Every finding on record at Manassas Health and Rehab Center

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to dispose of refuse properly. The facility staff failed to maintain a clean dumpster area during the facility task- kitchen observation 1/20/26 at 11:50 AM. The findings include: On 1/20/26 at 11:50 AM, an observation was conducted in the dumpster area outside of the kitchen. On the left side of the dumpster on the ground there were blue and white gloves and plastic straw.An interview was conducted on 1/20/26 at 1:10 PM with OSM #1, the dining services director. When asked about the findings, OSM #1 stated, we only wear black gloves. I will talk with housekeeping about it. It sounds like trash from the facility.On 1/21/26 at 11:00 AM ASM (administrator staff member) #1, the administrator was informed of the above concerns.The facility does not have a policy related to the dumpster.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical review, the facility staff failed to provide activities to promote the highest level of wellbeing for three of 43 residents in the survey sample, Residents #24, #17, and #72.The findings include:1. For Resident #24 (R24), the facility staff failed to provide activities to promote the resident's highest level of wellbeing in December 2025 and January 2026.On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 10/2/25, R24 was coded as having both short term and long term memory problems. She was coded as preferring the following activities: snacks between meals, reading books/newspapers/magazines, listening to music, and doing things with groups of people. On 1/20/26 at 12:57 p.m., R24 was observed sitting up in bed in her room on the memory care unit. The resident was being fed by a staff member who was seated in a chair next to the bed. On 1/20/26 at 2:43 p.m., R24 was observed sitting up in bed with her eyes open, looking around the room. There was no music playing in the room. At 3:02 p.m., OSM (other staff member) #7, the activities director, began a word and [NAME] activity in the memory care day room. There was no observation of any staff member attempting to invite R24 to the activity. At 3:06 p.m., R24 was sitting up in bed, eyes open, looking around the room. There was no music playing in the room.On 1/20/26 at 11:00 a.m., observation was made in the day room in the memory care unit. Several residents were seated around the room and two residents were independently ambulating around the day room, as well as up and down the hallway. No activity was occurring.A review of the facility's activities calendar for 1/20/26 revealed one activity in the morning (music) and one activity in the afternoon (Getting Creative). This review also revealed one activity on 1/21/26, an exercise activity at 11:00 a.m. This was the only activity listed in the memory care unit on 1/21/26.A review of the larger activities calendar for December 2025 and January 2026 revealed some days with two planned activities on the memory care unit, and some days with only one activity designated for the memory care unit.A review of R24's December 2025 and January 2026 (through 1/19/26) activity participation records revealed that she was in bed and therefore did not participate in any group activity on 31 different days. This review revealed no information at all for seven days. This review revealed no evidence of any attempts by the facility staff to provide individual activities matching R24's assessed activity interests on any day that she did not participate in group activities on the memory care unit.On 1/21/226 at 2:10 p.m., OSM #7 was interviewed. She stated the memory care unit is her area, and that she is the primary person who plans and implements activities on this unit. When asked what sources she uses to plan activities on the memory care unit, she stated she relies on training she received and from a website to which she subscribes. She stated this website has a section geared towards residents with dementia. She stated she is aware that some residents do not like to get up early in the morning for groups, and that there are some people who enjoy exercise. She stated there is usually music playing in the day room all the time. She stated she tries to include different types of activities (crafts, exercise, music, BINGO) in hopes of meeting everyone's needs, but acknowledged this is difficult to do, especially on the memory care unit. She stated she tries to plan two activities each day on the memory care unit, and this usually leaves her time to do one-on-one activities for residents. She stated: I like to drop in and see them one-on one. She stated she did not have any documentation for any one-on-one resident activities for any resident on the memory care unit. She stated the 11:00 a.m. activity that was on the calendar for the memory care unit on 1/21/26 should not have been on the calendar. She stated there was no memory care activity that morning because she was involved in taking other residents on an outing. She stated she would be willing to go over there and do some things with them when she returned from the outing. On 1/21/26 at 5:27 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of these concerns. ASM #3 stated the company had recently undertaken a new initiative to improve activities in all of its facilities.A review of the facility policy, Activities Program, Implementation, revealed, in part: The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and individual activities.An overall assessment of each resident.and the physical and mental condition of the residents is necessary when planning activities.The activities calendar shall be implemented as written. Cancellations will be noted on the calendar and during morning announcements.No additional information was provided prior to exit.2. For Resident #17 (R17), the facility staff failed to provide activities to promote the resident's highest level of wellbeing in December 2025 and January 2026.On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/28/25, R17 was coded as having no short term or long term memory problems, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was, however, coded as having Alzheimer's disease. She was coded as preferring listening to music, being around animals, going outside, and participating in religious services for activities.On 1/20/26 at 1:01 p.m., R17 was observed independently transferring from her wheelchair to sit on the side of her bed in her room on the memory care unit. On 1/20/26 at 3:02 p.m., OSM (other staff member) #7, the activities director, began a word and [NAME] activity in the memory care day room. At 3:08 p.m., R17 was sitting on the side of her bed in her room.On 1/20/26 at 11:00 a.m., observation was made in the day room in the memory care unit. Several residents were seated around the room and two residents were independently ambulating around the day room, as well as up and down the hallway. No activity was occurring.A review of the facility's activities calendar for 1/20/26 revealed one activity in the morning (music) and one activity in the afternoon (Getting Creative). This review also revealed one activity on 1/21/26, an exercise activity at 11:00 a.m. This was the only activity listed in the memory care unit on 1/21/26.A review of the larger activities calendar for December 2025 and January 2026 revealed some days with two planned activities on the memory care unit, and some days with only one activity designated for the memory care unit.A review of R17's December 2025 and January 2026 (through 1/19/26) activity participation records revealed that she either refused or was in bed and therefore did not participate in any group activity on 41 different days. This review revealed no information at all for five days. This review revealed no evidence of any attempts by the facility staff to provide individual activities matching R17's assessed activity interests on any day that she did not participate in group activities on the memory care unit.On 1/21/226 at 2:10 p.m., OSM #7 was interviewed. She stated the memory care unit is her area, and that she is the primary person who plans and implements activities on this unit. When asked what sources she uses to plan activities on the memory care unit, she stated she relies on training she received and from a website to which she subscribes. She stated this website has a section geared towards residents with dementia. She stated she is aware that some residents do not like to get up early in the morning for groups, and that there are some people who enjoy exercise. She stated there is usually music playing in the day room all the time. She stated she tries to include different types of activities (crafts, exercise, music, BINGO) in hopes of meeting everyone's needs, but acknowledged this is difficult to do, especially on the memory care unit. She stated she tries to plan two activities each day on the memory care unit, and this usually leaves her time to do one-on-one activities for residents. She stated: I like to drop in and see them one-on one. She stated she did not have any documentation for any one-on-one resident activities for any resident on the memory care unit. She stated the 11:00 a.m. activity that was on the calendar for the memory care unit on 1/21/26 should not have been on the calendar. She stated there was no memory care activity that morning because she was involved in taking other residents on an outing. She stated she would be willing to go over there and do some things with them when she returned from the outing. On 1/21/26 at 5:27 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of these concerns. ASM #3 stated the company had recently undertaken a new initiative to improve activities in all of its facilities.No additional information was provided prior to exit.3. For Resident #72 (R72), the facility staff failed to provide activities to promote the resident's highest level of wellbeing in December 2025 and January 2026.On the most recent comprehensive MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 1/20/25, R72 was coded as being severely cognitively impaired. She was coded as preferring the following activities: keeping up with the news, going outside when the weather is good, and participating in religious services for activities. On the following dates and times, R72 was observed in her bed in the memory care unit: 1/20/26 at 12:54 p.m. and 3:02 p.m.; and 1/21/26 at 8:00 a.m., 11:34 a.m., and 4:08 p.m.A review of the facility's activities calendar for 1/20/26 revealed one activity in the morning (music) and one activity in the afternoon (Getting Creative). This review also revealed one activity on 1/21/26, an exercise activity at 11:00 a.m. This was the only activity listed in the memory care unit on 1/21/26.A review of the larger activities calendar for December 2025 and January 2026 revealed some days with two planned activities on the memory care unit, and some days with only one activity designated for the memory care unit.A review of R72's December 2025 and January 2026 (through 1/19/26) activity participation records revealed that she was in bed and therefore did not participate in any group activity on 32 different days. This review revealed no information at all for two days. This review revealed no evidence of any attempts by the facility staff to provide individual activities matching R72's assessed activity interests on any day that she did not participate in group activities on the memory care unit.On 1/21/226 at 2:10 p.m., OSM #7 was interviewed. She stated the memory care unit is her area, and that she is the primary person who plans and implements activities on this unit. When asked what sources she uses to plan activities on the memory care unit, she stated she relies on training she received and from a website to which she subscribes. She stated this website has a section geared towards residents with dementia. She stated she is aware that some residents do not like to get up early in the morning for groups, and that there are some people who enjoy exercise. She stated there is usually music playing in the day room all the time. She stated she tries to include different types of activities (crafts, exercise, music, BINGO) in hopes of meeting everyone's needs, but acknowledged this is difficult to do, especially on the memory care unit. She stated she tries to plan two activities each day on the memory care unit, and this usually leaves her time to do one-on-one activities for residents. She stated: I like to drop in and see them one-on one. She stated she did not have any documentation for any one-on-one resident activities for any resident on the memory care unit. She stated the 11:00 a.m. activity that was on the calendar for the memory care unit on 1/21/26 should not have been on the calendar. She stated there was no memory care activity that morning because she was involved in taking other residents on an outing. She stated she would be willing to go over there and do some things with them when she returned from the outing. On 1/21/26 at 5:27 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the regional director of operations, were informed of these concerns. ASM #3 stated the company had recently undertaken a new initiative to improve activities in all of its facilities.No additional information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for two of 43 residents in the survey sample, Resident #6 and Resident #35.The findings include:1. For Resident #6 (R6), the facility staff failed to implement the comprehensive care plan to administer pain medication as ordered. Pain level parameters for the administration of Hydromorphone (1) were not followed during administration during dates in December 2025 and January 2026. The comprehensive care plan for R6 documented in part, Patient has pain or potential for pain. Date Initiated: 11/07/2025. Under Interventions it documented in part, Administer pain medication as ordered. Report s/s (signs/symptoms) potential negative side effects. Date Initiated: 11/07/2025 . Report breakthrough pain and/or unrelieved pain for further assessment and treatment. Date Initiated: 11/07/2025.On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 12/17/2025, the resident scored 14 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. Section J documented R6 receiving scheduled and as needed pain medication and having almost constant pain.On 1/20/2026 at 2:57 PM, an interview was conducted with R6 who stated that they had chronic pain and took medication every four hours as needed. R6 stated that the medication helped when they had knee pain. The physician orders for R6 documented in part, Hydromorphone HCl Tablet 4 MG (milligram) Give 1 tablet by mouth every 4 hours as needed for severe pain 8-10. Hold for sedation/confusion. Order Date: 12/09/2025.Review of the electronic medication administration record (eMAR) dated 12/1-12/31/2025 for R6 documented administration of the Hydromorphone 4mg on 44 occasions for pain levels between zero and seven.Review of the eMAR dated 1/1-1/31/2026 for R6 documented administration of the Hydromorphone 4mg on 23 occasions for pain levels between zero and seven.On 1/22/2026 at 11:48 AM, an interview was conducted with licensed practical nurse (LPN) #9 who stated that the purpose of the care plan was to individualize the care of the resident and provide a reference for nursing to have for that resident. She stated that the care plan should be implemented because they wanted the residents to feel comfortable with their care and for their safety. LPN #9 stated that when a resident complained of pain they went and assessed the pain level, offered non-pharmacological interventions first and if they were not effective they looked at pain medication orders. She stated that when an as needed pain medication had pain level parameters they administered them when the pain level was within the parameters. LPN #9 stated that if the resident requested the medication for a pain level lower than the parameter that was set in the orders they would need to speak with the physician because the medications may need to be adjusted to better control their pain. The facility policy Comprehensive Care Planning Process dated 2017 failed to evidence guidance on implementing the comprehensive care plan. On 1/22/2026 at 3:30 PM, administrative staff member (ASM) #1, the administrator and ASM #2, the director of nursing were made aware of the findings.No further information was provided prior to exit.Reference:(1) Hydromorphone is used to relieve severe pain. Hydromorphone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682013.html2. For Resident #35 (R35), the facility staff failed to implement the comprehensive care plan to offer ambulation daily. The comprehensive care plan for R35 documented in part, [R35] Demonstrates the need for ADL (activities of daily living) assistance, has history of CVA (cerebrovascular accident) with left sided weakness. Date Initiated: 08/24/2024. Revision on: 11/06/2025. Under Interventions it documented in part, Offer to assist with ambulation daily. Date Initiated: 12/11/2025 .On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 10/24/2025, the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The assessment documented use of a wheelchair and walking not attempted due to the residents medical condition or safety concerns. It documented no therapy services received during the assessment period.On 1/20/2026 at 2:05 PM, an interview was conducted with R35 who stated that they had recently been discharged from physical therapy (PT). R35 stated that their insurance had stopped the therapy, but they had been walking with therapy using their walker and since then, they had not been walking anymore. R35 stated that they were told that the CNAs (certified nursing assistants) would walk behind them with a wheelchair and assist them to walk using the walker, but the CNAs did not have time to do it. R35 stated that it took 15 minutes to do that and the staff do not have time for that. R35 stated that they were concerned that they would lose the mobility they had gained working with PT if they did not get up and walk around like they were supposed to. Review of the physical therapy discharge summary documented therapy services from 12/22-12/30/2025 with extent of progress documented as Patient continues to require Min A (minimal assistance) for STS (sit to stand) from w/c (wheelchair), once upright able to perform transfers and ambulation with CGA/SBA (contact guard assist/stand-by assist). Under follow-up care recommended it documented, SNF (skilled nursing facility) care. Review of the ADL documentation for R35 from 1/1/2026-1/21/2026 documented in part, How the resident walks 10 feet AFTER standing up with or without assistive device (anywhere except in therapy). It failed to evidence ambulation or a refusal to ambulate on 1/5/2026, 1/8/2026, 1/10/2026, 1/12/2026, 1/15/2026 and 1/18/2026.Review of the clinical record failed to evidence any refusals to ambulate on the dates listed above. On 1/21/2026 at approximately 5:00 PM, a request was made to administrative staff member (ASM) #1, the administrator for evidence that R35 was assisted to ambulate or offered to ambulate daily from 1/1-1/21/2026.On 1/22/2026 at 8:53 AM, ASM #1 provided the ADL documentation listed above which failed to evidence ambulation on the dates listed above. On 1/22/2026 at 10:50 AM, an interview was conducted with other staff member (OSM) #14, physical therapist (PT) who stated that they worked with R35 in December 2025. She stated that they did an FMP (functional maintenance plan) for R35, and the nursing staff are supposed to ambulate R35 50-150 feet with the hemi-walker and gait belt and following behind the resident with their wheelchair. She stated that it was not safe for R35 to walk by themselves and they had put in the plan for R35 to walk at least once a day because they would benefit walking to maintain their ability to walk and because R35 wanted to do it. OSM #14 stated that the facility did not have a restorative nursing program and the assigned CNAs should be walking R35 as recommended to maintain mobility. On 1/22/2026 at 11:04 AM, an interview was conducted with certified nursing assistant (CNA) #8 who stated that the Kardex showed them recommendations from PT for residents ambulation. She stated that when a resident had recommended ambulation from PT it could be done anytime depending on the instructions given by therapy and how often the resident was to be ambulated. On 1/22/2026 at 11:48 AM, an interview was conducted with licensed practical nurse (LPN) #9 who stated that the purpose of the care plan was to individualize the care of the resident and to give a reference to nursing about the residents care. She stated that the care plan should be implemented to respect the residents choices and for safety purposes. LPN #9 stated that prior to discharge from therapy, education was completed with the nurses and the CNAs by the therapist on what follow up care was to be provided for that resident. She stated that the follow up recommendations were documented on the care plan and the CNAs had access to the Kardex which were implemented from the care plan. LPN #9 stated that they followed the therapy recommendations so that the residents did not lose what they had gained in therapy. On 1/22/2026 at approximately 12:00 PM, a request was made to ASM #1, the administrator for the FMP (functional maintenance plan) for R35.On 1/22/2026 at 2:40 PM, ASM #2, the director of nursing stated that they did not have an FMP for R35, but they had continued to offer to ambulate them every day. She stated that there were times when R35 refused to walk or did not want to get out of bed and those instances should be documented. On 1/22/2026 at 3:30 PM, ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings.No further evidence was provided prior to exit.

Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to maintain the kitchen in a sanitary manner. The findings include: On 1/20/26 at 10:55 AM, an observation was conducted in the kitchen with the following findings: walk-in refrigerator #1, opened and undated five-pound bag of hash browns; walk-in refrigerator #2, one half chicken salad sandwich dated (prep 1/16/26 at 1:39 PM, expires 1/18/26 at 1:39 PM). An interview was conducted with OSM #1, the dining services director as the tour was being conducted, asked about opened and undated hash browns as well as the expired chicken salad sandwich OSM #1 stated, they should not be in there. I am throwing both of them out now. On 1/21/26 at 11:00 AM ASM (administrator staff member) #1, the administrator was informed of the above concerns.A review of the facility's Safe Food and Supply Storage policy revealed, Leftover prepared foods must be stored in approved containers, zip lock bags or wrapped with plastic wrap, be labeled as to contents and dated with a 'Use By' date. Opened packages must be securely closed and product identified.It is the center policy to ensure all dry goods will be appropriately stored in accordance with guidelines of the FDA (Food Drug Administration) Food Code. The Dining Services Director or designee ensures that all packaged and canned food items shall be kept clean, dry and properly sealed.No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for one of 43 residents in the survey sample, Resident #133. The findings include:For Resident #133 (R133), the facility staff failed to dress the resident in clothes on 1/20/26, 1/21/26, and 1/22/26. R133 was admitted to the facility on [DATE]. A nursing admission assessment signed by a nurse on 1/13/26 documented R133 was only oriented to self. On 1/20/26 at 12:45 p.m., R133 was observed lying in bed, only wearing an incontinence brief. The resident was visible from the hall. On 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., R133 was observed lying in bed with a gown pulled above the resident's waist. The resident's incontinence brief was exposed and visible from the hall. On 1/22/26 at 10:54 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #8 (the CNA caring for R133). CNA #8 stated she had pulled the resident's gown down three times that morning, but the resident continued to pull the gown up. CNA #8 stated if a resident has clothes, she dresses the resident every day. CNA #8 stated R133 was moved to a different room because of COVID and did not have clothes in the current room. CNA #8 stated she could obtain clothes from R133's old room and try to put the clothes on the resident. On 1/22/26 at 3:48 p.m., ASM (Administrative Staff Member) #1 (the Administrator), and ASM #2 (the Director of Nursing) were made aware of the above concern. On 1/22/26 at 5:02 p.m., an interview was conducted with ASM #2. ASM #2 stated she followed up with nursing staff and the social services assistant. ASM #2 stated staff had asked R133's daughter to bring the resident's clothes to the facility but she had not done so because she was sick. ASM #2 stated the CNAs said R133 did not have clothes and kicks the sheets off. ASM #2 stated on this date (after the above interviews), a CNA went to the laundry department to see if there were any clothes that would fit R133. The facility policy titled, ADL Care of Patients documented, It is the policy of this Center to provide ADL care for patients to ensure all ADL needs are met daily .2. Patients will be dressed in clean clothing .

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure dignity for one of 43 residents in the survey sample, Resident #133. The findings include:For Resident #133 (R133), the facility staff failed to ensure the resident's incontinence brief was not exposed and visible from the hall. R133 was admitted to the facility on [DATE]. A nursing admission assessment signed by a nurse on 1/13/26 documented R133 was only oriented to self. On 1/20/26 at 12:45 p.m., R133 was observed lying in bed, only wearing an incontinence brief. The resident was visible from the hall. On 1/20/26 at 2:25 p.m., 1/21/26 at 3:55 p.m., and 1/22/26 at 10:41 a.m., R133 was observed lying in bed with a gown pulled above the resident's waist. The resident's incontinence brief was exposed and visible from the hall. On 1/22/26 at 10:54 a.m., an interview was conducted with CNA (Certified Nursing Assistant) #8 (the CNA caring for R133). CNA #8 stated she had pulled the resident's gown down three times that morning, but the resident continued to pull the gown up. CNA #8 stated if a resident has clothes, she dresses the resident every day. CNA #8 stated R133 was moved to a different room because of COVID and did not have clothes in the current room. CNA #8 stated she could obtain clothes from R133's old room and try to put the clothes on the resident. On 1/22/26 at 11:49 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #9. LPN #9 stated if she wore an incontinence brief, she would not want it to be exposed because she would feel very embarrassed. On 1/22/26 at 3:48 p.m., ASM (Administrative Staff Member) #1 (the Administrator), and ASM #2 (the Director of Nursing) were made aware of the above concern. On 1/22/26 at 5:02 p.m., an interview was conducted with ASM #2. ASM #2 stated she followed up with nursing staff and the social services assistant. ASM #2 stated staff had asked R133's daughter to bring the resident's clothes to the facility but she had not done so because she was sick. ASM #2 stated the CNAs said R133 did not have clothes and kicks the sheets off. ASM #2 stated on this date (after the above interviews), a CNA went to the laundry department to see if there were any clothes that would fit R133. The facility did not provide a policy regarding dignity.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to ensure all discharge needs were met prior to discharge from the facility for one of 43 residents in the survey sample, Resident #136.The findings include:For Resident #136 (R136), the facility staff failed to ensure needed durable medical equipment (DME), a bedside commode, was delivered to the residents home prior to discharging them from the facility to reside independently in a multi-level home with a bathroom located up 13 steps on the second level when they were unable to negotiate stairs. On the admission minimum data set (MDS), with an assessment reference date (ARD) of 12/12/2023, R136 was assessed as requiring partial/moderate assistance for bathing, upper body dressing, and standing from a sitting position, requiring substantial/maximal assistance of a helper for toileting and lower body dressing. Toilet transfers and walking were not attempted due to medical condition or safety concerns. The assessment coded R136 as frequently incontinent of bowel and bladder, having frequent severe pain, and utilizing scheduled and as needed pain medications. It documented the resident having a fall in the last month prior to admission with a major surgery during the 100 days prior to admission.The social services admission assessment dated [DATE] documented in part, .[R136] is adjusting to her new environment thus far. She arrived after 10:00 pm last night, 12/6/23, so her true adjustment is unknown at this time. There are no family supports in the area . Potential barriers/needs to meeting expressed goals (include physical barriers such as stairs, level of supervision/assistance available, location, lack of resources, etc.) Lives alone. 13 steps to bathroom level of home. No supervision. no family supports . Social Services staff will arrange home health, PT/OT/ST/Nurse/Aide (physical therapy/occupational therapy/speech therapy) and any equipment needed at discharge .The safe transition meeting for R136 dated 12/7/2023 documented attendance of the social worker, unit manager, rehab representative, business office manager, activities assistant and the resident. It further documented, .Patient's Transition Expectations: Return to home alone . Potential Barriers: Potential barriers to safe transition to desired destination (including financial/copay concerns, family/community support availability, etc.): Lives alone, 13 steps to bathroom on 2nd. level. No family in the area .A letter dated 2/5/2024 to the facility and R136 documented denial of appeals of the decision of Medicare Non-Coverage with services ending on 1/28/2024.The OT discharge summary for R136 dated 1/31/2024 documented in part, .Toilet transfer: Discharge (1/31/2024) Supervision or touching assistance . Discharge Recommendations: Home health services, Remove throw rugs, Remove environmental barriers, Assistive device for safe functional mobility. Elevated toilet seat/3 in 1 commode, shower bench (unpadded/over tub edge), Grab bars, Assistance w/ADLs (activities of daily living) and Lifeline for safety .The PT discharge summary for R136 dated 1/31/2024 documented in part, .Discharge Recommendations: Patient requires supervision for all bed mobility and transfer .The progress notes documented in part,- 1/19/2024 15:15 (3:15 PM) Social Services Note. Note Text: [R136] received her NOMNC (notice of Medicare non-coverage) with LCD (last covered day) 1/22/2024 and D/C (discharge) 1/23/2024. The appeal process was reviewed and the Livanta number given, [phone number] to be called by noon 01/21/2024. [R136] stated she is still not yet ready, unable to put any weight on her leg, and her other leg has become weak, so she plans to appeal once again.- 1/25/2024 18:55 (6:55 PM) Social Services Note. Note Text: [R136] was given and signed her NOMNC with LCD 1/28/2024 and DC 1/29/2024. Appeal information was provided. Appeal by noon 1/27/2024 by calling Livanta @ [phone number]. [R136] stated she would be appealing again, her wounds are not healing, and she is doing better in therapy.- 1/29/2024 09:53 (9:53 AM) Social Services Note. Note Text: [R136] lost her appeal Saturday, Jan. 27th. Liability begins today, 1/29/2024. She has filed a second level appeal.- 01/31/2024 14:58 (2:58 PM) Social Services note. LATE ENTRY Note Text: [R136] is being discharged [DATE]. Writer has attempted to order oxygen and a bedside commode, due to her bathroom being on the second floor of her home and her inability to walk or climb stairs. [R136] does not qualify for oxygen, as her O2 (oxygen) stats [sic] are above 90 with room air.- 2/1/2024 08:55 (8:55 AM) Nurse Practitioner Note . Pt to be discharged to home with home health and skilled nursing. Course at [Name of facility] included PT/OT, medication monitoring and pain management. In stable condition for discharge. RX (prescription) was provided to assigned nurse. Spent over 55 min on discharge planning, coordination, and education, coordinating DME with SW, assessing the pt, writing prescriptions and documentation . Recent discharge from a facility following Right knee replacement and wound management. The patient is unable to leave home because he/she is unable to negotiate stairs leading outside his/her home due to endurance, weakness or dyspnea .- 2/1/2024 12:35 (12:35 PM) Note Text : Resident discharged home, took all personal belongings including remaining medications.- 2/2/2024 11:32 (11:32 AM) Note Text : Home health was set up through [Name of home health agency], where she will receive PT/OT/Nursing and an Aide.The Notice of Transfer or Discharge for R136 documented an effective date of transfer home on 2/1/2024 due to The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center . The notice was dated as written on 1/25/24 with R136's name written on it. On 1/22/2026 at approximately 7:43 AM, administrative staff member (ASM) #1, the administrator, provided a printed copy of a chat between the facility and the DME provider for R136. The chat documented the social worker at the facility creating the order for the 3 in 1 bedside commode on 1/31/2024 at 5:11 PM with the order accepted by the DME provider on 1/31/2024 at 6:38 PM. The chat documented the order pending further review on 1/31/2024 at 6:59 PM and the DME company attempting to contact the resident on 2/1/2024 at 12:06 PM. A note from the DME company dated 2/1/2024 at 12:58 PM documented We contacted the patient/family. We are awaiting a callback to discuss financial obligation and delivery. We will continue our outreach if we do not hear back in a timely fashion. We just wanted to provide a quick update. Thank you! The next note was cancellation of the order on 3/27/2024 at 10:33 AM.ASM #1 also provided a fax from the home health agency which documented an email chain between staff at the home health agency. The first email dated 2/1/2024 at 10:50 AM sent the referral and eligibility form for review, the second email documented them leaving a message at 2:00 PM and to attempt to call again later. The third email documented staff calling again at 4:36 PM and the fourth email documented speaking with R136 at 4:59PM on 2/5/2024. It documented, I spoke to pt (patient) at 4:59pm. She fell at home when she was DC (discharged ) on 2/1 and went to the emergency room. She refused to go back to [Name of facility] so she was admitted to [Name of other facility] I shared that we would be happy to provide her HH (home health) services upon her DC. This will be a canceled referral. Thanks .The information provided by ASM #1 failed to evidence the bedside commode delivery to R136's home prior to them being discharged from the facility.On 1/22/2026 at 9:31 AM, an interview was conducted with other staff member (OSM) #10, the social services assistant who stated that she remembered R136. She stated that R136 had received a NOMNC and filed an appeal but had lost. OSM #10 stated that she had discussed with therapy about what DME R136 was going to need to go home with and had set up home health services. She stated that she had ordered a 3 in 1 commode for R136 that therapy had recommended for them. OSM #10 stated that she was not aware that the DME company had called R136 or that they had gone to the hospital. She stated that she had ordered everything prior to R136 going home and sometimes it was delivered to the home. She stated that R136 may have had a copay and that may have been the reason that it was not delivered. OSM #10 stated that they could only do what was required of them to do and that was why the 3 in 1 commode was ordered. She stated that they tried to make sure DME was delivered prior to discharge but they were at the mercy of the insurance. She stated that if the resident lived alone with no family and were dependent, they tried to let the home health agency know to expedite the service and that it should be documented in their notes if it were done for R136. OSM #10 stated that it was difficult for her because they were at the mercy of the insurance, but maybe she could have notified APS (adult protective services) that the resident was going home alone and dependent on someone for care. She stated that they could not go to each persons home to make sure they were safe and it was unfortunate because she did not know R136 had fallen. On 1/22/2026 at 2:43 PM, an interview was conducted with OSM #9, rehab director who stated that they did not remember R136. OSM #9 stated that the physical therapist and occupational therapist who worked with R136 during their stay no longer worked at the facility. She stated that she had reviewed the PT and OT discharge summaries for R136 and they were non-weight bearing to the right leg throughout their stay at the facility. She stated that at discharge, R136 was unable to bear weight on the right leg and was not able to go up or down stairs. OSM #9 stated that the discharge plan was for a bedside commode at home that was recommended by therapy, and it was set up by the social worker. She stated that R136 would have performed better if their weight bearing status had changed but the orthopedic physician had not allowed them to put weight on that leg. OSM #9 stated that R136 needed supervision at the time of discharge, but she could not determine by the notes whether it was constant or not. OSM #9 stated that therapy recommended the DME, but social services were the ones who set up and ensured that everything was in place at the time of discharge.On 1/22/2026 at 11:48 AM, an interview was conducted with licensed practical nurse (LPN) #9 who stated that she did not remember R136. She stated that when a resident was discharged home they provided patient teaching and educated the caregiver. She stated that therapy played a part in determining when a resident was ready for discharge and what DME was needed at home. LPN #9 stated that if a resident required assistance or if there were concerns regarding DME not being at home prior to discharge, she would speak with the social worker and physician to let them know that she did not feel that it was safe to discharge the resident. She stated that they could do peer to peer reviews but unfortunately the insurance usually made the decision. On 1/22/2026 at 3:30 PM, ASM #1, the administrator and ASM #2, the director of nursing were made aware of the concern.No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a complete pain management program for one of 43 residents in the survey sample, Resident #6.The findings include:For Resident #6 (R6), the facility staff failed to follow pain level parameters for the administration of hydromorphone (1). On the most recent minimum data set (MDS), a significant change assessment with an assessment reference date of 12/17/2025, the resident 14 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. Section J documented R6 receiving scheduled and as needed pain medication and having almost constant pain.On 1/20/2026 at 2:57 PM, an interview was conducted with R6 who stated that they had chronic pain and took medication every four hours as needed. R6 stated that the medication helped when they had knee pain. The physician orders for R6 documented in part, Hydromorphone HCl Tablet 4 MG (milligram) Give 1 tablet by mouth every 4 hours as needed for severe pain 8-10. Hold for sedation/confusion. Order Date: 12/09/2025.Review of the electronic medication administration record (eMAR) dated 12/1-12/31/2025 for R6 documented administration of the Hydromorphone 4mg on 44 occasions for pain levels between zero and seven.Review of the eMAR dated 1/1-1/31/2026 for R6 documented administration of the Hydromorphone 4mg on 23 occasions for pain levels between zero and seven.The comprehensive care plan for R6 documented in part, Patient has pain or potential for pain. Date Initiated: 11/07/2025. Under Interventions it documented in part, Administer pain medication as ordered. Report s/s potential negative side effects. Date Initiated: 11/07/2025 . Report breakthrough pain and/or unrelieved pain for further assessment and treatment. Date Initiated: 11/07/2025.On 1/22/2026 at 11:48 AM, an interview was conducted with licensed practical nurse (LPN) #9 who stated that when a resident complained of pain they went in and assessed the pain level, offered non-pharmacological interventions first and if they were not effective they looked at pain medication orders. She stated that when an as needed pain medication had pain level parameters they administered them when the pain level was within the parameters. LPN #9 stated that if the resident requested the medication for a pain level lower than the parameter they would need to speak with the physician because the medications may need to be adjusted to better control their pain.The facility policy Pain Management revised 3/13/2025 documented in part, The center must ensure that pain management is provided to patients that require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the patient's goals and preferences . Center employees will notify the medical practitioner, if the patient's pain is not controlled by the current treatment regimen . On 1/22/2026 at 3:30 PM, administrative staff member (ASM) #1, the administrator and ASM #2, the director of nursing were made aware of the findings.No further information was provided prior to exit.Reference:(1) Hydromorphone is used to relieve severe pain. Hydromorphone is in a class of medications called opiate (narcotic) analgesics. It works by changing the way the brain and nervous system respond to pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682013.html

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement interventions to prevent a decrease in mobility for one of 43 residents in the survey sample, Resident #35.The findings include:For Resident #35 (R35), the facility staff failed to ambulate as recommended by physical therapy and care plan interventions to prevent a decrease in mobility.On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 10/24/2025, the resident scored 15 out of 15 on the brief interview for mental status (BIMS) assessment, indicating they were cognitively intact for making daily decisions. The assessment documented use of a wheelchair and walking not attempted due to the residents medical condition or safety concerns. It documented no therapy services received during the assessment period.On 1/20/2026 at 2:05 PM, an interview was conducted with R35 who stated that they had recently been discharged from physical therapy (PT). R35 stated that their insurance had stopped the therapy, but they had been walking with therapy using their walker and since then they had not been walking anymore. R35 stated that they were told that the CNAs (certified nursing assistants) would walk behind them with a wheelchair and assist them to walk using the walker, but the CNAs did not have time to do it. R35 stated that it took 15 minutes to do that and the staff do not have time for that. R35 stated that they were concerned that they would lose the mobility they had gained working with PT if they did not get up and walk around like they were supposed to. Review of the physical therapy discharge summary documented therapy services from 12/22-12/30/2025 with extent of progress documented as Patient continues to require Min A (minimal assistance) for STS (sit to stand) from w/c (wheelchair), once upright able to perform transfers and ambulation with CGA/SBA (contact guard assist/stand-by assist). Under follow-up care recommended it documented, SNF (skilled nursing facility) care. The comprehensive care plan for R35 documented in part, [R35] Demonstrates the need for ADL (activities of daily living) assistance, has history of CVA (cerebrovascular accident) with left sided weakness. Date Initiated: 08/24/2024. Revision on: 11/06/2025. Under Interventions it documented in part, Offer to assist with ambulation daily. Date Initiated: 12/11/2025 .Review of the ADL documentation for R35 from 1/1/2026-1/21/2026 documented in part, How the resident walks 10 feet AFTER standing up with or without assistive device (anywhere except in therapy). It failed to evidence ambulation or a refusal to ambulate on 1/5/2026, 1/8/2026, 1/10/2026, 1/12/2026, 1/15/2026 and 1/18/2026.Review of the clinical record failed to evidence any refusals to ambulate on the dates listed above. On 1/21/2026 at approximately 5:00 PM, a request was made to administrative staff member (ASM) #1, the administrator for evidence that R35 was assisted to ambulate or offered to ambulate daily from 1/1-1/21/2026.On 1/22/2026 at 8:53 AM, ASM #1 provided the ADL documentation listed above which failed to evidence ambulation on the dates listed above. On 1/22/2026 at 10:50 AM, an interview was conducted with other staff member (OSM) #14, physical therapist (PT) who stated that they worked with R35 in December 2025. She stated that they did an FMP (functional maintenance plan) for R35, and the nursing staff are supposed to ambulate R35 50-150 feet with the hemi-walker and gait belt and following behind the resident with their wheelchair. She stated that it was not safe for R35 to walk by themselves and they had put in the plan for R35 to walk at least once a day because they would benefit walking to maintain their ability to walk and because R35 wanted to do it. OSM #14 stated that the facility did not have a restorative nursing program and the assigned CNAs should be walking R35 as recommended to maintain mobility. On 1/22/2026 at 11:04 AM, an interview was conducted with certified nursing assistant (CNA) #8 who stated that the Kardex showed them recommendations from PT for residents ambulation. She stated that when a resident had recommended ambulation from PT it could be done anytime depending on the instructions given by therapy and how often the resident was to be ambulated. On 1/22/2026 at 11:48 AM, an interview was conducted with licensed practical nurse (LPN) #9 who stated that prior to discharge from therapy, education was completed with the nurses and the CNAs by the therapist on what follow up care was to be provided for that resident. She stated that the follow up recommendations were documented on the care plan and the CNAs had access to the Kardex which were implemented from the care plan. LPN #9 stated that they followed the therapy recommendations so that the residents did not lose what they had gained in therapy. On 1/22/2026 at approximately 12:00 PM, a request was made to ASM #1, the administrator for the FMP (functional maintenance plan) for R35.On 1/22/2026 at 2:40 PM, ASM #2, the director of nursing stated that they did not have an FMP for R35, but they had continued to offer to ambulate them every day. She stated that there were times when R35 refused to walk or did not want to get out of bed and those instances should be documented. No policy was provided on prevention of decrease in mobility in residents.On 1/22/2026 at 3:30 PM, ASM #1, the administrator and ASM #2, the director of nursing were made aware of the findings.No further evidence was provided prior to exit.

Based on staff interviews, family interview, clinical record review, and facility document reviews, it has been determined that the facility staff failed to ensure that a resident was free from neglect when they neglected to properly assess, monitor, treat, and consult a physician or practitioner for 1 of 15 residents (Resident #15, closed record review) in the survey sample who was unresponsive and presented with respiratory distress, which constituted harm. The findings include: For Resident #15, the facility neglected to properly administer supplemental oxygen, assess, and monitor during signs and symptoms of respiratory distress for approximately two (2) hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was discharged from the nursing facility, admitted to the local hospital on 12/21/23, and did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as extensive assistance with the physical assistance of 1-2 for transfers, toileting, and bed mobility. Resident #15's person-centered care plan dated 9/24/23 notes that she required extensive assistance with physical assistance of 1-2 for transfers, toileting, and bed mobility. This care plan also noted the intervention that staff should report changes in breathing patterns or difficulty breathing including wheezing, shortness of breath, rales, rhonchi, note on observation and/or auscultation for further assessment by nurse or practitioner due to diagnosis of allergic rhinitis. A review of the Emergency Medical Service (EMS) Fire and Rescue System Report read they received a call on 12/21/23 at 12:56 AM from the facility concerning resident #15 being in acute respiratory distress. EMS was at the bedside at 1:08 am. EMS documented that they did not receive a report from the nursing staff concerning the resident's condition, although there were 6 staff members at the bedside. The nursing staff at the bedside could not give them any information about Resident #15. EMS documented that they heard audible rales (abnormal breath sounds), and Resident #15 was found to have on a simple mask connected to a 02 cylinder that was not turned on. When staff was asked about this, they ignored EMS staff and walked away. EMS staff placed Resident #15 on an NRB with 12 liters of 02 and the resident's initial 02 saturations were noted to be 82% (95-100%=normal). Resident #15's 02 saturation via pulse oximetry started to rise to 90% and she then was placed on a continuous positive airway pressure machine (CPAP) with positive end-expiratory pressure (PEEP) of 5. EMS documented that the facility staff was unable to provide information on the resident's normal mental status. Resident #15 was also hypotensive with recorded BPs of 77/33 at 1:11 AM, 60/36 at 1:21 AM, 66/25 at 1:26 AM, and 96/70 at 1:30 AM. There were some problems getting the resident oxygen levels to register, her PEEP was increased to 7.5, and the resident started to open her eyes. On 12/21/23 at 1:26 AM, EMS transferred the resident to the local hospital emergency department for evaluation and she was subsequently admitted to the hospital. An interview was conducted on 2/8/24 at approximately 1:15 PM with Licensed Practical Nurse (LPN) #5 who worked the 3:00 PM to 11:00 PM shift on 12/20/23. LPN #5 shared that Resident #15 was readmitted around 8:00 PM on 12/20/23 from the hospital. LPN #5 said Resident #15 was very weak, and they noticed at some point that evening (she did not remember the time), that the resident was trying to get out of bed. LPN #5 said that she and a certified nursing assistant (CNA) got the resident dressed, out of bed, into the wheelchair, and brought her into the common area. LPN #5 said that they helped the resident eat a peanut butter sandwich, juice, and ice cream. LPN #5 said during that time Resident #15 had no breathing issues. LPN #5 said when they later recognized that she was having breathing issues (sometime during shift change during the 11:00 PM hour), they got her back to bed, put the head of the bed up, the CNA got a set of vital signs (VS), and the resident's oxygen level was low, but she does not remember how low. LPN #5 said she put the resident on oxygen at 2 liters via nasal cannula, and the resident's breathing did not get better, she then changed the resident to a non-rebreather oxygen mask (NRB), called the doctor, and 911. EMS report reads that they received a call from the facility at 12:56 AM and when they arrived the resident was on a simple face mask with the oxygen tank turned off. LPN #5 said she really could not remember who did what, but that all the above took place. An interview was conducted on 2/8/24 at approximately 3:54 PM with the Director of Nursing (DON). The DON confirmed receiving a voicemail from Adult Protective Services (APS) when she returned to work from leave in December 2023. She shared that the message included concerns about the neglect of care and services including failure to assess and monitor the decline in the resident's level of consciousness that included proper application of oxygen therapy. The message included EMS's first assessment of Resident #15 the oxygen tubing was not connected to an oxygen source and the six (6) nursing staff members at the bedside could not tell them anything about Resident #15. The DON said she spoke to registered nurse (RN) #2 because this nurse was supervising the facility at the time the above event occurred. The DON added that after getting feedback from RN #2 there was no further investigation of the event. An interview was conducted on 2/9/24 at approximately 12:12 AM with RN #2 (Nursing Supervisor). RN #2 shared that on 12/21/23 he came to work a little after midnight. RN #2's timecard verified that he clocked in at 1:01 AM. RN #2 said while doing rounds he saw nursing staff in Resident #15's room. RN #2 said that when he made his rounds, Resident #15 was on a non-rebreather mask with 100% oxygen and that EMS came up right after he arrived. RN #2 did not assess the resident or equipment, he just observed the scene and left to continue his rounds. The EMS report read the resident was on a simple face mask and the oxygen tank was not on. An interview was conducted on 2/9/24 at approximately 12:37 AM with RN #6 who worked the 11:00 PM to 7:00 AM shift on the Dogwood unit. RN#6 shared that on 12/20/23 during the 11:00 PM hour, a CNA came to her unit yelling Help. RN #6 said she then went to the Evergreen unit to help, and Resident #15 was unresponsive and with an oxygen saturation of 69%, so she left the Evergreen unit and went to her unit to get 02 and 02 tubing. When asked, Why did you leave the Evergreen unit to go to another unit to get oxygen? She responded that Evergreen did not keep 02 on their unit. It was confirmed that Evergreen did keep one (1) oxygen tank on their code cart. RN #6 said she was not sure of how the events truly played out and who did what. RN #6 said although no one got a new set of vital signs (VS) to include pulse oximetry reading on the resident, they put her on a non-rebreather mask (NRB) with 10 liters of oxygen. The EMS report read the resident was on a simple face mask and the oxygen tank was not on. RN #6 also confirmed that although she was the nurse providing most of the care for Resident #15 during this time the primary nurse left the unit to open the door at the main entrance for EMS. She said they did not give a report to EMS although she was one of six at the bedside when they inquired about what was going on with the resident. RN #6 did not chart any of the observations she made or interventions she implemented while caring for Resident #15. An interview was conducted on 2/9/24 at approximately 1:05 AM with CNA #8. CNA #8 said that when she came to work on 12/20/23 for the 11:00 PM to 7:00 AM shift Resident #15 was in the wheelchair and appeared to be asleep. CNA #8 said shortly after 11:00 PM during shift change, she noticed that Resident #15 didn't sound right. CNA #8 said she notified LPN #3, and she, LPN #3, and LPN #5 got the resident in the bed. CNA #8 said that she took her VS, but did not remember what they were, but did remember that the resident's vital signs including pulse oximetry readings resulted in a low oxygen saturation level and the nurses put 02 on the resident. The CNA stated she thought she remembered CNA # 9 went and got a 02 concentrator and that LPN #3 applied 02 to the resident. RN#6 shared during her interview (2/9/24 at 12:37 AM) that she went to get an oxygen tank from her unit. These two statements from CNA #8 and RN#6 conflicted with the method of O2 that may have been in use. A phone interview was conducted on 2/12/24 at approximately 12:31 PM with LPN #3. The LPN shared she worked the 12/20/23 11:00 PM to 7:00 AM shift. LPN #3 said that Resident #15 was admitted on the evening shift and when she arrived at work at approximately 11:00 PM the resident was in the common area in her wheelchair and her breathing was off. LPN #3 said she called 911 immediately (the EMS report read that they were called at 12:56 AM), they got the resident to bed, put the head of the bed up, and a nurse from the Dogwood unit put 02 on Resident #15. LPN #3 said she went to the front door/main entrance to wait for EMS to arrive. A review of documents that were provided and reviewed supported that LPN #3 clocked in at 11:03 PM on 12/20/2023 and the RN #2 supervisor clocked in at 1:01 AM on 12/21/2023. Based on that timeline, from approximately 11:03 PM to 1:08 AM (EMS with resident) Resident #15 was having breathing difficulties. A review of Resident #15's medical record dated 12/21/23 documented vital signs at approximately 2:45 AM (after Resident #15 left the building) were temperature(T) 97, pulse (P) 36, respirations (R) 18, blood pressure (BP) 104/20, and oxygen saturations (02) 69%. A review of Resident #15 medical record indicated there was no admission assessment and no comprehensive assessments completed. In addition, there was no documented evidence that ongoing respiratory assessments and follow-up vital signs were done especially when the nursing staff identified a change in the resident's condition (unresponsive, breathing difficulties). A phone interview was conducted on 2/13/24 at approximately 1:15 PM with the Administrator, DON, Assistant Director of Nursing (ADON) shared that under the circumstances of what happening with Resident #15, 911 should have been called immediately and the physician was made aware when the LPN recognized breathing difficulties at the beginning of her shift. On 2/13/24 at approximately 3:00 PM the above findings were further discussed with the Administrator, DON, and Corporate Nurse Consultant. An opportunity was offered to the facility's staff to present additional information. No additional information was provided before the survey exit. A review of facility policy Abuse Prevention with a review and revised date of 10/7/22, states neglect is the failure of the center, its employees, or any service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. A review of facility policy Oxygen Administration with a review and revised date of 5/27/22, indicated oxygen is administered to patients that need it, consistent with professional standards of practice .Licensed nurses will document the initial and ongoing assessment of the patient's condition warranting oxygen and the response to oxygen therapy . Licensed nurses will notify the physician and the patient's legal representative of any changes in the patient condition, including changes in VS, oxygen concentrations, or evidence of complications associated with the use of oxygen. Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block breathing in people with obstructive sleep apnea and other breathing problems (http://medlineplus.gov/ency/article/001916.htm). Positive end-expiratory pressure (PEEP) is a constant amount of low pressure to keep the air sacs in the lung from collapsing (www.thoracic.org/patients/patient-resources/resources/mechanical-ventilation.pdf). Vital signs show how well your body is functioning. A normal blood pressure reading for adults is lower than 120/80 and higher than 90/60 (http://medlineplus.gov/ency/article/002341.htm). Hypoxia/Hypoxemia is low levels of oxygen in your blood. It causes symptoms like headache, difficulty breathing, rapid heart rate, and bluish skin. Many heart and lung conditions put you at risk for hypoxemia. Hypoxia/Hypoxemia can be life-threatening (http://my.clevelandclinic.org/health/disease/177727-hypoxemia). Pulse oximetry is a test that uses a small, clip-like device called a pulse oximeter to measure oxygen levels in the blood. When you breathe, your lungs take in oxygen and send it into your bloodstream. This oxygen-rich blood is carried into your heart, which pumps it to the rest of your body. If your blood oxygen level (oxygen saturation) is too low (normal range is 95-100%), it can make it hard for your body to work properly. It can put a dangerous strain on your vital organs (http://medlineplus.gov/lab-test/pluse-oximetry/). Face masks: A simple facemask is a mask with no bag attached, which delivers oxygen at 5 to 8 liters per minute (LPM). A non-rebreathing mask has a bag attached to the mask known as a reservoir bag, which inhalation draws from to fill the mask through a one-way valve and features ports at each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at higher LPM flow rate (www.ncbi.nlm.nih.gov/books/NBK5516171/).

Based on staff interviews, Emergency Medical Service (EMS) report, facility document review, and clinical record review, it was determined that the facility staff failed to assess, monitor, and appropriately treat an unresponsive resident who presented with respiratory distress for 1 of 15 residents (Resident #15, closed record review) in the survey sample, which constituted harm. The findings include: For Resident #15, the facility failed to properly administer supplemental oxygen, assess, and monitor an unresponsive resident including vital signs and signs and symptoms of hypoxia for approximately 2 hours before calling 911. Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was discharged from the nursing facility, admitted to the local hospital on 12/21/23, and did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as extensive assistance with the physical assistance of 1-2 for transfers, toileting, and bed mobility. Resident #15 person-centered care plan dated 9/24/23 noted that she required extensive assistance with physical assistance of 1-2 for transfers, toileting, and bed mobility. This care plan also noted the intervention that staff should report changes in breathing patterns or difficulty breathing including wheezing, shortness of breath, rales, rhonchi, note on observation and/or auscultation for further assessment by nurse or practitioner due to diagnosis of allergic rhinitis. A review of the Emergency Medical Service (EMS) Fire and Rescue System Report read they received a call on 12/21/23 at 12:56 AM from the facility concerning resident #15 being in acute respiratory distress. EMS was at the bedside at 1:08 am. EMS documented that they did not receive a report from the nursing staff concerning the resident's condition, although there were 6 staff members at the bedside. The nursing staff at the bedside could not give them any information about Resident #15. EMS documented that they heard audible rales (abnormal breath sounds), and Resident #15 was found to have on a simple mask connected to a 02 cylinder that was not turned on. When staff was asked about this, they ignored EMS staff and walked away. EMS staff placed Resident #15 on an NRB with 12 liters of 02 and the resident's initial 02 saturations were noted to be 82% (95-100%=normal). Resident #15 02 saturation via pulse oximetry started to rise to 90% and she then was placed on a continuous positive airway pressure machine (CPAP) with positive end-expiratory pressure (PEEP) of 5. EMS documented that the facility staff was unable to provide information on the resident's normal mental status. Resident #15 was also hypotensive with recorded BPs of 77/33 at 1:11 AM, 60/36 at 1:21 AM, 66/25 at 1:26 AM, and 96/70 at 1:30 AM. There were some problems getting the resident oxygen levels to register, her PEEP was increased to 7.5, and the resident started to open her eyes. On 12/21/23 at 1:26 AM, EMS transferred the resident to the local hospital emergency department for evaluation and she was subsequently admitted to the hospital. An interview was conducted on 2/8/24 at approximately 1:15 PM with Licensed Practical Nurse (LPN) #5 who worked the 3:00 PM to 11:00 PM shift on 12/20/23. LPN #5 shared that Resident #15 was readmitted around 8:00 PM on 12/20/23 from the hospital. LPN #5 said Resident #15 was very weak, and they noticed at some point that evening (she did not remember the time), that the resident was trying to get out of bed. LPN #5 said that she and a certified nursing assistant (CNA) got the resident dressed, out of bed, into the wheelchair, and brought her into the common area. LPN #5 said that they helped the resident eat a peanut butter sandwich, juice, and ice cream. LPN #5 said during that time Resident #15 had no breathing issues. LPN #5 said when they later recognized that she was having breathing issues (sometime during shift change during the 11:00 PM hour), they got her back to bed, put the head of the bed up, the CNA got a set of vital signs (VS), and the resident's oxygen level was low, but she did not remember how low. LPN #5 said she put the resident on oxygen at 2 liters via nasal cannula, and the resident's breathing did not get better, she then changed the resident to a non-rebreather oxygen mask (NRB), called the doctor, and 911. EMS report reads that they received a call from the facility at 12:56 AM and when they arrived the resident was on a simple face mask with the oxygen tank turned off. LPN #5 said she really could not remember who did what, but that all the above took place. An interview was conducted on 2/9/24 at approximately 12:12 AM with RN #2 (Nursing Supervisor). RN #2 shared that on 12/21/23 he came to work a little after midnight. RN #2 timecard verified that he clocked in at 1:01 AM. RN #2 said while doing rounds he saw staff in Resident #15's room. RN #2 said that when he made his rounds, Resident #15 was on a non-rebreather mask with 100% oxygen and that EMS came up right after he arrived. RN #2 did not assess the resident or equipment, he just observed the scene and left to continue his rounds. The EMS report read the resident was on a simple face mask and the oxygen tank was not on. An interview was conducted on 2/9/24 at approximately 12:37 AM with RN #6 who worked the 11:00 PM to 7:00 AM shift on the Dogwood unit. RN#6 shared that on 12/20/23 during the 11:00 PM hour, a CNA came to her unit yelling Help. RN #6 said she then went to the Evergreen unit to help, and Resident #15 was unresponsive and with an oxygen saturation of 69%, so she left the Evergreen unit and went to her unit to get 02 and 02 tubing. When asked, Why did you leave the Evergreen unit to go to another unit to get oxygen? She responded that Evergreen did not keep 02 on their unit. It was confirmed that Evergreen did keep one (1) oxygen tank on their code cart. RN #6 said she was not sure of how the events truly played out and who did what. RN #6 said although no one got a new set of vital signs (VS) to include pulse oximetry reading on the resident, they put her on a non-rebreather mask (NRB) with 10 liters of oxygen. The EMS report read the resident was on a simple face mask and the oxygen tank was not on. RN #6 also confirmed that although she was the nurse providing most of the care for Resident #15 during this time the primary nurse left the unit to open the door at the main entrance for EMS. She said they did not give a report to EMS although she was one of six at the bedside when they inquired about what was going on with the resident. RN #6 did not chart any of the observations she made or interventions she implemented while caring for Resident #15. An interview was conducted on 2/9/24 at approximately 1:05 AM with CNA #8. CNA #8 said that when she came to work on 12/20/23 for the 11:00 PM to 7:00 AM shift Resident #15 was in the wheelchair and appeared to be asleep. CNA #8 said shortly after 11:00 PM during shift change, she noticed that Resident #15 didn't sound right. CNA #8 said she notified LPN #3, and she, LPN #3, and LPN #5 got the resident in the bed. CNA #8 said that she took her VS, but did not remember what they were, but did remember that the resident's vital signs including pulse oximetry readings resulted in a low oxygen saturation level and the nurses put 02 on the resident. The CNA stated she thought she remembered CNA # 9 went and got a 02 concentrator and that LPN #3 applied 02 to the resident. RN#6 shared during her interview (2/9/24 at 12:37 AM) that she went to get an oxygen tank from her unit. These two statements from CNA #8 and RN#6 conflicted with the method of O2 that may have been in use. A phone interview was conducted on 2/12/24 at approximately 12:31 PM with LPN #3. The LPN shared she worked the 12/20/23 11:00 PM to 7:00 AM shift. LPN #3 said that Resident #15 was admitted on the evening shift and when she arrived at work at approximately 11:00 PM the resident was in the common area in her wheelchair and her breathing was off. LPN #3 said she called 911 immediately (the EMS report read that they were called at 12:56 AM), they got the resident to bed, put the head of the bed up, and a nurse from the Dogwood unit put 02 on Resident #15. LPN #3 said she went to the front door/main entrance to wait for EMS to arrive. A review of documents that were provided and reviewed supported that LPN #3 clocked in at 11:03 PM on 12/20/2023 and the RN #2 supervisor clocked in at 1:01 AM on 12/21/2023. Based on that timeline, from approximately 11:03 PM to 1:08 AM (EMS at bedside) Resident #15 was having breathing difficulties and signs and symptoms of hypoxia. A review of Resident #15's medical record dated 12/21/23 documented vital signs at approximately 2:45 AM (after Resident #15 left the building) were temperature(T) 97, pulse (P) 36, respirations (R) 18, blood pressure (BP) 104/20, and oxygen saturations (02) 69%. A review of Resident #15 medical record indicated there was no admission assessment and no comprehensive assessments completed. In addition, there was no documented evidence that ongoing respiratory assessments and follow-up vital signs were done especially when the nursing staff identified a change in the resident's condition (unresponsive, breathing difficulties). A phone interview was conducted on 2/13/24 at approximately 1:15 PM with the Administrator, DON, Assistant Director of Nursing (ADON) shared that under the circumstances of what happening with Resident #15, 911 should have been called immediately and the physician was made aware when the LPN recognized breathing difficulties at the beginning of her shift. On 2/13/24 at approximately 3:00 PM, the above findings were further discussed with the Administrator, Corporate Nurse Consultant, Director of Nursing, and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information. No further information was provided before the survey exit. A review of facility policy Oxygen Administration with a review and revised date of 5/27/22, indicated oxygen is administered to patients that need it, consistent with professional standards of practice .Licensed nurses will document the initial and ongoing assessment of the patient's condition warranting oxygen and the response to oxygen therapy . Licensed nurses will notify the physician and the patient's legal representative of any changes in the patient condition, including changes in VS, oxygen concentrations, or evidence of complications associated with the use of oxygen. Positive airway pressure (PAP) treatment uses a machine to pump air under pressure into the airway of the lungs. This helps keep the windpipe open during sleep. The forced air delivered by CPAP (continuous positive airway pressure) prevents episodes of airway collapse that block breathing in people with obstructive sleep apnea and other breathing problems (http://medlineplus.gov/ency/article/001916.htm). Positive end-expiratory pressure (PEEP) is a constant amount of low pressure to keep the air sacs in the lung from collapsing (www.thoracic.org/patients/patient-resources/resources/mechanical-ventilation.pdf). Vital signs show how well your body is functioning. A normal blood pressure reading for adults is lower than 120/80 and higher than 90/60 (http://medlineplus.gov/ency/article/002341.htm). Hypoxia/Hypoxemia is low levels of oxygen in your blood. It causes symptoms like headache, difficulty breathing, rapid heart rate, and bluish skin. Many heart and lung conditions put you at risk for hypoxemia. Hypoxia/Hypoxemia can be life-threatening (http://my.clevelandclinic.org/health/disease/177727-hypoxemia). Pulse oximetry is a test that uses a small, clip-like device called a pulse oximeter to measure oxygen levels in the blood. When you breathe, your lungs take in oxygen and send it into your bloodstream. This oxygen-rich blood is carried into your heart, which pumps it to the rest of your body. If your blood oxygen level (oxygen saturation) is too low (normal range is 95-100%), it can make it hard for your body to work properly. It can put a dangerous strain on your vital organs (http://medlineplus.gov/lab-test/pluse-oximetry/). Face masks: A simple facemask is a mask with no bag attached, which delivers oxygen at 5 to 8 liters per minute (LPM). Non-rebreathing masks have a bag attached to the mask known as a reservoir bag, which inhalation draws from to fill the mask through a one-way valve and features ports at each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at higher LPM flow rate (www.ncbi.nlm.nih.gov/books/NBK5516171/).

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide two-person assistance while transferring Resident #13, which resulted in a fall for 1 of 3 residents reviewed for falls in the survey sample. The findings included: Resident #13 was originally admitted to the facility 8/30/23 for rehabilitation services after a left hip fracture and surgical repair. The admission diagnoses included; fracture of left femur and a stroke with left hemiparesis. The resident was transferred from the facility on 8/31/23 therefore a closed record review was conducted. The resident's Minimum Data Set (MDS) was not completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated 8/30/23. The tool revealed the resident was oriented to person, place, and situation. In section GG (Usual Performance Admission) the resident was coded as requiring substantial/maximal assistance with chair/bed-to-chair transfer and the resident was coded dependent with toilet transfers. A fall risk assessment was conducted on 8/30/23. Resident #13 was categorized as a moderate risk for falls due to a history of experiencing falls over the last six months. A care plan problem dated 8/30/23 read, risk for falls. The goal read, will not sustain an avoidable fall or injury through the next review. The interventions included assess fall risk per facility protocol and implement appropriate measures. Reassess per protocol and as needed. A synopsis of the event dated 9/1/23 revealed that Resident #13 had a fall while being transferred by one Certified Nursing Assistant (CNA)#1 on 8/31/23. A review of Resident #13's nurses note dated 8/31/23 at 11:54 AM read that it was reported to Registered Nurse (RN) #4 that the resident's lower extremities gave out during a transfer from the bedside commode and the resident was lowered to the floor by CNA #1. The nurses note further read that CNA #1 stated Family Member #1 was at bedside when the fall occurred and assisted to transfer the resident from the floor to the wheelchair. The nurses note also read that the resident was without injuries, denied pain, and denied being lowered to the floor. Nurse Practitioner (NP) #1 was notified of the fall and ordered a stat x-ray of the hip and knee. On 2/7/24 at 2:20 PM an interview was conducted with CNA #1. CNA #1 stated that although not assigned to this resident, she still went to check on the resident when the call light was observed on. CNA #1 stated that Resident #13 was on the bedside commode and desired to get back into bed, therefore the resident was cleaned up and assisted back into bed. CNA #1 stated the resident complained of discomfort and requested to sit in the wheelchair. While transferring Resident #13 from the bed to the wheelchair, CNA #1 stated that she experienced difficulties due to the resident's weight, and it became necessary to lower the resident to the floor. CNA #1 stated that Family Member #1 assisted with transferring the resident from the floor to the wheelchair. An interview was conducted on 2/12/24 at 12:00 PM with Licensed Practical Nurse (LPN) #1. LPN #1 stated the resident required two-person assistance for all transfers because the resident was recovering from a left hip fracture and the staff was to follow standard hip precautions. LPN #1 also stated that on 8/30/23 at approximately 8:30 AM, CNA #1 responded to a call bell in Resident #13's room. LPN #1 stated that CNA #1 was doing what was right, but CNA #1 did not have all the information about this resident. This included not seeking out additional information such as the need to have two-person assistance with transfers prior to rendering care. A synopsis of an event dated 9/1/23 revealed that Resident #13 had a fall while being transferred by one CNA #1 on 8/31/23. Family member #1 spoke with the Nursing Supervisor at approximately 9:00 AM concerning Resident #13's fall, shortly thereafter Family member #1 spoke with the Administrator and with the Social Worker multiple times concerning the residents fall. Family member #1 expressed dissatisfaction with the NP assessment, the lack of interventions for Resident #13's complaints of intense pain, and absence of on-going assessment's including an x-ray for 6.5 hours after the fall. A review of the x-ray results of Resident #13's left hip/knee revealed that the pictures were taken on 8/31/23 at 3:45 PM. The results were made available to Family Member #5 on 8/31/23 at 6:15 PM as they were removing the resident from the facility. On 2/13/24 at 2:10 PM a final interview was conducted with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing, and the Corporate Nurse. The Administrator stated that that the resident was lowered to the floor by CNA #1, and she voiced that they do not know what occurred after Family Member #1 transferred the resident from the facility. The facility staff voiced they had no additional concerns. The Facility's Fall Prevention Program document with a revision date of 5/27/22 read: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likeliness of falls.

Based on staff interview, Emergency Medical Service (EMS) report, facility document review, and clinical record review, it was determined that the facility staff failed to ensure the licensed nurses and other nursing personnel have the knowledge, competencies, and skill sets to provide care and respond to emergencies for a resident who was unresponsive with breathing difficulties for 1 of 15 residents (Resident #15, a closed record review) in the survey sample. The findings include: Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE].The resident was discharged and admitted to the local hospital on 12/21/23. The resident did not return to the nursing facility. Resident #15 diagnoses included dementia, left lower leg cellulitis, anxiety, and allergic rhinitis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as extensive assistance with the physical assistance of 1-2 for transfers, toileting, and bed mobility. Resident #15's person-centered care plan dated 9/24/23 notes that she required extensive assistance with physical assistance of 1-2 for transfers, toileting, and bed mobility. This care plan also noted the intervention that staff should report changes in breathing patterns or difficulty breathing including wheezing, shortness of breath, rales, rhonchi, note on observation and/or auscultation for further assessment by nurse or practitioner due to diagnosis of allergic rhinitis. A review of the Emergency Medical Service (EMS) Fire and Rescue System Report read they received a call on 12/21/23 at 12:56 AM from the facility concerning resident #15 being in acute respiratory distress. EMS was at the bedside at 1:08 AM. EMS documented that they did not receive a report from the nursing staff concerning the resident's condition, although there were 6 staff members at the bedside. The nursing staff at the bedside could not give them any information about Resident #15. EMS documented that they heard audible rales (abnormal breath sounds), and Resident #15 was found to have on a simple mask connected to a 02 cylinder that was not turned on. When staff was asked about this, they ignored EMS staff and walked away. EMS staff placed Resident #15 on an NRB with 12 liters of 02 and the resident's initial 02 saturations were noted to be 82% (95-100%=normal). Resident #15's 02 saturation via pulse oximetry started to rise to 90% and she then was placed on a continuous positive airway pressure machine (CPAP) with positive end-expiratory pressure (PEEP) of 5. EMS documented that the facility staff was unable to provide information on the resident's normal mental status. Resident #15 was also hypotensive with recorded BPs of 77/33 at 1:11 AM, 60/36 at 1:21 AM, 66/25 at 1:26 AM, and 96/70 at 1:30 AM. There were some problems getting the resident oxygen levels to register, her PEEP was increased to 7.5, and the resident started to open her eyes. On 12/21/23 at 1:26 AM, EMS transferred the resident to the local hospital emergency department for evaluation and she was subsequently admitted to the hospital. A review of documents that were provided and reviewed supports LPN #3 clocked in at 11:03 PM on 12/20/2023 and RN #2, supervisor clocked in at 1:01 AM on 12/21/2023. When LPN #3 was interviewed by phone on 2/12/24 at approximately 12:31 PM she said she noticed Resident #15's breathing was off when she arrived at the unit, shortly after 11:03 PM. When RN #2 was interviewed on 2/9/24 at 12:12 AM he said he arrived at 1:01 AM and EMS showed up right after at 1:03 AM. Based on that timeline, from approximately 11:03 PM to 1:08 AM (EMS at bedside) Resident #15 was having breathing difficulties without oxygen therapy. The RN could not provide evidence that he assessed the resident and the resident's equipment. A phone interview was conducted on 2/13/24 at approximately 1:15 PM with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON). The ADON shared in her role that she also covers staff education. She said that nursing staff should be assessed for their competencies, skills, and knowledge annually. The Administrator on 2/12/24 at 3:30 PM, acknowledged that the facility could locate all the skills competencies for the nurses. The ADON confirmed that they were not done. The DON and ADON shared that under the circumstances of what happened with Resident #15, 911 should have been called immediately when the LPN recognized breathing difficulties during the early 11:00-hour shift change. An interview was conducted on 2/9/24 at approximately 11:00 AM with the DON concerning staff education and whether drills such as mock codes were provided to staff to help them know how to respond to emergencies in the facility. The DON said that they provided this education but were unable to provide supporting documentation. A review of Resident #15's medical record dated 12/21/23 documented vital signs at approximately 2:45 AM (after Resident #15 left the building) were temperature(T) 97, pulse (P) 36, respirations (R) 18, blood pressure (BP) 104/20, and oxygen saturations (02) 69%. A review of Resident #15 medical record indicated there was no admission assessment and no comprehensive assessments completed. In addition, there was no documented evidence that ongoing respiratory assessments and follow-up vital signs were done especially when the nursing staff identified a change in the resident's condition (unresponsive, breathing difficulties). On 2/13/24 at approximately 3:00 PM the above findings were further discussed with the Administrator, Corporate Nurse Consultant, Director of Nursing, and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided before the survey exit. A review of facility policy Oxygen Administration with a review and revised date of 5/27/22, indicated oxygen is administered to patients that need it, consistent with professional standards of practice .Licensed nurses will document the initial and ongoing assessment of the patient's condition warranting oxygen and the response to oxygen therapy . Licensed nurses will notify the physician and the patient's legal representative of any changes in the patient condition, including changes in VS, oxygen concentrations, or evidence of complications associated with the use of oxygen.

Based on staff interviews and clinical record review the facility staff failed to honor a Family Member/Responsible Party's verbalized choice for a transfer from the facility to the hospital or to another facility for 1 of 3 resident's (Resident #13) reviewed for participation in treatment options which resulted in the responsible party physically removing the resident from the facility. The findings included: Resident #13 was originally admitted to the facility 8/30/23 for rehabilitation services after a left hip fracture and surgical repair. The admission diagnoses included; fracture of left femur and a stroke with left hemiparesis. The resident was transferred from the facility on 8/31/23 therefore a closed record review was conducted. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed therefore the following information was obtained from the Admission/Readmission Nursing Collection Tool dated 8/30/23. The tool revealed the resident was oriented to person, place, and situation. In section GG (Usual Performance Admission) the resident was coded as requiring substantial/maximal assistance with toileting hygiene, upper body dressing, sit to stand, and chair/bed-to-chair transfer. The resident was coded dependent with toilet transfers. A synopsis of an event dated 9/1/23 revealed that Resident #13 had a fall around 8:30 AM while being transferred by CNA #1 on 8/31/23. Family member #1 spoke with the Nursing Supervisor at approximately 9:00 AM concerning Resident #13's fall, shortly thereafter Family member #1 spoke with the Administrator and the Social Worker separately concerning the residents fall and they did not seem interested. Family member #1 expressed dissatisfaction with the Nurse Practitioner's (NP's) #1 assessment and the lack of interventions. As a result, Family Member #1 requested x-rays and a comprehensive assessment by an outside provider. A review of Resident #13's progress note dated 8/31/23 at 12:15 PM stated that Family member #1 spoke with the Social Worker and was very upset concerning Resident's #13's fall and lack of assessment and care. The Social Worker asked Family member #1 if he wanted the resident to go to the hospital or to another facility. Family member #1 stated to the social worker that he would let the Doctor decide but insisted that she would not stay here. Family member #1 continued to express dissatisfaction with the NP's absence of on-going assessments, lack of interventions, and response to Resident #13's complaints of intense pain. Also, Family member #1 was not satisfied that an x-ray had not been completed 6.5 hours after the fall. A review of Resident #13's progress note dated 8/31/23 at 4:21 PM stated that the Social Worker received a call from the insurance company representative with Family #1 present on the phone call. Family #1 insisted that Resident #13 be transferred from the facility. On 2/12/24 at 12:00 PM an interview was conducted with LPN #1. LPN #1 stated that Family member #1 was very upset about Resident's #13's fall and was yelling that an x-ray be obtained. LPN #1 also stated that Family Member #1 was set on taking the resident from the facility and it was explained to Family member #1 that it takes a couple hours to arrange transportation to a hospital or another facility, when requested by a responsible party and/or resident. A further review of Resident #13's progress note dated 8/31/23 at 5:22 PM stated that (NP) #1 told LPN #1 that Resident #13 could be sent to the emergency room for further evaluation of her left hip due to the fall however this was only after Family Member #1 became upset and continued to ask for the x-ray results. On 2/12/24 at 12:00 PM an interview was conducted with LPN #1. The x-ray results of the left hip were handed to Family Member #5 on 8/31/23 at 6:15 PM as Family Member #1 was removing the resident from the facility without staff assistance. LPN #1 stated that Family Member #1 transferred the resident into a wheelchair, took the resident outside, and then transferred the resident into the front seat of the car and drove off. A synopsis of an event dated 9/1/23 stated that Family Member #1 transported the resident from the facility to a local hospital on 8/31/23. A review of the local Hospital's Discharge Summary dated 9/7/23 read, that the resident sustained a new peri-prosthetic fracture of the left hip which required surgical repair on 9/3/23. On 2/13/24 at 2:10 PM a final interview was conducted with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing, and the Corporate Nurse. The Administrator stated that that the resident was lowered to the floor by CNA #1, and she voiced that they do not know what occurred after Family Member #1 transferred the resident from the facility.

Based on staff interview, facility document review, and clinical record, it was determined that the facility staff failed to notify the on-call practitioner of a resident's change in condition including shortness of breath, difficulty breathing, and unresponsiveness for approximately 2 hours, and the decision to transfer from the facility to the emergency room for 1 of 15 residents in the survey sample, Resident #15 (a closed record resident). The findings include: For Resident #15, the facility staff failed to notify the on-call practitioner of a resident's change in condition and the decision to transfer from the facility to the hospital emergency room . Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The resident was discharged from the nursing facility and admitted to the local hospital on 12/21/23. The resident did not return to the nursing facility. Resident #15 diagnoses included dementia, anxiety, and allergic rhinitis and a primary re-admission diagnosis of left lower leg cellulitis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/7/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 99 which indicated severely impaired cognition. In section G Activities of Daily Living Assistance (ADLs), the resident was coded as extensive assistance with the physical assistance of 1-2 for transfers, toileting, and bed mobility. Resident #15 person-centered care plan dated 9/24/23 noted that the resident required extensive assistance with physical assistance of 1-2 for transfers, toileting, and bed mobility. This care plan also noted the intervention that staff should report changes in breathing patterns or difficulty breathing including wheezing, shortness of breath, rales, rhonchi, note on observation and/or auscultation for further assessment by nurse or practitioner due to diagnosis of allergic rhinitis. An interview was conducted on 2/12/24 over the phone with LPN #3 at approximately 12:31 PM. LPN #3 shared that Resident #15 was admitted on the evening shift and when she arrived to work on 12/21/23 at approximately 11:00 PM Resident #15 was in the common area in her wheelchair and the resident's breathing was off. LPN #3 said she called 911 immediately. The Emergency Medical Services (EMS) report read, that the facility called at 12:56 AM. LPN #3 said she notified a doctor but did not remember who, that the resident was having breathing problems, and that the resident left the facility after 1:00 AM to go to the emergency room . A phone interview was conducted on 2/12/24 at approximately 1:15 PM with Other #4, a Nurse Practitioner (NP), who stated she was not on call the night of 12/21/23. Other #4 said it would have been Other #5, (Attending Physician). A phone interview was conducted on 2/12/24 at approximately 1:21 PM with Other #5, who stated he was out of the country on 12/21/23. Other #5 said Other #6 was on call for him. A phone interview was conducted on 2/12/24 at approximately 1:54 PM with Other #6 and she did not recall being notified by the nursing staff on 12/21/23 that Resident #15 was in respiratory distress and/or that she was transferred to the hospital. Other #6 checked her phone call log and messages during the phone interview and said that she had no record of a call from the facility on 12/20/23 or 12/21/23 regarding Resident #15 in respiratory distress or that she was transferred to the hospital. A review of a nurse's note dated 12/21/23 at 2:36 AM by LPN #3 read, that Resident #15 was transferred to the hospital for shallow breathing, congestion, drainage, unresponsive, and weakness. It also read that Family Member #3 was notified and yes MD was aware. A review of Emergency Medical Services (EMS) Fire and Rescue System Report read, that they received a call on 12/21/23 at 12:56 AM from the facility concerning Resident #15 being in acute respiratory distress. EMS arrived on the scene at 1:03 AM. EMS treated Resident #15 who was hypoxic and unresponsive, once they got her oxygen saturation above 90% and saw the resident start to open her eyes, they departed the facility at 1:26 AM and transferred the resident to the local hospital emergency room . A review of facility policy Notification of Changes with a review and revised date of 5/27/2022 notes the purpose of this policy is to ensure the center promptly informs the patient, consults the patient's physician/physician extender, and notifies the patient's legal representative when there is a change requiring notification. A phone interview was conducted on 2/13/24 at approximately 1:15 PM with the Administrator, DON, Assistant Director of Nursing (ADON) shared that under the circumstances of what was happening with Resident #15, 911 should have been called immediately and the physician was made aware when the LPN recognized breathing difficulties at the beginning of her shift. On 2/13/24 at approximately 3:00 PM the above findings were further discussed with the Administrator, Corporate Nurse Consultant, Director of Nursing, and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided before the survey exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement the comprehensive care plan for five of 46 residents in the survey sample, Residents #45, #24, # 64, #56 and # 103. The findings include: 1. The facility staff failed implement Resident # 45's comprehensive care plan to administer oxygen at two liters per minute. Resident # 45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 45 for Oxygen Therapy while a resident. On 03/08/22 at approximately 1:36 p.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. On 03/09/22 at approximately 8:35 a.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. On 03/09/22 at approximately 12:50 p.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 02/19/2022. Start Date 02/19/2022. The comprehensive care plan for Resident # 45 dated 09/04/2021 documented in part, Focus: [Resident # 45] has respiratory problem (s) related to acute illness or chronic condition r/t (related to) [CONDITION(S)], Asthma. Date Initiated: 09/04/2021 .Provide oxygen as ordered. Date Initiated: 09/04/2021. On 03/09/2022 at approximately 12:55 p.m., an observation of Resident # 45's flow meter on their oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 4. When asked how they read the oxygen flow rate on an oxygen concentrator LPN # 4 stated, The liter line goes through the middle of the ball. When asked to read the oxygen flow rate on Resident # 45's oxygen concentrator, LPN # 4 read the flow meter and stated, Three liters per minute. After reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked to describe the purpose of a resident's care plan, LPN # 4 stated, How we go about taking care of the resident. After reviewing the comprehensive care plan for Resident # 45's respiratory care LPN # 4 was asked if the care plan was being followed. LPN # 4 stated, Right now, no. On 03/09/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, interim administrator and ASM # 2, director of clinical services, were made aware of the above findings. A review of the facility document Comprehensive Care Planning Process was conducted. This policy did not specifically direct that the care plan must be followed / implemented. No further information was provided prior to exit. 2. The facility staff failed implement Resident # 24's comprehensive care plan to maintain regular communication with the [CONDITION(S)] center. Resident # 24 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 24 for [CONDITION(S)] while a resident. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] Days: Tues-Thurs-Sat 4) [CONDITION(S)] Medical DX: [CONDITION(S)] 5) [CONDITION(S)] Transport (company): [Name of Company]. 6) Chair time: 10:55am (a.m.). Start Date 08/10/2021. The comprehensive care plan for Resident # 24 dated 08/10/2021 documented in part, Focus: [Resident # 24] has Renal Disease requiring [CONDITION(S)] Date Initiated: 08/10/2021 .Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes .Date Initiated: 08/10/2021. Review of the facility's Transfer and Treatment Forms for Resident # 24's [CONDITION(S)] failed to evidence documentation of the following: all vital signs on 01/03/0221 and 01/08/2021; respiration and temperature on 01/11/2021 and the nurse's signature on 01/03/0221, 01/08/2021, 01/11/2021, 01/13/0221, 01/18/2021, 01/25/2021, 01/27/2021, 02/05/2021, 03/01/2021 and 03/05/2021. On 03/09/2022 at approximately 4:05 p.m. an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked what portions of the [CONDITION(S)] sheets the facility was responsible for completing, ASM # 2 stated, The resident's name, date, vital signs (blood pressure, respiration, pulse, and temperature), and the nurse's signature. After reviewing the facility's Transfer and Treatment Forms for Resident # 24 as dated above, ASM # 2 was asked if the forms were completed. ASM # 2 stated, No. When asked to describe the purpose of a care plan, ASM # 2 stated, It's a plan of care, tells us what we have to do. When asked if Resident # 24's comprehensive care plan was implemented to maintain regular communication with the [CONDITION(S)] center for the dates listed above, ASM # 2 stated, No. On 03/09/2022 at approximately 5:00 p.m., ASM # 1, interim administrator and ASM # 2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: [1] [CONDITION(S)] treats end-stage kidney failure. It removes waste from your blood when your kidneys can no longer do their job. Hemodialysis (and other types of [CONDITION(S)]) does some of the job of the kidneys when they stop working well. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 7.htm. [2] The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm. 3. The facility staff failed to implement the comprehensive care plan for coordination with [CONDITION(S)] services for Resident #64. Resident #64 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 2/7/22, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status, indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. The resident was coded as receiving [CONDITION(S)] services during the look back period. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the comprehensive care plan revealed one dated 1/31/22 for, [Resident #64] has Renal Disease requiring [CONDITION(S)] Further review revealed an intervention dated 1/31/22 for Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes. A review of the [CONDITION(S)] communication book revealed Transfer and Treatment Forms that were to be completed for Resident #64 prior to being sent to [CONDITION(S)]. This form included the following information: name, date, facility, address, provider, diagnosis, code status, allergies, current medical condition, vital signs, height, weight, and skin condition. The dates of 3/4/22, 3/7/22 and 3/9/22, the facility did not complete the communication forms for the required vital signs and current weight for communication to the [CONDITION(S)] center. The form dated 3/9/22 did have the blood pressure only documented but did not have complete vital signs documented. On 3/10/22 at 7:45 AM an interview was conducted with RN #3 (Registered Nurse). When asked the purpose of the [CONDITION(S)] communication book, she stated it is to let [CONDITION(S)] know a resident's status, especially blood pressure and weight. When asked if the information was not completed, was the [CONDITION(S)] center was provided with the required information they needed, she stated they were not. When asked if the care plan documented to communicate pre treatment notes with [CONDITION(S)], was the care plan followed, she stated it was not. On 3/10/22 at 8:25 AM, ASM #2, (Administrative Staff Member) the Director of Nursing, was notified of the findings. When asked if the [CONDITION(S)] forms that were incomplete evidenced that the facility communicated with the [CONDITION(S)] center, she stated that the [CONDITION(S)] forms should have been completed When asked the purpose of the care plan, she stated It tells us what we have to do, everything about the resident. When asked if the care plan was being followed regarding the missing communication data for the above dates, she stated it was not. On 3/10/22 at approximately 10:15 AM, ASM #1, the Administrator, was made aware of the findings. No further information was provided by the end of the survey. 4. The facility staff failed to implement the comprehensive care plan for coordination with [CONDITION(S)] services for Resident #56. Resident #56 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/26/22, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status, indicating the resident was moderately cognitively impaired for making daily decisions. The resident was coded as requiring limited to extensive assistance for all areas of activities of daily living. The resident was coded as receving [CONDITION(S)] services during the look back period. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the comprehensive care plan revealed one dated 10/20/21 for, [Resident #56] has Renal Disease requiring [CONDITION(S)] .Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes. A review of the [CONDITION(S)] communication book revealed Transfer and Treatment Forms that were to be completed for Resident #64 prior to being sent to [CONDITION(S)]. This form included the following information: name, date, facility, address, provider, diagnosis, code status, allergies, current medical condition, vital signs, height, weight, and skin condition. The dates of 3/9/22, 3/7/22, 3/4/22, 3/2/22, 2/28/22, 2/23/22, 2/14/22, and 2/7/22, the facility did not complete the communication forms for the required vital signs and current weight for communication to the [CONDITION(S)] center. On 3/10/22 at 7:45 AM an interview was conducted with RN #3 (Registered Nurse). When asked the purpose of the [CONDITION(S)] communication book, she stated it is to let [CONDITION(S)] know a resident's status, especially blood pressure and weight. When asked if the information was not completed, was [CONDITION(S)] center provided with the required information they needed, she stated they were not. When asked if the care plan for communicating pre-treatment notes with the [CONDITION(S)] center was being followed, she stated it was not. On 3/10/22 at 8:25 AM, ASM #2, (Administrative Staff Member) the Director of Nursing, was notified of the findings. When asked if the [CONDITION(S)] forms that were incomplete evidenced that the facility communicated with the [CONDITION(S)] center, she stated that the [CONDITION(S)] forms should have been completed. When asked the purpose of the care plan, she stated It tells us what we have to do, everything about the resident. When asked if the care plan was being followed for [CONDITION(S)] communication data for the above dates, she stated it was not. On 3/10/22 at approximately 10:15 AM, ASM #1, the Administrator, was made aware of the findings. No further information was provided by the end of the survey. 5. The facility staff failed to implement the comprehensive care plan for the call light for Resident #103. Resident #103 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 2/24/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. MDS Section G coded the resident as requiring the extensive assistance of staff for bed mobility, transfers, dressing, hygiene; total dependence for bathing. Section H coded the resident as frequently incontinent for bowel and for bladder. A review of the comprehensive care plan dated 2/18/22 revealed, in part, FOCUS: At risk for falls related to recent history of falls at home .Orient patient to room, call bell, lighting and bathroom. Encourage to use call bell for assistance with needs. An interview was conducted on 3/8/22 at 10:05 AM with Resident #103. When asked if she had her call bell, Resident #103 stated, It's probably on the floor. It is on the floor frequently because it slides off of the bed I guess. An interview was conducted on 3/8/22 at 10:07 AM with OSM (other staff member) #2, a physical therapist in Resident #103's room. When OSM #2 was asked about the location of Resident #103's call bell, OSM #2 stated, Yes, it is on the floor. When asked where the call bell should be located, OSM #2 stated, It should be within the resident's reach. I'm just going to wipe it and give it back to her, it should not be on the floor. OSM #2 observed sanitized the call bell and cord, and gave it back to the resident. On 3/8/22 at 10:15 AM, an interview was conducted with LPN (licensed practical nurse) #2. When asked if she had administered Resident #103's morning medications, LPN #2 stated, Yes, I gave her the morning meds but did not see the call bell on the floor. I'm sorry about that. It should not be on the floor. An interview was conducted on 3/9/22 at approximately 1:10 PM with LPN #3. When asked the purpose of the care plan, LPN #3 stated, It is to outline the plan of care for the resident. When asked if the care plan was implemented if the interventions listed were not implemented, LPN #3 stated, No, it was not implemented. On 3/9/22 at 4:58 PM, ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing were informed of the above findings. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and service for a complete [CONDITION(S)] [1] program for three of 46 residents in the survey sample, Residents # 24, # 64 and # 56. The findings include: 1. The facility staff failed to maintain accurate communication regarding Resident #24's care with the [CONDITION(S)] center for January 2022 through March 2022. Resident # 24 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 24 as having received [CONDITION(S)] while a resident. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] Days: Tues-Thurs-Sat 4) [CONDITION(S)] Medical DX: [CONDITION(S)] 5) [CONDITION(S)] Transport (company): [Name of Company]. 6) Chair time: 10:55am (a.m.). Start Date 08/10/2021. The comprehensive care plan for Resident # 24 dated 08/10/2021 documented in part, Focus: [Resident # 24] has [CONDITION(S)] requiring [CONDITION(S)] Date Initiated: 08/10/2021 .Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes .Date Initiated: 08/10/2021. Review of the facility's Transfer and Treatment Forms for Resident # 24's [CONDITION(S)] failed to evidence documentation of the following: all vital signs on 01/03/0221 and 01/08/2021; respiration and temperature on 01/11/2021 and the nurse's signature on 01/03/0221, 01/08/2021, 01/11/2021, 01/13/0221, 01/18/2021, 01/25/2021, 01/27/2021, 02/05/2021, 03/01/2021 and 03/05/2021. On 03/09/2022 at approximately 4:05 p.m. an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked what portions of the [CONDITION(S)] sheets the facility was responsible for completing, ASM # 2 stated, The resident's name, date, vital signs (blood pressure, respiration, pulse, and temperature), and the nurse's signature. After reviewing the facility's Transfer and Treatment Form for Resident # 24 as dated above, ASM # 2 was asked if the forms were complete. ASM # 2 stated, No. When asked why it was important for the forms to be completed ASM # 2 stated, To document and changes in the resident and the nurse that completed the form. Then facility's policy documented in part, Hemodialysis. Compliance Guidelines: 1. The licensed nurse will communicate to the [CONDITION(S)] facility via telephonic communication or written format, such as a [CONDITION(S)] communication form or other form, that will include, but not limit itself to: b. Physician/treatment orders, laboratory values, and vital signs . On 03/09/2022 at approximately 5:00 p.m., ASM # 1, interim administrator and ASM # 2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References: [1] [CONDITION(S)] treats end-stage kidney failure. It removes waste from your blood when your kidneys can no longer do their job. Hemodialysis (and other types of [CONDITION(S)]) does some of the job of the kidneys when they stop working well. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 7.htm. [2] The last stage of chronic kidney disease. This is when your kidneys can no longer support your body's needs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm. 2. The facility staff failed to evidence communication and coordination of [CONDITION(S)] care and services for Resident #64 between the facility and the [CONDITION(S)] center. Resident #64 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set), a 5-day assessment with an ARD (Assessment Reference Date) of 2/7/22, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status, indicating the resident was not cognitively impaired for making daily decisions. The resident was coded as requiring supervision for eating and extensive assistance for all other areas of activities of daily living. The resident was coded as receiving [CONDITION(S)] services during the look back period. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the [CONDITION(S)] communication book revealed Transfer and Treatment Forms that were to be completed for Resident #64 prior to being sent to [CONDITION(S)]. This form included the following information: name, date, facility, address, provider, diagnosis, code status, allergies, current medical condition, vital signs, height, weight, and skin condition. On 3/4/22, 3/7/22 and 3/9/22, the facility did not complete the communication forms for the required vital signs and current weight for communication to the [CONDITION(S)] center. The form dated 3/9/22 did have the blood pressure only documented but did not have complete vital signs documented. On 3/10/22 at 7:45 AM an interview was conducted with RN #3 (Registered Nurse). When asked the purpose of the [CONDITION(S)] communication book, she stated it is to let [CONDITION(S)] know a resident's status, especially blood pressure and weight. When asked if the information was not completed, was the [CONDITION(S)] center was provided with the required information they needed, she stated they were not. On 3/10/22 at 8:25 AM, ASM #2, (Administrative Staff Member) the Director of Nursing, was notified of the findings. When asked if the [CONDITION(S)] forms that were incomplete evidenced that the facility communicated with the [CONDITION(S)] center, she stated that the [CONDITION(S)] forms should have been completed. A review of the comprehensive care plan revealed one dated 1/31/22 for, [Resident #64] has [CONDITION(S)] requiring [CONDITION(S)] .Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes. On 3/10/22 at approximately 10:15 AM, ASM #1, the Administrator, was made aware of the findings. No further information was provided by the end of the survey. 3. The facility staff failed to evidence communication and coordination of [CONDITION(S)] care and services for Resident #56 between the facility and the [CONDITION(S)] center. Resident #56 was admitted to the facility on [DATE] and had the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (Minimum Data Set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/26/22, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status, indicating the resident was moderately cognitively impaired for making daily decisions. The resident was coded as requiring limited to extensive assistance for all areas of activities of daily living. The resident was coded as receiving [CONDITION(S)] services during the look back period. A review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the [CONDITION(S)] communication book revealed Transfer and Treatment Forms that were to be completed for Resident #64 prior to being sent to [CONDITION(S)]. This form included the following information: name, date, facility, address, provider, diagnosis, code status, allergies, current medical condition, vital signs, height, weight, and skin condition. On 3/9/22, 3/7/22, 3/4/22, 3/2/22, 2/28/22, 2/23/22, 2/14/22, and 2/7/22, the facility did not complete the communication forms for the required vital signs and current weight for communication to the [CONDITION(S)] center. On 3/10/22 at 7:45 AM an interview was conducted with RN #3 (Registered Nurse). When asked the purpose of the [CONDITION(S)] communication book, she stated it is to let [CONDITION(S)] know a resident's status, especially blood pressure and weight. When asked if the information was not completed, was [CONDITION(S)] center provided with the required information they needed, she stated they were not. On 3/10/22 at 8:25 AM, ASM #2, (Administrative Staff Member) the Director of Nursing, was notified of the findings. When asked if the [CONDITION(S)] forms that were incomplete evidenced that the facility communicated with the [CONDITION(S)] center, she stated that the [CONDITION(S)] forms should have been completed. A review of the comprehensive care plan revealed one dated 10/20/21 for, [Resident #56] has [CONDITION(S)] requiring [CONDITION(S)] .Coordinate with [CONDITION(S)] center for [CONDITION(S)] treatments as ordered. Communicate with [CONDITION(S)] provider regularly via pre/post treatment notes. On 3/10/22 at approximately 10:15 AM, ASM #1, the Administrator, was made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, clinical record review, facility document review and staff interviews it was determined that the facility failed to maintain a complete and accurate clinical record for one of 46 residents in the survey sample, Resident #42. The findings include: The facility staff failed to maintain a complete and accurate ADL (activities of daily living) record for Resident #42. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (Assessment Reference Date) of 1/15/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section G documented Resident #42 requiring extensive assistance of two or more persons for bed mobility and one person for dressing and personal hygiene. On 3/8/2022 at 10:00 a.m., an interview was conducted with Resident #42. Resident #42 stated that the facility staff used a mechanical lift to get him out of bed to take him to the shower. Resident #42 stated that he was scheduled for showers on Tuesdays and Fridays and at times they were not offered, and he was not sure why. Resident #42 stated that he did refuse showers on some days, but not always. The comprehensive care plan documented in part, [Resident #42] demonstrates the need for ADL assistance as related to impaired mobility, s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Generalized weakness, altered balance, Incontinence, pain and [CONDITION(S)] . Date Initiated: 06/26/2020 . The Documentation Survey Report dated 2/1/2022-2/28/2022 was reviewed for bathing/shower documentation. The report failed to evidence documentation for the bathing/shower area on 2/4/2022, 2/11/2022 and 2/25/2022. The areas for those dates were blank. On 3/10/2022 at 9:45 a.m., an interview was conducted with CNA (certified nursing assistant) #3. CNA #3 stated that baths and showers were provided twice a week and documented in the computer. CNA #3 stated that they entered documentation if a resident refused, was out of the building, or received the shower, and how much assistance the resident required. CNA #3 stated that they were not sure about blanks on the ADL documentation but thought the CNA who was caring for the resident may not have charted the bath or shower. On 3/10/2022 at 10:00 a.m., an interview was conducted with LPN (licensed practical nurse) #6. LPN #6 stated that blanks on the bathing/shower documentation probably meant that the CNAs did not document the care or the refusal of care on those dates. LPN #6 stated that the blanks indicated the charting was not complete. The facility policy Documentation in Medical Record dated 6/1/21 documented in part, Each resident's medical record should contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation .Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy . On 3/10/2022 at approximately 10:00 a.m., ASM (administrative staff member) #1, the interim administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to place a call bell within reach for one of 46 residents in the survey sample, Resident #103. The findings include: The facility staff failed to place Resident #103's call bell within reach. Resident #103 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #103's most recent MDS (minimum data set) assessment, a five day Medicare assessment, with an assessment reference date of 2/24/22, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G coded the resident as requiring extensive staff assistance with bed mobility, transfers, dressing, hygiene; total dependence for bathing. Section H coded the resident as frequently incontinent for bowel and for bladder. A review of the comprehensive care plan dated 2/18/22 revealed, in part, FOCUS: At risk for falls related to recent history of falls at home .Orient patient to room, call bell, lighting and bathroom. Encourage to use call bell for assistance with needs. On 3/8/22 at 8:05 AM, Resident #103's call bell was noted to be on the floor in between her bed her roommate's bed. Breakfast was observed being delivered to Resident #103 at approximately 8:15 AM. On 3/8/22 at 10:05 AM, Resident #103's call bell was in the same location, on the floor between the two beds. An interview was conducted on 3/8/22 at 10:05 AM with Resident #103. When asked if she had her call bell, Resident #103 stated, It's probably on the floor. It is on the floor frequently because it slides off of the bed, I guess. An interview was conducted on 3/8/22 at 10:07 AM with OSM (other staff member) #2, a physical therapist. OSM #2 entered Resident #103's room, and was asked about the location of Resident #103's call bell. OSM #2 stated, Yes, it is on the floor. When asked where the call bell should be located, OSM #2 stated, It should be within the resident's reach. I'm just going to wipe it and give it back to her, it should not be on the floor. OSM #2 was observed wiping the call bell and cord with an antibacterial wipe, and giving it back to the resident. On 3/8/22 at 10:15 AM, an interview was conducted with LPN (licensed practical nurse) #2. When asked if she had administered Resident #103's morning medications, LPN #2 stated, Yes, I gave her the morning meds but did not see the call bell on the floor. I'm sorry about that. It should not be on the floor. On 3/9/22 at 4:58 PM, ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing were informed of the above findings. On 3/10/22 at 8:42 AM, ASM #1 stated, With regards to the call light, I wanted to talk about the accommodation of needs. The resident was able to make her needs known at the time. She asked the social worker if she had washcloths. When asked how the social worker was contacted, ASM #1 stated, The social worker was going by the room in the hall and the resident called out. When asked if calling out was an accommodation of needs, ASM #1 stated, No, I don't expect them to call out. We were able to accommodate her needs. We round each shift, the leadership. From a regulatory standpoint there is the requirement that the call bell should be in reach within all times. I do not deny that it happened I just do not think it is widespread. A review of the facility's Call Lights: Accessibility and Timely Response policy dated 6/1/2021, which revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow residents to call for assistance. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of the resident and secured, as needed. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory services according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Facility staff failed to maintain Resident # 45's oxygen flow rate at 2 liters per minute according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident # 45 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/17/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 45 for Oxygen Therapy while a resident. On 03/08/22 at approximately 1:36 p.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. On 03/09/22 at approximately 8:35 a.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. On 03/09/22 at approximately 12:50 p.m., an observation of Resident # 45 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate of three liters per minute. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 02/19/2022. Start Date 02/19/2022. The comprehensive care plan for Resident # 45 dated 09/04/2021 documented in part, Focus: [Resident # 45] has respiratory problem (s) related to acute illness or chronic condition r/t (related to) [CONDITION(S)], Asthma. Date Initiated: 09/04/2021 .Provide oxygen as ordered. Date Initiated: 09/04/2021. On 03/09/2022 at approximately 12:55 p.m., an observation of Resident # 45's flow meter on their oxygen concentrator, and an interview was conducted with LPN (licensed practical nurse) # 4. When asked how they read the oxygen flow rate on an oxygen concentrator LPN # 4 stated, The liter line goes through the middle of the ball. When asked to read the oxygen flow rate on Resident # 45's oxygen concentrator, LPN # 4 read the flow meter and stated, Three liters per minute. After reviewing the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why it was important to maintain the oxygen flow rate according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The User Manual by [Name of Manufacturer] for [Name of Oxygen Concentrator] for Resident # 45 documented in part, 6. Adjust the flow to the prescribed setting by turning the knob at the top of the flow meter until the ball is centered on the line marking the specific flow rate. On 03/09/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, interim administrator and ASM # 2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and review of facility documentation the facility staff failed to perform services to prevent, identify, assess and appropriately treat pressure ulcers for three Residents (Resident #6, Resident #14 and Resident #15) resulting in harm for one resident (Resident #6) in the survey sample of 24 residents. 1(a) The facility staff failed to provide care and services to prevent the development of three facility acquired pressure ulcers (one on the right buttock area, one on each heel) after two CNA (certified nursing assistant) staff members notified nursing staff on two separate occasions between 12/6/14 and 12/8/14 of developing areas of redness observed on Resident #6. On 12/10/14 Resident #6 was observed to have developed three DTI (deep tissue injuries) one on the right lower buttock and one on each heel. On 12/16/14 the area on the right lower buttock had declined to unstageable necrosis*** (death of body tissue which occurs when there is not enough blood flowing to the tissue. Necrosis is not reversible) with 100% eschar*** (dead tissue that falls off (sheds) from healthy skin) requiring debridement on 12/24/14 by the wound clinic. 1(b) Facility staff failed to perform wound care in a manner to prevent infection. During a wound care observation for Resident #6, LPN (licensed practical nurse) #4 placed packages of skin prep that had been touched with her bare hands directly on top of the disinfected scissors. LPN #4 used the unclean scissors to cut packing that was placed directly into Resident #6's wound. 2. Facility staff failed to perform wound care in a manner to prevent infection. During a wound care observation for Resident #14, LPN #4 placed a plastic zip lock bag with [MEDICATION NAME] inside of it (anti-bacterial honey based dressing*) that she had obtained from her cart, on top of the clean field and scissors. LPN #4 then used the unclean scissors to cut a dressing that was placed directly into Resident #14's wound. 3. For Resident #15, the facility staff failed to assess and/or treat the following pressure ulcers (1) (with identification dates): left buttock (2/23/15); right buttock (3/2/15); sacrum (3/30/15) and coccyx (4/20/15). The findings include: 1(a) Resident #6 was admitted to the facility on [DATE] with a readmission of 3/20/15 with [DIAGNOSES REDACTED].*(occurs when your stomach contents regurgitate into your esophagus), spinal stenosis (a narrowing of the spinal canal), [MEDICAL CONDITION] bladder** (lacks bladder control due to a brain, spinal cord, or nerve condition), and dementia. Resident #6's MDS (minimum data set) with an ARD (assessment reference date) of 11/17/14 was a 30 day assessment. Resident #6 was coded as a 14 out of a possible summary score of 15 on the Brief Interview for Mental Status (BIMS), indicating that the resident was cognitively intact. In Section G, functional status, Resident #6 was coded as requiring two person assist with transfers and bed mobility. In section M, skin conditions, Resident #6 was coded as being at risk of developing pressure ulcers and did not have any unhealed pressure ulcers at Stage 1^ or higher at the time of the assessment. Further review of Resident #6's MDS submissions revealed the following information related to her cognitive decline and pressure ulcer development: · A 60 day MDS with an ARD of 12/15/14 coded Resident #6 as 12 out of a possible summary score of 15 on the BIMS, indicating that the resident was moderately cognitively impaired. Section G, functional status, Resident #6 was coded as requiring a two person assist for bed mobility and transfers. Section M, skin conditions, coded Resident #6 as being at risk of developing pressure ulcers and having three unstageable^ - deep tissue pressure ulcers which were not present on admission. · A five day MDS with an ARD of 1/11/15 coded Resident #6 as unable to complete the BIMS interview for cognition, the staff assessment coded Resident #6 as a 1 indicating modified independence and having some difficulty in new situations. In Section G, functional status, Resident #6 was coded as requiring a two person assist with bed mobility and transfers. Section M, skin conditions, coded Resident #6 as being at risk of developing pressure ulcers and having one unstageable pressure ulcer with slough and eschar measuring 4.5 cm (centimeters) x 3.0 cm x 2.0 cm and two unstageable - deep tissue pressure ulcers (DTIs). A review of Resident #6's clinical record revealed a nurses note dated 12/10/2014 at 20:55 (10:55 p.m.) that documented, in part, the following: This nurse was called by the can (sic) during patient care to observe an opened wound black on right lower buttock. Area was cleaned with NS (normal saline); duoderm (a moisture-retentive wound dressing) was applied. Note left for wound nurse to follow up. A review of the physician orders revealed a telephone order dated 12/11/14 and signed by the physician on 12/11/14 which provided the following orders: 1. Duoderm to R (right) buttock 3x (three times) a week (Sun (Sunday), Tue (Tuesday), Fri (Friday) and PRN (as needed. 2) Air matress (sic) properly inflated Q (every) shift. 3) Heel cushion to bilateral feet while in bed. 4) Gell (sic) cushion to wheelchair when OOB (out of bed) Q shift. Further review of the physician orders revealed a telephone order dated 12/11/14 and signed by the physician on 12/22/14 which documented, in part, the following: 12/11/14 1) Order Prostat AWC (a nutritional supplement) 30 ml (milliliters) BID (two times per day) to promote wound healing. Further review of Resident #6's clinical record revealed a facility document titled, Braden Scale for Predicting Pressure Sore Risk. This document was used to calculate the level of risk Resident #6 had for developing a pressure ulcer based on the following predictors; sensory perception, moisture, activity, mobility, nutrition, friction and shear. The Braden Scale for Predicting Pressure Sore Risk was completed on the following four occasions for Resident #6 prior to the documentation that she had developed three DTIs on 12/10/14: · 10/20/14 - Category: Moderate Risk · 10/27/14 - Category: Low Risk · 11/3/14 - Category: Low Risk · 11/10/14 - Category: Low Risk A review of Resident #6's care plan revealed, in part, the following documentation: Focus: (Name of Resident #6) presents with a skin integrity risk and problem related to: immobility and impaired joint mobility r/t (related to) spinal stenosis and [MEDICAL CONDITION] intervertebral disk, bowel incontinence, obesity. Date initiated: 10/21/2014. Revision on: 4/22/2015. Goal: Resolved. Resident will not develop an avoidable decline in skin integrity through the next review date. Date initiated: 10/21/2014. Revision on: 4/21/2015. Interventions/Tasks: Apply moisturizer to skin per facility protocol. Date initiated 10/31/2014. Encourage/remind/assist to turn and reposition (Resident #6's name) frequently per facility protocol. Date initiated: 10/21/2014. Peri care after each incontinent episode/apply barrier cream per facility protocol. Date initiated: 10/31/2014. Pressure reduction support surface for (Resident #6's name) by checking air mattress for proper inflation per facility protocol. Date initiated 10/31/2014. (*Note there was a discrepancy for the 10/31/14 initiation date for a pressure reduction surface and checking air mattress for proper inflation. The physicians order for this was dated 12/11/14 after the wounds for Resident #6 were found. On 5/13/15 at 12:20 p.m., when ASM #1, the administrator was asked what type of mattress Resident #6 had at the time the wounds developed, the administrator responded, It was our standard mattress. The Director of Nursing ASM #2 was present and confirmed this.) A review of the physical therapy plan of care completed on 10/21/14 revealed, in part, the following documentation: Initial Assessment: Functional Deficits: Bed mobility, rolling side to side. Current level: maximum assistance x 2 (76 - 99% assist with 2 people). Bed mobility, bridging/scooting: maximum assistance x 2 (76-99% assist with 2 people). Transfers bed/chair: maximum assistance x2 (76-99% assist with 2 people). The facility document Body Audits was completed on Resident #6 on 11/27/14 which documented, in part, the following: Skin integrity intact - Yes. No areas of wounds, bruising, skin tears, redness or spongy areas were indicated. The next body audit was completed on 12/23/14 and revealed three areas of concern; Open area to the right buttocks, redness to the heels, small red area noted on the chest. Further review of Resident #6's clinical record revealed a wound note dated 12/11/2014 at 12:17 p.m. that documented, in part, the following: Resident (Resident #6) presents with a purple dusky area to her right buttock that is indicative of an Unstageable DTI^ (deep tissue injury). The area measures 4.0 x 3.0 x <(less than) 0.1 cm (centimeter). 100% dark purple skin. Wound edges are not well defined. Periwound (the skin surrounding the wound) is pink and intact. No drainage, no odor, no pain. Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Purple dusky area noted to left heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. MD (medical doctor) / RP (responsible party) aware. Resident #6's clinical record contained the following pressure ulcer reports: · 12/11/14. Site: Right buttock. Description: Resident presents with a purple dusky area to her right buttock that is indicative of an Unstageable DTI^. The area measures 4.0 x 3.0 x <0.1 cm. 100% dark purple skin. Wound edges are not well defined. Periwound is pink and intact. No drainage, No odor. No pain. Site: Right heel. Description: Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Site: Left heel. Description: Purple dusky area noted to left heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. · 12/16/14. Site: Sacrum. Description: Resident presents with a dark black and purple area to her right buttock that is indicative of an Unstageable necrosis. The area measures 3.5 x 0.5 x 0.1 cm. 100% black eschar. Wound edges are not well defined. Periwound is pink and intact. Light serosanguineous exudate, no odor, no pain. Site: Right heel. Description: Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Stable. Site: Left heel. Description: Purple dusky area noted to left heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Stable. · 12/23/14. Site: Right buttock. Description: Resident presents Unstageable necrosis to the right buttock. The area measures 3.5 x 0.5 x<0.8 cm. 100% necrosis. Site: Right heel. Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Site: Left heel. Description: Purple dusky area noted to left heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. · 12/30/14. Site: Right buttock. Description: Resident medicated for pain prior to wound care and assessment. Presents with a dark black and purple area to her right buttock that is indicative of an Unstageable necrosis. The area measures 3.5 x 4.5 x 0.8 cm. 100% black eschar. Wound edges are not well defined. Periwound is pink and intact. Light sersanguineous exudate noted, odor present upon dressing change. No pain. Site: Right heel. Description: Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Stable. Site: Left heel. Description: Purple dusky area noted to right heel that is indicative of an Unstageable DTI^. The area measures 1.0 x 1.0 x <0.1 cm. 100% purple skin. No drainage, no odor, no pain. Stable. Further review of physician orders for Resident #6 between the dates of 12/11/14 and 12/30/14 revealed the following order dated 12/22/14 and signed by the physician on 1/2/15: 12/22/14. Late entry effective 12/19/14: Cont (continue) skilled OT (occupational therapy) services 5 x (five times) wk (week) for up to 30 days. OT tx (treatment) to include w/c (wound care) management, pt (patient)/family education and d/c (discharge) planning. No other treatment orders were documented during this time period in the clinical record. Review of Resident #6's clinical record revealed, in part, the following wound care specialist evaluation notes: · 12/23/14. Unstageable (due to necrosis) of the right buttock. Focused wound exam. Etiology (quality): Pressure. MDS 3.0 Stage: Unstageable necrosis. Wound size: e3.5 x 0.5 x not measureable cm. Surface area: 1.75 cm2 (squared). Exudate: light serous. Thick adherent devitalized necrotic tissue: 100%. Consent: Treatment options, risks, benefits and the possible need for subsequent additional debridement of this wound was explained on 12/23/14 to the patient and health care surrogate, (name of responsible party), who indicated agreement to proceeded with the procedure. Description: Wound debrided via surgical excision and subcutaneous tissue removed along with necrotic tissue. Continue: Santyl (a sterile enzymatic [MEDICATION NAME] ointment) once daily. Calcium alginate (an exudates absorbing dressing), once daily. Follow up within 7 days. · 12/23/14. Unstageable DTI of the right heel. Etiology (quality): Pressure. MDS 3.0 Stage: Unstageable DTI. Wound size: 1x2xNot Measurable cm. Surface area: 2.0 cm2. Exudate: None. · 12/23/14. Unstageable DTI of the left heel. Etiology (quality): Pressure. MDS 3.0 Stage: Unstageable DTI. Wound size 1x1xNot Measurable cm. Surface area: 2.0 cm2. Exudate: None. The next wound clinic visit was 1/27/15. On 5/12/15 at approximately 2:00 p.m. ASM (administrative staff member) #2, the DON (director of nursing) was asked to provide any and all documentation related to the skin integrity of Resident #6 prior to 12/10/15 when pressure ulcers were found on Resident #6's bilateral heels and right buttock. On 5/13/15 at approximately 10:00 a.m. the DON provided an investigative package that she stated she had completed on 12/11/15 after the pressure ulcers were found on Resident #6. The investigative package included, in part, the following six statements from the nursing staff involved with Resident #6's care on and around 12/11/15: · 12/11/14. (Name of CNA (certified nursing assistant) #4). I called the nurse to the room, (name of CNA #3) was helping me, we showed the nurse the red rash (sic) on her lower buttocks. We did (sic) put anything on it because she is allergic to [MEDICATION NAME] (sic) on the weekend of Dec (December) 6, 14, 12/7/14. · 12/11/14. (Name of CNA #3). Call nurse to room on weekend 12/6/14, 12/7/14, turned (name of Resident #6) and the skin area was red on rash (sic) lower buttocks. We didn't put any [MEDICATION NAME] (sic) she is allergic that's posted in her room. Also reported the red area to nurse on Monday 12/8/14. · 12/11/14. On 12/10/14 at 10 p.m. this nurse was called into resident (Resident #6) room by CNA to observe a wound blackish on right lower buttock. Area was cleansed with NS and pat dry-duoderm was applied. Supervisor was notified of resident skin condition. Note was left under wound nurse door for update and follow up. Signed by LPN (licensed practical nurse) #2. · 12/11/14. 3-11(3:00 p.m. - 11:00 p.m.) nurse reported to me about the sacral wound in (Resident #6's) buttocks. I did not notice any sore or receive any report from the CNA regarding (Resident #6's) sacral wound. Signed by LPN #5. · 12/11/14. On Monday CNA stated to me resident (Resident #6) had a rash on the (R) (right) gluteal fold. This nurse saw small redness on the area. Possible sheering. Monday was 12/8/14. Signed by LPN #4. On 5/13/14 at 9:40 a.m. an interview was conducted with LPN #2. LPN #2 was asked to relay when she was made aware of a skin issue with Resident #6. LPN #2 stated, The CNA came to me and said she saw something on (Resident #6's) bottom, on 12/10/14, I went in and assessed the area, it looked like a black spot, I cleaned it and put duoderm on it. I looked at the previous body audit to see if there was anything documented previously and there was nothing. I went to the supervisor and told her what I had found and what I had done. I wrote a note and put it under the wound nurses' door because I wanted to be sure that she followed up with the resident. I was really worried so the next morning when I got up I called the facility and talked to the wound nurse. I wanted to make sure she had seen (Resident #6) and taken care of it. LPN #2 was asked about the heels, LPN #2 stated that she had not noticed the heels at that time. On 5/13/15 at 10:45 a.m. an interview was conducted with LPN #4. LPN #4 was asked whether or not she remembered taking care of Resident #6 on 12/8/14. LPN #4 stated, That was my first day back after maternity leave. LPN #4 was asked whether or not she remembered a CNA asking her to assess a reddened area on Resident #6's skin on that day. LPN #4 stated, I don't remember the CNAs talking to her, I don't remember assessing skin on that day. CNAs usually tell me what's going on as they see more on a daily basis. I do remember that (Resident #6) had a wound that developed shortly after I came back to work. (Name of LPN #2) found the wound originally. LPN #4 was asked if she remembered an investigation being conducted by the DON regarding the wound, LPN #4 stated, Not really, but I do remember that there was a tiny red dot, it wasn't an open area until after the weekend when it was found. LPN #4 was asked when she saw the tiny red dot and where it was located, LPN #4 responded, The CNA did ask me to look at (Resident #6's) bottom on that Monday (12/8/14) and that's when I saw it. LPN #4 pointed to her right hip area and stated, It was right around this area. LPN #4 was asked what she did when she saw it, LPN #4 stated, I don't remember, I would have gone to the wound nurse, it may have been caused by sheering, when they (the CNAs) pulled her up. I would usually use a barrier cream but she was allergic to aloe vera so I didn't use anything. LPN #4 was asked whether or not she notified anyone about the area found, LPN #4 stated, If I had called the MD (medical doctor) or RP (responsible party) I would have written a note. I don't think this was the same redness she does get excoriation but the wound was on the hip. Something should have been done, I don't remember doing anything. LPN #4 was asked what she would normally do when a skin issue was observed, LPN #4 responded, I would contact the wound nurse and do a body audit at that time. LPN #4 was asked whether or not any of her assessment was documented, LPN #4 responded, No, I didn't document it. On 5/13/15 at 11:20 a.m. an interview was conducted with CNA #3. CNA #3 was asked what she did if she observed skin issues during ADL (activities of daily living) care. CNA #3 responded, I always look for red areas when bathing, cuts, bruises or anything like that and then report the findings to the nurse on the hallway. CNA #3 was asked what the nurse does when told about abnormal findings on the skin. CNA #3 responded, They generally finish up what they are doing and then come and do an assessment. CNA #3 was asked about whether or not she had reported any skin concerns on Resident #6 in December CNA #3 responded, (Resident #6) had a red area on her right side that was on the weekend, 12/6/14 or 12/7/14. CNA #3 pointed to her lower right buttock. CNA #3 continued, I reported what I saw to LPN #5 and she came and looked at it. She (LPN #5) stated okay and that we couldn't use the aloe vera because the resident was allergic to it. I don't know if she called the doctor or RP (responsible party). CNA #3 was asked to describe what she remembered of the red area. CNA #3 stated, It was a red area, the skin was not open and it was the size of a quarter. CNA #3 was asked whether or not she saw the area again, CNA #3 stated, The first time was over the weekend (12/6/14 and 12/7/14) then next time was on the Monday (12/8/14), I reported the redness to LPN #4. LPN #4 looked at it and said OK I don't know what she did after that, whether or not she called the doctor. CNA #3 was asked what the nurse did at that moment, CNA #3 responded, She just looked at it then left. CNA #3 was asked whether or not she saw the wound after 12/8/14. CNA #3 stated, I saw it later in the week. CNA #3 was asked to describe how the area looked later that week. CNA #3 responded, Later in the week it had turned darker, not really bigger and it was not open at that time. CNA #3 was asked whether she had noticed any areas on her heels, CNA #3 stated, Her heels were red, I think her shoes were too tight, we started putting slippers on her. On 5/13/15 at 11:30 a.m. an interview was conducted with CNA #4. CNA #4 was asked what she did if she observed any skin issues on a resident during ADL care. CNA #4 stated, When I am bathing/dressing a resident I look at their skin. If I notice anything different or out of place I will notify the nurse. The nurse will come and check and make a note of the findings and I guess tell the wound nurse. CNA #4 was asked whether she cared for Resident #6 in December 2014. CNA #4 stated that she did care for Resident #6. CNA #4 was asked whether or not she had ever reported any skin concerns she had observed on Resident #6 to the nurse. CNA #4 responded, In December, on a weekend (12/6/14 or 12/7/14), I found a small red rash on her right hip, kind of below her hip. CNA #4 pointed to her right lower buttock. CNA #4 continued, I notified (name of LPN #5), I think she may have put it in the computer system, I don't know what else she did. I took care of her again on the Monday (12/8/14) following that weekend and I told (name of LPN #4) that day and she came and looked, I think she called the wound nurse and she came down and took over the care. CNA #4 was asked what the red rash looked like on the two days that she called the nurse. CNA #4 responded, On the first day, that weekend, it looked like a red rash, on the second day (Monday) it had a different coloration, more blue in color than before. CNA #4 was asked whether or not she noticed any areas on Resident #6's heels, CNA #4 responded, Her heels looked a little red, the wound nurse told us to float her heels. CNA #4 was asked whether or not the wound nurse told her to float her heels on that Monday, CNA #4 stated, No, I don't remember when she told us to do that. On 5/13/15 at 12:20 p.m. a meeting was conducted with ASM (administrative staff member) #1, the administrator and ASM #2, the DON. ASM #1 and ASM #2 were both advised that there was continued concern for harm. ASM #2 stated that she did not understand what else they could have done, that Resident #6 had spinal stenosis and was participating in therapy and that the DTIs were unavoidable. ASM #2 was asked to provide her definition of a DTI, ASM #2 stated It's some kind of internal injury. She (Resident #6) had spinal stenosis, it could come from that, we can't see it. ASM #2 was asked whether or not a DTI could be classified as a pressure ulcer, ASM #2 stated, I don't know I am not a certified wound nurse. ASM #1 and ASM #2 were informed of the concern that two CNAs had reported on two separate dates between 12/6/14 and 12/8/14 to two different nurses that Resident #6 had redness on her right lower buttock. Both nurses had assessed the area observed by the CNAs but neither nurse had documented any interventions or any assessments regarding the concern of redness. On 12/10/14 the area on Resident #6's right lower buttock had developed into an unstageable DTI and two other unstageable DTIs were observed on Resident #6's bilateral heels. The wound on Resident #6's right lower buttock then declined to eschar and necrosis by 12/16/14. ASM #2 stated, Well she has spinal stenosis and she was on physical therapy, what else could we have done. We kept monitoring her; we were turning her and repositioning her. We had no reason to suspect anything bad. The DON was asked then to provide the documentation that would evidence monitoring and repositioning between 12/6/14 and 12/10/14, when the wounds were documented as present. The DON stated that she would provide the information. ASM #2 was asked what was in place to protect Resident #6 from acquiring a pressure ulcer. ASM #2 responded, We had the pressure relieving mattress in place, she was getting up out of bed and working with physical therapy all the time. The clinical record demonstrated that Resident #6 was participating in therapy during this period of time but there was no documentation related to a wound in the therapy notes. ASM #2 was asked whether the mattress on Resident #6's bed at that time was a standard mattress that all the residents were provided on admission or an air mattress specifically to address pressure ulcer prevention, ASM #1 responded, It was our standard mattress. ASM #2 was asked about the heels, ASM #2 stated, The heel thing popped up at the same time. We had no reason to suspect anything bad prior to 12/10/14. ASM #2 was asked why she initiated an investigation, ASM #2 responded, So we could educate the nurses. ASM #2 was asked what the conclusion was of the investigation, ASM #2 responded, I'm not sure what it was. I will look and get back to you. ASM #2 did not provide any information that evidenced the monitoring and repositioning of Resident #6 between 12/6/14 and 12/10/14 or any information regarding the conclusion to her investigation. On 5/13/15 at 2:45 p.m. an interview was conducted with LPN #5. LPN #5 was asked whether she remembered any issues with Resident #6's skin on the weekend she worked with Resident #6, 12/6/14 and 12/7/14. LPN #5 stated, I don't remember the CNAs coming to me, I do remember looking at her skin, there was redness, it wasn't open, redness from pressure, you know after a while in the same position you get redness from the pressure. LPN #5 was asked where the redness was observed, LPN #5 responded, On her right buttock, I repositioned her and put a pillow behind her. LPN #5 was asked whether or not she re-assessed the area after she had repositioned her, LPN #5 stated, No, I don't remember, it was just some redness. LPN #5 was asked whether or not she documented any of her findings, LPN #5 stated, No, it was just redness, I repositioned her. LPN #5 was asked whether or not she should have documented anything, LPN #5 stated, Yes. LPN #5 was asked whether or not she told anyone about the redness on Resident #6's right buttock. LPN #5 stated, I didn't tell the oncoming nurse, I really don't remember much about what I did that day. A review of the clinical record did not reveal any nurses notes that addressed Resident #6's skin between the dates of 12/6/14 and 12/10/14. A review of physician notes revealed a physician note dated 12/4/14 completed by ASM #3, the physiatrist, which documented, in part, the following information: 12/4/14. 87 y.o. (year old) F (female) with cervical stenosis c/o (complaint of) pain in sacral area. Pain Min (minimal) (1-3). Skin (no areas checked). Problem: Plan/Recommendations/Status: 4. Sacral area pain. Spoke to nurse who said there is no lesion in sacral area. Monitor. An interview was conducted with ASM #3 on 5/13/14 at 9:20 a.m. ASM #3 was asked about his visit with Resident #6 on 12/4/14, ASM #3 stated, I don't remember. This surveyor read the note to ASM #3 that he had written following his examination of Resident #6. ASM #3 stated, I don't remember the specifics, but if there was a concern with a skin issue, a wound, I would ask the nurse, they know more as they see the residents every day. If the nurse said there were no issues then I would take the nurse's word for it. ASM #3 stated that he did not conduct an examination of Resident #6's sacral area. ASM #3 further stated, Resident #6 has chronic pain, she uses a lot of narcotics, she has spinal stenosis. On 5/13/15 at 3:15 p.m. a meeting was conducted with ASM #1 and ASM #2. ASM #2 stated she had reviewed the federal regulations and felt that they had met all the requirements to provide care and services to prevent and treat a pressure ulcer. ASM #2 was asked to provide evidence of what was done between 12/4 and 12/10 to address skin concerns that were documented during that time period for Resident #6. ASM #2 provided a physician note dated 12/8/14 completed by ASM #4, Resident #6's primary care physician. ASM #2 stated, (Resident #6's) primary physician saw the resident on 12/8/14 and he did not see any issues with her skin at that time. ASM #2 was asked whether or not ASM #4 conducted a full examination that included an examination of Resident #6's skin. ASM #2 responded, Yes, he always looks at their skin. An interview was conducted with ASM #4 on 5/13/15 at 4:00 p.m. ASM #4 was asked whether or not he was aware of Resident #6's wound. ASM #4 stated that he was. ASM #4 was asked to describe what was included in his general physical examination of the residents. ASM #4 stated, I do a patient centered exam, I do not assess the groin or peri anal area, I just ask the nurses if there are any concerns and I will look at any areas that they indicate are of concern. ASM #4 was asked if he remembered being asked to look at Resident #6's skin on 12/8/14 during his visit. ASM #4 stated, If I was asked to look at the skin I would have done so and written that in my note. A review of the physician note written by ASM #4 on 12/8/14 did not reveal any information regarding the assessment of Resident #6's skin or sacral area. Further review of the physician orders revealed two orders dated and signed by the physician on 1/2/15 for antibiotics to treat a wound infection. No physician note was documented regarding the wound. A wound culture observed in the clinical record dated 1/2/15 documented that Resident #6's wound was infected with [MEDICATION NAME] (a bacteria normally found in feces); treatment with antibiotics was provided at that time. A care plan was created on 1/18/15 to address Resident #6's wound infection. The care plan documented, in part, the following: (Resident #6's name) has infection (sacral osteo[DIAGNOSES REDACTED] {bone infection^^} /wound) requiring IV (intravenous) antibiotics. Further review of documentation regarding wound care provided by the wound care specialist revealed, in part, the following information: 5/7/15. Stage 4^ pressure wound of the right buttock: Focused wound exam: Etiology (quality): Pressure. MDS 3.0 stage: 4. Duration: > (greater than) 105 days. Wound size: 4x3x4.5 cm. Surface area: 12.00 cm2. Undermining: 10cm at 11 o'clock (clock face reference). Exudate: light serous. Granulation tissue: 100%. Wound progress: deteriorated. Findings that indicate deterioration: infection, generalized decline of patient. On 5/13/15 at 9:26 a.m. LPN #4 was observed to provide wound care to Resident #6. A wound vac (vacuum) **** was noted to Resident #6's right buttock. LPN #4 removed the wound vac and surrounding duoderm. A stage 4 pressure ulcer was observed with granulation tissue in the wound bed. A review of the facility policy titled Pressure Ulcer Identification revealed, in part, the following documentation: