollar on left heel small drainage .(signature of physician). A nursing note dated 11/10/16 and timed 11:52 a.m. documented, .wounds assessed at this time, NP in to assess as well, gave this nurse verbal order to send resident to ED (emergency department) due to wounds not improving and odor to wounds .left foot measured 2 cm X 2 cm X 0 depth . Eschar observed to left heel . right heel observed purple in color, odor . area to right top of foot observed black in color, heavy odor, measured 4 xm (sic) X 4 cm X 0 depth . heavy odor . It was documented that the resident left the facility via EMT (emergency medical transport) at approximately 1:15 p.m. The facility staff were informed of the above information regarding Resident # 23 in a meeting with the survey team on 04/13/17 at approximately 9:00 a.m. The facility staff were made aware that the resident had several wounds that were documented as acquired. Resident # 23's CCP did not have any interventions in place to address the use of the leg braces or any intervention to address the resident's skin in relation to the leg braces. Assistance was requested from facility staff for any and all information and/or documentation to evidence that the resident had received appropriate care/services and interventions from facility staff for the prevention of pressure related ulcers. At approximately 11:00 a.m., in a meeting with the survey team, the facility staff were again informed of serious concerns regarding Resident # 23 and the potential for harm for the resident who had acquired multiple wounds. The facility staff stated that they were aware of the concerns and stated that they (staff) were checking the resident's skin, but failed to document it. The facility staff was asked to present any information and/or documentation to evidence Resident #23's pressure ulcers were unavoidable. No further information and/or documentation was presented prior to the exit conference on 04/13/16 at 12:30 p.m., to evidence that Resident # 23 received adequate interventions for the preventions of pressure related ulcers or that the resident's pressure ulcers were unavoidable. The Lippincott Manual of Nursing Practice 10th edition on page 183 states, Pressure ulcers (decubitus ulcers) are localized ulcerations of the skin or deeper structures. They most commonly result from prolonged periods of bed rest in acute- or long-term care facilities; however, they can develop within hours in the compromised individual . Page 184 of this reference describes a stage 3 pressure ulcer as, .full-thickness tissue loss, with subcutaneous fat that may be visible but bone, tendon, or muscle are not exposed; may include undermining and tunneling. Slough may be present but does not obscure the depth of tissue loss. (1) (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. This is a complaint deficiency.

Based on staff interview, clinical record, facility document review and complaint investigation the facility staff failed to perform skin assessments for the prevention of a wound for one of 1 resident, in the survey sample. Identified as Resident #1. Facility staff failed to identify and assess a wound before necrotic tissue had formed on Resident #1's right 5th toe (little toe) resulting in harm. The findings include: Resident #1 was admitted to the facility on [DATE] with a readmission on 6/26/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 as cognitively intact. This MDS assessed Resident #1 to require the extensive assistance of two person for transfers and bed mobility and dressing. Resident #1's closed clinical record was reviewed on 9/22/15. A Braden Scale (tool used to predict pressure sore risk) dated 7/30/15 documented that Resident #1 scored 14 indicating moderate risk for skin break down. Resident #1's care plan dated 3/1/15 (most current) for pressure ulcer which read under the heading of Interventions Administer treatments as ordered and monitor for effectiveness. (no other interventions). Resident #1's weekly skin assessments were reviewed from mid July through September 9th, 2015. The skin assessment dated [DATE], 8/05/15, and 8/12/15 indicated scattered scabs on the right lower extremity with no other assessment details as to size, drainage, odor or exact location of the scabs. A Wound Record was reviewed and dated 8/12/15 and revealed a skin tear to the right foot indicating the skin tear was 4 centimeters (cm) by 2 cm dry and intact. The documentation did not evidence where on the right foot the skin tear was located. No other documentation of any other wounds or skin impairments were evidenced. Throughout the remainder of August through September 9th, 2015 the weekly skin assessments only indicated the skin tear to Resident #1's right foot and stated to continue with treatment. Again there were no other documentation of a detailed assessment. On 9/23/15 at 10:30 a.m. this surveyor contacted the [MEDICAL TREATMENT] center where Resident #1 is a patient on Tuesday's, Thursday's and Saturday's. An interview with registered nurse (RN #1) was conducted regarding necrotic tissue found (according to complaint intake information) on Resident #1's little toe by a nurse at the center. RN #1 verbalized on the evening of 9/12/15 she was taking care of Resident #1 and observed that Resident #1 did not have a sock on, so RN #1 took the shoe off to relieve pressure to Resident #1 foot and observed the little toe to be black and the great toe to be raw and with drainage. RN #1 verbalized that she knew that Resident #1 could not dress himself as he has had a stroke and is flaccid on the left side (indicating that someone had dressed him and not applied a sock). After observing Resident #1's foot, RN #1 reported the findings to her medical director. RN #1 verbalized that the medical director assessed the foot and thought that the toe was necrotic and instructed the nurse to finish with [MEDICAL TREATMENT] and then send Resident #1 to the emergency department. During the interview with RN #1, RN #1 verbalized that a dressing was intact to the foot with a date of 9/11/15, indicating that when the dressing was changed, why was the toe not assessed by the nurse at the facility as necrotic tissue is unlikely in a short period of time. Also RN #1 verbalized approximately two weeks earlier, Resident #1 had an open wound to the right leg which was cultured by the [MEDICAL TREATMENT] center and treated with [MEDICATION NAME] (antibiotic) due to infection. At this time, this surveyor asked if it would be possible for her to FAX all this information. Documentation received from the [MEDICAL TREATMENT] center regarding Resident #1 evidenced the following assessments: assessment dated [DATE] evidenced .open sore to R (right) foot and 2 other open areas covered with bandaides (SIC) on R lower leg cultures obtained and notified (name of charge nurse). 8/18/15 .PA (Physician's Assistant) .notified of open sores on RLE (right lower extremity) and discoloration to right foot distally to wound skin is purple in color. [MEDICATION NAME] and [MEDICATION NAME] was prescribed and given at [MEDICAL TREATMENT] center. 8/20/15 .culture results .right foot ulcer 3+[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus), RLE wound 3+ mixed gram neg (negative) flora . 8/29/15 .RLE dressing removed note R foot to be deep purple in color wound on top of R foot noted green drainage on abd (sic) pad noted odor to pad .R great toe that is soft and boggy deep purple in color Noted 2 areas on R pinky toe that are small but area next to toenail a small wound with a greenish film over top and area distal to toenail that is red in color . Noted a 2 inch line on lateral side of R foot to be deep purple and squishy unable to blanch any area of foot. 9/12/15 .arrival noted that he (Resident #1) had a shoe on R foot which has multiple wounds upon removing shoe noted there was no sock great toe noted to be bright red and sero-sanguinous drainage from bottom of toe, remove [MEDICATION NAME] from foot that was dated 9/11/15 .last toe on RLE black and hard to the touch wound on top of R foot covered with tefla pad and appears to be improving R foot lateral side area skin is white and peels back reveals yellowish wound. Dr (doctor name) in building and made aware . 9/12/15 .(name of doctor) at bedside to eval pt (patient), believed to have gangrene in R 5th toe and he will direct admit to (name of hospital) for R foot infection. 9/12/15 Contacted pt (patients) wife via phone and informed her of pt status she voiced concerns about lack of care pt is receiving at (name of facility . 9/12/15 Contacted (name of facility where resident #1 resides) spoke with (name of person taking care of Resident #1 at the time of telephone conversation) inquired about who does the wound care there, she reported that the nurses are responsible for wound care at the facility I asked why the necrotic 5th toe was not addressed yesterday when the dressing was changes (sic) and she replied she does not know but there is nothing documented about the appearance of the toe. Also informed her that a diabetic pt who already has wounds and [MEDICAL CONDITIONS] on their only remaining lower extremity should never have a shoe on without a socks. Explained to (name of person at the facility) that I would be making a complaint due to being preventable with early detection and possibly risk management should be involved since pt may lose part or all of R foot . According to the clinical record Resident #1 was admitted to the hospital on [DATE]. Hospital records were reviewed and evidenced on admission to the hospital Resident #1 was assessed as having a right foot diabetic ulcer, stage two pressure ulcer to right sacral area, a right leg abrasion, scab, questionable fungal rash to the groin and scrotum area, and necrotic gangrene to the 5th right toe. Pre-op [DIAGNOSES REDACTED]. Subsequently Resident was prepped for surgery and underwent a below knee right leg amputation. On 9/22/15 at 3:40 p.m. an interview was conducted with the nurse consultant (Admin. #3) regarding wound assessments versus weekly skin assessments. Admin. #3 verbalized weekly skin assessments are done weekly and documentation is provided regarding a full assessment of the skin. Wound assessments are only filled out when a new wound or skin issue is found, from that point on, the documentation of that wound or skin issue is documented on the weekly skin assessments until healed. On 9/23/15 at 9:40 a.m. Resident #1's wife was interviewed by telephone regarding facility notifications of any skin conditions. Resident #1's wife verbalized that the facility does not usually contact her of Resident #1's status. Resident #1's wife also verbalized, that she visits often and has on more than one occasion observed Resident #1 without a sock on the right foot, blood on the right foot and marks on the right leg. When asked when was this observed, Resident #1 wife verbalized some time in August and went onto say that she had taken pictures of this. On 9/23/15 at 10:00 a.m. LPN #3 (an evening nurse that often does treatments on Resident #1) was interviewed. LPN #3 verbalized there were scabs/scars on the right leg. When asked about documentation of skin assessments, LPN #3 verbalized that she would only document if a wound was open, not on closed dry areas. When asked about Resident #1's shoe, LPN #3 verbalized that the shoe was tight. This interview was conducted with the administrator present. On 9/23/15 at 11:15 a.m. RN #2 was interviewed via telephone (RN #2 was the nurse that did the dressing change to Resident #1 on 9/11/15). RN #2 was asked to describe her assessment of Resident #1's right foot when the dressing change was performed. RN #2 verbalized that there was black eschar to Resident #1's heel which she did a dressing change on and there was a scab on the little toe. This surveyor questioned exactly where the wound was on the heel (since there was no documentation of a wound on the heel). RN #2 explained that the area was on the bottom of the heel, this surveyor asked, If Resident #1 was to stand up would Resident #1 be standing on the wound? RN #2 stated Yes. This surveyor asked about the scab to Resident #1's toe and if this was reported or documented. RN #2 verbalized that the toe appeared to be a scab and was not documented. On 9/23/15 at 11:40 a.m. a meeting with the administrator took place. This surveyor expressed concern to the administrator that documentation from the [MEDICAL TREATMENT] center and hospital did not correlate with the staff weekly skin assessments indicating the [MEDICAL TREATMENT] center is assessing Resident #1 with necrotic tissue to the little toe, the hospital assessment evidences necrotic tissue to the little toe on the right foot that is gangrenous. RN #2 verbalizing a wound to the bottom of Resident #1's heel and a scab to the little toe. At this time the administrator verbalized there was no wound to the heel, to which this surveyor agreed there was no documentation of this, or assessment of any wound to the heel. Throughout the survey process, this surveyor kept the administrator, director of nursing, and nurse consultant informed of all concerns and had open dialog throughout the process. On 9/23/15 at 2:30 p.m. a meeting was held with the administrator, director of nursing (DON) and nurse consultant and informed them of the above findings. No other information was presented prior to exit conference on 9/23/15. This was a complaint deficiency at harm level.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to promptly notify the physician of a change in condition for two of 28 residents in the survey sample. 1. Nurses failed to notify Resident #24's physician after multiple reports from certified nurses' aides (CNAs) of a change in condition regarding the resident's left leg. Reports of increased pain, swelling, bruising and a change in the alignment of the resident's left leg went unreported to the physician or a designated alternate for 5 days resulting in delayed treatment/care of a fractured femur. 2. Resident #7's low blood sugar readings were not reported to the physician. The findings include: 1. Nurses failed to notify Resident #24's physician after multiple reports from certified nurses' aides of a change in condition of the resident's left leg. Reports of increased pain, swelling, bruising and a change in the alignment of the resident's left leg went unreported to the physician or a designated alternate for 5 days resulting in delayed treatment and care of a fractured femur. Resident #24 was admitted to the facility on [DATE] with a re-admission on [DATE]. The resident died in the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #24 with moderately impaired cognitive skills for decision-making. This MDS assessed Resident #24 to require the extensive assistance of two people for bed mobility and transfers. A facility reported incident dated [DATE] documented Resident #24 was diagnosed with [REDACTED]. The facility's investigation revealed no evidence of a fall or incident that caused the fracture but documented a failure by nursing staff to assess, notify the physician and promptly obtain treatment of [REDACTED].(CNAs) over a five day period. Written statements from seven CNAs documented reports to nurses on [DATE], [DATE], [DATE], [DATE] and [DATE] of the resident's complaints of pain in her left leg and that the resident's left leg was swollen, bruised and was turned inward with one leg shorter than the other. The facility's investigation documented the following written statements from CNAs caring for Resident #24 in the days prior to the diagnosed fractured femur on [DATE]. CNA #5's statement dated [DATE] stated, "Tonight upon arrival to work when talking to (LPN #6) I asked her to take a look at (Resident #24's) leg. (CNA #11), myself and (CNA#6) all reported (Resident #24's) leg on different days. I reported leg on both Monday the 26th and Wednesday the 28th. I reported this to (LPN - licensed practical nurse #9)." CNA #6's written statement dated [DATE] documented, "On the 27th of May during 3rd shift, I went in to change (Resident #24) and I noticed that her left leg was laying strangely flat on the bed and I notified the charge nurse and she said that it was arthritis." CNA #9's statement dated [DATE] documented, "On Friday [DATE]th, 2014 I went in to change (Resident #24)...The first thing I noticed was her left leg swolen (swollen) from her hip down to her knee and also a bruise on her left knee cap as well. Resident was in pain and didn't want me to touch her. I went out the room to find her nurse before I touched her to see if anyone knew about it. Her nurse was (RN #3). I told the nurse what I seen and the nurse informed me that it was the resident's arthritis that was making her leg swell. I replied that 'all the time that I have work and taken care of (Resident #24), I've never seen her legs swell like that.' And I said 'she also has a bruise on her left knee cap.' She informed me again that 'they knew about it and someone had already looked at it!'..." (sic) CNA #8's statement dated [DATE] stated, "When making round with (CNA #12) on first sift (shift) she asked me to look at (Resident #24's) leg and I did, she sayed (said) that it look funny to her and that she had told the nurse on first sift (shift) and the nurse had sayed (said) that it was arthritis. Later on in the evening I asked the nurse (LPN #3) to look at it she told me she would. And that she had arthritis in her leg." (sic) CNA #10's statement dated [DATE] documented, "On [DATE] I came into work and the CNA reported to me and told me that (Resident #24) had been complaining about her leg saying that it was broken...When I would wash her she was complaing (complaining) about her leg. When we changed her she kept saying my leg my leg." (sic) An additional statement from CNA #5 dated [DATE] documented, "...with (Resident #24) the night she was taken to the hospital. Upon arrival to work on Friday [DATE]th I filled out a STOP paper and had (LPN #8) look at (Resident #24's) leg, which was swollen, bruised, turned into her R (right) leg and her L leg was also shorter. I had previously turned in (Resident #24's) leg for looking turned in towards her right leg - I was assured by nurse (LPN #9) on 2 occassions (occasions) that it was (Resident #24's) arthritis - On [DATE]th and 28th. (Resident #24) was complaining of pain and also protecting her left leg..." (sic) CNA #7's statement dated [DATE] documented, "...on Wednesday ,[DATE] (CNA #11) asked me to help her change (Resident #24)... (Resident #24's) left knee was swollen and charge nurse (LPN #9) said that she had arthritis. On Friday [DATE] (CNA #5) reported to LPN #8 that (Resident #24) had something wrong with her leg that one leg was longer than the other one. (LPN #8) checked her leg called (physician) sent (Resident #24) to ER (emergency room )." CNA #4's undated statement documented, "On [DATE] @ about 9:30 a.m. I went in to give (Resident #24) a bed bath as I proceed to give her a bath she asked me not to roll her or touch her leg. I then asked her what was wrong and she replied my leg is hurting. I then ask her if she meant her right hip and she said no my left leg. I then covered her and immedately (immediately) went and told nurse (LPN #3). (LPN #3) replied by saying it's probably arthuris (arthritis) aching her and she (LPN #3) said she would go in and look at her...I went in on 2 other occansions (occasions) to make sure she was dry; comfortable and she would say the same thing, that her leg was hurting." (sic) Written statements by LPN #3 and RN #3 documented swelling to the resident's left knee but there was no further assessment of the leg's condition, assessment of the resident's pain or notification to the physician concerning the leg. RN #3's written statement documented, "On [DATE] after lunch aide informed this nurse that she thought resident had old bruise light yellow in color to (L) knee. Went in and assessed knee no bruising noted. After change of shift another nurse asked me to come and look at resident's knee for swelling. Knee did not look any more swollen than usual. It is usually little swollen. I stated to nurse we would put name in NP book to access (assess) for (increase) in arthritis symptoms ? gout. No complaints of pain except to neck/arms/back which is typical for resident. No unusal (unusual) report given to me that morning [DATE] from night shift nurse." LPN #3's written stated dated [DATE] documented, "On Friday [DATE]th this nurse assessed (Resident #24's) left knee due to it appearing to be swollen compared to right knee. No bruising noted but resident has hx (history) of arthritis and c/o (complains of) tenderness during palpation." The facility's investigation summary documented a failure by facility nurses to assess Resident #24 and report to the physician a change in condition in response to the resident's pain and appearance of the left leg. The investigation summary by the DON dated [DATE] documented, "On [DATE], an investigation was initiated concerning (Resident #24) and the fracture she sustained to her hip. (LPN #9) stated that she did not look at her hip but only the knee because she was informed by the c.na on Friday [DATE]th that (Resident #24's) knee was swollen. (LPN #9) stated that it was swollen, but no more than usual due to her arthritis. She did state that she forgot to enter in the NP (nurse practitioner) book for the resident to be seen after being informed on [DATE]th..." An additional note written by the DON dated [DATE] stated, "...discussed with (LPN #9) that 3 c.na's had come to her on 3 different days to inform her that the residents' leg was swollen and looked strange. (LPN #9) did not assess the leg on any of the occasions and informed the c.na's that the resident was having pain due to her history of arthritis..." Nursing notes from [DATE] through [DATE] documented no assessment of the resident's leg in response to the CNA reports of swelling, bruising, pain and positioning. The clinical record documented no description of the leg's appearance, positioning, temperature, color or of any attempts by nursing staff to determine the source or severity of the resident's complaints of pain. There was no notification to the physician or nurse practitioner regarding any issues with the resident's leg or expressions of pain. No entry was made in the NP log by RN #3 as referenced in her written statement. A note on [DATE] documented, "Son in to visit after shower...No respiratory distress noted or facial grimace as in pain. Monitoring..." No further notes were documented until [DATE] at 3:08 a.m. stating, "cna notified this writer of resident screaming out in pain when moving left leg. this writer went in room to observe left leg, left leg noted to be swollen with yellow bruising to it, leg also noted to be shorter than right leg. this writer called MD (physician) and got verbal order to send to ER for eval (evaluation)...EMt (EMT) arrived around 1:45 am, resident left via stretcher..." (sic) The hospital report dated [DATE] documented the resident presented to the emergency with pain and was diagnosed with [REDACTED]. I am not sure why the patient was not examined and why they didn't find any problems, but today found that she was having pain in her leg. Her leg was short and externally rotated. When she came in it was noted that she had a distal femur fracture. I am assuming she has had this for the last three days...Patient will be admitted for this..." X-ray results for Resident #24 dated [DATE] assessed the resident with an oblique [MEDICAL CONDITION] left femoral shaft with significant dislocation. The resident was hospitalized and had surgical repair of the fractured femur. The resident was discharged back to the nursing facility on [DATE] with instructions to be non-weight bearing on her left leg for two months. The resident returned to the facility on [DATE]. A nursing note dated [DATE] documented, "Resident verbalize acute pain to her left leg...Skin assessment completed and resident has three surgical incisions: #1 left hip proximal to left side groin measuring 3.2 cm (centimeters) long with 5 staples, #2 L knee area measuring 12 cm with 25 staples, #3 posterior lateral knee area measuring 1.3 cm with 4 staples...Left leg has an immobilizer in place following surgery..." (sic) The MDS assessment dated [DATE] prior to the leg fracture assessed Resident #24 to require the extensive assistance of one person for bed mobility and transfers. The MDS assessment dated [DATE] after the fracture listed the resident required the extensive assistance of two people for bed mobility and transfers. Further review of Resident #24's clinical record documented no ongoing complaints of pain, swelling or any issues with the resident's left leg prior to [DATE]. Notes from [DATE] through [DATE] documented no complaints of pain by the resident. Notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] documented the resident had no verbal or non-verbal expressions of pain. The record documented the resident was on "comfort care" and was prescribed and administered Tylenol 500 mg three times a day for pain starting on [DATE]. The resident's care plan in place prior to the fracture (review date [DATE]) listed the resident experienced pain with interventions listed as, "scheduled medicines as scheduled...Evaluate effectiveness of medication; notify MD, as indicated...Assess for side effects of [MEDICATION NAME] or eliminate contributing factors of pain, as capable...Assess for contributing factors of pain...Assess for pain through verbal or nonverbal expression of the resident...Provide methods to help decrease pain, as indicated (cold packs, repositioning, heat applications)..." The record made no mention of the location of the resident's pain. On [DATE] at 10:00 a.m. licensed practical nurse (LPN) #3 caring for Resident #24 during [DATE] was interviewed about Resident #24's fractured femur. LPN #3 stated on that Saturday ([DATE]) a CNA reported that Resident #24's leg was swollen. LPN #3 stated, "I did know she (Resident #24) had arthritis." LPN #3 stated she assessed Resident #24's knee and when she moved the knee the resident stated we were killing her. LPN #3 stated, "That was normal for her." LPN #3 stated, "I think I would have noticed if she had a bruise." LPN #3 stated she focused on the resident's knee and did not really look at her hip area. LPN #3 stated she performed range of motion on the resident's left knee and stated, "She (Resident #24) didn't scream just her usual you're killing me." LPN #3 stated she was not assigned to Resident #24 that day so she reported the swollen knee to the assigned registered nurse (RN #3). LPN #3 stated RN #3 said she would check the resident. When asked if she documented any assessment of Resident #24's knee, leg or expressions of pain, LPN #3 stated, "No because I wasn't her nurse and that nurse (RN #3) said she was going to assess her." When asked about any notification to the physician LPN #3 stated she only reported the swollen knee to RN #3. LPN #3 stated the next morning RN #3 told her she forgot to put Resident #24 on the NP book and asked me to list the resident on the NP log. LPN #3 stated, "I didn't realize she was gone (to hospital)." On [DATE] at 10:15 a.m. CNA #4 was interviewed about Resident #24's fractured femur. CNA #4 stated she routinely cared for Resident #24 on the day shift during her stay. CNA #4 stated on that Tuesday ([DATE]) she went in to bathe Resident #24 and the resident complained of her knee "hurting like the dickens." CNA #4 stated the resident said, "It just hurts. It just hurts." CNA #4 states she stopped the bath and saw that the left knee was swollen. CNA #4 stated she reported the swelling and pain to LPN #3 and LPN #3 stated she would look at it. CNA #4 stated she went back and checked on the resident again and Resident #24 stated her knee was hurting. CNA #4 stated, "It was hurting her a lot." CNA #4 stated the resident had a history of [REDACTED]. On [DATE] at 2:00 p.m. the administrator was interviewed about their investigation regarding Resident #24's fractured femur. The administrator stated they did a full investigation following the diagnosed fracture including interviews with nurses and aide. The administrator stated their investigation concluded that the "nurses didn't do their job, used their judgment wrong." The administrator stated LPN #3, LPN #9 and RN #3 failed to assess Resident #24 in response CNA reports of swelling, pain and improper alignment of the leg. The administrator stated "If they (nurses) assessed they didn't do anything, didn't write anything and didn't notify the MD (physician)." When asked about physician coverage for the facility, the administrator stated a nurse practitioner was in the facility 5 days a week to assess/treat residents as needed in addition to 24 hours/7 days per week coverage by the physicians. The administrator stated the healthcare providers were not notified of a need to check/assess Resident 24's leg or pain prior to [DATE]. The facility's policy titled Significant Change of Condition (#2002) stated, "The patient's change of condition shall be reported immediately to a licensed nurse...A licensed nurse shall assess the patient for signs and symptoms of physical or mental change of condition...This assessment shall be reported to primary physician or designated alternate... Notification of physician, time, and date (month, day and year) are to be documented in the Nurses Notes. A licensed nurse must speak directly to physician; you may not leave a message with an answering service or receptionist...Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a patient should be transferred to an acute care setting...Each change of condition shall be documented in the Nurses Notes and Shift Report." The Lippincott Manual of Nursing Practice 10th Edition on page 1130 defines a fracture as, "a break in the continuity of bone. A fracture occurs when the stress placed on a bone is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints, and other organs may be injured when fracture occurs." This reference describes an oblique fracture as a fracture at an angle across the bone. Page 1130 of this reference lists the clinical manifestations of a fracture to include pain at the site of injury, swelling, tenderness, deformity, loss of function, ecchymosis, progressive uncontrollable pain, pain on passive movement and pallor. (1) These findings were reviewed with the administrator and corporate nursing consultants on [DATE] at 2:20 p.m. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. This was a complaint deficiency. 2. The facility staff failed to ensure Resident # 7's physician was notified of low blood glucose levels. Findings include: Resident # 7, an [AGE] year old female resident was admitted to the facility originally on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "7", indicating the resident was severely impaired in daily decision making skills. The resident also required extensive assistance for most all ADL's (activities of daily living), including eating. During clinical record review on [DATE], nursing notes were reviewed an documented that the resident was sent out to the hospital on [DATE] due to having a low blood sugar. The resident was hospitalized for [REDACTED]. Resident # 7's physician's orders [REDACTED]. day) notify physician if blood sugar below 100 or greater than 350..." This order was initiated originally on [DATE] and was not discontinued until [DATE]. Another physician's orders [REDACTED].# 7 that documented: "...accu checks before breakfast on Monday, Wednesday and Friday...(no blood sugar parameters were included with this order). This order was initiated originally on [DATE] and was discontinued on [DATE]. These two orders overlapped each other from [DATE] through [DATE]. Resident # 7's MAR's (medication administration records) for the month of [DATE], were reviewed and revealed the following blood glucose levels: [DATE]-BS (blood sugar)= 77 (6:30 a.m. reading) [DATE]-BS=53 (4:30 p.m. reading) [DATE]-BS=89 (4:30 p.m. reading) [DATE]-BS=75 (6:30 a.m. reading) [DATE]-BS=97 (6:30 a.m. reading) Nursing notes were then reviewed for the same time frame, along with physician orders. The only physician notification, was found for the [DATE] blood sugar reading of "53." No other notification could be found or located in the clinical record to indicate the physician was ever notified of the other blood sugar readings that were below normal, as ordered by the physician. Resident # 7's MAR's (medication administration records) for the month of [DATE], were reviewed and revealed the following blood glucose levels: [DATE]-BS=44 (6:30 a.m. reading) A nursing note dated [DATE] (timed 8:09 a.m.) documented: "6:00 a.m. Resident bs was 44, given cup of supplement, will recheck in one hr. (hour). There was no notification that the physician was notified of this blood sugar level and no evidence that the blood sugar level was rechecked in 1 hour. On this particular day ([DATE]), the resident's regularly scheduled [MEDICATION NAME] was documented as administered at 12:32 p.m., not at 9:00 a.m. as ordered. [DATE]-BS=54 (6:30 a.m. reading) No nursing notes were found regarding the resident's blood sugar of '54' on [DATE]. No information was found to evidence the physician had been notified of this blood sugar reading for Resident # 7. On this particular day the resident's regularly scheduled [MEDICATION NAME] was documented as administered at 3:04 p.m., not at 9:00 a.m. as ordered. Resident # 7 had been experiencing low blood sugar levels without physician notification. The resident experienced another low blood sugar on [DATE] of '31', the physician was notified of this low blood sugar and the resident was subsequently sent out to the hospital for evaluation related to [DIAGNOSES REDACTED]. The resident was out of the facility from [DATE] and readmitted on [DATE]. The resident's CCP (comprehensive care plan) was then reviewed and documented: "...Resident has diabetes...medication as ordered by doctor, Monitor for side effects and effectiveness...educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections...Monitor/document/report PRN (as needed) any s/sx (signs and/or symptoms) [DIAGNOSES REDACTED] (low blood sugar): sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait...labs as ordered, report abnormal lab results to the MD (medical doctor)..." On [DATE] at approximately 2:00 p.m., the DON (director of nursing) was asked for assistance with the above information. At approximately 2:45 p.m., the DON voiced that the resident had two orders for accu checks and they were overlapping from [DATE] through [DATE]. The DON also voiced that she would have to look into the above information. On [DATE] at approximately 4:15 p.m., in a meeting with the survey team, the administrator, DON (director of nursing), and corporate nurse # 4 and # 5 were made aware of the above concerns regarding the physician not being notified of Resident # 7's low blood sugars. Corporate nurse # 4 was asked, what the expectation was for physician notification regarding low blood sugars. Corporate nurse #4 responded, 'anything below 60...' On [DATE] at 10:40 a.m., in a meeting with the survey team Corporate nurse # 4 voiced that the nurse's know they are supposed to notify the physician and while reviewing this information, noticed there was a pattern of the nurse's administering or signing (medications) out late. The corporate nurse stated, "You document when you give it." On [DATE] at approximately 2:00 p.m. in a meeting the survey team, the administrative staff were again made aware of the concerns regarding Resident # 7's not being notified and nursing staff continuing to administer insulin to the resident. Corporate nurse # 4 voiced regarding notification, if it isn't documented it isn't done. No further information or documentation was presented prior to the exit conference on [DATE] at 5:30 p.m.

Based on resident interview, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed provide prompt treatment in response to pain and a change in condition for one of 28 residents in the survey sample (Resident #24); The facility staff also failed to follow physician orders [REDACTED].#17). 1. Nurses failed to provide prompt assessment, notification and treatment for [REDACTED]. leg. Reports of increased pain, swelling, bruising and a change in the alignment of the resident's left leg were not assessed or reported to the physician for 5 days resulting in delayed treatment/care of a fractured femur requiring hospitalization and surgical repair. There were no attempts by nurses to determine the source or severity of Resident #24's complaints of pain associated with the fracture. 2. Resident #17 was not administered insulin as ordered by the physician. The findings include: 1. Nurses failed to provide prompt assessment, notification and treatment for [REDACTED]. leg. Reports of increased pain, swelling, bruising and a change in the alignment of the resident's left leg were not assessed or reported to the physician for 5 days resulting in delayed treatment/care of a fractured femur. There were no attempts by nurses to determine the source or severity of Resident #24's complaints of pain associated with the fracture. Resident #24 was admitted to the facility on [DATE] with a re-admission on [DATE]. The resident died in the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #24 with moderately impaired cognitive skills for decision-making. This MDS assessed Resident #24 to require the extensive assistance of two people for bed mobility and transfers. A facility reported incident dated [DATE] documented Resident #24 was diagnosed with [REDACTED]. The facility's investigation revealed no evidence of a fall or incident that caused the fracture but documented a failure by nursing staff to assess, notify the physician and promptly obtain treatment of [REDACTED].(CNAs) over a five day period. Written statements from seven CNAs documented reports to nurses on [DATE], [DATE], [DATE], [DATE] and [DATE] of the resident's complaints of pain in her left leg and that the resident's left leg was swollen, bruised and was turned inward with one leg shorter than the other. The facility's investigation documented the following written statements from CNAs caring for Resident #24 in the days prior to the diagnosed fractured femur on [DATE]. CNA #5's statement dated [DATE] stated, "Tonight upon arrival to work when talking to (LPN #6) I asked her to take a look at (Resident #24's) leg. (CNA #11), myself and (CNA#6) all reported (Resident #24's) leg on different days. I reported leg on both Monday the 26th and Wednesday the 28th. I reported this to (LPN - licensed practical nurse #9)." CNA #6's written statement dated [DATE] documented, "On the 27th of May during 3rd shift, I went in to change (Resident #24) and I noticed that her left leg was laying strangely flat on the bed and I notified the charge nurse and she said that it was arthritis." CNA #9's statement dated [DATE] documented, "On Friday [DATE]th, 2014 I went in to change (Resident #24)...The first thing I noticed was her left leg swolen (swollen) from her hip down to her knee and also a bruise on her left knee cap as well. Resident was in pain and didn't want me to touch her. I went out the room to find her nurse before I touched her to see if anyone knew about it. Her nurse was (RN #3). I told the nurse what I seen and the nurse informed me that it was the resident's arthritis that was making her leg swell. I replied that 'all the time that I have work and taken care of (Resident #24), I've never seen her legs swell like that.' And I said 'she also has a bruise on her left knee cap.' She informed me again that 'they knew about it and someone had already looked at it!'..." (sic) CNA #8's statement dated [DATE] stated, "When making round with (CNA #12) on first sift (shift) she asked me to look at (Resident #24's) leg and I did, she sayed (said) that it look funny to her and that she had told the nurse on first sift (shift) and the nurse had sayed (said) that it was arthritis. Later on in the evening I asked the nurse (LPN #3) to look at it she told me she would. And that she had arthritis in her leg." (sic) CNA #10's statement dated [DATE] documented, "On [DATE] I came into work and the CNA reported to me and told me that (Resident #24) had been complaining about her leg saying that it was broken...When I would wash her she was complaing (complaining) about her leg. When we changed her she kept saying my leg my leg." (sic) An additional statement from CNA #5 dated [DATE] documented, "...with (Resident #24) the night she was taken to the hospital. Upon arrival to work on Friday [DATE]th I filled out a STOP paper and had (LPN #8) look at (Resident #24's) leg, which was swollen, bruised, turned into her R (right) leg and her L leg was also shorter. I had previously turned in (Resident #24's) leg for looking turned in towards her right leg - I was assured by nurse (LPN #9) on 2 occassions (occasions) that it was (Resident #24's) arthritis - On [DATE]th and 28th. (Resident #24) was complaining of pain and also protecting her left leg..." (sic) CNA #7's statement dated [DATE] documented, "...on Wednesday ,[DATE] (CNA #11) asked me to help her change (Resident #24)... (Resident #24's) left knee was swollen and charge nurse (LPN #9) said that she had arthritis. On Friday [DATE] (CNA #5) reported to LPN #8 that (Resident #24) had something wrong with her leg that one leg was longer than the other one. (LPN #8) checked her leg called (physician) sent (Resident #24) to ER (emergency room )." CNA #4's undated statement documented, "On [DATE] @ about 9:30 a.m. I went in to give (Resident #24) a bed bath as I proceed to give her a bath she asked me not to roll her or touch her leg. I then asked her what was wrong and she replied my leg is hurting. I then ask her if she meant her right hip and she said no my left leg. I then covered her and immedately (immediately) went and told nurse (LPN #3). (LPN #3) replied by saying it's probably arthuris (arthritis) aching her and she (LPN #3) said she would go in and look at her...I went in on 2 other occansions (occasions) to make sure she was dry; comfortable and she would say the same thing, that her leg was hurting." (sic) Written statements by LPN #3 and RN #3 documented swelling to the resident's left knee but there was no further assessment of the leg's condition, assessment of the resident's pain or notification to the physician concerning the leg. RN #3's written statement documented, "On [DATE] after lunch aide informed this nurse that she thought resident had old bruise light yellow in color to (L) knee. Went in and assessed knee no bruising noted. After change of shift another nurse asked me to come and look at resident's knee for swelling. Knee did not look any more swollen than usual. It is usually little swollen. I stated to nurse we would put name in NP book to access (assess) for (increase) in arthritis symptoms ? gout. No complaints of pain except to neck/arms/back which is typical for resident. No unusal (unusual) report given to me that morning [DATE] from night shift nurse." LPN #3's written stated dated [DATE] documented, "On Friday [DATE]th this nurse assessed (Resident #24's) left knee due to it appearing to be swollen compared to right knee. No bruising noted but resident has hx (history) of arthritis and c/o (complains of) tenderness during palpation." The facility's investigation summary documented a failure by facility nurses to assess Resident #24 and report to the physician a change in condition in response to the resident's pain and appearance of the left leg. The investigation summary by the DON dated [DATE] documented, "On [DATE], an investigation was initiated concerning (Resident #24) and the fracture she sustained to her hip. (LPN #9) stated that she did not look at her hip but only the knee because she was informed by the c.na on Friday [DATE]th that (Resident #24's) knee was swollen. (LPN #9) stated that it was swollen, but no more than usual due to her arthritis. She did state that she forgot to enter in the NP (nurse practitioner) book for the resident to be seen after being informed on [DATE]th..." An additional note written by the DON dated [DATE] stated, "...discussed with (LPN #9) that 3 c.na's had come to her on 3 different days to inform her that the residents' leg was swollen and looked strange. (LPN #9) did not assess the leg on any of the occasions and informed the c.na's that the resident was having pain due to her history of arthritis..." Nursing notes from [DATE] through [DATE] documented no assessment of the resident's leg in response to the CNA reports of swelling, bruising, pain and positioning. The clinical record documented no description of the leg's appearance, positioning, temperature, color or of any attempts by nursing staff to determine the source or severity of the resident's complaints of pain. There was no notification to the physician or nurse practitioner regarding any issues with the resident's leg or expressions of pain. No entry was made in the NP log by RN #3 as referenced in her written statement. A note on [DATE] documented, "Son in to visit after shower...No respiratory distress noted or facial grimace as in pain. Monitoring..." No further notes were documented until [DATE] at 3:08 a.m. stating, "cna notified this writer of resident screaming out in pain when moving left leg. this writer went in room to observe left leg, left leg noted to be swollen with yellow bruising to it, leg also noted to be shorter than right leg. this writer called MD (physician) and got verbal order to send to ER for eval (evaluation)...EMt (EMT) arrived around 1:45 am, resident left via stretcher..." (sic) The hospital report dated [DATE] documented the resident presented to the emergency with pain and was diagnosed with [REDACTED]. I am not sure why the patient was not examined and why they didn't find any problems, but today found that she was having pain in her leg. Her leg was short and externally rotated. When she came in it was noted that she had a distal femur fracture. I am assuming she has had this for the last three days...Patient will be admitted for this..." X-ray results for Resident #24 dated [DATE] assessed the resident with an oblique [MEDICAL CONDITION] left femoral shaft with significant dislocation. The resident was hospitalized and had surgical repair of the fractured femur. The resident was discharged back to the nursing facility on [DATE] with instructions to be non-weight bearing on her left leg for two months. The resident returned to the facility on [DATE]. A nursing note dated [DATE] documented, "Resident verbalize acute pain to her left leg...Skin assessment completed and resident has three surgical incisions: #1 left hip proximal to left side groin measuring 3.2 cm (centimeters) long with 5 staples, #2 L knee area measuring 12 cm with 25 staples, #3 posterior lateral knee area measuring 1.3 cm with 4 staples...Left leg has an immobilizer in place following surgery..." (sic) The MDS assessment dated [DATE] prior to the leg fracture assessed Resident #24 to require the extensive assistance of one person for bed mobility and transfers. The MDS assessment dated [DATE] after the fracture listed the resident required the extensive assistance of two people for bed mobility and transfers. Further review of Resident #24's clinical record documented no ongoing complaints of pain, swelling or any issues with the resident's left leg prior to [DATE]. Notes from [DATE] through [DATE] documented no complaints of pain by the resident. Notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] documented the resident had no verbal or non-verbal expressions of pain. The record documented the resident was on "comfort care" and was prescribed and administered Tylenol 500 mg three times a day for pain starting on [DATE]. The resident's care plan in place prior to the fracture (review date [DATE]) listed the resident experienced pain with interventions listed as, "scheduled medicines as scheduled...Evaluate effectiveness of medication; notify MD, as indicated...Assess for side effects of [MEDICATION NAME] or eliminate contributing factors of pain, as capable...Assess for contributing factors of pain...Assess for pain through verbal or nonverbal expression of the resident...Provide methods to help decrease pain, as indicated (cold packs, repositioning, heat applications)..." The record made no mention of the location of the resident's pain. On [DATE] at 10:00 a.m. licensed practical nurse (LPN) #3 caring for Resident #24 during [DATE] was interviewed about Resident #24's fractured femur. LPN #3 stated on that Saturday ([DATE]) a CNA reported that Resident #24's leg was swollen. LPN #3 stated, "I did know she (Resident #24) had arthritis." LPN #3 stated she assessed Resident #24's knee and when she moved the knee the resident stated we were killing her. LPN #3 stated, "That was normal for her." LPN #3 stated, "I think I would have noticed if she had a bruise." LPN #3 stated she focused on the resident's knee and did not really look at her hip area. LPN #3 stated she performed range of motion on the resident's left knee and stated, "She (Resident #24) didn't scream just her usual you're killing me." LPN #3 stated she was not assigned to Resident #24 that day so she reported the swollen knee to the assigned registered nurse (RN #3). LPN #3 stated RN #3 said she would check the resident. When asked if she documented any assessment of Resident #24's knee, leg or expressions of pain, LPN #3 stated, "No because I wasn't her nurse and that nurse (RN #3) said she was going to assess her." When asked about any notification to the physician LPN #3 stated she only reported the swollen knee to RN #3. LPN #3 stated the next morning RN #3 told her she forgot to put Resident #24 on the NP book and asked me to list the resident on the NP log. LPN #3 stated, "I didn't realize she was gone (to hospital)." On [DATE] at 10:15 a.m. CNA #4 was interviewed about Resident #24's fractured femur. CNA #4 stated she routinely cared for Resident #24 on the day shift during her stay. CNA #4 stated on that Tuesday ([DATE]) she went in to bathe Resident #24 and the resident complained of her knee "hurting like the dickens." CNA #4 stated the resident said, "It just hurts. It just hurts." CNA #4 states she stopped the bath and saw that the left knee was swollen. CNA #4 stated she reported the swelling and pain to LPN #3 and LPN #3 stated she would look at it. CNA #4 stated she went back and checked on the resident again and Resident #24 stated her knee was hurting. CNA #4 stated, "It was hurting her a lot." CNA #4 stated the resident had a history of [REDACTED]. On [DATE] at 2:00 p.m. the administrator was interviewed about their investigation regarding Resident #24's fractured femur. The administrator stated they did a full investigation following the diagnosed fracture including interviews with nurses and aide. The administrator stated their investigation concluded that the "nurses didn't do their job, used their judgment wrong." The administrator stated LPN #3, LPN #9 and RN #3 failed to assess Resident #24 in response CNA reports of swelling, pain and improper alignment of the leg. The administrator stated "If they (nurses) assessed they didn't do anything, didn't write anything and didn't notify the MD (physician)." When asked about physician coverage for the facility, the administrator stated a nurse practitioner was in the facility 5 days a week to assess/treat residents as needed in addition to 24 hours/7 days per week coverage by the physicians. The administrator stated the healthcare providers were not notified of a need to check/assess Resident 24's leg or pain prior to [DATE]. The facility's policy titled Significant Change of Condition (#2002) stated, "The patient's change of condition shall be reported immediately to a licensed nurse...A licensed nurse shall assess the patient for signs and symptoms of physical or mental change of condition...This assessment shall be reported to primary physician or designated alternate... Notification of physician, time, and date (month, day and year) are to be documented in the Nurses Notes. A licensed nurse must speak directly to physician; you may not leave a message with an answering service or receptionist...Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a patient should be transferred to an acute care setting...Each change of condition shall be documented in the Nurses Notes and Shift Report." The Lippincott Manual of Nursing Practice 10th Edition on page 1130 defines a fracture as, "a break in the continuity of bone. A fracture occurs when the stress placed on a bone is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints, and other organs may be injured when fracture occurs." This reference described an oblique fracture as a fracture at an angle across the bone. Page 1130 of this reference lists the clinical manifestations of a fracture to include pain at the site of injury, swelling, tenderness, deformity, loss of function, ecchymosis, progressive uncontrollable pain, pain on passive movement and pallor. (1) These findings were reviewed with the administrator and corporate nursing consultants on [DATE] at 2:20 p.m. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. This was a complaint deficiency. 2. The facility staff failed to administer Resident # 17's insulin per physician's orders [REDACTED]. Resident # 17 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an admission assessment dated [DATE]. Resident # 17 was assessed as cognitively intact with a total summary score of 15 out of 15. The electronic medical record was reviewed [DATE] at approximately 7:15 a.m. The current physician orders [REDACTED]." The eMAR (electronic medication administration record) for February 2015 and [DATE] was then reviewed. The administration time on the eMAR was scheduled for 9:00 a.m. with staff initials indicating the insulin was administered. The actual administration time on the eMAR for the insulin included the "Scheduled Time" and "Administered Time". The "Administered Time" included times ranging from 8:15 a.m. to 11:26 a.m. On [DATE] at approximately 8:00 a.m. this surveyor went to Resident # 17's room. After knocking on the door and given permission to enter, Resident # 17 was observed eating breakfast. CNA (certified nursing assistant) # 1 was assisting the resident, and this surveyor asked what time the breakfast trays were served. CNA # 1 stated "trays are usually on the floor by 7:30 a.m. They were a little late today." This surveyor then left the resident's room and proceeded down the hallway where LPN (licensed practical nurse) # 2 was preparing to administer medications. LPN # 2 was asked what time Resident # 17 was administered the morning dose of insulin. LPN # 2 stated "Let me look on the MAR. I know it can be given an hour before or an hour after the scheduled time." LPN # 2 then looked at the eMAR and stated "Looks like it's due at 9:00 a.m." This surveyor then asked LPN # 2 about the order which directed the insulin be administered with breakfast. LPN # 2 stated "Oh, well, yes, that is a little more specific. But the system doesn't 'open up' until 8:00 a.m. so it can't be signed off until then." LPN # 2 was asked if Resident # 17 had been administered the insulin given with breakfast and LPN # 2 stated "No." On [DATE] at approximately 8:15 a.m. this surveyor returned to Resident # 17's room, knocked, and was given permission to enter. Resident # 17 was asked when she was usually administered her morning dose of insulin. Resident # 17 stated "Well, typically sometime after breakfast to right before lunch." The administrator, DON (director of nursing), and three regional nurse consultants were informed of the above findings. No further information was provided prior to the exit conference.

Based on medication pass observation, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to follow professional standards of nursing practice for four of 30 residents in the survey sample. 1. Nurses failed to follow professional standards of practice to assess, notify the physician and obtain/provide treatment for [REDACTED]. This resulted in a five day delay in treatment of [REDACTED]. 2. Nurses failed to record insulin given to Resident #7 at the time of administration. 3. During a medication pass observation Resident # 29 was administered a medication labeled for Resident # 30. The findings include: 1. Nurses failed to assess, notify the physician and obtain treatment for [REDACTED]. leg. On the sixth day after reports of pain, Resident #24 was sent to the hospital and diagnosed with [REDACTED]. Resident #24 was admitted to the facility on [DATE] with a re-admission on [DATE]. The resident died in the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #24 with moderately impaired cognitive skills for decision-making. This MDS assessed Resident #24 to require the extensive assistance of two people for bed mobility and transfers. A facility reported incident dated [DATE] documented Resident #24 was diagnosed with [REDACTED]. The facility's investigation revealed no evidence of a fall or incident that caused the fracture but documented a failure by nursing staff to assess, notify the physician and promptly obtain treatment of [REDACTED].(CNAs) over a five day period. Written statements from seven CNAs documented reports to nurses on [DATE], [DATE], [DATE], [DATE] and [DATE] of the resident's complaints of pain in her left leg and that the resident's left leg was swollen, bruised and was turned inward with one leg shorter than the other. The facility's investigation documented the following written statements from CNAs caring for Resident #24 in the days prior to the diagnosed fractured femur on [DATE]. CNA #5's statement dated [DATE] stated, "Tonight upon arrival to work when talking to (LPN #6) I asked her to take a look at (Resident #24's) leg. (CNA #11), myself and (CNA#6) all reported (Resident #24's) leg on different days. I reported leg on both Monday the 26th and Wednesday the 28th. I reported this to (LPN - licensed practical nurse #9)." CNA #6's written statement dated [DATE] documented, "On the 27th of May during 3rd shift, I went in to change (Resident #24) and I noticed that her left leg was laying strangely flat on the bed and I notified the charge nurse and she said that it was arthritis." CNA #9's statement dated [DATE] documented, "On Friday [DATE]th, 2014 I went in to change (Resident #24)...The first thing I noticed was her left leg swolen (swollen) from her hip down to her knee and also a bruise on her left knee cap as well. Resident was in pain and didn't want me to touch her. I went out the room to find her nurse before I touched her to see if anyone knew about it. Her nurse was (RN #3). I told the nurse what I seen and the nurse informed me that it was the resident's arthritis that was making her leg swell. I replied that 'all the time that I have work and taken care of (Resident #24), I've never seen her legs swell like that.' And I said 'she also has a bruise on her left knee cap.' She informed me again that 'they knew about it and someone had already looked at it!'..." (sic) CNA #8's statement dated [DATE] stated, "When making round with (CNA #12) on first sift (shift) she asked me to look at (Resident #24's) leg and I did, she sayed (said) that it look funny to her and that she had told the nurse on first sift (shift) and the nurse had sayed (said) that it was arthritis. Later on in the evening I asked the nurse (LPN #3) to look at it she told me she would. And that she had arthritis in her leg." (sic) CNA #10's statement dated [DATE] documented, "On [DATE] I came into work and the CNA reported to me and told me that (Resident #24) had been complaining about her leg saying that it was broken...When I would wash her she was complaing (complaining) about her leg. When we changed her she kept saying my leg my leg." (sic) An additional statement from CNA #5 dated [DATE] documented, "...with (Resident #24) the night she was taken to the hospital. Upon arrival to work on Friday [DATE]th I filled out a STOP paper and had (LPN #8) look at (Resident #24's) leg, which was swollen, bruised, turned into her R (right) leg and her L leg was also shorter. I had previously turned in (Resident #24's) leg for looking turned in towards her right leg - I was assured by nurse (LPN #9) on 2 occassions (occasions) that it was (Resident #24's) arthritis - On [DATE]th and 28th. (Resident #24) was complaining of pain and also protecting her left leg..." (sic) CNA #7's statement dated [DATE] documented, "...on Wednesday ,[DATE] (CNA #11) asked me to help her change (Resident #24)... (Resident #24's) left knee was swollen and charge nurse (LPN #9) said that she had arthritis. On Friday [DATE] (CNA #5) reported to LPN #8 that (Resident #24) had something wrong with her leg that one leg was longer than the other one. (LPN #8) checked her leg called (physician) sent (Resident #24) to ER (emergency room )." CNA #4's undated statement documented, "On [DATE] @ about 9:30 a.m. I went in to give (Resident #24) a bed bath as I proceed to give her a bath she asked me not to roll her or touch her leg. I then asked her what was wrong and she replied my leg is hurting. I then ask her if she meant her right hip and she said no my left leg. I then covered her and immedately (immediately) went and told nurse (LPN #3). (LPN #3) replied by saying it's probably arthuris (arthritis) aching her and she (LPN #3) said she would go in and look at her...I went in on 2 other occansions (occasions) to make sure she was dry; comfortable and she would say the same thing, that her leg was hurting." (sic) Written statements by LPN #3 and RN #3 documented swelling to the resident's left knee but there was no further assessment of the leg's condition, assessment of the resident's pain or notification to the physician concerning the leg. RN #3's written statement documented, "On [DATE] after lunch aide informed this nurse that she thought resident had old bruise light yellow in color to (L) knee. Went in and assessed knee no bruising noted. After change of shift another nurse asked me to come and look at resident's knee for swelling. Knee did not look any more swollen than usual. It is usually little swollen. I stated to nurse we would put name in NP book to access (assess) for (increase) in arthritis symptoms ? gout. No complaints of pain except to neck/arms/back which is typical for resident. No unusal (unusual) report given to me that morning [DATE] from night shift nurse." LPN #3's written stated dated [DATE] documented, "On Friday [DATE]th this nurse assessed (Resident #24's) left knee due to it appearing to be swollen compared to right knee. No bruising noted but resident has hx (history) of arthritis and c/o (complains of) tenderness during palpation." The facility's investigation summary documented a failure by facility nurses to assess Resident #24 and report to the physician a change in condition in response to the resident's pain and appearance of the left leg. The investigation summary by the DON dated [DATE] documented, "On [DATE], an investigation was initiated concerning (Resident #24) and the fracture she sustained to her hip. (LPN #9) stated that she did not look at her hip but only the knee because she was informed by the c.na on Friday [DATE]th that (Resident #24's) knee was swollen. (LPN #9) stated that it was swollen, but no more than usual due to her arthritis. She did state that she forgot to enter in the NP (nurse practitioner) book for the resident to be seen after being informed on [DATE]th..." An additional note written by the DON dated [DATE] stated, "...discussed with (LPN #9) that 3 c.na's had come to her on 3 different days to inform her that the residents' leg was swollen and looked strange. (LPN #9) did not assess the leg on any of the occasions and informed the c.na's that the resident was having pain due to her history of arthritis..." Nursing notes from [DATE] through [DATE] documented no assessment of the resident's leg in response to the CNA reports of swelling, bruising, pain and positioning. The clinical record documented no description of the leg's appearance, positioning, temperature, color or of any attempts by nursing staff to determine the source or severity of the resident's complaints of pain. There was no notification to the physician or nurse practitioner regarding any issues with the resident's leg or expressions of pain. No entry was made in the NP log by RN #3 as referenced in her written statement. A note on [DATE] documented, "...No respiratory distress noted or facial grimace as in pain. Monitoring..." No further notes were documented until [DATE] at 3:08 a.m. stating, "cna notified this writer of resident screaming out in pain when moving left leg. this writer went in room to observe left leg, left leg noted to be swollen with yellow bruising to it, leg also noted to be shorter than right leg. this writer called MD (physician) and got verbal order to send to ER for eval (evaluation)...EMt (EMT) arrived around 1:45 am, resident left via stretcher..." (sic) The hospital report dated [DATE] documented the resident presented to the emergency with pain and was diagnosed with [REDACTED]. I am not sure why the patient was not examined and why they didn't find any problems, but today found that she was having pain in her leg. Her leg was short and externally rotated. When she came in it was noted that she had a distal femur fracture. I am assuming she has had this for the last three days...Patient will be admitted for this..." X-ray results for Resident #24 dated [DATE] assessed the resident with an oblique [MEDICAL CONDITION] left femoral shaft with significant dislocation. The resident was hospitalized and had surgical repair of the fractured femur. The resident was discharged back to the nursing facility on [DATE] with instructions to be non-weight bearing on her left leg for two months. The resident returned to the facility on [DATE]. A nursing note dated [DATE] documented, "Resident verbalize acute pain to her left leg...Skin assessment completed and resident has three surgical incisions: #1 left hip proximal to left side groin measuring 3.2 cm (centimeters) long with 5 staples, #2 L knee area measuring 12 cm with 25 staples, #3 posterior lateral knee area measuring 1.3 cm with 4 staples...Left leg has an immobilizer in place following surgery..." (sic) The MDS assessment dated [DATE] prior to the leg fracture assessed Resident #24 to require the extensive assistance of one person for bed mobility and transfers. The MDS assessment dated [DATE] after the fracture listed the resident required the extensive assistance of two people for bed mobility and transfers. Further review of Resident #24's clinical record documented no ongoing complaints of pain, swelling or any issues with the resident's left leg prior to [DATE]. Notes from [DATE] through [DATE] documented no complaints of pain by the resident. Notes dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] documented the resident had no verbal or non-verbal expressions of pain. The record documented the resident was on "comfort care" and was prescribed and administered Tylenol 500 mg three times a day for pain starting on [DATE]. The resident's care plan in place prior to the fracture (review date [DATE]) listed the resident experienced pain with interventions listed as, "scheduled medicines as scheduled...Evaluate effectiveness of medication; notify MD, as indicated...Assess for side effects of [MEDICATION NAME] or eliminate contributing factors of pain, as capable...Assess for contributing factors of pain...Assess for pain through verbal or nonverbal expression of the resident...Provide methods to help decrease pain, as indicated (cold packs, repositioning, heat applications)..." The record made no mention of the location of the resident's pain. On [DATE] at 10:00 a.m. licensed practical nurse (LPN) #3 caring for Resident #24 during [DATE] was interviewed about Resident #24's fractured femur. LPN #3 stated on that Saturday ([DATE]) a CNA reported that Resident #24's leg was swollen. LPN #3 stated, "I did know she (Resident #24) had arthritis." LPN #3 stated she assessed Resident #24's knee and when she moved the knee the resident stated we were killing her. LPN #3 stated, "That was normal for her." LPN #3 stated, "I think I would have noticed if she had a bruise." LPN #3 stated she focused on the resident's knee and did not really look at her hip area. LPN #3 stated she performed range of motion on the resident's left knee and stated, "She (Resident #24) didn't scream just her usual you're killing me." LPN #3 stated she was not assigned to Resident #24 that day so she reported the swollen knee to the assigned registered nurse (RN #3). LPN #3 stated RN #3 said she would check the resident. When asked if she documented any assessment of Resident #24's knee, leg or expressions of pain, LPN #3 stated, "No because I wasn't her nurse and that nurse (RN #3) said she was going to assess her." When asked about any notification to the physician LPN #3 stated she only reported the swollen knee to RN #3. LPN #3 stated the next morning RN #3 told her she forgot to put Resident #24 on the NP book and asked me to list the resident on the NP log. LPN #3 stated, "I didn't realize she was gone (to hospital)." On [DATE] at 10:15 a.m. CNA #4 was interviewed about Resident #24's fractured femur. CNA #4 stated she routinely cared for Resident #24 on the day shift during her stay. CNA #4 stated on that Tuesday ([DATE]) she went in to bathe Resident #24 and the resident complained of her knee "hurting like the dickens." CNA #4 stated the resident said, "It just hurts. It just hurts." CNA #4 states she stopped the bath and saw that the left knee was swollen. CNA #4 stated she reported the swelling and pain to LPN #3 and LPN #3 stated she would look at it. CNA #4 stated she went back and checked on the resident again and Resident #24 stated her knee was hurting. CNA #4 stated, "It was hurting her a lot." CNA #4 stated the resident had a history of [REDACTED]. On [DATE] at 2:00 p.m. the administrator was interviewed about their investigation regarding Resident #24's fractured femur. The administrator stated they did a full investigation following the diagnosed fracture including interviews with nurses and aide. The administrator stated their investigation concluded that the "nurses didn't do their job, used their judgment wrong." The administrator stated LPN #3, LPN #9 and RN #3 failed to assess Resident #24 in response CNA reports of swelling, pain and improper alignment of the leg. The administrator stated "If they (nurses) assessed they didn't do anything, didn't write anything and didn't notify the MD (physician)." When asked about physician coverage for the facility, the administrator stated a nurse practitioner was in the facility 5 days a week to assess/treat residents as needed in addition to 24 hours/7 days per week coverage by the physicians. The administrator stated the healthcare providers were not notified of a need to check/assess Resident 24's leg or pain prior to [DATE]. The facility's policy titled Significant Change of Condition (#2002) stated, "The patient's change of condition shall be reported immediately to a licensed nurse...A licensed nurse shall assess the patient for signs and symptoms of physical or mental change of condition...This assessment shall be reported to primary physician or designated alternate... Notification of physician, time, and date (month, day and year) are to be documented in the Nurses Notes. A licensed nurse must speak directly to physician; you may not leave a message with an answering service or receptionist...Potentially life-threatening conditions require nursing assessment skills and expertise to determine whether a patient should be transferred to an acute care setting...Each change of condition shall be documented in the Nurses Notes and Shift Report." The Lippincott Manual of Nursing Practice 10th Edition on page 1130 defines a fracture as, "a break in the continuity of bone. A fracture occurs when the stress placed on a bone is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints, and other organs may be injured when fracture occurs." This reference described an oblique fracture as a fracture at an angle across the bone. Page 1130 of this reference lists the clinical manifestations of a fracture to include pain at the site of injury, swelling, tenderness, deformity, loss of function, ecchymosis, progressive uncontrollable pain, pain on passive movement and pallor. Pages 16 and 17 of this reference documents common departures from standards of nursing care include, "...failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measure, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record...failure to monitor or observe a change in a patient's clinical status...failure to communicate or document a significant change in a patient's condition to appropriate professional..." Page 16 of this reference states concerning standards of nursing practice, "A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events." (1) These findings were reviewed with the administrator and corporate nursing consultants on [DATE] at 2:20 p.m. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. This was a complaint deficiency. 2. The facility staff failed to ensure Resident # 7's physician was notified of low blood glucose levels. Resident # 7, an [AGE] year old female resident was admitted to the facility originally on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) with CAAS (care area assessment summary) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "7", indicating the resident was severely impaired in daily decision making skills. The resident also required extensive assistance for most all ADL's (activities of daily living), including eating. During clinical record review on [DATE], nursing notes were reviewed an documented that the resident was sent out to the hospital on [DATE] due to having a low blood sugar. The resident was hospitalized for [REDACTED]. Resident # 7's physician's orders [REDACTED]. day) notify physician if blood sugar below 100 or greater than 350..." This order was initiated originally on [DATE] and was not discontinued until [DATE]. Another physician's orders [REDACTED].# 7 that documented: "...accu checks before breakfast on Monday, Wednesday and Friday...(no blood sugar parameters were included with this order). This order was initiated originally on [DATE] and was discontinued on [DATE]. These two orders overlapped each other from [DATE] through [DATE]. Resident # 7's MAR's (medication administration records) for the month of [DATE], were reviewed and revealed the following blood glucose levels: [DATE]-BS (blood sugar)= 77 (6:30 a.m. reading) [DATE]-BS=53 (4:30 p.m. reading) [DATE]-BS=89 (4:30 p.m. reading) [DATE]-BS=75 (6:30 a.m. reading) [DATE]-BS=97 (6:30 a.m. reading) Nursing notes were then reviewed for the same time frame, along with physician orders. The only physician notification, was found for the [DATE] blood sugar reading of "53." No other notification could be found or located in the clinical record to indicate the physician was ever notified of the other blood sugar readings that were below normal, as ordered by the physician. Resident # 7's MAR's (medication administration records) for the month of [DATE], were reviewed and revealed the following blood glucose levels: [DATE]-BS=44 (6:30 a.m. reading) A nursing note dated [DATE] (timed 8:09 a.m.) documented: "6:00 a.m. Resident bs was 44, given cup of supplement, will recheck in one hr. (hour). There was no notification that the physician was notified of this blood sugar level and no evidence that the blood sugar level was rechecked in 1 hour. On this particular day ([DATE]), the resident's regularly scheduled [MEDICATION NAME] was documented as administered at 12:32 p.m., not at 9:00 a.m. as ordered. [DATE]-BS=54 (6:30 a.m. reading) No nursing notes were found regarding the resident's blood sugar of '54' on [DATE]. No information was found to evidence the physician had been notified of this blood sugar reading for Resident # 7. On this particular day the resident's regularly scheduled [MEDICATION NAME] was documented as administered at 3:04 p.m., not at 9:00 a.m. as ordered. [DATE]-BS=31 (6:30 a.m. reading) A nursing note dated [DATE] (timed 8:08 a.m) documented: "Pt found lying in bed by nurse unresponsive...vomited large amount of liquid. Pt is diabetic and blood sugar was 30...MD [MEDICATION NAME] injection given...Oxygen was low O2 sat (85%)...Pt BS came up to 104 before EMS (emergency medical services) arrival...still was not responding to verbal or physical stimuli..." Resident # 7 had been experiencing low blood sugar levels without physician notification. Although, the physician was notified on [DATE] of a blood sugar level of '31', the resident was sent out to the hospital for evaluation on [DATE] and was admitted to the hospital, the resident did not return to the facility until [DATE]. On [DATE] the resident had a blood sugar level of 66 at 6:30 a.m. (night shift), the physician was notified and was ordered to administer [MEDICATION NAME], which was done and the resident's blood sugar came up to 77. The resident's MAR's for [DATE] were reviewed and documented that the resident received her scheduled [MEDICATION NAME] at 8:31 a.m. On [DATE], it was documented that Resident # 7 received her regularly scheduled 9:00 a.m. dose of [MEDICATION NAME] at 2:45 p.m. A nursing note dated [DATE] (timed 5:50 p.m.) documented: "At 5:15 p.m. resident was found unresponsive. Blood sugar checked and was 34...given [MEDICATION NAME] up to 47. Another injection of [MEDICATION NAME] was given and blood sugar came up to 65...sending her to the emergency department..." The resident was admitted to the hospital and was not discharge back to the facility until [DATE]. The resident's CCP (comprehensive care plan) was then reviewed and documented: "...Resident has diabetes...medication as ordered by doctor, Monitor for side effects and effectiveness...educate resident/family/caregivers as to the correct protocol for glucose monitoring and insulin injections...Monitor/document/report PRN (as needed) any s/sx (signs and/or symptoms) [DIAGNOSES REDACTED] (low blood sugar): sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait...labs as ordered, report abnormal lab results to the MD (medical doctor)..." On [DATE] at approximately 2:00 p.m., the DON (director of nursing) was asked for assistance with the above information. At approximately 2:45 p.m., the DON voiced that the resident had two orders for accu checks and they were overlapping from [DATE] through [DATE]. The DON also voiced that she would have to look into the above information. On [DATE] at approximately 4:15 p.m., in a meeting with the survey team, the administrator, DON (director of nursing), and corporate nurse # 4 and # 5 were made aware of the above concerns regarding the physician not being notified of Resident # 7's low blood sugars. Corporate nurse # 4 was asked, what the expectation was for physician notification regarding low blood sugars. Corporate nurse #4 responded, 'anything below 60...' On [DATE] at 10:40 a.m., in a meeting with the survey team, the administrative staff were made aware of concerns regarding the resident continuing to get insulin and getting it late, according to the documentation on several occasions. The Corporate nurse # 4 voiced that the nurse's know they are supposed to notify the physician of low blood sugars and while reviewing this information (surveyor provided), noticed there was a pattern of the nurse's administering or signing (medications) out late. The corporate nurse stated, "You document when you give it." On [DATE] at approximately 1:30 p.m., an interview was conducted via telephone with LPN (Licensed Practical Nurse) # 10. LPN # 10 voiced that she had contacted the doctor on [DATE], but did not document that she spoke with him. LPN # 10 further voiced that the doctor just said to "feed her (the resident)." LPN # 10 voiced that she did give report to the day shift nurse, but could not remember who it was. On [DATE] at approximately 2:00 p.m. in a meeting the survey team, the administrative staff were again made aware of the concerns regarding Resident # 7's not being notified and nursing staff continuing to administer insulin to the resident. Corporate nurse # 4 provided a written statement from RN (Registered Nurse) # 3 who administered the insulin at 2:45 p.m. on [DATE]. The statement was dated [DATE] and documented: "...gave her 9 am insulin at approximately 9:30 a.m. on [DATE]th, 2015 after she ate breakfast. After reviewing the Mars and Tars to ensure I had signed out all medications and treatments I realized I had not signed out this dose, so I signed it out. Signature of RN." The administrative staff were made aware that the above information did not make sense, because a medication audit was requested for all medications administered that day and it was provided by facility staff. The medication audit documented that all of Resident # 7's medications were signed out at about the same time, which was 2:45 p.m. No further information or documentation was presented prior to the exit conference on [DATE] at 5:30 p.m. 3. The facility staff failed failed to follow professional standards of nursing practice during a medication pass and pour observation; the facility staff did not administer medications from the correct source. During the medication pass and pour observation on [DATE] at 9:45 a.m., RN (Registered Nurse) #4 prepared medications for administration to the resident in room Resident # 29. One of the medications prepared was, one Tums 500 mg (milligrams) tablet. RN #4 reached into the medication cart and pulled out a bottle of Tums, dispensed one tablet into a plastic medication cup. The Tums bottle had a pharmacy identification label, which included the resident's name, and room number of who the medication belonged to. The medication was not labeled for the Resident # 29, it was label for Resident # 30. RN #4 completed the medication preparation, returned the Tums bottle along with the other medication packaging (supply source) to the medication cart. RN #4 then took the prepared medication into Resident # 29 and administered the medications. At approximately 10:20 a.m., a medication reconciliation was completed on the above medication pass and pour observation. Resident # 29 did indeed, have a physician's orders [REDACTED]. Resident # 30's (whose Tums was used for the Resident # 29) medications were then checked. Resident # 30 was a current resident of the facility and did have a physician's orders [REDACTED]. At approximately 11:30 a.m., RN #4 was interviewed regarding the above. RN #4 open the medication cart and pulled out the same bottle of Tums and stated, "I thought they were stock, I didn't know that (they belonged to someone else)." On [DATE] at 2:40 p.m. in a meeting with the survey team, the administrator, DON (Director of Nursing) and corporate nurse # 4 were made aware of the above. A policy on medication administration was requested at this time. At approximately 3:10 p.m., a policy was requested and reviewed. The facility's policy on "General Dose Preparation and Medication Administration" documented: "...Facility staff should verify that the medication name and dose are correct...Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident..." No further information or documentation was provided prior to the exit conference on [DATE] at 5: 30 p.m.

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure one of 4 residents, Resident #3, received care and services to maintain highest practicable well-being. The facility staff failed to assess or monitor Resident #3 to determine the cause for decreased oxygen levels during her stay at the facility, and failed to identify a change in condition, which led to the resident being admitted to the hospital and diagnosed with [REDACTED]. The findings include: Resident #3 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/13 was an admission assessment. The resident was assessed as a 3 for cognitive skills. On 4/23/13 at approximately 11:00 a.m., Resident #3's Electronic Medical Records (EMRs) were reviewed to include the following: An "ED (Emergency Department) Summary" dated 3/17/13: "Chief complaint Quote: pt reports she lost balance 4 days ago, fell on to buttocks injuring lower back...ABC's (airway, breathing, and circulation): The airway is open and patent. Breathing is spontaneous and nonabsorbent. Breath sounds equal bilaterally..LOC (level of consciousness): The patient is awake, alert, with calm affect. The patient is oriented to person, place and time..." A Hospital "History and Physical" dated 3/17/13...Chief complaint: Back pain...Vital signs: The patient is current febrile, pulse 82, respiratory rate 16, blood pressure 123/80, 97 percent in room air..." "A Discharge Summary dated 3/21/13...Hospital Course. The patient is admitted through the ER after she had unfortunately fallen. She had some significant acute back pain...She was found to have a compression fracture at T 8 ([MEDICATION NAME] vertebrae #8). There were fractures at L 1 (lumbar 1) and L 2...The decision was thus made to treat her conservatively with a brace. She had significant acute delusion and initially. Her delusion has largely resolved today. She is markedly better and clear...At this point she is doing well and the plan is to discharge to skilled care...Disposition: Discharge to skilled care for ongoing PT (physical therapy) OT (occupational therapy) strengthening. Plan will be to go there for a few weeks and then potentially go home with son again. Depending on how she is doing upon discharge home she will either need skilled care or if she doing very poorly Hospice. At this point I do not clearly see a [DIAGNOSES REDACTED]. The Admission / Nursing Assessment Form" dated 3/21/13...A set of admission vital signs were documented to include: "Lying: BP 120/70, IP 72, R 18, Temp 97, Pulse ox 95%. Sitting: BP 122/76, 74, Pulse Ox 96%...Chest: Respiratory: Respirations regular...Lung Sounds: Clear left were checked." An admission nursing note was reviewed to include: "3/21/13 10:03 p.m. Patient arrived via stretcher...Patient and oriented time 3 able to voice needs. Patient LOC awake, alert and oriented...Patient Esp even non labored and even...Lung sound clear in upper and lower lobes..." A "Physician's Admission Medical Care Plan (History and Physical)" dated 3/24/13: "ROMS (review of systems) Check if negative:...Lungs cough, SOB (shortness of breath) were checked as being negative for the resident." Another nursing note dated 3/25/13 was reviewed to include: "3/25/13 3:05 p.m. PT (physical therapy) daily note...O: pt is very sick today and could not participate in therapy. Per LPN (licensed practical nurse) and one nurse, pt has [MEDICAL CONDITION] infection and currently on IV due to dehydration. OT (occupational therapy) could note get any treatment minutes w/ (with) pt d/t sickness. therapist informed Rehab manager regarding pt's condition." "3/25/13 4:12 p.m. OT daily note: Pt. ill and COTA (certified occupational therapist assistant) unable to arouse. She was supine, asleep, with IV in place. Will try again tomorrow." A "physician's progress note" written by the NP (nurse practitioner): "3/25/13 Pt had some vomiting during the night & received IM [MEDICATION NAME] 25 mg- I'm not aware of diarrhea...she is confused & does not recognize her niece (named). It is difficult to maintain her attention. She is having some twitching of her arms. Lungs are clear but she does have a non productive cough...VS...O2 97% Another "physician's progress note" written by the NP: "3/26/13 Pt is slightly more awake today than yesterday. The myoclonic movements are virtually gone. Esp are deep / even..." The last documented "physician's progress note" written by the NP was dated 3/28/13. This note addressed the resident's sleep habits and the addition of another medication to aide in sleep. A nursing note: "3/29/13 8:45 a.m. 11p .m.-7 a.m. (3rd shift) incident: Resident observed sitting on her bottom with her back against her bed at 12:30 a.m....Weakness noted to lower extremities...Resident stated she was trying to go to work...Resident alert with confusion. Resident continued to state that she needed to go to work and that she needed to get up. Resident's O2 noted to be 85% at the time of incident. O2 placed on resident at 3 l/m and O2 increased to 98%...MD made aware of incident and verbal order received for O2 @ 2L/min via nasal canula prn; may titrate to keep sats above 90%..." "3/29/13 10:44 a.m. Resident sitting up in w/c (wheelchair) c/o (complain of) feeling nauseated today...O2 sat 88% on R/A (room air). O2 applied at 2 L/min via NC. O2 sat 92%..." "4/1/13 9:53 a.m....O2 at 2L/min via NC intact. No c/o's voiced..." There were no documented O2 sats to indicate the need for the O2. "4/1/13 7:19 p.m. PT daily note: S: I feel very weak... O: COTA and PT co treated w/ pt in today's session. Pt was more alert, awake, coherent and cooperative, although reported feeling very weak...Post tx (treatment) vital signs were as follows: BP=111/79, HR=105 to 116 bpm (beats per minute), SaO2=89-90% at 3 L.min. Pt was returned to her bed, placed call button close to her, attached her nasal canula to oxygen concentrator..." "4/2/13 10:10 a.m. Resident alert, verbal, and confused at times...O2 at 2L/min via NC intact..." There were no documented O2 sats to indicate the need for the O2. "4/3/13 1:17 p.m. ...Resident alert, verbal and confusion at times...O2 at 2L/min via NC intact..." There were no documented O2 sats to indicate the need for the O2. "4/3/13 4:29 p.m. PT Daily Note: S: I just feel very weak...Post vital signs were as follows: HR=72 to 92 bpm, SaO2 88-91 % at 3 L/min. Pt was returned to her bed...attached her nasal canula to oxygen concentrator..." "4/4/13 11:54 a.m. Resident sitting in w/c participating with therapy...O2 at 2L/min via NC intact..." There were no documented O2 sats to indicate the need for the O2. Upon review of the clinical record a "Vital Signs History" form was reviewed to include that the O2 sats were only obtained nightly from 3/29/13 through 4/5/13 on the 11p.m.-7 a.m. but the resident was documented as wearing the O2 on the 7 a.m. to 3 p.m. shift without O2 monitoring as ordered by the physician. The Treatment Administration Record (TAR) for 3/29/13 through 4/6/13 was reviewed and it was documented that the resident had received O2 on 3/29/13 at 10:31 and again on 4/6/13 at 03:26, when the resident was sent out to the hospital. "4/5/13 3:28 p.m. OT daily note: Pt presented up in w/c, having just returned from shower room with CNA (certified nursing assistant). She agreed to come to tx session. Pt. required Mod (moderate) A (assist) x2 for scooting back and repositioning in w/c. She was on 3 ltrs O2, but appeared to be SOB (short of breath). Vitals taken with O2 sat=71% and pulse 106. Worked with pt on trained breathing tech, and education for same. O2 sat climbed steadily, but only to 93-84%. Check O2 sat with 2 instruments for accuracy, with matching readings obtained. Reported to nurse, who made notes on same. Nurse stated oxygen was originally for PRN (as needed), but needed order changed to continuous, and she would do this." There was no documentation in the clinical record indicating that the MD or NP was made aware of the need to change the oxygen order from PRN to continuous nor was there documentation that the MD or NP was made aware of the above incident in the shower. "4/5/13 4:35p.m. PT daily note: Post tx vital signs were as follows: HR=104 bpm SaO2=88-91% at 3 L/min. Pt continue to participate in therapy despite of continued c/o weakness d/t sickness last week. ...Pt breathing difficulties and O2 sats continue to limit her ability to participate fully in PT." "4/5/13 4:36 p.m. PT Daily note: Pt O2 in supine 86% and unable to tolerate OT today due to low O2 levels. Nursing notified. no PT done." "4/5/13 8:39 p.m. ...Therapist spoke with me regarding her O2 sats. Therapist received resident after shower. During shower O2 was not in progress so when she went to therapy she was satting in the 80's. O2 was placed on and after a few minutes she was back up to 93 % on 2L. Resident O2 is PRN not continuous..." There were no other notes documented that the MD or NP was made aware of the above low O2 sat levels during therapy. "4/6/13 5:31 a.m. Resident brought to nurses station trembling and c/o not feeling well. Vitals taken BP 132/76 IP-119 Temp. 97.3 O2 82 Resident was on 3 liters of O2, it was increased to 4 liters and O2 sat remained low. I called Dr (named) and he gave orders to send resident to ER if this is what the family requested. Called (responsible person named) he came to facility to see his mom. While RP (named) was in facility resident said she needed to use the restroom. Resident was taken to bathroom and upon coming back to the nurse's station she once again began to tremble. O2 was hooked back up and O2 sat was measured to be 64. Resident was very weak and lethargic at this time. I called 911 and EMS arrived shortly thereafter..." "4/6/13 2:25 p.m. Son in facility. Son took all resident's belongings out of facility. Son states resident admitted to hospital for pneumonia." "4/8/13 11:33 a.m. PT Discontinue Note...Summary: Pt did not do good in her rehab. First she got sick w/ with stomach [MEDICAL CONDITION] infection for a week immediately during his first day in facility. Then pt showed some progress in functional mobility for 1-2 days after getting sick, thinking she will bounce back from the sickness. But pt did the opposite direction, she steadily declined in all functional mobility and her oxygen continuously to desaturate (especially with movement and activity) despite supplemental O2 at 3L/min. Pt was then sent to hospital on [DATE] d/t pneumonia (per LPN note). The Patient Transfer Form dated 4/6/13 was reviewed to include: "Reason for transfer: SOB, increased pulse, decreased O2 sat O2 (arrow pointing downward) to 64 at times...VS: BP 132/74, HR 119, RR 38, Pox 78-82 on 5 liters..." A care plan (CP) initiated on 3/24/13 and updated on 3/25, 3/26, 3/28, 4/3 and 4/5/13 was reviewed the CP did not address the resident's requiring the use of O2 for difficulty breathing and the monitoring for low O2 sats. On 4/24/13 at approximately 8:30 a.m., the following hospital records were reviewed to include the following: "Prehospital Care Report: 4/6/13 Primary Impression: Respiratory [MEDICAL CONDITION] breathing...A-Upon arrival find female sitting in her wheelchair. Nurse stated pt's O2 saturations were low. Nurse stated was getting readings in the 60's. Nurse also stated that this had been going on for a while...R-Pt's lungs had crackles on both sides...Pt's O2 sat was 80 pt was placed on 15 lpm (liters per minute) via NRB (nonrebreather)..." "4/6/13 Triage: ...The patient is having flu-like symptoms. The patient is having the following symptoms congestion, cough and upper respiratory symptoms...Chief complaint Quote: Pt presents to ED (emergency department) from assisted living c/o difficulty breathing with crackles bilaterally. No history of previous...Breathing: Breathing is labored. Patient is tachypneic. The breathing is shallow...O2 amounts: The patient is on O2 at 10 via non-rebreather mask...Speech: broken sentences d/t respiratory distress...Nursing Note 05:48 Pt's son states that for the past week she has had a progressively worsening cough. He noted that the nursing facility had also placed her on oxygen around the clock for the past 10 days. He reports that she does not have a significant cardiac or respiratory history and has never had an episode like this or needed O2. Tonight her conditioned worsened and her O2 sats dropped as low as 60%...History of Present Illness: ...Patient reports that her nose is "stuffed up." According to her son, the nurse at the nursing home said her oxygen was low, "they couldn't get it above 82." They talked to the doctor who said "it's your call whether to send her to the ER." Patient's son went to the nursing home to see her and fond her fairly coherent, but when they took her oxygen off her sat dropped to 60% and she became incoherent...Patient's son reports she has had basically no medical problems. He also reports that they put her on oxygen about ten days ago but her son reports they did not do any work up for her low oxygen, which she has never had problems with before..." "4/6/13 Hospital Disposition: Admit to hospital...Physician: Patient is critically ill with what I interpret as pneumonia...She has a fever, and her WBC (white blood count) is 20.6 and she has rales..." "4/6/13 RT (respiratory therapy) assessment: Breath sounds: RLL (right lower lobe) 12:00 diminished..15:15 (3:15 p.m.) diminished...19:40 (7:40 p.m.) diminished...23:30 (11:30 p.m.) diminished (modified). LUL (left upper lobe) 12:00 crackles...LLL (left lower lobe) 12:00 crackles diminished, 15:15 crackles diminished, 19:40 diminished, 23:30 crackles diminished." "4/6/13 Pulmonology Consultation Report: ...She was noted to be increasingly short of breath at least for 24 hours with arterial oxygen saturations which were low. Was brought in at 5 o'clock this morning. She says she may have been feeling bad for a few days but really did not appreciate the fact that she was getting sick. She was noted to be hypoxemic in the emergency room . Chest x-ray revealed diffuse bilateral [MEDICAL CONDITION] infiltrates and chest CT scan was done to rule out [MEDICAL CONDITION]. It is also demonstrated diffuse bilateral air space filling disease consistent with pneumonia or ARDS ([DIAGNOSES REDACTED]). There was no evidence of [MEDICAL CONDITION]. She has never been hypotensive but apparently was febrile at some point. She has marked leukocytosis. She was admitted with [DIAGNOSES REDACTED]. "4/8/13 RT Assessment: PT placed on NRM (nonrebreathing mask) to move from CTICU to PULM, PT set back up on high flow upon arrival to room..." "4/8/13 Progress Note: I talked to her son (named) about an hour ago. Advised him that patient's high oxygen requirement and pretty impressive infiltrates could turn out poorly for her. Intensive did move her up to the floor...Her sats are now in the 50's on high-flow and her blood pressures were 70s systolic and she is not responsive. I think at this point the patient is dying and there is very little else that we can do..." "4/8/13 Discharge Summary: Final Diagnoses: [REDACTED]. Community acquired pneumonia, 3. ARDS...Summary of hospital course: ...She was at the nursing home, developed increasing cough and shortness of breath. Presented back to the emergency room where she was found have bilateral pneumonia and possible diastolic [MEDICAL CONDITION]. [MEDICATION NAME] quickly but developing worsening infiltrates on her chest x-ray. Had worsening [MEDICAL CONDITION]. Looked to be developing some ARDS. She actually was holding her home for quite some time but was moved out of ICU to the floor. She then suddenly decompensated quickly with dropping her oxygen levels despite high-flow oxygen. We were unable to maintain any reasonable saturations and the patient passes away quickly thereafter..." "4/8/13 Organ / Tissue / Eye Donation Routine Inquiry form...probable cause of death "[MEDICAL CONDITION]." On 4/24/13 at approximately 1:07 p.m., the Physical therapy manager (Other staff #4) was interviewed regarding the resident's decline while in therapy. OS #4 stated, "I went down to meet her (Resident #3) in the beginning. I knew she had difficulty participating. I wasn't sure if it was motivation or medical... We even tried to get the DON (director of nursing) to talk to her about therapy; thought maybe she could get her motivated because it was her aunt." On 4/24/13 at approximately 1:09 p.m., the Certified Occupational Therapy Assistant (COTA) who will be identified as Other Staff (OS #5) was interviewed regarding the above allegation. OS #5 stated that the resident "came to therapy with prn oxygen," I spoke with one of the nurses regarding her O2 sats and stated that we (therapist) was keeping it on her all the time due to sats dropped when working with therapy. I think the nurse changed the O2 to be worn all the time, which is what we were doing anyways." OS #5 was asked if the physician was made aware of the resident's condition and the need for the O2 continuous. OS #5 stated, "I am not sure but we did communicate this to the nurse's." On 4/24/13 at approximately 2:30 p.m. the Physical Therapy Assistant (Other Staff # 6) was interviewed regarding the resident's participation in therapy and her O2 sat levels. OS #6 stated that after the resident "became sick with the stomach virus, she became inconsistent with her performance but after [MEDICAL CONDITION] I thought she was bouncing back but she didn't, her O2 sats were low even with the oxygen so we had to keep it on her all the time during treatment." On 4/24/13 at approximately 1:47 p.m., the licensed practical nurse (LPN# 1), who was caring for the resident during her stay at the facility was interviewed regarding the resident's condition. LPN #1 stated, "she stayed sleepy a lot she was not doing much. The NP was here to evaluate her and started her on IV fluids. I knew she had IV but that was during the GI (gastrointestinal) virus. She got better after that and was alert and she started going back to therapy, then she was started on O2 because her O2 sats were down." LPN #1 stated, when interviewed of the start date of O2, "I think she was started right after she was admitted . The doctor was notified and he gave he an order to start the O2 and to titrate it according to her O2 sats." LPN #1 was asked of the location of the O2 sats to monitor the resident's oxygen levels. LPN #1 stated, "They were checked the next day and it was 92% and it was put in the nursing notes." LPN #1 was asked if there were other O2 sats to show that the resident's O2 sats were being monitored. LPN #1 stated, "It (O2 sats) would either be in the nursing notes or on the vital signs log." LPN #1 pulled up the vital sign log in the computer for review. The vital sign log was noted with O2 sats obtained on 11 p.m. to 7 a.m. shifts only. LPN #1 was asked if the she had documented the O2 sats in the resident's clinical record, as there was documentation by LPN #1 that the resident's "O2 was intact," on the 7 a.m. to 3 p.m. shift. LPN #1 stated, "No there are no other documentation other than on 3rd shift. They do the vital signs on their shift. LPN #1 was asked how was she aware that the resident's O2 sats were low if they were not being monitored to indicate the need for the oxygen. LPN #1 stated, "You don't. You have to monitor them (O2 sats) to know if they are low." On 4/24/13 at approximately 2:00 p.m., the Certified Nursing Assistant (CNA#4), who was caring for the resident at the facility, was interviewed regarding the resident's condition and if the resident was wearing oxygen. CNA #4 stated, "She (Resident #3) was fine until the stomach virus, she wasn't wearing oxygen until after she was getting up going to therapy." When asked if the resident's O2 sat were checked, CNA #4 stated, "Yes, but the most it would get up to was 92% with the oxygen on; it stayed mostly in the 80's. After [MEDICAL CONDITION], she went downhill." On 4/24/13 at approximately 4:16 p.m., during the meeting with the administrator, regional nurse consultants and the director of nursing, the allegations of the complaint were discussed. The DON was interviewed regarding the resident's condition and if the resident had been assessed to determine the reason her O2 sats were low, and if the physician was made aware of the resident change in condition. The DON stated, "No, there isn't an assessment. The nurse practitioner saw her, she (NP) would tell me, when I passed her in the hall, "I saw your aunt today." The DON further stated, "She looked fine to me I saw her twice a day; she was confused at times, mostly at 2:00 a.m., but that was the norm for her. I know staff was telling me she was getting up early in the morning saying she had to go to work, she delivered mail and would get up early when she was working. I thought that's where the confusion was coming from." The DON also stated, "When I saw her I did not notice any shortness of breath but I did see she was on oxygen. When asked if she was aware of the reason for the oxygen, the DON stated, "She was very kyphotic (curvature of the back, hunchback) with a corset and stooped over. I wasn't surprised to see she was on oxygen to help with her breathing. On 4/24/13 at approximately 4:20 p.m., the DON was interviewed and asked if the resident had breathing difficulties requiring the use of oxygen prior to her admission to the facility. The DON stated, "No." The DON was asked of the expectation regarding O2 sat monitoring for the use of the O2 and physician notification of a significant change in the resident's condition. The DON stated, "The expectation is to notify the doctor and to monitor and assess the resident for changes. The order did say to titrate the oxygen to keep sats above 90% but if you are not doing the O2 sats you have no way of knowing." The DON was made aware that the last physician progress notes [REDACTED]. The DON was asked if the NP documented in the clinical record on the progress note when she saw the resident. The DON stated, "I can't answer for NP (named). She is here if you would like to talk to her." The DON was asked how often the NP was in the facility. The DON stated, "She is here everyday. Five days a week." The DON was also made aware that the resident's care plan did not address the use of O2 nor the need to monitor the resident's O2 sats to maintain her O2 level above 90%. The DON was asked if the information should have been added to the resident's CP, the DON shook her head up and down, indicating, "Yes." On 4/24/13 at approximately 4:48 p.m., the regional nurse consultant (Admin #3) stated, "I know there are holes on the TAR (treatment administration) where the oxygen was documented as being administered twice but we should have gotten O2 sats; that's what the order said to titrate to keep the sats above 90. You don't know if you don't do the O2 sats but the staff may not have known that there was a change if there was no fever, no signs and symptoms of cough. Is there an assessment, 'No,' but without the signs and symptoms they may not have known what to assess for (sic)." Admin #3 was made aware that there was documentation in the clinical record where the resident was reported with low O2 sats and nursing was made aware. Admin #3 was also made aware that, according to the documentation, when the resident's O2 sats were low the facility staff placed her on oxygen but did not assess the need for the oxygen or notify the physician when there was a change from PRN oxygen to continuous. When asked if the facility had standing orders for the application of oxygen, Admin #3 stated, "No, there isn't a standing order." On 4/24/13 at approximately 4:55 p.m., the nurse practitioner (NP), who will be identified as OS #7 was interviewed regarding being notified of the resident's condition and if there was a progress note documenting that the resident was assessed regarding the low O2 sats. OS #7 stated, "I believe she was on oxygen when she had the [MEDICAL CONDITION] and was weak. I saw her sitting in the chair when she recovered; she was not wearing oxygen, she was eating and she appeared to be breathing fine." When asked if she was aware of the resident's low O2 sats requiring the use of oxygen continuously, OS #7 stated, "I was not aware until after she went to the hospital. The nurse's wrote something in the book about her (the resident) having problems with her O2 sats during therapy." On 4/24/13 at approximately 4:55 p.m. OS #7 was interviewed and asked how often was she in the facility, OS #7 stated, "I am here everyday for the most part." When asked if there was a progress note after 3/28/13 indicating that the resident was assessed by OS #7 or the physician, OS #7 stated, "No." OS #7 was made aware that the resident's O2 was changed from PRN (as needed) to continuous without an order or assessment by the NP or MD. OS #7 stated, "I see. I wasn't aware of her (the resident's) condition until after she was in the hospital." A copy of the facility's policy regarding Physician Notification was requested, a copy of a policy titled "Significant Change of Condition" was received and reviewed to include the following: "Policy: All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. Procedure: 1. The resident's change of condition shall be reported immediately to a licensed nurse, 2. A licensed nurse shall assess the resident for signs and symptoms of physical or mental change of condition, 3. This assessment shall be reported to primary physician or designated alternate..." This is a complant deficiency.